Typology of Adolescents Exposed to Non-medical Cannabis Marketing and Associations with Consumption Patterns.

Latent class analysis (LCA) identified subtypes of cannabis marketing exposure among adolescents and assessed whether the classes were associated with three cannabis use outcomes: past 28-day use, poly-cannabis use, and symptoms of cannabis use disorder (CUD). Survey data were from 471 adolescents (aged 15-19 years) who lived in four states with legal non-medical cannabis in 2018. Measures included social media engagement and cannabis outcomes. LCA with robust maximum likelihood estimation identified latent classes. Chi-squared tests assessed whether empirically derived classes differed across demographics, and logistic regression tested associations with cannabis use outcomes. Three classes were identified: digitally engaged (35.5%), digitally unengaged (36.5%), and traditional (28.0%). Both digitally engaged and unengaged classes were exposed to marketing on social media platforms, but youth in the engaged class interacted with posts and brands. Class membership differed by age (χ2 = 14.89, p < 0.001) and school type, with the digitally engaged group older and not in school or in non-traditional schools (χ2 = 16.22, p=0.01). As compared to the traditional class, youth in the digitally engaged class had 10.63 times the odds of past 28-day cannabis use (95% CI: 5.25, 21.51), 7.84 times the odds of poly-cannabis use (95% CI: 3.54, 17.33), and 13.85 times the odds of symptoms of CUD (95% CI: 3.96, 48.48). Youth in the digitally engaged class had higher odds of all cannabis use behaviors than the traditional class. These findings point to the possible use of algorithmic marketing to adolescents and suggest a need for monitoring and possible restrictions on digital cannabis marketing.

Effect of Washington State and Colorado's cannabis legalization on death by suicides.

In the U.S., death by suicide is a leading cause of death and was the 2nd leading cause of death for ages 15-to-34 in 2018. Though incomplete, much of the scientific literature has found associations between cannabis use and death by suicide. Several states and the District of Columbia have legalized cannabis for general adult use. We sought to evaluate whether cannabis legalization has impacted suicide rates in Washington State and Colorado, two early adopters. We used a quasi-experimental research design with annual, state-level deaths by suicide to evaluate the legalization of cannabis in Washington State and Colorado. We used synthetic control models to construct policy counterfactuals as our primary method of estimating the effect of legalization, stratified by age, gender, and race/ethnicity. Overall death by suicide rates were not impacted in either state. However, when stratified by age categories, deaths by suicide increased 17.9% among 15-24-year-olds in Washington State, or an additional 2.13 deaths per 100,000 population (p-value ≤0.001). Other age groups did not show similar associations. An ad hoc analysis revealed, when divided into legal and illegal consumption age, 15-20-year olds had an increase in death by suicides of 21.2% (p-value = 0.026) and 21-24-year olds had an increase in death by suicides of 18.6% (p-value ≤0.001) in Washington State. The effect of legalized cannabis on deaths by suicide appears to be heterogeneous. Deaths by suicide among 15-24-year-olds saw significant increases post-implementation in Washington State but not in Colorado.

Driving and riding under the influence of recent marijuana use: Risk factors among a racially diverse sample of young adults.

Driving (DUIM) and riding (RUIM) with a driver under the influence of marijuana increases crash risk. This study assessed risk factors for DUIM and RUIM among ethnically diverse young adults. Randomly selected individuals were surveyed. Multivariable regression was used to assess risk factors associated with DUIM and RUIM. Participants (N = 335, response rate = 34.9%) were 33.7% White non-Hispanic. Reported DUIM and RUIM was not statistically significant by race/ethnicity. Frequency of marijuana use was significantly associated with greater risk of DUIM. Peer marijuana use was associated with greater risk of RUIM. Public health efforts to target social norms around marijuana-impaired driving are warranted.

Interrupting violence: how the CeaseFire Program prevents imminent gun violence through conflict mediation.

