On average, young adults perceive marijuana as less harmful to health, less addictive, and more socially acceptable than tobacco , and are less ready to quit marijuana than cigarettes . While a few studies have found that marijuana users were less likely to quit smoking than non-users , others have found no significant differences in smoking outcomes between marijuana co-users and non-marijuana users . Previous research focused on general adult populations, collected data in-person, and was conducted before the advent of widespread changes in marijuana legalization and social norms . It is unclear whether and to what extent marijuana use interferes with smoking cessation and related outcomes among young adults in an era of rapidly shifting laws and attitudes regarding marijuana. It is particularly important to study young adults in this context, because they are less likely to seek smoking cessation treatment and are more likely to use marijuana than are older adults. Moreover, due to the stigma around marijuana use and its illegal status in many states, collecting data online may be a useful strategy to improve accuracy of self-reported marijuana use and to further examine its relationship with smoking cessation. Lastly, marijuana use has become increasingly accepted in society and increasingly common among cigarette smokers . Given the widespread availability and acceptability of marijuana among young adults, current tobacco smokers may experience more difficulty quitting than those surveyed in previous decades. As such, this study uses data from a randomized controlled trial of the Tobacco Status Project , a smoking cessation intervention for young adults delivered on Facebook, to examine differences in smoking outcomes between marijuana users and non-marijuana users. Participants were young adult smokers who reported smoking 100+ cigarettes in their lifetime, currently smoking 1+ cigarettes per day 3+ days per week and using Facebook 4+ days per week, and who were English literate. Recruitment consisted of a paid Facebook ad campaign from October 2014 to July 2015 . Clicking on an ad redirected participants to a confidential eligibility survey. Eligible, growing cannabis indoors consented participants were randomly assigned to one of two conditions: 1) the Tobacco Status Project intervention, or 2) referral to the National Cancer Institute’s Smoke free.gov website .
Participants in both conditions were included in all analyses except treatment engagement and perceptions . TSP included assignment to a private Facebook group tailored to participants’ readiness to quit smoking, daily Facebook contact with study staff, weekly live counseling sessions, and six additional Cognitive Behavioral Therapy counseling sessions for those ready to quit. Study staff posted once a day for 90 days and participants were asked to comment on the posts. Post content varied by readiness to quit smoking and included strategies informed by the Transtheoretical Model and the U.S. Clinical Practice Guidelines for smoking cessation .Nicotine dependence was assessed using the 6-item Fagerström Test of Cigarette Dependence , scored on a scale of 0 to 10, from low to heavy dependence. Daily smoking at baseline was measured with the item, “On average, how many days in a week do you smoke cigarettes ?”. Responses were recoded into daily smoking or non-daily smoking . The Smoking History Questionnaire assessed early smoking as well as usual number of cigarettes smoked per day. The Stages of Change Questionnaire was used to categorize participants into one of three stages of change based on their readiness to quit smoking at baseline. Alcohol is another substance commonly used by young adults, and use of alcohol can co-occur with tobacco and/or marijuana . Hence, we measured alcohol use for possible inclusion as a covariate in the models, using the item, “Have you consumed alcohol in the past 30 days?” .Current marijuana use was measured at each time point using the Staging Health Risk Assessment , based on the Transtheoretical Model stages of change and the Healthy People 2020 goals for the United States . The item read: “Marijuana is also called pot, weed, and grass. Are you planning to stop using marijuana?” . Participants were categorized as marijuana users if they indicated recent use on the staging item. All others were categorized as non-marijuana users. Participants in the intervention group reported their perceptions of the intervention at treatment end by rating their agreement with 7 items. Items addressed whether the intervention was easy to understand, gave sound advice, gave participants something to think about, and helped them to be healthier, as well as whether they used the information, thought about the information, and would recommend the intervention .
Responses were coded as disagreement or agreement . Engagement was measured by the number of Facebook comments an individual posted during the 90-day intervention, including comments on posts and during live counseling sessions . First, marijuana users and non-users at baseline were compared on baseline demographic and smoking characteristics. Second, differences in reported smoking outcomes between users and non-users during the follow-up period were analyzed using a series of generalized estimated equations with binary distributions and logit link functions for dichotomous variables and a multi-nomial distribution with a logit link function for the ordinal variable . Longitudinal analyses controlled for intervention group and adjusted for baseline stage of change , baseline average cigarettes per day, sex, alcohol use, and age participants began smoking regularly. The first two covariates were determined a priori and the latter were selected based on the observed baseline differences between marijuana users and non-marijuana users. Because all participants were smokers at baseline, longitudinal analyses only included data from the three follow-up points . Largely due to attrition, there were 493 missing data points across all three time points on the abstinence variable, 498 on the reduction variable, 489 on the quit attempts variable, and 502 on the readiness to quit variable. GEE analyses are relatively robust to missingness, and a participant’s data could still be included in the analyses if they were missing one or more time points. Third, chi-square tests for independence were used to compare marijuana users’ and non-marijuana users’ perceptions of the intervention. An independent-samples t-test was used to compare treatment engagement between marijuana users and non-marijuana users in the treatment group.This study showed longitudinal patterns of marijuana use, point-prevalence abstinence from smoking, and reduction in smoking among young adults participating in a digital smoking cessation intervention trial. Most importantly, results showed that young adult smokers who coused marijuana were less likely to reduce their cigarette smoking or to have been abstinent from smoking than were those who did not use marijuana; however, they did not differ in readiness to quit smoking or likelihood of having made a quit attempt.
