Abstract
Background:
People with HIV (PWH) report higher rates of cannabis use than the general population. It is unclear how cannabis use among PWH has been impacted by the COVID-19 pandemic and the implications for the health and wellbeing of PWH.
Objectives:
To describes changes in frequency of cannabis use among a sample of PWH during the pandemic, reasons for those changes, and implications of the findings.
Methods:
Data are cross-sectional and come from questions asked in a follow-up phone survey administered to a prospective cohort of PWH in Florida between May 2020-March 2021. Participants who used cannabis were asked about changes in their frequency of cannabis use in a quantitative survey and reasons for changes in a qualitative open-ended question. Qualitative data were analyzed using thematic analysis.
Results:
Among 227 PWH (mean age 50, 50% men, 69% Black/African American, 14% Hispanic/Latino); 13% decreased frequency of cannabis, 11% increased frequency, and 76% reported no change. The most common reasons for increasing frequency of cannabis use were reducing anxiety/stress or trying to relax, coping with grief or reducing symptoms of depression, and reducing boredom during the pandemic. Supply or access issues, health concerns, and having already wanted to reduce cannabis use were common reasons for decreased frequency.
Conclusion:
Nearly 25% of the sample changed their cannabis use frequency during the pandemic. These findings shed light on the behaviors and motivations of PWH who use cannabis and can inform clinical practice and interventions during public health emergencies and beyond.
Keywords: HIV, cannabis, COVID-19
Introduction
Cannabis is one of the most commonly used drugs in the United States, with prevalence of use in 2019 at approximately 18% in the general population (1). Among people with HIV (PWH), estimates of recent cannabis use are usually greater than in the general population and could be as high as 33% (2-4). Longitudinal studies done before the coronavirus disease 2019 (COVID-19) pandemic found that the frequency of use has increased among PWH, with up to 51% of PWH who use cannabis using daily (3,5). Those who use cannabis report several benefits such as improving pain, appetite, nausea, anxiety, depression, sleep, and other physical and mental symptoms (5-8) and pleasure or relieving boredom (8-10). In addition to the reported benefits of cannabis, in both the general population and PWH, cannabis use is also associated with negative health outcomes such as impairment in memory and cognition (11-13), weakening of the immune system (14-16), and aggravations to the lungs or even lung disease if cannabis is inhaled (17-22). Given that other substances like alcohol have been found to have a negative association with antiretroviral therapy (ART) medication adherence (23-25), it is hypothesized that cannabis might as well although the literature on this topic is mixed (5,26,27).
A previous study by the team found that, using a measure of cannabis use that combined frequency and amount, 28% of a sample of PWH in Florida self-reported an increase in cannabis use, 16% reported decreased use, and 55% reported no change in use during the COVID-19 pandemic (28). Additionally, we found that increased cannabis use was more common among those who used more frequently or who had post-traumatic stress disorder (PTSD) symptoms prior to the pandemic, had worsened mental health experiences during the pandemic, and who did not perceive cannabis as a risk factor for COVID-19 (28). However, there is much more to be known about motivations for changing cannabis use during the pandemic. Qualitative data are uniquely suited to address this, as they provide context for quantitative findings and can bring to light items that never would have been elicited on a standard questionnaire. This multi-methods study will combine results from quantitative surveys and qualitative responses to follow-up questions on the surveys to describe the full spectrum of changes in frequency of cannabis use and the reasons for these changes among a cohort of PWH in Florida.
Assessing and understanding the reasons driving cannabis use among PWH could provide critical insights into how to help maximize the therapeutic benefits and minimize potential harms of cannabis use. Additionally, it is important to understand reasons for changes in cannabis use as it is unclear if PWH will return to pre-pandemic use levels. This could have longstanding health implications, and thus a deep understanding of reasons for cannabis use and motivations in changing use patterns are necessary to address the needs of this population. The objectives of this study are to 1) describe self-reported changes in cannabis use frequency during the COVID-19 pandemic among a cohort of PWH in Florida and 2) understand the reasons behind these changes through an analysis of an open-ended qualitative question. These findings can guide future interventions and public health programs aimed at improving health outcomes for PWH who might use cannabis or other substances in a variety of situations.
