Why Are Adolescent Cannabis Use Disorder Treatment Admissions Declining in the US? The Mediated Pathway of State Treatment Admissions Rates before and after Recreational Cannabis Legalization.

Purpose: State-level prevalence data are used to investigate whether recreational cannabis legalization moderates the mediated pathway from the perception of low risk of harm, to cannabis use, to cannabis use disorder (CUD) treatment admissions, among adolescents (age 12-17) in the US. Methods: Annual state prevalence measures of perception of low risk, cannabis use, and CUD treatment admissions between 2008 and 2019 (N = 542 state-year observations) were collected from the National Survey on Drug Use and Health (NSDUH) and the Treatment Episode Dataset - Admissions (TEDS-A). A two-way fixed effects (state and year) moderated mediation model was used to test whether recreational legalization moderated the indirect effect of perception of low risk on treatment admissions via cannabis use. Results: A positive indirect effect of perceiving cannabis as low risk on CUD treatment admissions via cannabis use was observed prior to legalization but not afterwards. After legalization, the positive association of perceiving cannabis as low risk with cannabis use was strengthened, and the positive association of cannabis use with treatment admissions was suppressed, as compared to before legalization. Discussion: Recreational legalization may alter the social acceptability and medical self-administration of cannabis, potentially leading to CUD treatment utilization decline among adolescents even as risk factors for CUD increase. Linking recreational cannabis legalization to advancing awareness of the health risks associated with adolescent cannabis use and promoting adolescent CUD treatment engagement through mHealth approaches and primary care providers are key to addressing potential adolescent health challenges brought about by expanding cannabis legalization.

Peer Network Counseling Effects on Substance Use: an Individual Participant Data Meta-Analysis Integrating Three Randomized Controlled Trials.

The current study describes an individual participant data meta-analysis (IPDMA) testing the efficacy of a peer-network counseling (PNC) intervention for preventing substance use escalation in adolescents and young adults. PNC has shown efficacy in reducing substance use among adolescents and young adults across small-scale randomized controlled trials (RCTs). Identifying expected large-scale effects and moderators is an important next step in guiding use of PNC in practice. To this end, we combine three small-scale RCTs to test PNC intervention effects on substance use change in a combined sample of 421 adolescents and young adults (50% intervention, 55% female, 69% Black/African-American, M age [SD] = 17.3 [2.2] years). Our approach combines latent change score modeling in a structural equation modeling (SEM) framework with study-level fixed effects to obtain (a) a more generalizable PNC effect than we could obtain with each constituent sample and (b) greater power and precision for individual-level moderation of treatment effects. We found that although PNC main effects on substance use outcomes (past 30-day cannabis, alcohol, tobacco, and drug use) were not significant, PNC effects were moderated by individual-level pre-intervention substance use frequency. PNC more strongly reduced drug use at the 1-month follow-up and cannabis use at the 3-month follow-up among participants who showed higher baseline use of these substances. Implications of our approach and findings for prevention researchers are discussed.

Incorporating Geographic Information Science and Technology in Response to the COVID-19 Pandemic.

Incorporating geographic information science and technology (GIS&T) into COVID-19 pandemic surveillance, modeling, and response enhances understanding and control of the disease. Applications of GIS&T include 1) developing spatial data infrastructures for surveillance and data sharing, 2) incorporating mobility data in infectious disease forecasting, 3) using geospatial technologies for digital contact tracing, 4) integrating geographic data in COVID-19 modeling, 5) investigating geographic social vulnerabilities and health disparities, and 6) communicating the status of the disease or status of facilities for return-to-normal operations. Locations and availability of personal protective equipment, ventilators, hospital beds, and other items can be optimized with the use of GIS&T. Challenges include protection of individual privacy and civil liberties and closer collaboration among the fields of geography, medicine, public health, and public policy.

Relational victimization and peer affiliate prosocial behaviors in African American adolescents: Moderating effects of gender and antisocial behavior.

