Age differences in patterns of cannabis use among an online US sample of adults who consume cannabis frequently.

Background: Cannabis use is increasing among middle-aged and older US adults, populations that are particularly vulnerable to the adverse effects of cannabis. Risks for adverse effects differ by cannabis use patterns, which have become increasingly heterogeneous. Nevertheless, little is known about age differences in such patterns.Objective: To investigate age differences in cannabis use patterns, comparing younger (age 18-49), middle-aged (age 50-64), and older adults (age ≥65).Methods: A total of 4,151 US adults with past 7-day cannabis consumption completed an online survey (35.1% male; 60.1% female; 4.8% identified as "other"). Regression models examined age differences in cannabis use patterns.Results: Compared to younger adults, middle-aged and older adults were more likely to consume cannabis during evening hours (50-64: adjusted odds ratio [aOR] = 2.98, 95% CI 2.24-3.96; ≥65: aOR = 4.23, 95 CI 2.82-6.35); by only one method (50-64: aOR = 1.67, 95% CI 1.34-2.09; ≥65: aOR = 3.38, 95 CI 2.24-5.09); primarily by smoking as the only method (50-64: aOR = 1.52, 95% CI 1.29-1.78; ≥65: aOR = 2.12, 95 CI 1.64-2.74); but less likely to consume concentrated cannabis products (concentrates) with extremely high %THC (50-64: aOR = 0.71, 95% CI 0.54-0.93; ≥65: aOR = 0.30, 95 CI 0.16-0.55). Age differences in cannabis use patterns were also observed between middle-aged and older adults.Conclusion: Findings suggest that middle-aged and older adults may engage in less risky cannabis use patterns compared to younger groups (e.g. lower likelihood of consuming highly potent concentrates). However, findings also underscore the importance of recognizing risks unique to these older demographics, such as smoking-related health events. Consequently, prevention strategies targeting such use patterns are needed.

Exploring survey methods for measuring consumption quantities of cannabis flower and concentrate products.

Background: Researchers need accurate measurements of cannabis consumption quantities to assess risks and benefits. Survey methods for measuring cannabis flower and concentrate quantities remain underdeveloped.Objective: We examined "grams" and "hits" units for measuring flower and concentrate quantities, and calculating milligrams of THC (mgTHC).Methods: Online survey participants (n = 2,381) reported preferred unit (hits or grams), past-week hits and grams for each product, and product %THC. Quantile regression compared mgTHC between unit-preference subgroups. Hits-based mgTHC calculations assumed a universal grams-per-hit ratio (GPHR). To examine individualized GPHRs, we tested a "two-item approach," which divided total grams by total hits, and "one-item approach," which divided 0.5 grams by responses to the question: "How many total hits would it take you to finish 1/2 g of your [product] by [administration method]?"Results: Participants were primarily daily consumers (77%), 50% female sex, mean age 39.0 (SD 16.4), 85% White, 49% employed full-time. Compared to those who preferred the hits unit, those who preferred the grams unit reported consuming more hits and grams, higher %THC products, and consequently, larger median mgTHC (flower-hits mgTHC: 32 vs. 91 (95%CI: 52-67); flower-grams mgTHC: 27 vs. 113 (95%CI: 73-95); concentrate-hits mgTHC: 29 vs. 59 (95%CI: 15-43); concentrate-grams mgTHC: 61 vs. 129 (95%CI: 43-94)). "Two-item" and "one-item" approach GPHRs were similar and frequently 50% larger or smaller than the universal GPHR.Conclusion: Allowing respondents to choose "hits" or "grams" when reporting cannabis quantities does not compromise mgTHC estimates. A low-burden, one-item approach yields individualized "hit sizes" that may improve mgTHC estimates.

Exploring how tobacco advertisements are associated with tobacco use susceptibility in tobacco naive adolescents from the PATH study.

