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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: Addict Behav. 2022 Jul 16;134:107427. doi: 10.1016/j.addbeh.2022.107427

Cannabis use for sleep aid among high school students: Concurrent and prospective associations with substance use and sleep problems

Patricia A Goodhines 1, Amelia V Wedel 2, Fatima Dobani 3, Michelle J Zaso 4, Les A Gellis 5, Aesoon Park 6
PMCID: PMC9999445  NIHMSID: NIHMS1879128  PMID: 35872526

Abstract

Introduction:

Adolescents are at risk for both sleep problems and cannabis use. Despite emerging evidence for college students’ self-medication with cannabis to help sleep, generalizability to earlier developmental stages remains unknown. This study remedied this literature gap by characterizing high school students’ cannabis sleep aid use in terms of psychosocial correlates and prospective associations with substance use and sleep.

Methods:

Data were drawn from a longitudinal urban adolescent health behavior study, Project Teen, including 407 9th-11th graders (Year 1 Mage=16.00 [SD=1.08, range=13–19]; 58% female; 41% Black, 22% White, 18% Asian, 17% multiracial, 2% Native Hawaiian or other Pacific Islander, 1% American Indian or Alaska Native; 12% Hispanic/Latinx). Students completed two web-based surveys (Minterval=388.89 days [SD=27.34]) assessing substance use and sleep at Year 1 (Y1) and Year 2 (Y2).

Results:

Students reporting lifetime cannabis sleep aid use (8%) endorsed greater depression and anxiety symptoms at Y1, as well as greater cannabis, alcohol, and cigarette use (but not insomnia symptoms or sleep durations) at Y1 and Y2, compared to non-using peers. Over one year, cannabis sleep aid use was associated with increased cannabis dependence symptoms among students using cannabis, past-2-week binge drinking among students using alcohol, and lifetime cigarette use. However, cannabis sleep aid use was not prospectively associated with changes in insomnia symptoms or sleep durations.

Conclusions:

Although replication is needed, cannabis sleep aid use among high school students may be associated with exacerbated cannabis dependence symptoms and increased binge drinking and cigarette use over time, without the intended sleep benefit.

Keywords: self-medication, cannabis, substance use, sleep, mood, adolescent

Substantial public health burden is generated by adult cannabis use (Devylder et al., 2021; Fischer et al., 2020) and sleep problems (e.g., insomnia symptoms; Rosenberg, 2021). Cannabis sleep aid use has been documented among college students (e.g., Drazdowski et al., 2019; Goodhines, Gellis, Ansell, et al., 2019; Goodhines, Gellis, Kim, et al., 2019), whereas adolescents remain a critical literature gap. This study of high school students remedies this literature gap by characterizing cross-sectional and one-year prospective correlates of lifetime self-medication with cannabis for sleep aid.

Reciprocal sleep-substance use models (e.g., Brower, 2003) posit that sleep problems prompt self-medication (e.g., cannabis, alcohol), which inadvertently maintains or worsens sleep problems due to toxic effects on sleep-related brain systems (Pasman et al., 2020). Over time, self-medication may increase to compensate for substance tolerance and ongoing sleep problems, increasing risk for substance use and associated consequences. Further, reciprocal models (e.g., Edwards et al., 2015) acknowledge that bi-directional sleep-substance associations are robust to complex interplay with emotion dysregulation (e.g., depression and anxiety symptoms) within the context of lifetime stress exposures. Brower’s (2003) reciprocal influences model has been supported among sub-clinical populations of cannabis/alcohol-using college students (e.g., Goodhines, Gellis, Kim, et al., 2019). This study extends sleep self-medication theory to high school students, a developmental group at elevated risk for sleep problems and cannabis use.

High school years are a critical period for onset of cannabis use, sleep problems, and associated impairment. U.S. adolescents typically report cannabis initiation in grades 9–10 (Keyes et al., 2019), and 18% of 10th graders reported past-month cannabis use (Miech, 2020). Adolescence is also a “perfect storm” for sleep problems (Carskadon, 2011), with 69% of U.S. high school students reporting insufficient sleep duration (≤7 hours; Wheaton et al., 2016) and 10–12% reporting clinically-significant insomnia symptoms (grades 7–11; Alvaro et al., 2017). Biopsychosocial consequences have been documented for both adolescent cannabis use (e.g., academic performance, externalizing problems, and long-term substance disorder risk; Levine et al., 2017; Meier et al., 2015) and sleep problems (e.g., academic performance, depression/anxiety symptoms, motor vehicle accidents, and long-term cardiovascular risk; Donskoy & Loghmanee, 2018).

