Trends in Varenicline Use for Tobacco Cessation, and Their Implications.

BACKGROUND: Tobacco use remains a leading cause of death in the U.S. Varenicline is a preferred medication for tobacco cessation, and a prior report in the literature showed its use fell dramatically after the voluntary recall of Chantix (name-brand varenicline) in July 2021. OBJECTIVES: Working with data on prescriptions for varenicline and nicotine-replacement therapy (NRT), we studied use from 2018 to 2023 to determine if varenicline use had recovered or if there had been a compensatory increase in NRT use. METHODS: Data are yearly from state employees and their dependents who were aged >18 years and were health-insurance beneficiaries of the Washington Public Employees Benefits Board from July 2018 through June 2023. Data include numbers of tobacco users and numbers of prescriptions filled. RESULTS: The 5-year prevalence of tobacco use among 224,816 beneficiaries was 4.6%. The percentage of tobacco users who filled a prescription for varenicline fell from highs of 9.5% and 9.6% in the 2018-2019 and 2019-2020 year to lows of 5.3% and 6.4% in the 2021-2022 and 2022-2023 years. For nicotine replacement therapy, prescriptions rose modestly over the 5 years, from 4.5% in 2018-2019 to 6.0% in 2022-2023. DISCUSSION: Varenicline use dropped after the voluntary recall of Chantix by Pfizer in mid-2021 and has not returned to pre-recall levels. CONCLUSION: Pharmacists and other clinicians should address this drop, in addition to addressing longer-term challenges to increasing varenicline use; these include the requirement for a prescription and the black-box warning by the Food and Drug Administration, rescinded in 2016.

Threaten, Distract, and Discredit: Cannabis Industry Rhetoric to Defeat Regulation of High-THC Cannabis Products in Washington State.

OBJECTIVE: Washington State legislators have attempted to regulate high delta-9-tetrahydrocannabinol (THC) cannabis to reduce cannabis-related harms. Historically, industry actors of other health-compromising products have influenced governments' adoption of evidence-based regulation policies. A better understanding of the industry rhetoric can be used by public health advocates to develop counterarguments and disseminate alternative narratives that protect the public's health. We analyzed the arguments used by cannabis industry actors opposing regulations to de-incentivize the availability and use of high-THC products in Washington State. METHOD: We analyzed 41 testimonies transcribed from 33 cannabis industry actors in 3 public bill hearings and one legislative work session that occurred between 2020 and 2023. Using a deductive thematic analysis, informed by industry actors' arguments opposing regulation of alcohol, tobacco, and high-sugar beverages, we developed a codebook to analyze and identify themes within cannabis industry rhetorical strategies. RESULTS: We identified three main rhetorical strategies used by cannabis industry actors to oppose THC content regulation: threaten, distract, discredit. The most frequently used rhetorical strategy was threats to economic benefits, public health, and the will of the people. The other two most apparent strategies were distracting from the bill's focus by introducing a tangential topic and discrediting the science that supported regulation of cannabis products with high THC concentration or its advocates. CONCLUSIONS: Cannabis industry actors have leveraged several arguments used by industry actors of other health-compromising products to undermine initiatives to advance public health. They have also adapted rhetoric from other industries to the unique conditions of the cannabis regulatory landscape.

Identifying policy options to regulate high potency cannabis: A multiple stakeholder concept mapping study in Washington State, USA.

