Abstract
Introduction
Marijuana-use patterns differ among racial and sexual minority groups, but few studies have examined health effects in these subgroups. The authors aimed to study the relationship between marijuana use and history of myocardial infarction, current asthma, and history of depression within racial and sexual subgroups.
Methods
Cross-sectional data from the 2016–2022 Behavioral Risk Factor Surveillance System questionnaire was analyzed in April–December 2024. Current marijuana use was defined as at least 4 days of use within the past month. Weighted logistic regression assessed the unadjusted and covariate-adjusted associations between current marijuana use and myocardial infarction, asthma, and depression (overall and among subgroups).
Results
Marijuana use information was available for 729,240 individuals, of whom 44,555 (8.2%) were current marijuana users. Unadjusted, significant differences in the associations between marijuana use and myocardial infarction, asthma, and depression were found among racial and sexual orientation subgroups. After covariate adjustment, sexual orientation significantly modified the association between marijuana use and depression. In the covariate-adjusted models, marijuana use was associated with increased odds of myocardial infarction (OR=1.243, 95% CI=1.045, 1.478), asthma (OR=1.154, 95% CI=1.037, 1.285), and depression (OR=1.816, 95% CI=1.681, 1.963), although many of the associations with myocardial infarction and asthma were insignificant within subgroups.
Conclusions
Marijuana use was significantly associated with increased odds of history of depression, and sexual orientation modified this association. Significant, unadjusted, overall associations between marijuana use, previous myocardial infarction, and current asthma were found, but these associations were not typically significant after adjusting for covariates and looking within subgroups.
Keywords: Depression, myocardial infarction, asthma, marijuana use, race/ethnicity, sexual/gender minorities
HIGHLIGHTS
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Marijuana use is associated with increased odds of history of depression.
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Marijuana’s association with depression differs by sexual orientation.
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Covariate-adjusted associations with heart attack and asthma are insignificant.
INTRODUCTION
The relationships between marijuana use and health outcomes are under study. Cannabis use has been shown to activate CB1 receptors in the brain, which regulate the cardiovascular system.1 A study using 2017–2018 Behavioral Risk Factor Surveillance System (BRFSS) data showed that a history of myocardial infarction (MI) was associated with using cannabis more than 4 times per month.2 However, several other studies have shown that marijuana use was either not associated with MI or was associated with decreased odds of MI.3,4 More research is needed to understand this relationship.
Asthma symptoms are known to be affected by smoking combustible products such as marijuana and tobacco.5 Cannabis use has been shown to be more common among youth with asthma than among those without.5 In addition, several BRFSS studies have shown that the combined use of marijuana with E-cigarettes has been associated with asthma.6,7 Another study showed that marijuana use was associated with asthma, regardless of tobacco couse.8 However, most of these studies have examined the combined effect of tobacco and marijuana use and not marijuana use alone.
Marijuana use has previously been found to be associated with depression, although it is unclear whether cannabis use may lead to depression or whether depression may lead to cannabis use.9,10 Several studies have shown that marijuana use was associated with increased risks of depression and the worsening of depressive symptoms.11,12 A study using 2016–2018 BRFSS data showed that among cancer survivors, cannabis use was found to be associated with depression, although this association only existed among nonmedical marijuana users.13
Marijuana use is also more prevalent among sexual, racial, and ethnic minorities,14,15 but few studies have studied its effect on health outcomes in these populations. People belonging to minority groups often deal with discrimination and minority-related stress and often have difficulties accessing care, which can result in poorer health than that of nonminorities.16, 17, 18 For example, one study found evidence for pathways linking ethnic discrimination, depression, and marijuana use.19 Another study found sexual identity and racial differences in the ability to identify heart attack symptoms,20 which may affect their ability to seek care. Although asthma outcomes tend to be worse among minorities, research has also shown that culture-specific interventions can improve asthma outcomes.21
Although BRFSS data have been used to explore the relationship between marijuana use and MI, asthma, and depression, these studies have typically been limited to only a few years, certain states, or certain populations. The authors plan to evaluate the larger, overall associations using 2016–2022 BRFSS data from all states. The authors seek to expand on the previous research by examining these associations within racial and sexual minority subgroups.
METHODS
Study Population
Data were obtained from the 2016–2022 BRFSS surveys. The sampling and weighting methodology for BRFSS have been previously described in detail.22 Briefly, BRFSS is a dual frame (landline and cell phone) telephone survey that collects information on chronic health conditions, health-related risk behaviors, healthcare services, and the use of preventative services. Participants come from a large-scale probability-based sample and are intended to represent the noninstitutionalized adult population (aged ≥18 years) in all 50 U.S. states, the District of Columbia, and certain U.S. territories. BRFSS data are weighted by calculating a design weight to represent a participant’s probability of selection based on several factors. Iterative proportional fitting (raking) is used to adjust these weights for demographic differences between the sample and the population.22 For this study, the authors limited the data to participants who responded to the question regarding marijuana use. This study did not need IRB review because it only used deidentified publicly available data.