Cities are increasingly adopting CeaseFire, an evidence-based public health program that uses specialized outreach workers, called violence interrupters (VIs), to mediate potentially violent conflicts before they lead to a shooting. Prior research has linked conflict mediation with program-related reductions in homicides, but the specific conflict mediation practices used by effective programs to prevent imminent gun violence have not been identified. We conducted case studies of CeaseFire programs in two inner cities using qualitative data from focus groups with 24 VIs and interviews with eight program managers. Study sites were purposively sampled to represent programs with more than 1 year of implementation and evidence of program effectiveness. Staff with more than 6 months of job experience were recruited for participation. Successful mediation efforts were built on trust and respect between VIs and the community, especially high-risk individuals. In conflict mediation, immediate priorities included separating the potential shooter from the intended victim and from peers who may encourage violence, followed by persuading the parties to resolve the conflict peacefully. Tactics for brokering peace included arranging the return of stolen property and emphasizing negative consequences of violence such as jail, death, or increased police attention. Utilizing these approaches, VIs are capable of preventing gun violence and interrupting cycles of retaliation.

Street conflict mediation to prevent youth violence: conflict characteristics and outcomes.

BACKGROUND: Mediation of potentially violent conflicts is a key component of CeaseFire, an effective gun violence-prevention programme. OBJECTIVE: To describe conflicts mediated by outreach workers (OW) in Baltimore's CeaseFire replication, examine neighbourhood variation, and measure associations between conflict risk factors and successful nonviolent resolution. METHODS: A cross-sectional study was conducted using records for 158 conflicts mediated between 2007 and 2009. Involvement of youth, gangs, retaliation, weapons and other risk factors were described. Principal component analysis (PCA) was used for data-reduction purposes before the relationship between conflict risk components and mediation success was assessed with multivariate logistic regression. RESULTS: Most conflicts involved 2-3 individuals. Youth, persons with a history of violence, gang members and weapons were commonly present. OWs reported immediate, nonviolent resolution for 65% of mediated conflicts; an additional 23% were at least temporarily resolved without violence. PCA identified four dimensions of conflict risk: the risk-level of individuals involved; whether the incident was related to retaliation; the number of people involved; and shooting likelihood. However, these factors were not related to the OW's ability to resolve the conflict. Neighbourhoods with programme-associated reductions in homicides mediated more gang-related conflicts; neighbourhoods without programme-related homicide reductions encountered more retaliatory conflicts and more weapons.

Emergency department reported head injuries from skiing and snowboarding among children and adolescents, 1996-2010.

OBJECTIVES: To evaluate the incidence of snow-sports-related head injuries among children and adolescents reported to emergency departments (EDs), and to examine the trend from 1996 to 2010 in ED visits for snow-sports-related traumatic brain injury (TBI) among children and adolescents. METHODS: A retrospective, population-based cohort study was conducted using data from the National Electronic Injury Surveillance System for patients (aged ≤17 years) treated in EDs in the USA from 1996 to 2010, for TBIs associated with snow sports (defined as skiing or snowboarding). National estimates of snow sports participation were obtained from the National Ski Area Association and utilised to calculate incidence rates. Analyses were conducted separately for children (aged 4-12 years) and adolescents (aged 13-17 years). RESULTS: An estimated number of 78 538 (95% CI 66 350 to 90 727) snow sports-related head injuries among children and adolescents were treated in EDs during the 14-year study period. Among these, 77.2% were TBIs (intracranial injury, concussion or fracture). The annual average incidence rate of TBI was 2.24 per 10 000 resort visits for children compared with 3.13 per 10 000 visits for adolescents. The incidence of TBI increased from 1996 to 2010 among adolescents (p<0.003). CONCLUSIONS: Given the increasing incidence of TBI among adolescents and the increased recognition of the importance of concussions, greater awareness efforts may be needed to ensure safety, especially helmet use, as youth engage in snow sports.

Associations between social media displays and event-specific alcohol consumption by college students.

