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Income inequality and daily use of cannabis, cigarettes, and e-cigarettes among Canadian secondary school students: Results from COMPASS 2018-19
Abstract
Introduction:
Cannabis, cigarette, and e-cigarette use among Canadian adolescents is a major public health concern. Income inequality has been associated with adverse mental health among youth and may contribute to the risk of frequent cannabis, cigarette, and e-cigarette use. We tested the association between income inequality and the risk of daily cannabis, cigarette, and e-cigarette use among Canadian secondary school students.
Methods:
We used individual-level survey data from Year 6 (2018/19) of Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary Behavior (COMPASS) and area-level data from the 2016 Canadian Census. Three-level logistic models were used to assess the relationship between income inequality and adolescent daily and current cannabis use, cigarette smoking, and e-cigarette use.
Results:
The analytic sample included 74,501 students aged 12-19. Students were most likely to report being male (50.4%), white (69.1%), and having weekly spending money over $100 (23.5%). We found that a standard deviation unit increase in Gini coefficient was significantly associated with increased likelihood of daily cannabis use (OR=1.25, 95% CI = 1.01-1.54) when adjusting for relevant covariates. We found no significant relationship between income inequality and daily smoking. While Gini was not significantly associated with daily e-cigarette use, we observed a significant interaction between Gini and gender (OR=0.87, 95% CI= 0.80-0.94), indicating that increased income inequality was associated with higher risk of reporting daily e-cigarette use among females only.
Discussion:
An association between income inequality and the likelihood of reporting daily cannabis use across all students and daily e-cigarette use in females were observed. Schools in higher income inequality areas may benefit from targeted prevention and harm reduction programs. Results emphasize the need for upstream discussion on policies that can mitigate the potential effects income inequality.
... While Gini was not significantly associated with daily e-cigarette use, the study documented a significant interaction between Gini and gender (Odds Ratio: OR=0.87, 95% CI= 0.80-0.94), indicating that increased income inequality was associated with higher risk of reporting daily e-cigarette use among females only 13 . ...
Background
Association between cannabis use and metabolic syndrome (MetS) has been documented; yet variation by race/ethnicity is understudied. We examined cannabis use and MetS by race/ethnicity among emerging adults (18-25 years old), the age group with the highest prevalence of cannabis use.
Methods
Data from 18- to 25-year-olds who completed the National Health and Nutrition Examination Survey (2009-2018) were analyzed. Current cannabis use was defined as ≥1 day of use in the last 30 days. MetS was defined using standardized guidelines as ≥3 of the following: elevated fasting glucose, triglycerides, systolic (SBP) and/or diastolic blood pressure (DPB), waist circumference, and/or low high-density lipoprotein (HDL) cholesterol. Logistic regression was used to examine the association between current cannabis use (CCU) and MetS, adjusting for covariates.
Results
Of 3974 respondents, 48.8% were female, mean age 21.1 years (SD = 2.4), 56.7% non-Hispanic white, 20.4% Hispanic, and 14.0% non-Hispanic black (NHB). Hispanics had the highest MetS prevalence (7.9%) and lowest CCU prevalence (23.5%). NHB had highest CCU prevalence (33.4%, P < .0001) and lowest MetS prevalence (4.8%, P = .2543). CCUs had a higher mean SBP (P = .020) and Hispanics (P = .002) than never users. Conversely, NHB CCUs exhibited lower mean SBP than NHB never users (P = .008). CCUs had 42% reduced odds of MetS than never users (AOR: 0.58, 95% CI: 0.35-0.95). Among NHB, CCUs had 78% lower likelihood of having MetS than never users (AOR: 0.22, 95% CI: 0.06-0.81).
Conclusions
Cannabis use impacts MetS and blood pressure differently by race/ethnicity. Current cannabis use was associated with lower odds of MetS overall and among NHB. Further research is warranted to investigate how administration routes, dosages, and usage duration affect MetS.
Background: Historically substance use literature has focused on smoking as the main mode of cannabis consumption, so there are knowledge gaps surrounding current understanding of edibles and vaping. These alternative modes of cannabis use are already common among Canadian youth; however, little is known about how these cannabis use patterns change over time. Methods: This study examined the mode (smoking, eating/drinking, vaping) and frequency of cannabis use among a large sample of Canadian youth who participated in 2017–2018 and 2018–2019 data collection waves of the COMPASS study. Using latent transition analysis, this sample consisting of 18,824 youth in grades 9–12 were categorized into cannabis use classes stratified by sex, and their transition between these classes over the one-year period was examined. Results: Three cannabis use classes were identified (occasional multimode, regular multimode, and smoking) alongside one nonuse class. Among youth who reported cannabis use at baseline, transitioning to a multimode group, and/or increasing frequency of multimode use was likely over the one-year period. Conclusions: These findings may highlight a key leverage point for harm-reduction strategies which aim to prevent cannabis related harms associated with high frequency use.
Background
Nearly one-third of secondary school students report experiencing depressive symptoms in the past year. Existing research suggests that increasing rates of depression are due in part to increasing income inequality. The aim of this study is to identify mechanisms by which income inequality contributes to depression among Canadian secondary school students.
Methods
We used data from a large sample of Canadian secondary school students that participated in the 2017/18 wave of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) study. The sample included 61,642 students across 43 Census divisions (CDs) in Quebec, Ontario, Alberta, and British Columbia. We used multilevel path analysis to determine if the relationship between CD-level income inequality and depression was mediated by student's psychosocial well-being and/or social cohesion.
Results
Attending schools in CDs with higher income inequality was related to higher depression scores among Canadian secondary students [unstandardized ß (ß) = 5.36; 95% CI = 0.74, 9.99] and lower psychosocial well-being (ß = −14.83, 95% CI = −25.05, −4.60). Income inequality was not significantly associated with social cohesion, although social cohesion was associated with depression scores among students (ß = −0.31; 95% CI = −0.34, −0.28).
Discussion
Findings from this study indicate that income inequality is associated with adolescent depression and that this relationship is mediated by psychosocial well-being. This study is the first of its kind in Canada to assess the mechanisms by which income inequality contributes to adolescent depression. These findings are applicable to school-level programs addressing mental health.
Importance
Cannabis use has increased, but there are few studies on frequent and daily cannabis use among US adults. Individuals who engage in higher frequency use may suffer more health consequences.
Objective
To examine frequency of cannabis use and associated factors among US adults.
Design, Setting, and Participants
This survey study included data from 21 US states and 2 US territories reported in the Behavioral Risk Factor Surveillance System surveys from 2016 to 2019. Cross-sectional data on US adults ages 18 years and older were used to estimate demographic, socioeconomic, and behavioral risk factors for cannabis use, taking into account the survey strata and sampling weights for the 4 years of combined data. Using a multivariable ordinal logistic analysis, the association of demographic, socioeconomic status, and behavioral risk factors with past month cannabis frequency were examined.
Exposures
Sociodemographic characteristic, ie, age, gender, race and ethnicity, educational attainment, employment status, and annual household income.
Main Outcomes and Measures
Ordinal categorization of number of days of cannabis use in the past 30 days in terms of nonuse, infrequent use (1-5 days), frequent use (6-29 days), and daily use.
