Abstract
Introduction:
Alcohol and cannabis are commonly involved in motor vehicle crashes and fatalities. This study examines whether simultaneous use of alcohol/cannabis is associated with driving under the influence of alcohol and cannabis in the U.S.
Methods:
Drivers aged ≥16 years with any past-year alcohol and cannabis use in the 2016–2019 National Survey on Drug Use and Health (n=34,514) reported any past-year driving under the influence of alcohol-only, cannabis-only, both alcohol/cannabis, or not driving under the influence. Survey-weighted associations between simultaneous alcohol/cannabis use and each of the driving under the influence outcomes were computed adjusting for sociodemographics and daily alcohol/cannabis use. Analyses were conducted from November 2020 to September 2021.
Results:
In 2016-2019, 42% of drivers with past-year alcohol and cannabis use reported driving under the influence (8% alcohol-only, 20% cannabis-only, 14% alcohol/cannabis). Simultaneous alcohol/cannabis use was associated with 2.88-times higher adjusted odds of driving under the influence of cannabis-only (95% CI=2.59, 3.19) and 3.51-times higher adjusted odds of driving under the influence of both alcohol/cannabis (95% CI=3.05, 4.05), compared to not driving under the influence. Associations with driving under the influence of alcohol-only were unexpectedly in the opposite direction (adjusted conditional odds ratio=0.59, 95% CI=0.45, 0.79).
Conclusions:
Overall, 2 in 5 drivers who used alcohol and cannabis reported driving under the influence of alcohol and/or cannabis. People reporting simultaneous alcohol/cannabis use were more likely to report cannabis-related driving under the influence. Prevention strategies should target individuals reporting simultaneous alcohol/cannabis use to reduce the occurrence of driving under the influence.
INTRODUCTION
Alcohol and cannabis are 2 of the most common substances involved in impaired driving and motor vehicle crashes in the U.S.1–5 From September 2019 to March 2020, a total 22% of all seriously injured drivers tested positive for alcohol and 21% for cannabis.6 The effects of alcohol on driving have been well characterized,3,7,8 including a dose-dependent effect on driving performance, psychomotor, and cognitive impairments.9
Cumulative evidence shows associations between acute cannabis use and psychomotor and cognitive functioning impairment, which interferes with driving skills; cannabis dose, tolerance, and driver’s experience also contribute to driving impairment.4,10–13 In simulated driving studies, driving under the influence (DUI) of acute cannabis use affected reaction time, lane tracking, and attention.14–16 Additionally, greater impairment is observed among individuals with higher levels of Δ9-tetrahydrocannabinol (THC),17 and with alcohol and cannabis co-use.15,16,18 Findings from simulation studies16 are consistent with literature indicating that acute cannabis use increases the odds of motor vehicle crashes.1,3,19,20
Simultaneous alcohol/cannabis use may have an additive or synergistic effect on driving abilities, and it is associated more severe driving related outcomes than either substance alone.9,15,16 Compared with drivers without any substance use, simultaneous alcohol/cannabis use increased the risk of involvement in a fatal crash 25 times,2 and alcohol/cannabis co-use increased the risk of causing a car crash 5 times.21 One study examining the rates of simultaneous alcohol/cannabis use among under-aged injured drivers in Arizona found that 32% of drivers who were tested for both substances had alcohol and cannabis positive tests.22 Another study found that high school seniors who reported simultaneous alcohol/cannabis use had higher rates of traffic violations and motor vehicle crashes than individuals who used either substance individually.23 Also, simulation driving studies show that low amounts of either alcohol or cannabis can potentiate the effect of the other substance.15,16
Concerningly, the number of drivers testing positive for alcohol and other drugs have increased,6 and the prevalence of simultaneous alcohol/cannabis use in the past year is about 5% of the general U.S. population.5 Similar sociodemographic characteristics are associated with simultaneous alcohol/cannabis use24–27 and with DUI28–30 such as younger age, male sex, and non-Hispanic White race. High income is also associated with DUI.29 Collectively, research suggests that simultaneous alcohol/cannabis use increases driving impairment, and increases the risk of traffic fatality more than either substance individually, particularly among young adolescents.16,31 However, no nationally representative study has tested these relationships among adults.
The U.S. has consistent legislation on which levels of alcohol are considered illegal to drive and impaired driving (blood alcohol concentration of ≥08 g/dL, except for Utah, blood alcohol concentration of ≥05 g/dL)32 and standard measures for determining acute alcohol intoxication.10,22,27 However, the same is lacking for THC (the main active psychoactive constituent of cannabis) intoxication by itself, and with the interaction with other substances, as alcohol use.14,34 Additionally, the relationship between biological measures of THC metabolites and cognitive and motor functions is complex, as THC metabolites remain in a person’s system for days after acute intoxication.35–38 Considering the limitations in biological measures to determine impairment due to cannabis use, self-reported DUI could provide clinically relevant information.