BACKGROUND: The Mifflin Street Block Party is a yearly Wisconsin event known for high levels of alcohol consumption and previous negative outcomes. This study investigated displayed Mifflin references on Facebook and their association with alcohol consumption at the block party. METHODS: Participants included first-year college students who were enrolled in a longitudinal study involving Facebook profile assessments and interviews. We identified a subset of participants who were interviewed within 28 days following the Mifflin St Block Party. Participants were categorized as "Mifflin Displayers" or "Non-displayers" based on Facebook profile content. Interviews included the timeline follow-back method to assess alcohol use in the past 28 days. Analysis included logistic and linear regression. RESULTS: Among the 66 participants included in this study, 45 (68.2%) were female and 38 (50%) were Mifflin Displayers on Facebook. Among the Mifflin Displayer participants, 18 (27.2%) displayed prior to Mifflin, 11 displayed the day of Mifflin (16.7%) and 19 (28.8%) displayed after. Some participants displayed in more than 1 time frame. A total of 40 (60.6%) reported alcohol use on the day of the Mifflin Street Block Party. The mean number of drinks reported on the day of Mifflin was 8.8 (SD = 6.1), with a range of 1 to 35. Displayed references to Mifflin on Facebook were positively associated with reporting alcohol use at Mifflin (OR = 20.9, 95% CI 5.6-78.8). CONCLUSION: Displaying Facebook references to Mifflin was associated with alcohol consumption on the day of the event. Future prevention efforts could consider creating Facebook advertisements with safety messages triggered by Mifflin displays.

Risk Factors for Adolescent Cannabis Use in a State With Legal Recreational Cannabis: The Role of Parents, Siblings, and Friends.

PURPOSE: Cannabis use during adolescence can have harmful consequences, including poor educational outcomes, neurocognitive defects, and an increased risk of addiction to other drugs, such as tobacco, alcohol, and opioids. Perceived family and social network cannabis use is a risk factor for use among adolescents. It is not currently known whether there is an association between perceived family/social network cannabis use and adolescent cannabis use in the context of legalization. The purpose of this study was to examine associations between adolescent perceptions of parent, sibling, and best friend medical and/or recreational cannabis use and adolescents' own use and whether the association changed pre-legalization and post-legalization in Massachusetts. METHODS: We analyzed responses from surveys administered to students at 2 high schools in Massachusetts before legalization in 2016 (wave 1) and after legalization but before the start of regulated retail cannabis sales in 2018 (wave 2). We used χ2 tests and multiple logistic regression to examine associations between adolescent perception of parent, sibling, and best friend use and adolescent past 30-day cannabis use before and after legalization. FINDINGS: In this sample, no statistically significant differences were found in the prevalence of past 30-day cannabis use before and after legalization among adolescents. There was an increase in the proportion of adolescents who reported any perceived parent cannabis use from before to after legalization (18% before legalization to 24% after legalization; P = 0.018). Perceived parent, sibling, and best friend medical and recreational cannabis use were all associated with an increased odds of adolescent use, with the highest increase in odds found for perceived best friend use (adjusted odds ratio, 17.2; 95% CI, 12.4-24.0). IMPLICATIONS: Adolescent perceptions of their parents as cannabis users increased after legalization, even before state-regulated retails sales began. Parent, sibling, and best friend cannabis use is each independently associated with increased odds of adolescent's own use. These findings from 1 Massachusetts district should be explored in larger and more representative populations and motivate additional attention to interventions that consider family and friend influences when seeking to address adolescent cannabis use.

Adolescents' Views on Preventing Youth Cannabis Marketing Exposure: A Concept Mapping Approach.

OBJECTIVE: The increasing number of states legalizing recreational cannabis use has raised growing concerns about exposure and access to cannabis for youth. The objective of this study was to develop an adolescent stakeholder-driven concept map toward identifying priority areas for preventing youth cannabis marketing influence. METHOD: This study used concept mapping, a validated research method that leverages both qualitative and quantitative approaches to integrate stakeholder input on complex topics. We recruited adolescents for the five steps of concept mapping: preparation, generation, structuring, representation, and interpretation. Analysis included hierarchical cluster analysis to develop a concept map representing approaches to protect youth from the influence of cannabis marketing, and youth focus groups to interpret the concept map. RESULTS: A total of 208 participants contributed to the study, including 74.0% females, 62.0% Caucasian, and 38.9% with previous cannabis use. There were 119 brainstorming items generated and sorted into a concept map that included 8 clusters. Clusters represented existing approaches, including education and regulation, and novel approaches, such as changing interpersonal communication and media norms around cannabis. Youth prioritized education-based approaches, including "showing both positive and negative effects of marijuana." CONCLUSIONS: This study leveraged adolescent input toward a stakeholder-driven concept map focused on prevention of youth cannabis use. Based on this concept map, there are existing and novel approaches to improve current efforts. The concept map brings adolescent voices forward to advance research, educational, and policy efforts.

