Effects of cannabis legalisation on patterns of cannabis consumption among adolescents in Ontario, Canada (2001-2019).

INTRODUCTION: Cannabis legalisation was enacted on 17 October 2018 in Canada. Accordingly, the effects of cannabis legalisation on patterns of cannabis consumption were examined among adolescents, including on cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence. METHODS: Data from a biennial population-based, cross-sectional survey of students in Ontario were pooled in a pre-post design (2001-2019; N = 89,238). Participants provided self-reports of cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence. Long-term trends in these patterns of cannabis consumption over two decades of observation were characterised to provide a broader context of usage. The effects of cannabis legalisation on patterns of cannabis consumption were quantified using logistic regression analyses. RESULTS: Long-term trends over the two decades of observation indicated that cannabis initiation decreased and then increased (p = 0.0220), any cannabis use decreased and daily cannabis use decreased (p < 0.0001 and p = 0.0001, respectively) and cannabis dependence remained unchanged (p = 0.1187). However, in comparisons between the pre-cannabis legalisation period (2001-2017) and the post-cannabis legalisation period (2019), cannabis legalisation was not associated with cannabis initiation (odds ratio; 95% confidence interval 1.00; 0.79-1.27), but it was associated with an increased likelihood of any cannabis use (1.31; 1.12-1.53), daily cannabis use (1.40; 1.09-1.80) and cannabis dependence (1.98; 1.29-3.04). DISCUSSION AND CONCLUSIONS: Cannabis legalisation was not associated with cannabis initiation, but it was associated with an increased likelihood of any cannabis use, daily cannabis use and cannabis dependence.

Increases in Serious Psychological Distress among Ontario Students between 2013 and 2017: Assessing the Impact of Time Spent on Social Media.

OBJECTIVE: The objective of the current research was to examine the association between time spent on social media and serious psychological distress between 2013 and 2017, a period when the rates of both were trending upward. METHODS: The current study analyzed population-based data from 3 waves of the Ontario Student Drug Use and Health Survey (N = 15,398). Multivariate logistic regression models were used to examine the association between time spent on social media and serious psychological distress controlling for theoretically relevant covariates. Interactions were tested to assess whether the association changed over time. RESULTS: The prevalence of serious psychological distress increased from 10.9% in 2013 to 16.8% in 2017 concomitantly with substantial increases in social media usage, especially at the highest levels. In the multivariate context, we found a significant interaction between social media use and the survey year which indicates that the association between time spent on social media and psychological distress has decreased from 2013 to 2017. CONCLUSION: Although both social media use and psychological distress increased between 2013 and 2017, the interaction between these variables indicates that the strength of this association has decreased over time. This finding suggests that the higher rate of heavy social media use in 2017 compared to 2013 is not actually associated with the higher rate of serious psychological distress during the same time period. From a diffusion of innovation perspective, it is possible that more recent adopters of social media may be less prone to psychological distress. More research is needed to understand the complex and evolving association between social media use and psychological distress. Researchers attempting to isolate the factors associated with the recent increases in psychological distress could benefit from broadening their investigation to factors beyond time spent on social media.

Adolescent traumatic brain injuries: Onset, mechanism and links with current academic performance and physical injuries.

BACKGROUND: Traumatic brain injuries (TBIs) in adolescence are associated with adverse outcomes, but whether the timing of the onset of TBIs leads to greater deficits has not been determined. We evaluate the relationship between the first and most recent TBI, and current academic performance and medically treated physical injuries. METHODS: Data were derived from the 2015 Ontario Student Drug Use and Health Survey (OSDUHS) administered to adolescents in grades 7 to 12 (ages 12 to 18). TBI was defined as a head injury that resulted in loss of conscious for at least five minutes or at least one overnight hospitalization. RESULTS: One in five students reported having had a history of TBI in their lifetime and were more prevalent in males. Odds ratios were 2 times higher for males to have had their first (or only) and most recent TBI in grades 5 to 8, compared to females. Sports-related TBIs accounted for 41.1% of all TBIs. Hockey related TBIs were more frequent compared to soccer related TBIs. Reports of history of TBI was associated with lower academic performance and more physical injuries. First or only TBI occurring in grades 9-12 (occurring on average between 14 to 19 years of age) had higher significant odds of poorer academic performance than TBIs occurring in earlier grades (younger ages than 14 years old). Students who reported more visits for medical treatment of physical injuries in the past year had higher odds to report a history of TBIs in higher school grades. CONCLUSIONS: Adverse physical and academic outcomes among young TBI survivors are associated with the onset and frequency of history of lifetime TBI. Prevention efforts to minimize TBIs during youth is critical.

