Racial and Ethnic Differences in Cannabis Use and Cannabis Use Disorder: Implications for Researchers

Abstract

Purpose:

Heavy and prolonged use of cannabis is associated with several adverse health, legal and social consequences. Although cannabis use impacts all U.S. racial/ethnic groups, studies have revealed racial/ethnic disparities in the initiation, prevalence, prevention and treatment of cannabis use and Cannabis Use Disorder (CUD). This review provides an overview of recent studies on cannabis and CUD by race/ethnicity and a discussion of implications for cannabis researchers.

Findings:

The majority of studies focused on cannabis use and CUD among African American/Black individuals, with the smallest number of studies found among Native Hawaiians/Pacific Islanders. The limited number of studies highlight unique risk and protective factors for each racial/ethnic group, such as gender, mental health status, polysubstance use and cultural identity.

Summary:

Future cannabis studies should aim to provide a deeper foundational understanding of factors that promote the initiation, maintenance, prevention and treatment of cannabis use and CUD among racial/ethnic groups. Cannabis studies should be unique to each racial/ethnic group and move beyond racial comparisons.

Introduction

In 2019, approximately 48 million people (17.5%) ages 12 and over in the United States reported using cannabis in the past year [1]. Moreover, among past-year cannabis users, 3.5 million reported initiating cannabis use for the first time that year. The heavy and prolonged use of cannabis has been linked to several adverse health effects such as memory impairment, issues with executive functioning, and increased risk for developing a mental illness [2, 3, 4]. Furthermore, the literature posits that 30% of weekly cannabis users will be diagnosed with Cannabis Use Disorder (CUD) in their lifetime [5]. Despite the associated health risks, the perceived risk associated with weekly cannabis use has declined among all age groups (i.e., 12 and over) within the past-year, indicating increased likelihood for problematic use [1]. The increased risk of problematic cannabis use highlights the need for more research on prevention, treatment and policy interventions that target cannabis use, especially among understudied and underserved populations who often experience the most detrimental health, social and legal consequences of cannabis use, such as racial/ethnic minorities [6].

Although cannabis use is a significant public health problem for all racial/ethnic groups, several racial/ethnic differences have been observed in the prevalence and consequences of use, as well as in the prevention and treatment of cannabis use. For example, in a recent review of time trends in U.S. prevalence of cannabis use and CUD [7], findings revealed an increase in the prevalence of adult cannabis use for all racial/ethnic groups and other sociodemographic groups (e.g., men, women, all income levels, all education levels) since 2007. However, a marked increase in cannabis use was noted among African American/Black adolescents and adults, representing a significant shift in the historical pattern of African American/Black individuals displaying similar or lower rates of cannabis use and CUD relative to their White counterparts [8]. Moreover, studies highlight the racial disparities observed in the prevalence of emergency department visits [9], referral to cannabis treatment [10] and treatment utilization and outcomes [11, 12]. These studies underscore the importance of contextualizing data by assessing and considering race/ethnicity throughout the entire development, execution and dissemination of research in the cannabis field. The purpose of this review is to describe the prevalence of current cannabis use by race using data from a national surveillance system, provide an overview of current studies (published between 2017–2021) on cannabis use among racial/ethnic minorities and then discuss real world implications for cannabis researchers who seek to decrease cannabis-related disparities among racial/ethnic minorities.

Prevalence of Current Cannabis Use among Racial/Ethnic Minorities

As noted in Figure 1, there has been a steady increase in the prevalence of past month cannabis use among U.S. adults from 2015 (8.45%) to 2019 (11.86%). Pooled data from the National Survey on Drug Use and Health (NSDUH), an annual nationwide survey of alcohol, tobacco, illicit drug use and mental health among U.S. individuals ages 12 or older, also displays significant racial/ethnic differences in current cannabis use. Specifically, the rates of past month cannabis use among Asian Americans are much lower than the national average, while the rates are slightly higher among White, Hispanic and Native Hawaiian/Pacific Islander populations. The highest rates of past month cannabis use are seen among American Indian/Alaska Native individuals, followed by African American/Blacks. Although current marijuana use has been consistently high over time among American Indian/Alaska Native individuals, there was a significant decrease in prevalence from 2018 (15.64%) to 2019 (13.83%). This same time period was marked with an increase among African American adults (13.07% to 14.47%). These racial/ethnic differences should continue to be monitored over time, as critical observations about use will inform the appropriate populations to target in cannabis prevention and treatment interventions and policies.

