Abstract
Purpose:
This study investigated whether adult use marijuana sales were associated with changes in lifetime and past 30-day (P30D) marijuana use among middle school students in Nevada (NV), which had adult-use marijuana sales during the study period, compared to New Mexico (NM), which did not have adult-use marijuana sales during the study period.
Methods:
Data were drawn from the middle school 2017 and 2019 NV Youth Risk Behavior and NM Youth Risk and Resiliency Surveys. Difference-in-difference analyses compare changes in lifetime and P30D marijuana use in NV (adult-use sales implemented July 2017) vs. NM (no adult-use sales during the study period).
Results:
There was no difference in lifetime (aOR 1.11; 95% CI 0.91,1.36) and P30D (aOR 1.17; 95% CI 0.91,1.51) marijuana use by adult-use sales status. The odds of lifetime and P30D marijuana use increased in both states, particularly among students who were female, older, non-White, or attending a Title 1 school.
Discussion:
Adult-use sales were not associated with an increase in lifetime or P30D marijuana use. State-level prevention efforts should focus on sub-populations with increasing lifetime and P30D use regardless of adult-use sales status.
Keywords: Marijuana use, Adolescents, Marijuana legalization, Policy
INTRODUCTION
Early adolescence is a critical developmental period marked by rapid neurocognitive, behavioral, and psychosocial changes.1 Marijuana use during this sensitive period may affect health and social outcomes across the lifespan. 2-5 Any marijuana use before age 14 is associated with increased risk of future problematic marijuana use and development of cannabis use disorder.6,7 Prospectively, regular marijuana use before age 14 is associated with poorer attentional control, working memory, and response inhibition in early adulthood.7,8 These potential harms highlight the public health importance of monitoring social and policy factors that may influence marijuana use during this developmental period.
As more states enact legislation legalizing adult use marijuana sales, or marijuana sales to anyone ages 21 or older, there is concern that marijuana commercialization may increase drug supply, pro-marijuana community norms, and the diversity of products that are appealing to youth, potentially increasing adolescent use.9 To-date, research has not found evidence of significant increases in adolescent marijuana use post-adult-use marijuana sales in the short term10; however, studies have primarily focused on older adolescents (e.g., high school or college). Only four population-based studies assessed changes in marijuana use among younger adolescents pre/post adult-use marijuana sales, with mixed results.11-14 Previous research could not accurately generate state-level estimates,11 did not include 6th and/or 7th graders, 11-14 lacked control groups,12,14 or did not disaggregate the results of high school and middle school students.13
The purpose of this study was to examine whether implementation of adult-use marijuana sales in Nevada (NV) in 2017 was associated with changes in lifetime and past 30-day (P30D) marijuana use among middle school students in 2019, using New Mexico (NM) as a comparison state which only had medical marijuana sales at the time of the study.
METHODS
This quasi-experimental study uses data from the 2017 and 2019 NV Youth Risk Behavior Survey (NV-YRBS) and NM Youth Risk and Resiliency Survey (NM-YRRS), two state-run surveys that are part of the Youth Risk Behavior Surveillance System (YRBSS). The YRBSS is a national surveillance system designed by the Centers for Disease Control and Prevention to primarily monitor health behaviors among US high school students.15,16 NV and NM are two of a limited number of states that collect data biennially from middle school as well as high school samples. The NV-YRBS and NM-YRRS use similar methods to recruit representative samples of middle school students (grades 6-8), weighting data at the region/district level to account for the complex survey design and missing data. The NV YRBS and NM YRRS were approved by the University of Nevada, Reno and University of New Mexico IRBs, respectively. The current study was reviewed by and received ethics clearance through the University of Nevada, Reno Institutional Review Board (IRB number 1305327-1).