A Scoping Review of Data Sources for the Conduct of Policy-Relevant Substance Use Research.

OBJECTIVE: Existing administrative and survey data are critical for understanding the effects of exigent policies on population health outcomes related to opioid, cannabis, and other substance use disorders (SUDs). The objective of this study was to determine the state of the data available for evaluating SUD-related health outcomes. METHODS: We performed a scoping review of national and state government data sources to measure and evaluate the effects of state policy changes on substance use and SUD-related health outcomes and health care use. We used Massachusetts as a case study for availability of relevant state-level data as well as national datasets with state-level indicators available to measure outcomes. We compared key features of each dataset to assess their usefulness for research and policy evaluation. We conducted our review during November 2018-March 2019, and we updated data availability as of March 2019 for all data sources. RESULTS: We identified 11 survey datasets, 12 national administrative datasets, and 10 state administrative datasets as being suitable for policy-relevant research and practice purposes. These datasets varied substantially in their usefulness for evaluation and research. Despite substantial data limitations, including prohibitive regulatory and monetary costs to obtain the data and limited availability, these data can be mined to examine a diversity of policy-relevant questions. CONCLUSIONS: Findings provide a comprehensive resource for using survey and administrative data to evaluate the health effects of SUD-related policies and interventions. The construction of state-level public health data warehouses or record linkage projects connecting individual-level information in state data sources is valuable for analyzing the effects of policy changes. Understanding strengths and limitations of available data sources is important for ongoing research and evaluation.

A Content Analysis of Cannabis Company Adherence to Marketing Requirements in Four States.

OBJECTIVE: Marketing messages can influence adolescents' attitudes and behaviors toward alcohol and tobacco. In the era of legalized cannabis use, retail cannabis companies often use social media marketing on platforms popular among youth. The purpose of this study was to evaluate adherence to state-based regulations for restricted and required content across social media from recreational cannabis businesses. METHOD: A retrospective content analysis was used to evaluate one year of publicly displayed posts by retail cannabis companies on Facebook and Instagram from four states in which recreational cannabis use is legal (Alaska, Colorado, Oregon, and Washington State). We evaluated restricted content including the following: (a) business practices, such as avoiding discounts/promotions or promoting branded products; (b) modeling cannabis use or overconsumption; (c) youth-focused messaging; and (d) health benefits. We evaluated required content including three types of warnings: (a) limiting cannabis use to those age 21 and over, (b) avoiding impaired driving, and (c) describing health risks. RESULTS: A total of 2,660 posts were evaluated from 14 businesses. In the area of restricted content, discounts/promotions were present in approximately 35% of all posts. Another common category was overconsumption, found in 12% of posts. Required content regarding warnings was present in less than half of all social media posts. CONCLUSIONS: Despite state-based advertising restrictions, recreational cannabis business pages use messages with youth appeal. Required safety message adherence is not typical on social media business pages.

Youth perspectives on street outreach workers: results from a community-based survey.