Adolescents' susceptibility to pro-tobacco marketing advertisements puts them at risk for initiating and continued use of tobacco. The objective of this study was to quantify the cross-sectional association between tobacco ad exposure and tobacco use susceptibility (e.g., curiosity about tobacco products, willingness, and future intention to try tobacco products) among tobacco-naive adolescents. Data came from Wave 4 of the Population Assessment of Tobacco and Health (PATH) study, a nationally-representative sample of US adolescents ages 12-17. We used logistic regression to examine (1) characteristics associated with tobacco ad exposure; (2) associations between tobacco ad exposures (by product type/venue) and tobacco use susceptibility (among tobacco-naive adolescents only). The results suggested that higher household income, living with tobacco user(s), substance use history, and mental health problem(s) were associated with increased odds of tobacco marketing exposure. Among tobacco naïve adolescents (N = 9455), tobacco ads exposure was positively associated with tobacco use susceptibility, compared with the non-exposure group. Seeing cigarettes/other non-ENDS tobacco products only was associated with a 1.64 increase in odds being susceptible to tobacco use; tobacco ads exposure via website and/or social media sites only (cigarette/other non-ENDS tobacco, AOR: 1.87, 95%CI: 1.25-2.81; ENDS, AOR: 2.25, 95%CI: 1.43-3.55) was associated with higher odds of tobacco use susceptibility, compared to the non-exposure group. With rapidly increasing rates of ENDS use in adolescents, it is crucial that advertisements promoting the initiation and continued use of ENDS are strictly regulated, especially among advertisements that are online and on social media sites.

The impact of discomfort with HIV status and hopelessness on depressive symptoms among adolescents living with HIV in Uganda.

Introduction: Discomfort with and reluctance to disclose HIV status can lead to depression, social isolation, and poor medication adherence; we examined relationships among these variables within a sample of adolescents living with HIV in Uganda. Methods: We used baseline data from the Suubi + Adherence study, which recruited a total of 702 adolescents (ages 10-16 years) living with HIV in southwestern Uganda. Structural equation models were conducted separately among in-school adolescents and out-of-school adolescents to assess associations between discomfort level with HIV status and depressive symptoms and if this association was mediated by hopelessness. Results: Out-of-school adolescents had significantly higher depression scores compared with those in-school youth (M = 6.24 vs. M = 5.03, p < 0.001). Although high discomfort level with HIV status was significantly associated with higher depression scores among both in-school adolescents and out-of-school adolescents, this association among out-of-school adolescents (B = 0.49, 95%CI: 0.19, 0.79), was more substantial than for in-school adolescents (B = 0.10, 95%CI: 0.03, 0.17). Discussion: One's discomfort with their HIV status and the extent to which they are hopeful about the future can contribute to the development of depressive symptoms and these factors need to be considered in the development of assessments and interventions for the treatment of depression among adolescents living with HIV.

Exploring How Social Media Exposure and Interactions Are Associated With ENDS and Tobacco Use in Adolescents From the PATH Study.

INTRODUCTION: Tobacco use is a current public health epidemic that puts individuals at risk for many health conditions and diseases, and adolescents are at high risk for the initiation and persistence of tobacco use behaviors partly due to engagement with social media content. The objective of this study is to examine the association between engaging in social media behaviors and patterns of electronic nicotine delivery systems (ENDS) and tobacco use at a 1-year follow-up among 11 279 adolescents from the PATH study. METHODS: Five social media variables were questioned at Wave 2 and then compared to ENDS and tobacco status transitions (i.e., initiation, persistence, and escalation) at a 1-year follow-up, respectively. Survey-weighted multivariable logistic regression models were used to calculate adjusted odds ratios and 95% confidence interval. RESULTS: Passive behaviors on social media were related to higher likelihoods of starting to use ENDS and other tobacco products. Additionally, active behaviors on social media were related to higher likelihoods for the initiation and persistence of tobacco use. In particular, sending tobacco content to other users was further associated with a higher likelihood of escalation of tobacco product use. DISCUSSION: Both exposure to and interactions with social media tobacco content had a significant impact on the patterns of ENDS and tobacco use in adolescents. Due to the amount of time adolescents spend engaging with online content, social media may be a critical place in which to intervene, possibly with the use of antitobacco or tobacco prevention messages. IMPLICATIONS: The results of this study have implications for public health and the policies surrounding adolescents and their exposure to social media. Reducing the ENDS and tobacco content to which adolescents are exposed has the potential to decrease the instances of initiation and persistence of ENDS and tobacco use. Intervening on social media may prevent or slow the progression of ENDS and tobacco use, and increase motivation and actions toward the cessation of tobacco use in adolescents.