Substance use and internalizing symptoms among high school students and access to health care services: results from a population-based study.

OBJECTIVES: To examine co-occurring mental health problems among a population-based sample of high school students in Ontario, Canada, to understand their prevalence, associated risk factors, and relationship with mental health service access and utilization. METHODS: The data were derived from the 2013 Ontario Student Drug Use and Health Survey, a biennial survey of students attending publicly funded Ontario schools, from a subsample of students who completed both the internalizing and substance use portions of the survey (n = 2945). Rates of co-occurring problems were calculated for the previous 12 months. Service use for students with co-occurring problems was also calculated for the past 12 months. Odds ratios were estimated using binary logistic regression models correcting for the survey design. RESULTS: In an adjusted model, youth with internalizing symptoms were 2.40 times more likely and youth with substance use problems were 2.24 times more likely to have accessed mental health services during the past 12 months than youth without these problems. Youth with co-occurring internalizing and substance use problems were 6.74 times more likely (95% CI 4.66-9.76, p < 0.001) to have accessed mental health services during the past year compared with youth without co-occurring problems, but only 52.8% of youth with co-occurring problems (95% CI 45.6-59.9%) used mental health services. CONCLUSIONS: The findings suggest that just over half of Ontario students in grades 9 through 12 who have co-occurring internalizing and substance use problems are utilizing mental health services. Further research should examine the factors related to service use in this population in order to better inform policy and program development.

The prevalence and correlates of texting while driving among a population-based sample of Ontario students.

OBJECTIVE: Texting while driving (TWD) has a deleterious impact on driving performance and may pose a significant challenge to traffic safety. This challenge may be particularly relevant for young and inexperienced drivers. This study examined the prevalence and risk factors of writing text messages or emails while driving during the past 12 months. METHOD: This study analyzed a subpopulation of 1,133 licensed students 16 years of age or older from the 2013 Ontario Student Drug Use Survey (OSDUHS), a population-based survey of students in Ontario, Canada. RESULTS: Our results indicate that 36% of licensed drivers reported writing a text message while driving during the past 12 months; of those who did, 56% reported doing so 4 or more times. Graduated licensing was the strongest factor predicting TWD. Compared to students with the more restrictive G1 license, students with a G2 or full license were 9.4 times more likely to report TWD after controlling for the effect of all other factors. Older students, white students, and students attending school in urban centers were more likely to report TWD, and the amount of time spent on social media sites, being a passenger with a driver using substances, and past-year collisions were also significantly associated with TWD. Gender differences and participation in driver education training were not associated with TWD. CONCLUSIONS: This research demonstrates that TWD is an extremely common behavior among licensed student drivers in Ontario, particularly among those who have passed the first stage of graduated licensing. TWD is associated with other risky driving behaviors and outcomes, and the findings from this study underscore the need to better understand the harms associated with this behavior.

Ethnoracial differences in cannabis use among native-born and foreign-born high school students in Ontario.

The objective of this study was to examine the association of ethnoracial background and immigrant status to cannabis use among students in Ontario, Canada. Data were derived from the Ontario Student Drug Use and Health Survey, a school-based, province-wide survey of students in Grades 7-12. The survey utilized a stratified two-stage cluster design. Analyses were based on a pooled subsample of 12,527 students in Grades 9-12 during the 2011 and 2013 survey cycles and included adjustments for the complex sample design. Results indicate that youth who were of South Asian or East/Southeast Asian background were at lower odds of cannabis use than those who were White, Black, or mixed-race backgrounds. Youth who were of mixed-race background (i.e., White and another group) were at higher odds of cannabis use than youth who were of White background. The association between ethnoracial background and cannabis use also varied for some foreign-born and native-born youth. These findings suggest that ethnoracial background should be an important consideration in investigations of cannabis use among foreign- relative to native-born youth.

Cross Validation of the Gambling Problem Severity Subscale of the Canadian Adolescent Gambling Index (CAGI/GPSS) on a Sample of Ontario High School Students.

