Focus Groups of Parents and Teens Help Develop Messages to Prevent Early Marijuana Use in the Context of Legal Retail Sales

Abstract

Purpose

The changes in Washington State and Colorado marijuana laws call for the development of new brief family-focused adolescent marijuana use preventive interventions that are relevant for and tailored to the context of legalization for retail sale. To that end, focus groups with parents and teens were conducted to find out about their concerns and needs in the context of legalization.

Methods

Six semi-structured focus groups (3 with parents, 3 with teens) were conducted in Washington State in 2013 related to consequences of teen marijuana use and messages that would be effective in helping to prevent teens from using marijuana in the context of legal adult use. A total of 33 teens and 35 parents participated.

Results

Three primary themes were common to these parents and teens: the negative consequences of marijuana use during adolescence on mental, physical, and social health; the need for more or better information; and the need for information/messages to come from trusted sources. The themes related to potential prevention messages include the use of fear; stories about real people; focusing on short-term consequences; and teens needing alternative activities (something better to do).

Conclusions

The results suggest that parents and teens need information about the new retail marijuana legalization law. Teens are open to both information and guidance from parents as long as it is calm and respectful. Firsthand accounts of consequences of marijuana use from peers and adults, rather than threats from authority figures, could hold some promise for persuading teens to avoid marijuana use.

Introduction

Since 2012, four U.S. states (AK, CO, OR, WA) and the District of Columbia have legalized non-medical use of marijuana for those over age 21. A major concern with the legalization of marijuana use for adults is the potential impact on adolescents. Although sale to youth under age 21 remains illegal, it is possible that legalization of retail sales will lead to greater exposure to and availability of marijuana for adolescents. Community norms influenced by legalization may lead to more early initiation of marijuana use which, in turn, may lead to higher rates of heavy use and dependence (Guttmannova et al., 2016). Early onset and heavy use have been shown to disrupt individual functioning in school, peer, and family life (Hall, Degenhardt, & Teesson, 2009; Jacobus, Bava, Cohen-Zion, Mahmood, & Tapert, 2009).

Legalization may also influence parents’ use, attitudes toward marijuana, and expectations regarding their children’s use. Parents have expressed confusion over how to communicate with their adolescent children about marijuana now that it is legal for adults (Mason, Hanson, Fleming, Ringle, & Haggerty, 2015; Roffman, 2012). This is important because research has consistently shown that parents’ behavior, attitudes, and communication with their children about substance use predict substance use among their teens (Huansuriya, Siegel, & Crano, 2014; Lamb & Crano, 2014; Oxford, Harachi, Catalano, & Abbott, 2001). Furthermore, family-focused interventions have been shown to reduce adolescent substance use, including marijuana use (Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2003; Mason et al., 2009; Spoth, Redmond, Shin, & Azevedo, 2004). These interventions rely on clear messages from parents about expectations and rules regarding substance use. Thus, both data and theory suggest parents can play a key role in mitigating the potential impact of legalization on adolescent marijuana use (Oxford et al., 2001; Patterson, Reid, & Dishion, 1992). However, in the context of legal use by adults, messages contained in current family-focused interventions may not be compelling. Furthermore, parents may feel they cannot make the same claims about the detrimental effects of marijuana given legalization.

The recent changes in marijuana laws highlight the need for new family-focused marijuana use preventive messages that are relevant for the context of legalization. Such messages must be based on a foundation of knowledge regarding what will be acceptable to parents and teens. There is some evidence that community-wide advertising campaigns can reduce youth marijuana use (for example, Palmgreen, Donohew, Lorch, Hoyle, & Stephenson, 2001). Public information campaigns have demonstrated some effectiveness in relation to changes in laws related to seatbelt use (Nichols, Tippetts, Fell, Eichelberger, & Haseltine, 2014), texting and driving (Kareklas & Muehling, 2014), and driving under the influence (Elder et al., 2004). Derzon and Lipsey (2002) conducted a meta-analysis of 72 anti-drug campaigns from around the world and found mixed results. Creating a campaign in the age of retail marijuana legalization is new territory. In order to have impact, messages must be perceived as relevant, trustworthy, credible, and persuasive (Crano & Prislin, 2006; Kazdin, 2000; Morawska et al., 2011). To that end, focus groups of parents and teens could provide meaningful information about their concerns and needs in the context of legalization. Knowledge from the focus groups can help ensure that the content of prevention messages will meet the needs of targeted families, potentially maximizing the acceptability and impact of prevention efforts.

