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. Author manuscript; available in PMC: 2024 Nov 18.
Published in final edited form as: Drug Alcohol Depend. 2023 Aug 9;251:110915. doi: 10.1016/j.drugalcdep.2023.110915

Perceived risk of harm for different methods of cannabis consumption: A brief report

Autumn Rae Florimbio a,*, Maureen A Walton a,b, Lara N Coughlin a,b, Lewei (Allison) Lin a,b,c, Erin E Bonar a,b
PMCID: PMC11573003  NIHMSID: NIHMS2035157  PMID: 37597308

Abstract

Background:

Emerging adults’ (EAs; ages 18–25) perceived risk of cannabis-related harms has decreased in recent decades, potentially contributing to their high prevalence of cannabis consumption. With the changing cannabis policy and product landscape, it is critical to understand perceived risk related to different consumption methods (e.g., smoking, dabbing). We examined differences in cannabis risk perceptions by method and consumption patterns.

Methods:

EAs recruited from an emergency department (N=359, 71.3% female, 53.5% Black) completed assessments on individual characteristics, cannabis/other substance use, and perceived risk of cannabis-related harm for four different methods (smoking, vaping, dabbing, ingestion) and two use frequencies (occasional, regular). Analyses examined associations between variables of interest and three mutually exclusive groups: no cannabis use, smoking-only, and multiple/other methods.

Results:

Forty-two percent of EAs reported no past 3-month cannabis use, 22.8% reported smoking only, and 35.1% reported consumption via multiple/other methods. Among all participants, the methods and frequency with the largest number of EAs endorsing any perceived risk from cannabis were dabbing and vaping cannabis regularly; smoking occasionally had the smallest number of EAs endorsing perceived risk. A greater proportion of EAs in the no use group viewed vaping cannabis regularly as having the most risk (63.6%), whereas the largest proportion of EAs in the smoking-only (64.6%) and multiple/other methods (47.2%) groups perceived dabbing regularly as having the most risk.

Conclusions:

This work shows that EAs vary in perceptions of risk across methods of cannabis use and can inform potential directions for public health and policy efforts.

1. Introduction

Cannabis use prevalence in the United States is highest among emerging adults (EAs; 18–25 years), with 24.1% reporting past-month cannabis use (Substance Abuse and Mental Health Services Administration, 2022, 2023). In the last two decades, EAs’ risk perceptions related to cannabis use have substantially decreased (Schulenberg et al., 2021; Waddell, 2022), which is concerning given the potential influence of risk perceptions on cannabis consumption within the changing cannabis landscape (Romm et al., 2022; Salloum et al., 2018). Importantly, greater legalization of recreational cannabis appears to be associated with increases in cannabis consumption (Lachance et al., 2022; Melchior et al., 2019).

Common cannabis administration routes, or the process by which cannabis is consumed, include inhalation and ingestion via different methods (i.e., inhalation: smoking, vaping, dabbing; ingestion: eating, drinking) (Russell et al., 2018). There are many different product types, including dried flower, vaping liquids, edibles, butane hash oil concentrates, etc. (Calhoun et al., 2022). The tetrahydrocannabinol (THC) amount in cannabis products has increased over time, and can vary widely across and within product types (e.g., ~20% THC with flower, ~70% THC with concentrates) (Chandra et al., 2019; ElSohly et al., 2021; Smart et al., 2017). Recent findings indicate greater odds of using high-potency concentrates for residents of states with recreational than medical or no cannabis legalization (Hasin et al., 2021). Consuming high-potency products can increase health consequences (e.g., psychological distress, injury), including developing a cannabis use disorder (Arterberry et al., 2019; Chiu et al., 2021; Matheson and Le Foll, 2020).

Although certain cannabis routes and products are associated with variation in onset, intensity, and duration of intoxication, perceived risks unique to each method are under-studied. Prior to cannabis legalization in Canada, Leos-Toro et al. (2020) examined Canadian 16–30 year-olds’ perceived risk of harming themselves via smoking, vaporizing, eating/drinking, using high-potency extracts, and using synthetic cannabis, and found that daily use (vs. occasional) was perceived as riskier across products. Using high-potency extracts and synthetic cannabis was also perceived as riskier than smoking, vaping, and edible use. Additionally, they reported that young people perceived less risk associated with a particular method if they had consumed cannabis via that same method previously. This early research suggests the importance of additional studies to understand perceived risks by consumption method to inform public health efforts and policy, particularly in the US which, unlike Canada, enacts cannabis legalization policies at the state-level leaving room to potentially implement policies that vary access to different lower or higher risk methods and products.

