Examining Changes in Quality of Life as an Outcome Measure in Three Randomized Controlled Trials of Online Interventions That Included an Intervention for Hazardous Alcohol Use.

BACKGROUND: Quality of life (QOL) summarizes an individual's perceived satisfaction across multiple life domains. Many factors can impact this measure, but research has demonstrated that individuals with addictions, physical, and mental health concerns tend to score lower than general population samples. While QOL is often important to individuals, it is rarely used by researchers as an outcome measure when evaluating treatment efficacy. METHODS: This secondary analysis used data collected during three separate randomized controlled trials testing the efficacy of different online interventions to explore change in QOL over time between treatment conditions. The first project was concerned with only alcohol interventions. The other two combined either a gambling or mental health intervention with a brief alcohol intervention. Males and females were analyzed separately. RESULTS: This analysis found treatment effects among female participants in two projects. In the project only concerning alcohol, female quality of life improved more among those who received an extensive intervention for hazardous alcohol use compared to a brief intervention (p = .029). QOL among females who received only the mental health intervention improved more than those who also received a brief alcohol intervention (p = .049). CONCLUSION: Poor QOL is often cited as a reason individuals decide to make behavior changes, yet treatment evaluations do not typically consider this patient-important outcome. This analysis found some support for different treatment effects on QOL scores in studies involving at least one intervention for hazardous alcohol use.

Using a consistency check during data collection to identify invalid responding in an online cannabis screening survey.

BACKGROUND: Inconsistent responding is a type of invalid responding, which occurs on self-report surveys and threatens the reliability and validity of study results. This secondary analysis evaluated the utility of identifying inconsistent responses as a real-time, direct method to improve quality during data collection for an Internet-based RCT. METHODS: The cannabis subscale of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was administered as part of eligibility screening for the RCT. Following the consent procedure, the cannabis subscale was repeated during the baseline interview. Responses were automatically compared and individuals with inconsistent responses were screened out. RESULTS: Nearly half of those initially eligible for the RCT were subsequently screened out for data quality issues (n = 626, 45.3%). Between-group bivariate analysis found that those screened out (OUT) were significantly older (OUT = 39.5 years (SD = 13.9), IN = 35.7 years (SD = 12.9), p < .001), more had annual incomes less than $20,000CND (OUT = 58.3%, IN = 53.0%, p = .047), used cannabis less often in the past 30 days (OUT = 23.3 days (SD = 9.7), IN = 24.8 days (SD = 11.3), p < .006), and had lower total ASSIST scores at screener (OUT = 19.3 (SD = 8.0), IN = 23.8 (SD = 10.4), p < .001) and baseline (OUT = 17.5 (SD = 7.9), IN = 23.3 (SD = 10.3), p < .001) compared to participants who were screened in to the RCT. CONCLUSION: Inconsistent responding may occur at high rates in Internet research and direct methods to identify invalid responses are needed. Comparing responses for consistency can be programmed in Internet surveys to automatically screen participants during recruitment and reduce the need for post-hoc data cleaning.

Learning to quit: can reinforcement theories predict the success of smoking cessation attempts using nicotine replacement therapy patches in a general population sample of smokers at 8-weeks and 6-months follow-up?

Primary, secondary, and tertiary reinforcement contribute to the maintenance of smoking behaviour and may influence the efficacy of different cessation treatments. This analysis examined these relationships in a large general population sample and investigated how previous experiences of the different reinforcement mechanisms impacted future quit attempts. Random digit telephone dialing was used to recruit a sample of Canadian adults who smoked and were interested in being part of a hypothetical program that would provide nicotine replacement therapy (NRT) patches free by mail and half of the eligible participants were randomized to actually receive a five-week supply of NRT patches. During the interviews, reasons for relapse to smoking during previous quit attempts were collected and coded by two reviewers (disagreements were settled by a third reviewer). Binary logistic regression was used to determine if type of reinforcer moderated the intervention effect of the patches. Participants who made cessation attempts in the past year were more likely to report negative (p = .039), secondary (p = .041), and tertiary (p = .010) reinforcers and less likely to report positive reinforcers (p = .016) compared to those who did not attempt to quit. Logistic regressions revealed no significant conditional effects of the intervention on the relationship between reinforcer type and quit attempts or 30-day smoking abstinence. Analysis including all three reinforcers showed negative reinforcers decreased but tertiary reinforcers increased the odds participants reported a cessation attempt before the baseline interview and between baseline and 8-weeks. Understanding the different ways nicotine reinforces smoking behaviour could help guide individuals to more effective treatment options.