We conducted six focus groups in Tacoma, Washington in 2013, about a year after the law legalizing adult use of marijuana was passed but before retail outlets were open. Participants were parents and teens who had recently engaged in a family-focused intervention to improve the transition to high school and prevent problem behaviors (including substance use) among teens. The experience in the intervention served to ‘prime the pump’ so that they came to the focus group having already given some thought to the challenges of reducing the risk of underage marijuana use in the context of legal adult use.

Methods

The focus groups were part of a larger study on the efficacy of family-focused interventions. In the trial, families were randomly assigned to the Common Sense Parenting condition (CSP, a general parent training program currently in widespread use by Boys Town, a national service provider), the CSP Plus Stepping Up to High School condition (CSP Plus; an adaptation of the standard CSP program that includes adolescents in the workshops), or a minimal contact control condition. Families who had been in the CSP Plus condition, which included a focus on communication skills and messages parents can give their children about substance use, were recruited for the focus groups. The CSP Plus intervention was not specifically targeted to marijuana use prevention. No intervention effects on parent or teen attitudes or beliefs about substance use were evident in the larger study (Mason et al., in press). Overall, 47% of parents reported any lifetime use of marijuana, but this was unrelated to their attitudes about teen use (Mason et al., 2015).

Thirty-five parents and 33 teens participated in three parent and teen focus groups in Tacoma, Washington. Parents and their teen selected a meeting time convenient for them both: Saturday morning, Tuesday evening, or Thursday evening. Parents and their teens attended at the same time, but the focus groups were conducted separately at a conveniently located community center.

Procedures/Data Collection

Invitation letters were sent to the 70 eligible parents of 9th- to 11th-grade students (Table 1). One family had two participating teens (twins). Follow-up calls were completed with 46 families and stopped when enough families had verbally consented to participate. Of those 46 families, 35 agreed to be in the study. Of the 11 parents who did not agree, 4 refused and 7 said they would think about it but did not call back. Once the parents and teens verbally consented, confirmation was sent via email or mail with information about their assignment. A day or two prior to the focus group, reminders were sent via text or phone.

Table 1.

Recruiting focus group participants

Recruitment phase	#
Recruitment letter	701
Follow-up (self- or project-initiated)	46
Follow-up - self (phone or email)	18
Follow-up - by staff	28
No follow-up	24

¹70 parents - 71 teens who had attended at least 1 CSP+ session (1 set of twins)

Prior to the start of each focus group, most participants completed a brief survey to collect demographic data (age, gender, and ethnicity). This survey included open-ended warmup questions. Participants were asked to provide a list of three things in each of three areas: major concerns parents have in raising teens, concerns about teens using marijuana, and what parents can do to help their teens make good decisions about marijuana. Most frequently mentioned concerns teens mentioned were health and safety, accidents, and allergies (19); and cognitive effects on brain development, concentration, and memory (11). In response to the same question, parents most frequently listed marijuana use leading to alcohol and other drug use and drug dealing (12). Of the things parents can do to help their teens make good decisions about marijuana, parents and teens both most frequently listed educating teens about consequences (31 parents, 25 teens) and communicating calmly and honestly (27 parents, 12 teens).

The focus groups were approximately 90 minutes long. Refreshments were provided. Two researchers experienced in conducting focus groups facilitated, and two research assistants took notes. None of them were previously associated with the CSP project. Teens and parents initially met together with facilitators for about 30 minutes for introductions and questions and answers about the new marijuana law itself, and were given written information about the law. Parents and teens then met separately for 60-minute guided discussions.