Although smoking marijuana in addition to cigarettes increases young adults’ likelihood of negative physical effects , smoking marijuana may make quitting cigarettes more difficult in part by perpetuating the habit of smoking. Quitting smoking requires breaking associations or cues between the behavior of smoking and other contextual factors . Young adults commonly use marijuana in conjunction with cigarettes . Thus, continuing to use marijuana may hamper cigarette smokers’ efforts to change their behavior. Indeed, results showed that marijuana users were less likely to have recently abstained from smoking or reduced their smoking over a 12-month period. On the other hand, growing indoor cannabis use status was consistently unrelated to readiness to quit smoking at baseline and during the followup period. Moreover, users and non-users did not significantly differ in the likelihood of making a quit attempt over 12 months. Results are consistent with research showing that young adult marijuana users do generally view quitting smoking as important , but have less ability to follow through with a complete abstinence goal despite a desire to quit smoking . Overall, our finding that marijuana users are less likely to report recent abstinence or reduction in smoking is consistent with extant literature suggesting that marijuana users are less likely to be successful at quitting smoking . Encouragingly, marijuana users and non-marijuana users participating in the digital smoking cessation arm of the intervention did not differ in their perceptions of the intervention or their engagement in it. This suggests that young adults who use marijuana were receptive to the content and digital platform of the smoking cessation intervention. The intervention content included minimal information on the potential harmful effects of marijuana use. Future intervention content could highlight the negative effects continued marijuana use may have on quitting smoking, and could serve as a resource for young adults who want to quit using one or both substances. The variables most strongly and consistently associated with smoking outcomes over time were baseline stage of change for quitting smoking and marijuana use. Both should be assessed to inform treatment efforts with young adult smokers. Strengths of this study include multiple smoking-related outcomes, a 12-month longitudinal design, and a focus on young adults . This study had a few notable limitations. First, outcomes were self-reported. Our group has previously demonstrated the reliability and validity of young adults’ online self-reported tobacco and marijuana use , as well as the accuracy and limited bias of self-reported point prevalence abstinence in the present sample . Therefore, we opted to use self-reported abstinence, which had a much higher response rate. Second, current marijuana use was categorized into use versus non-use. It is possible that the relationship between marijuana use and smoking outcomes differs by heaviness of marijuana use, which our survey item did not assess. Although past research has shown that readiness to avoid marijuana use is significantly correlated with past 30 day marijuana use , future research should include a more detailed measure of marijuana use.
The measure of alcohol use was similarly nonspecific, and a more detailed measure may yield different results. Moreover, up to twice as many of the participants indicated being abstinent for 7 days at each follow-up than identified as being in action/maintenance for having quit smoking. This was especially true of participants who were not using marijuana concurrently, as reflected in the significant difference in point prevalence abstinence and reduction between marijuana users and non-marijuana users. This finding may be due to the sample including non-daily smokers, and/or the young adult age of the participants. Based on self-report, 5-10% of the sample refrained from smoking for at least one week, yet were not committing to quitting. Future research could include more nuanced measure of marijuana use and measures of smoking specific to non-daily cigarette smokers. The opioid epidemic in the United States has seen an almost sixfold increase in overdose deaths since 1999, a rise that parallels a 30% increase in the suicide rate between 2000-2016.While the association between opioid use and suicidal ideation has been documented, the impact of opioid use on the current escalation in suicides is unclear.It is likely that suicides caused by opioid overdose are under reported and that many opioid overdose deaths classified as “undetermined” by coroners are suicides.Treating individuals with opioid use disorders must include attention to suicide risk. The 99.4% increase in opioid-related visits to emergency departments between 2005-2014 represents an opportunity for EDs to encourage patients already in a vulnerable period to make behavioral changes.This includes offering medication-based treatment with methadone and buprenorphine to OUD patients. Studies show that EDinitiated buprenorphine decreases opioid use and increases engagement in outpatient substance use treatment.A limitation of these studies is that OUD patients with SI have University of Maryland School of Medicine, Department of Psychiatry, Baltimore, Maryland been excluded, despite some evidence that buprenorphine might reduce SI.We present observational data on 14 OUD patients with SI who presented to the ED for treatment. Our goals were to explore the feasibility of starting buprenorphine in these patients in the ED, and to determine whether ED-initiated buprenorphine treatment would be associated with improvements in SI and engagement in outpatient substance use treatment. This study was approved by the medical school’s institutional review board. The 14 patients presented to the ED of a tertiary care hospital between July 2012–August 2018. All met criteria for OUD and reported current SI or a suicide attempt at their index ED visit. All were evaluated by a psychiatrist and offered buprenorphine with a referral to an outpatient substance use treatment program.