Measures
Marijuana use, the primary predictor of interest, was assessed by asking participants During the past 30 days, on how many days did you use marijuana or cannabis? Previous studies have shown that regular use of cannabis at least 1 time per week (4 times per month) has been associated with adverse effects.2,23 In addition, current frequent use of marijuana is often associated with lifetime use.24 The authors defined current regular marijuana use as yes if 4–30 days of marijuana use was reported and no if 0–3 days of marijuana use were reported.
The outcomes of interest were history of MI, current asthma, and history of depression. Respondents were asked whether they had ever had an MI, asthma, or depression (yes/no) and whether they still had asthma. The authors categorized those who still had asthma as current asthma, those who had previously had asthma or those who had never had asthma as not current asthma.
Because association studies can be affected by confounding, it is important to consider the effect of covariates in the analysis.25,26 The authors considered the following covariates: sex (male/female), age (18–24, 25–34, 35–44, 45–54, 55–64, ≥65 years), sexual orientation (gay/lesbian, straight, bisexual, other), transgender (yes/no), race/ethnicity (non-Hispanic [NH] White, NH Black, NH Asian, NH American Indian/Alaskan Native, Hispanic, NH other), education (lower than high school, high school, some college, college graduate), income (<$25,000; $25,000–$50,000; >$50,000), marital status (married, divorced/separated, widowed, not married), employment status (yes/no), type of marijuana use (smoke/vape, other type of use, not a marijuana user), smoking status (current/not current), heavy drinking status (yes/no), exercise (yes/no), BMI (kg/m2), time since last checkup (never, within 1 year, within 2 years, within 5 years), diabetes (yes/no), E-cigarette usage (current/not current), healthcare access (yes/no), healthcare coverage (yes/no), general health status (excellent, very good, good, fair, poor), other tobacco usage (current/not current), and geographic region (Northeast, Midwest, South, West).
Statistical Analysis
The authors combined BRFSS data from 2016–2022 for this analysis. A new stratification variable was created that combined the year of the survey with the stratification variable from that year. Sample sizes for each year were divided by the combined sample size to obtain proportions. The original sample weights were adjusted using the sample size proportions from each year to create a final sampling weight.27 The authors examined the relationship between each variable and marijuana use and reported unweighted and weighted frequencies, weighted percentages, and Rao-Scott chi-square p-values for categorical variables and weighted mean, weighted SE, and weighted ANOVA p-values for continuous variables. Bivariate associations between some important predictors28 and each health condition were assessed using weighted logistic regression. Multivariable weighted logistic regression models assessed the relationship between marijuana use and each health condition. All covariates were considered for the models, with model selection being used to select a set of covariates for the final model. Subgroup analyses were conducted to examine the unadjusted and covariate-adjusted associations between current marijuana use within each race/ethnicity, sexual orientation, and transgender subgroup. Interactions between marijuana use and race/ethnicity, sexual orientation, and transgender subgroup were tested to see whether the relationships within subgroups were significantly different. Observations with missing values were excluded from analysis. A 2-sided significance level of 0.05 was used for all tests. All analyses were conducted in SAS, Version 9.4, in April–December 2024.
RESULTS
In total, 729,240 participants (47,408,776 weighted) responded to the marijuana-use question from 2016 to 2022. Among these participants, 44,555 (3,859,770 weighted; 8.2%) reported at least 4 days of marijuana use within the last 30 days, and 684,685 (43,027,215 weighted; 91.8%) reported 3 or less days of marijuana use. In general, the rates of missing information were low (<10%) for most variables, although annual income (16%) and E-cigarette use (15%) had higher rates of missing values. In addition, sexual orientation and transgender status were not assessed in 9 states. In the states where these were collected, 27% were missing sexual orientation, and 26% were missing transgender.
Statistically significant relationships were observed between marijuana use and each variable studied (Table 1). A history of MI was reported among 3.6% of current marijuana users and 4.5% of nonusers. Current asthma was reported among 12.4% current marijuana users and 9.0% nonusers. A history of depression was reported in 34.7% of current marijuana users and 17.7% of nonusers.
Table 1.