Methods
Study Participants and Procedures
Data came from the Marijuana Associated Planning and Long-Term Effects (MAPLE) study, a prospective cohort study focused on identifying the long-term health effects of cannabis on PWH. All participants were given informed consent prior to enrollment. People were eligible if they were PWH and permanent residents of Florida, and could be classified as having current use or no history of use of cannabis based on study needs. Researchers planned to enroll three people who used cannabis currently for every one person who did not use cannabis currently. Participants were recruited between 2018-2020 from healthcare settings in the Alachua, Hillsborough, and Miami-Dade counties of Florida for the baseline study. Healthcare settings included a mix of county health department clinics and private clinics. They were then classified as either a) a person who currently used cannabis, defined as self-reported use of cannabis at least monthly, or b) a person who did not use cannabis currently, defined as no cannabis use in the past five years and never using cannabis monthly or more frequently at any point in their lifetime. PWH with use in the past five years but less than monthly use currently or who have used more than monthly at any point in their lifetime were excluded from the study. Use status at baseline was confirmed with a Tetrahydrocannabinol (THC) urine test. Three-hundred people participated in the baseline study. While in the study, participants were given a brief telephone-based follow-up every three months as well as an in-person visit annually. A more detailed description of the study procedure can be found in Wang et al., 2021.
Between May 2020-March 2021, the research team added additional questions to the 3-month follow-up phone calls. These additional questions assessed experiences in the COVID-19 pandemic including a quantitative assessment of changes in cannabis use frequency and a qualitative open-ended follow-up question asking reasons for those changes. This paper presents the analysis of data from 227 PWH from the larger sample of 300 eligible MAPLE participants. These 227 PWH are the participants who responded to the COVID-19 specific 3-month follow-up calls, making up a response rate of 76%. At baseline, 180 of these participants used cannabis (79%), while 47 (21%) did not use cannabis. For the purposes of this cross-sectional study, we only use the first follow-up that occurred in which they would have been asked specific questions on experiences during the COVID-19 pandemic, even if they received these questions during follow-up appointments multiple times throughout the time of the study.
The MAPLE study was approved by the University of Florida Institutional Review Board and the Florida Department of Health Institutional Review Board, with other participating institutions approving under a reciprocity agreement.
Measures
At baseline, participants answered questions on their age, sex, race, ethnicity, income, education, health behaviors such as ART medication usage and adherence, current cannabis use, and past-year alcohol use. Depression symptoms were measured using the Patient Health Questionnaire Depression Scale (PHQ-8) (29). To measure other drug use, participants were asked about past-year and lifetime use of intravenous substance use and any of the following: hashish, synthetic cannabis, cocaine and crack cocaine, heroin, prescription opioids, stimulants, prescription or non-prescription benzodiazepines, ecstasy/MDMA, hallucinogens, poppers (amyl nitrate), and other drugs.
A total of three questions were asked to assess changes in cannabis use frequency; the original wording of the questions used the term “marijuana” rather than cannabis. Two questions were about pre-pandemic frequency of cannabis use and one on the frequency of cannabis use during the pandemic. Each of these questions had the following possible answer options: “Do not use marijuana; Less than once a week; 1-3 times a month [less than weekly]; 1-3 times a week; 4-6 times a week; Everyday.” If there was a discrepancy between the two answers, this indicated a change in frequency use which triggered a follow-up open-ended question about reasons for changes in cannabis use frequency. Participants could give as full a description as they wanted about the reasons behind the change in use frequency. Only participants who indicated a change in their frequency of use from pre-pandemic to the time of the follow-up could answer the open-ended question (see Table I for the specific questions asked).
Table I.
Questions Assessing Cannabis Use and Perceived Benefits/Harms of Cannabis
| Questions measuring cannabis use frequency and changes in cannabis use frequency. | “First we want to ask about before the pandemic. Before the coronavirus pandemic, on average, how often did you use marijuana?” (Possible Responses: Do not use marijuana; Less than once a week; 1-3 times a month [less than weekly]; 1-3 times a week; 4-6 times a week; Everyday) |
| “Now, the same question, but now thinking the time since the coronavirus pandemic arrived until today. About how often do you use marijuana currently?” (Possible Responses: Do not use marijuana; Less than once a week; 1-3 times a month [less than weekly]; 1-3 times a week; 4-6 times a week; Everyday) | |
| “It looks like there has been a change in the frequency of use from before to after. What would you say is the main reason for this change?” (Possible Responses: open-ended) |
Analysis
Descriptive analyses were conducted using SAS 9.4 (30) to evaluate the frequency of cannabis use and to determine whether there were any significant differences by key sociodemographic variables using chi-square/Fisher’s exact or ANOVA depending on the variable and sample size. Thematic analysis was adapted for our purposes to analyze the data from the open-ended questions (31,32). Given that the qualitative response sample was not large, data from the open-ended questions were organized in Microsoft Excel rather than formal qualitative analysis software. Data were coded manually by two independent coders using a codebook created by the primary author with input from an academic qualitative working group. The coders used thematic analysis and consensus coding procedure. Coders met weekly to discuss the codes and resolve the differences after they each separately did their coding. Additional codes were generated and discussed as new ideas emerged from the participant responses. Separate sets of codes were created for people who indicated increased versus decreased frequency of cannabis use. Codes that were similar were compiled together under larger themes to answer the research questions. This is a multi-methods study due to the analysis of quantitative and qualitative data that build upon and strengthen the results of each analysis and the use of quantitative and qualitative methods.
