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BackgroundIn U.S. states that legalized and commercialized recreational cannabis, cannabis sales in illegal markets are still sizable or even larger than those in legal markets. This study aimed to assess cannabis consumers' preferences for purchasing cannabis from legal and illegal markets and estimate the trade-offs under various policy scenarios.Methods963 adults were recruited, who used cannabis in the past year and lived in a state with recreational cannabis legalization. In a discrete choice experiment, participants chose purchasing cannabis from a legal dispensary or an illegal dealer with varying levels in product attributes including quality, safety, accessibility, potency, and price. Mixed logit models were used to analyze preferences.ResultsThe likelihood of choosing legal cannabis increased with a higher quality, the presence of lab test, a shorter distance to seller, a higher tetrahydrocannabinol level, and a lower price. The likelihood of choosing illegal cannabis increased with a higher quality, a shorter distance to seller, and a lower price. Among product attributes, quality and accessibility were perceived to be the most important for legal cannabis and price was perceived to be the most important for illegal cannabis. Policy simulations predicted that improving quality, ensuring safety, allowing delivery services, increasing dispensary density, and lowering prices/taxes of legal cannabis may reduce illegal cannabis market share.ConclusionsIn the U.S., cannabis consumers' preferences for illegal cannabis were associated with both legal and illegal cannabis product attributes. Policies regulating legal cannabis markets should consider potential spillover effects to illegal markets.

ObjectiveTo investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000-2019 decline in cigarette smoking among US 18-24 year-olds.MethodsSmoking behaviour was assessed in the 24 most populous US states using the 1992-2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011.ResultsBetween 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018-2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean.ConclusionNational programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

ObjectiveTo compare trends in cigarette smoking and nicotine vaping among US population aged 17-18 years and 18-24 years.MethodsRegression analyses identified trends in ever and current use of cigarettes and e-cigarettes, using three US representative surveys from 1992 to 2022.ResultsFrom 1997 to 2020, cigarette smoking prevalence among those aged 18-24 years decreased from 29.1% (95% CI 27.4% to 30.7%) to 5.4% (95% CI 3.9% to 6.9%). The decline was highly correlated with a decline in past 30-day smoking among those aged 17-18 years (1997: 36.8% (95% CI 35.6% to 37.9%; 2022: 3.0% (95% CI 1.8% to 4.1%). From 2017 to 2019, both ever-vaping and past 30-day nicotine vaping (11.0% to 25.5%) surged among those 17-18 years, however there was no increase among those aged 18-24 years. Regression models demonstrated that the surge in vaping was independent of the decline in cigarette smoking. In the 24 most populous US states, exclusive vaping did increase among those aged 18-24 years, from 1.7% to 4.0% to equivalent to 40% of the decline in cigarette smoking between 2014-15 and 2018-19. Across these US states, the correlation between the changes in vaping and smoking prevalence was low (r=0.11). In the two US states with >US$1/fluid mL tax on e-cigarettes in 2017, cigarette smoking declined faster than the US average.ConclusionsSince 1997, a large decline in cigarette smoking occurred in the US population under age 24 years, that was independent of the 2017-19 adolescent surge in past 30-day e-cigarette vaping. Further research is needed to assess whether the 2014-15 to 2018-19 increase in exclusive vaping in those aged 18-24 years is a cohort effect from earlier dependence on e-cigarette vaping as adolescents.

Cannabis users use different forms of cannabis, which are associated with distinct public health concerns. Policies that aim to regulate one specific form may have unintended impacts on other forms. This study examined the behavioral economic relationship between flower and concentrates, the two most common forms of cannabis. We surveyed 605 adult cannabis users (21+) who lived in one of the U.S. states that had legalized recreational cannabis by the time of interview in 2019. The participants completed simulated purchase tasks, which asked how much cannabis flower and concentrates they would purchase in the next 30 days at escalating prices. We estimated (a) demand indices and own-price elasticities using nonlinear exponential demand models and (b) group- and individual-level cross-price elasticities using log-linear demand models. The estimated rate of change in demand elasticity (α) was 0.00066 for cannabis flower (SE = 0.00002, p < .001) and 0.00058 for cannabis concentrate (SE = 0.00002, p < .001). Group-level cross-price elasticity estimate (slope = -0.075, SE = 0.0135, p < .001) indicated that cannabis flower and concentrates were weak complements. Individual-level cross-price elasticity estimates showed that flower and concentrates were treated as independent by 76.2% of the users, as complements by 19.0% of the users, and as substitutes by 4.8% of the users. The findings suggested that cannabis flower and concentrates were overall weak complements and for most adult cannabis users were treated as independent of each other. Price and tax policies regulating either cannabis form may have minimal impacts on the other form. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

BackgroundIn the United States (U.S), cannabis policies have been increasingly liberalized whereas tobacco policies have been increasingly stringent. Given the high prevalence of cannabis and tobacco dual use, there are concerns that a policy regulating one substance may unintendedly influence the other. This study examined the responsiveness of the demand for cannabis joints and cigarettes when price varied.MethodsThe study included 338 adult participants (21+) who used both cannabis and tobacco and lived in one of the U.S. states with recreational cannabis legalized by the time of interview in 2019. They completed hypothetical purchase tasks to indicate the quantity desired of cannabis joints and cigarette packs 1) when only one substance was available with escalating prices and 2) when both substances were concurrently available with escalating prices of cannabis joints and a fixed price of cigarette packs. We estimated 1) the own-price elasticity of demand for each substance using nonlinear exponential demand model, and 2) the cross-price elasticity of demand at aggregate level using nonlinear exponential demand model and at individual level using log-linear demand model.ResultsThe estimates for the rate of change of own-price elasticity (α) were 0.0011 (SE = 0.000039, p  0.05) suggest an independent relationship between the two substances. At individual level, 78.70% of the participants treated the two substances as independent, 17.46% as complements, and 3.85% as substitutes.ConclusionsFor most adults who used both cannabis and tobacco in the U.S., cannabis joints and cigarettes had an independent relationship. Policies regulating the price of cannabis may not have large unintended consequences on cigarette use.

BackgroundOlder adults are the least active population in the U.S. Low-income communities have fewer physical activity (PA) resources, contributing to less PA and increased chronic disease risk. This study assessed the effect of the multilevel, peer-led, Peer Empowerment Program 4 Physical Activity (PEP4PA) on moderate-to-vigorous PA (MVPA) and health outcomes, over 2 years of follow up.MethodsIn a cluster-randomized controlled trial, 12 senior or community centers serving low-income older adults were assigned to a PA intervention (n = 6) or usual programming (n = 6) condition. PEP4PA included self-monitoring, health coaching, group walks, social support, and community advocacy to improve walking conditions. The primary outcome was daily minutes of MVPA (7-day accelerometer). Secondary outcomes included Perceived Quality of Life (PQoL), 6-Minute Walk Test (6-MWT), blood pressure (BP), and depressive symptoms at baseline, 6, 12, 18 and 24 months. Mixed effects regression models estimated the effects on outcomes between groups over time and included random effects for repeated measures and center clustering. Effect modification by sex and income status was assessed. We calculated the incremental cost per daily minute of MVPA gained in the intervention group relative to the control group to assess cost effectiveness.ResultsWe enrolled 476 older adults (50 + years). Participants were on average 71 years old, 76% female, 60% low income, and 38% identified as racial or ethnic minorities. Compared to the control group, intervention participants sustained roughly a 10 min/day increase in MVPA from baseline at all time points and increased mean PQoL scores from unsatisfied at baseline to satisfied at 12, 18 and 24 months. Males and higher-income groups had greater improvements in MVPA. No significant effects were observed for 6-MWT or depressive symptoms, and BP results were mixed. The incremental cost per minute MVPA gained per person was $0.25, $0.09, $0.06, and $0.05 at 6, 12, 18 and 24 months, respectively.ConclusionsPEP4PA achieved increases in MVPA and PQoL in low-income older adults, over 2 years of follow up. The peer-led, community-based intervention provides a sustainable and cost-effective model to improve health behaviors in underserved, aging populations.Trial registrationClinicalTrials.gov ( NCT02405325 ) March 20, 2015.