This paper reports on the cross validation of the Gambling Problem Severity Subscale of the Canadian Adolescent Gambling Index (CAGI/GPSS). The CAGI/GPSS was included in a large school based drug use and health survey conducted in 2015. Data from students in grades 9-12 (ages 13-20 years) derived from the (N = 3369 students). The CAGI/GPSS produced an alpha of 0.789. A principle component analysis revealed two eigenvalues greater than one. An oblique rotation revealed these components to represent consequences and over involvement. The CAGI/GPSS indicated that 1% of the students fell into the "red" category indicating a severe problem and an additional 3.3% scored in the "yellow" category indicating low to moderate problems. The CAGI/GPSS was shown to be significantly correlated with gambling frequency (r = 0.36), largest expenditure (r = 0.37), sex (more likely to be male) (r = -0.19), lower school marks (r = -0.07), hazardous drinking, (r = 0.16), problem video game play (r = 0.16), as well as substance abuse. The CAGI/GPSS was cross validated using a shorted version of the short SOGS, r = 0.48. In addition the CAGI/GPSS and short SOGS produced very similar patterns of correlations results. The results support the validity and reliability of the CAGI/GPSS as a measure of gambling problems among adolescents.

Smoking and binge-drinking among adolescents, Ontario, Canada: Does the school neighbourhood matter?

This study examines whether access to alcohol and tobacco around the school relates to higher or lower odds of cigarette smoking and binge-drinking among Ontario high school students. The 2013 Ontario Student Drug Use and Health Survey provides data on self-reported smoking and drinking, individual covariates and subjective socio-economic status for 6142 students (grades 9-12) in Ontario, Canada. Locations of schools were geocoded and 1.6km network buffers defined the school neighbourhoods. Multi-level logistic regression examines individual and school neighbourhood factors with smoking and binge drinking as the dependent variable. Higher density of retail outlets increased the odds of smoking, but not the odds of binge-drinking. Older age, lower SES and being male increased the odds of smoking; while older age and being male also increased the odds of binge-drinking. Lower SES and higher population density decreased the odds of binge-drinking. Proximity to tobacco and alcohol outlets was not significant. Findings showed that a greater number of outlets in the school neighbourhood is significantly associated with higher odds of smoking, but not binge-drinking. School neighbourhood access to tobacco outlets should be considered when formulating policy interventions to reduce smoking for adolescents.

Possession of weapon and school violence among adolescents and their association with history of traumatic brain injury, substance use and mental health issues.

PURPOSE: Assessment of the association between illegal possession of weapon and assault on school property among adolescents with and without a history of traumatic brain injury (TBI) while assessing risk factors for these outcomes. METHODS: Data were derived from the Centre for Addiction and Mental Health's 2013 Ontario Student Drug Use and Health Survey completed by students in grades 7-12 (ages 11-20). RESULTS: In this sample of 5478 adolescents, 6.1% (95% CI: 5.0, 7.4) reported carrying a weapon (e.g., gun or knife) on school property, 10.8% (95% CI: 9.5, 12.3) were engaged in a physical fight and 6.4% (95% CI: 5.4, 7.6) reported having beat up or hurt someone on purpose at school, during last year. Youth who reported carrying a weapon, who were engaged in a physical fight and those who assaulted peers on school property during last year had statistically significantly higher odds of reporting a history of TBIs, being male, in first years of high-school, scored positive for elevated psychological distress, and were current regular alcohol (weapon possession only) and cannabis users. CONCLUSION: Previously it was thought that alcohol and drugs were the main contributors to school violence. Here we show that history of TBIs is yet another significant predictor of violence at school among adolescents. The results suggest that school vigilance and combined violence and TBI prevention, treatment and rehabilitation programs in this population are warranted.

Looking beyond cigarettes: Are Ontario adolescents with asthma less likely to smoke e-cigarettes, marijuana, waterpipes or tobacco cigarettes?