Examining the effect of simultaneous alcohol/cannabis use on self-report DUI of alcohol-only, cannabis-only, and both substances using a nationally representative sample could contribute to better understanding the impact in U.S. adolescents and adults. This study uses the National Survey on Drug Use and Health (NSDUH) to investigate whether simultaneous alcohol/cannabis use is associated with higher odds of DUI of alcohol/cannabis (DUI-A/C) compared with simultaneous use. The hypothesis is that simultaneous alcohol/cannabis use is associated with higher odds of DUI-A/C compared with no simultaneous use in this national sample of U.S. adolescents and adults.
METHODS
Public files from the 2016–2019 NSDUH were used. NSDUH is a nationally representative sample of non-institutionalized civilians in the U.S. including individuals aged ≥12 years conducted by the Substance Abuse and Mental Health Services Administration. Data were collected via face-to-face household interviews using computer-assisted interviewing and audio computer-assisted survey instruments to increase the accuracy of responses to potentially sensitive questions. The overall interview response rates for screening and interviews during 2016–2019 ranged from 45.8% to 53.3% in individuals aged ≥12 years.5,35–37 Detailed methodological descriptions on NSDUH can be found elsewhere.38
Study Sample
Across the 4 survey years, 225,622 observations were pooled, adding survey year indicators. Observations from participants aged 12–15 years (n=36,150) were excluded, because age 16 years is the most common minimum age for a driver’s permit in the U.S.39 Observations from respondents who reported not being a driver (n=16,721), without use of both alcohol and cannabis in the past year (n=137,541), or had missing data on simultaneous alcohol/cannabis use (n=696) were also excluded. The final study sample included 34,514 observations from drivers who were aged ≥16 years reporting past-year alcohol and cannabis use.
Measures
Two questions were used to create 4 mutually exclusive self-report DUI categories: (1) During the past 12 months, have you driven a vehicle while you were under the influence of alcohol? and (2) During the past 12 months, have you driven a vehicle while you were under the influence of marijuana? Categories included reporting no DUI, DUI of alcohol-only (DUI-A), DUI of cannabis-only (DUI-C), and reporting both DUI of alcohol and DUI of cannabis (DUI-A/C).
A binary exposure variable of simultaneous alcohol/cannabis use indicated using marijuana or hashish at the same time or within a couple hours of their last alcohol use.
Covariates included 2 binary variables of substance use frequency: (1) daily alcohol use (≥300 days in the past year)40 and (2) daily cannabis use (≥300 days in the past year).
Substance use binary variables (yes/no) included past-year tobacco use (i.e., any use of cigarettes, cigars, pipes, or smokeless tobacco), past-year drug use other than cannabis (i.e., any use of cocaine, hallucinogens, heroin, inhalants, methamphetamine, and misuse of pain reliever, sedatives, stimulants, and tranquilizers). Meeting DSM-5 proxy criteria indicated past-year alcohol use disorder (AUD) and cannabis use disorder (CUD) (AUD and CUD variables were created based on a proxy measure of the DSM-5 categories excluding craving and withdrawal, as done by Compton et al.41). Living in a medical cannabis law (MCL) state indicated the state of residence had a law approving cannabis for medical use before the date of interview. In 2016–2017, the question about MCL referred to the interpretation of the date when a state’s law took effect, and in 2018–2019, it was based on the date that a medical marijuana bill was signed into law or an initiative was approved by voters.38
Sociodemographic variables included age (16–20, 21–25, 26–34, 35–49, ≥50 years), sex (male, female), ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or Other non-Hispanic [i.e., non-Hispanic Asian, Native American/Alaska Native, Native Hawaii/Other Pacific Islander, or >1 race]) and family income (<$20,000, $20,000–$39,999, $40,000-$74,999, ≥$75,000).
Statistical Analysis
First, a descriptive analysis of the overall sample was performed by the exposure variable (simultaneous alcohol/cannabis use versus no simultaneous use) using chi-square tests with Rao–Scott corrections for categorical variables of the survey-weighted sample characteristics. Second, a series of multinomial logistic regression models tested associations between sociodemographic and substance use variables with DUI outcomes. Bivariate models included each variable unadjusted for covariates, and then the multivariate models adjusted for sociodemographic variables (Appendix Table 1 provides details). Third, a weighted logistic regression was conducted to observe the association between simultaneous alcohol/cannabis use and any DUI (alcohol, cannabis, and other drugs) adjusting for sociodemographic variables (age, sex, race/ethnicity, family income). Fourth, a series of weighted multinomial logistic regression models were run to observe the association between self-report DUI outcome categories (using different reference categories: no DIU, DUI-A, DUI-C, compared with DUI-A/C) and simultaneous alcohol/cannabis use adjusting for sociodemographic variables (age, sex, race/ethnicity, family income). Then, a second series composed by weighted multinomial logistic regression models testing the association between self-report DUI categories and simultaneous alcohol/cannabis use adjusting for sociodemographic characteristics, alcohol, and cannabis daily use variables was run to obtain the separate conditional AORs and 95% CIs.