Investigating the role of familial and peer-related factors on electronic nicotine delivery systems (ENDS) use among U.S. adolescents.

INTRODUCTION: Tobacco use is a public health concern, and adolescents are at an increased risk of starting and continuing to use tobacco relative to other age groups. Parent involvement and other social environmental factors may influence the development and persistence of tobacco use behaviors in adolescence. This study used the nationally representative Population Assessment of Tobacco and Health (PATH) study data set, and responses from 7025 adolescent participants were analyzed to illustrate the longitudinal relationship between social environment influences and use of adolescent electronic nicotine delivery systems (i.e., ENDS). METHODS: Social environmental factors were assessed at Wave 3 and then compared to electronic nicotine delivery systems (ENDS) status transitions (i.e., initiation, expansion, persistence) at follow-up. Survey-weighted multivariable logistic regression models were used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI). RESULTS: Initiation and persistence of ENDS use were associated with tobacco availability in the house, perception of having no adverse parent reaction to discovering ENDS use and having a best friend who uses ENDS. Initiation of ENDS use was further associated with having biological relatives who have ever been diagnosed with a substance use disorder (SUD) and persistence of ENDS use was also positively associated with lack of in-house rules. Parents talking about ENDS use with adolescents had no association across all three outcomes. CONCLUSIONS: Findings suggest that parental and environmental factors alter the risk of initiation and persistence of ENDS and tobacco use in adolescents, and these should be considered when working with this at-risk population.

Perceived safety of cannabis intoxication predicts frequency of driving while intoxicated.

Driving under the influence of cannabis (DUIC) is a public health concern, and data are needed to develop screening and prevention tools. Measuring the level of intoxication that cannabis users perceive as safe for driving could help stratify DUIC risk. This study tested whether intoxication levels perceived as safe for driving predicted past-month DUIC frequency. Online survey data were collected in 2017 from a national sample of n = 3010 past-month cannabis users with lifetime DUIC (age 18+). Respondents indicated past-month DUIC frequency, typical cannabis intoxication level (1-10 scale), and cannabis intoxication level perceived as safe for driving (0-10 scale). Approximately 24%, 38%, 13%, and 24% of respondents engaged in DUIC on 0, 1-9, 10-19, and 20-30 days respectively in the past month. Among these four DUIC frequency groups, median typical intoxication varied little (5-6), but median intoxication perceived as safe for driving varied widely (3-8). Higher intoxication levels perceived as safe for driving corresponded to frequent DUIC (Spearman's rho: 0.46). For each unit increase in intoxication level perceived as safe for driving, the odds of past-month DUIC increased 18% to 68% (multinomial logistic regression odds ratio - MOR1-9 days: 1.18, 95% CI: 1.13-1.23; MOR10-19 days: 1.40, 95% CI: 1.30-1.50; MOR20-30 days: 1.68, 95% CI: 1.57-1.80). In this targeted sample of past-month cannabis users, DUIC frequency varied widely, but daily/near-daily DUIC was common (24%). Measuring intoxication levels perceived as safe for driving permits delineation of past-month DUIC frequency. This metric has potential as a component of public health prevention tools.

Trends in Prescribed Central Nervous System Depressant Medications Among Adults Who Regularly Consume Alcohol: United States 1999 to 2014.