Results
Participant Characteristics
Of the 227 participants, 25 (11%) increased their frequency of cannabis use, 29 (13%) decreased their frequency of cannabis use, and 173 (76%) did not change their frequency of cannabis use. At baseline, their average age was 50 years (SD=11.2). There was equal distribution of men and women in the study (50% men). The participants were 14% Hispanic/Latino, 69% Black/African American, 22% White, and 8% Other Race. Almost 30% of the participants had less than a high school education, 34% had a high school education, and 37% had education greater than a high school education level. Most of the participants (70%) reported an annual income of less than $20,000. Nearly all the participants (94%) used ART medication at the time of data collection. Over a quarter of the participants (28%) had moderate or severe depression. Three-quarters of the participants (76%) consumed alcohol in the past year, while 34% used other drugs in the past year. See Table II for a summary of the results. The only participant characteristic in which there were differences between those who did and did not change their cannabis use frequency was past-year alcohol use; those who changed their cannabis use frequency had a higher prevalence of past-year alcohol use (87% vs 73%, p=0.032) (see Table III).
Table II.
Baseline Participants Characteristics, N (%)
| Total N=227 |
Increased Frequency of Cannabis Use N=25 (11.0%) |
Decreased Frequency of Cannabis Use N=29 (12.8%) |
No Change in Frequency of Cannabis Use N=173 (76.2%) |
Change in Frequency of Cannabis Use N=54 (23.8%) |
Differences Between Those with and Without a Change in Frequency of Cannabis Use (P-value) |
|
|---|---|---|---|---|---|---|
| Mean Age (Standard Deviation) | 50.0 (11.1) | 51.5 (9.1) | 50.8 (11.6) | 49.8 (11.4) | 51.1 (10.4) | 0.842 |
| Age Group | ||||||
| 18-29 | 14 (6.2%) | 1 (4.0%) | 2 (6.9%) | 11 (6.4%) | 3 (5.6%) | 0.718 |
| 30-39 | 30 (13.2%) | 1 (4.0%) | 4 (13.8%) | 25 (14.5%) | 5 (9.3%) | |
| 40-49 | 45 (19.8%) | 6 (24.0%) | 3 (10.3%) | 36 (20.8%) | 9 (16.7%) | |
| 50-59 | 95 (41.9%) | 14 (56.0%) | 12 (41.4%) | 69 (39.9%) | 26 (48.1%) | |
| 60 and older | 43 (18.9%) | 3 (12.0%) | 8 (27.6%) | 32 (18.5%) | 11 (20.4%) | |
| Gender Assigned at Birth | ||||||
| Men | 113 (49.8%) | 10 (40.0%) | 15 (51.7%) | 88 (50.9%) | 25 (46.3%) | 0.558 |
| Women | 114 (50.2%) | 15 (60.0%) | 14 (48.3%) | 85 (49.1%) | 29 (53.7%) | |
| Race | ||||||
| White | 52 (22.9%) | 1 (4.0%) | 5 (17.2%) | 46 (26.6%) | 6 (11.1%) | 0.053 |
| Black/African American | 157 (69.2%) | 22 (88.0%) | 22 (75.9%) | 113 (65.3%) | 44 (81.5%) | |
| Other | 18 (7.9%) | 2 (8.0%) | 2 (6.9%) | 14 (8.1%) | 4 (7.4%) | |
| Ethnicity | ||||||
| Hispanic or Latino | 32 (14.1%) | 2 (8.0%) | 4 (13.8%) | 26 (15.0%) | 6 (11.1%) | 0.470 |
| Non-Hispanic or Latino | 195 (85.9%) | 23 (92.0%) | 25 (86.2%) | 147 (85.0%) | 48 (88.9%) | |
| Education | ||||||