Distribution of Health Conditions and Covariates by Marijuana Use, BRFSS 2016–2022
| Factor | Current marijuana users n=44,555 N=3,859,770 (8.2%) |
Not current marijuana users n=684,685 N=43,027,215 (91.8%) |
Overall n=729,240 N=46,886,986 |
p-value | ||||
|---|---|---|---|---|---|---|---|---|
| n | N (%) | n | N (%) | n | N (%) | |||
| Ever had heart attack (yes) | 2,219 | 139,078 (3.6%) | 40,222 | 1,943,518 (4.5%) | 42,441 | 2,082,596 (4.5%) | <0.001 | |
| Missing | 219 | 3,280 | 3,499 | |||||
| Current asthma (yes) | 5,724 | 472,707 (12.4%) | 62,837 | 3,837,386 (9%) | 68,561 | 4,310,092 (9.3%) | <0.001 | |
| Missing | 479 | 4,515 | 4,994 | |||||
| Ever had depression (yes) | 16,195 | 1,331,335 (34.7%) | 123,238 | 7,587,681 (17.7%) | 139,433 | 8,919,016 (19.1%) | <0.001 | |
| Missing | 294 | 2,962 | 3,256 | |||||
| Sex (male) | 26,410 | 2,353,641 (61%) | 302,189 | 20,246,594 (47.1%) | 328,599 | 22,600,235 (48.2%) | <0.001 | |
| Missing | 10 | 126 | 136 | |||||
| Age group, years | <0.001 | |||||||
| 18–24 | 5,680 | 826,011 (21.4%) | 33,831 | 4,493,172 (10.4%) | 39,511 | 5,319,183 (11.3%) | ||
| 25–34 | 9,123 | 1,057,094 (27.4%) | 61,668 | 6,459,303 (15%) | 70,791 | 7,516,396 (16%) | ||
| 35–44 | 8,141 | 725,655 (18.8%) | 80,293 | 6,817,370 (15.8%) | 88,434 | 7,543,025 (16.1%) | ||
| 45–54 | 6,572 | 477,819 (12.4%) | 103,840 | 7,112,753 (16.5%) | 110,412 | 7,590,571 (16.2%) | ||
| 55–64 | 8,325 | 482,508 (12.5%) | 141,649 | 7,646,398 (17.8%) | 149,974 | 8,128,906 (17.3%) | ||
| ≥65 | 6,714 | 290,684 (7.5%) | 263,404 | 10,498,220 (24.4%) | 270,118 | 10,788,905 (23%) | ||
| Race/ethnicity | <0.001 | |||||||
| NH White | 32,178 | 2,403,545 (63.5%) | 52,3997 | 27,524,117 (65.1%) | 556,175 | 29,927,662 (65%) | ||
| NH Black | 3,487 | 543,018 (14.4%) | 47,178 | 4,474,110 (10.6%) | 50,665 | 5,017,128 (10.9%) | ||
| NH Asian | 573 | 104,356 (2.8%) | 18,769 | 2,406,031 (5.7%) | 19,342 | 2,510,387 (5.4%) | ||
| NH AIAN | 1,323 | 55,501 (1.5%) | 8,456 | 312,226 (0.7%) | 9,779 | 367,727 (0.8%) | ||
| Hispanic | 3,422 | 536,539 (14.2%) | 50,442 | 6,649,090 (15.7%) | 53,864 | 7,185,629 (15.6%) | ||
| NH other | 2,654 | 140,008 (3.7%) | 22,982 | 916,300 (2.2%) | 25,636 | 1,056,307 (2.3%) | ||
| Missing | 918 | 12,861 | 13,779 | |||||
| Sexual orientationa | <0.001 | |||||||
| Gay | 999 | 98,094 (4.3%) | 6,269 | 430,501 (1.7%) | 7,268 | 528,595 (1.9%) | ||
| Straight | 23,259 | 1,903,699 (83.4%) | 390,330 | 24,579,470 (94.6%) | 413,589 | 26,483,169 (93.7%) | ||
| Bisexual | 2,198 | 217,646 (9.5%) | 7,906 | 660,673 (2.5%) | 10,104 | 878,319 (3.1%) | ||
| Other | 639 | 62,518 (2.7%) | 4,460 | 305,918 (1.2%) | 5,099 | 368,436 (1.3%) | ||
| Missing | 8,398 | 148,986 | 157,384 | |||||
| Transgender (yes)a | 357 | 49,262 (2.1%) | 2,001 | 154,088 (0.6%) | 2,358 | 203,350 (0.7%) | <0.001 | |
| Missing | 8,241 | 142,609 | 150,850 | |||||
| Educational level | <0.001 | |||||||
| Lower than high school | 3,383 | 484,029 (12.6%) | 43,220 | 5,260,639 (12.3%) | 46,603 | 5,744,668 (12.3%) | ||
| High school | 13,915 | 1,246,538 (32.3%) | 180,115 | 11,798,451 (27.5%) | 194,030 | 13,044,989 (27.9%) | ||
| Some college | 14,492 | 1,413,222 (36.7%) | 190,949 | 13,392,576 (31.2%) | 205,441 | 14,805,798 (31.7%) | ||
| College graduate | 12,684 | 709,803 (18.4%) | 268,246 | 12,427,066 (29%) | 280,930 | 13,136,868 (28.1%) | ||
| Missing | 81 | 2,155 | 2,236 | |||||
| Annual income | <0.001 | |||||||
| <$25,000 | 11,375 | 945,635 (28%) | 123,620 | 8,340,798 (23.3%) | 134,995 | 9,286,433 (23.7%) | ||
| $25,000–$50,000 | 10,760 | 884,147 (26.2%) | 142,042 | 8,423,774 (23.5%) | 152,802 | 9,307,920 (23.7%) | ||
| ≥$50,000 | 16,987 | 1,548,433 (45.8%) | 305,423 | 19,086,891 (53.2%) | 322,410 | 20,635,324 (52.6%) | ||
| Missing | 5,433 | 113,600 | 119,033 | |||||
| Marital status | <0.001 | |||||||
| Married | 15,055 | 1,166,720 (30.4%) | 369,864 | 22,690,224 (53.1%) | 384,919 | 23,856,944 (51.2%) | ||