The 2017 and 2019 NV-YRBS data collection occurred from January to June. NV did not have adult-use marijuana sales during the 2017 NV-YRBS data collection as NV implemented adult-use marijuana sales beginning on July 1, 2017, after 2017 data collection was complete. Over 80% of the NV-YRBS sample in 2017 and 2019 lived in urban areas of the state such as Las Vegas, Reno/Sparks, and Carson City, all areas that allowed implementation of marijuana retail sales and had dispensaries soon after sales began on July 1, 2017. The 2017 and 2019 NM-YRRS data collection occurred from September to December each year; NM did not implement adult-use marijuana sales until 2022, after the study period. Both states had similar medical marijuana sales environments (2-3 medical dispensaries/100,000 people)17,18 and imposed similar limits on medical marijuana cards, home cultivation, and advertising.19,20 Despite these similarities, NM had higher marijuana use prevalence than NV for several years preceding the study period.21,22
Measures
Unlike the standard middle school CDC YRBSS, which only includes a lifetime marijuana use variable, the NV middle school YRBS and the NM middle school YRRS also assess P30D marijuana use using the standard YRBSS high school variable, dichotomized as any vs. no marijuana use. Covariates included sex (male or female), age (≤ 11 years, 12 years, 13 years, or ≥ 14 years old), race/ethnicity (non-Hispanic White, non-Hispanic American Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black/African American, Hispanic/Latino, non-Hispanic Native Hawaiian/Pacific Islander, or non-Hispanic “other”/mixed racial/ethnic identity), rurality of school’s county (urban [≥ 50,000 people]; rural [<50,000 people23 and population density ≥6 people/square mile]; or frontier [population density <6 people/square mile],24 and school’s Title 1 status (yes/no). All covariates were self-reported except school rurality and school Title 1 status, which were obtained from Census25 and federal education sources.26 There were no significant interactions by covariates.
Statistical analyses
We calculated weighted prevalence estimates and used survey-weighted generalized logistic models to find the average treatment effect on the treated (e.g., the average effect on Nevada adolescents) for change in lifetime and P30D marijuana use. We adjusted for individual- and school-level variables, time (2017 vs 2019), state (NV vs NM), and a treatment indicator (0/1).
RESULTS
A summary of individual sociodemographic and school characteristics (covariates) as well as marijuana use by state and year are presented in Table 1. The distribution of individual and school characteristics remained stable over time within each state.
Table 1.
Sociodemographic, school-level characteristics, and marijuana use among middle school students in Nevada and New Mexico; Nevada Youth Risk Behavior Survey and New Mexico Youth Risk and Resiliency Survey, 2017 & 2019
| Nevada | New Mexico | |||
|---|---|---|---|---|
| 2017 (n=5,467) % (95% CI) |
2019 (n=5,341) % (95% CI) |
2017 (n=22,061) % (95% CI) |
2019 (n=19,255) % (95% CI) |
|
| Individual-level characteristics | ||||
| Sex | ||||
| Male | 50.7 (48.2, 53.2) | 51.3 (48.3, 54.3) | 51.1 (49.9, 52.2) | 51.1 (50.1, 52.1) |
| Female | 49.3 (46.8, 51.7) | 48.7 (45.7, 51.7) | 48.9 (47.8, 50.1) | 48.9 (47.9, 49.9) |
| Age | ||||
| ≤ 11 years | 17.0 (14.2, 20.2) | 14.8 (11.6, 18.7) | 23.6 (20.5, 27.0) | 21.8(19.1, 24.7) |