| Less than High School | 67 (29.5%) | 7 (28.0%) | 9 (31.0%) | 51 (29.5%) | 16 (29.6%) | 0.435 |
| Completed High School or Equivalent | 78 (34.4%) | 7 (28.0%) | 15 (51.7%) | 56 (32.4%) | 22 (40.7%) | |
| Greater than High School | 82 (36.1%) | 11 (44.0%) | 5 (17.2%) | 66 (38.2%) | 16 (29.6%) | |
| Income | ||||||
| Less than $10,000 | 111 (48.9%) | 14 (56.0%) | 17 (58.6%) | 80 (46.5%) | 31 (57.4%) | 0.081 |
| $10,000-$29,999 | 76 (33.5%) | 9 (36.0%) | 10 (34.5%) | 57 (33.1%) | 19 (35.2%) | |
| $30,000 or more | 39 (17.2%) | 2 (8.0%) | 2 (6.9%) | 35 (20.4%) | 4 (7.4%) | |
| Depression by Patient Health Questionnaire Depression Scale (PHQ-8) Score | ||||||
| 0-9, None/Mild | 152 (67.0%) | 15 (60.0%) | 22 (75.9%) | 115 (66.5%) | 37 (68.5%) | 0.870 |
| 10 or Greater, Moderate/Severe | 63 (27.8%) | 10 (40.0%) | 6 (20.7%) | 47 (27.2%) | 16 (29.6%) | |
| Current Antiretroviral Therapy (ART) Medication | ||||||
| Yes | 214 (94.3%) | 25 (100.0%) | 29 (100.0%) | 160 (92.5%) | 54 (100.0%) | 0.116 |
| No | 12 (5.3%) | 0 (0.0%) | 0 (0.0%) | 12 (6.9%) | 0 (0.0%) | |
| Past-Year Alcohol Use | ||||||
| Yes | 173 (76.2%) | 22 (88.0%) | 25 (86.2%) | 126 (72.8%) | 47 (87.0%) | 0.032 |
| No | 54 (23.8%) | 3 (12.0%) | 4 (13.8%) | 47 (27.2%) | 7 (13.0) | |
| Past-Year Use of Other Drugs | ||||||
| Yes | 77 (33.9%) | 8 (32.0%) | 12 (41.4%) | 57 (32.9%) | 20 (37.0%) | 0.679 |
| No | 148 (65.2%) | 17 (68.0%) | 17 (58.6%) | 114 (65.9%) | 34 (63.0%) | |
Column percentages
Ns in each of the categories might not add up to 227 due to missing data.
Significant differences (p < 0.05) between those who did and who did not have a change (either an increase or decrease) in their frequency of cannabis use were detected by chi-square test for categorical variables and F-test for continuous variables.
Table III.
Degree of Change in Cannabis Use Frequency, N (%)
| Cannabis Use Frequency During the COVID-19 Pandemic | ||||||||
|---|---|---|---|---|---|---|---|---|
| Did Not Use Cannabis |
Less than Once a Week |
1-3 Times a Month |
1-3 Times a week |
4-6 Times a Week |
Every Day | Total | ||
| Cannabis Use Frequency Before the COVID-19 Pandemic | Did Not Use Cannabis | 42 (95.5%) | 1 (2.3%) | 0 (0.0%) | 1 (2.3%) | 0 (0.0%) | 0 (0.0%) | 44 (19.4%) |
| Less than Once a Week | 2 (50.0%) | 1 (25.0%) | 1 (25.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 4 (1.8%) | |
| 1-3 Times a Month | 2 (22.2%) | 0 (0.0%) | 5 (55.6%) | 0 (0.0%) | 0 (0.0%) | 2 (22.2%) | 9 (4.0%) | |
| 1-3 Times a week | 1 (2.4%) | 2 (4.8%) | 5 (11.9%) | 22 (52.4%) | 4 (9.5%) | 8 (19.0%) | 42 (18.5%) | |
| 4-6 Times a Week | 0 (0.0%) | 1 (4.5%) | 0 (0.0%) | 3 (13.6%) | 10 (45.5%) | 8 (3.6%) | 22 (9.7%) | |
| Everyday | 2 (1.9%) | 2 (1.9%) | 0 (0.0%) | 3 (2.8%) | 6 (5.7%) | 93 (87.7%) | 106 (46.7%) | |
| Total | 49 (21.6%) | 7 (3.1%) | 11 (4.8%) | 29 (12.8%) | 20 (8.8%) | 111 (48.9%) | 227 (100.0%) | |
Table shows row percentages except for the rightmost “Total” column, which are column percentages.