All statistical analyses were conducted using R software, version 4.1.0, packages survey and svrepmisc,42–44 adjusted for the NSDUH complex survey design. NSDUH sampling weights account for selection probability, non-response, and population distribution.38 To account for 4 years of NSDUH data pooling, yearly survey weights were divided by 4 to make estimates nationally representative, and type I error was set at 5%.
RESULTS
Most participants were male (57.02%), non-Hispanic White (66.91%), with a family income ≤$40,000 (62.75%), and reported living in a state with an MCL (67.87%). Two thirds of participants reported any tobacco use in the past year and one third used any drug other than cannabis. In addition, 8.33% reported daily alcohol use, 19.62% daily cannabis use, and 21.46% met criteria for AUD and 17.73% for CUD. More than a quarter of the sample (27.53%) reported simultaneous alcohol/cannabis use.
Table 1 displays sociodemographic characteristics, substance use, and MCL according to simultaneous alcohol/cannabis use. Significant differences in all variables were observed while comparing individuals with and without simultaneous alcohol/cannabis use. Higher proportions of past-year tobacco use, drug use other than cannabis, daily alcohol use, daily cannabis use, AUD and CUD were observed in respondents with simultaneous alcohol/cannabis use.
Table 1.
Descriptive Sociodemographic Characteristics and Substance Use Patterns of Drivers by Simultaneous Use of Alcohol/Cannabis (N=34,514)
| Characteristics | Overall proportion Col. Weight % |
Yes, simultaneous alcohol/canî.bis use (27.53%) Col. Weight % |
No, simultaneous alcohol/cannabis use (72.47%) Col. Weight % |
|---|---|---|---|
| Age group, years | |||
| 16–20 | 13.86 | 12.30 | 14.29 |
| 21–25 | 18.66 | 20.22 | 17.96 |
| 26–34 | 25.18 | 27.42 | 24.37 |
| 35–49 | 22.03 | 22.97 | 21.85 |
| ≥50 | 20.27 | 17.10 | 21.53 |
| Sex | |||
| Male | 57.02 | 63.52 | 54.44 |
| Female | 42.98 | 36.48 | 45.56 |
| Ethnicity | |||
| Non-Hispanic White | 66.91 | 64.73 | 68.04 |
| Non-Hispanic Black | 12.65 | 15.77 | 11.35 |
| Hispanic | 6.82 | 13.29 | 13.63 |
| Others | 13.62 | 6.21 | 6.98 |
| Family income | |||
| <$20,000 | 18.49 | 20.17 | 17.70 |
| $20,000–$39,999 | 18.76 | 20.40 | 18.04 |
| $40,000–$74,999 | 25.07 | 26.84 | 24.37 |
| ≥$75,000 | 37.68 | 32.59 | 39.88 |
| Substance use and MCL variables | |||
| Any tobacco use, past year | 59.74 | 68.82 | 56.13 |
| Any drug use other than cannabis, past year | 33.36 | 44.51 | 29.21 |
| Daily alcohol use | 8.33 | 11.25 | 7.24 |
| Daily cannabis use | 19.62 | 46.02 | 9.43 |
| AUD DSM-5 proxy | 21.46 | 26.81 | 19.39 |
| CUD DSM-5 proxy | 17.73 | 33.40 | 11.49 |
| Living in MCL state | 67.87 | 71.04 | 66.75 |
Note: Table describes sociodemographic characteristics, substance use variables and status of MCL residence weighted prevalence of drivers ≥16 years old who reported any use of alcohol and cannabis in the past year divided by simultaneous use of alcohol/cannabis (NSDUH 2016–2019). All comparisons showed p-value ≤0.001.
AUD, alcohol use disorder; CUD, cannabis use disorder; MCL, medical cannabis laws; NSDUH, National Survey on Drug Use and Health.
Figure 1A shows the prevalence of self-reported DUI categories, and within each DUI category, the proportion of daily alcohol use (Figure 1B), daily cannabis use (Figure 1C), and simultaneous alcohol/cannabis use (Figure 1D). Most participants reported no DUI-A/C (57.63%), whereas 42.37% had any DUI. This included DUI-C (20.42%), DUI-A/C (14.06%) and DUI-A (7.89%).
Figure 1.
Proportion of self-report driving under the influence of alcohol only, cannabis only and alcohol and cannabis, and alcohol and cannabis use patterns in each DUI outcome category.
Notes: The figure a refers to the proportion of DUI in each category. The figures b, c and d describe the proportions of daily alcohol use, daily cannabis use, and simultaneous alcohol/cannabis use, and the error bars in the lines refer to CIs.
DUI, driving under the influence; DUI-A, DUI of alcohol-only; DUI-C, DUI of cannabis-only; DUI-A/C, reporting both DUI of alcohol and DUI of cannabis.
