Increases in Secondhand Smoke After Going Smoke-Free: An Assessment of the Impact of a Mandated Smoke-Free Housing Policy.

OBJECTIVE: The 12-month impact of federally mandated smoke-free housing (SFH) policy adoption (July 2018) was assessed using two markers of ambient secondhand smoke (SHS): airborne nicotine and particulate matter at the 2.5-micrometer threshold (PM2.5). METHODS: We measured markers of SHS in Norfolk, VA from December 2017 to December 2018 in six federally subsidized multi-unit public housing buildings. Multi-level regression was used to model the following comparisons: (1) the month immediately before SFH implementation versus the month immediately after, and (2) December 2017 versus December 2018. RESULTS: There was a 27% reduction in indoor PM2.5 and a 32% reduction in airborne nicotine in the first month after SFH adoption, compared to the month prior to adoption. However, there was a 33% increase in PM2.5 and a 25% increase in airborne nicotine after 12 months. CONCLUSIONS: US Department of Housing and Urban Development (HUD)-mandated SFH can reduce SHS in multi-unit housing. However, SFH could also plausibly increase indoor smoking. Policy approaches adopted by individual properties or housing authorities-for example, property-wide bans versus allowing designated smoking areas-could be driving this potential unintended consequence. IMPLICATIONS: Successful implementation of SFH by public housing authorities in response to the HUD rule requires ongoing attention to implementation strategies. In this sense, SFH likely differs from other policies that might be seen as less intrusive. Long-term success of SFH will depend on careful policy implementation, including plans to educate and support housing authority staff, inform and engage residents, and build effective partnerships with community agencies.

Longitudinal Analysis of Associations Between Reasons for Electronic Cigarette Use and Change in Smoking Status Among Adults in the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Electronic cigarette (ECIG) use and changes in cigarette smoking status may be influenced by self-reported reasons for using ECIGs. METHODS: We analyzed adult current and former cigarette smokers who were also current or former ECIG users at wave 1 (n = 3044) using wave 1 and wave 2 Population Assessment of Tobacco and Health Study data (2013-2015). Prevalence of reporting 13 reasons for ECIG use at wave 1 was examined and weighted logistic regressions were conducted predicting smoking status changes from wave 1 to wave 2. RESULTS: Reasons for ECIG use ranged from 18.1% (people in the media or public figures use them) to 82.5% (they might be less harmful to people around me than cigarettes). From wave 1 to wave 2, 27.2% of former smokers (n = 249) became current smokers and 11.6% of current smokers (n = 246) became former smokers. Among wave 1 former smokers, using ECIGs because of the availability of flavors (AOR = 0.57, 95% CI = 0.39-0.85) or because they don't smell (AOR = 0.64, 95% CI = 0.42-0.97) was associated with lower odds of relapse to smoking, but using ECIGs because using them helps people quit smoking (AOR = 1.55, 95% CI = 1.01-2.38) was associated with greater odds of relapse. Among wave 1 current smokers, using ECIGs because they can be used where smoking is not allowed (AOR = 0.56, 95% CI = 0.38-0.85) was associated with reduced odds of quitting cigarettes. CONCLUSIONS: Some reasons for ECIG use are associated with changes in self-reported smoking status. Researchers should examine ECIG user characteristics when assessing associations between ECIG use and smoking status transitions. IMPLICATIONS: Given that certain reasons for ECIG use, such as using ECIGs in locations are where smoking is not allowed, may inhibit smoking reduction, policies may be developed to prevent ECIG use in locations where smoking is banned. In addition, because certain reasons for ECIG use may aid in relapse prevention, such as availability of desired flavors, efforts should be made to identify ECIG device characteristics that are appealing to smokers but not youth or nontobacco users. These results provide support for future research on reasons for ECIG use to inform regulatory policies.

Patterns of youth tobacco and polytobacco usage: The shift to alternative tobacco products.