The uptake rate of COVID-19 vaccines among children remains low in the U.S. This study aims to 1) identify sociodemographic and behavioral factors influencing parental refusal of vaccinating children, and 2) quantify the relative importance of vaccine characteristics in parental hesitancy of vaccinating children. An online survey was conducted from October to November 2021 among a probability-based, representative sample of 1456 parents with children under age 18. The survey included a discrete choice experiment asking parents to choose between two hypothetical COVID-19 vaccine alternatives with varying levels of characteristics in 10 hypothetical scenarios. Logistic regressions were used to estimate parental refusal (refused to choose any vaccine alternatives in all hypothetical scenarios) and random parameter logit regressions were used to estimate parental hesitancy (choice of vaccine alternatives depended on vaccine characteristics) of vaccinating children. About 20% parents refused to vaccinate children. The refusal is predicted by parents' sociodemographic characteristics, political orientation, vaccination status, and parents' and children's previous exposure with COVID-19. Among parents who were willing to consider vaccinating children, the most important vaccine characteristics are risk of severe side effects (31.2% relative importance) and effectiveness (30.7%), followed by protection duration (22.6%), local coverage (9.4%), and hospitalization rate of unvaccinated children (6.1%). Our findings imply that policymakers and public health professionals could develop outreach programs at community level to encourage specific subgroups and focus on vaccination depoliticization. Effectively communicating the low risk of severe side effects and high effectiveness of the vaccines may relieve some of the parental hesitancy.

AimsThis study estimated the likelihoods of individuals transitioning to different cannabis use status following recreational cannabis legalization (RCL) in the United States.DesignSecondary analysis of a nationally representative longitudinal cohort in the United States. We used propensity score matching to balance individual characteristics between RCL and comparison states and generalized mixed regressions to estimate behavioral transitions in matched samples.ParticipantsA longitudinal cohort of 21 863 individuals (6925 youths and 14 938 adults) participating in the Population Assessment of Tobacco and Health waves 3 and 4.SettingFour RCL states that implemented RCL between waves 3 and 4 (California, Massachusetts, Nevada and Maine) and comparison states in the United States.MeasurementsTransitions in cannabis use over the two waves: (1) from non-users to users; (2) from non-users to weekly users; (3) from users to non-users. Individuals in RCL states were compared with matched individuals in (1) states with medical cannabis legalization (MCL), (2) states not legalizing cannabis (non-legalizing) and (3) MCL and non-legalizing states combined.FindingsAmong youths, the association between RCL and greater odds of transition from non-users to users was seen in comparison with non-legalizing states [odds ratio (OR) = 2.18, 95% confidence interval (CI) = 1.37-3.45] and combined states (OR = 1.73, 95% CI = 1.23-2.42). Evidence was lacking regarding the associations between RCL and transitions from non-users to weekly users and from users to non-users. Among adults, RCL was associated with greater odds of transitions from non-users to users and non-users to weekly users if RCL states were compared with non-legalizing states (OR = 1.68, 95% CI = 1.15-2.46; OR = 1.82, 95% CI = 1.00-3.31, respectively) or combined states (OR = 1.51, 95% CI = 1.11-2.07; OR = 2.09, 95% CI = 1.19-3.66, respectively). RCL was also associated with lower odds of transition from users to non-users if RCL states were compared with non-legalizing states (OR = 0.54, 95% CI = 0.35-0.81).ConclusionsThere appears to be some evidence that recreational cannabis legalization in the United States is associated with elevated odds of transition to cannabis use among both youths and adults.

BackgroundHeated tobacco products (HTP) generate nicotine-containing aerosol by heating tobacco rather than burning it. The US Food and Drug Administration (FDA) has recently authorised the sale of one HTP brand, iQOS, in the USA. This study examined the awareness, use and risk perceptions of HTP in the USA following FDA authorisation.MethodsA national probability sample of 20 449 US adults completed an online survey between November 2019 and February 2020. In addition to assessing awareness and use of HTP, two ratios were calculated: the ratio of those who experimented with HTP given that they had heard about it (E/H) and the ratio of those who currently used HTP given experimentation (C/E). These ratios for HTP were compared against those for e-cigarettes from a similar national survey in 2012.ResultsOverall, 8.1% of respondents had heard of HTP. Only 0.55% had tried and 0.10% were current users. The rate of experimentation among those who heard about HTP and the rate of current use among experimenters were, however, similar to those for e-cigarettes in 2012: E/H and C/E for HTP were 6.8% and 18.2%, respectively; and 10.7% and 17.8%, respectively for e-cigarettes. The majority of respondents considered HTP either less harmful than (11.6%), or equally harmful as e-cigarettes (42.7%).ConclusionsOnly a small fraction of US population in 2020 have tried any HTP. However, the similarity in early adoption rates following awareness, suggests that future adoption for HTP may be similar to that for e-cigarettes, if HTP are marketed more aggressively.

BackgroundThere is an expanding unregulated market for a psychotropic compound called ∆8-Tetrahydrocannabinol (delta-8-THC) that is being derived from hemp, but there are no empirical estimates of public interest in this compound.MethodsTo measure public interest, we obtained yearly Google query fractions (QFs) that mentioned delta-8-THC (i.e., "delta 8," "delta-8," or "Δ8") for the past decade (from January 2011 through August 2021) for every country and territory in the world and every state in the United States (US) from Google Trends. We also obtained the same trends for the last complete month of data for all US states (July 2021) to compare across cannabis use policies. We summarized QFs across years, countries, US states and cannabis policies in US states using linear regression, means and ratios. We estimated raw search counts for the US using comscore.com.ResultsThe global rate of delta-8-THC searches was stable between 2011 and 2019 before increasing by 257.0% from 2019 to 2020 and 705.0% from 2020 to 2021. In 2021, the rate of delta-8-THC searches in the US was at least 10 times higher than the rates in other countries or territories. In absolute terms, there were 22.3 million delta-8-THC searches in the US in the first 8 months of 2021 alone. Increases in delta-8-THC searches from 2020 to 2021 occurred in all 50 US states and the District of Columbia (Mean 854.2%; range = 256.4% - 2831.2%) but continued to vary substantially between states in 2021. In July 2021, the legal status of delta-9-THC use across US states explained 49.0% of the variance in delta-8-THC QFs between US states (R2 = 0.490; p < 0.001) and was inversely associated, where delta-8-THC QFs were higher in jurisdictions with stricter cannabis use policies.ConclusionPublic interest in delta-8-THC increased rapidly in 2020 and 2021 and was particularly high in US states that restricted delta-9-THC use. Jurisdictions should clarify whether delta-8-THC can be sold as a hemp product.