Binomial logistic regression revealed that simultaneous alcohol/cannabis use was associated with 2.88 (95% CI=2.69, 3.09) times the odds of driving under the influence of alcohol or any other drug including cannabis (result not shown in tables). DUI-A/C (compared with no DUI) was associated with being younger, male, non-Hispanic White, reporting higher income, not living in a MCL state, and all substance use variables (any tobacco use, any drug use other than cannabis, daily alcohol use, daily cannabis use, and simultaneous alcohol/cannabis use). Appendix Table 1 provides more details.
Table 2 reports multinomial logistic regression models of self-report DUI categories by simultaneous alcohol/cannabis use adjusted for sociodemographic characteristics (age, sex, ethnicity, family income). Compared with no DUI, individuals with simultaneous alcohol/cannabis use were more likely to report DUI-A/C (AOR=4.39, 95% CI=3.92, 4.39) and DUI-C (AOR=4.28, 95% CI=3.89, 4.71), and less likely to report DUI-A. Compared with DUI-A only, reporting simultaneous alcohol/cannabis use was associated with 9.48 (95% CI=7.29, 12.33) times the odds of DUI-A/C. Compared with DUI-C only, simultaneous alcohol/cannabis use was not associated with DUI-A/C.
Table 2.
Associations of Self-Report DUI and Simultaneous Alcohol/Cannabis Use Among Drivers (N=34,514)
| Simultaneous alcohol/cannabis use | DUI alcohol-only X no DUI | DUI cannabis-only X no DUI | DUI A/C X no DUI | DUI A/C X DUI alcohol-only | DUI A/C X DUI cannabis-only |
|---|---|---|---|---|---|
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| Yes |
0.46
(0.36, 0.59) ** |
4.28
(3.89, 4.71) ** |
4.39
(3.92, 4.39) ** |
9.48
(7.29, 12.33) ** |
1.03 (0.91, 1.16) |
| No | ref | ref | ref | ref | ref |
Note: Boldface indicates statistical significance (*p<0.05; **p<0.01). Tables reflects the results of multinomial logistic regression models of self-report driving under the influence categories by simultaneous alcohol/cannabis use adjusted for sociodemographic characteristics (age, sex, ethnicity, income) in drivers ≥16 years old who reported any use of alcohol and cannabis in the past year (NSDUH 2016–2019).
DUI, driving under the influence; DUI A/C, DUI alcohol and cannabis in the past 12 months; AOR, adjusted conditional odds ratio; NSDUH, National Survey on Drug Use and Health
Table 3 reports estimates from multinominal logistic regression models of self-report DUI categories and simultaneous alcohol/cannabis use adjusted for sociodemographic characteristics (age, sex, ethnicity, family income), including daily alcohol use and daily cannabis use. Compared with the no DUI category, daily alcohol use was positively associated with DUI-A (AOR=2.35, 95% CI=1.80, 3.07), and daily cannabis use was positively associated with DUI-C (AOR=3.57, 95% CI=3.16, 4.04). Both daily alcohol (AOR=1.72, 95% CI=1.72, 2.20) and daily cannabis use (AOR=1.92, 95% CI=1.62, 2.27) were associated with DUI-A/C. Compared with no DUI, respondents reporting simultaneous use had 3 times higher odds of reporting DUI-C (AOR=2.88, 95% CI=2.59, 3.19) and 3.51 times higher odds of DUI-A/C (95% CI=3.05, 4.05). Simultaneous alcohol/cannabis use was also associated with DUI-A/C when the reference category was changed to DUI-A (AOR=5.93, 95% CI=4.33, 8.11) and DUI-C (AOR=1.22, 95% CI=1.05, 1.42).
Table 3.
Associations of Self-Report DUI, Daily Substance Use and Simultaneous Alcohol/Cannabis Use Among Drivers (N=34,514)
| Variable | DUI alcohol-only X no DUI | DUI cannabis-only X no DUI | DUI A/C X no DUI | DUI A/C X DUI alcohol-only | DUI A/C X DUI cannabis-only |
|---|---|---|---|---|---|
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| Daily alcohol use, last year (≥300 days) | |||||
| Yes |
2.35
(1.80, 3.07) ** |
0.60
(0.46, 0.77) ** |
1.72
(1.72, 2.20) ** |
0.73
(0.54, 0.99) * |
2.90
(2.20, 3.82) ** |
| No | ref | ref | ref> | ref | ref |
| Daily cannabis use, last year (≥300 days) | |||||
| Yes |
0.12
(0.07, 0.21) ** |
3.57
(3.16, 4.04) ** |
1.92
(1.62, 2.27) ** |
16.09
(8.67, 29.84) ** |
0.54
(0.45, 0.64) ** |
| No | ref | ref | ref | ref | ref |
| Simultaneous alcohol/cannabis use | |||||
| Yes |
0.59
(0.45, 0.79) ** |
2.88
(2.59, 3.19) ** |
3.51
(3.05, 4.05) ** |
5.93
(4.33, 8.11) ** |
1.22
(1.05, 1.42) * |
| No | ref | ref | ref | ref | ref |
Note: Boldface indicates statistical significance (*p<0.05; **p<0.01). Table reflects the results of multinomial logistic regression models of self-report driving under the influence categories by simultaneous alcohol/cannabis use, daily alcohol use and daily cannabis use adjusted for sociodemographic characteristics (age, sex, ethnicity, income) in drivers ≥16 years old who reported any use of alcohol and cannabis in the past year (NSDUH 2016–2019, N=34,514).