OBJECTIVES: The purpose of this paper is to examine whether high school students in Ontario with asthma smoke cigarettes, waterpipes, marijuana or e-cigarettes more or less than those without asthma. METHODS: The 2013 Ontario Student Drug Use and Health Survey provides self-report data on tobacco cigarettes, waterpipes, marijuana and e-cigarette smoking and asthma rates from 109 high schools in Ontario, Canada. Individual and social characteristics were also collected. Multiple binary logistic regression models measures the association with the various types of smoking in relation to asthma. RESULTS: Adolescents with asthma have higher odds of smoking e-cigarettes or smoking any type including either cigarettes, waterpipes, marijuana or e-cigarettes. Respondents of lower socio-economic status had a higher odds of smoking marijuana or any type. Boys were more likely to smoke waterpipes, e-cigarettes or any type, while students in higher grades had a higher odds of smoking cigarettes, waterpipes, marijuana or any type. CONCLUSIONS: Results from this study suggest that adolescents with asthma have a higher odds of smoking e-cigarettes than those without asthma, but no relationship was found for cigarettes, waterpipes or marijuana. Findings present some new challenges as technology changes how adolescents can smoke. Public health campaigns should target adolescents, especially those with asthma, to raise their awareness of the risks of all types of smoking including e-cigarettes.

Ten-year trends in overweight/obesity among Ontario middle and high school students and their use in establishing baseline measures for government reduction targets.

OBJECTIVES: Public health concern about increasing levels of child/youth overweight and obesity has resulted in initiatives to address this issue. In 2012, the Ontario Ministry of Health and Long-Term Care (MOHLTC) established a target to reduce childhood obesity by 20% within five years. In this paper, we examine trends and establish baseline levels of overweight/obesity to assess the impacts of population-level interventions. METHODS: We analyzed 10 years (2003-2013) of data accumulated from six cycles of the Ontario Student Drug Use and Health Survey using logistic regression to assess trends in the prevalence of overweight/obesity among middle and high school students. The 2013 data are used to begin monitoring progress toward achieving the MOHLTC target. RESULTS: From 2003 through 2013, the prevalence of overweight/obesity among middle school students in the province remained stable overall and among all subgroups except 7th-grade females, who showed a significant linear decline. Among high school students, the prevalence of overweight/obesity showed a significant linear increase and an increase among 11th graders, females, and 10th- and 11th-grade females specifically. The prevalence remained stable but elevated among 9th- and 12th-grade females as well as among males in all grades. In 2013 (baseline for the MOHLTC target), 25.1% of students in grades 7-12 were overweight or obese, implying a presumed 2018 target of 20.1%. CONCLUSION: Ten-year trends in overweight/obesity indicate stability among males and significant linear increases in some female subgroups. Also, baseline data (2013) will facilitate the monitoring of future interventions aimed at achieving the 2018 MOHLTC target.

Cross-sectional examination of the association of co-occurring alcohol misuse and traumatic brain injury on mental health and conduct problems in adolescents in Ontario, Canada.

OBJECTIVE: This study describes the impact of traumatic brain injury (TBI) and hazardous drinking on mental health and behavioural issues among Ontario adolescents. In particular, we assessed the incremental co-occurrence of hazardous drinking with a history of TBI, in comparison to experiencing just one of these conditions. METHODS: A cross-sectional subsample of 3130 Ontario adolescents attending grades 9-12, and aged 10-21 were surveyed in 2013 as a part of the Centre for Addiction and Mental Health's Ontario Student Drug Use and Health Survey. Recent (past year) and former (lifetime and excluding the last year) TBI were defined as trauma to the head that resulted in loss of consciousness for at least 5 min or overnight hospitalisation. Current hazardous drinking was derived using the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: An estimated 11.8% of Ontario adolescents (95% CI 10.1% to 13.8%) reported a history of former TBI and were not hazardous drinkers; 4.0% (95% CI 2.9% to 5.5%) reported recent TBI and were not hazardous drinkers; 13.7% (95% CI 12.3% to 15.3%) were hazardous drinkers who never had a TBI; 4.1% (95% CI 2.9% to 5.8%) had former TBI with co-occurring hazardous drinking; and 2.2% (95% CI 1.6% to 3.0%) had recent TBI with co-occurring hazardous drinking. Most odds increased significantly and were two to three times higher for reporting compromised mental health, violent and non-violent conduct behaviours, and reported victimisation for classifying as a hazardous drinker at the time of testing with co-occurring either former or recent TBI compared to classifying as not having either of these conditions. Adolescents classified as hazardous drinkers with former TBI had numerous and higher ORs for conduct behaviours than those with recent TBI. CONCLUSIONS: Results emphasise the strong interplay between TBI and hazardous drinking and point to the need for integrating prevention efforts to reduce these conditions and their co-occurrence among adolescents.