BACKGROUND: Despite significant declines in youth cigarette smoking, overall tobacco usage remains over 20% as non-cigarette tobacco product usage is increasingly common and polytobacco use (using 1+ tobacco product) remains steady. OBJECTIVES: The present study was designed to identify patterns of youth tobacco use and examine associations with sociodemographic characteristics and tobacco dependence. METHODS: The current analysis uses Latent Class Analysis (LCA) to examine the 6,958 tobacco users (n = 2,738 female) in the National Youth Tobacco Survey (2012 and 2013). We used as indicators past month use of tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, snus, pipes, bidis, and kreteks) and regressed resulting classes on sociodemographic characteristics and tobacco dependence. RESULTS: Nine classes emerged: cigarette smokers (33.4% of sample, also included small probabilities for use of cigars and e-cigarettes), cigar smokers (16.8%, nearly exclusive), smokeless tobacco users (12.3%, also included small probabilities for cigarettes, cigars, snus), hookah smokers (11.8%), tobacco smokers/chewers (10.7%, variety of primarily traditional tobacco products), tobacco/hookah smokers (7.2%), tobacco/snus/e-cig users (3.3%), e-cigarette users (2.9%,), and polytobacco users (1.7%, high probabilities for all products). Compared to cigarette smokers, tobacco/hookah smokers and hookah smokers were more likely to report Hispanic ethnicity. Polytobacco users were more likely to report dependence (AOR:2.77, 95% CI:[1.49-5.18]), whereas e-cigarette users were less likely (AOR:0.49, 95% CI:[0.24-0.97]). CONCLUSION: Findings are consistent with other research demonstrating shifts in adolescent tobacco product usage towards non-cigarette tobacco products. Continuous monitoring of these patterns is needed to help predict if this shift will ultimately result in improved public health.

The Impact of the Minimum Legal Drinking Age on Alcohol-Related Chronic Disease Mortality.

BACKGROUND: The minimum legal drinking age (MLDA) of 21 has been associated with a number of benefits compared to lower MLDAs, including long-term effects, such as reduced risk for alcoholism in adulthood. However, no studies have examined whether MLDA during young adulthood is associated with mortality later in life. We examined whether individuals exposed to permissive MLDA (<21) had higher risk of death from alcohol-related chronic disease compared to those exposed to the 21 MLDA. Because prior work suggests that MLDA affects college students differently, we also conducted conditional analyses based on ever having attended college. METHODS: Data from the 1990 through 2010 U.S. Multiple Cause-of-Death files were combined with data on the living population and analyzed. We included individuals who turned 18 during the years 1967 to 1990, the period during which MLDA varied across states. We examined records on death from several alcohol-related chronic diseases, employing a quasi-experimental approach to control for unobserved state characteristics and stable time trends. RESULTS: Individuals who reported any college attendance did not exhibit significant associations between MLDA and mortality for the causes of death we examined. However, permissive MLDA for those who never attended college was associated with 6% higher odds for death from alcoholic liver disease, 8% higher odds for other liver disease, and 7% higher odds for lip/oral/pharynx cancers (odds ratio [OR] = 1.06, 95% confidence interval [CI] [1.02, 1.10]; OR = 1.08, 95% CI [1.03, 1.13]; OR = 1.07, 95% CI [1.03, 1.12], respectively). CONCLUSIONS: The 21 MLDA likely protects against risk of death from alcohol-related chronic disease across the lifespan, at least for those who did not attend college. This is consistent with other work that shows that the long-term association between MLDA and alcohol-related outcomes is specific to those who did not attend college.

Effects of state cigarette excise taxes and smoke-free air policies on state per capita alcohol consumption in the United States, 1980 to 2009.

BACKGROUND: Increasing state cigarette excise taxes and strengthening smoke-free air (SFA) laws are known to reduce smoking prevalence. Some studies suggest that such policies may also reduce alcohol use, but results for cigarette taxes have been mixed, and associations with smoke-free air policies have been limited to some demographic subgroups. To shed further light on the potential secondary effects of tobacco control policy, we examined whether increases in cigarette taxes and strengthening of SFA laws were associated with reductions of per capita alcohol consumption and whether any reductions were specific to certain beverage types. METHODS: State per capita alcohol consumption from 1980 to 2009 was modeled as a function of state price per pack of cigarettes and SFA policy scores while controlling for secular trends and salient state covariates. Both policy measures also accounted for local policies. Total alcohol, beer, wine, and spirits consumption per capita were modeled separately. For each type of beverage, we used a nested models approach to determine whether the 2 policies together were associated with reduced consumption. RESULTS: For total alcohol consumption, and for beer or spirits (but not wine), one or both tobacco policies were associated with reductions in consumption. A 1% increase in cigarette price per pack was associated with a 0.083% decrease in per capita total alcohol consumption (95% confidence interval [CI] 0.0002 to 0.166, p = 0.0495), and a 1-point increase in SFA policy score, measured on a 6-point scale, was associated with a 1.1% decrease in per capita total alcohol consumption (95% CI 0.4 to 1.7, p = 0.001; p < 0.001 for the hypothesis that the 2 policies are jointly associated with reduced alcohol consumption). CONCLUSIONS: The public health benefits of increasing cigarette taxes and smoke-free policies may go beyond the reduction of smoking and extend to alcohol consumption, specifically beer and spirits.