The United Teen Equality Center in Lowell, Massachusetts uses Street Outreach Workers (SWs) to intervene with individuals 13-23 years old who are involved in high risk behaviors or in need of assistance. Few studies have explored the perceptions of SWs by their target population (both individuals they have worked with and those who they have not yet worked with). To better understand how youth perceive the SWs and to contribute to the scant literature regarding their roles and impacts, we conducted a community-based survey to capture youth perspectives of, and experiences with SWs. Regardless of whether they had worked with a SW, youth respondents reported that their peers believed the SWs made Lowell a better place. Youth who had prior contact with a SW were more likely to respond that their peers view the SWs as helpful to youth and respected. Youth who had no prior contact with SWs were more likely to report that SWs were not present where they lived. Among youth who had worked with a SW 38% received help finding a job and 67% indicated that working with a SW made a difference in their lives. Approximately 82% of individuals who participated in mediation activities led by the SWs reported that it resolved their conflict. These results support the value of SWs in helping youth meet their needs and in mediating disputes. SWs should continue to connect with local agencies to address the needs of youth, especially employment, which was a priority.

Navigating the U.S. health insurance landscape for children with rare diseases: a qualitative study of parents' experiences.

BACKGROUND: Parents of children with rare diseases often face uncertainty about diagnosis, treatment, and costs associated with healthcare for their child. Health insurance status impacts each of these areas, but no U.S. study has explored parents' perceptions of the health insurance impacts on their child's care. This study aimed to qualitatively explore how these parents navigate the complex health insurance system for their children and their experiences in doing so. METHODS: Semi-structured interviews were conducted with parents of children with metachromatic leukodystrophy (MLD) and spinal muscular atrophy (SMA), chosen for specific disease characteristics and orphan drug status. Participants were recruited via e-mail through patient advocacy organizations between September and December 2018. Interviews were conducted via Skype, were recorded, and professionally transcribed. Modified grounded theory was utilized as a methodology to analyze transcripts in an iterative process to determine themes and sub-themes based on participant described experiences. RESULTS: Major themes and subthemes that emerged across the 15 interviews included: (1) difficulties obtaining secondary insurance based on state eligibility criteria; (2) difficulty accessing needed healthcare services; and (3) need for repeated interactions with insurance representatives. The absence of clearly documented or widely recognized clinical guidelines exacerbated the difficulty accessing care identified as necessary by their healthcare team, such as therapy and equipment. An explanatory model for parent's experiences was developed from the themes and subthemes. The model includes the cyclical nature of interacting with insurance for redundant reauthorizations and the outside support and financial assistance that is often necessary to address their child's healthcare needs. CONCLUSIONS: With complex health conditions, small setbacks can become costly and disruptive to the health of the child and the life of the family. This study suggests that patients with rare diseases may benefit from time limits for processing coverage decisions, increasing transparency in the claims and preauthorization processes, and more expansive authorizations for on-going needs. Additional studies are needed to understand the full scope of barriers and to inform policies that can facilitate better access for families living with rare diseases.

Cannabis Marketing and Problematic Cannabis Use Among Adolescents.

OBJECTIVE: Health consequences of commercializing nonmedical cannabis remain unclear, but data suggest that youth may encounter unintended risks. This study examined whether cannabis marketing exposure and engagement are associated with problematic cannabis use among adolescents. METHOD: The analytic sample included 172 lifetime cannabis users (15-19 years old) who lived in one of six states with legalized nonmedical cannabis in 2018. Predictors included having exposure to or engagement with cannabis marketing on Facebook or Instagram, seeing cannabis billboards, owning/likely to own cannabis-branded merchandise, and reporting a favorite cannabis brand. Logistic regression assessed whether these predictors were associated with weekly cannabis use, high-intensity cannabis use, and cannabis use disorder (CUD). RESULTS: Adolescents who saw billboards rarely/sometimes had 5 times the odds of CUD, whereas youth who saw them most/all of the time had 7 times the odds of weekly use and 6 times the odds of CUD. Adolescents who owned/were likely to own branded merchandise had nearly 23 times the odds of weekly use, and those with a favorite brand had 3 times the odds of weekly use and CUD. Adolescents who reported seeing promotions on Instagram rarely/sometimes had 85% lower odds of weekly use, and those who saw them most/all of the time had 93% lower odds. CONCLUSIONS: The ways cannabis businesses market their products, especially branding, may affect patterns of underage cannabis use. Future research should test whether these associations persist in longitudinal designs. In the interim, states should consider an approach that offers youth additional means to protect them from cannabis marketing.