BACKGROUND: Although the risks of using central nervous system depressant (CNS-D) medications with alcohol are well documented, little is known about trends in prescribed use of these medications among individuals who regularly consume alcohol (i.e., trends in "concurrent use"). We examined changes in the prevalence of prescribed CNS-D medications among individuals who drank alcohol on 52 or more occasions in the past year ("regular drinking"). CNS-D medications included sedative-hypnotics (subclassified as anxiolytics or sleep medications) and opioids. METHODS: We used 8 cross-sectional cycles of the National Health and Nutrition Examination Survey (1999-2000 to 2013-2014) from participants aged 20 and older (n = 37,709). We used log-binomial regression to examine (i) prevalence trends of prescribed CNS-D medication use, (ii) trend differences by drinking status, and (iii) correlates of CNS-D medication use. RESULTS: Among those who drink regularly, the relative annual increase in prevalence of sedative-hypnotic use was 5.3% (95% CI: 2.7 to 7.9): Anxiolytic and sleep medication use increased annually by 3.7% (95% CI: 0.8 to 6.7) and 11.2% (95% CI: 6.5 to 16.0), respectively. Opioid use trends among those who drink regularly were not statistically significant but were nonlinear. Differences in CNS-D medication trends between those who drink regularly and those who drink infrequently/abstain were not statistically significant. Those who drink regularly were less likely than those who drink infrequently/abstain to use opioids (adjusted relative risk [ARR]: 0.69, 95% CI: 0.60 to 0.78) and anxiolytics (ARR: 0.71, 95% CI: 0.61 to 0.81), but not sleep medications (ARR: 1.04, 95% CI: 0.80 to 1.35). Those aged 40 and older were 2 to 5 times as likely as those aged 20 to 29 to use sedative-hypnotics. CONCLUSIONS: Among those who drink regularly, the prevalence of prescribed sedative-hypnotic use increased and prescribed opioid use remained common. These trends indicate that a substantial portion of the population is at risk of alcohol-related adverse drug reactions-particularly those aged 40 and older.

An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use.

Confusion and controversy related to the potential for cannabis use to cause harm, or alternatively to provide benefit, continues globally. This issue has grown in intensity and importance with the increased recognition of the public health implications related to the escalation of the legalization of cannabis and cannabinoid products. This selective overview and commentary attempt to succinctly convey what is known about one potential consequence of cannabis use, the development of cannabis use disorder (CUD). Such knowledge may help guide a reasonable and objective public health perspective on the potential impact of cannabis use and CUD. Current scientific data and clinical observation strongly support the contention that cannabis use, like the use of other substances such as alcohol, opioids, stimulants, and tobacco, can develop into a use disorder (addiction) with important clinical consequences. Epidemiological data indicate that the majority of those who use cannabis do not have problems related to their use, but a substantial subset (10-30%) do report experiencing symptoms and consequences consistent with a CUD. Treatment seeking for CUD comprises a substantial proportion of all substance use treatment admissions, yet treatment response rates show much room for improvement. Changing cannabis policies related to its therapeutic and recreational use are likely to impact the development of CUD and its course; however, definitive data on such effects are not yet available. Clearly, the development of more effective prevention and treatment strategies is needed for those vulnerable to developing a CUD and for those with a CUD.

Cannabis regulatory science: risk-benefit considerations for mental disorders.

The evolving legal cannabis landscape in the US continues to present novel regulatory challenges that necessitate the development of a Cannabis Regulatory Science. Two specific issues of concern within Cannabis Regulatory Science are (1) the impact that cannabis use has on the incidence, prevalence, and severity of mental disorders, and (2) how cannabis laws and regulations modify this impact. This paper first provides several conceptual points that are useful for evaluating the relationship between cannabis use and mental disorders. Second, it selectively reviews and comments on data relevant to the relationship between cannabis use and depression, several forms of anxiety, post-traumatic stress disorder, schizophrenia, and bipolar disorder. Next, regulatory and public health parallels between the nascent cannabis industry and the pharmaceutical, tobacco, and alcohol industries are discussed. The focus is on specific types of industry practices that may harm those with or at risk for mental disorders. Recommendations are then offered for legal cannabis regulations that could mitigate this harm. Last, future research goals are discussed for building the field of Cannabis Regulatory Science and addressing the potential negative impact of cannabis on those with mental disorders.

The potential impact of cannabis legalization on the development of cannabis use disorders.

Specific provisions of legal cannabis legislation and regulation could influence cannabis initiation, frequency and quantity of use, and progression to cannabis use disorder. This brief essay highlights scientifically based principles and risk factors that underlie substance use and addiction that can be leveraged to inform policies that might mitigate the development and consequences of cannabis use disorder. Specifically, pharmacologic, access/availability, and environmental factors are discussed in relation to their influence on substance use disorders to illustrate how regulatory provisions can differentially affect these factors and risk for addiction. Relevant knowledge from research and experience with alcohol and tobacco regulation are also considered. Research designed to inform regulatory policy and to evaluate the impact of cannabis legislation on cannabis use and problems is progressing. However, definitive findings will come slowly, and more concerted efforts and resources are needed to expedite this process. In the meantime, policymakers should take advantage of the large body of scientific literature on substance use to foster empirically-guided, common sense approaches to cannabis policy that focus on prevention of addiction.