Cannabis Sleep Aid Use among High School Students: A Literature Gap

In absence of guiding literature on high school cannabis sleep aid use, hypotheses may be guided by empirical work characterizing (a) profiles of high school substance use and sleep and (b) college cannabis sleep aid use.

Adolescent cannabis use and sleep may be characterized by gender, race/ethnicity, substance use, and mood. Adolescent cannabis use has historically been more common among boys (versus girls; Miech, 2020) and Black adolescents (versus White peers; Hamilton et al., 2019) youth, with sex and race differences narrowing over recent years (Johnson et al., 2015; Miech, 2020). Adolescent sleep problems are more common among girls (versus boys; de Zambotti et al., 2018) and Black and Hispanic adolescents (versus White peers; Guglielmo et al., 2018); for both cannabis and sleep, further explication of racial disparities remains precluded by insufficient empirical data. Adolescent lifetime cannabis use tends to overlap other substances, including alcohol (91% lifetime) and cigarettes (73% lifetime; Knapp et al., 2019), which may inform prospective sleep problems (Ogeil et al., 2019). Adolescent cannabis use (Weinberger et al., 2020) and sleep problems (Raniti et al., 2017) have been independently associated with depression symptoms (Weinberger et al., 2020).

A growing body of work characterizes prevalence and psychosocial correlates of college cannabis sleep aid use. Among college students endorsing past-year cannabis use, 44% reported using for sleep aid (Drazdowski et al., 2019), and among past-month college cannabis and/or alcohol users, 14–15% endorsed past two-week cannabis sleep aid use (Goodhines, Gellis, Kim, et al., 2019). College cannabis sleep aid use has been positively associated with substance use risk concurrently (cannabis and/or alcohol sleep aid use; Goodhines, Gellis, Ansell, et al., 2019) and prospectively over two months (negative drinking consequences such as such as social-interpersonal or occupational-academic problems, impaired control and risk behaviors, and dependence symptoms; Goodhines, Gellis, Kim, et al., 2019). Despite associations of cannabis sleep aid use with concurrent sleep problems (Drazdowski et al., 2019; Goodhines, Gellis, Kim, et al., 2019) and next-day fatigue (although note reduced same-night wake-time after sleep onset) within-person day-to-day (Goodhines, Gellis, Ansell, et al., 2019), prospective between-person associations with downstream sleep problems have been null (e.g., over two months; Goodhines, Gellis, Kim, et al., 2019), consistent with adult insomnia literature (Pasman et al., 2020). College findings demonstrate potential for adverse substance-related (but potentially not sleep-related) outcomes of cannabis sleep aid use, although generalizability to high school students remains unknown.

Current Study

This two-wave longitudinal study of high school-attending adolescents characterized cross-sectional and one-year prospective correlates of lifetime cannabis sleep aid use. Consistent with aforementioned literature, it was hypothesized that students using cannabis for sleep aid would report (a) greater depression/anxiety symptoms; (b) more frequent cannabis use and greater cannabis dependence symptoms; (c) more alcohol and cigarette use; and (d) more severe insomnia symptoms and insufficient sleep duration. Further, it was hypothesized that cannabis sleep aid use would be associated with increased cannabis use/consequences (i.e., past-year frequency, dependence symptoms) and alcohol and cigarette use, but potentially not sleep problems (i.e., insomnia symptom severity and insufficient sleep duration; consistent with college and general adult sample findings reviewed herein), one year later.