Results
Among the 387 179 respondents, 58 009 (27.9%) were ages 18 to 34 years, 186 923 (50.3%) were ages 35 to 64 years, and 142 225 (21.8%) were age 65 years or older (mean [SD] age, 48.3 [0.1] years). The sample included 28 345 (9.8%) Black, 36 697 (22.6%) Hispanic, and 292 210 (57.3%) White respondents. Smoking was the most common form of cannabis use. The frequency of cannabis use varied significantly by age, gender, race, marital status, education, and employment. Higher frequency cannabis use was associated with younger age (ages 18-34 years: adjusted odds ratio [aOR],4.12; 95% CI, 3.63-4.68; ages 35-64 years: aOR,2.22; 95% CI, 1.98-2.49), Black (aOR, 1.46; 95% CI, 1.33-1.71) and Native American (aOR, 1.25; 95% CI, 1.04-1.52) race, and less educational attainment (high school or less: aOR,1.09; 95% CI, 1.02-1.17; some college: aOR,1.27; 95% CI, 1.19-1.35). Being married (aOR, 0.54; 95% CI, 0.51-0.58) or identifying as Asian (aOR, 0.60; 95% CI, 0.51-0.71) or Hispanic (aOR, 0.71; 95% CI, 0.65-0.77) was associated with lower-frequency cannabis use after accounting for other baseline factors.
Conclusions and Relevance
This nationally based study found that higher-frequency cannabis use is more common among young and racial minority populations, as well as respondents with low socioeconomic status. Given the known and emerging negative health effects of cannabis use, more attention may need to be paid to high-frequency use among underserved populations in the form of screening, risk stratification, and treatment.
Objectives:
Previous research has indicated that area-level income inequality is associated with increased risk in alcohol consumption. However, few studies have been conducted among adolescents living within smaller area units, such as neighborhoods. We investigated whether neighborhood income inequality is associated with alcohol consumption among adolescents.
Methods:
We analyzed cross-sectional data from a sample of 1878 adolescents living in 38 neighborhoods participating in the 2008 Boston Youth Survey. Multilevel logistic regression modeling was used to determine the role of neighborhood income inequality and the odds for alcohol consumption and to determine if social cohesion and depressive symptoms were mediators.
Results:
In comparison to the first tertile of income inequality, or the most equal neighborhood, adolescent participants living in the second tertile (AOR = 1.20, 95% CI: 0.89, 1.61) and third tertile (AOR = 1.44, 95% CI: 1.06, 1.96) were more likely to have consumed alcohol in the last 30 days. Social cohesion and depressive symptoms were not observed to mediate this relationship.
Conclusions:
Findings indicate that the distribution of incomes within urban areas may be related to alcohol consumption among adolescents. To prevent alcohol consumption, public health practitioners should prioritize prevention efforts for adolescents living in neighborhoods with large gaps between rich and poor.
Background
Knowledge of factors relating to patterns of cannabis use is important for informing drug policy. This study determined factors associated with recent and current cannabis use. In addition, we explored factors related to having a cannabis use disorder (CUD)—defined using the Diagnostic and Statistical Manual of Psychiatric Disorders—among current users.
Methods
We analyzed data from Ireland’s 2010–11 and 2014–15 National Drug Prevalence Surveys, which recruited 5134 and 7005 individuals respectively, aged 15 years or more, living in private households. Multinomial logistic regression was used to identify factors associated with recent (last year) and current (last month) cannabis use compared to experiential use. Binary logistic regression was used to determine factors related to CUD among current users.
Results
The weighted prevalence of experiential cannabis use was 18.3%, with 3.0% and 3.3% of participants indicating recent or current use, respectively; 41.3% of current users indicated having a CUD. Factors associated with both recent or current cannabis use included younger age, not being married or cohabiting, having no dependent children and current use of tobacco or alcohol. Male gender, younger age and lower educational levels were significantly related to CUD among current users.
Conclusions
Males, adolescents/young adults and individuals with lower educational levels are more likely to be current users of cannabis and are at a greater risk of having a CUD. Health professionals should be aware of these factors to improve detection and prevention of CUD.
Currently, boys and men use cannabis at higher rates than girls and women, but the gender gap is narrowing. With the legalization of recreational cannabis use in Canada and in multiple US states, these trends call for urgent attention to the need to consider how gender norms, roles and relations influence patterns of cannabis use to inform health promotion and prevention responses. Based on a scoping review on sex, gender and cannabis use, this article consolidates existing evidence from the academic literature on how gender norms, roles and relations impact cannabis-use patterns. Evidence is reviewed on: adherence to dominant masculine and feminine norms and cannabis-use patterns among adolescents and young adults, and how prevailing norms can be both reinstated or reimagined through cannabis use; gendered social dynamics in cannabis-use settings; and the impact of gender roles and relations on cannabis use among young adults of diverse sexual orientations and gender identities. Findings from the review are compared and contrasted with evidence on gender norms, roles and relations in the context of alcohol and tobacco use. Recommendations for integrating gender transformative principles in health promotion and prevention responses to cannabis use are provided.
Background: Vaping has become an increasingly common mode of administration for both nicotine and cannabis, with overlap among users, devices, as well as nicotine and cannabis companies. There is a need to understand patterns of use among youth, including the way nicotine and cannabis are administered. Methods: Data are from Wave 2 of the ITC Youth Tobacco and Vaping survey, an online survey conducted in 2018 among 16–19 year-olds recruited from commercial panels in Canada (n = 3757), England (n = 3819), and the U.S. (n = 3961). The prevalence of past 30-day vaping nicotine, non-nicotine and cannabis substances, as well as cannabis modes of use was examined. Logistic regression models examined between country differences in prevalence. Results: Past 30-day cannabis use was highest among Canadian youth (16.6%), followed by youth in the U.S. (13.8%) and England (9.0%). Vaping e-cigarettes was substantially more prevalent than vaping cannabis in all three countries. All forms of cannabis use were higher among Canadian and U.S. youth compared to England (p < 0.001 for all). Past 30-day cannabis users in the U.S. were more likely to report vaping cannabis oil (30.1%), and consuming solid concentrates such as wax and shatter (30.2%), compared to cannabis users in Canada (18.6% and 22.9%) and England (14.3% and 11.0%; p < 0.001 for all). Conclusions: Youth are administering cannabis and nicotine using a wide diversity of modes. Cannabis users in the U.S.—where an increasing number of states have legalized medical and non-medical cannabis—reported notably higher use of more potent cannabis products, including cannabis oils and extracts.
Objectives
The Government of Canada has proposed an ‘endgame’ target for cigarette smoking that aims to reduce prevalence below 5% by 2035. To meet this difficult goal, it will be necessary to identify populations where interventions will (1) have the greatest impact in reducing the number of smokers and (2) have the greatest impact in addressing smoking disparities.
Method(s)
Using data from the Canadian Community Health Survey, smoking prevalence was estimated for populations that differed with respect to demographic, substance use, and mental health factors. Risk difference, relative risk, and attributable disparity number, which describes the magnitude of the potential impact if the disparity were addressed, were calculated for each group.
Results
The strongest disparities (relative risk ⩾ 2) were associated with immigration status (for women), substance use, marital status, and lifetime experience of mental health or substance use disorders. The smallest disparities (relative risk ⩽ 1.5) were associated with sexual orientation, household income, immigration status (men), and province of residence. The groups with the largest attributable disparity number were among those who used cannabis, and those who were not immigrants, not married, and white.
Conclusions
Disparities which were both strong and had a large potential impact on prevalence overall were found for populations facing mental health and substance use concerns. Differences in rankings were found depending on the scale of the measure. Addressing disparities in smoking rates is an important component of developing tobacco endgame strategies.
Purpose of review:
The present review will provide an overview of the neurobiology, epidemiology, clinical impact, and treatment of cannabis use disorder (CUD) in mood disorders.