DUI A/C, DUI alcohol and cannabis in the past 12 months; AOR, adjusted conditional odds ratio; NSDUH, National Survey on Drug Use and Health.
DISCUSSION
This study examined whether simultaneous alcohol/cannabis use was associated with self-report DUI outcomes in a nationally representative sample of drivers aged ≥16 years with past-year use of alcohol and cannabis. Forty-two percent of participants reported DUI of alcohol or cannabis (8% DUI-A, 20% DUI-C, and 14% DUI-A/C) in this sample. Simultaneous alcohol/cannabis use was associated with DUI-A/C (compared with no DUI, DUI-A, and DUI-C) and with DUI-C (compared with no DUI) after adjusting for sociodemographic characteristics and frequency of alcohol and cannabis use. Findings are in accordance with prior research showing that the association of simultaneous alcohol/cannabis use and DUI (when compared with concurrent use,26 alcohol use only,28 and fatal crashes2). This study adds to the literature reporting more recent nationally representative data from the U.S. (2016–2019) and compares different types of DUI categories.
Daily alcohol/cannabis use increased the likelihood of DUI-A and DUI-C, respectively, and both alcohol and cannabis daily use were associated with DUI-A/C. The association of daily cannabis use and DUI raises concern as the proportion of individuals aged 18–64 years reporting daily cannabis use increased (compared with 2007–201440 and 2002–201741). Despite a decrease in the proportion of people with CUD from 2002 to 2017,41 associations of daily use and DUI highlight the potential hazards from this pattern of consumption.
Of note, the use of biological measures to determine THC intoxication remains challenging, considering that the presence of cannabis metabolites is not sufficient to determine cognitive and motor impairment.34,45–47 Implications of cannabis testing are also inconsistent across states (non-zero versus zero-tolerance THC blood concentrations laws).48 Future studies should investigate whether it is possible to establish a threshold of THC metabolites that indicate impaired driving skills, and also examine how THC dose, tolerance, and driving experience interact in combination with alcohol and cannabis acute use.
From a harm reduction perspective, identifying which population subgroups are at high risk for DUIs could assist the development of more focused prevention strategies considering risk patterns of substance intake. For example, a systematic review identified a consistent association of lower prices for alcohol sales (i.e., drink specials/happy hour) with higher levels of alcohol use, and also negative consequences such as DUI.49 The authors also suggested the need for investigations on the association of drink regulations with reducing harmful alcohol use and related outcomes. Another issue that could potentially impact simultaneous alcohol/cannabis use is the density and proximity of cannabis and alcohol outlets.50 Considering ongoing shifts in cannabis availability,51 future research should also investigate the potential impact of low or “promotional” cannabis prices with higher levels of use, intoxication, and simultaneous use of other substances.
Cannabis legislation is an important environmental factor that may influence cannabis availability as well as cannabis-involved DUI. As of June 2021, a total of 36 states and the District of Columbia had medical cannabis laws, and 18 states and the District of Columbia legalized recreational use.52 These shifts in cannabis policies may also impact the occurrence of DUI and alcohol/cannabis use. One study comparing the prevalence of DUI-C before and after MCL implementation reported that DUI-C doubled (1.02% to 1.92%) from 1991–1992 to 2012–2013.53 The increase was higher in states that enacted an MCL compared with those that did not enact this law,53 but no change was observed in DUI-A. Although a study looking at the number of traffic fatalities and recreational cannabis laws (RCLs) during the years of 2005–2017 revealed an increase in traffic fatalities after the implementation of RCLs in Colorado but not in Washington State.50 Additionally, studies using nationally representative data reported increase in co-use and simultaneous alcohol/cannabis use related to MCLs/RCLs.54,55 Future studies should investigate more severe patterns of DUI, such as DUI-A/C, and observed the associations of simultaneous use as well as MCLs and RCLs within each state.
Limitations
Limitations are noted. First, DUI information was self-reported, which can be affected by recall bias and individuals’ perception of whether they were under the influence of a substance. Self-perception of intoxication may not correspond with perceived driving skills, as individuals with observed motor impairment in cognitive tasks reported low subjected feeling of intoxication after 45 minutes of cannabis use.45 However, considering the challenges on accessing cannabis recent use thorough biological measures, self-report is a feasible alternative to measure DUI behaviors. Second, DUI-A/C combined 2 DUI questions; as the NSDUH assessed these separately, it is not clear whether DUI-A/C reflected use of both alcohol and cannabis on the same occasion or 2 different episodes of DUI (e.g., 1 episode of DUI-A and a separate occasion of DUI-C). Future studies should investigate differences between simultaneous DUI-A and DUI-C (on the same occasion) versus separate episodes of DUI-A and DUI-C in the past year. Despite this limitation, the categorical outcome allowed comparisons across different DUI combinations. There is no information regarding the number of occasions that the DUI occurred, other data on driving experience (e.g., years of experience, frequency of driving), and drivers aged ≤15 years.
