For Aim 1, we hypothesized that greater cigarette use would be associated with greater marijuana use. We also explored the association between past year quit attempts for the two substances without an explicit hypothesis. For Aim 2, given perceptions that cigarette smoking is more harmful and less socially acceptable than marijuana use among young people, we hypothesized young adults would have a stronger desire to quit and be more likely to have a goal of abstinence for cigarettes than marijuana. Further, given that cigarette smoking is legal federally and in more states, more readily available, and publicly used than marijuana, we expected that cousers would have lower efficacy for quitting cigarette smoking and staying quit from cigarettes than marijuana. For Aim 3, we hypothesized that the stage distributions would differ for cigarettes and marijuana with more young adults in preparation for quitting smoking than quitting marijuana. Given strong associations between cigarette smoking and marijuana use , we anticipated temptations to use and that the pros and cons of using would be associated across the two substances. Given that temptations and decisional balance are known to vary by stage of change , we included stage of change for both cigarettes and marijuana as covariates in examination of Aim 3 hypotheses.Understanding young adults’ co-use and their thoughts about use of cigarettes and marijuana will help inform whether interventions should be targeted similarly,best way to dry cannabis and possibly even simultaneously, for the two substances. Data for the present study were taken from a U.S.-based Internet survey of English-literate young adult cigarette smokers aged 18 to 25. Characteristics of the full sample and the three recruitment methods utilized have been described previously .
Advertisements that targeted young adult cigarette smokers or cigarette and marijuana users contained a hyperlink that directed potential participants to a separate website that included: 1) the study’s IRB-approved consent form with verification questions to determine understanding of the consent process; and 2) a screener for determining eligibility including English literacy. The survey assessed demographic characteristics and then cigarette and marijuana use and thoughts about use as well as alcohol use for inclusion as a covariate. Participants were required to answer all questions before they could continue to the next page of the survey, but could quit the survey at any time. Computer IP addresses were tracked with one entry allowed from a single computer to prevent duplicate entries from the same person; however, multiple entries were allowed from the same Internet connection . Over 7567 people accessed the online survey, 7260 signed online consent, and 4242 met criteria to participate . Eligibility checks excluded 494 respondents who had invalid data due to verifiably inaccurate responses, leaving 3748 valid entries , of which 1987 completed the entire 30–45 minute survey. The 972 survey completers who reported use of both cigarettes and marijuana were included in the present analyses. This study examined differences in patterns of cigarette smoking and marijuana use, quit attempts, and thoughts about use and abstinence in a national online sample of young adults who used both substances. Consistent with previous cross-sectional and longitudinal research, the frequency and severity of cigarette and marijuana use were related as were quit attempts and some cognitions related to use. Frequency of alcohol use independently predicted cigarette use frequency, consistent with prior research with young adults , yet was unrelated to the measure of nicotine dependence. Epidemiological data indicate young adult drinking and smoking are highly co-morbid with the risk of co-use of alcohol and tobacco found at any level of smoking .
The consistent association between cigarette, marijuana, and alcohol use in young adults, regardless of level of dependence, supports interventions to target these multiple substances concurrently. While young adults’ cigarette and marijuana use frequency and severity were related, as were some of their thoughts about use, reported levels of interest and perceived ability with quitting were found to differ in interesting ways. Despite greater desire to quit cigarettes, greater preparation stage membership, and greater likelihood of tobacco abstinence goals, participants also reported more temptations to use tobacco, less expected success with quitting, greater perceived difficulty staying quit, and identified more pros as well as cons for using cigarettes. Very few individuals in this study were ready to quit both cigarettes and marijuana concurrently, and being motivated to quit one substance was not associated with being motivated to quit the other substance. Young adults may be more receptive to interventions for cigarettes than marijuana use, especially interventions that seek to increase self-efficacy for quitting and staying quit by providing cognitive and behavior skills to manage smoking urges. Notably, however, a sample majority reported a past year failed quit attempt for both tobacco and marijuana , and a quit attempt on one substance was associated with a 2-fold greater likelihood of a quit attempt for the other. It would seem that behaviorally, a majority of young adults are reporting recent unsuccessful efforts to quit both substances. In adults, there is mixed evidence as to whether marijuana use interferes with tobacco treatment outcomes . Data from the present study suggest that clinicians should not be deterred from supporting cigarette smoking cessation efforts for young people who use both cigarettes and marijuana. Given that many young people in the community are not ready to quit using marijuana, intervention strategies ought to include those designed to increase motivation .