Figure 1.

Trends in the past month of cannabis use.

Note. AA = African American/Black, AI/AN = American Indian/Alaska Native, AS = Asian, NH/PI = Native Hawaiian/Pacific Islander

Cannabis Research among African Americans/Blacks

Despite the limited availability of literature on cannabis use and CUD overall among racial/ethnic minorities, most existing studies focus on findings among African American/Black individuals. Several recent studies have found an increased use of cannabis among African American/Black people relative to their White counterparts [13, 14, 15, 16, 17], especially among adolescents [18, 19] and young adults [20, 21, 22, 23]. The increased use of cannabis and CUD was also observed among patients with mental and physical health conditions, such as conduct disorder [24], psychosis [25], epilepsy [26, 27], irritable bowel syndrome [28], and congestive heart failure [29]. The higher rates of cannabis use relative to other racial/ethnic groups (except for American Indian/Alaska Natives) found overall and in these subpopulations are fairly consistent with that of national surveillance data, as shown in Figure 1.

Studies have also shown that cannabis use among African Americans/Black individuals is linked to other drug use, especially among those who live in urban areas [30, 31]. The literature has primarily focused on two patterns of dual use among African American/Black people, showing heavy rates of cannabis and tobacco co-use [32, 33, 34, 35, 36; 37, 38] and cannabis and alcohol co-use [39, 40, 41, 42] relative to other racial/ethnic groups. For example, in a national study of pregnant women, African American/Black women were at an increased odds of using cannabis and tobacco relative to tobacco only [32]. Moreover, in another national examination of alcohol, cigarette and marijuana use among adolescents [40], findings revealed that African American/Black adolescents were more likely than their White peers to co-use cannabis and alcohol. A recent study also found that cannabis use increased the likelihood of gambling among African American/Black males [43].

Racial/ethnic differences have also been shown in ways in which African American/Black individuals use and purchase cannabis. For example, in a sample of young adult cannabis users in Los Angeles [44], African American/Blacks reported significantly greater hits per day of cannabis compared to their White counterparts. A growing body of literature also suggests that African American/Black cannabis smokers are more likely to consume their cannabis through blunts (hollowed out little cigars or cigarillos that are filled with cannabis] than other racial/ethnic groups [45, 46, 47, 48, 49, 50]. Further, recent studies have also found that African American/Black individuals spend more money on their cannabis and use different types of cannabis products (e.g., edibles, bongs, dabs) relative to their White peers [51, 52], and highlighted an increase in cannabis-associated emergency department visits among African American/Blacks [53]. Unfortunately, disparities are also observed in the enforcement of cannabis use and possession laws in the African American/Black community, with more sales and possession charges [54, 55] and arrest rates [6, 56], even in cases where the rates of cannabis use/possession are similar to or less than that of their White counterparts.

Some studies have also identified individual and social factors that are associated with cannabis use and cannabis-related problems among African American/Black individuals, such as anxiety sensitivity [57], motives for cannabis use (i.e., depressive symptomatology) [58], age and emotion regulation (i.e., adolescent age and ability to regulate emotions were associated with abstinence from cannabis initiation) [59], peer pressure [60], and living in a disadvantaged community [61]. Attitudes towards cannabis use [62, 63, 64] and gender [65, 66, 67, 68, 69, 70, 71, 72, 73] also have a major impact on cannabis use outcomes among African Americans/Blacks, with gender differences observed within the African American/Black community and specific race by gender interactions found. For instance, one recent study found that among 1,173 African American/Black adult cigarette smokers, cannabis use was associated with an increased odds of menthol cigarette use among women, but a decreased odds of menthol cigarette use among men [70]. Another study using national data indicated that African American/Black men had higher prevalence of lifetime cannabis use and past year cannabis initiation than White men, but this pattern was not found among women [68].

Several studies also discuss the role of racial discrimination [74, 75] and race-related stress [76] and cannabis use. However, recent studies have shown that a strong racial identity serves as a protective factor against the increased frequency of cannabis use [77, 78, 79].