Recent findings:
Patients with mood disorders including major depressive disorder (MDD) and bipolar disorder (BD) have higher rates of cannabis use, and CUD compared to the general population. Reasons for this association are not clear, nor are the putative therapeutic effects of cannabis use, or its components delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), in these illnesses. The evidence surrounding treatments for patients with this comorbidity is lacking, with more support for psychotherapeutic treatments compared with pharmacological treatments.
Summary:
Cannabis use may be associated mood disorders, but more research is needed to increase our understanding of the mechanisms for this association, and to develop more effective treatments for this comorbidity.
The inverse association between socioeconomic status and smoking is well established, yet the mechanisms that drive this relationship are unclear. We developed and tested four theoretical models of the pathways that link socioeconomic status to current smoking prevalence using a structural equation modeling (SEM) approach. Using data from the 2013 National Health Interview Survey, we selected four indicator variables (poverty ratio, personal earnings, educational attainment, and employment status) that we hypothesize underlie a latent variable, socioeconomic status. We measured direct, indirect, and total effects of socioeconomic status on smoking on four pathways through four latent variables representing social cohesion, financial strain, sleep disturbance, and psychological distress. Results of the model indicated that the probability of being a smoker decreased by 26% of a standard deviation for every one standard deviation increase in socioeconomic status. The direct effects of socioeconomic status on smoking accounted for the majority of the total effects, but the overall model also included significant indirect effects. Of the four mediators, sleep disturbance and psychological distress had the largest total effects on current smoking. We explored the use of structural equation modeling in epidemiology to quantify effects of socioeconomic status on smoking through four social and psychological factors to identify potential targets for interventions. A better understanding of the complex relationship between socioeconomic status and smoking is critical as we continue to reduce the burden of tobacco and eliminate health disparities related to smoking.
Most countries have witnessed a dramatic increase of income inequality in the past three decades. This paper addresses the question of whether income inequality is associated with the population prevalence of depression and, if so, the potential mechanisms and pathways which may explain this association. Our systematic review included 26 studies, mostly from high-income countries. Nearly two-thirds of all studies and five out of six longitudinal studies reported a statistically significant positive relationship between income inequality and risk of depression; only one study reported a statistically significant negative relationship. Twelve studies were included in a meta-analysis with dichotomized inequality groupings. The pooled risk ratio was 1.19 (95% CI: 1.07-1.31), demonstrating greater risk of depression in populations with higher income inequality relative to populations with lower inequality. Multiple studies reported subgroup effects, including greater impacts of income inequality among women and low-income populations. We propose an ecological framework, with mechanisms operating at the national level (the neo-material hypothesis), neighbourhood level (the social capital and the social comparison hypotheses) and individual level (psychological stress and social defeat hypotheses) to explain this association. We conclude that policy makers should actively promote actions to reduce income inequality, such as progressive taxation policies and a basic universal income. Mental health professionals should champion such policies, as well as promote the delivery of interventions which target the pathways and proximal determinants, such as building life skills in adolescents and provision of psychological therapies and packages of care with demonstrated effectiveness for settings of poverty and high income inequality.
p> OBJECTIVES: The objectives of this study are to describe marijuana use in Canada and explore factors associated with problematic use.
METHODS: Data from the 2010–2012 circulations of the Canadian Alcohol and Drug Use Monitoring Survey were used to create three logistic regression models for the purposes of identifying and comparing factors associated with the degree of marijuana use, as determined via the WHO Alcohol, Smoking and Substance Abuse Involvement Screening Test (non-problematic, problematic) and European Monitoring Centre for Drugs and Drug Addiction (experiential, recent, current) methods.
RESULTS: Canadians aged 15–24 years are 15 times ( p < 0.001) more likely to be current users than Canadians aged 65 or older, with the odds of exhibiting problematic marijuana use being 10 times ( p < 0.001) greater. The odds of a male exhibiting problematic marijuana use are 2.46 times ( p < 0.001) greater than for females. The odds of exhibiting problematic marijuana use are 41.0% ( p = 0.031) and 53.0% ( p = 0.008) greater for marijuana users with household incomes 40,000–80,000 and less than $40,000 respectively compared to those aged 65+. An earlier age of first marijuana use is associated with problematic use but not necessarily with being a current user.
CONCLUSION: The majority of our findings are consistent with the literature, showing that Canadians who are: male, adolescent or young adult, smokers, heavy drinkers, other illicit drug users, and who have poorer mental health status are more likely to engage in any marijuana use, particularly higher levels of marijuana use. These findings can be used to inform the development of policy in Canada to address problematic marijuana use and prepare for its possible legalization.
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Background:
Although recent evidence has shown that area-level income inequality is related to increased risk for depression among adults, few studies have tested this association among adolescents.
Methods:
We analysed the cross-sectional data from a sample of 1878 adolescents living in 38 neighbourhoods participating in the 2008 Boston Youth Survey. Using multilevel linear regression modelling, we: (1) estimated the association between neighbourhood income inequality and depressive symptoms, (2) tested for cross-level interactions between sex and neighbourhood income inequality and (3) examined neighbourhood social cohesion as a mediator of the relationship between income inequality and depressive symptoms.
Results:
The association between neighbourhood income inequality and depressive symptoms varied significantly by sex, with girls in higher income inequality neighbourhood reporting higher depressive symptom scores, but not boys. Among girls, a unit increase in Gini Z-score was associated with more depressive symptoms (β=0.38, 95% CI 0.28 to 0.47, p=0.01) adjusting for nativity, neighbourhood income, social cohesion, crime and social disorder. There was no evidence that the association between income inequality and depressive symptoms was due to neighbourhood-level differences in social cohesion.
Conclusions:
The distribution of incomes within an urban area adversely affects adolescent girls' mental health; future work is needed to understand why, as well as to examine in greater depth the potential consequences of inequality for males, which may have been difficult to detect here.
Population-based estimates of substance use patterns have been regularly reported now for several decades. Concerns with the quality of the survey methodologies employed to produce those estimates date back almost as far. Those concerns have led to a considerable body of research specifically focused on understanding the nature and consequences of survey-based errors in substance use epidemiology. This paper reviews and summarizes that empirical research by organizing it within a total survey error model framework that considers multiple types of representation and measurement errors. Gaps in our knowledge of error sources in substance use surveys and areas needing future research are also identified.
Few researchers have the data required to adequately understand how the school environment impacts youth health behaviour development over time.
COMPASS is a prospective cohort study designed to annually collect hierarchical longitudinal data from a sample of 90 secondary schools and the 50,000+ grade 9 to 12 students attending those schools. COMPASS uses a rigorous quasi-experimental design to evaluate how changes in school programs, policies, and/or built environment (BE) characteristics are related to changes in multiple youth health behaviours and outcomes over time. These data will allow for the quasi-experimental evaluation of natural experiments that will occur within schools over the course of COMPASS, providing a means for generating "practice based evidence" in school-based prevention programming.
COMPASS is the first study with the infrastructure to robustly evaluate the impact that changes in multiple school-level programs, policies, and BE characteristics within or surrounding a school might have on multiple youth health behaviours or outcomes over time. COMPASS will provide valuable new insight for planning, tailoring and targeting of school-based prevention initiatives where they are most likely to have impact.
Although cross-sectional and ecological studies have shown that higher area-level income inequality is related to increased risk for depression, few longitudinal studies have been conducted. This investigation examines the relationship between state-level income inequality and major depression among adults participating in a population-based, representative longitudinal study.