CONCLUSIONS
In this sample of drivers with past-year alcohol and cannabis use, 2 in 5 people reported DUI of alcohol-only, DUI of cannabis-only or both in the past year. Simultaneous alcohol/cannabis use was common in the DUI-C and DUI-A/C categories, with about half of the participants in each category reporting this pattern. Simultaneous use was associated with increased odds of these DUI outcomes. These findings have public health implications showing that people who report simultaneous alcohol/cannabis use are at high risk for DUI-C and DUI-A/C in the past years (2016–2019). Prevention strategies targeting specific behaviors, such as simultaneous alcohol/cannabis use, should be tested to reduce DUI burden.
Supplementary Material
ACKNOWLEDGMENTS
This study was funded by grants from the U.S. NIH, National Institute on Drug Abuse (NIDA) T32DA031099 (Hasin), R01DA037866 (Martins) and K01 DA045224 (Mauro), and the National Center for Injury Prevention and Control (HHS, Centers for Disease Control and Prevention) R49CE003094 (Branas). The protected time for the contribution of Dr. Castaldelli-Maia toward the research reported in this publication was supported by NIDA under the NIDA INVEST Drug Abuse Research Fellowship. The funders had no role in the study design, collection, analysis, or interpretation of the data; writing the manuscript; or the decision to submit the paper for publication.
Dr. Castaldelli-Maia was awarded with Independent Grants for Learning and Change from Pfizer during the last 5 years, which had no relationship with the present study. The authors have no other financial disclosures.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.Li M-C, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34(1):65–72. 10.1093/epirev/mxr017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Chihuri S, Li G, Chen Q. Interaction of marijuana and alcohol on fatal motor vehicle crash risk: a case–control study. Inj Epidemiol. 2017;4(1):8. 10.1186/s40621-017-0105-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Berning A, Compton R, Wochinger K. Results of the 2013–14 National Roadside Survey of Alcohol and Drug Use by Drivers. U.S. Department of Transportation, National Highway Traffic Safety Administration. https://www.nhtsa.gov/sites/nhtsa.gov/files/812118-roadside_survey_2014.pdf. Published 2015. Accessed November 30, 2021.
- 4.Rogeberg O, Elvik R. The effects of cannabis intoxication on motor vehicle collision revisited and revised: cannabis and motor vehicle collision risk. Addiction. 2016;111(8):1348–1359. 10.1111/add.13347. [DOI] [PubMed] [Google Scholar]
- 5.Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/. Published 2020. Accessed March 10, 2021.
- 6.Thomas F, Berning A, Darrah J, et al. Drug and Alcohol Prevalence in Seriously and Fatally Injured Road Users before and during the COVID-19 Public Health Emergency. National Highway Traffic Safety Administration. https://rosap.ntl.bts.gov/view/dot/50941. Published 2020. Accessed September 30, 2021.
- 7.U.S. Department of Transportation. National Highway Traffic Safety Administration. Traffic Safety Facts 2016 Data: Alcohol-Impaired Driving. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812450. Published 2017. Accessed April 22, 2021.