BACKGROUND: Cannabis legalization in some U.S.A. states has catapulted the mass production of concentrates, with tetrahydrocannabinol (THC) concentrations ranging from 50-90%. A major public health concern is that these products will increase cannabis-related harms such as use disorders, psychotic symptoms, and accidental poisonings. This paper describes and contextualizes the results of a study requested by the WA State Legislature to understand perspectives of WA stakeholders on the topic. METHODS: Concept Mapping (CM), a mixed-methods research approach that supports people-centered policy decisions was utilized. The goal of the study was to explore stakeholders' concern levels and support of policies to address the availability of high THC cannabis products. For analysis purposes, stakeholders were categorized into three groups: community, professionals, and cannabis advocates. RESULTS: CM generated an inventory of policy ideas for regulating high-potency cannabis from a variety of stakeholders. Notably, stakeholders from community and professional groups supported environmental policy changes such as such as taxation, increasing minimum age for high concentration cannabis products, and advertising prohibition. Meanwhile, cannabis advocates (mostly industry actors) opposed taxation per THC content, proposed lowering taxes, and supported policies with low population impact such as educating parents, teachers, and youth. CONCLUSION: Support for regulating high concentration THC products varied by stakeholder group. Consistent with how other health compromising industries have historically acted, cannabis industry stakeholders rejected regulation of their products. Future studies should explore non-cannabis industry stakeholders' willingness to work towards minimizing the influence of the cannabis industry in policy development processes to assure public health regulations prevail.

How should policymakers regulate the tetrahydrocannabinol content of cannabis products in a legal market?

An increased use of high-potency cannabis products since cannabis legalization in the United States, Canada and elsewhere may increase cannabis-related harm. Policymakers have good reasons for regulating more potent cannabis in ways that minimize harm, using approaches similar to those used to regulate alcohol; namely, banning the sale of high-potency cannabis, setting a cap on tetrahydrocannabinol (THC) content and imposing higher rates of taxes on more potent cannabis products. Given the difficulty that US policymakers have had in regulating cannabis extracts and edibles, governments that are planning to legalize cannabis need to put policies on extracts into enabling legislation and evaluate the impact of these policies on cannabis use and cannabis-related harms.

Cannabis-only use in the USA: prevalence, demographics, use patterns, and health indicators.

BACKGROUND: The prevalence of adults who consume cannabis while abstaining from other substances is not known in the USA. This study used nationally representative data to estimate the prevalence and explore the demographic characteristics, cannabis use behaviors, and self-reported health of US adults with past 30-day cannabis-only use, as compared with adults who used cannabis as well as other substances. METHODS: Data came from adults 18 years and older who responded to the 2017 or 2018 National Survey on Drug Use and Health and reported past 30-day cannabis use (n = 12,143). Cannabis-only use was defined as past 30-day cannabis use with no past 30-day use of other substances (alcohol, tobacco, other illicit substances, non-prescribed controlled medications). Weighted frequencies and 95% confidence intervals (CI) were computed for all sociodemographic and cannabis-related variables, overall, and across the two categories of cannabis consumers, stratified by age. RESULTS: The prevalence of past 30-day cannabis-only use among US adults was 0.9% (95% CI: 0.8, 1.0) and varied by age (2.0% of 18-25 years old; 0.7% of 26-49 year olds, and 0.6% of those ≥ 50 years). Among adults with any past 30-day cannabis use, 8.4% (95% CI: 7.6, 9.2; n = 980) reported cannabis-only use. Age was significantly associated with past 30-day cannabis-only use, with adults 18-25 years and 26-49 years having higher odds of cannabis-only use compared with older adults. Past year cannabis dependence was lowest among cannabis-only consumers aged ≥ 50 years (0.2%; 95% CI: 0.1, 0.5) and highest among young adult cannabis and other substance consumers (16.7%; 95% CI: 15.3, 18.2). Past year prevalence of any mental illness was generally similar across cannabis use groups and by age. CONCLUSIONS: The prevalence of adult cannabis-only use in the US is low - most cannabis consumers report using other substances in the past 30 days as well. While cannabis-only use among older adults is rare, it does not appear to be accompanied by a high prevalence of dependence. These findings should guide future research and policymaking.

Cannabis Industry Marketing Violations in Washington State, 2014-2019.