| 12 years | 30.3 (27.9, 32.9) | 33.1 (29.2, 37.2) | 33.0 (30.1, 36.1) | 33.9 (31.5, 36.3) |
| 13 years | 34.0 (30.8, 37.2) | 34.0 (30.9, 37.2) | 33.6 (30.8, 36.6) | 34.5 (32.2, 36.9) |
| ≥ 14 years | 18.7 (15.6, 22.3) | 18.9 (15.3, 23.2) | 9.7 (8.4, 11.2) | 9.8 (8.7, 11.1) |
| Racial/ethnic identity | ||||
| Non-Hispanic White | 32.2 (27.4, 37.4) | 29.5 (26.2, 33.1) | 20.8(18.8, 23.0) | 19.0 (17.7, 20.3) |
| Non-Hispanic American Indian/Alaska Native | 1.0 (0.7, 1.4) | 0.8 (0.6, 1.0) | 6.5 (5.8, 7.2) | 7.5 (6.4, 8.8) |
| Non-Hispanic Asian | 5.7 (4.4, 7.5) | 5.6 (4.1, 7.6) | 1.3 (0.9, 1.5) | 1.4 (1.2, 1.6) |
| Non-Hispanic Black/African American | 11.0 (7.8, 15.2) | 11.5 (9.7, 13.5) | 2.3 (2,0, 2.7) | 2.6 (2.3, 2.9) |
| Hispanic/Latino | 44.1 (40.4, 47.9) | 44.9 (41.1, 48.8) | 65.0 (63.0, 67.0) | 65.4 (63.4, 67.4) |
| Non-Hispanic Native Hawaiian/Pacific Islander | 0.1 (0.01, 0.2) | 1.5 (1.1, 2.0) | 0.6 (0.5, 0.8) | 0.8 (0.6, 1.0) |
| Non-Hispanic “Other” or mixed racial/ethnic identity | 5.9 (4.9, 7.0) | 6.2 (5.3, 7.3) | 3.5 (3.0, 4.0) | 3.4 (3.0, 3.8) |
| School characteristics | ||||
| School location | ||||
| Urban | 90.6 (84.4, 94.4) | 91.4 (90.4, 92.3) | 82.7 (79.8, 85.2) | 83.6 (81.4, 85.6) |
| Rural | 3.5 (2.0, 6.0) | 3.1 (2.5, 3.9) | 11.9 (9.7, 14.4) | 11.5 (9.8, 13.5) |
| Frontier | 5.9 (3.4, 10.2) | 5.5 (4.9, 6.2) | 5.7 (4.4, 6.8) | 4.9 (3.8, 6.3) |
| School Title 1 Status | ||||
| Not Title I Recipient | 32.2 (22.2, 44.1) | 32.5 (26.0, 39.7) | 23.4 (15.9, 33.0) | 19.8 (16.9, 23.0) |
| Title I Recipient | 67.8 (55.9, 77.8) | 67.5 (60.3, 74.0) | 76.6 (67.0, 84.1) | 80.2 (77.0, 83.1) |
| Marijuana use behaviors | ||||
| Any lifetime marijuana use | ||||
| No | 90.3 (89.1, 91.4) | 86.7 (84.7, 88.5) | 85.9 (84.3, 87.3) | 82.6 (81.5, 83.7) |
| Yes | 9.7 (8.6, 10.9) | 13.3 (11.5, 15.3) | 14.1 (12.7, 15.7) | 17.4 (16.3, 18.5) |
| Any past 30-day marijuana use | ||||
| No | 93.7 (92.5, 94.7) | 91.1 (89.7, 92.3) | 91.3 (90.3, 92.3) | 89.5 (88.6, 90.3) |
| Yes | 6.3 (5.3, 7.5) | 8.9 (7.7, 10.3) | 8.7 (7.7, 9.7) | 10.5 (9.7, 11.4) |
NOTES - Age distributions skew younger in New Mexico than Nevada because New Mexico fields its survey in the fall, while Nevada fields its survey in the spring. Data were missing at <0.8% for all variables except: Nevada, 2017 – racial/ethnic identity (3.2%), lifetime marijuana use (5.4%); Nevada, 2019 -- racial/ethnic identity (3.9%), lifetime marijuana use (5.3%); New Mexico, 2017 -- racial/ethnic identity (3.8%), lifetime marijuana use (3.7%); New Mexico, 2019 -- racial/ethnic identity (4.2%), lifetime marijuana use (3.9%).
The prevalence of lifetime and P30D marijuana use increased in both states from 2017-2019. In NV, lifetime marijuana use increased from 9.7% (95% CI: 8.6, 10.9) to 13.3% (95% CI: 11.5, 15.3) and P30D marijuana use increased from 6.3% (95% CI: 5.3, 7.5) to 8.9% (7.7, 10.3). In NM, lifetime marijuana use increased from 14.1% (95% CI: 12.7, 15.7) to 17.4% (95% CI: 16.3, 18.5) and P30D marijuana use increased from 8.9% (95% CI: 7.7, 10.3) to 10.5% (9.7, 11.4) (Table 1).
The effect of adult-use marijuana sales on lifetime (aOR 1.1; 95% CI 0.91, 1.36) and P30D (aOR 1.2; 95% CI 0.91, 1.51) marijuana use was not statistically significant. On average across states, female sex, increasing age, non-White race/ethnicity, and attending a Title 1 school were associated with higher odds of lifetime and P30D marijuana use (Table 2).
Table 2.