Prevalence and Correlates of Cannabis Use in Massachusetts after Cannabis Legalization and before Retail Sales.

We determined the prevalence and correlates of cannabis use in Massachusetts after recreational use was passed, but before recreational cannabis stores opened. A cross-sectional, population-based survey of Massachusetts adults, age 18 years or older, (n = 3,022) was conducted in November-December, 2017. We estimated population-level prevalence and correlates of past 30-day cannabis use. 21.1% [95% CI: 18.6, 23.6] of Massachusetts adults reported past 30-day cannabis use. Among cannabis users, 56.0% [CI 49.1, 62.9] reported non-medical cannabis use, 15.5% [12.1, 18.9] reported medical cannabis use, and 28.5% [CI 22.3, 34.8] reported both types of use. Men were more likely than women to use cannabis (Risk Ratio: 1.3 [CI 1.1, 1.6]), as were young adults (18-25 years old), those with lower socioeconomic status, non-parenting individuals, those who used alcohol (1.9 [CI 1.4, 2.6]) or other substances (1.7 [CI 1.3, 2.4]), and residents of Western Massachusetts (2.0 [1.3, 3.0]; ref: Boston area), the Northeast (1.8 [CI 1.2, 2.7]), and the Southeast (1.8 [CI 1.1, 2.7]). Cannabis is widely used in Massachusetts, with varying prevalence rates by gender, age, socioeconomic status, poly-substance use, and region. Findings may inform public health efforts and serve as a baseline for measuring health and social impacts of opening retail cannabis stores.

Kratom exposures among older adults reported to U.S. poison centers, 2014-2019.

BACKGROUND: In recent years, use of the herbal supplement kratom has increased in the United States. The reasons for use include pain relief, particularly as a substitute for opioids. OBJECTIVES: To describe epidemiologic trends in kratom-related exposures among older adults reported to U.S. poison centers. DESIGN: Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS). SETTING: Data from all U.S. poison centers from 2014 to 2019 were examined. PARTICIPANTS: Kratom exposure cases involving adults aged 18 and older. Kratom cases were identified by product and NPDS generic codes. Non-human and information-only calls were excluded. Data were examined for all calls for exposures among adults, with a focus on older adults aged 60-69 years and above 70 years. MEASUREMENTS: Descriptive analyses were used to characterize individual demographic, exposure information, clinical effects, and medical outcomes associated with kratom exposures among older adults. Comparisons across age groups (18-59, 60-69, and 70+ years) were made using Fisher's exact tests. RESULTS: Among 3484 kratom-related exposures reported between 2014 and 2019, 4.6% (n = 162) were among adults over 60 years. The number of kratom-related exposures increased over time. Most cases originated with calls from healthcare facilities (81.1%) and involved kratom as a single ingestant (63.0%). The reason for most ingestions was intentional (74.5%). One in five exposures among adults aged 70 and older involved an adverse reaction (e.g., drug interaction; 21.9%), compared with 12.3% among ages 60-69 and 9.6% among ages 18-59 years. Neurological and cardiovascular clinical effects were observed. Twenty-three deaths were observed among older adults. CONCLUSION: Healthcare providers and older adult patients should be aware of the potential risks of kratom use, including medication interactions and falls. When reviewing medication lists, providers should query this population for all medications and substances being used, especially in people being treated for pain.

SARS-CoV-2 Seroprevalence and Drug Use in Trauma Patients from Six Sites in the United States.