Most of the participants who used cannabis in this sample used cannabis every day, and this was true both before and during the pandemic (106 [47%] vs 111 [49%] participants). Of those who changed their cannabis use frequency, most only changed by 1-2 levels on the frequency scale described in Table 1; that is, most participants did not have a dramatic change in their frequency of use. Twelve (5%) participants changed their frequency of use by more than 2 levels. Seven (3%) participants who used cannabis before the pandemic stopped using during the pandemic. Conversely, 2 (1%) participants who did not use cannabis before the pandemic began using during the pandemic. These results can be seen in Table IV.
Table IV.
Coding Framework and Frequency of Reasons for Increased Frequency of Cannabis Use (n=24)
| Theme | Code | Definition | N (%) |
|---|---|---|---|
| Mental Health | Anxiety and Stress | Self-reported anxiety and stress. Use cannabis to cope with, minimize, or tolerate stress/anxiety. | 10 (41.7%) |
| Calm Down or Relax | Trying to calm down or experience feelings of relaxation with cannabis. | 4 (16.7%) | |
| Coping/Grief | Helped the participant cope with their living situation, get “peace of mind,” cope with the COVID-19 pandemic, or deal with grief from the pandemic or loss. | 2 (8.3%) | |
| Depression | Self-reported depression or sadness. Cannabis can lessen or be a cause of depression. | 2 (8.3%) | |
| Activity | Activity | Use of cannabis as an activity, something to do, fill the time, and/or to relieve boredom. | 6 (25.0%) |
| Location | Location | Being home more or in a location that allows for an increase in use. | 5 (20.8%) |
| Social Distancing | Social Distancing | Social distancing procedures, being isolated, not being able to travel, or coping with being away from others. | 4 (16.7%) |
| Furloughed | Furloughed | Furloughed or lost job; unemployed. | 2 (8.3%) |
| Physical Health | Health Concerns | Physical health concerns including cough or COVID-19 symptoms. | 1 (4.2%) |
| Non-COVID Health Concerns | Health condition not related to COVID-19. | 1 (4.2%) | |
| No Reason | No Reason | No reason indicated for increase in frequency of use or does not know why there is a change. | 3 (12.5%) |
For this table, N=24 instead of 25 due to non-response from one participant who increased their frequency of cannabis use.
Percentages do not sum to 100% because participants could give multiple reasons why their cannabis use frequency increased.
Of the 54 participants who had a change in their cannabis use frequency, 53 (98%) responded to open-ended questions about reasons for their change in use. The one non-respondent was a participant who had increased their frequency of cannabis use.
Reasons for Changes in Cannabis Use
Reasons for Increase in Cannabis Use Frequency
Twenty-five participants increased their cannabis use frequency during the pandemic. The reasons why are shown in Table V. Of the 25 participants who increased their use, one participant chose not to respond to the open-ended follow-up question on reasons for change in frequency of use, so Table V presents data from 24 participants. The most common reason for increasing the frequency of cannabis use was to reduce the increased anxiety or stress experienced during the COVID-19 pandemic (N=10). Participants also mentioned specific reasons for increased stress such as worries about being around other people, or dealing with consequences related to the pandemic such as losing their job.
Table V.
Coding Framework and Frequency of Reasons for Decreased Frequency of Cannabis Use (n=29)
| Theme | Code | Definition | N (%) |
|---|---|---|---|
| Access | Supply Problems | Supply of cannabis ran out and participant does not have cannabis to use. | 5 (17.2%) |
| Money | Cannot afford it or having money issues. | 4 (13.8%) | |
| Access | Change in source of cannabis such as having to go to a new location or new person to access cannabis. | 3 (10.3%) | |
| Opportunity | Wanted to Quit | Saw the pandemic as an opportunity to use less or had been planning already to use less or quit. | 5 (17.2%) |
| Future Plans | Pursuing future plans such as a new job. | 1 (3.4%) | |
| Physical Health | Virus Exposure | Worry about being exposed to or contracting COVID-19 | 4 (13.8%) |
| Health Concerns | Physical health concerns including cough or COVID-19 symptoms. | 3 (10.3%) | |
| Social Distancing | Social Distancing | Decrease in frequency as a result of social distancing procedures | 4 (13.8%) |
| Busy | Busy | Too busy to use. | 2 (6.9%) |
| Waste of Time | Waste of Time | Do not want to use, see cannabis as a “waste of time.” | 1 (3.4%) |
| Location | Location | Being in a location that inhibits use or not having privacy. | 1 (3.4%) |
| Anxiety and Stress | Anxiety and Stress | Self-reported anxiety and stress. Lessened cannabis use frequency to cope with, minimize, or tolerate stress/anxiety. | 1 (3.4%) |
| Furloughed | Furloughed | Furloughed or lost job; unemployed. | 1 (3.4%) |
| No Reason | No Reason | No reason indicated for decrease in frequency of use or does not know why there is a change. | 1 (3.4%) |
Percentages do not sum to 100% and N does not sum to 29 because participants could give multiple reasons why their cannabis use frequency decreased.