Alcohol consumption, heavy drinking, and mortality: rethinking the j-shaped curve.

BACKGROUND: High average daily consumption of alcohol has been associated with elevated mortality risk, but more moderate consumption, relative to abstinence, has been associated with reduced mortality risk. However, average daily consumption can be complicated to assess, limiting its usefulness in both research and clinical practice. There are also concerns that average consumption fails to capture the risk associated with certain drinking patterns, such as heavy episodic drinking. This study assessed mortality associated with drinking pattern, operationalized as the frequency of both heavy and nonheavy drinking occasions. METHODS: Data from the 1997 to 2001 administrations of the National Health Interview Survey (NHIS; n = 111,511) were paired with the current release of the NHIS Linked Mortality Files, which provided mortality follow-up data through the end of 2006. We estimated the impact of drinking pattern on all-cause mortality, operationalized as the frequency of heavy (5+ drinks) and nonheavy (<5 drinks) drinking occasions. Other covariates in the model included survey wave, sex, age, race/ethnicity, ratio of family income to poverty threshold, educational attainment, body mass index, and smoking status. RESULTS: Over a third of past-year drinkers reported heavy drinking. Mortality risk increased steadily as heavy drinking frequency increased; daily heavy drinkers exhibited an almost 2-fold risk of death compared with abstainers (p < 0.001). Regular nonheavy drinking was associated with decreased mortality, similar to the "J-shaped curve" highlighted in past research on alcohol mortality; this potential protective effect peaked around 2 nonheavy occasions per week. CONCLUSIONS: Any heavy drinking likely elevates mortality risk, and substantial health benefits could be realized by reducing heavy drinking occasions or limiting overall drinking. Heavy and nonheavy drinking frequencies are valid targets for clinical screening and could be helpful in assessing risk and promoting less harmful drinking behavior.

Probing the smoking-suicide association: do smoking policy interventions affect suicide risk?

INTRODUCTION: Smokers exhibit elevated risk for suicide, but it is unknown whether smoking interventions reduce suicide risk. We examined whether state-level policy interventions-increases in cigarette excise taxes and strengthening of smoke-free air laws-corresponded to a reduction in suicide risk during the 1990s and the early 2000s. We also examined whether the magnitude of such reductions correlated with individuals' predicted probability of smoking, which would be expected if the associations stemmed from changes in smoking behavior. METHODS: We paired individual-level data on suicide deaths from the U.S. Multiple Cause of Death files, years 1990-2004, with living population data from the same period. These were linked with state data on cigarette excise taxes and smoke-free air policies. Utilizing a quasiexperimental analytical approach, we estimated the association between changes in policy and suicide risk. To examine whether associations correlated with individuals' probability of smoking, we used external survey data to derive a predicted probability of smoking function from demographic variables, which was then used to stratify the population by predicted smoking prevalence. RESULTS: Cigarette excise taxes, smoke-free air policies, and an index combining the two policies all exhibited protective associations with suicide. The associations were strongest in segments of the population where predicted smoking prevalence was the highest and weaker in segments of the population where predicted smoking prevalence was the lowest, suggesting that the protective associations were related to changes in smoking behavior. CONCLUSION: These results provide support for the proposition that population interventions for smoking could reduce risk for suicide.

Long-term effects of laws governing youth access to tobacco.