Cannabis Research among American Indian/Alaska Natives

American Indians/Alaska Natives have increased risk for early cannabis use initiation [80, 81, 82]. Frequency of use has been found to peak between the ages of 11 and 14, [83, 84], with males endorsing higher rates of use [85, 82]. Positive peer attitudes towards cannabis, association with antisocial peers (including gang affiliation), and familial substance use are risk factors for lifetime use [85, 86, 87, 88], whereas familial disapproval of substance use, strong cultural identity, and perceived risk to others serve as protective factors [89, 87, 90]. Strong community ties also decrease the likelihood of lifetime cannabis use [91]. Coping as a motivating factor for use is associated with cannabis use among this population [92]; these findings are supported by literature noting that exposure to stressful life events increases the likelihood of use [93]. Those engaging in polysubstance use (e.g., tobacco, alcohol) also have increased risk for cannabis use [82, 84, 94].

Cannabis Research among Asian Americans

The literature notes lower rates of cannabis use among Asian Americans when compared to other racial/ethnic groups [95, 96, 97], however, multiple correlates for use were identified. Mental health challenges including anxiety, suicidal ideation, and attempting suicide are associated with cannabis use among Asian Americans [98, 99]. In a sample investigating use among 3,744 individuals receiving outpatient treatment for Schizophrenia, using cannabis increased the odds of exhibiting aggressive behavior, delusions, and treatment with long-acting injectable antipsychotic medications [100]. Environmental stressors such as food insecurity, being bullied or physically assaulted, and having low-income also increased the odds of lifetime cannabis use [98, 12]. Males and young adults consistently demonstrate higher rates of use [95, 100, 12, 101]. Asian-American adults also have lower rates of treatment utilization for cannabis dependence compared to White adults [12].

Cannabis Research among Hispanic/Latinos

Gender is a significant predictor of cannabis use among Latinx individuals, with males demonstrating higher rates of use [102, 103, 104]. However, female trauma survivors are more likely to endorse lifetime cannabis use, relative to males who endorsed experiencing trauma [105]. Polysubstance use is associated with increased risk for cannabis use among Latinx populations, with tobacco [106, 46], alcohol [107, 105, 47, 48], and illicit substances [48] being commonly used with cannabis among Latinx people. Additionally, depressive symptomatology has also been linked to cannabis use within this population [108; 109; 48]. In a study investigating acculturation and substance use among 1,494, Latinx adults (i.e., 18 and older), high levels of acculturation were found to be associated with decreased likelihood of reporting lifetime cannabis use [103]. Research investigating the relationship between school-based ethnic discrimination and marijuana use among Latinx adolescents found that youth with substance-using peers were more likely to have favorable marijuana attitudes and increased likelihood for past-month use [108]. Familial relationships are also associated with cannabis use, with Latinx youth who report not receiving homework assistance or encouragement from parents being more likely to endorse current and lifetime use [110]; those who report negative father-figure interactions are more likely to initiate cannabis use early [111].

Cannabis Research among Native Hawaiian/Pacific Islanders

The literature demonstrated limited findings of cannabis use among Native Hawaiian/ Pacific Islander individuals. However, one study revealed that current cannabis use was associated with increased likelihood of lifetime e-cigarette use among individuals 18–30 years of age[112].

Conclusions: Implications for Cannabis Researchers

Findings from this review clearly indicate the need for further cannabis research among racial/ethnic minority populations, especially among Native Hawaiian/Pacific Islanders. Only one recent study was found and its major focus was on e-cigarettes. The lack of cannabis research among Native Hawaaiian/Pacific Islanders is problematic given the high prevalence of cannabis use that has been previously observed in older studies. For instance, the prevalence of past year cannabis use was 18.8% in 2011 among Native Hawaaiian/Pacific Islanders, which was significantly higher than that of Whites (11.8% in 2011) and Asian-Americans (4.9% in 2011) [113]. Due to small sample sizes, Native Hawaaiian/Pacific Islanders (and Asian-Americans) are often combined in an “Other” category in health studies, therefore limiting the conclusions that can be drawn for this population. Future research should specifically focus on risk and protective factors and effective treatments for Native Hawaiian/Pacific Islanders, as well as all other racial/ethnic groups.