| Divorced or separated | 8,825 | 560,155 (14.6%) | 101,631 | 5,645,812 (13.2%) | 110,456 | 6,205,967 (13.3%) | ||
| Widowed | 2,000 | 107,525 (2.8%) | 84,998 | 3,317,487 (7.8%) | 86,998 | 3,425,012 (7.4%) | ||
| Not married | 18,412 | 2,006,621 (52.2%) | 123,589 | 11,079,123 (25.9%) | 142,001 | 13,085,744 (28.1%) | ||
| Missing | 263 | 4,603 | 4,866 | |||||
| Employed (yes) | 25,488 | 2,406,916 (62.7%) | 339,139 | 23,967,767 (56.1%) | 364,627 | 26,374,683 (56.7%) | <0.001 | |
| Missing | 277 | 4,704 | 4,981 | |||||
| Geographic region | <0.001 | |||||||
| Northeast | 8,662 | 265,770 (6.9%) | 78,450 | 1,938,241 (4.6%) | 87,112 | 2,204,011 (4.8%) | ||
| Midwest | 11,105 | 1,251,144 (32.6%) | 209,939 | 14,565,778 (34.4%) | 221,044 | 15,816,922 (34.3%) | ||
| South | 9,734 | 973,618 (25.4%) | 202,617 | 13,847,045 (32.7%) | 212,351 | 14,820,663 (32.1%) | ||
| West | 14,187 | 1,342,797 (35%) | 173,718 | 11,984,569 (28.3%) | 187,905 | 13,327,366 (28.9%) | ||
| Missing | 867 | 19,961 | 20,828 | |||||
| Type of marijuana use | NA | |||||||
| Smoke or vape | 36,296 | 3,224,997 (86.2%) | 0 | 36,296 | 3,224,997 (6.9%) | |||
| Other type of use | 6,743 | 515,864 (13.7%) | 0 | 6,743 | 515,864 (1.1%) | |||
| Nonuser | 0 | 684,685 | 43,027,215 (100%) | 684,685 | 43,027,215 (92.0%) | |||
| Missing | 1,516 | |||||||
| Smoking status (current) | 16,049 | 1,360,320 (35.4%) | 82,171 | 5,503,122 (12.9%) | 98,220 | 6,863,442 (14.7%) | <0.001 | |
| Missing | 253 | 4,195 | 4,448 | |||||
| E-cigarette use (current) | 6,561 | 629,850 (20.1%) | 17,149 | 1,400,682 (4%) | 23,710 | 2,030,531 (5.3%) | <0.001 | |
| Missing | 6,132 | 105,727 | 111,859 | |||||
| Other tobacco products use (current) | 2,494 | 207,103 (5.4%) | 21,860 | 1,344,270 (3.1%) | 24,354 | 1,551,372 (3.3%) | <0.001 | |
| Missing | 69 | 806 | 875 | |||||
| Heavy drinking (yes) | 7,225 | 603,164 (16.1%) | 35,733 | 2,180,747 (5.2%) | 42,958 | 2,783,910 (6.1%) | <0.001 | |
| Missing | 1,139 | 12,165 | 13,304 | |||||
| Time since last checkup | <0.001 | |||||||
| Within last year | 28,974 | 2,393,936 (62.7%) | 536,540 | 32,416,653 (76.3%) | 565,514 | 34,810,589 (75.1%) | ||
| Within last 2 years | 5,876 | 580,561 (15.2%) | 70,461 | 4,993,795 (11.7%) | 76,337 | 5,574,356 (12%) | ||
| Within last 5 years | 4,047 | 397,159 (10.4%) | 34,811 | 2,586,799 (6.1%) | 38,858 | 2,983,959 (6.4%) | ||
| More than 4 years | 4,706 | 419,600 (11%) | 31,264 | 2,190,491 (5.2%) | 35,970 | 2,610,092 (5.6%) | ||
| Never | 371 | 26,456 (0.7%) | 3,950 | 324,087 (0.8%) | 4,321 | 350,543 (0.8%) | ||
| Missing | 581 | 7,659 | 8,240 | |||||
| Access to health care provider (yes) | 32,652 | 2,643,504 (68.9%) | 583,506 | 34,717,065 (81.1%) | 616,158 | 37,360,569 (80.1%) | <0.001 | |
| Missing | 284 | 3,360 | 3,644 | |||||
| Health care coverage (yes) | 38,125 | 3,248,025 (85.5%) | 632,054 | 38,367,555 (90.5%) | 670,179 | 41,615,581 (90.1%) | <0.001 | |
| Missing | 696 | 8,562 | 9,258 | |||||
| Diabetes (yes) | 3,985 | 261,544 (6.8%) | 102,333 | 5,716,468 (13.3%) | 106,318 | 5,978,012 (12.8%) | <0.001 | |
| Missing | 80 | 1,071 | 1,151 | |||||
| General health status | <0.001 | |||||||
| Excellent | 6,145 | 552,946 (14.4%) | 118,211 | 7,885,855 (18.4%) | 124,356 | 8,438,801 (18%) | ||
| Very good | 13,406 | 1,190,269 (30.9%) | 232,263 | 14,114,405 (32.9%) | 245,669 | 15,304,674 (32.7%) | ||
| Good | 14,550 | 1,283,003 (33.3%) | 213,509 | 13,531,353 (31.5%) | 228,059 | 14,814,356 (31.7%) | ||
| Fair | 7,296 | 610,165 (15.8%) | 88,393 | 5,613,799 (13.1%) | 95,689 | 6,223,965 (13.3%) | ||
| Poor | 3,036 | 214,748 (5.6%) | 30,870 | 1,797,502 (4.2%) | 33,906 | 2,012,250 (4.3%) | ||
| Missing | 122 | 1,439 | 1,561 | |||||
| BMI (kg/m2) | 27.4 (±0.07) | 28.4 (±0.02) | 28.3 (±0.02) | <0.001 | ||||
| Missing | 1,303 | 45,643 | 46,946 | |||||
| Exercise (yes) | 34,482 | 3,035,084 (78.7%) | 509,750 | 32,131,161 (74.8%) | 544,232 | 35,166,244 (75.1%) | <0.001 | |
| Missing | 89 | 1,468 | 1,557 | |||||
Note: Boldface indicates statistical significance (p<0.05).