INTRODUCTION: Experiencing relational victimization (e.g., peer exclusion, untrue rumors) during adolescence can have negative social-emotional consequences, including increased antisocial behavior and substance use. The negative impact of relational victimization may be lessened by spending time with supportive, prosocial peers. METHODS: This study examined the concurrent and predictive associations between relational victimization and peer affiliates' prosocial behaviors in 244 predominately African American adolescents (ages 13-14) living in U.S. urban neighborhoods. Questionnaires were collected every six months for two years. Overt victimization was controlled for in the analysis and the moderation of gender and antisocial behaviors were tested. RESULTS: Peer affiliates' prosocial behavior was stable across the two years. Relational victimization was not associated with peers' prosocial behavior at baseline or across time. Gender did not moderate the association between relational victimization and peers' prosocial behavior. Moderating effects were found for antisocial behavior; relational victimization was positively associated with peer affiliates' prosocial behavior but only for adolescents who were low on antisocial behavior at baseline. CONCLUSIONS: For African American youth, efforts to reduce relational aggression and increase peer support in prosocial activities prior to adolescence may be useful for preventing social-emotional problems.

School, Friends, and Substance Use: Gender Differences on the Influence of Attitudes Toward School and Close Friend Networks on Cannabis Involvement.

The school environment is extremely salient in young adolescents' lives. Adolescents who have unfavorable attitudes toward school and teachers are at elevated risk for dropping out of school and engaging in behavioral health risks. Peer network health-a summation of the positive and negative behaviors in which one's close friend group engages-may be one way by which attitudes toward school exert influence on youth substance use. Utilizing a sample of 248 primarily African-American young urban adolescents, we tested a moderated mediation model to determine if the indirect effect of attitude to school on cannabis involvement through peer network health was conditioned on gender. Attitude toward school measured at baseline was the predictor (X), peer network health measured at 6 months was the mediator (M), cannabis involvement (including use, offers to use, and refusals to use) measured at 24 months was the outcome (Y), and gender was the moderator (W). Results indicated that negative attitudes toward school were indirectly associated with increased cannabis involvement through peer network health. This relationship was not moderated by gender. Adolescents in our sample with negative attitudes toward school were more likely to receive more offers to use cannabis and to use cannabis more frequently through the perceived health behaviors of their close friends. Implications from these results point to opportunities to leverage the dynamic associations among school experiences, friends, and cannabis involvement, such as offers and use.

Young Urban Adolescents' Activity Spaces, Close Peers, and the Risk of Cannabis Use: A Social-Spatial Longitudinal Analysis.

BACKGROUND: An understudied, yet important area of youth development research is the examination of how place affects critical psychosocial processes such as identity formation, problem solving, emotional regulation, and in particular with adolescents, belongingness, autonomy, social competency, and behavioral health. A growing spatially informed literature indicates that youth interact with meaningful places as environmental strategies, shaping developmental trajectories related to behavioral health. OBJECTIVES: The objective is to investigate the relationship between place preference and health behavior among adolescents, with a focus on substance use behavior, specifically, cannabis use. We theorize that cannabis use is associated with place preference for urban, city types of places, and that this particular place preference interacts with close peer network behaviors. METHODS: To understand the role of preferred locations, close peer relations, and mental health on cannabis use, 248 adolescents (ages 13 to 14) were studied longitudinally. Logistic regression models tested the moderating effects of peer network health (sum of close friends risk and protective behaviors) on selecting city locations (urban stress/neighborhoods) as preferred places, and subsequent cannabis use. RESULTS: Results indicated that peer network health moderated the effects of choosing city locations as favorite, increasing the odds of cannabis use more than eight-fold at 24 months. CONCLUSIONS: Favorite places located in city environments appear to interact with peer risk behaviors influencing the cannabis use of young urban adolescents, even after controlling for the influence of baseline cannabis use, neighborhood disorder the home neighborhood, age, gender, and mental health effects.

Urban Greenspace is Associated with Reduced Psychological Stress among Adolescents: A Geographic Ecological Momentary Assessment (GEMA) Analysis of Activity Space.