It could also be important to assess young people’s perceptions of the interaction between cigarette and marijuana use to identify relapse risk and target prevention efforts accordingl. Finally, brief, motivational interventions matched to risk level such as Screening, Brief Intervention, and Referral to Treatment could be particularly helpful with young adults who may be at risk for problems associated with substance use but may not be physically dependent or willing to engage in more intensive treatment. SBIRT screens individuals with substance use and administers treatment tailored to risk: those with low risk are given a time-limited motivational interview to increase awareness of risks, while those with high risk are offered more intensive treatment. Given the frequency of cigarette and marijuana use among young adults, SBIRT screening protocols should consider substance co-use in delineating risk profiles of patients. In contrast to thoughts about abstinence, cognitions related to temptations to use and decisional balance for cigarettes and marijuana were related in our study and notable given measurement differences for the two behaviors. The smoking temptations measure was shorter and assessed three domains , while the marijuana temptation scale was longer with only one factor . Post hoc analyses demonstrated that within each substance, temptations and pros of using decreased while cons of using increased across the stages of change, consistent with work found by others across a number of health behaviors . The findings further validate the TTM constructs of temptations and decisional balance in a young adult population applied to both cigarettes and marijuana, and suggest that for both substances, interventions should target decreasing the pros and increasing the cons of using to facilitate movement toward preparation and action. Homelessness poses a major community mental health challenge,how to cure cannabis placing millions of unhoused residents at severe risk for mental health, substance use, and physical health problems each year. An estimated 326,000 to 580,000 individuals experience sheltered homelessness in the U.S. each night and 2.3 to 3.5 million individuals experience homelessness each year , with about one-third living unsheltered . These individuals are disproportionately racial/ethnic minority and many reside in locations burdened by extreme housing costs , with the number of individuals experiencing chronic homelessness—who are most likely to be unsheltered and bear the greatest mental and physical health risks—increasing 20% from 2020 to 2021 . In prior data, homelessness has been linked to numerous adverse mental health outcomes including high rates of depression, anxiety, serious mental illness, and alcohol and other substance use disorders . In addition, individuals experiencing homelessness— particularly the unsheltered or chronically unhoused—sufer heightened prevalence of chronic disease , dying an average of 20–30 years earlier than the general population with up to 10 times greater rates of all-cause mortality . Yet, despite their immense risk, we know surprisingly little about the mental health, substance use, and behavioral health treatment need of the millions of community dwelling unhoused individuals living outside of major U.S. urban centers such as New York or Los Angeles as most extant data is derived from nonresearch point-in-time counts or pre-pandemic studies with urban populations conducted at point-of-contact locations/ services versus the community locations in which they live . Accordingly, using funding from the National Institute of Mental Health and National Institute on Drug Abuse, the present community-based participatory research study investigated the scope of mental health and substance use disorders, mental health treatment need, and physical health among community-dwelling individuals experiencing homelessness—many unsheltered or chronically unhoused—in Hawai‘i. We conducted this novel mental health study in Hawai‘i because it possesses the nation’s second highest rate of homelessness yet is unique among major U.S. communities battling extreme homelessness in being predominantly rural .
However, despite its rural nature, Hawai‘i mirrors many U.S. cities with high homelessness rates in having the nation’s highest costs of living, real estate, and rental prices —rendering nearly half of Hawai‘i residents just paychecks away from homelessness . Similarly, numerous news reports and growing evidence suggest that illicit substance use and fatal drug overdoses may be rampant among unhoused individuals in Hawai‘i; consuming substantial social service, policing, and healthcare resources . Despite this, almost no empirically-focused studies have detailed the mental health or substance use challenges of unhoused individuals in Hawai‘i and relatively few have studied non-urban unhoused community populations in the U.S. . This lack of research is particularly problematic given indications that up to 40% of Hawai‘i unhoused residents may be Native Hawaiians/Pacifc Islanders ; who possess the state’s poorest economic and health outcomes due to the profound negative effects of U.S. colonization and cultural trauma on this understudied racial group . Therefore, by conducting this novel mental health investigation of unhoused individuals in a non-urban community deeply affected by homelessness , study findings may provide key insights into the potential health disparities facing other non-urban U.S. communities as they become increasingly afficted by the dual problems of rising housing costs and homelessness.Demographic variables of age, gender, education, and marital status were assessed. Depression and anxiety severity were assessed via the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 , which uses diagnostic cut-points of 10+to identify major depressive disorder and generalized anxiety disorder , respectively . Alcohol use disorder was screened using the Alcohol Use Disorders Identification Test-Consumption, which uses diagnostic cut-points of ≥ 4 for men and ≥ 3 for women . Lifetime and current cigarette, cannabis, prescription opioids, heroin, and methamphetamine use were assessed using items from established assessments . Opioid use disorder and methamphetamine use disorder were assessed using the Rapid Opioid Dependence Screen and ASSIST , respectively. Mental health and substance use treatment need and treatment delay/avoidance were assessed via four commonly-used Medical Expenditure Panel Survey items . Health outcomes included general health and three key CDC-defined health indices linked to chronic disease: obesity , unhealthy sleep , and current cigarette smoking . As the first study to our knowledge to detail the mental health, substance use, and treatment needs confronting Hawai‘i’s unhoused, and often unsheltered, individuals— and one of very few community-based empirical studies of U.S. unhoused populations conducted during COVID- 19—study findings revealed exceptionally high prevalence of mental health and substance use problems in this understudied and under served community population. On average, participants evidenced high levels of COVID-19-related distress along with clinical levels of depression and anxiety as nearly 60% of participants screened positive for MDD, over half screened positive for GAD, and two thirds screened positive for AUD. Consequently, over 60% of participants reported needing past-year mental health treatment with 65% delaying/avoiding needed treatment; revealing a substantial need and unmet need for formal treatment services in this high-risk community population. Illicit substance use was pervasive in the sample with 7 in 10 participants currently using methamphetamines and one quarter currently using illicit opioids, leading approximately 80% of participants to screen positive for opioid or methamphetamine use disorders.