Thus, in the present study, we examined perceived risk of cannabis-related harms by method among EAs presenting to a US emergency department [ED] in a state with legal recreational and medical cannabis. In 2018, there were 1.7 million cannabis-related ED visits in the US (Roehler et al., 2022), and, as in prior studies (Bonar et al., 2021), the ED can serve as a setting to connect and intervene early with at-risk EAs to avoid consequences of consumption and to extend prevention efforts incorporating information regarding cannabis risks. We examined differences in perceived risk of harm by cannabis method and individual characteristics (e.g., sociodemographic characteristics, other substance use) based on cannabis use patterns.

2. Method

2.1. Participants and procedures

We examined cross-sectional data from the screening survey of a pilot randomized controlled trial (Bonar et el., In Press). Study staff used electronic health records to identify and recruit EAs ages 18–25 who visited the ED (for any reason excluding acute sexual assault, suicidality, conditions precluding consent, etc.) of an urban level-1 trauma center in an under-resourced community. Among 364 EAs who completed the survey, 5 were excluded from analyses for inconsistent or missing data on relevant variables, leaving a final sample of N=359. Institutional review boards at University of Michigan and Hurley Medical Center approved procedures.

2.2. Measures

Items adapted from prior studies assessed sex, age, race, and ethnicity (Centers for Disease Control and Prevention 2020). We assessed past 3-month cannabis use and severity using six items based on the National Institute on Drug Abuse (NIDA)-Modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; Humeniuk et al., 2008; NIDA, n.d.) to compute cannabis use frequency and a total ASSIST severity score (α=0.77). We adapted a prior item (Cranford et al., 2016) to assess cannabis use method: “During the PAST 3 MONTHS, did you use marijuana or marijuana products that contained THC in the following ways?” Response options (choose all that apply) were “smoked it,” “vaped it,” “ate it,” “drank it,” and “dabbed it,” (with ate it/drank it responses combined for analysis as both are ingestion methods). One item assessed past 3-month binge drinking: “In the PAST 3 MONTHS, how often did you have 4/5 (tailored for: women/men) or more drinks on one occasion?”, with responses of 0=Never to 4=Daily or almost daily (Bush et al., 1998). Items modified from the National Youth Tobacco Survey assessed past-month tobacco use and vaping nicotine (CDC, n.d.; response options: 0–30 days; recoded to yes/no for analyses).

We assessed perceived risk associated with occasional and regular cannabis use by adapting prior items (Johnston et al., 2016). Participants were asked, “How much do you think people risk harming themselves (physically or in other ways), if they smoke/vape/dab/use marijuana edibles occasionally/regularly?” There were 8 items reflecting combinations of the four methods (smoke, vape, dab, use edibles) and two consumption frequencies (occasionally, regularly). Response options were 1=No risk, 2=Slight Risk, 3=Moderate Risk, and 4=Great risk. For analyses, we combined the moderate and great risk options to account for smaller cell sizes while conveying information reflecting gradations in levels of perceived risk.

2.3. Data analysis

We used SPSS v28.0 for analyses. First, we examined frequencies and descriptive statistics (e.g., means, standard deviations) for the total sample and cannabis use groups, separately. We used cannabis frequency and method items to create mutually exclusive groups (no use, smoking-only, multiple/other methods). Within the multiple/other methods group, 6.4% reported only one method other than smoking and 93.6% reported smoking plus another method (see Table 1 note). To examine differences between cannabis groups on variables of interest, we used chi-square tests and one-way analyses of variance, with Tukey’s post-hoc tests to explore group differences when indicated. We used an independent samples t-test to evaluate differences on continuous variables between the two cannabis-using groups (i.e., smoking-only vs. multiple/other methods).

Table 1.