“I have anxiety due to school, trying to work…and worries about income.” (43-year-old Black/African American woman)
“I use more to cope with anxiety about being around people…” (53-year-old Black/African American woman)
Participants also reported that cannabis helped them cope with self-reported depression (N=2) and other negative life events (N=2). Some indicated that cannabis was used in conjunction with other substances, like alcohol, to enhance the relaxing or calming effects.
“[I am] feeling down and out, depressed due to the situation, wanted to take mind off of things—feel more relaxed, at ease and peaceful…” (58-year-old Black/African American man)
“Because of COVID-19. All the bad reports keep [me] using it because the situation is depressing, can't get away from it, when [I] come home, [I] relax with marijuana and a drink.” (53-year-old Black/African American man)
One of the other most commonly cited reasons for increased use during the pandemic was using cannabis as an activity to prevent boredom (N=6). For many, using cannabis replaced their usual pre-pandemic activities that were restricted because of COVID-19 guidelines at the time. Being in a location that facilitated or encouraged increased use (N=5) or being isolated due to social distancing (N=4) also contributed to increased frequency of cannabis use.
I am staying at home more now so it is a cycle: staying home, smoking weed, eating, repeat.” (55-year-old Black/African American woman).
“I have boredom at home; I have no option to go anywhere so it is something to do.” (51-year-old Other Race woman)
“I’m at home all the time, cannot go anywhere, cannot socialize, therefore smoking more because [I am at] home.” (57-year-old Black/African American man)
Reasons for Decrease in Cannabis Use Frequency
Twenty-nine participants decreased their frequency of cannabis use. The reasons why are shown in Table V. The most commonly cited reason for decreasing the frequency of cannabis use was access issues (N=12). Participants said that they had money issues, problems with being able to access their previous or new locations to obtain cannabis, general supply issues, or were often worried about being exposed to COVID-19 while obtaining cannabis through their supplier.
“It is somewhat harder to find marijuana, I am worried about the people who get it to you. I don't know if they have been exposed to the coronavirus, and if I contact them if they will give me the disease, so it's harder, especially that I don't want to get anything, I try to make sure to get good marijuana.” (52-year-old Black/African American man)
“It is harder to get to dispensaries–they switched to delivery only and [I am] outside the delivery range” (24-year-old White man)
Four participants decreased their frequency of use due to social distancing. Some expressed that they primarily liked to use cannabis with others and that social isolation diminished the effects of cannabis, which led to decrease in their use. Others said that it was easier to avoid using cannabis since they were separated from their usual peers with whom they often used cannabis, which similarly contributed to decreased use.
“Not around people who are smoking, so it's easier to avoid, and [I] stopped using in the last six months due to health concerns.” (61-year-old Black/African American woman)
“[I am] no longer sharing with or hanging out with people when using marijuana.” (62- year-old Black/African American man)
“…[I] do not want to smoke alone, cannot have company cause of quarantine." (51-year-old Hispanic woman)
Several others indicated that the pandemic was a perfect “opportunity” to cut back or quit cannabis use altogether to improve their mental and/or physical health and wellbeing, particularly if they had thought of quitting or reducing their cannabis use before the pandemic or needed to decrease their use for future plans or a job interview (N=6). One participant said that they lost interest, and cannabis was a “waste of time” for them.
“Marijuana has become a waste of time for me.” (50-year-old Black/African American woman)
“[I] had tried to quit marijuana before the pandemic, now [I] only smoked three times due to stress and health issues.” (58-year-old Black/African American woman)
Additionally, some expressed concerns about being exposed to COVID-19 through the cannabis itself (N=4) or having worse symptoms if they smoked cannabis due to the potential for lung damage and knowledge that COVID-19 primarily impacts the lungs (N=3). One person noted that cannabis enhanced feelings of anxiety or that obtaining cannabis was stressful, which led them to decrease their use.