Impact of Early-Life Adversity on Cannabis Use: Exploring the Mediating and Moderating Effects of Chronic Pain.

Background: Although research suggests that early-life adversity (ELA) and cannabis use are linked, researchers have not established factors that mediate or modify this relationship. Identifying such factors could help in developing targeted interventions. We explored chronic pain as a potential mediator or moderator of this relationship. Methods: Using an online study, we collected cross-sectional data about ELA, cannabis use, and chronic pain to test whether ELA (adverse childhood experiences total score) is associated with cannabis use, and to examine pain as a potential mediator or moderator. Cannabis use was examined two ways: times used per day, and categorized as non-, some, or regular use. Chronic pain was measured as present/absent and as the number of painful body locations (0-8). Analyses used linear and multinomial regression. Results: ELA, chronic pain, and cannabis use were common among respondents. ELA was strongly associated with both measures of cannabis use. The number of painful body locations modestly mediated the association of ELA with cannabis use, reducing the magnitude of regression coefficients by about 1/7. The number of painful body locations modified the association between ELA and cannabis use (p≤0.006), while chronic pain presence/absence (a less-informative measure) had only a nonsignificant modification effect (p≥0.10). When either ELA or pain was high, the other was not associated with cannabis use; when either ELA or pain was low, more painful locations or higher ELA (respectively) was associated with more intense cannabis use. Conclusion: These exploratory findings suggest the importance of ELA and chronic pain as factors contributing to cannabis use, and of accounting for these factors in developing treatment and prevention strategies addressing cannabis use.

Evaluating age-related disparities in cannabis-related problems among LGBT+ versus non-LGBT+ adults.

LGBT+ adults demonstrate greater cannabis-related problems (e.g., Cannabis Use Disorder [CUD]) compared to non-LGBT+ counterparts. No study has explored age-related disparities in cannabis problems across the adult lifespan, nor have studies identified specific CUD criteria that contribute to elevated CUD among LGBT+ adults. The purpose of this study was to examine associations between LGBT+ identity and age with endorsement of CUD criteria in a sample of regular cannabis consumers. An online sample of N = 4334 (25.1% LGBT+) adults aged 18-64 residing in the U.S. completed an online survey about cannabis use behaviors and CUD diagnostic criteria. Bivariate contrasts revealed significantly greater CUD criteria endorsement among LGBT+ respondents, largely driven by differences at younger ages. However, this effect disappeared in the majority of adjusted logistic regression models. LGBT+ identity was associated with greater probability of use in larger amounts (adjOR = 2.10, 95% CI: 1.22-3.60) and use despite physical/mental health problems (adjOR = 2.51, 95% CI:1.23-5.03). No age*LGBT+ identity interactions were detected. Plotted trends depict more pronounced disparities in outcomes among LGBT+ adults under 35 years. Several potential risk and protective factors including employment, education, and reasons for use were identified. There were age-related differences in these characteristics among LGBT+ and non-LGBT+ respondents. Initial findings highlight the need for LGBT+ research examining trends in health outcomes and sociodemographic and cannabis characteristics across the lifespan. The study also provides a substantive contribution regarding specific cannabis-related problems that young LGBT+ cannabis consumers may be more likely to endorse than their non-LGBT+ counterparts.

Engagement, initiation, and retention in medication treatment for opioid use disorder among young adults: A narrative review of challenges and opportunities.

INTRODUCTION: Opioid Use Disorder (OUD) is a catastrophic public health problem for young adults (YAs) and their families. While medication for OUD (MOUD) is safe, effective, and recognized as the standard of care, its' uptake and success have been limited in YAs compared to older adults. METHODS: This narrative review summarizes the existing literature and highlights select studies regarding barriers to YA MOUD, potential explanations for those barriers, and strategies to overcome them. RESULTS: Barriers are prominent along the entire cascade of care, including: treatment engagement and entry, MOUD initiation, and MOUD retention. Hypothesized explanations for barriers include: developmental vulnerability, inadequate treatment system capacity, stigma against MOUD, among others. Interventions to address barriers include: promotion of family involvement, increasing provider capacity, integration of MOUD into primary care, assertive outreach, and others. CONCLUSIONS: Integrating an adapted version of family coaching from the Community Reinforcement Approach and Family Training (CRAFT) and other models into YA MOUD treatment serves as an example of an emerging novel practice that holds promise for broadening the funnel of engagement in treatment and initiation of MOUD, and enhancing treatment outcomes. This and other developmentally-informed approaches should be evaluated as part of a high-priority clinical and research agenda for improving OUD treatment for YAs.