RationaleMinorities often bear the brunt of unequal enforcement of drug laws. In the U.S., Blacks have been disproportionately more likely to be arrested for cannabis possession than Whites despite a similar rate of cannabis use. Decriminalizing cannabis has been argued as a way to reduce racial disparity in cannabis possession arrests. To date, however, the empirical evidence to support this argument is almost non-existent.ObjectivesTo examine whether cannabis decriminalization was associated with reduced racial disparity in arrests for cannabis possession between Blacks and Whites in the U.S.MethodsUsing FBI Uniform Crime Report data from 37 U.S. states, cannabis possession arrest rates were calculated separately for Blacks and Whites from 2000 to 2019. A difference-in-differences framework was used to estimate the association between cannabis decriminalization and racial disparity in cannabis possession arrest rates (Blacks/Whites ratio) among adults and youths.ResultsCannabis possession arrest rates declined over 70% among adults and over 40% among youths after the implementation of cannabis decriminalization in 11 states. Among adults, decriminalization was associated with a roughly 17% decrease in racial disparity in arrest rates between Blacks and Whites. Among youths, arrest rates declined among both Blacks and Whites but there was no evidence for a change in racial disparity between Blacks and Whites following decriminalization.ConclusionsCannabis decriminalization was associated with substantially lower cannabis possession arrest rates among both adults and youths and among both Blacks and Whites. It reduced racial disparity between Blacks and Whites among adults but not youths. These findings suggested that cannabis decriminalization had its intended consequence of reducing arrests and may have potential to reduce racial disparity in arrests at least among adults.

Background and aimsCannabis use disorder (CUD) during pregnancy has increased dramatically in the United States (US). This study examined the associations between prenatal CUD and adverse neonatal outcomes and heterogeneities in the associations by mothers' tobacco use status and race/ethnicity.DesignPopulation-based, retrospective cohort study.SettingCalifornia, USA.ParticipantsA total of 4.83 million mothers who delivered a live singleton birth during 2001 to 2012 and their paired infants. Data were obtained from mother-infant linked hospital discharge records and birth and death certificates. Identified by ICD-9 codes recorded at delivery, 20 237 mothers had prenatal CUD.MeasurementsNeonatal outcomes included length of gestation, preterm birth, birth weight, admission into neonatal intensive care unit, hospitalization within 1 year of birth, and death within 1 year of birth. Propensity score matching was used to balance maternal, paternal, and infant characteristics in the comparisons between infants exposed and unexposed to prenatal CUD.FindingsCUD increased from 2.8 to 6.9 per 1000 deliveries during 2001 to 2012. Multivariable regressions in matched samples estimated that prenatal CUD was associated with greater odds of being small for gestational age (OR = 1.13, 95% CI = 1.08, 1.18), preterm birth (OR = 1.06, 95% CI = 1.01, 1.12), low birth weight (OR = 1.13, 95% CI = 1.07, 1.20), and death within 1 year of birth (OR = 1.35, 95% CI = 1.12, 1.62). Compared with infants whose mothers were tobacco non-users, infants whose mothers were tobacco users had greater odds of preterm birth, low birth weight, hospitalization, and death in association with prenatal CUD. Compared with infants whose mothers were non-Hispanic White, infants whose mothers were Hispanic had greater odds of hospitalization and death and infants whose mothers were non-Hispanic Black had greater odds of being small for gestational age in association with prenatal CUD.ConclusionPrenatal cannabis use disorder appears to be associated with escalated odds of major adverse neonatal outcomes, with heterogeneities in the associations by mothers' tobacco use status and race/ethnicity.

This cross-sectional study examines the compliance of recreational cannabis dispensaries with underage access and exposure to products and marketing in California.

BackgroundIn the past two decades, the U.S. saw an alarmingly increasing trend of benzodiazepine prescribing. Mandatory use of Prescription Drug Monitoring Programs (PDMPs) was suggested to have the potential to reduce opioid prescribing, but little is known about its impacts on benzodiazepines. This study examined whether PDMP data use mandates were associated with changes in benzodiazepine prescribing in the U.S. Methods: Aggregate state quarterly prescription drug records of benzodiazepines for Medicaid enrollees during 2010-2017 were obtained from the U.S. Medicaid State Drug Utilization Data. Three population-adjusted outcome variables were evaluated, including quantity, dosage, and Medicaid spending of benzodiazepine prescriptions per quarter per 100 Medicaid enrollees. The primary policy variable was the state-wide implementation of PDMP data use mandates for benzodiazepines. To account for between-state variations in mandates, an additional policy variable was considered to indicate strong mandates on PDMP data use, which required all prescribers to query a patient's PDMP records for first prescribing and subsequent prescribing at least every 12 months. Linear regressions with difference-in-difference approach were used to assess the associations between PDMP data use mandates and benzodiazepine prescribing, controlling for state-level time-varying policy and socioeconomic covariates. Results: The state-wide implementation of PDMP data use mandates for benzodiazepines was not associated with quantity, dosage, or Medicaid spending of benzodiazepine prescriptions. Strong mandates on PDMP data use were not associated with any benzodiazepine prescribing outcomes, either. Conclusions: There was no evidence for the associations between PDMP data use mandates for benzodiazepines and changes in benzodiazepine prescribing among Medicaid enrollees. Future research is warranted to replicate the study in other populations using individual patient records and continuously monitor the trends in benzodiazepine prescribing in association with PDMPs.

Background and aimsDifferent cannabis administration methods have differential impacts on health. This study aimed to describe administration methods among cannabis users in the United States categorized by (1) use purpose and (2) state legalization status.DesignCross-sectional, probability-based online survey in 2020.SettingAll 50 states and Washington DC in the United States.ParticipantsA total of 21 903 adults (18+) were recruited from a probability-based online panel to provide nationally representative estimates.MethodsEleven administration methods were grouped into combustion, vaporization, ingestion and topicals. Weighted prevalence was reported among (1) medical-only, recreational-only and dual-purpose users based on self-reported purposes and (2) users in states that legalized both recreational and medical cannabis (RCL states), legalized medical cannabis only and did not legalize cannabis.FindingsAmong past-year users, the proportions of medical-only, recreational-only and dual-purpose users were 25.55, 43.81 and 30.64%, respectively. The most common primary methods were combustion (42.08%) and topicals (28.65%) for medical purposes and combustion (72.07%) and ingestion (15.05%) for recreational purposes. Dual-purpose users were more likely to report combustion and vaporization but less likely to report ingestion and topicals as primary methods for medical use than medical-only users (P  0.05).ConclusionCannabis users whose purposes are medical, recreational or both tend to differ in their selected administration methods.

Currently one-third of children in the United States have overweight or obesity (OW/OB). The goal of Healthy People 2020 is to reduce the proportion of children with OW/OB and increase the proportion of primary care visits that include nutrition and weight-related counseling. Unfortunately, many health care providers find it difficult to offer effective weight-related counseling and treatment in the primary care setting. Therefore, new models of care are needed that allow a greater proportion of children with OW/OB and their parents to access care and receive quality weight management treatment. The current paper describes the GOT Doc study which is designed to test the effectiveness of a Guided Self-Help (GSH) model of obesity treatment that can be delivered in the primary care setting compared to a traditional Family-Based Behavioral weight loss treatment (FBT) delivered at an academic center. We will assess the impact of this program on attendance (access to care) and changes in child BMI percentile/z-score. We will also examine the impact of this treatment model on change in child lifestyle behaviors, parent support behaviors, and parent self-efficacy and empowerment to make behavior change. Finally, we will assess the cost-effectiveness of this model on changes in child BMI percentile/z-score. We believe the GSH intervention will be a cost-effective model of obesity management that can be implemented in community practices around the country, thereby increasing access to treatment for a broader proportion of our population and decreasing rates of childhood obesity.