To thine own self, be true: Examining change in self-reported alcohol measures over time as related to socially desirable responding bias among people with unhealthy alcohol use.

BACKGROUND: Due to a conscious or unconscious desire to be perceived favorably by others, some participants may under or overexaggerate when reporting sensitive behaviors or attitudes, including those related to addictions. This socially desirable responding bias should be considered when using self-reports in predictive models since it introduces error. Methods: A total of 1711 participants were recruited using Amazon's Mechanical Turk crowdsourcing platform for two randomized controlled trials investigating the effectiveness of brief online interventions for hazardous alcohol use. At baseline, participants completed the Balanced Inventory of Desirable Responding (BIDR). Four measures of alcohol use were collected at baseline and follow-up: number of drinks consumed in a typical week, on one occasion, consequences experienced, and amount of perceived risk of injury or illness from alcohol use. Results: As expected, individuals scoring high on the BIDR subscales reported less alcohol use and related behaviors (p < 0.05); however, repeating the analyses for each gender showed no difference for females asked direct questions about the frequency of their alcohol use. Mixed-effects models investigating the interaction of socially desirable responding bias over time on alcohol-related measures showed some significant differences in the amount of change reported depending on BIDR scores. Participants with higher self-deceptive enhancement scores reported less change over time in their ratings of risk of illness or injury (p = 0.001) compared to lower-scoring participants. Likewise, high-scoring participants reported less change in the number of consequences experienced due to alcohol use over time on both BIDR subscales. Neither direct measure of alcohol use seemed affected by BIDR scores over time. A different pattern was found in males and females analyzed separately. Conclusions: These findings suggest that researchers should consider including measures of socially desirable responding bias in longitudinal studies involving self-reported alcohol use, particularly when modeling alcohol-related measures using rating scales across time. In addition, separate gender analyses may be appropriate. Trial registration: ClinicalTrials.gov NCT03008928. Registered 30 December 2016; ClinicalTrials.gov NCT03060135. Registered 17 February 2017.

Examining Change in Self-Reported Gambling Measures Over Time as Related to Socially Desirable Responding Bias.

Socially desirable responding is a response bias that can affect the accuracy of self-reports. It is especially likely when questions address sensitive topics, such as gambling attitudes, problems and behaviours. A sample of 321 participants were recruited from Amazon's mTurk crowdsourcing platform for a randomized controlled trial investigating an online gambling intervention. Data from this study was used to examine the influence of socially desirable responding on gambling self-report measures over time. At baseline, self-deception (SD), a factor of socially desirable responding, was significantly higher among males than females and among those with household incomes greater than $20,000 per year. Controlling for demographic variability, mixed effects models examining the relationship between socially desirable responding factors [SD and impression management (IM)] and time were conducted. Among males, there were significant interactions between IM with the NORC DSM-IV screen for gambling problems (NODS) and the gambling symptom assessment scale (G-SAS) scores respectively, over time. In other words, males with higher IM scores, demonstrated less change in NODS and G-SAS scores from baseline to 6-month follow-up compared to males with lower IM scores. There were no significant interactions in any models among females or among the full sample. Controlling the well-documented effect of socially desirable responding on self-reported measures in addictions research should be considered as a method to help reduce error and improve validity. Future research should continue to examine the effect of this bias on gambling measures over time and in each gender.Trial registration: https://ClinicalTrials.gov/NCT03124589 , registered 19 January 2017.

Targeting mailed nicotine patch distribution interventions to rural regions of Canada: protocol for a randomized controlled trial.