This study investigates the momentary association between urban greenspace, captured using Normalized Difference Vegetation Index (NDVI) derived from Landsat imagery, and psychological stress, captured using Geographic Ecological Momentary Assessment (GEMA), in the activity spaces of a sample of primarily African American adolescents residing in Richmond, Virginia. We employ generalized estimating equations (GEE) to estimate the effect of exposure to urban greenspace on stress and test for moderation by sex, emotional dysregulation, season, neighborhood disadvantage, and whether the observation occurs at home or elsewhere. Results indicate that urban greenspace is associated with lower stress when subjects are away from home, which we speculate is due to the properties of stress reduction and attention restoration associated with exposure to natural areas, and to the primacy of other family dynamics mechanisms of stress within the home. Subjects may also seek out urban greenspaces at times of lower stress or explicitly for purposes of stress reduction. The greenspace-stress association away from home did not differ by sex, emotional dysregulation, neighborhood disadvantage, or season, the latter of which suggests that the observed greenspace-stress relationship is associated with being in a natural environment rather than strictly exposure to abundant green vegetation. Given the association of urban greenspace with lower stress found here and in other studies, future research should address the mediated pathways between greenspace, stress, and stress-related negative health outcomes for different population subgroups as a means toward understanding and addressing health disparities.

The Dynamic Role of Urban Neighborhood Effects in a Text-Messaging Adolescent Smoking Intervention.

INTRODUCTION: Neighborhood features such as the density of tobacco outlets relative to one's home and evaluations of safety of one's activity space (routine locations), are known to influence health behaviors. Understanding the time-varying nature of these aspects of the urban ecology provides unique insights into the dynamic interactions of individuals and their environments. METHODS: The present study tested the time-varying effects of tobacco outlets and perceived safety within a randomized controlled trial of an adolescent text-messaging smoking intervention. We used ecological momentary assessment data (EMA) from an automated text-messaging smoking cessation randomized trial with 197 primarily African American urban adolescents. We employed a time-varying effect model to estimate the effects of density of tobacco outlets within one-half mile of participants' home locations (time-invariant covariate) and evaluations of safety of their activity space (time-varying covariate) on momentary smoking over 6 months by treatment condition. The time-varying effect model approach models behavioral change and associations of coefficients expressed dynamically and graphically represented as smooth functions of time. RESULTS: Differences in trajectories of smoking between treatment conditions were apparent over the course of the study. During months 2 and 6, the association between tobacco outlet density and smoking was significantly stronger in the control condition, suggesting treatment dampens this association during these time periods. The intervention also significantly reduced the association of perceived safety and smoking among the treatment condition during months 3 through 6. CONCLUSIONS: Results support testing the time-varying effects of urban ecological features and perceptions of safety among adolescents in text-based smoking cessation interventions. IMPLICATIONS: This study makes a unique contribution towards understanding the time-varying effects of urban neighborhoods on adolescent tobacco use within the context of a text-delivered intervention. Helping to adjust the long-held conceptualization of intervention effects as a static outcome, to that of a dynamic, time-varying process, is an important contribution of this study. The ability to specify when behavioral change occurs within the context of a randomized control trial provides understanding into the time-varying treatment effects of text-based smoking intervention. For example, researchers can modify the intervention to have strategically timed booster sessions that align with when the odds of smoking begin to increase in order to provide more precise treatment. The current study results show that increasing support to participants during months 2 and 4 may help suppress smoking over the course of a 6-month intervention.

Tobacco outlet density and attitudes towards smoking among urban adolescent smokers.

BACKGROUND: This study investigates whether residential exposure to tobacco outlets (i.e., convenience stores and other stores selling tobacco) is associated with attitudes towards smoking among a sample of urban, primarily African American, adolescent smokers. METHODS: Cross-sectional survey data for 197 adolescents were integrated with spatial data on tobacco outlets via subject home addresses. Ordinal regression was employed to test hypotheses that closer proximity to, and higher concentrations of, tobacco outlets are associated with higher measures of intention to continue to smoke in the future, weaker self-efficacy related to stopping smoking, and more accepting social norms related to smoking, while controlling for characteristics of age, gender, family and peer smoking contexts, and level of nicotine dependence. Moderation by age and gender was also investigated. RESULTS: Higher residential tobacco outlet density is significantly associated with a greater intention to smoke in the next 3 months, a lower readiness to stop smoking, and a greater likelihood of accepting a cigarette from a friend. Residential proximity to a tobacco outlet is significantly associated with a greater intention to smoke 5 years on. Evidence of a relationship between exposure to tobacco outlets and social norms related to smoking was not found, nor was there evidence for moderation of these relationships by age or gender. CONCLUSIONS: These results suggest that among urban adolescents who currently smoke, higher residential exposure to tobacco outlets is associated with greater predisposition towards future smoking and lower self-evaluation of the ability to stop smoking.