We used data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=34 653). Respondents completed structured diagnostic interviews at baseline (2001-2002) and follow-up (2004-2005). Weighted multilevel modelling was used to determine if US state-level income inequality (measured by the Gini coefficient) was a significant predictor of depression at baseline and at follow-up, while controlling for individual-level and state-level covariates. We also repeated the longitudinal analyses, excluding those who had a history of depression or at baseline, in order to test whether income inequality was related to incident depression.
State-level inequality was associated with increased incidence of depression among women but not men. In comparison to women residing in states belonging to the lowest quintile of income inequality, women were at increased risk for depression in the second (OR=1.18, 95% CI 0.86 to 1.62), third (OR=1.22, 95% CI 0.91 to 1.62), fourth (OR=1.37, 95% CI 1.03 to 1.82) and fifth (OR=1.50, 95% CI 1.14 to 1.96) quintiles at follow-up (p<0.05 for the linear trend).
Living in a state with higher income inequality increases the risk for the development of depression among women.
Although several social network studies have demonstrated peer influence effects on adolescent substance use, findings for marijuana use have been equivocal. This study examines whether structural features of friendships moderate friends' influence on adolescent marijuana use over time.
Using 1-year longitudinal data from the National Longitudinal Study of Adolescent Health, this article examines whether three structural features of friendships moderate friends' influence on adolescent marijuana use: whether the friendship is reciprocated, the popularity of the nominated friend, and the popularity/status difference between the nominated friend and the adolescent. The sample consists of students in grade 10/11 at wave I, who were in grade 11/12 at wave II, from two large schools with complete grade-based friendship network data (N = 1,612).
In one school, friends' influence on marijuana use was more likely to occur within mutual, reciprocated friendships compared with nonreciprocated relationships. In the other school, friends' influence was stronger when the friends were relatively popular within the school setting or much more popular than the adolescents themselves.
Friends' influence on youth marijuana use may play out in different ways, depending on the school context. In one school, influence occurred predominantly within reciprocated relationships that are likely characterized by closeness and trust, whereas in the other school adopting friends' drug use behaviors appeared to be a strategy to attain social status. Further research is needed to better understand the conditions under which structural features of friendships moderate friends' influence on adolescent marijuana use.
This paper describes the survey development, design and data collection protocol for the 2008/2009 Youth Smoking Survey (YSS) and the changes to the YSS survey and protocols across the 5 survey cycles (1994, 2002, 2004/2005, 2006/2007, 2008/2009). Canada's Youth Smoking Survey is a nationally representative school-based survey of students (grades 6 to 12 in 2008/2009) from randomly sampled public and private schools in the ten provinces. The main objective of the YSS is to provide benchmark data on national smoking prevalence rates for youth. Key features of the 2008/2009 YSS include consistent measures across survey cycles, a survey team of researchers and non-governmental organizations, a link to school and student level measures, provision of tailored feedback reports to schools and publicly available datasets.
To illustrate how limitations in the cannabis literature undermine our ability to understand cannabis-related harms and problems experienced by users and identify users at increased risk of experiencing adverse outcomes of use.
Limitations have been organized into three overarching themes. The first relates to the classification systems employed by researchers to categorize cannabis users, their cannabis use and the assumptions on which these systems are based. The second theme encompasses methodological and reporting issues, including differences between studies, inadequate statistical control of potential confounders, the under-reporting of effect sizes and the lack of consideration of clinical significance. The final theme covers differing approaches to studying cannabis use, including recruitment methods. Limitations related to the nature of the data collected by researchers are discussed throughout, with a focus on how they affect our understanding of cannabis use and users.
These limitations must be addressed to facilitate the development of effective and appropriately targeted evidence-based public health campaigns, treatment programmes and preventative, early intervention and harm minimization strategies, and to inform cannabis-related policy and legislation.
Objective To provide quantitative evaluations on the association between income inequality and health.
Design Random effects meta-analyses, calculating the overall relative risk for subsequent mortality among prospective cohort studies and the overall odds ratio for poor self rated health among cross sectional studies.
Data sources PubMed, the ISI Web of Science, and the National Bureau for Economic Research database.
Review methods Peer reviewed papers with multilevel data.
Results The meta-analysis included 59 509 857 subjects in nine cohort studies and 1 280 211 subjects in 19 cross sectional studies. The overall cohort relative risk and cross sectional odds ratio (95% confidence intervals) per 0.05 unit increase in Gini coefficient, a measure of income inequality, was 1.08 (1.06 to 1.10) and 1.04 (1.02 to 1.06), respectively. Meta-regressions showed stronger associations between income inequality and the health outcomes among studies with higher Gini (≥0.3), conducted with data after 1990, with longer duration of follow-up (>7 years), and incorporating time lags between income inequality and outcomes. By contrast, analyses accounting for unmeasured regional characteristics showed a weaker association between income inequality and health.
Conclusions The results suggest a modest adverse effect of income inequality on health, although the population impact might be larger if the association is truly causal. The results also support the threshold effect hypothesis, which posits the existence of a threshold of income inequality beyond which adverse impacts on health begin to emerge. The findings need to be interpreted with caution given the heterogeneity between studies, as well as the attenuation of the risk estimates in analyses that attempted to control for the unmeasured characteristics of areas with high levels of income inequality.
The relation of seven coping dimensions to substance (tobacco, alcohol, marijuana) use was tested with a sample of 1,668 participants assessed at mean age 12.5 years and two yearly follow-ups. An associative latent-growth model showed one index of engagement (behavioral coping) to be inversely related to initial level of adolescent use and growth over time in peer use. Three indices of disengagement (anger coping, helpless coping, and hangout coping) were positively related to initial levels of peer use and adolescent use and to growth in adolescent use. Life stress was positively related to initial levels for peer use and adolescent use and to growth in adolescent use. Moderation tests indicated that effects of coping were significantly greater at higher level of stress; behavioral coping buffered the effects of disengagement. Effects of life stress were greater for girls than for boys. Results are discussed with reference to mechanisms of coping-substance use relationships.
Canada legalized and regulated non-medical cannabis in October 2018, and in the lead up to this policy change much debate was generated around the Federal Government's stated objective of "keeping cannabis out of the hands of children and youth". As Canada moved through the process of passing Bill C-45 (the Cannabis Act), a contentious issue was whether the 'public health approach' to legalization with strict regulation guiding Federal policy would protect young people from accessing cannabis and from the potential harms of use. Now that we are several years post-legalization of cannabis, in this brief commentary we reconsider the arguments made about the potential consequences of legalization for youth, centered on three key concerns: that prevalence would significantly increase, that there would be greater incidence of harms to youth brain development, and that there would be increased presentations of severe mental illnesses associated with cannabis use. We also consider how focusing narrowly on clinical outcomes has neglected the association between criminalization and social inequities, where the burdens are disproportionate for marginalized and racialized youth.
Introduction
Marijuana vaping among adolescents is a growing public health concern. Marijuana vaping exposes youth to greater levels of tetrahydrocannabinol (THC) and may be related to e-cigarette or vaping product use-associated lung injury (EVALI). This study examined the risk factors for initiating marijuana vaping among US adolescents.
Methods
We analyzed Waves 3 (2015–2016) and 4 (2016–2018) of the Population Assessment of Tobacco and Health (PATH) Study. We estimate a multivariable logistic regression to model marijuana vaping initiation at Wave 4 among those who never vaped marijuana at Wave 3 (N = 7,821) as a function of key risk factors associated with youth substance use.