“Simply because of the virus I am hesitant to use the same amount because I don’t know how it will affect the virus. I’m also trying to quit.” (64-year-old Black/African American woman)
“I have too much anxiety to smoke marijuana. I am now more in control of [my] use.” (60-year-old Black/African American woman)
“Just trying to stop smoke all together. I quit cigarettes, now trying to quit marijuana.” (57-year-old Black/African American woman)
Discussion
Of 227 participants, 13% reported decreased frequency of cannabis, 11% reported increased frequency, and 76% reported no change in their frequency of cannabis use. There was a wide variety in the reasons for changes in use.
Interestingly, the most commonly reported reason for increased use frequency was stress and anxiety, while one person who decreased their use also cited anxiety as a reason for change. For those who increased their use, participants cited worries about the pandemic and coping with stress and anxiety as triggers while the participant who decreased use simply said that they had too much anxiety to use cannabis. The unknown aspects of COVID-19 and how it could impact the health of PWH was a common reason for reducing frequency of use among participants. This shows that for situations such as the COVID-19 pandemic and other wide-spread public health emergencies, no two people’s experiences and perspectives of events are the same.
Three-quarters of the participants did not experience any changes in their self-reported frequency of cannabis use from pre-pandemic baseline to during-pandemic follow-up 3 months later. However, this means that a quarter of the participants did experience changes. Of note, more people reported decreases in the frequency of cannabis use than increases, though this is not a significant difference. The literature has primarily found increases in cannabis use in the general population and among PWH during the COVID-19 pandemic (28,33-36), although a recent study of PWH did find overall decreases in substance use from pre-pandemic to post-pandemic levels, supporting our findings (37). Perhaps this discrepancy is due to self-report of cannabis use frequency rather than objective evaluation. In addition to supporting the mix of findings in the literature, this study goes further by qualitatively investigating reasons for changes in use. This provides a fuller picture of drivers and barriers to use which could be used in future interventions attempting to motivate change in cannabis use or promote healthy behaviors.
These findings come directly from PWH who, in describing their lived experiences using cannabis, provide areas for intervention that are truly affecting their lives and are not just hypothesized by experts. It also is likely that these participants are not the only ones experiencing these motivations, so addressing these items could have a widespread impact. When providing clinical care to patients who are having negative effects from cannabis use or who want to reduce their use, providers can incorporate addressing their patients’ reasons for use into a care plan. At a public health policy level, participants indicated areas of potential action such as access to medical cannabis and mental and physical health care, opportunities for community and social connection, and more accessible programs to aid in reducing cannabis and other substance use.
Twenty-five participants of 227 increased their frequency of cannabis use. Most of these participants said that it was to reduce their anxiety during the pandemic. Some participants even said that their anxiety increased because of the pandemic. This follows along with findings in the literature about worsening stress, anxiety, and overall mental health among the general population during the pandemic (38,39). The literature has also found that many PWH use cannabis for therapeutic purposes (40,41), and these findings support PWH using cannabis to ease adverse mental health symptoms during the pandemic. Another common reason for increased frequency of cannabis use was due to using cannabis as an activity to prevent boredom, which is also supported in the literature (8-10). Having an activity aided many participants in dealing with the isolating and limiting aspects of lockdown, and prevented feelings of boredom that could potentially spiral into worse feelings in the future.
A surprising perspective was that some people decreased their cannabis use frequency because they had already wanted to make a change to decrease their use habits and the COVID-19 pandemic was an opportunity for them to do so. Many had wanted to reduce their use for the potential benefits to their health and well-being, which is consistent with recent literature showing that many people had greater engagement in positive health behaviors during the pandemic (42). Others were afraid of the exacerbation of negative effects on their lungs if they smoked cannabis given that COVID-19 is a respiratory disease and the established negative effects of inhaling cannabis on the lungs (17-22). Further studies might investigate the methods of cannabis use and see if it had any impact on use patterns during the pandemic if people did or did not use an administration route that impacted the lungs.