Text Message Delivered Peer Network Counseling for Adolescent Smokers: A Randomized Controlled Trial.

Although adolescent tobacco use has declined in the last 10 years, African American high school seniors' past 30-day use has increased by 12 %, and as they age they are more likely to report lifetime use of tobacco. Very few urban youth are enrolled in evidenced-based smoking prevention and cessation programming. Therefore, we tested a text messaging smoking cessation intervention designed to engage urban youth through an automated texting program utilizing motivational interviewing-based peer network counseling. We recruited 200 adolescents (90.5 % African American) into a randomized controlled trial that delivered either the experimental intervention of 30 personalized motivational interviewing-based peer network counseling messages, or the attention control intervention, consisting of text messages covering general (non-smoking related) health habits. All adolescents were provided smart phones for the study and were assessed at baseline, and at 1, 3, and 6 months post intervention. Utilizing repeated measures general linear models we examined the effects of the intervention while controlling for race, gender, age, presence of a smoker in the home, and mental health counseling. At 6 months, participants in the experimental condition significantly decreased the number of days they smoked cigarettes and the number of cigarettes they smoked per day; they significantly increased their intentions not to smoke in the future; and significantly increased peer social support among girls. For boys, participants in the experimental condition significantly reduced the number of close friends in their networks who smoke daily compared to those in the control condition. Effect sizes ranged from small to large. These results provide encouraging evidence of the efficacy of text messaging interventions to reduce smoking among adolescents and our intervention holds promise as a large-scale public health preventive intervention platform.

Latino Population Growth and Hospital Uncompensated Care in California.

OBJECTIVES: We examined the association between the size and growth of Latino populations and hospitals' uncompensated care in California. METHODS: Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models. RESULTS: We found a significant association between the growth of California's Latino population and hospitals' uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant. CONCLUSIONS: Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals' uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.

Development and Outcomes of a Text Messaging Tobacco Cessation Intervention With Urban Adolescents.

BACKGROUND: This paper describes the development of an urban adolescent text messaging tobacco cessation intervention and preliminary findings from a randomized, controlled trial. The authors successfully adapted a face-to-face intervention into a personalized, automated, and interactive 5-day texting protocol. METHODS: Respondent-driven sampling was used beginning at a community substance abuse facility. Seventy-two tobacco-dependent adolescents were randomized into an automated computer texting program that delivered either the experimental condition of 30 motivational interviewing- and social network counseling-based personalized messages or the attention control condition consisting of a texting program covering general (non-smoking-related) health habits. All teens were provided smartphones for the study and were assessed at baseline and at 1, 3, and 6 months post intervention. Analyses examined condition×time interactions. RESULTS: At 6 months, the experimental condition decreased the number of cigarettes smoked in the past 30 days, increased intentions not to smoke in the future, and increased peer social support compared with controls. Effect sizes were moderate to large. CONCLUSIONS: These findings are unique, as they target urban adolescents with a mobile health format and add to the growing literature on the efficacy of text-delivered interventions.

Peer attitudes effects on adolescent substance use: the moderating role of race and gender.

We examined the relationship between adolescents' perceptions of their close friends' attitudes about substance use, and their own use of cigarettes, alcohol, and marijuana. Using data from the 2010 National Survey on Drug Use and Health, a multistage area probability sample sponsored by the Substance Abuse and Mental Health Services Administration (n = 17,865), we tested the direct and moderating effects of subgroups of race and gender on perceptions of adolescents' close friends on past month substance use. Significant effects were found on peer attitudes influencing substance use for all race and gender subgroups. Close friends' attitudes of indifference were associated with increased substance use and disapproval associated with reduced use, controlling for age, income, family structure, and adolescents' own attitudes of risk of substance use. Significant moderating effects of peer attitudes on cigarette and marijuana use were found for both gender and race moderators. Conditional effects of the moderation by race were also examined for gender subgroups. The moderating effect of race on close friends' attitudes impacting cigarette and marijuana use was stronger in magnitude and significance for females compared to males. Female marijuana and cigarette use was more influenced by close friends' attitudes than males, and whites were more influenced by their close friends than Hispanics and blacks. White females are more susceptible to close friends' attitudes on cigarette use as compared to white males and youth of other races. Implications for socially oriented preventive interventions are discussed.