OBJECTIVE: The purpose of this study was to describe marketing violations from the cannabis industry in Washington State. METHOD: The study team obtained records of all Washington State cannabis marketing violations from October 2014 to September 2015, immediately following the legal cannabis market opening, and May 2017 to July 2019. A code book was developed based on the Washington State regulations related to marijuana advertising. Each marketing violation was coded according to ad characteristics including ad size, location, or type; content; business practices; and lack of mandatory health warnings. RESULTS: A total of 328 violations were analyzed, from 183 different businesses. Marketing violations occurred most frequently in content posted online or directly in front of cannabis stores. Community members were as likely to identify violations as officers from the Washington State Liquor and Cannabis Board (WSLCB), the state agency in charge of regulation and enforcement of cannabis businesses. Very few violations were reported from competing members of the cannabis industry. Violations reported by the community were mostly related to content appealing to minors, whereas WSLCB officers were more likely to identify violations related to ad location in public spaces and ad size. CONCLUSIONS: This study shows the conflict between prevention and profit in the nascent cannabis industry and the importance of community involvement in the regulation of cannabis marketing.

Cannabis Retail Staff ("Budtenders") Attitudes Towards Cannabis Effects on Health and Experiences Interacting with Consumers - Washington State, USA.

Cannabis legalization in Washington State has increased the availability, consumption, and potency of cannabis products for adults. Public health education promoting safe use for adult consumers has lagged behind these trends. This study assesses the potential of cannabis retail workers (budtenders) to engage in responsible use education with adult consumers at point of sale. Focus groups explored how budtenders perceive their professional role, including educating consumers about cannabis over intoxication, storage, and risks of use before driving and during pregnancy. Transcripts were analyzed to develop a coding scheme, which was then applied with an iterative review by the research team. Budtenders identified three main professional roles: creating a good experience for customers; being compliant with the state law and regulations, and educating customers on products. Budtenders did not believe their job involved discussing use during pregnancy or while driving or safe storage. They prioritized customers' autonomy over education on these topics, and they did not necessarily consider these behaviors to be harmful. Budtenders are committed to keeping minors outside stores and educating consumers on how to avoid over intoxication and exposure to cannabis contaminants. Future research could build on this to develop point-of-sale education to reduce cannabis use risks.

The Kids Are Not All Right: E-cigarettes, Cannabis Co-Use, and an Emerging Public Health Crisis--A Commentary on Roberts et al. (2022).

The Roberts et al. commentary highlights the "looming public health emergency" of e-cigarettes and cannabis co-use among young people and the urgency to make deliberate efforts to address dual use now. We agree and want to further elaborate on some of their comments.

Understanding the intergenerational transmission of substance use and problem behavior: Implications for future research and preventive interventions.

The Constitution of the Iroquois Nation states that we should "look and listen for the welfare of the whole people and have always in view not only the present, but also the coming generations." The excellent intergenerational longitudinal studies represented here help us better understand patterns of behaviors across generations. Collectively, these studies provide a pathway for future research on contexts and trends in substance use, research on age of onset among early generations, and research related to epigenetics to improve prevention interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Marijuana Use and Adherence to Smoking Cessation Treatment Among Callers to Tobacco Quitlines.

INTRODUCTION: Tobacco kills over half a million adults annually in the United States. Most smokers want to quit, and over 400,000 call state-funded quitlines for help each year. Marijuana use among tobacco users is common and may impede quitting, but co-use rates among quitline callers are unknown. The purpose of our observational study was to describe marijuana use among quitline callers in states with legalized marijuana. METHODS: Participants were 1,059 smokers aged 21 or older from Oregon, Alaska, and Washington, DC, who called quitlines from September through December 2016. Data on quitline callers' demographics, tobacco and marijuana use, and quitline use were collected. We used χ2 and regression analyses to compare marijuana users with nonusers on demographic characteristics and quitline use. RESULT: Among quitline callers in our study, 24% reported using marijuana in the past 30 days: 28.9% in Alaska, 16.7% in Washington, DC, and 25.0% in Oregon (P = .009). Current users, compared with non-users (n = 772), were less likely to be women (48.4% vs 62.0%, respectively, P < .001). Current marijuana users were less likely to be given nicotine replacement therapy (68.4%) than current nonusers (74.1%) (P < .001), but more likely to complete 3 or more counseling calls (P = .005). Of those who used marijuana in the past 30 days, 62.3% used marijuana on 1 to 19 days, 9.0% used on 20 to 29 days, and 28.7% on all 30 days. Among current marijuana users, the percentage who wanted to quit or reduce marijuana use (42.6%) was higher in Alaska (54.6%) and the District of Columbia (56.8%) than in Oregon (37.9%), P = .03. CONCLUSION: One in 4 quitline callers reported past 30-day marijuana use. Given that nearly half (43%) wanted to reduce marijuana use, addressing co-use may be an important addition to quitline treatment. Future studies should assess co-use effects on tobacco cessation outcomes and explore combined treatment or bidirectional referrals between quitlines and marijuana treatment providers.