BACKGROUND: Quitting smoking is the most effective way of reducing the risk of cancer among smokers. One way of helping people stop smoking is to provide them with free Nicotine Replacement Therapy (NRT), such as when NRT is sent to people by postal mail as part of a mass distribution initiative. Our previous research indicated that there may be a substantial impact on increasing quit rates of a mailed NRT intervention in rural areas. The current research seeks to confirm this finding and to understand the social determinants of health driving these anticipated large effects. METHODS/DESIGN: Telephone numbers will be randomly selected from across rural regions of Canada in order to recruit adult smokers interested in completing a smoking survey and willing to be interviewed again in 6 months. The survey will ask participants about their smoking history, demographic characteristics, and a hypothetical question: would they be interested in receiving nicotine patches if they were provided to them free of charge? Half of the smokers interested in receiving nicotine patches will be selected by chance and offered the NRT package. The other half of smokers will not be offered the nicotine patches. In addition, the municipality where each participant lives will be identified and, once the relevant general population data becomes available, attempts will be made to link participant data to relevant municipal characteristics (e.g., smoking rates, availability of health services). Characteristics of the participants and the municipalities in which they live will be used to explain why the nicotine patch intervention may have a larger impact in some rural regions compared to others. DISCUSSION: The findings from the proposed RCT are timely and of high relevance as the distribution of nicotine patches has substantial potential to combat the public health problem of cigarette related cancer, other diseases, and premature death from tobacco use. Targeting such tobacco cessation initiatives to rural regions may substantially increase the impact of this intervention, helping to optimize the use of limited prevention resources while aiming to save the maximum number of lives. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov NCT04606797 , October, 27, 2020.

Out damn bot, out: Recruiting real people into substance use studies on the internet.

While the Internet has become a popular and effective strategy for recruiting substance users into research, there is a large risk of recruiting duplicate individuals and Internet bots that pose as humans. Strategies to mitigate these issues are outlined and categorized into two groups: (1) automatic techniques which are often embedded into surveys and (2) ongoing manual techniques implemented during recruitment. Potential limitations of these strategies are discussed, and an example of the prevalence of duplicate data within a substance using sample is provided. Overall, it is recommended that researchers consider the use of routine strategies to mitigate the risks associated with recruiting online samples such as: verifying participant contact information, IP address checks, and ongoing cross-checking of participant information for duplicates, similarities and inconsistencies.

Correction to: Self-Directed Gambling Changes: Trajectory of Problem Gambling Severity in Absence of Treatment.

The original version of this article unfortunately contained errors in the Methods section. The citations blinded during the review process were inadvertently omitted during the production process and subsequent stages.

Outcomes of two randomized controlled trials, employing participants recruited through Mechanical Turk, of Internet interventions targeting unhealthy alcohol use.

BACKGROUND: Two randomized controlled trials (RCTs) were conducted to explore the utility of the Mechanical Turk (MTurk) crowdsourcing platform to conduct rapid trials evaluating online interventions for unhealthy alcohol use. METHODS: Both trials employed a staged recruitment procedure where participants who drank in an unhealthy fashion were identified using a baseline survey and then invited to take part in a 6-month follow-up. Participants in both trials were randomized to receive one of several different online interventions or to a no intervention control condition. In study 1, the online interventions were password protected and only those who accessed the study portal were randomized to condition. In study 2, participants were directed to free-of charge interventions and asked to send a screenshot of the intervention to demonstrate that they had complied. RESULTS: Participants reporting unhealthy alcohol use were recruited fairly rapidly. Large numbers of screeners were completed (Study 1: n = 4910; Study 2: n = 5812), found eligible (Study 1: n = 3741; Study 2: n = 4095), and randomized to condition (Study 1: n = 511; Study 2: n = 878). Fair follow-up rates were observed at 6 months for each study (Study 1: 82%; Study 2: 66%). Neither trial was able to clearly demonstrate that providing access to the online interventions lead to increased reductions in alcohol use as compared to the control group. CONCLUSIONS: While recruitment through a crowdsourcing platform is rapid and relatively low cost, it is possible that the lack of impact of the online websites employed in these trials could be due to the source of participants rather than the lack of efficacy of the interventions. TRIAL REGISTRATION: ClinicalTrials.gov # NCT02977026 and NCT03060135 .

Betting on Life: Associations Between Significant Life Events and Gambling Trajectories Among Gamblers with the Intent to Quit.