Each group facilitator used a semi-structured interview guide to focus and motivate discussion. The general topics discussed by parents were: what names do people use to refer to marijuana; what are some good things about using marijuana; what are the risks to teens using marijuana; what are the challenges for parents trying to keep their teens from using, especially in light of legalization; what skills do parents need; and what messages would be effective in helping to prevent teens from using marijuana. Topics for teens were similar: names; good things and not-so good things about use; concerns, especially about teens using; what information about marijuana might help them to decide whether to use; what are the most persuasive things parents say about not using marijuana; and what messages would be effective in preventing teen marijuana use. As facilitators introduced each new topic they reminded participants that the researchers were especially interested in their thoughts in light of the new legal status of marijuana in Washington State. All discussion was digitally recorded and professionally transcribed verbatim. All procedures for this study were approved by the University of Washington Institutional Review Board.

Sample

Of the 35 families assigned to a focus group, 31 attended. In addition, one family attended a focus group after only receiving their invitation letter (no follow-up call). In total, 33 teens (31 singletons, 1 pair of twins) and 35 parents (3 families had 2 attending parents) attended one of the focus groups. Each parent and teen received $50. Focus groups were assigned as follows: FG1: 12 teens and 12 adults, FG2: 11 teens and 13 adults, FG3: 10 teens and 10 adults. Thirty-four parents and 29 teens completed the warmup questions. Demographic characteristics of the parent and teen participants are presented in Table 2.

Table 2.

Demographic characteristics of parents and teens participating in focus groups

	Parents	Teens
Male	21%	52%
Ethnicity	59% White	48% White
	21% Black	28% Black
	6% Hispanic/Latino	0% Hispanic/Latino
	6% Pacific Islander	3% Pacific Islander
	6% Mixed race	17% Mixed race
		7% did not indicate
Grade		52% 10th grade (age 15–16)
		31% 11th grade (age 16–17)
		3% 9th grade (age 14–15)
		14% did not indicate

Analysis

Four members of the research team individually reviewed transcripts, verbatim notes, and facilitators’ notes, each identifying themes they observed in the data (Saldana, 2009). All of these themes were then reviewed and discussed by all four researchers. Two team members refined the list of themes based on team discussions and then validated the themes by reviewing the transcripts and identifying direct quotes which pertained to each theme. Themes and quotes from the transcripts were then reviewed by all four team members. There were some themes noted by only one researcher. In the review of the master list, some themes were consolidated because they overlapped a great deal, or a slightly more general theme was developed to include two or more closely related themes. There was consensus that all of the themes identified were present in the transcripts and none should be eliminated simply because they were not initially apparent to all of the researchers on the team.

Results

Results are presented in two sections: general themes, and themes specific to possible prevention messages. We consider the three general themes primary because they arose in all six groups, occupied a significant portion of the discussion time, and therefore seemed particularly salient to both parents and teens. These primary themes were: the need for more or better information about the law and the consequences of breaking the law; the negative consequences of marijuana use during adolescence on mental, physical and social health; and the need for information/messages to come from trusted sources. The themes related to potential prevention messages include the use of fear, stories about real people, focusing on short-term consequences, and teens needing alternative activities. Overall the discussions were characterized more by consensus than disagreement. Where there was debate, both sides of the issue are reported with quotes to illustrate each point of view. Because the prompts included reminders about the recent legalization of non-medical marijuana for adults, both parents and teens frequently referred to the new legal status of marijuana, the fact that it is still not legal for teens, and the potential increased availability and visibility of marijuana when retails sales began.

Primary Themes

The need for more or better information

A common theme among parent and teen participants was the need for information about the law itself, and the consequences of teens using illegally. Parents expressed strong concerns about what they consider misinformation they believe teens have, and the positive image that marijuana has now that it is legal for adults. They stated that teens need to know the “other side” of the story so they have a clearer understanding of the risks. Teens focused on the need for more balanced information, but from the opposite fear, that they are only being told the negative consequences. One teen put it this way, “A lot of things I hear are just don’t smoke. It’s bad. It’s not giving us information. It’s not convincing.” And another teen said, “Just tell them all there is to know about it. Most people would like to know what it does to them, the good, the bad, what happens if they use, and all the stuff that comes with that.”