Individual characteristics and substance use for all participants and by cannabis use groups.

All participants (N=359) n (%) or M (SD) No use (n=151) n (%) or M (SD) Smoking only (n=82) n (%) or M (SD) Multiple/Other methodsa (n=126) n (%) or M (SD) Statistic, p-value
Individual characteristics
Age 21.8 (2.2) 21.9 (2.1) 21.8 (2.4) 21.8 (2.3) F=0.08, p=.927
Race χ2=37.44, p<0.001
 White 139 (38.7%) 61 (40.7%) 13 (15.9%) 65 (51.6%)
 Black/African American 192 (53.5%) 83 (55.3%) 63 (76.8%) 46 (36.5%)
 Other 27 (7.5%) 6 (4.0%) 6 (7.3%) 15 (11.9%)
Sex χ2=4.65, p=.098
 Female 256 (71.3%) 116 (76.8%) 58 (70.7%) 82 (65.1%)
 Male 103 (28.7%) 35 (23.2%) 24 (29.3%) 44 (34.9%)
Substance use
Cannabis use frequencyb 2.8 (2.7) 0.0 (0.0) 4.3 (1.8) 5.0 (1.5) t=2.87, p=.002
Cannabis ASSIST score 6.9 (8.4) 0.4 (1.4) 10.4 (7.9) 13.0 (7.6) F=171.13, p<0.001
Past 3 M binge drinkingc 0.6 (1.0) 0.3 (0.8) 0.6 (0.9) 0.8 (1.2) F=8.96, p<0.001
Past 1 M tobacco use (Yes) 95 (26.5%) 28 (18.5%) 27 (32.9%) 40 (31.7%) χ2=8.58, p=.014
Past 1 M vape nicotine (Yes) 82 (22.9%) 31 (20.5%) 9 (11.0%) 42 (33.3%) χ2=15.19, p<0.001
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Note:

a

1.6% (n=2) reported only vaping, 4.8% (n=6) reported only edibles, 93.6% (n=118) reported smoking + at least one other method. Methods were defined as follows: • Smoked it (for example, in a joint, bong, blunt, or pipe) • Vaped it (for example, in an e-cigarette-like vaporizer or another vaporizing device) • Ate it (for example, in brownies, cakes, cookies, or candy) • Drank it (for example, in a tincture, tea, cola, or alcohol) • Dabbed it (for example, used waxes or concentrates)

b

0=Never, 2=Once or twice, 3=Monthly, 4=Weekly, 6=Daily or almost daily

c

0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily or almost daily

3. Results

3.1. Descriptive characteristics of participants

Overall, the sample was 71.3% female and 53.5% Black, with 7.0% Hispanic/Latino. Mean age was 21.8 years. Over half (57.9%) reported past 3-month cannabis use and, among those 208 participants, 43.3% used cannabis via one method (39.4% smoked, 2.9% ingested, 1.0% vaped), 22.1% reported two methods (13.5% smoked+ingested, 4.8% smoked+vaped, 3.8% smoked+dabbed), 20.7% reported three methods (8.7% smoked+vaped+ingested, 7.2% smoked+ingested+dabbed, 4.8% smoked+vaped+dabbed), and 13.9% reported cannabis consumption via all methods assessed. For the cannabis grouping variable used in remaining analyses, 42.1% of EAs were categorized as no use, 22.8% as smoking only, and 35.1% as using multiple/other methods. Table 1 displays descriptive information by group.

3.2. Group differences in sociodemographic and individual characteristics

Cannabis groups did not significantly differ on age or sex distribution; however, there was a significant association with race (coded as Black/African American, White, Other) reflecting more Black/African American EAs reporting smoking-only compared to other racial groups. Tobacco use and vaping nicotine were significantly related to cannabis groups, with larger proportions of EAs who consumed cannabis reporting tobacco use and larger proportions of EAs in the no use and multiple/other methods groups reporting vaping nicotine. With regard to binge drinking, post-hoc analyses showed that EAs in the multiple/other methods group reported more frequent binge drinking than those without recent cannabis use (p<0.001).