OBJECTIVES: We sought to examine the association between policies governing access to tobacco during adolescence and subsequent adult smoking. METHODS: We analyzed adult smoking data from the 1998 through 2006-2007 administrations of the US Current Population Survey Tobacco Use Supplement by employing a quasi experimental approach. Participants (n = 105,519) were adults, aged 18 to 34 years at the time of the survey. Smoking outcomes included having ever smoked 100 cigarettes, smoking at the time of the survey, and having smoked 10 or more cigarettes a day conditioned on being an ever smoker. These were predicted from exposure to state youth access policies at age 17 years. RESULTS: Four of the 9 policies exhibited significant associations with reduced prevalence of 1 or more smoking outcomes, primarily among women. Lesser effects for other policies could not be ruled out. CONCLUSIONS: Restrictions on youth access to tobacco might lead to reduction in smoking prevalence later in adulthood. The effect might be limited to women; we estimate that having all policies in place could be associated with a 14% reduction in lifetime smoking prevalence for women, and an additional 29% reduction in heavy smoking among ever smokers.

The persistent effects of minimum legal drinking age laws on drinking patterns later in life.

BACKGROUND: Exposure to permissive minimum legal drinking age (MLDA) laws not only affects young adults in the short term, but also later in life; for example, individuals who could legally purchase alcohol before the age of 21 are more likely to suffer from drinking problems as older adults, long after the laws had been changed. However, it is not known how permissive MLDA exposure affects specific drinking behavior. This present study uses changes in MLDA laws during the 1970s and 1980s as a natural experiment to investigate the potential impact of permissive MLDA exposure on average alcohol consumption, frequency of drinking, and patterns of binging and more moderate, nonheavy drinking. METHODS: Policy exposure data were paired with alcohol use data from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year drinkers born between 1949 and 1972 (n = 24,088) were included. Average daily intake, overall drinking frequency, and frequency of both binge episodes (5+ drinks) and days without a binge episode (nonheavy drinking) for the previous year at the time of interview were tracked for each respondent. RESULTS: Exposure to permissive MLDAs was associated with higher odds to report frequent binging and lower odds to report any moderate drinking; these associations were largely driven by men and those who did not attend college. Overall drinking frequency and average alcohol consumption were not affected by MLDA exposure. CONCLUSIONS: The ability to legally purchase alcohol before the age of 21 does not seem to increase overall drinking frequency, but our findings suggest that it is associated with certain types of problematic drinking behaviors that persist into later adulthood: more frequent binge episodes and less frequent nonheavy drinking. We also propose that policymakers and critics should not focus on college drinking when evaluating the effectiveness of MLDAs.

COVID-19 Stay-At-Home Orders and Secondhand Smoke in Public Housing.

INTRODUCTION: This study aimed to better understand the inequitable impact of the pandemic by examining the associations between stay-at-home orders and indoor smoking in public housing, measured by ambient particulate matter at the 2.5-micron threshold, a marker for secondhand smoke. METHODS: Particulate matter at the 2.5-micron threshold was measured in 6 public-housing buildings in Norfolk, VA from 2018 to 2022. Multilevel regression was used to compare the 7-week period of the Virginia stay-at-home order in 2020 with that period in other years. RESULTS: Indoor particulate matter at the 2.5-micron threshold was 10.29 µg/m3 higher in 2020 (95% CI=8.51, 12.07) than in the same period in 2019, a 72% increase. Although particulate matter at the 2.5-micron threshold improved in 2021 and 2022, it remained elevated relative to the level in 2019. CONCLUSIONS: Stay-at-home orders likely led to increased indoor secondhand smoke in public housing. In light of evidence linking air pollutants, including secondhand smoke, with COVID-19, these results also provide further evidence of the disproportionate impact of the pandemic on socioeconomically disadvantaged communities. This consequence of the pandemic response is unlikely to be isolated and calls for a critical examination of the COVID-19 experience to avoid similar policy failures in future public health crises.

Developing a peer-led intervention to promote COVID-19 testing in low-income housing settings.

Background: The Housing Collaborative project at Eastern Virginia Medical School has developed a method of adapting public health guidance from public housing communities, which face tremendous health challenges in cardiometabolic health, cancer, and other major health conditions. In this paper, we describe how academic and community partners in the Housing Collaborative came together to do this work with a focus on COVID-19 testing in the context of the emerging pandemic. Methods: The academic team used virtual community engagement methods to interact with the Housing Collaborative Community Advisory Board (HCCAB) and a separate cohort of research participants (N = 102) recruited into a study of distrust in COVID-19 guidance. We conducted a series of 44 focus group interviews with participants on related topics. Results from these interviews were discussed with the HCCAB. We used the collaborative intervention planning framework to inform adaptation of public health guidance on COVID-19 testing delivered in low-income housing settings by including all relevant perspectives. Results: Participants reported several important barriers to COVID-19 testing related to distrust in the tests and those administering them. Distrust in housing authorities and how they might misuse positive test results seemed to further undermine decision making about COVID-19 testing. Pain associated with testing was also a concern. To address these concerns, a peer-led testing intervention was proposed by the Housing Collaborative. A second round of focus group interviews was then conducted, in which participants reported their approval of the proposed intervention. Conclusion: Although the COVID-19 pandemic was not our initial focus, we were able to identify a number of barriers to COVID-19 testing in low-income housing settings that can be addressed with adapted public health guidance. We struck a balance between community input and scientific rigor and obtained high quality, honest feedback to inform evidence-based recommendations to guide decisions about health.