Unweighted frequencies (n), weighted frequencies (N), weighted percentages, and Rao-Scott chi-square P-values are reported for categorical variables. Mean (±SE) and weighted ANOVA p-value are reported for continuous variables.
Sexual orientation and transgender variables were not collected in 9 states. Numbers presented for these variables represent states where these variables were collected.
AIAN, American Indian and Alaska Native; NH, non-Hispanic.
More current marijuana users reported being gay or lesbian (4.3%), bisexual (9.5%), transgender (2.1%), or another sexual orientation besides straight (2.7%) than nonusers. About 14.4% of current marijuana users were NH Black, and 2.8% were NH Asian, whereas 10.6% of nonusers were NH Black, and 5.7% were NH Asian. About 86.2% of marijuana users smoked or vaped marijuana, with 13.7% using marijuana in some other form. In addition, 35.4% of current marijuana users and 12.9% of nonusers reported current smoking. Heavy drinking and E-cigarette use were reported among 16.1% and 20.1% of current marijuana users and 5.2% and 4% of nonusers, respectively.
Table 2 describes the results of the unadjusted bivariate analyses for selected covariates. Current marijuana use was associated with 21% lower odds of a history of MI than nonuse (OR=0.790, 95% CI=0.715, 0.794). Current marijuana use was associated with 1.4 times higher odds of current asthma (95% CI=1.345, 1.520) and 2.5 times higher odds of a history of depression (95% CI=2.369, 2.574) than nonuse. Current smokers had significantly higher odds of history of MI (OR=1.617; 95% CI=1.522, 1.717), current asthma (OR=1.406; 95% CI=1.347, 1.467), and history of depression (OR=2.236; 95% CI=2.170, 2.305) than nonsmokers. Heavy drinking was associated with 35% lower odds of MI (95% CI=0.561, 0.736) and 1.3 times greater odds of a history of depression (95% CI=1.258, 1.389) but was not significantly associated with current asthma. E-cigarette use was associated with lower odds of history of MI (OR=0.609; 95% CI=0.537, 0.691) and increased odds of current asthma (OR=1.294; 95% CI=1.199, 1.396) and history of depression (OR=2.583; 95% CI=2.451, 2.723).
Table 2.
Unadjusted Bivariate Associations With Heart Attack, Asthma, and Depression
| Variable | Heart attack (yes versus no) | Current asthma (yes versus no) | Depression (yes versus no) |
|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Marijuana use | |||
| Current | 0.790 (0.715, 0.872) | 1.430 (1.345, 1.520) | 2.469 (2.369, 2.574) |
| Not current | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Type of marijuana use | |||
| Smoke or vape | 0.762 (0.686, 0.847) | 1.380 (1.288, 1.379) | 2.492 (2.381, 2.608) |
| Other type of use | 1.059 (0.806, 1.390) | 1.758 (1.540, 2.007) | 2.447 (2.207, 2.714) |
| Nonuser | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Smoking status | |||
| Current | 1.617 (1.522, 1.717) | 1.406 (1.347, 1.467) | 2.236 (2.170, 2.305) |
| Not current | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| E-cigarette use | |||
| Current | 0.609 (0.537, 0.691) | 1.294 (1.199, 1.396) | 2.583 (2.451, 2.723) |
| Not current | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Heavy drinking | |||
| Yes | 0.643 (0.561, 0.736) | 1.027 (0.945, 1.117) | 1.322 (1.258, 1.389) |
| No | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Race/ethnicity | |||
| NH White | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| NH Black | 0.755 (0.682, 0.837) | 1.218 (1.154, 1.287) | 0.649 (0.619, 0.681) |
| NH Asian | 0.392 (0.291, 0.528) | 0.546 (0.466, 0.641) | 0.325 (0.290, 0.365) |
| NH AIAN | 1.730 (1.469, 2.036) | 1.671 (1.462, 1.909) | 1.282 (1.161, 1.416) |
| Hispanic | 0.574 (0.519, 0.635) | 0.793 (0.742, 0.847) | 0.683 (0.652, 0.716) |
| NH other | 0.933 (0.831, 1.047) | 1.454 (1.342, 1.575) | 1.203 (1.128, 1.282) |
| Sexual orientation | |||
| Gay/lesbian | 0.680 (0.556, 0.831) | 1.532 (1.299, 1.808) | 2.376 (2.139, 2.638) |
| Straight | 1.0 (ref)ss | 1.0 (ref) | 1.0 (ref) |
| Bisexual | 0.497 (0.399, 0.619) | 1.858 (1.671, 2.066) | 4.443 (4.122, 4.788) |
| Other | 1.109 (0.838, 1.469) | 1.524 (1.278, 1.817) | 2.725 (2.421, 3.068) |
| Transgender | |||
| Yes | 1.205 (0.880, 1.651) | 1.854 (1.484, 2.317) | 3.239 (2.776, 3.779) |
| No | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
AIAN, American Indian and Alaska Native; NH, non-Hispanic.