Considerable evidence has suggested that problem gambling may be transitory and episodic, with gamblers routinely moving in and out of clinical thresholds. Findings in qualitative and quantitative studies have converged on identifying preliminary evidence for the role of life events as motivators and contributing factors for gambling changes over time. The aim of this study was to conduct an exploratory analysis of the relationship between life events, their respective experience as positive or negative, and gambling trajectories among problem gamblers intending to quit. Life event occurrence and ratings as positive or negative, and changes in gambling severity were analyzed over a 12-month period for 204 adult problem gamblers intending to reduce or quit their gambling. Overall, mixed effects models revealed several relationships between life events and both the magnitude and direction of gambling change over time. In particular, gamblers who experienced a greater number of positive events or specific events such as legal events, the adoption/loss of a child, or negative changes to their social relationships, finances, work environments or social/health activities were more likely to exhibit greater gambling reductions over time. Conversely, gamblers who experienced a greater number of negative events, such as family bereavement, the dissolution of a marriage, or negative changes to their residence exhibited smaller gambling reductions or increases in gambling severity. Possible mechanisms which may explain the findings and the importance of examining the subjective experience of life events are discussed. Recommendations for future studies examining associations between life events and gambling trajectories are provided.

Self-Directed Gambling Changes: Trajectory of Problem Gambling Severity in Absence of Treatment.

Most problem gamblers do not seek formal treatment, recovering on their own through cognitive re-appraisal or self-help strategies. Although barriers to treatment have been extensively studied, there is a paucity of research on self-directed changes in problem gambling and very few studies have examined these changes prospectively. The aim of this study was to examine the trajectory of gambling severity and behavior change over an 18-month period, among a sample of non-treatment seeking/attending problem gamblers recruited from the community (N = 204) interested in quitting or reducing gambling. Separate mixed effects models revealed that in absence of formal treatment, significant reductions in gambling severity, frequency, and amount gambled could be observed over the course of a 6 to 9-month period and that changes experienced within the first 12 months were maintained for an extended 6 months. Problem gambling severity at baseline was significantly associated with changes in severity over time, such that participants with more severe gambling problems demonstrated greater reductions in their gambling severity over time. A total of 11.1% of participants gambled within a low-risk threshold at 18 months, although 28.7% of the sample reported consecutive gambling severity scores below problem levels for the duration of 1 year or longer. The findings suggest that among problem gamblers motivated to quit or reduce their gambling, significant self-directed changes in gambling severity can occur over a relatively short time. Additional prospective studies are needed to document the role of specific self-help tools or thought processes in exacting gambling changes.

Using Mechanical Turk to recruit participants for internet intervention research: experience from recruitment for four trials targeting hazardous alcohol consumption.

BACKGROUND: Mechanical Turk (MTurk) is an online portal operated by Amazon where 'requesters' (individuals or businesses) can submit jobs for 'workers.' MTurk is used extensively by academics as a quick and cheap means of collecting questionnaire data, including information on alcohol consumption, from a diverse sample of participants. We tested the feasibility of recruiting for alcohol Internet intervention trials through MTurk. METHODS: Participants, 18 years or older, who drank at least weekly were recruited for four intervention trials (combined sample size, N = 11,107). The same basic recruitment strategy was employed for each trial - invite participants to complete a survey about alcohol consumption (less than 15 min in length, US$1.50 payment), identify eligible participants who drank in a hazardous fashion, invite those eligible to complete a follow-up survey ($10 payment), randomize participants to be sent or not sent information to access an online intervention for hazardous alcohol use. Procedures where put in place to optimize the chances that participants could only complete the baseline survey once. RESULTS: There was a substantially slower rate of recruitment by the fourth trial compared to the earlier trials. Demographic characteristics also varied across trials (age, sex, employment and marital status). Patterns of alcohol consumption, while displaying some differences, did not appear to vary in a linear fashion between trials. CONCLUSIONS: It is possible to recruit large (but not inexhaustible) numbers of people who drink in a hazardous fashion. Issues for online intervention research when employing this sample are discussed.

What does it mean when people say that they have received expressions of concern about their drinking or advice to cut down on the AUDIT scale?

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is a commonly used scale to measure severity of alcohol consumption that contains an item asking if anyone has expressed concern about your drinking or suggested you cut down. What does it mean when a participant says yes to this question? METHODS: Participants who were 18 or older and who drank at least weekly were recruited to complete a survey about their drinking from the Mechanical Turk platform. Comparisons were made between at risk (n = 2565) and high risk drinkers (n = 581) who said that someone had expressed concern about their drinking regarding who had expressed concern. If the person expressing concern was a health professional, the participant was also asked what type of support was provided. RESULTS: Expressions of concern about drinking were received more often by high risk than at risk drinkers. The most common type of person to have expressed concern was a relative, followed by a friend, or a marital partner. About one quarter of participants had received expressions of concern from a medical doctor or other health professional. All health professionals' expressions of concern were accompanied by a suggestion to cut down and about half provided some additional support (the most common type of support was brief advice). CONCLUSIONS: Expressions of concern come from a variety of sources and the likelihood of their occurrence is partially related to amount of alcohol intake.