The consequences of marijuana use during adolescence

Both parents and teens talked about the potential negative physical and mental health consequences of using marijuana during adolescence. Parents and teens commented that providing information on negative effects on brain development would be persuasive as a prevention message. [Parent] “I think if kids knew the effects that it had on their brain that would be effective.” [Teen] “Brain growth persuades me.” Other than brain development, possible physical health consequences included obesity from eating too much, lung damage from smoking, and effects on muscles that might reduce athletic ability.

Addiction was also a concern of some. Several teens stated plainly that marijuana is addictive. However, not all participants agreed that marijuana is addictive, and some participants in both parent and teen groups noted positive and healthful effects of marijuana. Some of the parents had used medical marijuana and reported talking with their teen about that.

With me and my son I went through chemo, I resorted to marijuana but before that I had a sit down talk with him and he saw what I went through. I also showed him the other side and showed him what happens when you do it too much, he only saw that the marijuana helped with my pain so he knows what can happen and knows that he does not want to do it.

Teens noted that marijuana can help you sleep, it’s natural, and does not seem to have the same level of negative effects as alcohol. [Teen] “Too much of anything is bad, but honestly when it comes to other drugs it’s probably the lesser of evils.” and “You can binge drink yourself to death. You can chain smoke yourself to death. I’ve never heard somebody die of an overdose of marijuana.”

Both parents and teens expressed concern about the risk to mental health. One parent commented “…it also can affect your mental health and cause depression or suicide.” A teen said, “Smoking when you’re younger – it has an emotional setback because your mind is literally clouded by it.” And other teens agreed that marijuana causes a “lack of will to do stuff” and “makes you less active.” Teens talked about how they had heard marijuana could cause paranoia and short- and long-term memory loss. These concerns were expressed in relationship to related outcomes such as the impact on relationships with family. [Teen] “If you have a family who doesn’t like marijuana, they’re going to look down on you, definitely – probably lose some respect for you, but definitely still support you on trying to get out of it, I think.” “It’s a bigger punishment for kids if their parents are disappointed in you.” Some parents expressed concern about the impact on family relationships when a teen uses marijuana. “It can ruin family relationships if one sibling does it and another does not.” And, “If they are lying or stealing or just trying to sneak it in or out of the house… It could lead to distrust.”

Teens were also concerned about losing friends, acting stupid, becoming someone different and, as a consequence, not liking themselves. For instance, “It can make other people mad because of how you act. Because when you are under the influence of it, you can’t control how you act.” Related to lack of behavioral control, some teens talked about the association of marijuana with violence and crime. “I feel like one of the most dangerous things about marijuana is not necessarily the drug itself, but what comes along with it, the violence and the crime that can come along with it.” Parents also commented that kids who use marijuana might also commit crimes.

Parents and teens discussed legal problems as possible social consequences of using marijuana. Teens stated plainly, “You could be arrested.” Another teen elaborated, “Legally, consumption or possession of marijuana on State property, schools, courts – anything like that – that’s a federal offense.” One parent said “I don’t know if it’s going to be any different for parenting, because it is still illegal for them. You still have to talk to them and make them aware of consequences.”

Other social consequences of marijuana use were also mentioned. Some teens noted that being high at school gets in the way of learning and making good grades and, as such, has consequences for the future and plans for adulthood. One teen summed it up this way: “The military won’t take you, colleges probably won’t take you so it can, kind of, really screw up your whole life if you take it too far in using drugs.”

The need for trustworthy sources

Within the broad category of trusted sources, many ideas about who is a trusted source were mentioned, but teens focused most of their attention on whether or not parents are trusted sources of information. There was general agreement that it depends on your relationship with your parent. Some teens expressed confidence that their parents give them good information and are looking out for their best interest, while others stated they did not trust their parent(s) to really know what they are talking about, or to give them all of the information they need. Some teens went so far as to distinguish between their two parents, “Yah, my dad just asks me and I can tell him, but that’s just my dad. If it was my mom I would just flat out say no and walk away.” Teens were clear that trust is about the relationship they have with someone; if they trust someone else in their family more than their parents, such as a sibling or a cousin, they might listen to them. Teens also expressed desire for better communication with their parents about marijuana use. They asked for more open and respectful conversations, and emphasized the tone of the conversation (“be very chill and very calm”). One teen said, “If they’re yelling I won’t want to talk to them. Not accusing, not angry, not disappointing, nothing that will make it seem like I am doing something wrong and make me defensive.”