Energy Drinks, Alcohol, Sports and Traumatic Brain Injuries among Adolescents.

IMPORTANCE: The high prevalence of traumatic brain injuries (TBI) among adolescents has brought much focus to this area in recent years. Sports injuries have been identified as a main mechanism. Although energy drinks, including those mixed with alcohol, are often used by young athletes and other adolescents they have not been examined in relation to TBI. OBJECTIVE: We report on the prevalence of adolescent TBI and its associations with energy drinks, alcohol and energy drink mixed in with alcohol consumption. DESIGN, SETTINGS AND PARTICIPANTS: Data were derived from the Centre for Addiction and Mental Health's 2013 Ontario Student Drug Use and Health Survey (OSDUHS). This population-based cross-sectional school survey included 10,272 7th to 12th graders (ages 11-20) who completed anonymous self-administered questionnaires in classrooms. MAIN OUTCOME MEASURES: Mild to severe TBI were defined as those resulting in a loss of consciousness for at least five minutes, or being hospitalized for at least one night. Mechanism of TBI, prevalence estimates of TBI, and odds of energy drink consumption, alcohol use, and consumption of energy drinks mixed with alcohol are assessed. RESULTS: Among all students, 22.4% (95% CI: 20.7, 24.1) reported a history of TBI. Sports injuries remain the main mechanism of a recent (past year) TBI (45.5%, 95% CI: 41.0, 50.1). Multinomial logistic regression showed that relative to adolescents who never sustained a TBI, the odds of sustaining a recent TBI were greater for those consuming alcohol, energy drinks, and energy drinks mixed in with alcohol than abstainers. Odds ratios were higher for these behaviors among students who sustained a recent TBI than those who sustained a former TBI (lifetime but not past 12 months). Relative to recent TBI due to other causes of injury, adolescents who sustained a recent TBI while playing sports had higher odds of recent energy drinks consumption than abstainers. CONCLUSIONS AND RELEVANCE: TBI remains a disabling and common condition among adolescents and the consumption of alcohol, energy drinks, and alcohol mixed with energy drinks further increase the odds of TBI among adolescents. These associations warrant further investigation.

Waterpipe use among high school students in Ontario: Demographic and substance use correlates.

OBJECTIVE: To examine waterpipe use and its association with demographic factors, tobacco cigarette smoking, ever use of electronic cigarettes (e-cigarettes) and alcohol use among high school students. METHODS: Data were derived from the 2013 Ontario Student Drug Use and Health Survey, a school-based survey of 7th to 12th grade students. This province-wide survey was based on a stratified two-stage cluster design. Analyses were based on a subsample of 2,873 high school students and included adjustments for the complex sample design. RESULTS: Overall, 12.5% of high school students (grades 9-12) had used a waterpipe in the previous year. Awareness of waterpipes was high - 68.4% of students reported that they were aware of waterpipes but had not used one in the past year; 19.1% had never heard of waterpipes or hookah. The percentage of high school students reporting waterpipe use in the past year was similar to reports of tobacco cigarette use (12.5% and 11% respectively). Waterpipe use was highly associated with past-year tobacco cigarette and regular alcohol use as well as ever use of e-cigarettes. In multivariate analyses, males and females had similar odds of waterpipe use, and non-White students and those in higher grades had greater odds of use after controlling for other substance use. CONCLUSION: These findings suggest that waterpipe use among high school students should be of some concern and suggest the need for policy measures to address potential risks associated with use.

Ever Use of Nicotine and Nonnicotine Electronic Cigarettes Among High School Students in Ontario, Canada.