Clinician beliefs and attitudes about buprenorphine/naloxone diversion.

BACKGROUND AND OBJECTIVES: Concern about diversion of buprenorphine/naloxone (B/N) in the United States may affect prescribing patterns and policy decisions. This study examines addiction treatment clinician beliefs and attitudes regarding B/N diversion. METHODS: Participants (n = 369) completed a 34-item survey in 2010 during two national symposia on opioid dependence. We conducted multivariable regression, examining the relationship of perceived danger from B/N diversion with clinician characteristics and their beliefs about B/N treatment and diversion. We compared causal beliefs about diversion among clinicians with and without B/N treatment experience. RESULTS: Forty percent of clinicians believed that B/N diversion is a dangerous problem. The belief that B/N diversion increases accidental overdoses in the community was strongly associated with perceived danger from B/N diversion. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Attitudes and beliefs, not education level, were associated with clinician's perceived danger from B/N diversion. Clinicians with greater B/N patient experience were more likely to believe treatment access barriers are the major cause of B/N diversion.

Early life adversity and substance use: The mediating role of mood and the moderating role of impulsivity.

INTRODUCTION: Early life adversity (ELA) is a risk factor for substance use and misuse, and multiple factors mediate and moderate this association. We examined whether moods mediate the relationships between ELA and nicotine use, cannabis use, and co-use, and whether these mediation effects varied as a function of delay discounting. METHODS: A total of 2555 adults completed a delay discounting task and responded to questions related to demographics, ELA, mood, and substance use. Data were analyzed using Pearson correlations and moderated mediation using Hayes' PROCESS macro (V3.4, Model 15). RESULTS: ELA was positively associated with cannabis use, nicotine use, co-use of both substances, depressed and stressed moods, and it was negatively associated with positive mood. While cannabis use was associated negatively with stressed and depressed moods and positively with positive mood, nicotine use was associated negatively with positive mood. Moderated mediation analyses indicated that positive mood mediated the relationship between ELA and cannabis use for those with average and above average delay discounting. Positive mood also mediated the relationship between ELA and co-use among those with above average delay discounting. CONCLUSION: The results suggest that ELA's associations with cannabis use and cannabis-nicotine co-use may be partially attributable to ELA's effects on positive mood among those who are predisposed to moderately to highly impulsive decision making.

Adult use of highly-potent Δ9-THC cannabis concentrate products by U.S. state cannabis legalization status, 2021.

BACKGROUND: Compared to plant/flower cannabis products, cannabis concentrates have higher average potency of delta-9-tetrahydrocannabinol (Δ9-THC), which may be associated with greater likelihood of cannabis-related harms. Information on factors associated with use of cannabis concentrates is needed. METHODS: Respondents were 4,328 adult past-7-day cannabis users from all 50 U.S. states and Washington DC (DC) who participated in an online 2021 survey. Using logistic regression to generate adjusted odds ratios (aOR), we investigated whether participants in states that enacted recreational cannabis laws (RCL, 12 states plus DC [treated as a state], n = 1,236) or medical cannabis laws (MCL-only, 23 states, n = 2,030) by December 31, 2020 were more likely than those in states without cannabis laws (no-CL, 15 states, n = 1,062) to use cannabis concentrate products in the prior 7 days. RESULTS: Most participants (92.4%) used plant material in the prior 7 days; 57.0% used cannabis concentrates. In RCL, MCL and no-CL states, concentrate use was reported by 61.5%, 56.6%, and 52.5%, respectively. Compared to participants in no-CL states, odds of using cannabis concentrate products were greater among those in RCL states (aOR = 1.47; CI = 1.17-1.84) and MCL-only states (aOR = 1.29; CI = 1.08-1.55). Whether states had legally-authorized dispensaries had little effect on results. CONCLUSION: Results suggest that individuals in MCL-only and RCL states are more likely to use cannabis concentrate products. Determining mechanisms underlying these results, e.g., commercialization, could provide important information for prevention. Clinicians should be alert to patient use of concentrates, especially in MCL-only and RCL states. Continued monitoring is warranted as additional states legalize cannabis use.