Participants’ cannabis severity (ASSIST) scores significantly differed by cannabis group, with post-hoc analyses showing that the multiple/other methods group had significantly higher scores than those who smoked only (p=.008) and those without recent cannabis use (p<0.001); the smoking-only group also had significantly greater scores than EAs without recent use (p<0.001). Among the two sub-groups with past 3-month cannabis use, EAs in the multiple/other methods group used cannabis significantly more often than those who smoked-only.

3.3. General descriptions and comparisons of cannabis risk perceptions by method

Generally, more EAs perceived risk for regular vs. occasional use across modalities. Across cannabis methods and groups, the largest proportion of EAs perceived regular dabbing (30.4%) and vaping (30.3%) as having a moderate/great cannabis risk while the smallest proportion perceived smoking occasionally (16.2%) as risky (Table 2). When examining the prevalence of any risk (i.e., slight or moderate/great risk) descriptively, more EAs without recent cannabis use perceived vaping regularly as having risk (63.6%) whereas dabbing regularly had the largest proportion of EAs endorsing risk in the smoking-only (64.7%) and multiple/other methods groups (47.2%).

Table 2.

Associations between perceived risk and cannabis use group.

All participants (N=359) n (%) No use (n=151) n (%) Smoking only (n=82) n (%) Multiple/Other methodsa (n=126) n (%) Chi-square, p-value
Smoke occasionally 30.42, p<0.001
 No risk 206 (57.4) 66 (43.7) 52 (63.4) 88 (69.8)
 Slight risk 95 (26.5) 44 (29.1) 20 (24.4) 31 (24.6)
 Moderate/Great risk 58 (16.2) 41 (27.2) 10 (12.2) 7 (5.6)
Smoke regularly 37.14, p<0.001
 No risk 200 (55.7) 62 (41.1) 51 (62.2) 87 (69.0)
 Slight risk 84 (23.4) 36 (23.8) 23 (28.0) 25 (19.8)
 Moderate/Great risk 75 (20.9) 53 (35.1) 8 (9.8) 14 (11.1)
Vape occasionally 16.80, p=.002
 No risk 172 (47.9) 61 (40.4) 38 (46.3) 73 (57.9)
 Slight risk 95 (26.5) 38 (25.2) 21 (25.6) 36 (28.6)
 Moderate/Great risk 92 (25.6) 52 (34.4) 23 (28.1) 17 (13.5)
Vape regularlyb 27.10, p<0.001
 No risk 162 (45.4) 55 (36.4) 36 (43.9) 71 (57.3)
 Slight risk 87 (24.4) 32 (21.2) 19 (23.2) 36 (29.0)
 Moderate/Great risk 108 (30.3) 64 (42.4) 27 (32.9) 17 (13.7)
Dab occasionally 18.18, p=.001
 No risk 166 (46.2) 61 (40.4) 35 (42.7) 70 (55.6)
 Slight risk 103 (28.7) 37 (24.5) 27 (32.9) 39 (31.0)
 Moderate/Great risk 90 (25.1) 53 (35.1) 20 (24.4) 17 (13.5)
Dab regularlyc 18.55, p<0.001
 No risk 151 (42.2) 56 (37.1) 29 (35.4) 66 (52.8)
 Slight risk 98 (27.4) 34 (22.5) 29 (35.4) 35 (28.0)
 Moderate/Great risk 109 (30.4) 61 (40.4) 24 (29.3) 24 (19.2)
Edibles occasionally 22.43, p<0.001
 No risk 190 (52.9) 60 (39.7) 47 (57.3) 83 (65.9)
 Slight risk 98 (27.3) 49 (32.5) 19 (23.2) 30 (23.8)
 Moderate/Great risk 71 (19.8) 42 (27.8) 16 (19.5) 13 (10.3)
Edibles regularly 26.18, p<0.001
 No risk 183 (51.0) 57 (37.7) 47 (57.3) 79 (62.7)
 Slight risk 84 (23.4) 39 (25.8) 14 (17.1) 31 (24.6)
 Moderate/Great risk 92 (25.6) 55 (36.4) 21 (25.6) 16 (12.7)
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a

1.6% (n=2) reported only vaping, 4.8% (n=6) reported only edible use, 93.6% (n=118) reported smoking + at least one other method.

b

n for this variable is 124 due to missing data in the multiple/other methods group.

c

n for this variable is 125 due to missing data in the multiple/other methods group.