In comparison to the general patient population, trauma patients show higher level detections of bloodborne infectious diseases, such as Hepatitis and Human Immunodeficiency Virus. In comparison to bloodborne pathogens, the prevalence of respiratory infections such as SARS-CoV-2 and how that relates with other variables, such as drug usage and trauma type, is currently unknown in trauma populations. Here, we evaluated SARS-CoV-2 seropositivity and antibody isotype profile in 2,542 trauma patients from six Level-1 trauma centers between April and October of 2020 during the first wave of the COVID-19 pandemic. We found that the seroprevalence in trauma victims 18-44 years old (9.79%, 95% confidence interval/CI: 8.33 - 11.47) was much higher in comparison to older patients (45-69 years old: 6.03%, 4.59-5.88; 70+ years old: 4.33%, 2.54 - 7.20). Black/African American (9.54%, 7.77 - 11.65) and Hispanic/Latino patients (14.95%, 11.80 - 18.75) also had higher seroprevalence in comparison, respectively, to White (5.72%, 4.62 - 7.05) and Non-Latino patients (6.55%, 5.57 - 7.69). More than half (55.54%) of those tested for drug toxicology had at least one drug present in their system. Those that tested positive for narcotics or sedatives had a significant negative correlation with seropositivity, while those on anti-depressants trended positive. These findings represent an important consideration for both the patients and first responders that treat trauma patients facing potential risk of respiratory infectious diseases like SARS-CoV-2.

Evaluation of Availability of Survey Data About Cannabis Use.

Importance: In response to increasing public support for cannabis legalization, understanding associations of state and federal policy changes related to cannabis legalization with patterns of cannabis use is important. A challenge for public health monitoring and research is significant variation in data availability related to cannabis use behaviors and perceptions across and within states and over time, including the availability of prelegalization vs postlegalization data. Objective: To review data available on cannabis use and related behaviors over time in Massachusetts and the US. Design, Setting, and Participants: This case series examined state and national surveys on public health and related behaviors and outcomes to review availability of cannabis-related data for Massachusetts for 8 key indicators over time. Additionally, the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System for all states were reviewed. The analysis was conducted between February 1, 2019, and March 18, 2020. Exposures: Surveys that enable state-level estimation of cannabis use and related behaviors. Main Outcomes and Measures: Eight key indicators related to cannabis use behaviors and perceptions: lifetime cannabis use, age of initiation, frequency of use, location of use, method of use, source of cannabis, perceptions of cannabis, and reason for use (ie, medical vs nonmedical). Results: There were 7 surveys that monitored cannabis use and related behaviors in Massachusetts for adolescents and adults. No surveys monitored all 8 indicators of interest, and availability over time was limited. In the most recent BRFSS, 24 states asked cannabis-related questions, meaning BRFSS data on cannabis use was lacking for more than half of the US adult population. In the Youth Risk Behavior Surveillance System, 36 states asked standard cannabis questions; most other states had at least 1 question related to cannabis use and frequency. Conclusions and Relevance: These findings of limitations of existing surveys, and particularly the lack of national questions in the BRFSS and Youth Risk Behavior Surveillance System, suggest that available data have substantial limitations for monitoring cannabis use. As cannabis policy changes continue, there is a need to remain focused on the availability of high-quality data sources that allow for critical public health research.

Exposure to Cannabis Marketing in Social and Traditional Media and Past-Year Use Among Adolescents in States With Legal Retail Cannabis.

PURPOSE: The objective of this study was to examine adolescents' self-reported exposure to cannabis marketing in states with legalized cannabis and its association with past-year cannabis use. METHODS: We conducted a cross-sectional, online panel survey of 469 adolescents aged 15-19 years residing in four states with legal retail cannabis for adult use. Adolescents self-reported exposure to cannabis marketing on social or traditional media (i.e., outdoor or print) and past-year cannabis use. Logistic regression generated estimated odds of youths' past-year cannabis use by marketing exposure after adjusting for demographic factors and cannabis-related social norms. RESULTS: Exposure to cannabis marketing on Facebook, Twitter, and Instagram was associated with increased odds of past-year cannabis use of 96% (95% confidence interval [CI]: 15%-234%), 88% (95% CI: 11%-219%), and 129% (95% CI: 32%-287%), respectively. Odds of past-year cannabis use increased by 48% (95% CI: 16%-87%) with each additional social media platform where adolescents reported exposure. CONCLUSIONS: Despite restrictions that prohibit cannabis advertising on social media, adolescents are exposed to cannabis marketing via social media, and this exposure is associated with recent cannabis use. States should consider further regulation of cannabis marketing on social media.