Results
Marijuana vaping initiation is associated with current use of electronic nicotine delivery system (ENDS) (aOR = 2.16, 95 % CI = 1.20, 3.89), cigarettes (aOR = 2.65, 95 % CI = 1.10, 6.35), other marijuana products (aOR = 7.78, 95 % CI = 3.74, 6.15), and alcohol (aOR = 1.98, 95 % CI = 1.35, 2.91). Other factors contributing to marijuana vaping initiation include being 15−17 years old (aOR = 1.51, 95 % CI = 1.19, 1.90) and Hispanic (aOR = 1.37, 95 % CI = 1.08, 1.76), as well as having less than college-level parental education (aOR = 1.35, 95 % CI = 1.07, 1.70), vaping peers (aOR = 2.31; 95 % CI = 1.81, 2.96), and a high internalizing (aOR = 1.49, 95 % CI = 1.10, 2.02) and externalizing tendency (aOR = 1.66, 95 % CI = 1.14, 2.41).
Conclusions
Multi-level efforts are needed to target the varying risk factors leading to marijuana vaping initiation in adolescents. Knowledge of these risk factors can help policymakers and health program administrators to identify at-risk individuals and design interventions that can prevent marijuana vaping initiation at the individual, household, school, clinical and public health levels.
"Vaping" refers to the inhalation of aerosols produced in devices that heat liquid solutions. The aerosols may contain various additives, flavours, nicotine and other drugs such as cannabis. Nicotine is the most common psychoactive substance in vaping devices (or e-cigarettes) in Canada. While vaping has been viewed primarily as a cessation method or harm reduction strategy for smokers of combustible tobacco cigarettes, a new pattern is becoming evident in adolescents and youth (age 15-24) in Canada. In this age group, vaping is reported in increasing frequencies among those who have never smoked. This suggests the possible emergence of a de novo pattern of substance use and suggests the emergence of an unmet treatment need, vaping cessation. The mental health implications of vaping are largely unknown but available data suggest that vaping is associated with mental health changes similar to those seen with combustible tobacco cigarettes. Understanding the mental health impact of "vaping" will be challenging and research is needed. An important message from the smoking literature is that data from randomized cessation trials may be especially valuable because of complex issues of temporality and confounding connected to observational data.
Purpose
This review characterizes empirically derived patterns of multiple (multi-) substance use among adolescents. A secondary objective was to examine the extent to which mental health symptomatology was included in the empirical analyses examining substance use patterns.
Methods
Eligible studies included those that used cluster-based approaches, included the assessment of at least two different substances, and were based on study samples with mean ages between 11 and 18 years. 4,665 records were screened including 461 studies for full-text screening.
Results
70 studies were included with common clusters being: low use, single or dual substance use, moderate general multi-use, and high multi-use. The most common patterns of single or multi-substance use were: alcohol only, alcohol with cannabis and/or tobacco, and use of alcohol, tobacco, and cannabis with and without other drugs. Lower socioeconomic status, older age, and male gender were consistent predictors of multi-use clusters. Only 37% of studies compared differences in levels of mental health across clusters with symptoms consistently associated with a greater likelihood of multi-use. Only 29% of studies included mental health indicators in cluster-based analyses, with over half identifying distinct mental health and substance use clusters. Fit indices in cluster analyses and measurement properties of substance use were heterogeneous and inconsistently reported across studies.
Conclusions
Distinct patterns of substance use were derived but methodological differences prevented direct comparison and reduced capacity to generalize across studies. There is a need to establish standardized methodological approaches to identify robust patterns of substance use to enhance etiological, prognostic, and intervention research.
Aim:
To establish whether the population-level pattern of cannabis use by quantity is similar to the distributions previously reported for alcohol, in which a small subset of drinkers accounts for a majority of total population alcohol consumption.
Method:
The current study pooled Waves 1-3 of the 2018 National Cannabis Survey (n = 18,900; 2584 past-three-month cannabis users), a set of stratified, population-based surveys designed to assess cannabis consumption and related behaviors in Canada. Each survey systematically measured self-reported cannabis consumption by quantity across seven of the major cannabis-product types. In order to enable the conversion of self-reported consumption of non-flower cannabis products into a standard joint equivalent (SJE: equal to 0.5 g of dried cannabis), we created conversion metrics for physical production equivalencies across cannabis products.
Results:
Similar to the findings in the alcohol literature, study results show that cannabis consumption is highly concentrated in a small subset of users: the upper 10% of cannabis users accounted for approximately two-thirds of all cannabis consumed in the country. Males reported consuming more cannabis by volume than females (approximately 60% versus 40%), with young males (15-34 years old) being disproportionately represented in the heaviest-using subgroups.
Conclusions:
Most of the cannabis used in Canada is consumed by a relatively small population of very heavy cannabis users. Future research should attempt to identify the characteristics of the heaviest-using groups, as well as how population-level cannabis consumption patterns relate to the calculus of cannabis-related harms in society.
Background:
Cannabis use is a potential risk factor for respiratory disease but its role apart from tobacco use is unclear. We evaluated the association between regular cannabis use, with and without tobacco co-use, and onset of asthma, chronic obstructive pulmonary disease (COPD), and pneumonia.
Methods:
Analysis of a limited data set obtained through IBM Watson Health Explorys, an electronic-health-record-integration platform. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8932); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4678); and 3) without a TUD diagnosis (non-TUD; n = 4254). Patients had at least: one recorded blood pressure measurement and one blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens (UDSs). Control patients, not having cannabis-related diagnoses or cannabis-positive UDSs, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status.
Results:
Regular cannabis use was significantly associated with greater risk for asthma (odds ratio (OR) = 1.44; adjusted odds ratio (aOR) = 1.50; OR = 1.32), COPD (OR = 1.56; aOR = 1.44; OR = 2.17), and pneumonia (OR = 1.80; OR = 1.84; OR = 2.13) in the total sample and TUD and non-TUD subgroups, respectively. TUD-patients had the greatest prevalence of respiratory disease, regardless of cannabis-use indication.
Conclusions:
Regular cannabis use is associated with significantly greater risk of respiratory disease regardless of TUD status. Future research to understand the impact of cannabis use on respiratory health is warranted.
Background:
Youth may use a variety of tobacco products and e-cigarettes. However, there is a lack of evidence for the combinations of tobacco products and e-cigarettes commonly used by youth in Canada and whether youth from different usage classes share similar characteristics.
Methods:
A cohort of 9th grade students from Ontario, Canada was identified at baseline (2013-14) of the COMPASS study (n = 4651). Classes of youth that currently use similar combinations of tobacco products and e-cigarettes were identified at baseline, one (FY1) and two years later (FY2) using latent class analysis. Multinomial logistic regression models identified demographic and behavioural characteristics (e.g., environmental influences, substance use behaviours, etc.) of youth in current tobacco and e-cigarette use classes relative to youth in non-current use classes.
Results:
At baseline, a three-class model was identified as best, while a four-class model was identified at FY1 and FY2. A non-current use group and an all-product use group were identified every year. Students that reported having friends that smoked cigarettes, binge drinking, and using marijuana were more likely to be classified into a current use class.
Conclusions:
Tobacco cigarettes were more likely to be used with other products than on their own. An all-product use group was identified across all three survey waves and the prevalence of this group increased over time. Given that many youth in this study used more than one tobacco product or e-cigarette and commonly reported binge drinking and using marijuana, prevention and cessation activities should address the use of multiple products.
Introduction:
Earlier cannabis initiation is associated with more severe neuropsychiatric and social consequences. The authors investigated whether mothers' cannabis use is associated with earlier cannabis initiation by their children.