A Taxonomy of Consumers' Perspectives on the Function of Cannabis in Their Lives: A Qualitative Study in WA State, USA.

US state-level policy often divides legal cannabis use into medical and recreational categories. However, research suggests medical and non-medical cannabis consumption often overlaps and consumers' relationship with cannabis may change. This study aimed to understand cannabis consumption from the perspective of consumers. Focus group participants shared their perspectives on motivations, settings, and contexts for consumption. A three-category taxonomy of cannabis consumption emerged from the data - Casual, intentional, and therapeutic. Within each category, there is potential for high- and low-risk behaviors. In the casual group, participants rarely purchased cannabis and only partook if it was freely available. Participants in the intentional group were knowledgeable about the effects produced by different strains, THC levels, and product types, and were frequently self-aware. In the therapeutic group, participants consumed cannabis for physical or mental health conditions. Our findings suggest the medical/non-medical dichotomy used in policy development, clinical care, and research may not reflect how regular consumers perceive the function of cannabis in their lives. Our findings suggest more research is needed to identify cannabis' role in improving quality of life, when it increases behavioral risk, and the intersection of cannabis and disability.

Anytime is the Right Time: A Content Analysis of Marijuana Ads in Freely Distributed Print Media in Western Washington State, USA.

Background: Cannabis advertisement content in print media has not yet been studied, despite youth high exposure to them. This study analyzes cannabis ads content in two publications in Western Washington State, USA. Methods: Content analysis of 305 cannabis advertisements published in 2017 in two free print publications was performed with support of NVivo software. A deductive approach was utilized, leveraging alcohol advertisement studies' coding frames and adding cannabis-specific codes in an iterative process. Coding was performed using a two-step analytical procedure. Results: Ads depicted the use of cannabis as part of everyday life and coopted mainstream events such as holidays to promote sales. Ads of cannabis products emphasized lifestyles that conveyed enjoyment of time in nature; such as scenes of people sitting by waterfalls, contemplating natural landscapes, paddle boarding, and canoeing. A sizeable proportion of the cannabis ads shared with alcohol ads an emphasis on the personal and social rewards of using these products, rather than product features, such as quality and taste. Conclusions: In WA State, cannabis use ads content tend to focus on solitude and outdoor recreation rather than parties and team sports, a common theme in alcohol ads. While the themes differ from alcohol, marijuana marketing mimics strategies used by alcohol industries, such as promoting the identification of their products with lifestyles and values considered appealing to attract new consumers. Many ads presented content known to appeal to youth, with content designed to elicit responses based on emotions rather than cognition.

Predictors of engagement in post-discharge quitline counseling among hospitalized smokers.

Quitlines provide evidence-based tobacco treatment and multiple calls yield higher quit rates. This study aimed to identify subgroups of smokers with greater quitline engagement following referral during hospitalization. Data were from a randomized clinical trial assessing the effectiveness of fax referral (referral faxed to proactive quitline) versus warm handoff (patient connected to quitline at bedside) (n = 1054). Classification and regression trees analyses evaluated individual and treatment/health system-related variables and their interactions. Among all participants, warm handoff, higher ratings of the tobacco treatment care transition, and being older predicted completing more quitline calls. Among patients enrolled in the quitline, higher transition of care ratings, being older, and use of cessation medication post-discharge predicted completing more calls. Three of the four factors influencing engagement were characteristics of treatment within the hospital (quality of tobacco treatment care transition and referral method) and therapy (use of cessation medications), suggesting potential targets to increase quitline engagement post-discharge.