Gender Differences in Self-Conscious Emotions and Motivation to Quit Gambling.

Considerable gender differences have been previously noted in the prevalence, etiology, and clinical features of problem gambling. While differences in affective states between men and women in particular, may explain differential experiences in the process of gambling, the role of affect in motivations for quitting gambling and recovery has not been thoroughly explored. The aim of this study was to examine gender differences within a sample of problem gamblers motivated to quit with or without formal treatment, and further, to explore the interactions between gender, shame and guilt-proneness, and autonomous versus controlled reasons for change. Motivation for change and self-conscious emotional traits were analyzed for 207 adult problem gamblers with an interest in quitting or reducing their gambling (96.6 % not receiving treatment). Overall, gender differences were not observed in clinical and demographic characteristics. However, women exhibited greater shame [F(1,204) = 12.11, p = 0.001] and guilt proneness [F(1,204) = 14.16, p < 0.001] compared to men, whereas men scored higher on trait detachment [F(1,204) = 7.08, p = 0.008]. Controlling for demographic and clinical characteristics, general linear models revealed that autonomous motivation for change was associated with higher guilt-proneness, greater problem gambling severity, and the preparation stage of change; whereas controlled forms of motivation were significantly associated with higher shame-proneness and greater problem gambling severity. No gender effects were observed for either motivation for change. These findings suggest that the process of change can be different for shame-prone and guilt-prone problem gamblers, which may impact behavioral outcomes.

Remaining Between the Cracks - The Long-Term Effect of Different Suicide Risk Exclusion Criterion on Outcomes of an Online Intervention for Depression.

Background: Previous studies have demonstrated that excluding individuals at risk of suicide from online depression interventions can impact recruited sample characteristics. Aim: To determine if a small change in suicide risk exclusion criterion led to differences in the usage and effectiveness of an Internet depression intervention at 6 months of follow-up. Method: A partial sample of a recently completed online depression intervention trial was divided into two groups: those with no risk of suicide versus those with some risk. The two groups were compared for baseline demographic and clinical measures, as well as intervention uptake and treatment success across 6 months. Results: Overall, individuals with less risk of suicide at baseline reported significantly less severe clinical symptoms. Both groups interacted with the intervention at the same rate, but specific use of modules was different. Finally, the impact of intervention usage on outcomes over time did not vary by group. Limitations: While different suicide risk exclusion criteria can change recruited sample characteristics, it remains unclear how these differences impact intervention uptake and success. Conclusion: Overall, the findings suggest that researchers should exercise caution when excluding individuals at risk of suicide, as they greatly benefit from web-based interventions.

Patterns of remission from alcohol dependence in the United Kingdom: results from an online panel general population survey.

BACKGROUND: Previous research has demonstrated that remissions from alcohol use disorders can occur without accessing treatment. The current study explored the prevalence of such untreated remissions in the UK and further, examined the extent to which people who resolved an alcohol use disorder regarded themselves as ever, or currently, being in recovery. METHODS: Participants were recruited using the Prolific online platform. Participants who met criteria for lifetime alcohol dependence (ICD-10) were asked about their drinking at its heaviest, use of treatment services, whether they identified as being in recovery, and their current alcohol consumption (to identify those who were abstinent or drinking in a moderate fashion). RESULTS: A total of 3,994 participants completed surveys to identify 166 participants with lifetime alcohol dependence who were currently abstinent (n = 67) or drinking in a moderate fashion (n = 99). Participants who were currently abstinent were more likely to have accessed treatment than those who were currently moderate drinkers (44.4% versus 16.0%; Fischer's exact test = 0.001). Further, those who were abstinent were heavier drinkers prior to remission [Mean (SD) drinks per week = 53.6 (31.7) versus 29.1 (21.7); t-test = 5.6, 118.7 df, p < .001] and were more likely to have ever identified themselves as 'in recovery' (51.5% versus 18.9%; Fischer's exact test = 0.001) than current moderate drinkers. CONCLUSIONS: While participants with an abstinent remission were more likely than those currently drinking in a moderate fashion to have accessed treatment and to identify as being 'in recovery,' the majority of participants reduced their drinking without treatment (and did not regard themselves as in recovery).