Table 3 describes the unadjusted association between marijuana use and each health condition within each subgroup. The associations between marijuana use and each health outcome was significantly different among race/ethnicity and sexual orientation subgroups (p<0.001 for all). Transgender status did not modify the associations between marijuana use and heart attack (p=0.890) or current asthma (p=0.176) but did have a significant effect for depression (p=0.001). Current marijuana use was associated with lower odds of a history of MI among NH Whites (OR=0.754; 95% CI=0.669, 0.850) and NH Blacks (OR=0.727; 95% CI=0.547, 0.965) but was not significantly associated with a history of MI among other racial groups. Current marijuana use was significantly associated with increased odds of current asthma and a history of depression across all race/ethnicity categories, except NH Asian, which was insignificant for asthma. The ORs for current marijuana use were relatively weak (between 1 and 2) for all groups with significant associations. For all subgroups, the ORs between marijuana use and a history of depression were significant and near 2, except for NH Asians (OR=3.077; 95% CI=2.117, 4.473). Current marijuana use was significantly associated with lower odds of history of MI among nontransgender individuals (OR=0.833; 95% CI=0.730, 0.950) but was not associated with history of MI among straight, gay/lesbian, bisexual, other sexual orientations, and transgender individuals. Current marijuana use was significantly associated with higher odds of history of depression among all sexual orientation and transgender groups. Most ORs were near 2, except those for the other sexual orientation (OR=4.485; 95% CI=3.150, 6.387) and transgender (OR=3.612; 95% CI=2.255, 5.785) subgroups. Marijuana use was also significantly associated with higher odds of current asthma among straight (OR=1.242; 95% CI=1.142, 1.351), bisexual (OR=1.432; 95% CI=1.124, 2.826), and nontransgender subgroups (OR=1.338; 95% CI=1.237, 1.447).
Table 3.
Unadjusted, Bivariate Associations Between Current Marijuana Use and Health Outcomes in Subgroups
|
Subgroups |
Heart attack (yes versus no) |
Current asthma (yes versus no) |
Depression (yes versus no) |
|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Race/ethnicity | |||
| NH White | 0.754 (0.669, 0.850) | 1.302 (1.217, 1.392) | 2.508 (2.393, 2.628) |
| NH Black | 0.727 (0.547, 0.965) | 1.265 (1.062, 1.507) | 1.992 (1.737, 2.286) |
| NH Asian | 0.631 (0.182, 2.189) | 1.641 (0.801, 3.362) | 3.077 (2.117, 4.473) |
| NH AIAN | 1.054 (0.600, 1.853) | 1.616 (1.096, 2.383) | 2.305 (1.780, 2.985) |
| Hispanic | 0.803 (0.559, 1.152) | 1.955 (1.565, 2.443) | 2.554 (2.205, 2.959) |
| NH other | 0.970 (0.663, 1.421) | 1.332 (1.081, 1.640) | 2.214 (1.805, 2.499) |
| Sexual orientation | |||
| Gay/lesbian | 1.189 (0.690, 2.051) | 1.317 (0.757, 2.290) | 2.135 (1.570, 2.903) |
| Straight | 0.873 (0.759, 1.003) | 1.242 (1.142, 1.351) | 2.229 (2.104, 2.362) |
| Bisexual | 0.994 (0.546, 1.812) | 1.432 (1.124, 1.826) | 1.714 (1.427, 2.059) |
| Other | 0.715 (0.349, 1.462) | 1.438 (0.914, 2.262) | 4.485 (3.150, 6.387) |
| Transgender | |||
| Yes | 0.957 (0.420, 2.183) | 1.511 (0.848, 2.694) | 3.612 (2.255, 5.785) |
| No | 0.833 (0.730, 0.950) | 1.338 (1.237, 1.447) | 2.457 (2.329, 2.591) |
Note: Interactions between marijuana use and race/ethnicity and sexual orientation were significant for all health outcomes (p<0.001 for all). Interactions between marijuana use and transgender status were insignificant for heart attack (p=0.890) and current asthma (p=0.176) but was significant for depression (p=0.001).
AIAN, American Indian and Alaska Native; NH, non-Hispanic.