- 8.Oh S, Vaughn MG, Salas-Wright CP, AbiNader MA, Sanchez M. Driving under the influence of alcohol: findings from the NSDUH, 2002–2017. Addict Behav. 2020;108:106439. 10.1016/j.addbeh.2020.106439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Dubois S, Mullen N, Weaver B, Bédard M. The combined effects of alcohol and cannabis on driving: impact on crash risk. Forensic Sci Int. 2015;248:94–100. 10.1016/j.forsciint.2014.12.018. [DOI] [PubMed] [Google Scholar]
- 10.Moskowitz H Marihuana and driving. Accid Anal Prev. 1985;17(4):323–345. 10.1016/0001-4575(85)90034-x. [DOI] [PubMed] [Google Scholar]
- 11.Broyd SJ, van Hell HH, Beale C, Yücel M, Solowij N. Acute and chronic effects of cannabinoids on human cognition—a systematic review. Biol Psychiatry. 2016;79(7):557–567. 10.1016/j.biopsych.2015.12.002. [DOI] [PubMed] [Google Scholar]
- 12.Kroon E, Kuhns L, Hoch E, Cousijn J. Heavy cannabis use, dependence and the brain: a clinical perspective. Addiction. 2020;115(3):559–572. 10.1111/add.14776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ginsburg BC. Strengths and limitations of two cannabis-impaired driving detection methods: a review of the literature. Am J Drug Alcohol Abuse. 2019;45(6):610–622. 10.1080/00952990.2019.1655568. [DOI] [PubMed] [Google Scholar]
- 14.Hartman RL, Huestis MA. Cannabis effects on driving skills. Clin Chem. 2013;59(3):478–492. 10.1373/clinchem.2012.194381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Downey LA, King R, Papafotiou K, et al. The effects of cannabis and alcohol on simulated driving: influences of dose and experience. Accid Anal Prev. 2013;50:879–886. 10.1016/j.aap.2012.07.016. [DOI] [PubMed] [Google Scholar]
- 16.Karoly HC, Ross JM, Ellingson JM, Feldstein Ewing SW. Exploring cannabis and alcohol co-use in adolescents: a narrative review of the evidence. J Dual Diagn. 2020;16(1):58–74. 10.1080/15504263.2019.1660020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lenné MG, Dietze PM, Triggs TJ, Walmsley S, Murphy B, Redman JR. The effects of cannabis and alcohol on simulated arterial driving: influences of driving experience and task demand. Accid Anal Prev. 2010;42(3):859–866. 10.1016/j.aap.2009.04.021. [DOI] [PubMed] [Google Scholar]
- 18.Sewell RA, Poling J, Sofuoglu M. The effect of cannabis compared with alcohol on driving. Am J Addict. 2009;18(3):185–193. 10.1080/10550490902786934. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Compton R Marijuana-Impaired Driving - A Report to Congress. National Highway Traffic Safety Administration. https://www.nhtsa.gov/behavioral-research. Published 2017. Accessed April 21, 2021.
- 20.Romano E, Voas RB, Camp B. Cannabis and crash responsibility while driving below the alcohol per se legal limit. Accid Anal Prev. 2017;108:37–43. 10.1016/j.aap.2017.08.003. [DOI] [PubMed] [Google Scholar]
- 21.Li G, Chihuri S, Brady JE. Role of alcohol and marijuana use in the initiation of fatal two-vehicle crashes. Ann Epidemiol. 2017;27(5):342–347.e1. 10.1016/j.annepidem.2017.05.003. [DOI] [PubMed] [Google Scholar]
- 22.Shults RA, Jones JM, Komatsu KK, Sauber-Schatz EK. Alcohol and marijuana use among young injured drivers in Arizona, 2008–2014. Traffic Inj Prev. 2019;20(1):9–14. 10.1080/15389588.2018.1527032. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Terry-McElrath YM, O’Malley PM, Johnston LD. Alcohol and marijuana use patterns associated with unsafe driving among U.S. high school seniors: high use frequency, concurrent use, and simultaneous use. J Stud Alcohol Drugs. 2014;75(3):378–389. 10.15288/jsad.2014.75.378. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Linden-Carmichael AN, Stamates AL, Lau-Barraco C. Simultaneous use of alcohol and marijuana: patterns and individual differences. Subst Use Misuse. 2019;54(13):2156–2166. 10.1080/10826084.2019.1638407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Yurasek AM, Aston ER, Metrik J. Co-use of alcohol and cannabis: a review. Curr Addict Rep. 2017;4(2):184–193. 10.1007/s40429-017-0149-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Subbaraman MS, Kerr WC. Simultaneous versus concurrent use of alcohol and cannabis in the National Alcohol Survey. Alcohol Clin Exp Res. 2015;39(5):872–879. 10.1111/acer.12698. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Patrick ME, Terry-McElrath YM, Lee CM, Schulenberg JE. Simultaneous alcohol and marijuana use among underage young adults in the United States. Addict Behav. 2019;88:77–81. 10.1016/j.addbeh.2018.08.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Park J-Y, Wu L-T. Trends and correlates of driving under the influence of alcohol among different types of adult substance users in the United States: a national survey study. BMC Public Health. 2019;19:509. 10.1186/s12889-019-6889-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Whitehill JM, Rivara FP, Moreno MA. Marijuana-using drivers, alcohol-using drivers, and their passengers: prevalence and risk factors among underage college students. JAMA Pediatr. 2014;168(7):618–624. 10.1001/jamapediatrics.2013.5300. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Wettlaufer A, Florica RO, Asbridge M, et al. Estimating the harms and costs of cannabis-attributable collisions in the Canadian provinces. Drug Alcohol Depend. 2017;173:185–190. 10.1016/j.drugalcdep.2016.12.024. [DOI] [PubMed] [Google Scholar]
- 31.Azofeifa A, Mattson ME, Lyerla R. Driving under the influence of alcohol, marijuana, and alcohol and marijuana combined among persons aged 16–25 years — United States, 2002–2014. MMWR Morb Mortal Wkly Rep. 2015;64(48):1325–1329. 10.15585/mmwr.mm6448a1. [DOI] [PubMed] [Google Scholar]
- 32.Utah Department of Public Safety. Information about Utah’s. 05 BAC Law. https://highwaysafety.utah.gov/2018/12/11/information-about-utahs-05-bac-law/. Accessed September 29, 2021.