Virtual engagement of under-resourced communities: Lessons learned during the COVID-19 pandemic for creating crisis-resistant research infrastructure.

The COVID-19 pandemic led to an increased need to conduct research and community engagement using digital methods. Unfortunately, the shift away from in-person research activities can make it difficult to engage and recruit participants from under-resourced communities that lack adequate digital infrastructure. At the beginning of the pandemic, our team recognized that imminent lockdowns would significantly disrupt ongoing engagement with low-income housing resident community partners and that we would ultimately bear responsibility if that occurred. This manuscript outlines the development of methods designed to create capacity for virtual engagement with a community advisory board that were subsequently applied to a longitudinal mixed-methods study. We describe how our experience engaging low-income housing residents during the height of the pandemic influenced the approach and offer guidelines useful for engaging under-resourced communities regardless of setting. Of these, a strong commitment to providing technology, unlimited data connectivity, and basic digital literacy training/technical support is most important. While each of these is essential and failure in any one area will reduce overall effectiveness of the effort, providing adequate technical support while maintaining ongoing relationships with community members is the most important and resource-intensive.

Association of Racial Disparity of Cannabis Possession Arrests Among Adults and Youths With Statewide Cannabis Decriminalization and Legalization.

Importance: Despite calls for cannabis decriminalization and legalization, research investigating the association of policy with arrest rates and racial disparities is scarce. Objectives: To examine racial differences in cannabis arrest rates among adults and youths after statewide decriminalization, legalization, and no policy changes. Design Setting and Participants: This case-control study used race-based arrest data from the Uniform Crime Reporting Program and Surveillance, Epidemiology, and End Results county-level population data from January 2000 through December 2019. Data were analyzed in July 2021. Event-study analyses based on the arrest rates from 43 US states were conducted to compare preimplementation and postimplementation differences in arrest rates for states with decriminalization, legalization, and no policy changes. Exposures: Nine states implemented legalization, 8 implemented decriminalization, and 26 had no policy change. Main Outcomes and Measures: Outcome measures were cannabis arrest rates for Black and White adults and youths per year and by state, while controlling for several covariates. Results: Rates were reported per 100 000. When comparing absolute differences in arrests from January to December 2008 (before policy changes) to January to December 2019, legalization was associated with 561 and 195 fewer arrests and decriminalization with 448.6 and 117.1 fewer arrests for Black and White adults, respectively. States without a policy change saw reductions of 47.5 and 33.0 arrests for Black and White adults, respectively. Among youth, legalization was associated with 131.1 and 131.2 fewer arrests and decriminalization with 156.1 and 124.7 fewer arrests for Black and White youths, respectively. Among states without a policy change, arrests reduced by 35 and 52.4 for Black and White youths, respectively. Plotted trends of the arrest ratios from January 2000 through December 2019 suggests racial disparities remained over time. Event-study analyses suggest that decriminalization was associated with an arrest rate reduction for Black and White adults and youths. The timing of reductions suggests differential policy effects. Arrest disparities increased in states that did not have a cannabis policy change. Conclusions and Relevance: In this case-control study of states with and without cannabis decriminalization and legalization policies, increased arrest rate disparities in states without either policy highlight the need for targeted interventions to address racial injustice.

A Qualitative Study of Unfairness and Distrust in Smoke-free Housing.