Methods:
Mother and child data were from the National Longitudinal Survey of Youth 1979 (1980-1998 waves) and Child and Young Adults (1988-2014 waves) cohorts, respectively. Cox proportional hazard models assessed the effect of maternal cannabis use prior to a child's adolescence on the child's risk of subsequent cannabis initiation. Models were stratified by race and child's age category (6-16, 17-24, ≥25 years). Adjusted analyses controlled for sociodemographic variables. Analyses were conducted in 2017.
Results:
Median age of cannabis initiation for children of maternal ever users was age 16years compared with age 18years among children of maternal never users. Children of 1-year and multiple-year users were at increased risk of cannabis initiation between ages 6 and 16years (hazard ratio=1.38, p<0.001, and hazard ratio = 1.45, p<0.001, respectively). Effects were slightly stronger among non-Hispanic non-black children.
Conclusions:
As cannabis legalization expands across the U.S., adult use may become increasingly normative. This study indicates that maternal cannabis use may be a risk factor for early initiation among their offspring. Preventive interventions should consider strategies to delay initiation among children of cannabis users.
Based on results of the 2012 Canadian Community Health Survey-Mental Health, 1.2% of Canadians aged 15 to 64 (an estimated 282,000) experienced mental and substance use disorders concurrently in the previous year (at least one mood/anxiety disorder and one substance use disorder). Demographic, socioeconomic, health status and service use characteristics of the concurrent disorder group were compared with those of people who had only a mood/ anxiety disorder or only a substance use disorder. Those with concurrent disorders had consistently poorer psychological health and higher use of health services and were more likely to report partially met/unmet needs than the substance use disorder group, even when demographic and socioeconomic factors and number of chronic health conditions were taken into account. Apparent similarities in health status, service use and partially met/unmet needs between the concurrent disorders and mood/anxiety disorder groups did not persist in multivariate analysis. The findings suggest that the complexity of concurrent disorders contributes to poorer psychological health outcomes and higher health service use, compared with having only a mood/anxiety disorder or a substance use disorder.
The National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems released a consensus report, Public Health Consequences of e-Cigarettes,¹ in January. The report is a comprehensive review of the health effects of electronic cigarette (e-cigarette) use.
Background:
The influence of e-cigarette use on smoking initiation is a highly controversial issue, with limited longitudinal data available for examining temporal associations. We examined e-cigarette use and its association with cigarette-smoking initiation at 1-year follow-up within a large cohort of Canadian secondary school students.
Methods:
We analyzed data from students in grades 9-12 who participated in 2 waves of COMPASS, a cohort study of purposefully sampled secondary schools in Ontario and Alberta, Canada, at baseline (2013/14) and 1-year follow-up (2014/15). We assessed cigarette smoking and e-cigarette use at baseline and follow-up using self-completed surveys. We used generalized linear mixed-effects models to examine correlates of past 30-day e-cigarette use at baseline and smoking initiation between waves within the longitudinal sample.
Results:
Past 30-day e-cigarette use increased from 2013/14 to 2014/15 (7.2% v. 9.7%, p < 0.001), whereas past 30-day cigarette smoking decreased slightly (11.4% v. 10.8%, p = 0.02). Among the 44 163 students evaluated at baseline, past 30-day e-cigarette use was strongly associated with smoking status and smoking susceptibility. In the longitudinal sample (n = 19 130), past 30-day use of e-cigarettes at baseline was associated with initiation of smoking a whole cigarette (adjusted odds ratio [OR] 2.12, 95% confidence interval [CI] 1.68-2.66) and with initiation of daily smoking (adjusted OR 1.79, 95% CI 1.41-2.28) at follow-up.
Interpretation:
E-cigarette use was strongly associated with cigarette smoking behaviour, including smoking initiation at follow-up. The causal nature of this association remains unclear, because common factors underlying the use of both e-cigarettes and conventional cigarettes may also account for the temporal order of initiation.
Introduction:
Previous evidence linked low socioeconomic status with higher smoking prevalence. Our objective was to assess the strength of this association in the world population, updating a previous work.
Methods:
Systematic review and meta-analysis of observational studies. Subgroup analyses included continents, WHO regions, country mortality levels, gender, age, risk of bias and study publication date. Independent reviewers selected studies, assessed potential bias and extracted data. We searched MEDLINE, EMBASE, CENTRAL, SOCINDEX, AFRICAN INDEX MEDICUS, and LILACS, and other sources from 1989 to 2013 reporting direct measurements of income and current cigarette smoking.
Results:
We retrieved 13,583 articles and included 93 for meta-analysis. Median smoking prevalence was 17.8% (range 3-70%). Lower income was consistently associated with higher smoking prevalence (OR 1.45 95%CI 1.35-1.56). This association was statistically significant in the subgroup analysis by WHO regions for the Americas (OR 1.54 95%CI 1.42-1.68); South East Asia (OR 1.53 95%CI 1.10-2.00); Europe (1.45 95%CI 1.29-1.63); and Western Pacific (OR 1.32 95%CI 1.02-1.72), and in studies conducted during 1990s (OR 1.42 95%CI 12.4-1.62) and 2000s (1.48 95%CI 1.30-1.64). Likewise, it was noted in low-mortality countries (OR 1.48 95%CI 1.37-1.60) and for both genders. Prevalence was highest in the lowest income levels compared to the middle (OR 1.69 95%CI 1.49-1.92), followed by the middle level compared to the highest (OR 1.31 95%CI 1.20-1.43).
Conclusions:
Our results show that current cigarette smoking was significantly associated with lower income worldwide and across subgroups, suggesting a dose-response relationship.
Funding:
WHO.
Implications:
This unique updated systematic review shows a consistent inverse dose-response relationship between cigarette smoking and income level, present among most geographical areas and country characteristics. Public health measures should take into account this potential inequity and consider special efforts directed to disadvantaged populations.
Background: Cigarette smoking is associated with adverse health effects, including cancer, respiratory illness, heart disease and stroke. National data on smoking prevalence often rely on self-reports. This study assesses the validity of self-reported cigarette smoking status among Canadians. Data and methods: Data are from the 2007 to 2009 Canadian Health Measures Survey, a nationally representative cross-sectional survey of 4,530 Canadians aged 12 to 79. The survey included self-reported smoking status and a measure of urinary cotinine, a biomarker of exposure to tobacco smoke. The prevalence of cigarette smoking was calculated based on self-reports and also on urinary cotinine concentrations. Results: Compared with estimates based on urinary cotinine concentration, smoking prevalence based on self-report was 0.3 percentage points lower. Sensitivity estimates (the percentage of respondents who reported being smokers among those classifi ed as smokers based on cotinine concentrations) were similar for males and females (more than 90%). Although sensitivity tended to be lower for respondents aged 12 to 19 than for those aged 20 to 79, the difference did not attain statistical signifi cance. Interpretation: Accurate estimates of the prevalence of cigarette smoking among Canadians can be derived from self-reported smoking status data.
Cannabis use has been associated with impaired cognition during acute intoxication as well as in the unintoxicated state in long term users. However, the evidence has been mixed and contested and no systematic reviews of the literature on neuropsychological task-based measures of cognition have been conducted in an attempt to synthesise the findings. Here we systematically review the empirical research published in the past decade (January 2004– February 2015) on acute and chronic effects of cannabis and cannabinoids and on persistence or recovery following abstinence. We summarise the findings into the major categories of the cognitive domains investigated, considering sample characteristics and associations with various cannabis use parameters. Verbal learning and memory, and attention, continue to be most consistently impaired by acute and chronic exposure to cannabis. Psychomotor function is most affected during the acute intoxication, with some evidence for persistence in chronic users and following cessation of use. Impaired verbal memory, attention and some executive functions may persist after prolonged abstinence, but persistence or recovery across all cognitive domains remains under-researched. Associations between poorer performance and a range of cannabis use parameters, including a younger age of onset, are frequently reported. Little further evidence has emerged for the development of tolerance to the acutely impairing effects of cannabis. Evidence for potential protection of harms by cannabidiol continues to grow but is not definitive. The knowledge gained from this body of research needs to be incorporated into harm minimization strategies in light of increasing trends toward legalization of cannabis.