Method

Participants and Procedure

Data were drawn from a two-wave longitudinal study of 414 adolescents at an urban Northeastern U.S. public high school (recreational cannabis use not legalized at time of data collection) as part of a larger study, OMITTED FOR PEER REVIEW (AUTHOR DETAILS OMITTED FOR PEER REVIEW). Students were eligible if they were English-speaking and in 9th-11th grade at time of study enrollment. Of the original 414 participants, 7 were excluded due to missing data on cannabis sleep aid use, resulting in an analytic sample of 407 (Year 1 Mage=16.00 years [SD=1.08]; 58% assigned female sex at birth; 41% Black/African American, 22% White, 18% Asian, 17% multiracial, 2% Native Hawaiian/Pacific Islander, and 1% American Indian/Alaska Native; 12% Hispanic/Latinx). Independent-sample t-tests χ2 tests at Y1 demonstrate that participants who attrited at Y2 (n=44, 11%) endorsed greater age, cannabis use, depression/anxiety symptoms, and insufficient weekend sleep duration (ps<.001–.04), but not any other demographic, substance, or sleep-related variables (ps>.05), compared those completing both surveys (n=363, 89%).

All study procedures were approved by the Institutional Review Board and the school district, and participant confidentiality was protected by a Certificate of Confidentiality from National Institutes of Health. Recruitment and comprehensive demographic information are further detailed in previous publications (e.g., AUTHOR DETAILS OMITTED FOR PEER REVIEW).

Measures

Cannabis Sleep Aid Use

One investigator-developed item assessed lifetime frequencies of using cannabis/marijuana to help sleep at Y1 and Y2 (i.e., “Have you ever taken marijuana to help you sleep at night?”; response options: 0=no, 1=yes). Lifetime assessment timeframe was chosen because (a) highly infrequent behaviors in high school samples captured within a shorter period are likely determined by random chance versus stable risk behavior patterns and (b) a small percentage of non-zero endorsements within a shorter period would preclude planned analyses. Lifetime alcohol sleep aid use was assessed, but omitted from analyses due to low endorsement (n=9; 2%).

Participant Characteristics

Demographics.

Age, sex assigned at birth (0=female, 1=male), race (1=White, 0=Black or African American, Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaska Native, or multiracial), ethnicity (0=not Hispanic/Latinx, 1=Hispanic/Latinx), and eligibility for free or reduced-price lunch (0=Non-eligible, 1=Eligible; proxy for socioeconomic status, consistent with Nicholson et al., 2014) were assessed at Y1 and included as covariates in analyses based on demonstrated associations with adolescent sleep (Guglielmo et al., 2018) and cannabis use (Johnson et al., 2015; Ter Bogt et al., 2014). Note that models conservatively covary for male sex, although higher levels of cannabis use for males (versus females) observed historically have converged in recent years (Miech, 2020).

Depression and Anxiety Symptoms.

The 4-item Patient Health Questionnaire (Kroenke et al., 2009) assessed past-2-week frequency of depression and anxiety symptoms at Y1. Responses were on a 4-point Likert scale ranging from 0 (Not at all) to 3 (Nearly every day). Continuous subscale scores of depression (α=.75–.78) and anxiety (α=.81–.86) symptoms were used separately for analyses (Kroenke et al., 2009).

Cannabis

Students endorsing lifetime cannabis abstinence (74% [n=302] at Y1; 68% [n=246] at Y2) were coded as missing on cannabis items.

Past-Year Frequency.

One item (Johnston et al., 2016) assessed past-year cannabis use frequency (i.e., “On how many occasions have you used cannabis during the last 12 months?”) at Y1 and Y2. Responses were based on a 7-point Likert scale ranging from 0 (Never or 0 occasions) to 6 (40 or more occasions).

Dependence Symptoms.

The 5-item Severity of Dependence Scale (Gossop et al., 1995) adapted for cannabis (Swift et al., 1998) assessed past-year cannabis dependence symptoms at Y1 and Y2. Responses were based on a 4-point Likert scale ranging from 0 (Never/almost never) to 3 (Always/nearly always). Items assessed psychological dependence symptoms as evidenced by concern over impaired control. Continuous sum scores (α=.65–.69) were used for analyses, with values ≥ 4 indicating clinical symptoms (Martin et al., 2006).

Other Substances

Alcohol.

Two items (Johnston et al., 2016) assessed past-year drinking (with response options on a 7-point Likert scale ranging from 0 [Never] to 6 [40 or more occasions]) and past-2-week binge drinking (i.e., 4 or more drinks in a row for girls, 5 for boys; response options based on a 6-point Likert scale ranging from 0 [None] to 5 [10 or more times]) frequencies at Y1 and Y2; dichotomous “binge drinking status” was used for analyses (0=No, 1=Yes). Students endorsing lifetime alcohol abstinence (58% [n=235] at Y1; 55% [n=201] at Y2) were coded as missing on both alcohol frequency items.