Extending Gender- and Sex-Based Analyses in Cannabis Research: Findings from an Online Sample of Gender Diverse Young Adult Consumers.

Background: Gender and sex can influence cannabis behaviors and consequences (Cannabis Use Disorder [CUD]). Research typically examines sex and gender independently. Gender analyses often exclude transgender and gender diverse (TGD) populations. The objectives of this study were to (a) replicate less frequent cannabis use among TGD young adults compared to cisgender counterparts (b) compare severity of CUD, and (c) examine the role of sex on cannabis outcomes. Method: Online survey participants between 18 and 34 (N=1213) from the United States who reported past-week cannabis consumption provided information on cannabis practices and CUD from February to April 2022. Bivariate analyses explored gender differences across frequency (daily frequency across routes of administration [ROAs]; daily use of 2+ ROAs, use throughout the day) and CUD. Adjusted regression models provided model-estimated marginal probabilities and means to examine differences across four gender-by-sex categories (cisgender men: n=385; cisgender women: n=681; male-at-birth TGD: n=26; female-at-birth TGD: n=121). Benjamini-Hochberg adjustments (10% false discovery rate) were applied. Results: Among past-week consumers, female-at-birth TGD participants demonstrated lower probability of daily flower smoking compared to cisgender men (0.54 vs. 0.67). Cisgender men reported greater probability of daily concentrate vaping (0.55) compared to cisgender women (0.45) and female-at-birth TGD participants (0.27); they were also more likely to report daily use of 2+ ROAs (cisgender men: 0.51 vs. cisgender women: 0.39 and female at-birth TGD: 0.27). TGD participants reported greater CUD severity compared to cisgender counterparts, t(1096)=-3.69, p=0.002. Model-estimated means found lower severity among cisgender women compared to cisgender men and female-at-birth TGD participants. Stratified regression models support positive associations between daily cannabis use and CUD in both TGD in cisgender groups. Among cisgender participants, greater severity was predicted by male sex, younger age, and younger age of onset. Conclusions: The present study replicates and extends a prior finding that among past-week cannabis consumers, TGD young adults report less frequent use than cisgender counterparts. Despite this, TGD participants demonstrated greater severity of CUD. While analyses were limited by the small sample of male-at-birth TGD participants, the article highlights the importance of expanding sex- and gender-focused analyses. Future work is expanding efforts to target hard-to-reach consumers.

Evaluating cannabis exposure in survey items: Insights, strategies, and remaining challenges identified from cognitive interviewing.

Background: The diversity in characteristics of cannabis products and behavior patterns make evaluation of cannabis exposure in population-based, self-report surveys challenging. Accurate identification of cannabis exposure and related outcomes necessitates a thorough understanding of participants' interpretations of survey questions assessing cannabis consumption behaviors. Objectives: The current study utilized cognitive interviewing to gain insight on participants' interpretation of items in a self-reported survey instrument used to estimate the quantity of THC consumed in population samples. Methods: Cognitive interviewing was used to evaluate survey items assessing cannabis use frequency, routes of administration, quantity, potency, and perceived "typical patterns" of use. Ten participants ≥18 years (n = 4 cisgender-men; n = 3 cisgender-women; n = 3 non-binary/transgender) who had used cannabis plant material or concentrates in the past week were recruited to take a self-administered questionnaire and subsequently answer a series of scripted probes regarding survey items. Results: While most items presented no issues with comprehension, participants identified several areas of ambiguity in question or response item wording or in visual cues included in the survey. Generally, participants with irregular use patterns (i.e., non-daily use) reported more difficulty recalling the time or quantity of cannabis use. Findings resulted in several changes to the updated survey, including updated reference images and new quantity/frequency of use items specific to the route of administration. Conclusion: Incorporating cognitive interviewing into cannabis measurement development among a sample of knowledgeable cannabis consumers led to improvements in assessing cannabis exposure in population surveys, which may otherwise have been missed.