Finally, the authors examined the covariate-adjusted association between current marijuana use and each health condition within each subgroup (Table 4). After model selection, the model comparing marijuana use with history of MI was adjusted for sex, age, race, education, income, marital status, employment status, smoking status, time since last checkup, diabetes, access to health care, general health status, and region and contained 279,227 participants. The covariate-adjusted model showed that current marijuana use was associated with 1.2 times higher odds of a history of MI (95% CI=1.045, 1.478). However, this association was insignificant within all subgroups except NH other (OR=2.144; 95% CI=1.040, 5.298), straight individuals (OR=1.241; 95% CI=1.032, 1.491), transgender individuals (OR=3.805; 95% CI=1.280, 11.311), and nontransgender individuals (OR=1.225; 95% CI=1.027, 1.461), although interactions revealed that these differences between subgroups were not significantly different from each other. The model for current asthma contained 266,907 participants and was adjusted for sex, age, sexual orientation, race, education, income, marital status, employment status, smoking status, exercise, BMI, time since last checkup, access to health care, healthcare coverage, general health status, and region. In the overall population, current marijuana use was still associated with increased odds of current asthma (OR=1.154; 95% CI=1.037, 1.285), although this relationship was insignificant in all subgroups except for straight (OR=1.162; 95% CI=1.037, 1.301) and nontransgender (OR=1.145; 95% CI=1.029, 1.274) individuals. However, these differences between subgroups were not significant. Current marijuana use was associated with 1.8 times higher odds of history of depression (95% CI=1.681, 1.963) among 267,630 participants after adjusting for sex, age, sexual orientation, transgender status, race, education, income, marital status, employment status, smoking status, heavy drinking, exercise, BMI, time since last checkup, diabetes, E-cigarette use, access to health care, healthcare coverage, general health status, and region. This relationship remained significant in all subgroups except in NH Blacks and NH Asians, with ORs ranging from 1.321 to 2.537. Interactions between marijuana use and race/ethnicity (p=0.390) and transgender status (p=0.628) were not significant, indicating that differences between these subgroups were not significant. However, the associations between marijuana use and depression were found to differ significantly by sexual orientation (p=0.006), with the ORs being around 1.321 (95% CI=1.056, 1.653) for bisexual individuals, 1.792 (95% CI=1.267, 2.535) for gay/lesbian individuals, 1.859 (95% CI=1.709, 2.022) for straight individuals, and 2.537 (95% CI=1.581, 4.072) for those of other sexual orientations.
Table 4.
Covariate-Adjusted Associations Between Marijuana Use and Health Outcomes in Subgroups
|
Subgroups |
Heart attack (yes versus no) |
Current asthma (yes versus no) |
Depression (yes versus no) |
|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Model sample size | 279,227 | 266,907 | 267,630 |
| Overall | 1.243 (1.045, 1.478) | 1.154 (1.037, 1.285) | 1.816 (1.681, 1.963) |
| Race/ethnicity | |||
| NH White | 1.176 (0.967, 1.428) | 1.069 (0.955, 1.196) | 1.880 (1.727, 2.047) |
| NH Black | 1.262 (0.741, 2.150) | 1.146 (0.825, 1.592) | 1.250 (0.921, 1.695) |
| NH Asian | 0.212 (0.049, 0.918) | 0.642 (0.309, 1.336) | 1.760 (0.921, 3.364) |
| NH AIAN | 0.943 (0.457, 1.948) | 1.350 (0.842, 2.164) | 2.022 (1.350, 3.030) |
| Hispanic | 1.863 (0.889, 3.904) | 1.553 (0.982, 2.455) | 1.883 (1.432, 2.476) |
| NH other | 2.144 (1.040, 4.298) | 1.110 (0.806, 1.530) | 1.859 (1.439, 2.400) |
| Sexual orientation | |||
| Gay/lesbian | 1.098 (0.586, 2.056) | 0.706 (0.434, 1.149) | 1.792 (1.267, 2.535) |
| Straight | 1.241 (1.032, 1.491) | 1.162 (1.037, 1.301) | 1.859 (1.709, 2.022) |
| Bisexual | 1.052 (0.519, 2.132) | 1.136 (0.871, 1.482) | 1.321 (1.056, 1.653) |
| Other | 0.979 (0.460, 2.083) | 1.547 (0.927, 2.581) | 2.537 (1.581, 4.072) |
| Transgender | |||
| Yes | 3.805 (1.280, 11.311) | 1.338 (0.695, 2.576) | 2.172 (1.233, 3.828) |
| No | 1.225 (1.027, 1.461) | 1.145 (1.029, 1.274) | 1.813 (1.676, 1.960) |
Note: Model sample size is the number of participants with nonmissing information included in each model after adjusting for covariates. Heart attack model adjusted for sex, age, race, education, income, marital status, employment status, smoking status, time since last checkup, diabetes, access to health care, general health status, and region. Interactions between marijuana use and race (p=0.244), sexual orientation (p=0.541), and transgender status (p=0.057) were not significant. Current asthma model adjusted for sex, age, sexual orientation, race, education, income, marital status, employment status, smoking status, exercise, BMI, time since last checkup, access to health care, healthcare coverage, general health status, and region. Interactions between marijuana use and race (p=0.358), sexual orientation (p=0.869), and transgender status (p=0.550) were not significant. Depression model adjusted for sex, age, sexual orientation, transgender status, race, education, income, marital status, employment status, smoking status, heavy drinking, exercise, BMI, time since last checkup, diabetes, E-cigarette use, access to health care, healthcare coverage, general health status, and region. The interaction between marijuana use and sexual orientation (p=0.006) was significant, but the interactions with race (p=0.390), and transgender status (p=0.628) were not significant.
AIAN, American Indian and Alaska Native; NH, non-Hispanic.