Cigarettes.

One item (Johnston et al., 2016) assessed lifetime cigarette use at Y1 and Y2; dichotomous “lifetime cigarette use status” was used for analyses (0=No, 1=Yes).

Sleep

Insomnia.

The 7-item Insomnia Severity Index (Bastien et al., 2001) assessed past-2-week insomnia symptom severity (e.g., difficulty falling or staying asleep) at Y1 and Y2, consistent with previous adolescent sleep studies (e.g., Zhang et al., 2016). Responses were on item-specific 5-point Likert scales ranging from 0 to 4, with higher values indicating greater severity (e.g., none to very severe). A sum score (α=.76–.80) was used for analyses, with values 0–7 interpreted as non-clinical, 8–14 as sub-threshold, 15–21 as moderate, and 22–28 as severe insomnia symptoms (Buysse et al., 2006; Smith & Wegener, 2003).

Insufficient Duration.

Two items assessed subjective average sleep duration at Y1 and Y2 with responses based on a 7-point Likert scale ranging from 0 (0–5 hours) to 6 (Greater than 10 hours). Responses were coded dichotomously (0=meets recommendations for sleep duration [7 or more hours], 1=insufficient sleep duration [0–7 hours]), informed by the observed distribution for weekdays (M=2.55 [SD=1.49]; median=2.00; skewness=0.35) and weekends (M=3.17 [SD=1.75]; median=3.00; skewness=−0.26), and consistent with previous national studies of adolescent sleep (e.g., Wheaton et al., 2016).

Analyses

SPSS Version 26 (IBM Corp., 2018) was used for analyses. Descriptive statistics and group comparisons (independent-sample t tests and Cohen’s d for continuous variables, χ2 tests and Odds Ratios for categorical variables) by lifetime cannabis sleep aid use were computed for all Y1 and Y2 variables (see Table 1). Main regression analyses using complete data (n=363) examined associations of Y1 cannabis sleep aid use with Y2 substance use and sleep (linear regression for continuous outcomes, binary logistic regression for dichotomous outcomes; see Table 2), controlling for age, sex, White race, socioeconomic status, and Y1 assessment of the respective outcome variable. Notably, the model predicting Y2 lifetime cigarette use status did not control for Y1 lifetime cigarette use due to the lifetime measurement timeframe.

Table 1.

Means or percentages of Year 1 and Year 2 study variables as a function of lifetime cannabis sleep aid use reported at Year 1