INTRODUCTION: There are limited data on the use of electronic cigarettes (e-cigarettes) among youth, particularly with regard to the use of nicotine versus nonnicotine products. This study investigates ever use of nicotine and nonnicotine e-cigarettes and examines the demographic and behavioral correlates of e-cigarette use in Ontario, Canada. METHODS: Data for 2,892 high school students were derived from the 2013 Ontario Student Drug Use and Health Survey. This province-wide school-based survey is based on a 2-stage cluster design. Bivariate and multivariate analyses were used to investigate the factors associated with ever use of e-cigarettes. Ever use of e-cigarettes was derived from the question, "Have you ever smoked at least one puff from an electronic cigarette?" All analyses included appropriate adjustments for the complex study design. RESULTS: Fifteen percent of high school students reported using e-cigarettes in their lifetime. Most students who ever used e-cigarettes reported using e-cigarettes without nicotine (72%), but 28% had used e-cigarettes with nicotine. Male, White/Caucasian, and rural students, as well as those with a history of using tobacco cigarettes, were at greater odds of e-cigarette use. Seven percent of students who had never smoked a tobacco cigarette in their lifetime reported using an e-cigarette. Five percent of those who had ever used an e-cigarette had never smoked a tobacco cigarette. CONCLUSION: More students reported ever using e-cigarettes without nicotine than with nicotine in Ontario, Canada. This underscores the need for greater knowledge of the contents of both nicotine and nonnicotine e-cigarettes to better guide public health policies.

Problem Gambling Among Ontario Students: Associations with Substance Abuse, Mental Health Problems, Suicide Attempts, and Delinquent Behaviours.

This paper describes gambling problems among Ontario students in 2009 and examines the relationship between gambling problems and substance use problems, mental health problem indicators, and delinquent behaviors. Data were derived from the Ontario Student Drug Use and Health Survey of Ontario students in grades 7-12. Gambling problems were measured as 2 or more of 6 indicators of problem gambling. In total 2.8% of the students surveyed endorsed two or more of the problem gambling items. The odds of problem gamblers reporting mental distress was 4.2 times higher than the rest of the sample and the odds of problem gamblers reporting a suicide attempt were 17.8 times greater than the rest of the sample. In addition compared to the rest of the students, delinquent behaviors were also more common among problem gamblers, including theft (OR = 14.5), selling marijuana (OR = 19.6), gang fights (OR = 11.3) and carrying a handgun (OR = 11.2). In a multivariate analysis, substance-use problems, mental health problems, and the participation in a variety of delinquent behaviors remained significantly associated with youth problem gambling behavior. Students who report problem gambling behaviors show increased substance abuse, mental health, and delinquency/criminal problems that are similar to those seen among adult problem gamblers. The association between these problems suggests that these problems could be addressed in a unified manner.

Substance Use and Related Harms Among Adolescents With and Without Traumatic Brain Injury.

OBJECTIVE: The relationship between self-reported lifetime traumatic brain injury (TBI) and drug and alcohol use and associated harms was examined using an epidemiological sample of Canadian adolescents. SETTINGS AND DESIGN: Data were derived from a 2011 population-based cross-sectional school survey, which included 6383 Ontario 9th-12th graders who self-completed anonymous self-administered questionnaires in classrooms. Traumatic brain injury was defined as loss of consciousness for at least 5 minutes or a minimum 1-night hospital stay due to symptoms. RESULTS: Relative to high schoolers without a history of TBI, those who acknowledged having a TBI in their lifetime had odds 2 times greater for binge drinking (5+ drinks per occasion in the past 4 weeks), 2.5 times greater for daily cigarette smoking, 2.9 times greater for nonmedical use of prescription drugs, and 2.7 times greater for consuming illegal drug in the past 12 months. Adolescents with a history of TBI had greater odds for experiencing hazardous/harmful drinking (adjusted odds ratio [aOR] = 2.3), cannabis problems (aOR = 2.4), and drug problems (aOR = 2.1), compared with adolescents who were never injured. CONCLUSION: There are strong and demographically stable associations between TBI and substance use. These associations may not only increase the odds of injury but impair the quality of postinjury recovery.

The moderating effects of sex and age on the association between traumatic brain injury and harmful psychological correlates among adolescents.