Second, examining racial/ethnic differences in cannabis use is important, but use of this approach alone ignores heterogeneity within groups. As discussed in literature on best practices for studying race/ethnicity in addiction [114], research examining racial/ethnic differences provides an understanding of how minority populations differ from each other and the majority population, but it provides limited insight into factors that specifically impact the initiation, maintenance, prevention and treatment of cannabis use in a specific group. One positive observation from the limited number of studies in this review is that several of the articles highlight risk and protective factors that are unique to each racial/ethnic group, such as strong cultural identity among American Indian/Alaska Natives [89] and environmental stressors among Asian Americans [12]. Moreover, important gender differences that were observed within certain racial/ethnic groups would have been overlooked if the studies employed a race comparison design [68, 70]. Identifying unique risk and protective factors to target in interventions and policies for each racial/ethnic minority group is an important step in reducing cannabis-related health disparities.

Third, although limited, most of the existing literature on cannabis and race focuses on African American/Black individuals. Many studies demonstrate higher rates of cannabis use and CUD and greater rates of legal and social consequences [13, 54], which may at least partially explain why more research has been conducted among this racial group. Given that the greatest amount of literature focuses on African Americans/Blacks, the next set of recommendations will be guided from research on this population. First, one of the most important observations from this body of research is the need to focus on methods of cannabis consumption in cannabis research. Several studies have highlighted an increased use of cannabis among African American/Black individuals [14, 15], but a detailed assessment of consumption methods revealed that the majority of African American/Black cannabis users consume cannabis through blunts [45, 46, 47]. This revelation has informed a growing body of research on blunt use, helping to expand our understanding of cannabis use among certain subgroups with high prevalence, such as males, young adults and African American/Black individuals [115]. Further, although joints and blunts are both combustible forms of cannabis use, a recent study found that blunt smokers present to treatment with greater amounts of cannabis smoked and more intense withdrawal symptoms than joint smokers [116]. These types of studies help to provide insights into methods that are commonly used by certain groups and can provide deeper insights into cannabis-related issues among racial/ethnic minorities, such as increased prevalence and cannabis-related problems.

Another important emerging area of research in this area is on cannabis risk and protective factors related to race. Studies have clearly indicated a strong association between racial discrimination and cannabis use [74, 75, 76]. For example, African American/Black men who experienced major discrimination (e.g., unfairly fired, unfairly treated/abused by police, denied loan) had a higher odds of cannabis use [74]. Everyday discrimination (e.g., being treated with less respect than others, being treated as if they are not smart by others, being called names or insulted by others) was not associated with cannabis use among African American/Black men [74]. Studies that assess the impact of discrimination would be beneficial to conduct among all racial/ethnic minority groups, as some racial/ethnic minorities may use cannabis to cope with structural inequalities. There is a growing recognition of the importance of discrimination and structural racism and its role in poor health outcomes for racial/ethnic minorities, with major funding agencies calling for research in this area (e.g., National Institutes of Health’s Funding Opportunity (RFA-MD-21–004): Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities).

Lastly, there are a few areas in the field that warrant additional attention in the literature on racial/ethnic minorities. One important topic is that of identifying and strengthening protective factors that prevent or decrease the frequency of cannabis use, such as spirituality, strong racial identity and familiar disapproval of substance use, among racial/ethnic minorities. Another important area is the co-use of cannabis with both tobacco and alcohol among racial/ethnic minorities [32, 33, 39, 40], as some studies have demonstrated an increase in these patterns of use that exceed the prevalence of cannabis use alone. The increased rates of co-use are problematic; for instance, cannabis and tobacco co-use has been associated with heavier rates of cannabis use, tobacco use and greater problematic behaviors (i.e., selling cannabis, driving a car after using cannabis] relative to the single use of cannabis and tobacco [117]. Lastly, a significant gap in the literature is in the absence of studies assessing the prevalence and correlates of medical cannabis use among racial/ethnic groups [118]. As cannabis legalization evolves, it is important to ensure that existing health inequities are not widened by cannabis-related strategies and laws that harm understudied and underserved populations, such as racial/ethnic minorities. Overall, this review emphasizes the need to monitor cannabis use and CUD and identify culturally appropriate strategies for prevention, treatment and policy interventions for racial/ethnic minorities.