Parents approached the question of trusted sources from a wider perspective. They brainstormed and listed doctors, other kids (peers), mentors, schools, and churches. Parents did not seem to think marijuana prevention messages for teens should come from law enforcement, the judicial system, or celebrities. However, they also emphasized the importance of the relationship between the teen (or teens in general) and the source of information. If the source has a history of being unbalanced in their messages about marijuana, teens would be less likely to be persuaded. One parent said, “Schools need to have more updated information. They’re still telling kids about all these bad things and then you hear something completely different in public and then they think you are lying and they are getting mixed messages.”

Marijuana Prevention Message Themes

Fear

The role of fear in preventing dangerous behavior is complex. If authority figures are perceived to be heavy handed, arbitrary, or out of touch with reality, teens may ignore or even rebel and do exactly what they are told not to do (all possibilities mentioned by teen participants in the focus groups). On the other hand, teens expressed a strong desire for “the facts” about the consequences of marijuana use, and some facts are perceived as scary. Fear of the negative impact of marijuana on brain development was reported by both parents and teens as a compelling prevention message. Some teens pointed out that fear tactics can backfire. Others cited examples where parents had threatened immediate consequences, which had worked.

Parents were not in complete agreement about the use of fear or “scare tactics.” Some were in favor. [Parent] “Fear maybe uh they will get kicked off their sports team, or you can’t get a job.” Another saying, “Give them examples of someone who went down that road. That might scare the pants out of them.” But others expressed the opposite view. [Parent] “I think it’s important to communicate with your kids and not scaring them, but not condoning what they do and just communicating with them about why they shouldn’t.”

Stories about real people

Whether leveraging fear or not, using “real life” as a teacher emerged as a theme for both parents and teens. Some parents felt that their own experiences with marijuana gave them credibility with their teens while others were unclear about how to represent their own experiences. They expressed concern that “do as I say, not as I do” doesn’t work for teens. But, parents also thought teens might be persuaded by stories about other family members or friends who had started using marijuana and suffered very serious consequences (jail, poverty, death). Some teens also said that stories of the experiences of real people would be more meaningful than simply being cautioned about the dangers of using marijuana. The idea of using “real life” also included positive stories about successful teens and young adults who chose not to use marijuana (or stopped using) because it would interfere with their other goals such as sports or academics.

Focusing on short-term consequences

Parents understand that teens are mostly focused on their current situation. As one parent put it, “Sometimes more of the immediate, teenagers are always in the now, so that is what you need to focus on, how this is affecting you today, and combining that with passions.” Immediate consequences could be more effective than trying to convince teens they should be concerned about consequences far in the future. Monitoring (being sure you know where your kids are, who they are with, and what they are doing) and giving consequences were suggested as things parents can do that have an impact on their teens right now. [Parent] “I think a good thing too that would be immediate is consequences, if parents hold their children accountable and they know consequences will be enforced it may be a deterrent.”

Having something better to do

Parents also talked about providing enough positive activities and rewards for teens so that marijuana would not be so inviting. Teens talked about having other priorities which might not be compatible with using marijuana. Many teens expressed the belief that some use is inevitable, and that each person has to make their own decision. Marijuana is easy to get. The risk is right in front of you all the time. But that doesn’t make it impossible to choose not to use. One teen said, “If you know who you are, if you are a very confident person, if you have faith in yourself, if you have a lot going for you, you won’t do it. But if you don’t have anything going for you, you’re going to do it.”