When unique identifiers are unavailable, successful record linkage depends greatly on data quality and types of variables available. While probabilistic linkage theoretically captures more true matches than deterministic linkage by allowing imperfection in identifiers, studies have shown inconclusive results likely due to variations in data quality, implementation of linkage methodology and validation method. The simulation study aimed to understand data characteristics that affect the performance of probabilistic vs. deterministic linkage.
We created ninety-six scenarios that represent real-life situations using non-unique identifiers. We systematically introduced a range of discriminative power, rate of missing and error, and file size to increase linkage patterns and difficulties. We assessed the performance difference of linkage methods using standard validity measures and computation time.
Across scenarios, deterministic linkage showed advantage in PPV while probabilistic linkage showed advantage in sensitivity. Probabilistic linkage uniformly outperformed deterministic linkage as the former generated linkages with better trade-off between sensitivity and PPV regardless of data quality. However, with low rate of missing and error in data, deterministic linkage performed not significantly worse. The implementation of deterministic linkage in SAS took less than 1 minute, and probabilistic linkage took 2 minutes to 2 hours depending on file size.
Our simulation study demonstrated that the intrinsic rate of missing and error of linkage variables was key to choosing between linkage methods. In general, probabilistic linkage was a better choice, but for exceptionally good quality data (<5% error), deterministic linkage was a more resource efficient choice.
Copyright © 2015. Published by Elsevier Inc.
AimsTo examine changes in the evidence on the adverse health effects of cannabis since 1993.MethodsA comparison of the evidence in 1993 with the evidence and interpretation of the same health outcomes in 2013.ResultsResearch in the past 20 years has shown that driving while cannabis-impaired approximately doubles car crash risk and that around one in 10 regular cannabis users develop dependence. Regular cannabis use in adolescence approximately doubles the risks of early school-leaving and of cognitive impairment and psychoses in adulthood. Regular cannabis use in adolescence is also associated strongly with the use of other illicit drugs. These associations persist after controlling for plausible confounding variables in longitudinal studies. This suggests that cannabis use is a contributory cause of these outcomes but some researchers still argue that these relationships are explained by shared causes or risk factors. Cannabis smoking probably increases cardiovascular disease risk in middle-aged adults but its effects on respiratory function and respiratory cancer remain unclear, because most cannabis smokers have smoked or still smoke tobacco.Conclusions
The epidemiological literature in the past 20 years shows that cannabis use increases the risk of accidents and can produce dependence, and that there are consistent associations between regular cannabis use and poor psychosocial outcomes and mental health in adulthood.
Cannabis is the most widely used illicit drug in the world. Although the risk of problematic cannabis use is relatively low, the lifetime prevalence of dependence is greater than for all other illicit drugs. As such, the population burden of problematic cannabis use warrants attention. Many health and psychosocial risks associated with cannabis use are exacerbated or predicted by initiation of cannabis use in early adolescence and early adolescent users are more vulnerable to negative developmental outcomes, longer cannabis use trajectories, earlier transitions to heavier use and dependence. This suggests a need for effective prevention interventions targeting this age group. Unfortunately, most prevention efforts focus on individual-level risk factors and evidence indicates that they are not particularly effective for deterring use. This overview outlines a more effective approach for preventing cannabis-related harm. Using a social determinants of health perspective, it highlights peer networks and family structure and quality as the main risk factors associated with early adolescent cannabis use. This article suggests that interventions that targeting these determinants can be effective for preventing cannabis use. It concludes by suggesting complementary harm reduction programmes for older adolescents as a means to further reduce cannabis-related harm.
The respiratory health effects from tobacco smoking are well described. Cannabis smoke contains a similar profile of carcinogenic chemicals as tobacco smoke but is inhaled more deeply. Although cannabis smoke is known to contain similar harmful and carcinogenic substances to tobacco smoke, relatively little is understood regarding the respiratory health effects from cannabis smoking. There is a need to integrate research on cannabis and respiratory health effects so that gaps in the literature can be identified and the more consistent findings can be consolidated with the purpose of educating smokers and health service providers. This review focuses on several aspects of respiratory health and cannabis use (as well as concurrent cannabis and tobacco use) and provides an update to (i) the pathophysiology; (ii) general respiratory health including symptoms of chronic bronchitis; and (iii) lung cancer.
Aims:
To examine the relationships between income, income inequality and current smoking among youth in low- and middle-income countries.
Design:
Pooled cross-sectional data from the Global Youth Tobacco Surveys, conducted in low- and middle-income countries, were used to conduct multi-level logistic analyses that accounted for the nesting of students in schools and of schools in countries.
Participants:
A total of 169 283 students aged 13-15 from 63 low- and middle-income countries.
Measurements:
Current smoking was defined as having smoked at least one cigarette in the past 30 days. Gross domestic product (GDP) per capita was our measure of absolute income. Contemporaneous and lagged (10-year) Gini coefficients, as well as the income share ratio of the top decile of incomes to the bottom decile, were our measures of income inequality.
Findings:
Our analyses reveal a significant positive association between levels of income and youth smoking. We find that a 10% increase in GDP per capita increases the odds of being a current smoker by at least 2.5%, and potentially considerably more. Our analyses also suggest a relationship between the distribution of incomes and youth smoking: youth from countries with more unequal distributions of income tend to have higher odds of currently smoking.
Conclusions:
There is a positive association between gross domestic product and the odds of a young person in a low- and middle-income country being a current smoker. Given the causal links between smoking and a wide range of youth morbidities, the association between smoking and income inequality may underlie a substantial portion of the health disparities observed that are currently experiencing rapid economic growth.
Little consensus exists regarding the relationship between socioeconomic status (SES) and substance use. This study examined the associations of three indicators of family SES during childhood--income, wealth, and parental education--with smoking, alcohol use, and marijuana use during young adulthood.
Data were obtained from the national Panel Study of Income Dynamics, a survey of U.S. families that incorporates data from parents and their children. In 2005 and 2007, the Panel Study of Income Dynamics was supplemented with two waves of Transition into Adulthood data drawn from a national sample of young adults, 18-23 years old. Data from the young adults (N = 1,203; 66.1% White; 51.5% female) on their current use of alcohol, cigarettes, and marijuana were used as outcome variables in logistic regressions. Socioeconomic background was calculated from parental reports of education, wealth, and income during the respondent's childhood (birth through age 17 years).
Smoking in young adulthood was associated with lower childhood family SES, although the association was explained by demographic and social role covariates. Alcohol use and marijuana use in young adulthood were associated with higher childhood family SES, even after controlling for covariates.
Findings based on three indicators of family background SES--income, wealth, and parental education--converged in describing unique patterns for smoking and for alcohol and marijuana use among young adults, although functional relationships across SES measures varied. Young adults with the highest family background SES were most prone to alcohol and marijuana use.