Young Adult Depression and Cannabis Use: Associations Before and After Recreational Legalization.

INTRODUCTION: The co-occurrence of depression with cannabis use worsens both mood and substance use disorder outcomes, with young adults particularly at risk of co-occurrence. This research investigates whether the association of state-level prevalence rates of young adult (age 18-25) depression and cannabis use in the U.S. changed following enactment of recreational (adult use) cannabis legalization between 2008 and 2019. METHODS: Annual, state prevalence data on past-year major depressive episode (hereafter, depression) and past-month cannabis use were extracted from the National Survey on Drug Use and Health (N=600 state-year observations). Moderated regression models tested whether the association of depression with cannabis use differed before versus after recreational legalization by comparing prevalence rates of depression and cannabis use in states that enacted recreational legalization to those that did not, while fixing state, year, and medical legalization effects. Data were accessed and analyzed in 2023. RESULTS: Prevalence rates of both depression and cannabis use increased throughout the study period. The positive statistical effect of depression on cannabis use more than doubled in magnitude after legalization (ß=0.564, 95% CI=0.291, 0.838) as compared to before (ß=0.229, 95% CI=0.049, 0.409), representing a significant change (ß=0.335, 95% CI=0.093, 0.577). CONCLUSIONS: These results suggest that the association between prevalence rates of young adult depression and cannabis use strengthened following recreational legalization in the U.S. This is potentially due to increases in cannabis accessibility and the acceptance of the health benefits of cannabis, which may enhance the use of cannabis as a coping mechanism among young adults with depression.

Treating young adult cannabis use disorder with text message-delivered peer network counseling.

BACKGROUND: Approximately 16.5% of U.S. young adults have a cannabis use disorder (CUD) and are at risk for negative outcomes. Treatment can reduce cannabis use, but young adults are less likely to seek help than older adults. Peer Network Counseling-txt (PNC-txt) is a brief, text-delivered, Motivational Interviewing-informed substance use intervention focusing on peer relations and activity spaces as mechanisms for behavioral change. PNC-txt has shown evidence of reducing tobacco and cannabis use with adolescents and young adults, but it has not been tested in the context of legal cannabis use. The current randomized controlled trial sought to expand the evidence regarding the context of PNC-txt effects, comparing one state in which cannabis is legal (Colorado) and one state in which it is not (Tennessee). We hypothesized that participants randomized to PNC-txt would show significant reductions in cannabis use compared to controls, with larger reductions for females and those in Colorado, and that peer relations and activity space would mediate effects. METHODS: One thousand, seventy eight 18-25 year olds (CO: 551; TN: 527) who met screening criteria for CUD and biologically-verified cannabis use were randomly assigned to PNC-txt or waitlist control condition. Every other day for 4 weeks, participants assigned to PNC-txt received pre-programmed text conversations, tailored via data from the baseline assessment. Self-report and biological indicators of cannabis use were measured at 1-, 3-, and 6-months. DISCUSSION: Data analysis is underway. Results will provide evidence regarding whether, and how, PNC-txt reduces cannabis use in young adults with CUD. TRIAL REGISTRATION: This trial was prospectively registered on September 28, 2020 with ClinicalTrials.gov (NCT04567394).

Geospatial technology and the "exposome": new perspectives on addiction.

Addiction represents one of the greatest public health problems facing the United States. Advances in addiction research have focused on the neurobiology of this disease. We discuss potential new breakthroughs in understanding the other side of gene-environment interactions-the environmental context or "exposome" of addiction. Such research has recently been made possible by advances in geospatial technologies together with new mobile and sensor computing platforms. These advances have fostered interdisciplinary collaborations focusing on the intersection of environment and behavior in addiction research. Although issues of privacy protection for study participants remain, these advances could potentially improve our understanding of initiation of drug use and relapse and help develop innovative technology-based interventions to improve treatment and continuing care services.