DISCUSSION
The authors found that current marijuana use was associated with decreased unadjusted odds of a history of MI but was not associated with increased odds of a history of MI after adjusting for covariates (although this association was insignificant in most subgroups). The covariate-adjusted result appears to be consistent with a previous BRFSS study that found that the use of marijuana at least 4 times per month was associated with increased odds of a history of MI.2 However, the fact that this association was reversed in the unadjusted analysis and the insignificant results within most subgroups seem to support previous studies showing that marijuana use was not associated with MI or associated with decreased odds of MI.3,4 However, it should be noted that marijuana users tended to be younger than nonusers, with about 67.6% of marijuana users being under age 45 years compared with only 41.2% of nonusers. Because age is a known risk factor for MI, this could help to explain the decreased prevalence of a history of MI among current marijuana users.29
Unadjusted, the authors found that current marijuana use was significantly associated with increased odds of current asthma, both overall and within subgroups. After adjusting for covariates, the overall association was still significant, but most of the subgroup associations were not significant. The significant overall associations of current marijuana use with increased odds of current asthma are consistent with the findings of several other studies.5, 6, 7, 8 However, the insignificant subgroup associations after covariate adjustment are surprising. In some cases, such as in transgender or bisexual subgroups, the insignificant association could be partially due to the small sample sizes. However, some larger subgroups, such as straight individuals, still had insignificant associations.
Marijuana use was found to be significantly associated with a history of depression. This association held for both the unadjusted and covariate-adjusted results, for overall trends, and within nearly all subgroups. Although this does not indicate a causal association, the results of this study clearly indicate that marijuana use is associated with depression, which is consistent with the findings of previous studies.11, 12, 13 More thorough studies may be needed to better understand the link between marijuana use and depression.
In general, the association between marijuana use and MI, asthma, and depression tended to be similar across most racial/ethnic, sexual orientation, and transgender subgroups. Although significant differences between subgroups were detected for the unadjusted associations, most of these associations were no longer different after adjusting for covariates. However, statistically significant differences in the associations between marijuana use and depression were found among sexual orientation subgroups. Although more research is needed to determine whether there may be any causal associations present, this finding indicates that sexual orientation may be an important factor in evaluating the association between marijuana use and depression.
Limitations
This study has several limitations. BRFSS is a cross-sectional study, so the authors cannot draw any causal inferences from these data. Instead, the goal of this study was simply to assess possible associations between marijuana use and each health outcome. In addition, participants were asked only about their history of MI or depression, so responses might not reflect the participant’s current health status. Because no temporal data were available for these variables, it is possible that the MI and depression reported by participants may have occurred before the participants began using marijuana. However, previous research has shown that current frequent marijuana use is associated with lifetime marijuana use,24 so it is possible that many participants reporting current marijuana use have used marijuana in the past. Marijuana-use questions were part of an optional BRFSS module and were not answered by all BRFSS respondents, limiting the sample size for this analysis. Sexual orientation and transgender questions were also part of optional modules, and the rarity of certain sexual orientations and transgender individuals further limited the sample size for these subgroups.22 In addition, marijuana use is illegal in many U.S. states, which could make participants hesitant to report marijuana use accurately.30 Although nearly all other variables had low rates of missingness, the large amounts of missing data for some of these variables could have an impact on the sample weights because the authors limited the analysis to participants with complete data only, which could introduce some significant bias in the results. A future study may consider using multiple imputation to reduce missingness for some of these values.
This study also has several strengths. BRFSS is a large, nationwide survey, so the results should be generalizable to the entire noninstitutionalized adult U.S. population. Participants were selected using probability sampling, which helps to make the sample more representative of the entire population. Although the sample size is small compared with the entirety of BRFSS, the authors still had a very large sample size, considering that a total of 7 years of BRFSS data can also increase the statistical reliability of the results compared with data that only cover 1 year.31 Another strength of this study is the consideration of racial, gender, and sexual minority subgroups. To the authors’ knowledge, no other study has studied the relationship between marijuana use and health outcomes in this manner despite research that has shown that marijuana-use patterns differ among these individuals.14,15 Owing to the large sample size, representativeness of the data, and availability of minority population information, this study provides important association findings and evidence for helping with designing future cohort study for examining the causal effect of marijuana use and MI, asthma, and depression and specifically for minority populations.
CONCLUSIONS
The authors found that current marijuana use was significantly associated with increased odds of history of depression, and this differed among sexual orientation subgroups. In addition, the authors found that current marijuana use was significantly associated with decreased odds of history of MI and increased odds of current asthma, but these associations were not significant after the authors adjusted for covariates and looked within racial and sexual subgroups. The relationship between current marijuana use and each health condition were similar among most racial and sexual subgroups. More research is needed to determine whether causal relationships exist between marijuana use and health outcomes, both in the overall population and among minorities.
Acknowledgments
ACKNOWLEDGMENTS
Disclaimer: The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Funding: HRW did not receive any funding for this project. SC did not receive any funding for this project with an Institutional Development Award from National Institute of General Medical Sciences.
Declaration of interest: none.
CRediT AUTHOR STATEMENT
Heather R. Willmott: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Sixia Chen: Conceptualization, Methodology, Supervision, Writing – review & editing.
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