BackgroundConsumers' access to cannabis has been considerably expanded in US states where recreational cannabis was legalized and commercialized. However, little is known about the important factors influencing consumers' purchase decisions in cannabis retail dispensaries. This study examined cannabis users' perceptions of the relative importance of policy-relevant factors when they made cannabis purchase decisions.MethodsAn online survey was administered to 817 adult cannabis users in seven states in the US (California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington) that had approved cannabis commercialization by the time of interview in January 2018. Twenty policy-relevant cannabis attributes were evaluated, including those pertaining to product characteristics, quality, package characteristics, price and free sample, store characteristics, and restrictions on use. A best-worst scaling experiment was employed, which asked respondents to select the most and the least important attributes in a choice scenario. Each respondent answered 10 choice scenarios, each including a random combination of four attributes out of the 20. The relative importance of each attribute was evaluated using hierarchical Bayesian estimation of mixed logit models.ResultsOverall, 'quality', 'strain type', 'price', 'THC' (tetrahydrocannabinol) and 'pesticide' were the top five important attributes affecting cannabis users' willingness to buy cannabis in a dispensary. These five attributes jointly accounted for approximately half of the total importance. In subsample analysis, both recreational and dual-purpose users attached higher importance to 'quality', 'THC', and 'price', whereas medical users tended to think 'CBD' (cannabidiol) and 'pesticide' were more important. All cannabis users perceived 'package' to be the least important attribute. Gender had no major differences in perceptions.ConclusionsCannabis users in general perceived product characteristics, quality, and price to be important factors in their willingness to buy cannabis in dispensaries. There were heterogeneities in the perceptions by cannabis use purposes. The findings might deserve consideration in cannabis policy design.

BackgroundHeated tobacco products (HTP) generate nicotine-containing aerosol by heating tobacco rather than burning it. The US Food and Drug Administration (FDA) has recently authorised the sale of one HTP brand, iQOS, in the USA. This study examined the awareness, use and risk perceptions of HTP in the USA following FDA authorisation.MethodsA national probability sample of 20 449 US adults completed an online survey between November 2019 and February 2020. In addition to assessing awareness and use of HTP, two ratios were calculated: the ratio of those who experimented with HTP given that they had heard about it (E/H) and the ratio of those who currently used HTP given experimentation (C/E). These ratios for HTP were compared against those for e-cigarettes from a similar national survey in 2012.ResultsOverall, 8.1% of respondents had heard of HTP. Only 0.55% had tried and 0.10% were current users. The rate of experimentation among those who heard about HTP and the rate of current use among experimenters were, however, similar to those for e-cigarettes in 2012: E/H and C/E for HTP were 6.8% and 18.2%, respectively; and 10.7% and 17.8%, respectively for e-cigarettes. The majority of respondents considered HTP either less harmful than (11.6%), or equally harmful as e-cigarettes (42.7%).ConclusionsOnly a small fraction of US population in 2020 have tried any HTP. However, the similarity in early adoption rates following awareness, suggests that future adoption for HTP may be similar to that for e-cigarettes, if HTP are marketed more aggressively.

Vaping products containing cannabidiol (CBD), a cannabis-derived compound used in wellness products and available in all 50 US states, were recently implicated in outbreaks of poisonings. Little is known about the commercial availability of CBD products in vape shops (i.e., stores that sell e-cigarettes). To document the availability and marketing of CBD products in online vape shops, in June 2020, we used the Google Chrome browser without cached data to collect the first two pages of search results generated by five Google queries (n = 100 search results) indicative of shopping for vaping products (e.g., "order vapes"). We then determined whether and what type of CBD products could be mail-ordered from the returned websites, and whether any explicit health claims were made about CBD. Over a third of the search results (n = 37; 37.0%) directed to vape shops that allowed visitors to also mail-order CBD. These shops sold 12 distinct categories of CBD products-some with direct analogs of tobacco or cannabis products including CBD cigarettes, edibles, flowers, pre-rolled joints, and vapes. Two vape shops made explicit health claims of the therapeutic benefits of CBD use, including in the treatment of anxiety, inflammation, pain, and stress. The abundance and placement of CBD in online vape shops suggests a growing demand and appeal for CBD products among e-cigarette users. Additional surveillance on the epidemiology of CBD use and its co-use with tobacco is warranted.

BackgroundCalifornia Proposition 56 increased cigarette excise tax by $2 per pack with equivalent increases on non-cigarette tobacco products. We estimated the changes in cigarette price, cigarette use, and non-cigarette use following the implementation of Proposition 56 in California in 2017.MethodsSeven waves of Tobacco Use Supplements to the Current Population Survey (TUS-CPS) 2011-2019 data were used to obtain state-level aggregate self-reported outcomes, including cigarette price per pack, current and daily cigarette use, cigarette consumption per day, and current and daily use of non-cigarette tobacco products (hookah, pipe, cigar, and smokeless tobacco). A modified version of a synthetic control method was used to create a "synthetic" California that best resembled pre-policy sociodemographic characteristics and outcome trends in California while correcting time-invariant pre-policy differences. Various sensitivity analyses were also conducted.ResultsThe implementation of Proposition 56 was associated with an increase in self-reported cigarette price per pack in California ($1.844, 95%CI: $0.153, $3.534; p = 0.032). No evidence suggested that Proposition 56 was associated with the changes in the prevalence of current or daily cigarette use, cigarette consumption per day, or the prevalence of current or daily use of non-cigarette tobacco products.ConclusionMost of the cigarette tax increase following Proposition 56 in California was passed on to consumers. There is a lack of evidence that the implementation of Proposition 56 was associated with the changes in the use of cigarettes and other tobacco products such as hookah, pipe, cigar, and smokeless tobacco.

BackgroundSince early 2016, an increasing number of states passed legislations that limit the duration and/or dosage of initial opioid prescriptions or opioids for acute pain.ObjectiveThe objective of this study was to assess changes in the number of opioid prescriptions covered by Medicaid and received by Medicaid patients associated with state implementation of legislative limits on initial opioid prescriptions.Research designWe explored the natural experiment resulting from the staggered implementation of state legislative limits. The analysis adopted a Difference-in-Differences framework and controlled for other major state policies bearing implications for prescription opioid use. The main analysis included 26 states that implemented limits from early 2016 to late 2018. A secondary analysis included all 50 states and the District of Columbia.MeasuresPopulation-adjusted state-quarter level counts of Schedule II and III opioid prescriptions received by Medicaid patients, based on data from the Medicaid State Drug Utilization Data and state Medicaid enrollment reports for 2013-2018.ResultsImplementation of legislative limits on initial opioid prescriptions was associated with a 7% reduction in the number of opioid prescriptions per 100 Medicaid enrollees. Such reduction was largely attributable to a reduction in Schedule II opioid prescriptions. Secondary analysis by including all jurisdictions and sensitivity checks supported the robustness of results.ConclusionThe recent implementation of state legislative limits on initial opioid prescriptions was associated with meaningful reductions in the volume of Schedule II opioid prescriptions received by Medicaid patients.

Background and aimsRecreational cannabis has been legalized in 11 states and District of Columbia (DC) in the United States. Among these, 10 states further permitted retail sale to provide a legal supply to adults. This study examined the associations of cannabis exposures with recreational cannabis legalization and commercialization.DesignSecondary data analysis of state-quarter level cannabis exposures during 2010-17 in the United States. Linear regressions with a difference-in-differences design were used to compare pre- and post-legalization trends in states that legalized recreational cannabis to contemporaneous trends in states that did not legalize recreational cannabis.SettingUnited States, including all 50 states and DC.CasesCannabis exposures reported to the US National Poison Data System.MeasurementsThe primary outcome was state age-adjusted cannabis exposures reported to the US National Poison Data System per 1 000 000 population per quarter. The two policy variables of interest included (1) the enactment of recreational cannabis legalization (i.e. removing penalties for adults' possession of cannabis in a small amount for recreational use) and (2) the initiation of recreational cannabis commercialization (i.e. providing a legal supply of cannabis to adults through licensed dispensaries).FindingsThe association between a state's enactment of recreational cannabis legalization and its changes in cannabis exposures was statistically non-significant overall. After controlling for recreational cannabis legalization, however, the initiation of recreational cannabis commercialization was associated with 5.06-5.80 more exposures per 1 000 000 population per quarter (67-77% increase relative to the pre-legalization average), depending on the composition of comparison states. The increase associated with commercialization was higher among minors than adults (7.97-9.53 versus 3.83-4.21 more exposures), higher among males than females (6.16-7.56 versus 3.76-3.91 more exposures) and higher among exposures with medical consequences than those without medical consequences (4.09-4.79 versus 0.97-1.01 more exposures).ConclusionAn increase in cannabis exposures reported to the US National Poison Data System was observed following recreational cannabis commercialization in the United States.