Drug helplines and adult marijuana users: An assessment in Washington, Colorado, Oregon, and Alaska.

Drug helplines are well-known and widely utilized resources for those seeking help with managing their substance use. Using "secret shoppers," a preliminary assessment of the drug helplines in 4 states was performed. Eleven calls were placed to the helpline staff, where the secret shopper posed as an adult users of marijuana interested in decreasing their marijuana use and asked questions about cannabinoids and methods of marijuana consumption. In 100% of the calls placed, helpline staff had no knowledge about the effects and interactions of marijuana's 2 main components (tetrahydrocannabinol [THC] and cannabidiol [CBD]), neither could they explain the risk differential of smoking, eating, or vaporizing marijuana. In all but one of the calls placed, helpline responders were respectful and empathic. The assessment suggests that drug helplines are equipped with a respectful, empathetic, and nonjudgmental staff who lack important knowledge to best serve those seeking help for marijuana use.

Use of Marijuana and Other Substances Among Pregnant and Parenting Women With Substance Use Disorders: Changes in Washington State After Marijuana Legalization.

OBJECTIVE: In 2012, possession of marijuana for nonmedical use was legalized in Washington State. This study examined how legalization affected alcohol and drug use in a sample of pregnant and parenting women with substance use disorders. METHOD: Study participants from nine counties in Washington State (N = 1,359) were questioned about their substance use after completing a 3-year case management intervention program. The sample was divided into two cohorts based on whether participants had completed the program before or after legalization. RESULTS: Most study participants reported complete abstinence from alcohol and nonprescription drugs at program exit. Among those who were still using substances, women who completed the intervention after marijuana legalization were significantly more likely to report marijuana use at program exit compared with women who completed the intervention before marijuana legalization. Across both cohorts (pre- and post-legalization), we found a positive association of exit marijuana use with alcohol, illegal methadone, other opioids, amphetamines, and cocaine use; even when we controlled for historical period, the association with some of these substances with marijuana use remained evident. Independent of marijuana use, we saw increased use during the post-legalization period of alcohol, illicit methadone, and other opioids. CONCLUSIONS: Marijuana use at exit from the Parent-Child Assistance Program (PCAP) increased significantly after marijuana legalization in the state. Women who were not abstinent from marijuana at program exit were likely to report use of other substances as well. Our study design demonstrates an association but does not allow us to conclude that marijuana use leads to other substance use among this sample of women with a history of polysubstance use.

Medicinal Cannabis: A Survey Among Health Care Providers in Washington State

INTRODUCTION: Washington State allows marijuana use for medical (since 1998) and recreational (since 2012) purposes. The benefits of medicinal cannabis (MC) can be maximized if clinicians educate patients about dosing, routes of administration, side effects, and plant composition. However, little is known about clinicians' knowledge and practices in Washington State. METHODS: An anonymous online survey assessed providers' MC knowledge, beliefs, clinical practices, and training needs. The survey was disseminated through health care providers' professional organizations in Washington State. Descriptive analysis compared providers who had and had not authorized MC for patients. Survey results informed the approach and content of an online training on best clinical practices of MC. RESULTS: Four hundred ninety-four health care providers responded to the survey. Approximately two-third were women, aged 30 to 60 years, and working in family or internal medicine. More than half of the respondents were legally allowed to write MC authorizations per Washington State law, and 27% of those had issued written MC authorizations. Overall, respondents reported low knowledge and comfort level related to recommending MC. Respondents rated MC knowledge as important and supported inclusion of MC training in medical/health provider curriculum. Most Washington State providers have not received education on scientific basis of MC or training on best clinical practices of MC. Clinicians who had issued MC authorizations were more likely to have received MC training than those who had not issued MC authorization. DISCUSSION: The potential of MCs to benefit some patients is hindered by the lack of comfort of clinicians to recommend it. Training opportunities are badly needed to address these issues.