The current study examined the prevalence of alcohol, tobacco and drug use and comorbid use of these substances among 45,425 students in grades 7 to 12 as part of the 2008-09 Canadian Youth Smoking Survey. The results of this paper suggest that alcohol, tobacco, marijuana and illicit drugs are currently used by a substantial number of youth in Canada, and that comorbid use is also very widespread among users. Alcohol was the most prevalent substance used by youth and it was rare to find youth who had used tobacco or drugs without also currently using alcohol. By grade 12, the majority of students were current users of alcohol, tobacco or drugs. Future research should consider developing a better understanding of how to prevent substance use among this population.
Data from a state-wide survey of California middle and high school students (N=20,203) were used to assess whether county income inequality and poverty rates were associated with adolescent smoking. Greater county income inequality, but not poverty rates, was associated with higher established smoking risk (p=0.0019). The association was stronger in males than females, whites than other ethnic groups, and urban than rural settings. Neither county income inequality nor poverty rates were associated with experimental smoking. The findings suggest that it may be important to consider and address economic inequality in the prevention and control of adolescent tobacco use.
For over two decades, cannabis, commonly known as marijuana, has been the most widely used illicit drug by young people in high-income countries, and has recently become popular on a global scale. Epidemiological research during the past 10 years suggests that regular use of cannabis during adolescence and into adulthood can have adverse effects. Epidemiological, clinical, and laboratory studies have established an association between cannabis use and adverse outcomes. We focus on adverse health effects of greatest potential public health interest-that is, those that are most likely to occur and to affect a large number of cannabis users. The most probable adverse effects include a dependence syndrome, increased risk of motor vehicle crashes, impaired respiratory function, cardiovascular disease, and adverse effects of regular use on adolescent psychosocial development and mental health.
In clinical and research settings, self-report of substance use, in the form of daily diaries or the Time-Line Follow-Back method (1), is essential in monitoring baseline substance use and change over the course of treatment or research involvement. For alcohol and nicotine, completion of such self-reports is straightforward, with individuals reporting number of alcoholic beverages consumed and number of cigarettes smoked. Marijuana is more difficult to quantify for several reasons. It is consumed in a number of ways, including joints, blunts, pipes, bongs, and vaporizers, each potentially containing different amounts of marijuana per unit. Additionally, marijuana is very commonly shared, so that one joint may be divided between several people. Further complicating matters is the significant variation in potency of Δ9-THC in marijuana. Our adolescent research participants advise us of a continuum of potency, varying from “schwag” (low potency) to “kine bud” or “sinsemilla” (high potency). This has also been reported in the literature, with concentrations of Δ9-THC varying from 2% to more than 20% in smoked marijuana (2–4). While money spent on marijuana may be a reasonable proxy for potency, prices among dealers and geographic regions vary. Additionally, several marijuana smokers that we see do not purchase marijuana, instead sharing it with others who have made the purchase.
Previous published research reports have typically quantified marijuana use by number of joints smoked, number of smoking episodes per day, or by number of days (per week or month) of use. Methods for adjusting self-report measures to number of joints (e.g., converting from number of blunts or number of bong uses) have not been standardized among research and clinical groups. A more precise method may be necessary. We propose quantifying based on number of puffs (“hits”) taken. This allows users to more effectively quantify use of marijuana items that vary in size and may be shared with others. Puffs likely serve as a reliable standard of measure, since these increments convey similar psychoactive effects regardless of breathhold duration (5–8). In order to accommodate variations in potency, users may rate the relative potency of marijuana used on each occasion, with “0” representing average potency, “+1” more potent, “+2” most potent, “−1” less potent, and “−2” least potent. We propose multiplying number of puffs by 1.25 for +1 potency, 1.5 for +2, 0.75 for −1, and 0.5 for −2. This results in a quantity of marijuana use (“potency-adjusted puffs”) that may be tracked over time with an individual and may perhaps more accurately allow comparison between users. Please see Table 1 for examples from a sample of adolescent research participants. We welcome input from other research and clinical groups as we work to refine this method.
Table 1
Conversion from participant-reported amount smoked to number of puffs.
A study of 113 young multiple drug users, interviewed at one year follow-up, was designed to assess the validity of self-reported cannabis use. Subjects provided information about the recency, frequency and typical dose of their use of cannabis in the preceding 30 days. Urine samples were collected and analyzed for delta 9 THC metabolites. Recency of use was the best predictor of urine test result, but a measure of frequency of use significantly increased the proportion of variance accounted for. The results strongly supported the validity of self-reported cannabis use and indicate that valid self-reports of drug consumption can be obtained from multiple drug users in treatment.
That mortality in developed countries is affected more by relative than absolute living standards is shown by three pieces of evidence. Firstly, mortality is related more closely to relative income within countries than to differences in absolute income between them. Secondly, national mortality rates tend to be lowest in countries that have smaller income differences and thus have lower levels of relative deprivation. Thirdly, most of the long term rise in life expectancy seems unrelated to long term economic growth rates. Although both material and social influences contribute to inequalities in health, the importance of relative standards implies that psychosocial pathways may be particularly influential. During the 1980s income differences widened more rapidly in Britain than in other countries; almost a quarter of the population now lives in relative poverty. The effects of higher levels of relative deprivation and lower social cohesion may already be visible in mortality trends among young adults.
A “feel bad” factor in the health divide?
TONY WALLIS
The existence of wide-and widening-socioeconomic differences in health shows how extraordinarily sensitive health remains to socioeconomic circumstances. Twofold, threefold, or even fourfold differences in mortality have been reported within Britain, depending largely on the social classification used.1 2 3 This series will illustrate some of the most important mechanisms involved in the generation of these differences.
Fundamental to understanding the causes of these differences in health is the distinction between the effects of relative and absolute living standards. Socioeconomic gradients in health are simultaneously an association with social position and with different material circumstances, both of which have implications for health-but which is more important in terms of causality? Is the health disadvantage of the least well off part of the population mainly a reflection of the direct physiological effects of lower absolute material standards (of bad …
The relationship between income and health is well established: the higher an individual's income, the better his or her health. However, recent research suggests that health may also be affected by the distribution of income within society. We outline the potential mechanisms underlying the so-called relative income hypothesis, which predicts that an individual's health status is better in societies with a more equal distribution of incomes. The effects of income inequality on health may be mediated by underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital; and the harmful psychosocial effects of invidious social comparisons.
Evidence about the relationship between contextual variables and substance use is conflicting. Relationships between neighborhood income and income distribution and the prevalence and frequency of substance use in 59 New York City (NYC) neighborhoods were assessed while accounting for individual income and other socio-demographic variables. Measures of current substance use (in the 30 days prior to the survey) were obtained from a random-digit-dial phone survey of adult residents of NYC and data from the 2000 U.S. Census to calculate median neighborhood income and income distribution (assessed using the Gini coefficient). Among 1355 respondents analyzed (female=56.2%, mean age=40.4), 23.9% reported cigarette, 40.0% alcohol, and 5.4% marijuana use in the previous 30 days. In ecologic assessment, neighborhoods with both the highest income and the highest income maldistribution had the highest prevalence of drinking alcohol (69.0%) and of smoking marijuana (10.5%) but not of cigarette use; there was no clear ecologic association between neighborhood income, income distribution, and cigarette use. In multilevel multivariable models adjusting for individual income, age, race, sex, and education, high neighborhood median income and maldistributed neighborhood income were both significantly associated with a greater likelihood of alcohol and marijuana use but not of cigarette use. Both high neighborhood income and maldistributed income also were associated with greater frequency of alcohol use among current alcohol drinkers. These observations suggest that neighborhood income and income distribution may play more important roles in determining population use of alcohol and marijuana than individual income, and that determinants of substance use may vary by potential for drug dependence. Further research should investigate specific pathways that may explain the relationship between neighborhood characteristics and use of different substances.