All chi-square analyses examining associations between perceived risk and cannabis groups were statistically significant (detailed in Table 2). Generally, a higher proportion of EAs without recent cannabis use perceived a moderate/great risk of harm associated with cannabis use across frequency and methods. A larger proportion of EAs in the smoking-only and multiple/other methods groups perceived smoking and edible use as low risk relative to the no use group. EAs who consumed cannabis via multiple/other methods, tended to endorse less risk of cannabis use across methods.

4. Discussion

We examined perceived risk of harm associated with four cannabis administration methods and different consumption frequencies among EAs. The developmental period of emerging adulthood is a time associated with increased substance use, with the highest cannabis use prevalence among this age group (Patrick et al., 2022; SAMHSA, 2022; 2023). Understanding how EAs view cannabis products in today’s legal cannabis landscape, with varying product types and potencies, is critical. Our findings suggest that risk perceptions differ by cannabis consumption patterns and method for members of this at-risk group. Specifically, EAs who consumed cannabis via multiple/other methods reported less perceived risk of cannabis-related harms relative to the smoking-only and no use groups. EAs tended to perceive greater risk for methods that typically involve high-potency products, particularly when asked about regular (vs. occasional) cannabis use. These findings are consistent with Leos-Toro and colleagues’ (2020) findings that consuming high-potency products was perceived as riskier than smoking, vaping, and consuming edibles. However, our study differed in key ways including data collection with EAs specifically, in the US, in a state with legalized medical and recreational cannabis, which may have influenced levels of risk perception.

Low endorsement of perceived risk has implications for public health and policy efforts, for example, informing standardized labeling of high-potency products to include statements regarding health and impairment disclaimers so people who consume cannabis know about potential harms and safe use strategies (Kruger et al., 2022). Clinically, there may be opportunities to enhance risk perceptions across products via motivational and psychoeducational approaches to prevent cannabis use disorder and related harms. Enhancing risk perceptions and clarifying potential risks may also increase use of harm reduction strategies to reduce cannabis use frequency and potentially minimize consequences (Florimbio et al., 2023).

Our findings provide an initial step in understanding cannabis risk perceptions by modality and consumption patterns in the US among EAs, a key risk group, informing future investigations. Despite our study’s strengths, there are limitations. We recruited EAs from an ED in an urban, under-resourced community, which may not generalize to broader populations of EAs. Using self-report measures to collect data in an acute care setting limited the data that could be collected, such as detailed measures of consumption history, specific types of perceived harms (e.g., consequences, mental health), and exposure to cannabis messaging (e.g., billboards, dispensaries) which could provide useful information on cannabis risk perceptions. Additionally, as in prior work (Johnston et al., 2016), items assessing perceived risk did not define “occasional” vs. “regular” use, leaving these terms to participants’ interpretations which may be inconsistent.

Despite limitations, this initial work improves our understanding of risk perceptions in the new cannabis landscape among members of an age group with the highest risk for cannabis consumption and consequences. Future research should further explore these associations (i.e., across settings, locations, and age groups) to inform public health efforts geared at reducing health impacts of cannabis use.

Role of funding source

This work was funded by the National Institute on Drug Abuse [NIDA #045712; PI: Bonar] and ARF’s time was supported by the National Institute on Alcohol Abuse and Alcoholism [NIAAA #007477; PI: Blow]. The funding sources had no role in the study design, execution, analysis, or reporting of results.

Footnotes

CRediT authorship contribution statement

Dr. Florimbio led the conceptualization, statistical analysis, interpretation of results, and drafting of the manuscript. Dr. Walton was a co-investigator on the parent project and assisted with conceptualization, interpretation of results, and reviewing/editing the manuscript. Drs. Coughlin and Lin reviewed/edited the manuscript. Dr. Bonar was PI of the parent project and assisted with conceptualization, interpretation of results, and reviewing/editing drafts of the manuscript. All authors approve the manuscript and its submission to this journal.

Declaration of Competing Interest

The authors do not have any conflicts related to this manuscript to disclose.

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