Since cannabis in many places, including Florida, is not legal, people had to access cannabis largely through illegal means or through dispensaries if they had a medical cannabis prescription—both means of accessing cannabis might have been disrupted by the COVID-19 pandemic, which was a source of stress for many PWH that led to reduced utilization of cannabis. In fact, many of the reasons for change in use frequency, including access issues, might be temporary and imply that after the COVID-19 pandemic participants might have their use return for normal. For example, another common reason for decrease in use was due to not being able to gather socially, which will undoubtedly change when social distancing measures end. Participants who increased their use due to higher levels of anxiety during the pandemic might reduce their use again when the COVID-19 pandemic wanes and life approaches normalcy. Conversely, those participants who changed their use for more permanent reasons such as developing anxiety disorders or wanting to quit might maintain their changed levels of use. A follow-up study with these participants would provide not only a fuller picture of their changes in cannabis use before, during, and after the COVID-19 pandemic, but would also inform interventions to help people maintain levels of cannabis use that support a healthy lifestyle and allow PWH to cope with change.
Limitations
Most of the participants in this study were recruited from clinics and other healthcare locations around Florida. While this provides a highly generalizable and representative sample of PWH in Florida, this might not necessarily be representative of those outside of Florida, especially those in states with different laws surrounding medical and recreational use of cannabis. This could also mean that the participants could have differential health outcomes and healthcare access patterns compared with other PWH not in care. Future research should aim to recruit those who are not in regular care to make sure they are represented appropriately in studies of cannabis use among PWH.
The questions only ask about cannabis use frequency, not the amount of cannabis used, since participants were not asked open-ended questions about their amount of use. This leads to different findings from previous work by our study team, since that study used a combined measure of amount and frequency to determine changes in cannabis use during the pandemic (28) while this study only examines changes in frequency. Only frequency was examined for this study because only the frequency questions had the open-ended qualitative question that asked about reasons for changes in frequency of use; this was done to reduce the length of the survey and to avoid confusing the participants with questions that might seem redundant. Understanding the amount of use could provide further insight into participants’ experiences during COVID-19, but the additional work from Wang et al., 2021 provides more insight into this topic.
Only participants who indicated that they changed their frequency of cannabis use were asked the follow-up question about reasons for change. In hindsight, it would have been valuable to ask participants who did not change their frequency of use about reasons why they did not have any changes to better understand their motivations and experiences during the COVID-19 pandemic.
Reports on cannabis use frequency are based on self-report on telephone calls with research assistants, and could be subject to response bias such as social desirability bias, recall bias, and/or interviewer bias. Research assistants are trained to prevent interviewer bias, while the non-judgmental aspect of research is emphasized for participants to feel comfortable being honest to prevent response bias.
Our response rate of 76% was high, but there is a potential limitation of representativeness if those who did not respond to follow-ups had different cannabis use changes. In the regularly scheduled upcoming follow-ups the research team aimed to successfully recruit these participants to understand the full scope of their experiences and perspectives.
This is a cross-sectional examination of participants at the first follow-up that occurred during the COVID-19 pandemic. While multiple follow-ups occurred during this period, they are outside the scope of this study. Therefore, this study does not examine longitudinal changes in change in frequency of cannabis use. Future studies could aim to explore trajectories of cannabis use frequency among this population.
Finally, the qualitative data presented here are from the open-ended responses on a survey questionnaire, which may not have captured the full of reasons for changes in cannabis use frequency during the pandemic. Future research with this team will aim to conduct in-depth qualitative interviews to close the gaps in our collective knowledge on this subject.
Conclusions
The COVID-19 pandemic has disrupted the lives of people around the world and had a major impact on the behaviors and attitudes of PWH, especially regarding cannabis use. In a sample of PWH in Florida, 13% of the participants decreased their frequency of cannabis use, 11% increased their frequency of cannabis use, and 76% had no change in their cannabis use. These findings are important because changes in frequency of cannabis use experienced by PWH during the pandemic might continue and prevent a return to “normal.” While there are mixed findings in the literature regarding an overall decrease or increase in cannabis use among PWH (28,33-37), when designing interventions, knowing the reason why PWH changed their use and what motivates them to change is more powerful than only knowing use trends. Understanding the reasons behind changes in cannabis use patterns in this population, and what demographics, attitudes, and beliefs might separate these groups, can allow researchers and providers to make greater connections between HIV-specific health outcomes and cannabis use. These findings provide specific targets for interventions to maintain or even improve health among PWH during public health emergencies and beyond.
Acknowledgements:
We would like to thank all the participants and study staff who donated their time to make the MAPLE study possible.
Disclosure/Funding
This study is funded by the National Institute on Drug Abuse (R01DA042069 and R01DA042069-04S1). C.E.P is funded by the National Institute on Alcohol Abuse and Alcoholism (T32AA025877).
The authors report no relevant disclosures.
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