Weighted adjusted odds ratios for lifetime and past 30-day marijuana use among middle school students, adjusting for individual and school characteristics; Nevada Middle School Youth Risk Behavior Survey & New Mexico Youth Risk and Resiliency Survey, 2017 & 2019.
| Lifetime marijuana use AOR (95% CI) |
Past 30-day marijuana use AOR (95% CI) |
|
|---|---|---|
| Year | ||
| 2017 | Ref | Ref |
| 2019 | 1.27 (1.13-1.43) | 1.22 (1.07-1.39) |
| State | ||
| New Mexico | Ref | Ref |
| Nevada | 0.63 (0.54-0.75) | 0.69 (0.57-0.85) |
| Legal adult-use marijuana sales | ||
| No | Ref | Ref |
| Yes | 1.11 (0.91-1.36) | 1.17 (0.91-1.51) |
| Individual characteristics | ||
| Sex | ||
| Male | Ref | Ref |
| Female | 1.14 (1.04-1.26) | 1.16 (1.04-1.29) |
| Age | ||
| ≤ 11 years | Ref | Ref |
| 12 years | 2.74 (2.19-3.43) | 2.60 (2.02-3.34) |
| 13 years | 5.49 (4.56-6.62) | 4.44 (3.52-5.60) |
| ≥ 14 years | 9.71 (7.81-12.06) | 8.16 (6.30-10.57) |
| Racial/ethnic identity | ||
| Non-Hispanic White | Ref | Ref |
| Non-Hispanic American Indian/Alaska Native | 2.58 (2.20-3.03) | 2.75 (2.20-3.42) |
| Non-Hispanic Asian | 0.48 (0.26-0.87) | 0.61 (0.32-1.17) |
| Non-Hispanic Black/African American | 1.45 (1.06-1.98) | 1.63 (1.12-2.35) |
| Hispanic/Latino | 1.73 (1.53-1.95) | 1.67 (1.37-2.04) |
| Non-Hispanic Native Hawaiian/Pacific Islander | 1.60 (0.97-2.62) | 1.78 (1.00-3.16) |
| Non-Hispanic “Other” or mixed racial/ethnic identity | 1.68 (1.36-2.09) | 1.46 (1.11-1.93) |
| School characteristics | ||
| School location | ||
| Urban | Ref | Ref |
| Rural | 1.07 (0.92-1.25) | 1.04 (0.88-1.23) |
| Frontier | 1.05 (0.92-1.21) | 0.94 (0.80-1.10) |
| Title 1 school | ||
| Yes | 1.32 (1.14-1.51) | 1.36 (1.15-1.60) |
| No | Ref | Ref |
DISCUSSION
We did not find compelling evidence that implementation of adult-use marijuana sales was associated with an immediate increase in lifetime or P30D marijuana use among middle school youth in Nevada which aligns with previous research.10 However, the increase in marijuana use among middle school students in both Nevada and New Mexico from 2017-2019 is concerning given the negative health consequences associated with initiation of marijuana use at an early age.6,7 Our results are consistent with literature that identifies marijuana use as a mechanism for coping with poverty and discrimination,27 and literature that shows adolescent females are now reporting more marijuana use than their male counterparts.28 Our findings suggest a need for primary prevention, particularly for females, students of color, and those attending Title I schools. As more states legalize adult-use marijuana sales, it is imperative that state-level surveillance systems monitor substance use trends during early adolescence. In 2021, only 14 states had weighted middle school YRBS data, and P30D use is not a core survey question.29
We were only able to assess short-term changes in marijuana use related to adult-use marijuana sales comparing two states and we could not control for the possible influence of neighboring states that have legalized marijuana such as Colorado and California. We were also unable to speak to changes in frequency of marijuana use or changes in cannabis use disorder, both of which are important outcomes for future research even in this young age group. Additionally, while we controlled for a number of sociodemographic differences between the two states, it is important to note that legalization effects could manifest differently at the state level. While there is a need for more robust research evaluating the impact of adult-use marijuana sales on marijuana use among middle school students, our research highlights an immediate need for prevention efforts for youth at greatest risk, regardless of state legalization.
Highlights.
There was no immediate change in lifetime or past 30-day marijuana use among middle school-aged adolescents in Nevada compared to New Mexico.
Regardless of state, marijuana use increased among females, students of color, and those attending Title I schools.
Footnotes
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Declarations of interest: None.
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