- 33.Kelly AT, Mozayani A. An overview of alcohol testing and interpretation in the 21st century. J Pharm Pract. 2012;25(1):30–36. 10.1177/0897190011431149. [DOI] [PubMed] [Google Scholar]
- 34.Dobri SCD, Moslehi AH, Davies TC. Are oral fluid testing devices effective for the roadside detection of recent cannabis use? A systematic review. Public Health. 2019;171:57–65. 10.1016/j.puhe.2019.03.006. [DOI] [PubMed] [Google Scholar]
- 35.Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/. Published 2017. Accessed March 10, 2021.
- 36.Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/. Published 2018. Accessed March 10, 2021.
- 37.Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/. Published 2019. Accessed March 10, 2021.
- 38.2018. National Survey on Drug Use and Health: Methodological Summary and Definitions. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/. Published 2019. Accessed March 9, 2021.
- 39.The Insurance Institute for Highway Safety. Teenagers. https://www.iihs.org/topics/teenagers#graduated-licensing?topicName=teenagers. Accessed November 30, 2021.
- 40.Mauro PM, Carliner H, Brown QL, et al. Age differences in daily and nondaily cannabis use in the United States, 2002–2014. J Stud Alcohol Drugs. 2018;79(3):423–431. 10.15288/jsad.2018.79.423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Compton WM, Han B, Jones CM, Blanco C. Cannabis use disorders among adults in the United States during a time of increasing use of cannabis. Drug Alcohol Depend. 2019;204:107468. 10.1016/j.drugalcdep.2019.05.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.R Core Team. R: A Language and Environment for Statistical Computing. https://www.R-project.org/. Accessed March 9, 2021.
- 43.Lumley T Analysis of complex survey samples. J Stat Softw. 2004;9(8):1–19. 10.18637/jss.v009.i08. [DOI] [Google Scholar]
- 44.Ganz C Svrepmisc: Miscellaneous Functions for Replicate Weights. https://rdrr.io/github/carlganz/svrepmisc/. Published 2019. Accessed March 9, 2021.
- 45.Boggs DL, Cortes-Briones JA, Surti T, et al. The dose-dependent psychomotor effects of intravenous delta-9-tetrahydrocannabinol (Δ 9 -THC) in humans. J Psychopharmacol (Oxf). 2018;32(12):1308–1318. 10.1177/0269881118799953. [DOI] [PubMed] [Google Scholar]
- 46.Vandrey R, Herrmann ES, Mitchell JM, et al. Pharmacokinetic profile of oral cannabis in humans: blood and oral fluid disposition and relation to pharmacodynamic outcomes. J Anal Toxicol. 2017;41(2):83–99. 10.1093/jat/bkx012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Schlienz NJ, Spindle TR, Cone EJ, et al. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug Alcohol Depend. 2020;211:107969. 10.1016/j.drugalcdep.2020.107969. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Slater ME, Castle I-JP, Logan BK, Hingson RW. Differences in state drug testing and reporting by driver type in U.S. fatal traffic crashes. Accid Anal Prev. 2016;92:122–129. 10.1016/j.aap.2016.03.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Puac-Polanco V, Keyes KM, Mauro PM, Branas CC. A systematic review of drink specials, drink special laws, and alcohol-related outcomes. Curr Epidemiol Rep. 2020;7(4):300–314. 10.1007/s40471-020-00247-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Santaella-Tenorio J, Wheeler-Martin K, DiMaggio CJ, et al. Association of recreational cannabis laws in Colorado and Washington State with changes in traffic fatalities, 2005-2017. JAMA Intern Med. 2020;180(8):1061. 10.1001/jamainternmed.2020.1757. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Levy NS, Mauro PM, Mauro CM, Segura LE, Martins SS. Joint perceptions of the risk and availability of cannabis in the United States, 2002–2018. Drug Alcohol Depend. 2021;226:108873. 10.1016/j.drugalcdep.2021.108873. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Procon. Legal Medical & Recreational Marijuana States and DC. https://marijuana.procon.org/legal-recreational-marijuana-states-and-dc/. Accessed August 16, 2021.
- 53.Fink DS, Stohl M, Sarvet AL, Cerda M, Keyes KM, Hasin DS. Medical marijuana laws and driving under the influence of marijuana and alcohol. Addiction. 2020;115(10):1944–1953. 10.1111/add.15031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Kim JH, Weinberger AH, Zhu J, Barrington-Trimis J, Wyka K, Goodwin RD. Impact of state-level cannabis legalization on poly use of alcohol and cannabis in the United States, 2004–2017. Drug Alcohol Depend. 2021;218:108364. 10.1016/j.drugalcdep.2020.108364. [DOI] [PubMed] [Google Scholar]
- 55.Wen H, Hockenberry JM, Cummings JR. The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances. J Health Econ. 2015;42:64–80. 10.1016/j.jhealeco.2015.03.007. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.