Although children do spend a substantial period of time at school, which may or may not be in a similar geographical location to that of their primary residence. Lastly, there is not a direct correlation between external environmental exposures to chemicals and internal exposure doses. For some environmental toxins, internal biomarkers exist to determine internal dose , whereas others, like air pollution, do not. Nonetheless, these geospatial factors can lead to misclassification, or information bias, which can severely affect observed associations between the exposure and the outcome. Therefore, given these limitations, it is important to note that while the current LED Environment measures may help provide a snapshot as to the built and natural environment surrounding ABCD participants’ residential homes, the current data fall short of fully characterizing participant exposomes. Thus, while continued efforts by the LED Environment Working Group aim to mitigate these challenges, findings should be interpreted considering these potential pitfalls, and misclassification should be acknowledged and discussed when necessary. Another potential challenge for researchers using these data is conceptual and/or statistical collinearity and potential confounders. Environmental variables included from various databases can greatly overlap in terms of theoretical construct. For example, various factors may represent broad constructs of economic advantage, and many variables from the same databases may be highly collinear. It is also important to note that although some estimates may draw from similar linked databases , they may implement any number of transformations or operations when computing measures. In addition to considering the exposure of interest from these data, a number of spatial contextual variables may also be important to consider as source of confounding. For example, ecological variables, such as air pollution,indoor hydroponic system may be an important spatial confounder in examining associations between neighborhood socioeconomic factors and child health outcomes in ABCD.
Some models of exposures may also include other important geospatial or socioeconomic factors in establishing estimates of exposure, such as temperature and humidity in estimating ambient air pollution, or age of housing in compiling a metric for lead risk. Therefore, it is vital in the early stages of planning analyses with these data to consider the choice of which variables to use for a given construct, identifying potential ecological or spatial confounders, and understanding the raw datasets that were utilized in calculating various environmental and societal variables included in the ABCD Study. Additional sensitivity analyses should always be considered to evaluate the impact of potential confounds and the specificity of the tested environments. Lastly, researchers should note that the environmental estimates do not represent the ‘lived’ or subjective experience of these exposures, with careful consideration given to the potential interpretation of any effects seen between these variables and brain and cognitive outcomes of interest. For example, these data are derived from outside databases that may capture an objective perspective of a given geospatial location, as they do not rely on the subjective report of the participants. However, these objective constructs do not necessarily reflect any individual’s subjective experience in a given state, census tract, or even residential neighborhood. Further, neighborhood socioeconomic factors, environmental exposures, and potential health and behavioral outcomes should also be considered in light of local, state, and federal policies of racism, segregation, and inequality that has resulted in persistent inequalities in social, economic, and educational opportunities . For these reasons, socioeconomic and other family-level factors are likely to also be highly correlated to various built and natural exposure variables. Thus, thoughtful consideration is vital in reporting on potential exposure and outcome associations but also the nexus of neighborhoods, communities, and environmental justice and equity. The legal landscape around marijuana in the USA is changing rapidly. Currently, medical marijuana is legal in 25 states and Washington DC, with retail marijuana legalised in four states and Washington DC. On 1 January 2014, Colorado became the first state to legally sell retail marijuana to people 21 years or older. Shifting regulations have been accompanied by technological innovations, including electronic vaporisers for tobacco and marijuana.
These developments are likely to transform use of these substances, especially among young adults. Nationally, young adults have the highest rates of current marijuana use, with 18.9% aged 18–25 years using in 2013, compared to 7.1% aged 12–17 years and 5.5% aged ≥26 years.According to 2014 data, almost 30% of young adults in Colorado reported current marijuana use.Young adults also have the highest current rates of tobacco smoking .More young adults have ever tried e-cigarettes compared to other age groups.Rates of dual and poly use are also high: in 2013, among US young adults who smoked cigarettes in the past 30 days , 47% were current marijuana users.Given high rates of co-use of tobacco and marijuana among young adults,as well as transformations in the realm of policy and technology, tobacco, marijuana and vaporisers are most effectively studied in relationship to one another.Referred to as ‘the triangulum’ , this approach reflects interest in the intersection of tobacco, marijuana and electronic vaporiser use, with implications for surveillance , policy and treatment.Several quantitative studies examined some aspects of the triangulum, including co-use of combustible tobacco and marijuana,perceptions of comparative harm of tobacco and marijuana,prevalence of vaporiser use among marijuana users and reasons for use of marijuana vaporisers.Two qualitative studies examined the intersection of tobacco and marijuana by interviewing youth in Scotland.The data in the studies, however, were collected over a decade ago and do not reflect changing legal and normative environments around marijuana or the proliferation of vaporising devices. Several quantitative studies have addressed marijuana vaporisers use by adults, including Lee et al and Etter,but neither was designed to explore in depth why users choose to vaporise marijuana, or the social or policy contexts shaping vaporiser use. To the best of our knowledge, this is the first in-depth, qualitative investigation of the triangulum in the ‘natural laboratory’ of Colorado. We interviewed young adults in Colorado to understand how they use, perceive and ascribe meaning to various tobacco, marijuana and vaporiser products.As part of the State and Community Tobacco Control research initiative , this project was developed in strategic partnership with Denver Public Health and Jefferson County Public Health departments in Colorado.