ObjectivesTo assess 1) the validity of online crowdsourcing platforms in enumerating licensed brick-and-mortar marijuana dispensaries and 2) the validity of state licensing directory and online crowdsourcing platforms in enumerating active brick-and-mortar marijuana dispensaries in California.MethodsWe obtained business lists from California Bureau of Cannabis Control (BCC) licensing directory and three online crowdsourcing platforms (Weedmaps, Leafly, and Yelp) in May 2019. Calls were made to verify street address, operation status, dispensary category (recreational-only, medical-only, recreational & medical), and presence of storefronts in May-July 2019. Validity measures, including sensitivity, specificity, positive predictive value, and negative predictive value, were calculated when applicable.ResultsIn identifying licensed dispensaries in BCC, Leafly had the highest sensitivity (.66) and Yelp had the highest specificity (.87). The dispensary category posted on online crowdsourcing platforms in over 25 % licensed dispensaries and the dispensary category claimed in call verification in over 10 % licensed dispensaries disagreed with the approved category in BCC. There were 2121 businesses combined from BCC and online crowdsourcing platforms, among which 826 were verified to be active brick-and-mortar dispensaries. Weedmaps had the highest sensitivity (.80) and Yelp had the highest negative predictive value (.74) in identifying verified dispensaries. Weedmaps overall had the highest sensitivity in all three dispensary categories. Weedmaps had the highest sensitivity in more populated counties whereas BCC had the highest sensitivity in less populated counties.ConclusionsEach secondary data source has strengths and limitations. The findings inform surveillance and research regarding how to best strategize data use when resources are limited.

PurposeAfter marijuana commercialization, the presence of recreational marijuana dispensaries (RMDs) was rapidly increasing. The point-of-sale marketing poses concerns about children's exposure. This study examined advertising and promotions that potentially appeal to children and access restrictions in RMDs around California schools.MethodsThis was a cross-sectional and observational study conducted from June to September 2018. Trained fieldworkers audited retail environments in 163 RMDs in closest proximity to 333 randomly sampled public schools in California.ResultsAbout 44% of schools had RMDs located within 3 miles. Regarding interior marketing, 74% of RMDs had at least one instance of child-appealing products, packages, paraphernalia, or advertisements. RMDs closer to a school had a higher proportion with interior child-appealing marketing. More than three fourths of RMDs had generic promotional activities; particularly, 28% violated the free-sample ban. Regarding exterior marketing, only 2% of RMDs had those appealing to children. More than 60% of RMDs had exterior signs indicative of marijuana. Approximately, one-third had generic advertisements, and 13% had advertisements bigger than 1,600 square inches. Regarding access restrictions, almost all RMDs complied with age verification, but 84% had no age limit signs, and only 40% had security personnel.ConclusionsDespite minimal point-of-sale marketing practices appealing to children on the exterior of RMDs around California schools, such practices were abundant on the interior. Marketing practices not specifically appealing to children were also common on both the interior and exterior of RMDs. Dispensaries' violation of age verification law, lack of security personnel, and presence of child-appealing marketing should be continuously monitored and prevented.

ObjectivesStates in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures.MethodsState-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends.ResultsRequiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p

Background: Evidence is emerging on how state-wide marijuana legalization and increased supply of DATA-2000 waivered providers may be associated with outcomes related to opioids. It is unknown whether such associations remain at the neighborhood level. Objectives: This study examined the associations of neighborhood availability of marijuana dispensaries and DATA-2000 waivered providers with opioid-related hospital stays. Methods: Discharge-level records of inpatient (N = 264,013) and observation stays (N = 12,621) were obtained from the Washington Comprehensive Hospital Abstract Reporting System from January through June 2016. Outcomes were indicators for inpatient stays related to opioid use disorder (OUD), inpatient stays related to opioid overdose, and observation stays related to OUD. Primary predictors were the density of marijuana dispensaries and DATA-2000 waivered providers at the zip code level. Multilevel logistic regressions with random intercepts were used to examine the cross-sectional associations, controlling for other patient and neighborhood characteristics. Results: Patients living in neighborhoods with one more recreational marijuana dispensaries per square mile were more likely (OR = 1.54, p = .017) to be diagnosed with OUD in inpatient stays. Living in neighborhoods with increased density of medical marijuana dispensaries or DATA-2000 waivered providers was not associated with being diagnosed with OUD or opioid overdose in inpatient or observation stays. Conclusions: Recreational and medical marijuana dispensaries were differentially associated with opioid-related hospital stays. Further investigations are warranted to explore the causal pathways of the findings.

BackgroundRecreational cannabis has been legalized in 11 states and Washington DC in the US. However, little is known about individual preferences for legal cannabis products. This study estimated the impacts of tetrahydrocannabinol (THC), cannabidiol (CBD), warning messages, and price on preferences for cannabis flowers.MethodsA cross-sectional online survey with discrete choice experiments was implemented in October 2017. A sample of 2400 adults aged 21 years or older were recruited from 6 US states with recreational cannabis legalization, consisting of 1200 past-year nonusers and 1200 past-year users. Each respondent was randomly assigned to 12 discrete choice scenarios, each asking them to choose from an opt-out option and 3 cannabis flower products with varying levels in THC, CBD, warning messages, and price. The impacts of product attributes on individual choices were analyzed with nested logit regressions.ResultsBoth cannabis nonusers and users preferred higher CBD and lower price. Users also preferred higher THC. The results on warning messages were mixed: graphic warning on drugged driving and text warning message had positive impacts on nonusers' and users' preferences for cannabis flowers, respectively, whereas FDA disapproval disclaimer had negative impacts on nonusers' preferences. Heterogeneities in preferences were revealed among nonusers by former use status and among users by reason of use. Particularly, medical cannabis users were not as responsive to THC as recreational cannabis users or dual users were. Regarding relative importance of the attributes, all respondents but medical cannabis users perceived price as the most important attribute (relative importance 51-64%), whereas medical cannabis users perceived CBD as the most important attribute (relative importance 47%).ConclusionThe findings indicated that product characteristics may have influences on US adults' choices of legal cannabis flower products and may deserve consideration for cannabis regulatory framework.

Introduction and aimsPrevious research suggested that cannabis use was associated with increased risks of prescription opioid misuse and use disorder. This study examined whether these associations differed by cannabis use purpose.Design and methodsThis is a secondary analysis of cross-sectional surveys with propensity score matching. Medical cannabis users (N = 1295), cannabis dual users with both medical and non-medical purposes (N = 707) and non-medical cannabis users (N = 18 666) were compared with cannabis non-users (N = 57 196) in the pooled 2013-2016 US nationally representative National Survey on Drug Use and Health. Propensity score models were applied to match cannabis non-users to cannabis users with different purposes with respect to potential confounders in individual socioeconomic characteristics, other substance use disorders and health conditions. In a matched sample, logistic regressions were used to assess associations.ResultsPropensity score matching considerably improved the balance of the potential confounders between cannabis non-users and users. In a matched sample, non-medical cannabis use was associated with increased risks of prescription opioid misuse (OR = 3.15, 95%CI: 2.89-3.44) and use disorder (OR = 2.52, 95%CI: 2.06-3.10). Cannabis dual use and medical cannabis use were associated with increased risks of prescription opioid misuse (OR = 2.55, 95%CI: 1.78-3.65; OR = 2.15, 95%CI: 1.58-2.91, respectively), but they were not associated with prescription opioid use disorder.Discussion and conclusionsMedical and non-medical cannabis use both were both associated with increased risks of prescription opioid misuse. Medical cannabis use, however, was not associated with prescription opioid use disorder, and non-medical cannabis was. There appeared to be differential associations between cannabis use and prescription opioid use disorder by cannabis use purpose.