Discussion

The use of marijuana in the United States has become legal in the past decade, first through the legalization of medical marijuana, and most recently through passage of legal adult use in some states. These laws have led to a substantial change in the environment in which teens make decisions about their own marijuana use and in which parents address use among their children. We conducted focus groups in Washington State with parents and teens who had participated in a family-focused intervention in order to gain greater understanding of families’ concerns and what they feel they need in order to reduce the risk of underage marijuana use for their teens. Based on the information from youth and parents, the focus of future messages fell into three general categories: messages providing information about the law and consequences of use, messages offering general advice to parents and youth, and messages with an explicit prevention focus, such as providing alternative positive activities.

The results support our concern that parents and teens do not have enough information about the new marijuana law in Washington State (Mason et al., 2015). The law was very new, and information about the age and conditions under which use is now legal had not been widely advertised. Washington State already had a medical marijuana system, and some confusion exists about how the new law is different from what was already legal. Furthermore, participants expressed concern that what they have heard is inaccurate or biased. Since teens have to decide for themselves, they want enough accurate information to make the best decision they can. As we suspected, parents feel unclear about how to address concerns about marijuana use with their teens. They expressed concern about cautioning their teens against use given the positive message they feel the law is giving about marijuana, and that some parents will be using legally and openly.

Both parents and teens believed that messages about the negative consequences of marijuana use, especially during adolescence, could be effective—but teens were resistant to anything that looked unbalanced or like “scare tactics.” It is a challenging task to develop messages that provide a clear guideline, that empower parents to make a clear statement of expectation that their teens will not use marijuana, and still respect the teen’s power to make their own decision.

Teens and parents expressed a belief that youth who have something better to do will not use marijuana. This suggests that messages containing alternative activities or goals that are not consistent with marijuana use might be effective. Some emphasized that using marijuana could jeopardize something that is important to a teen right now, e.g., sports, grades, relationships with parents or friends. Others indicated that teens that have plans and goals for their future are at lower risk, and that encouraging teens to invest in their own future could be an effective strategy.

Perhaps surprising to some, teens expressed the need for guidance as well as information, but they will not accept it from just anyone. Some teens continue to turn to their parents. However, that depends on their relationship with their parents. These findings support a strategy that includes relationship building, such as the social development model (Catalano & Hawkins, 1996) which emphasizes the importance of bonding to prosocial others which leads to adopting and adhering to prosocial norms. In the context of stronger bonds, parents may feel more confident in cautioning their teens against marijuana use.

This study was limited in several ways. First, we highlight only those thoughts, feelings, and concerns expressed verbally by the participants. The parents and teens in this study did not represent parents or teens from any particular population. In fact, the participants in this study had participated in a parent-teen intervention which included content specifically related to substance use prevention. The ideas they expressed were probably influenced both by that content (although the larger study did not find shifts in attitudes about substance use due to the intervention; Mason et al., in press) and by the knowledge that the focus groups were connected to the intervention. Although there were several people involved in reviewing the transcripts and developing themes, these people were already involved in the research team in some way. Some effort was made to minimize the “research effect” by having focus group facilitators who had not been involved in the intervention; making it clear that this was a related study, but not part of the intervention; and conducting the groups in a different location than the intervention workshops.

The timing of the study is an important consideration. It is possible that these same parents and teens have different views now that retail marijuana outlets are open. No doubt, the presence and density of retail outlets in each family’s neighborhood could influence what they think the best strategies for prevention might be. The results of this study are bounded by their historical context, which is rapidly changing. Conducting focus groups with parents and teens every year would help to keep prevention efforts focused on current issues and concerns.

Conclusions

Marijuana legalization is growing and has potential negative consequences for youth who are entering a risk-taking period of development. We will need new prevention efforts based on messages that are acceptable and persuasive for parents and teens. Toward that end, the current study took an essential first step by discovering themes from focus groups conducted with parents and teens. Moving forward, the research team developed messages from trusted sources that provide information about the law and consequences of use and that offer general advice to parents and youth, with an explicit prevention focus. These messages are being tested in a preference survey of all the parents and teens in the original study (controls, CSP, and CSP Plus participants) with the goal of leading to effective prevention efforts for families within the context of legal adult marijuana use.