Beginning in early 2014, we worked with local agencies to identify research questions that would advance policy solutions and practice. These questions were further refined iteratively throughout the data collection period. Local agencies provided staff to recruit participants, assisted with interviewing, provided space for interviews and engaged key stakeholders in reviewing early findings.Participants were recruited using flyers placed in marijuana dispensaries, vape shops, cafes, stores and on bulletin boards at community colleges in the Denver Metro area. Online recruitment was conducted through Craigslist and posting on Facebook. Inclusion criteria included being 18–26 years old and current use of at least one of the three products . Prospective participants were screened and enrolled in the study via telephone by trained research staff. We attempted to interview all 32 enrolled participants twice, in order to allow conversations to develop more deeply. Twenty-four completed both interviews. Participants were compensated $35 for the first interview and $65 for the second. Each participant gave written consent. All study protocols were approved by the Committee on Human Research at the University of California, San Francisco.Semi-structured interviews were conducted between January and August 2015 by six trained interviewers , following a standard interview guide. Interviews were conducted individually in public places or in meeting rooms in local health departments. Before each interview, participants completed brief questionnaires with demographic information and past tobacco and marijuana use history. Discussion topics included definitions of smoking, experiences with tobacco, e-cigarettes, marijuana, marijuana vaporisers and other products, perceived benefits and risks of products and experiences with marijuana legalisation in Denver. Interviews lasted between 60 and 90 min, and were audio recorded.Audio recordings were professionally transcribed. Data were coded using Dedoose software. Researchers McDonald and Popova independently blind-coded a subset of transcripts, which were then compared to develop coding guidelines. Researchers created code definitions and developed a consistent coding scheme to ensure that codes were applied consistently. The larger set of transcripts was divided and coded independently. Themes were generated iteratively during review of coded transcripts. Memos summarising each theme with illustrative quotes were reviewed by authors and discussed iteratively to reach consensus and theme saturation. Pseudonyms are used for all participants quoted in this article and no real names have been used.Participants highlighted fluidity between use of tobacco,microgreen flood table marijuana and vaporisers. Reflecting this fluidity, the terms ‘smoke’ and to be a ‘smoker’ were used to describe either tobacco or marijuana use in ways that left unclear which substance was referred to. While dual and poly use was our primary focus, some participants also reported co-use through merging products, including use of tobacco wraps or little cigars/ cigarillos to smoke marijuana and the use of tobacco cigarettes to ‘extend’ the effects of marijuana. Vaporising devices were used to consume either nicotine or marijuana concentrates, with such devices nearly indistinguishable in appearance. Participants remarked upon the increasing popularity of ‘vaping’, expanded interest in vaporisers for nicotine and marijuana products and the convenience of vaporisers for use in public spaces. In some contexts, participants clearly distinguished between tobacco, marijuana and vaping, as they did when discussing the risks of secondhand smoke. Participants viewed secondhand tobacco smoke as potentially dangerous, often limiting or prohibiting use of combustible tobacco in homes or cars.
Marijuana secondhand smoke, in sharp contrast, was widely considered safer and more pleasant smelling than tobacco smoke, with few participants restricting combustible marijuana indoors.Our question ‘Do you smoke?’ was frequently met with the question: ‘smoke what?’ The term ‘smoking’ was used interchangeably to refer to the use of marijuana or tobacco, with this ambiguity only uncovered through conversation: when a researcher asked ‘Ethan’, ‘In terms of your social circle in Colorado, do many people smoke?’ ‘Ethan’ responded, ‘everyone that I work with under the age of 30 smokes. I have five roommates and they all smoke. Just about everyone I know in Denver smokes. I have one friend that doesn’t, just because he gets panic attacks’. When the researcher asked whether these friends were regular or occasional smokers, ‘Ethan’ responded, ‘Much more regular marijuana smokers…[pause] are we still talking about tobacco smoking? When I hear “smoking” now, I associate it more with marijuana than tobacco smoking’. ‘Ethan’ clarified that among his friends, only five were regular tobacco smokers, whereas the majority smoke marijuana. In Colorado, he elaborated, the term ‘smoke’ primarily indicates use of marijuana, but added, ‘If I go back to Texas, and somebody says, “I’m going to go for a smoke,” I know [they mean] cigarettes— tobacco’. When asked if he ever smoked while drinking, ‘Owen’, 20, commented, ‘Yeah… if I have one drink I’ll probably be smoking before, you know?’ When the researcher asked him to clarify whether he meant smoking marijuana or tobacco, he responded, ‘Marijuana. I don’t really smoke tobacco products like that. The only reason why I put 20 times [of tobacco use per month on the questionnaire] is because [of ] Swisher Sweets[cigarillos]. I’d have to get a Swisher Sweet to roll up the marijuana, you know?’. He added that he would not smoke cigarillos ‘straight’, but only as a wrap for marijuana.The emerging issues uncovered in this qualitative study highlight the need to reconsider the traditional silo-based approach to tobacco control and marijuana research. It is particularly important to consider the triangulum of tobacco, marijuana and vaporisers, and we believe this is the first study to address this intersection in the context of legalised marijuana. We found widespread ambiguity about whether ‘to smoke’ referred to the use of tobacco or marijuana products. While not unique to Colorado, this linguistic equivalence between tobacco and marijuana use may signal increasing normalisation of marijuana. Researchers should be aware of this ambiguity in designing precisely worded research instruments. Additionally, antitobacco messaging that focus on ‘smoke’ or ‘smoker’ identity may be diluted in this context, as combustible marijuana moves towards legality and widespread availability. Participants reported the use of tobacco products as part of the consumption of marijuana. This points to several key issues.