Background and aimsIn the US, benzodiazepine overdose deaths increased at an alarming rate in the past two decades. Benzodiazepines were also the most common drugs involved in prescription opioid overdose deaths. Benzodiazepine prescribing has been monitored by Prescription Drug Monitoring Programs (PDMPs), but little was known about whether PDMPs reduced drug overdose deaths involving benzodiazepines.Design and methodsThis study used a difference-in-difference design with state-quarter aggregate data on drug overdose deaths. The primary data source was Mortality Multiple Cause Files in 1999-2016. Three age-adjusted rates of drug overdose deaths were examined, including those involving benzodiazepines, those involving prescription opioids, and those involving both benzodiazepines and prescription opioids. The policy variables included PDMP data access for benzodiazepines and mandatory use of PDMP data for benzodiazepines. Linear multivariable regressions were used to assess the associations of PDMP policies specific to benzodiazepines with drug overdose death rates, controlling for other state-level policy and socioeconomic factors, state and time fixed effects, and state-specific time trends.ResultsNo significant associations were found between PDMP data access for benzodiazepines and changes in drug overdose death rates involving benzodiazepines and/or prescription opioids. Similarly, no significant associations were found between mandatory use of PDMP data for benzodiazepines and changes in drug overdose death outcomes.Discussion and conclusionsThis study suggested no evidence that PDMP policies specific to benzodiazepines were associated with reduction in benzodiazepine overdose death rates. Future research is warranted to examine detailed features of PDMPs and continuously monitor the impacts of PDMP policies on benzodiazepine-related consequences.

BackgroundFor patients with cancer, marijuana may be an alternative to prescription opioid analgesics. This study analyzed self-reported marijuana and prescription opioid use among people with cancer over a 10-year time period.MethodsPopulation-based data sets from the US National Health and Nutrition Examination Survey between 2005 and 2014 were compiled for respondents aged 20 to 60 years. Respondents with cancer and respondents without cancer were propensity score-matched (1:2) by demographics to compare substance use. Outcomes included current marijuana and prescription opioid use (ie, within the past 30 days). Pearson chi-square tests and logistic regressions were performed; a 2-tailed P value

PURPOSE: We provide a US national assessment of youth perceptions of the harm and addictiveness of six separate tobacco products, identifying a continuum of perceived harm associated with a range of products in relation to patterns of current use, former use, and susceptibility to use tobacco products. METHODS: We evaluated youth respondents (N = 13,651) ages 12-17 from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Analyses (2015-2016) focused on refining measures of perceived harm for each product and delineating youth characteristics (demographic, tobacco use status) associated with beliefs about the harmfulness and addictiveness of tobacco products. RESULTS: Cigars, hookah and e-cigarettes were each perceived as having significantly lower harm (ps

PurposeWe provide a US national assessment of youth perceptions of the harm and addictiveness of six separate tobacco products, identifying a continuum of perceived harm associated with a range of products in relation to patterns of current use, former use, and susceptibility to use tobacco products.MethodsWe evaluated youth respondents (N = 13,651) ages 12-17 from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Analyses (2015-2016) focused on refining measures of perceived harm for each product and delineating youth characteristics (demographic, tobacco use status) associated with beliefs about the harmfulness and addictiveness of tobacco products.ResultsCigars, hookah and e-cigarettes were each perceived as having significantly lower harm (p's

Background: A recent meta-analysis affirmed the benefit of medicinal cannabis for chronic neuropathic pain, a disabling and difficult-to-treat condition. As medicinal cannabis use is becoming increasingly prevalent among Americans, an exploration of its economic feasibility is warranted. We present this cost-effectiveness analysis of adjunctive cannabis pharmacotherapy for chronic peripheral neuropathy. Materials and Methods: A published Markov model comparing conventional therapies for painful diabetic neuropathy was modified to include arms for augmenting first-line, second-line (if first-line failed), or third-line (if first- and second-line failed) therapies with smoked cannabis. Microsimulation of 1,000,000 patients compared the cost (2017 U.S. dollars) and effectiveness (quality-adjusted life years [QALYs]) of usual care with and without adjunctive cannabis using a composite of third-party and out-of-pocket costs. Model efficacy inputs for cannabis were adapted from clinical trial data. Adverse event rates were derived from a prospective study of cannabis for chronic noncancer pain and applied to probability inputs for conventional therapies. Cannabis cost was derived from retail market pricing. Parameter uncertainty was addressed with one-way and probabilistic sensitivity analysis. Results: Adding cannabis to first-line therapy was incrementally less effective and costlier than adding cannabis to second-line and third-line therapies. Third-line adjunctive cannabis was subject to extended dominance, that is, the second-line strategy was more effective with a more favorable incremental cost-effectiveness ratio of $48,594 per QALY gained, and therefore, third-line adjunctive cannabis was not as cost-effective. At a modest willingness-to-pay threshold of $100,000/QALY gained, second-line adjunctive cannabis was the strategy most likely to be cost-effective. Conclusion: As recently proposed willingness-to-pay thresholds for the United States health marketplace range from $110,000 to $300,000 per QALY, cannabis appears cost-effective when augmenting second-line treatment for painful neuropathy. Further research is warranted to explore the long-term benefit of smoked cannabis and standardization of its dosing for chronic neuropathic pain.

ObjectivesMedical marijuana use may substitute prescription opioid use, whereas nonmedical marijuana use may be a risk factor of prescription opioid misuse. This study examined the associations between recreational marijuana legalization and prescription opioids received by Medicaid enrollees.MethodsState-level quarterly prescription drug utilization records for Medicaid enrollees during 2010-2017 were obtained from Medicaid State Drug Utilization Data. The primary outcome, opioid prescriptions received, was measured in three population-adjusted variables: number of opioid prescriptions, total doses of opioid prescriptions in morphine milligram equivalents, and related Medicaid spending, per quarter per 100 enrollees. Two difference-in-difference models were used to test the associations: eight states and DC that legalized recreational marijuana during the study period were first compared among themselves, then compared to six states with medical marijuana legalized before the study period. Schedule II and III opioids were analyzed separately.ResultsIn models comparing eight states and DC, legalization was not associated with Schedule II opioid outcomes; having recreational marijuana legalization effective in 2015 was associated with reductions in number of prescriptions, total doses, and spending of Schedule III opioids by 32% (95% CI: (-49%, -15%), p = 0.003), 30% ((-55%, -4.4%), p = 0.027), and 31% ((-59%, -3.6%), p = 0.031), respectively. In models comparing eight states and DC to six states with medical marijuana legalization, recreational marijuana legalization was not associated with any opioid outcome.ConclusionsNo evidence suggested that recreational marijuana legalization increased prescription opioids received by Medicaid enrollees. There was some evidence in some states for reduced Schedule III opioids following the legalization.

Three cigarette smoking behaviors influence lung cancer rates: how many people start, the amount they smoke, and the age they quit. California has reduced smoking faster than the rest of the United States and trends in these three smoking behaviors should inform lung cancer trends. We examined trends in smoking behavior (initiation, intensity, and quitting) in California and the rest of United States by regression models using the 1974-2014 National Health Interview Surveys (n = 962,174). Lung cancer mortality data for 1970-2013 was obtained from the National Surveillance, Epidemiology, and End Results (SEER) Program. Among those aged 18 to 35 years, California had much larger declines than the rest of the United States in smoking initiation and intensity, and increased quitting. In 2012-2014, among this age group, only 18.6% [95% confidence interval (CI), 16.8%-20.3%] had ever smoked; smokers consumed only 6.3 cigarettes/day (95% CI, 5.6-7.0); and 45.7% (95% CI, 41.1%-50.4%) of ever-smokers had quit by age 35. Each of these metrics was at least 24% better than in the rest of the United States. There was no marked California effect on quitting or intensity among seniors. From 1986 to 2013, annual lung cancer mortality decreased more rapidly in California and by 2013 was 28% lower (62.6 vs. 87.5/100,000) than in the rest of the United States. California's tobacco control efforts were associated with a major reduction in cigarette smoking among those under age 35 years. These changes will further widen the lung cancer gap that already exists between California and the rest of the United States.