Randomized controlled trial of a smartphone app designed to reduce unhealthy alcohol consumption.

Background and aims: Unhealthy alcohol use is common and causes tremendous harm. Most people with unhealthy alcohol use will never seek formal alcohol treatment. As an alternative, smartphone apps have been developed as one means to provide help to people concerned about their alcohol use. The aim of this study was to test the efficacy of a smartphone app targeting unhealthy alcohol consumption in a general population sample. Methods: Participants were recruited from across Canada using online advertisements. Eligible participants who consented to the trial were asked to download a research-specific version of the app and were provided with a code that unlocked it (a different code for each participant to prevent sharing). Those who entered the code were randomized to one of two different versions of the app: 1) the Full app containing all intervention modules; or 2) the Educational only app, containing only the educational content of the app. Participants were followed-up at 6 months. The primary outcome variable was number of standard drinks in a typical week. Secondary outcome variables were frequency of heavy drinking days and experience of alcohol-related problems. Results: A total of 761 participants were randomized to a condition. The follow-up rate was 81 %. A generalized linear mixed model revealed that participants receiving the full app reduced their typical weekly alcohol consumption to a greater extent than participants receiving the educational only app (incidence rate ratio 0.89; 95 % confidence interval 0.80 to 0.98). No significant differences were observed in the secondary outcome variables (p > .05). Discussion and conclusion: The results of this trial provide some supportive evidence that smartphone apps can reduce unhealthy alcohol consumption. As this is the second randomized controlled trial demonstrating an impact of this same app (the first one targeted unhealthy alcohol use in university students), increased confidence is placed on the potential effectiveness of the smartphone app employed in the current trial.ClinicalTrials.org number: NCT04745325.

Normative Misperceptions About Cannabis Use in a Sample of Risky Cannabis Users.

Introduction: This study examines normative misperceptions in a sample of participants recruited for a brief intervention trial targeting risky cannabis use. Methods: Participants who were concerned about their own risky cannabis use were recruited to help develop and evaluate intervention materials. At baseline, participants reported on their own cannabis use and provided estimates of how often others their gender and age used cannabis in the past 3 months. Comparisons were made between participants estimates of others cannabis use with reports of cannabis use obtained from a general population survey conducted during a similar time period. Results: Participants (N = 744, mean age = 35.8, 56.2% identified as female) largely reported daily or almost daily cannabis use (82.4%). Roughly half (55.3%) of participants estimated that others their age and gender used cannabis weekly or more often in the past 3 months, whereas the majority of people in the general population reported not using cannabis at all. Conclusions: Normative misperceptions about cannabis use were common in this sample of people with risky cannabis use. Limitations and possible future directions of this research are discussed, as well as the potential for targeting these misperceptions in interventions designed to motivate reductions in cannabis use. ClinicalTrialsorg number: NCT04060602.

Examining the influence of rurality on frequency of cannabis use and severity of consequences as moderated by age and gender.

AIM: A number of important health disparities associated with place of residence have been reported in the literature. The Remoteness Index (RI) was developed to account for community size, population density, and proximity to larger population centres. This exploratory analysis uses the RI to examine community level associations related to cannabis use. DESIGN: This secondary analysis uses data collected as part of a randomized controlled trial of a brief cannabis intervention. Participants' place of residence was matched to a corresponding value on the RI. Univariate regressions of RI and cannabis related outcomes were modeled with age and gender as moderating variables. Three outcomes were analyzed separately: 1) total number of days of cannabis use in the past 30 days; 2) risk of experiencing cannabis related problems; and 3) number of self-reported consequences related to cannabis. FINDINGS: Participants living in more remote areas were significantly more likely to drive within an hour of using cannabis, but also reported fewer consequences and less risky cannabis use. Although the overall regression models tested in the moderation analyses were significant, there were no interaction effects between RI and age or gender. CONCLUSION: While this analysis did not find significant conditional effects of age or gender on the relationship between cannabis use and place of residence, further research is needed to investigate other factors which may contribute to health disparities related to substance use between individuals living in different geographic regions.