Objectives: Whereas smoke-free housing (SFH) has the potential to protect residents from tobacco smoke, evidence suggests that SFH could lead to increased indoor smoking. In this study, we examine how perceptions of a residential smoking ban could be related to non-compliance. Methods: We conducted 8 focus group interviews of low-income housing residents living in Norfolk, Virginia (N=53). Interviews were semi-structured and based on a list of guided questions related to SFH compliance, developed in partnership with a standing community advisory board comprised of low-income housing residents. Results: Several themes emerged, including pervasive non-compliance, perceived unfairness and shame, barriers to compliance, and distrust of the housing authority. Smokers reported behavior primarily motivated by punishment avoidance, rather than out of any perceived obligation to comply with the ban. Conclusions: Results led us to consider Procedural Justice Theory as a conceptual framework, in which compliance is directly related to perceptions about the legitimacy of a rule or authority. When compliance is low due to a lack of perceived legitimacy, SFH should be adapted to promote changes in smoking behavior. We offer specific theory-supported adaptations to SFH focused on trust-building and improving perceived fairness.

Development of a Risk Behavior Diagnosis Scale for E-cigarette Use.

Objectives: Adolescent use of electronic cigarettes has risen dramatically, prompting concerns about the health effects. There is need for brief measures to assess adolescents' perceived threat and efficacy related to e-cigarette use and cessation. A 12-item Likert-type scale was modeled after the Risk Behavior Diagnosis Scale and designed to assess threat (ie, severity and susceptibility of threat) and efficacy (ie, self-efficacy and response efficacy) as they relate to e-cigarette use. Methods: The scale was administered online to a developmental sample of 674 adolescents to examine internal consistency and factor structure. Participants (52.1% female, M age = 14.6) were representative of the surrounding community (60% non-Hispanic white; 27% non-Hispanic black; 8% Hispanic). Results: Factor analysis and Velicer's minimum average partial test revealed 2 factors (as expected), which explained 68% of the variance. Analyses revealed strong internal consistency, with Cronbach's alpha of .93 overall and alphas of .92 and .87 for threat and efficacy subscales, respectively. The measure also exhibited good convergent and discriminant validity with other constructs. Conclusions: The measure demonstrates strong preliminary reliability and validity for a developmental sample of adolescents.

Youth and Adult Arrests for Cannabis Possession After Decriminalization and Legalization of Cannabis.

IMPORTANCE: Civil liberty advocates typically support legalization of cannabis, which targets adult use, rather than decriminalization, which can affect both adults and youths. However, it is unknown how arrests of youths for cannabis possession change when adult use of cannabis is legalized. OBJECTIVE: To model changes in arrest rates of adults and youths after decriminalization and legalization of cannabis. DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental study used the publicly available Uniform Crime Reporting Program Data: Arrests by Age, Sex, and Race administrative data set to examine arrest rates in 38 states from January 1, 2000, to December 31, 2016. Adult (age, ≥18 years) and youth (age, <18 years) arrests for possession of cannabis were examined. States were excluded if they did not report complete arrest data or if a policy was implemented that reduced penalties for possession of cannabis but fell short of decriminalization. Fixed-effects regression was used in an extended difference-in-differences framework. The analyses in their final form were conducted between January 17 and February 28, 2019. EXPOSURE: Living in a state with a cannabis decriminalization policy (ie, making the penalty for cannabis possession similar to the small fine for a traffic violation) or legalization policy (ie, creating a legal supply of cannabis along with the removal of penalties for possession of a small amount of cannabis for recreational use). MAIN OUTCOME AND MEASURES: State cannabis possession arrest rate per 100 000 population. RESULTS: Data from 38 states were examined, including 4 states with cannabis legalization policies and 7 states with cannabis decriminalization policies. The adult arrest rate decreased by 131.28 (95% CI, 106.23-154.21) per 100 000 population after the implementation of decriminalization and 168.50 (95% CI, 158.64-229.65) per 100 000 population after the implementation of legalization. The arrest rate for youths decreased by 60 (95% CI, 42-75) per 100 000 population after decriminalization but did not significantly change after legalization in a state (7 per 100 000 population; 95% CI, -15 to 30). CONCLUSIONS AND RELEVANCE: Legalization, as implemented through 2016, did not appear to reduce arrests for cannabis possession among youths, despite having benefited adults. The study's findings suggest that decriminalization reduces youth arrests in most cases, but these findings also suggest that any benefit for youths could be lost when adult use has also been legalized. To address this problem, it appears that state decriminalization policies should take the additional step to explicitly describe when youths can be arrested for possession of small amounts of cannabis.