BackgroundAs the US population ages, there is an increasing need for evidence based, peer-led physical activity programs, particularly in ethnically diverse, low income senior centers where access is limited.Methods/designThe Peer Empowerment Program 4 Physical Activity' (PEP4PA) is a hybrid Type II implementation-effectiveness trial that is a peer-led physical activity (PA) intervention based on the ecological model of behavior change. The initial phase is a cluster randomized control trial randomized to either a peer-led PA intervention or usual center programming. After 18 months, the intervention sites are further randomized to continued support or no support for another 6 months. This study will be conducted at twelve senior centers in San Diego County in low income, diverse communities. In the intervention sites, 24 peer health coaches and 408 adults, aged 50 years and older, are invited to participate. Peer health coaches receive training and support and utilize a tablet computer for delivery and tracking. There are several levels of intervention. Individual components include pedometers, step goals, counseling, and feedback charts. Interpersonal components include group walks, group sharing and health tips, and monthly celebrations. Community components include review of PA resources, walkability audit, sustainability plan, and streetscape improvements. The primary outcome of interest is intensity and location of PA minutes per day, measured every 6 months by wrist and hip accelerometers and GPS devices. Secondary outcomes include blood pressure, physical, cognitive, and emotional functioning. Implementation measures include appropriateness & acceptability (perceived and actual fit), adoption & penetration (reach), fidelity (quantity & quality of intervention delivered), acceptability (satisfaction), costs, and sustainability.DiscussionUsing a peer led implementation strategy to deliver a multi-level community based PA program can enhance program adoption, implementation, and sustainment.Trial registrationClinicalTrials.gov, USA ( NCT02405325 ). Date of registration, March 20, 2015. This website also contains all items from the World Health Organization Trial Registration Data Set.

Background and aimsWhile the United States has been experiencing an opioid epidemic, 29 states and Washington DC have legalized cannabis for medical use. This study examined whether state-wide medical cannabis legalization was associated with reduction in opioids received by Medicaid enrollees.DesignSecondary data analysis of state-level opioid prescription records from 1993-2014 Medicaid State Drug Utilization Data. Linear time-series regressions assessed the associations between medical cannabis legalization and opioid prescriptions, controlling for state-level time-varying policy covariates (such as prescription drug monitoring programs) and socio-economic covariates (such as income).SettingUnited States.ParticipantsDrug prescription records for patients enrolled in fee-for-service Medicaid programs that primarily provide health-care coverage to low-income and disabled people.MeasurementsThe primary outcomes were population-adjusted number, dosage and Medicaid spending on opioid prescriptions. Outcomes for Schedule II opioids (e.g. hydrocodone, oxycodone) and Schedule III opioids (e.g. codeine) were analyzed separately. The primary policy variable of interest was the implementation of state-wide medical cannabis legalization.FindingsFor Schedule III opioid prescriptions, medical cannabis legalization was associated with a 29.6% (P = 0.03) reduction in number of prescriptions, 29.9% (P = 0.02) reduction in dosage and 28.8% (P = 0.04) reduction in related Medicaid spending. No evidence was found to support the associations between medical cannabis legalization and Schedule II opioid prescriptions. Permitting medical cannabis dispensaries was not associated with Schedule II or Schedule III opioid prescriptions after controlling for medical cannabis legalization. It was estimated that, if all the states had legalized medical cannabis by 2014, Medicaid annual spending on opioid prescriptions would be reduced by 17.8 million dollars.ConclusionState-wide medical cannabis legalization appears to have been associated with reductions in both prescriptions and dosages of Schedule III (but not Schedule II) opioids received by Medicaid enrollees in the United States.

BackgroundIn the 1990s, California led the USA in state-level tobacco control strategies. However, after 2000, California lost ground on cigarette taxes, although it maintained higher levels of smoke-free homes among smokers.MethodsTrends in per capita cigarette consumption were assessed through taxed sales data and from self-report in repeated national cross-sectional surveys. Linear regressions identified changes in trends after year 2000 separately for California and the rest of the USA. Using data from each state, a linear regression tested the association between different tobacco control strategies and per capita consumption. Change in self-reported per capita consumption was partitioned into contributions associated with initiation, quitting and reduction in cigarette consumption level.ResultsBoth taxed cigarette sales and per capita consumption declined rapidly in the USA from 1985 to 2015. Declines were particularly fast in California before 2000 but slowed thereafter. In 2014, per capita consumption in California was 29.4 packs/adult/year, but 90% higher in the rest of the USA. Modelling state-level data, every $1 increase in cigarette taxes reduced consumption by 4.8 (95% CI 2.9 to 6.8) packs/adult/year. Every 5% increase in the proportion of smokers with smoke-free homes reduced consumption by 8.0 (95% CI 7.0 to 8.9) packs/adult/year. The different patterns in California and the rest of the USA are at least partially explained by these two variables. The slow down in per capita consumption in California can be attributed to changes in initiation, quitting and especially smokers reducing their consumption level.ConclusionsTobacco control strategies need to be continually updated to maintain momentum towards a smoke-free society.

Objective: In this paper, we examine whether a slowdown in implementing tobacco control policies in California after 2000 influenced trends in smoking behavior. Methods: We assessed the strength of state tobacco control policies using excise tax data (1990-2014), tobacco control expenditures per capita, and workplace and home smoking restrictions (from the Tobacco Use Supplement of the Current Population Survey, 1992-2015). Smoking prevalence was assessed with the National Health Interview Survey, 1985-2015. We compared trends between Californiaand the rest of the US using split regression models with a knot at 2000. Results: Throughout the 1990s, compared to the rest of the US, California had higher cigarette excise taxes, higher expenditures on tobacco control, more smoke-free workplaces, and more smokers with smoke-free homes. Except for smoke-free homes, these differences disappeared after 2000. During the 1990s, smoking prevalence declined much faster in California than in the rest of the US, but the decline slowed significantly after 2000. Conclusions: Smoking prevalence is sensitive to continued implementation of tobacco control policies.

PurposeWe aimed to examine the availability of medical marijuana dispensaries, price of medical marijuana products, and variety of medical marijuana products in school neighborhoods and their associations with adolescents' use of marijuana and susceptibility to use marijuana in the future.MethodsA representative sample of 8th, 10th, and 12th graders (N = 46,646) from 117 randomly selected schools in California participated in the cross-sectional 2015-2016 California Student Tobacco Survey (CSTS). Characteristics of medical marijuana dispensaries in California were collected and combined with school locations to compute availability, price, and product variety of medical marijuana in school neighborhoods. Multilevel logistic regressions with random intercepts at school level were conducted to test the associations, accounting for individual and school socioeconomic characteristics.ResultsThe distance from school to the nearest medical marijuana dispensary (within 0- to 1-mi and 1- to 3-mi bands) was not associated with adolescents' use of marijuana in the past month or susceptibility to use marijuana in the future, nor was the weighted count of medical marijuana dispensaries within the 3-mi band of school. Neither the product price nor the product variety in the dispensary nearest to school was associated with marijuana use or susceptibility to use. The results were robust to different specifications of medical marijuana measures.ConclusionsThere was no evidence supporting the associations of medical marijuana availability, price, or product variety around school with adolescents' marijuana use and susceptibility to use.

ImportanceCigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults.ObjectiveTo investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking.Design, setting, and participantsThe Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted.ExposuresAdvertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1.Main outcomes and measuresProgression to susceptibility or ever tobacco use at 1-year follow-up in wave 2.ResultsOf the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95% confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95% CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95% CL, 1.41-1.85; cigars: AOR, 2.01; 95% CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95% CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95% CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95% CL, 1.19-1.75; cigars: AOR, 2.07; 95% CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95% CL, 1.08-2.38).Conclusions and relevanceReceptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

[This corrects the article DOI: 10.1371/journal.pone.0201467.].

BackgroundLower rates of successful quitting among low-income populations in the United States may be from slower dissemination of smoke-free homes, a predictor of cessation.ObjectivesTo explore the role of smoke-free homes in cessation behavior across income levels.ParticipantsCurrent smokers who were ≥18 years and who participated in the longitudinal 2002-2003 (n = 2801) or 2010-2011 (n = 2723) Tobacco Use Supplements to the Current Population Survey.MeasurementsWe categorized income as multiples of the federal poverty level (FPL) (300%FPL). Although similar in 2002, the prevalence of smoke-free homes was 33% lower among individuals living

The purpose of this study was to investigate susceptibility and ever use of tobacco products among adolescents and young adults in the US. Cross-sectional analysis of Wave 1(2013-2014) adolescent (12-17year-olds; n=13,651) and young adult (18-24year-olds; n=9112) data from the nationally-representative Population Assessment of Tobacco and Health (PATH) Study was conducted. At 12years, 5% were ever tobacco users and 36% were susceptible to use. Seventy percent were susceptible at age 17years, and the same proportion were ever users at age 22years. Susceptibility levels were comparable for cigarettes and e-cigarette (28.6% and 27.4%, respectively), followed by hookah (22.0%), pipes (17.5%), cigars (15.2%), and smokeless tobacco (9.7%). Non-Hispanic (NH) Black (Adjusted Odds Ratio [ORadj]=1.36; 95% Confidence Limit [CL], 1.18-1.56) and Hispanic (ORadj=1.34: 95% CL,1.19-1.49) adolescent never- users were more likely to be susceptible to future use of a tobacco product than NH Whites. Susceptibility was higher with age (15-17yrs. vs 12-14yrs.: ORadj=1.69; 95% CL, 1.55-1.85) and parental education (college graduates vs less than HS education: ORadj=1.22, 95% CL, 1.08-1.39). Compared to exclusive users of hookah, cigars, or smokeless products, larger proportions of exclusive e-cigarette ever users were also susceptible to cigarette use. Among adolescents, lower levels of ever use of tobacco products are often counterbalanced by higher levels of susceptibility for future use, which may suggest delayed initiation in some groups. Ever users of a given tobacco product were more susceptible to use other tobacco products, putting them at risk for future multiple tobacco product use.

BackgroundAs the US population ages, there is an increasing need for evidence based, peer-led physical activity programs, particularly in ethnically diverse, low income senior centers where access is limited.Methods/designThe Peer Empowerment Program 4 Physical Activity' (PEP4PA) is a hybrid Type II implementation-effectiveness trial that is a peer-led physical activity (PA) intervention based on the ecological model of behavior change. The initial phase is a cluster randomized control trial randomized to either a peer-led PA intervention or usual center programming. After 18 months, the intervention sites are further randomized to continued support or no support for another 6 months. This study will be conducted at twelve senior centers in San Diego County in low income, diverse communities. In the intervention sites, 24 peer health coaches and 408 adults, aged 50 years and older, are invited to participate. Peer health coaches receive training and support and utilize a tablet computer for delivery and tracking. There are several levels of intervention. Individual components include pedometers, step goals, counseling, and feedback charts. Interpersonal components include group walks, group sharing and health tips, and monthly celebrations. Community components include review of PA resources, walkability audit, sustainability plan, and streetscape improvements. The primary outcome of interest is intensity and location of PA minutes per day, measured every 6 months by wrist and hip accelerometers and GPS devices. Secondary outcomes include blood pressure, physical, cognitive, and emotional functioning. Implementation measures include appropriateness & acceptability (perceived and actual fit), adoption & penetration (reach), fidelity (quantity & quality of intervention delivered), acceptability (satisfaction), costs, and sustainability.DiscussionUsing a peer led implementation strategy to deliver a multi-level community based PA program can enhance program adoption, implementation, and sustainment.Trial registrationClinicalTrials.gov, USA ( NCT02405325 ). Date of registration, March 20, 2015. This website also contains all items from the World Health Organization Trial Registration Data Set.

ObjectivesTwenty-eight states in the U.S have legalized medical marijuana, yet its impacts on severe health consequences such as hospitalizations remain unknown. Meanwhile, the prevalence of opioid pain reliever (OPR) use and outcomes has increased dramatically. Recent studies suggested unintended impacts of legalizing medical marijuana on OPR, but the evidence is still limited. This study examined the associations between state medical marijuana policies and hospitalizations related to marijuana and OPR.MethodsState-level annual administrative records of hospital discharges during 1997-2014 were obtained from the State Inpatient Databases (SID). The outcome variables were rates of hospitalizations involving marijuana dependence or abuse, opioid dependence or abuse, and OPR overdose in 1000 discharges. Linear time-series regressions were used to assess the associations of implementing medical marijuana policies to hospitalizations, controlling for other marijuana- and OPR-related policies, socioeconomic factors, and state and year fixed effects.ResultsHospitalizations related to marijuana and OPR increased sharply by 300% on average in all states. Medical marijuana legalization was associated with 23% (p=0.008) and 13% (p=0.025) reductions in hospitalizations related to opioid dependence or abuse and OPR overdose, respectively; lagged effects were observed after policy implementation. The operation of medical marijuana dispensaries had no independent impacts on OPR-related hospitalizations. Medical marijuana polices had no associations with marijuana-related hospitalizations.ConclusionMedical marijuana policies were significantly associated with reduced OPR-related hospitalizations but had no associations with marijuana-related hospitalizations. Given the epidemic of problematic use of OPR, future investigation is needed to explore the causal pathways of these findings.

BackgroundAlthough most US states prohibit cigarette smoking in public places and worksites, fewer jurisdictions regulate indoor use of electronic cigarettes (e-cigarettes). Given the dramatic increase in e-cigarette use and concern about its impact on non-users, there is a need to examine the use of e-cigarettes in smoke-free environments and related attitudes and perceptions.MethodsRecruited from a nationally representative adult panel (GfK's KnowledgePanel), 952 current users of e-cigarettes completed a cross-sectional online survey in 2014. Multivariate logistic regressions were conducted to examine the factors associated with ever using e-cigarettes in smoke-free environments.ResultsOverall, 59.5% of e-cigarette users had vaped where cigarette smoking was not allowed. Young adults (18-29 years) were most likely to do so, 74.2%. The places of first-time use most often mentioned were service venues (bar, restaurant, lounge and club), 30.7%, followed by worksites, 23.5%. Daily e-cigarette users were more likely to have vaped in smoke-free environments than non-daily users (OR=2.08, p=0.012). Only 2.5% of those who used e-cigarettes in smoke-free environments reported negative reactions from other people. Most e-cigarette users did not think e-cigarettes are harmful to themselves or to by-standers, and thus should not be banned where smoking is; those who had used e-cigarettes where smoking is banned were even more likely to hold these views.ConclusionsE-cigarette use in smoke-free environments was common, suggesting that most e-cigarette users do not consider smoke-free laws to apply to e-cigarettes. Explicit laws should be considered if jurisdictions want to prohibit e-cigarette use in public places.