BACKGROUND: Although it is well established that sex is a risk factor in acquiring a traumatic brain injury (TBI) among adolescents, it has not been established whether it also moderates the influence of other TBI psychological health correlates. METHODS AND FINDINGS: Data were derived from a 2011 population-based cross-sectional school survey, which included 9,288 Ontario 7th-12th graders who completed anonymous self-administered questionnaires in classrooms. Response rate was 62%. Preliminary analyses found no evidence of nonresponse bias in the reporting of TBI. TBI was defined as a hit or blow to the head that resulted in a 5 minutes loss of consciousness or at least one overnight hospitalization due to symptoms associated with it. Reports of lifetime TBI were more common among males than females (23.1%, 95% CI: 20.5, 25.8 vs. 17.1%, 95% CI: 14.7, 19.8). Thirteen correlates were examined and included cigarette smoking, elevated psychological distress, suicide ideation, bully victimization (at school, as well as cyber bullying), bullying others, cannabis use, cannabis dependence and drug use problems, physical injuries, daily smoking, drinking alcohol, binge drinking, use of cannabis, and poor academic performance. Among the outcomes examined, sex moderated the relationship between lifetime TBI and cigarette smoking. In addition, sex and age jointly moderated the relationship between lifetime TBI and daily smoking, alcohol use and physical injuries. Late adolescent males who reported lifetime TBI, relative to females, displayed elevated daily smoking and injuries, whereas their females counterparts displayed elevated past year drinking. Possible bias related to self-report procedures and the preclusion of causal inferences due to the cross-sectional nature of the data are limitations of this study. CONCLUSIONS: TBI differences in outcomes need to be assessed for potential moderating effects of sex and age. Results have important implications for more tailored injury prevention efforts.

Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents.

OBJECTIVE: Our knowledge on the adverse correlates of traumatic brain injuries (TBI), including non-hospitalized cases, among adolescents is limited to case studies. We report lifetime TBI and adverse mental health and conduct behaviours associated with TBI among adolescents from a population-based sample in Ontario. METHOD AND FINDINGS: Data were derived from 4,685 surveys administered to adolescents in grades 7 through 12 as part of the 2011 population-based cross-sectional Ontario Student Drug Use and Health Survey (OSDUHS). Lifetime TBI was defined as head injury that resulted in being unconscious for at least 5 minutes or being retained in the hospital for at least one night, and was reported by 19.5% (95%CI:17.3,21.9) of students. When holding constant sex, grade, and complex sample design, students with TBI had significantly greater odds of reporting elevated psychological distress (AOR = 1.52), attempting suicide (AOR = 3.39), seeking counselling through a crisis help-line (AOR = 2.10), and being prescribed medication for anxiety, depression, or both (AOR = 2.45). Moreover, students with TBI had higher odds of being victimized through bullying at school (AOR = 1.70), being cyber-bullied (AOR = 2.05), and being threatened with a weapon at school (AOR = 2.90), compared with students who did not report TBI. Students with TBI also had higher odds of victimizing others and engaging in numerous violent as well as nonviolent conduct behaviours. CONCLUSIONS: Significant associations between TBI and adverse internalizing and externalizing behaviours were found in this large population-based study of adolescents. Those who reported lifetime TBI were at a high risk for experiencing mental and physical health harms in the past year than peers who never had a head injury. Primary physicians should be vigilant and screen for potential mental heath and behavioural harms in adolescent patients with TBI. Efforts to prevent TBI during adolescence and intervene at an early stage may reduce injuries and comorbid problems in this age group.

Subjective social status, immigrant generation, and cannabis and alcohol use among adolescents.

Research indicates that subjective perceptions of socioeconomic status (SES) affect aspects of health and behavior. There has been little research attention to how objective (e.g., education) and subjective aspects of SES may differ in their influence on the substance use of adolescent immigrants. The present study examined whether the associations between subjective SES and substance use, and between parental education and substance use varied by immigrant generation. Data were derived from the 2011 Ontario Student Drug Use and Health Survey, a representative survey of students in the 7th to 12th grade. The sample for this study consisted of 9177 students 12-19 years of age; 48.4 % were female, 66.4 % were White/European, 5.2 % Black/Afro-Caribbean, 16.4 % Asian and 12 % other. Results indicated that subjective SES was more strongly associated with cannabis and alcohol use among first-generation immigrants than among adolescents of other immigrant generations even after adjusting for parental education. First-generation immigrants with low subjective SES had a lower probability of cannabis and regular alcohol use, but there was no difference in use between immigrant generations at high subjective SES. The associations between parental education and cannabis and alcohol use did not significantly vary with immigrant generation. The findings highlight the importance of status beliefs among adolescents, particularly among first-generation immigrants, and suggest that further research attention to such beliefs would enhance our understanding of SES and its links to adolescent health risk behaviors.