Full Sample (N = 407) Sleep Aid Users (8%; n = 33) Non-Sleep Aid Users (92%; n = 374) Group Comparison Test Statistics Effect Size
N (%) M (SD) or % M (SD) or %
Year 1 Variables (possible range)
Participant Characteristics
 Age 407 (100%) 16.26 (0.89) 15.98 (1.09) t(405) = 1.47 d = 0.29
 Male Sex Assigned at Birth (1 vs. 0 female) 407 (100%) 46% 42% χ2(1) = 0.13 OR = 1.14
 Black Race (1 vs. 0 non-Black) 407 (100%) 30% 42% χ2(1) = 1.78 OR = 0.59
 White Race (1 vs. 0 non-White) 407 (100%) 30% 21% χ2(1) = 1.60 OR = 1.65
 Asian Race (1 vs. 0 non-Asian) 407 (100%) 12% 18% χ2(1) = 0.83 OR = 0.61
 Multiracial (1 vs. 0 non-Multiracial) 407 (100%) 24% 16% χ2(1) = 1.47 OR = 1.68
 Other Race (1 vs. 0 Black/White/Asian/Multiracial) 407 (100%) 3% 2% χ2(1) = 0.05 OR = 1.27
 Hispanic/Latinx Ethnicity (1 vs. 0 non-Hispanic/Latinx) 407 (100%) 12% 12% χ2(1) = 0.00 OR = 1.03
 Free/Reduced-Price Lunch Eligibility (1 vs. 0 non-eligible) 407 (100%) 73% 89% χ2(1) = 6.77** OR = 0.35
 Depression Symptoms (0 – 6) 402 (99%) 2.16 (1.95) 1.48 (1.66) t(400) = 2.16* d = 0.38
 Anxiety Symptoms (0 – 6) 402 (99%) 2.26 (1.95) 1.47 (1.70) t(400) = 2.44* d = 0.43
Cannabis Use
  Past-Year Cannabis Use Frequency (0 – 6) 105 (26%) a 4.43 (1.87) 1.79 (1.74) t(103) = 6.89*** d = 1.46
  Cannabis Dependence Symptoms (0 – 15) 104 (25%) a 2.63 (2.98) 1.46 (2.32) t(102) = 2.15* d = 0.44
Other Substance Use
 Past-Year Drinking Frequency (0 – 6) 170 (42%) a 2.43 (1.48) 1.11 (1.08) t(168) = 4.51*** d = 1.02
 Past-2-Week Binge Drinking Status (1 vs. 0) 163 (40%) a 21% 4% χ2(1) = 3.73 OR = 2.63
 Lifetime Cigarette Use Status (1 vs. 0) 406 (99.8%) 27% 9% χ2(1) = 10.56** OR = 3.74
Sleep
 Insomnia Symptom Severity (0 – 21) 407 (100%) 8.94 (5.24) 8.11 (5.13) t(405) = 0.89 d = 0.16
 Insufficient (<7 hours) Weekday Sleep Duration (1 vs. 0) 407 (100%) 55% 51% χ2(1) = 0.20 OR = 1.18
 Insufficient (<7 hours) Weekend Sleep Duration (1 vs. 0) 407 (100%) 36% 34% χ2(1) = 0.10 OR = 1.13
Year 2 Variables (possible range)
Cannabis Use
 Past-Year Cannabis Use Frequency (0 – 6) 116 (29%) a 4.35 (2.13) 2.08 (1.85) t(114) = 4.86*** d = 1.14
 Cannabis Dependence Symptoms (0 – 15) 116 (29%) a 2.80 (2.61) 1.08 (1.85) t(114) = 2.80* d = 0.76
Other Substance Use
 Past-Year Drinking Frequency (0 – 6) 162 (40%) a 2.22 (1.48) 1.23 (1.18) t(160) = 3.27** d = 0.74
 Past-2-Week Binge Drinking Status (1 vs. 0) 161 (40%) a 15% 3% χ2(1) = 6.36* OR = 4.20
 Lifetime Cigarette Use Status (1 vs. 0) 361 (89%) 24% 6% χ2(1) = 24.20*** OR = 8.23
Sleep
 Insomnia Symptom Severity (0 – 21) 363 (89%) 8.59 (4.56) 8.43 (5.21) t(361) = 0.14 d = 0.03
 Insufficient (<7 hours) Weekday Sleep Duration (1 vs. 0) 363 (89%) 46% 61% χ2(1) = 0.02 OR = 1.06
 Insufficient (<7 hours) Weekend Sleep Duration (1 vs. 0) 363 (89%) 15% 28% χ2(1) = 0.59 OR = 0.67
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Note. Individuals missing on lifetime cannabis sleep aid use (n = 7; 2% of full sample) were excluded from group comparison analyses.

a

Lifetime abstainers of the substance coded as missing.

*

p < .05.

**

p < .01.

***

p < .001.

Table 2.

Regression analyses examining effect of lifetime cannabis sleep aid use at Year 1 on substance use and sleep outcomes at Year 2 after accounting for Year 1

Year 2 Outcomes
Substance Use Sleep
Past-Year Cannabis Use Frequency (n = 74)a Cannabis Dependence Symptoms (n = 74)a Past-Year Drinking Frequency (n = 122)a Past-2-Week Binge Drinking Status (n = 116)a Lifetime Cigarette Use Statusb (n = 361) Insomnia Symptom Severity (n = 363) Insufficient (<7 hours) Weekday Sleep Duration (n = 363) Insufficient (<7 hours) Weekend Sleep Duration (n = 363)
β β β OR OR β OR OR
Year 1 Cannabis Sleep Aid (1 vs. 0) .08 .28* .07 5.31* 8.42*** −.02 0.85 0.80
Age −.11 .13 .11 2.02* 1.35 .04 1.02 1.18
Male Sex (Assigned at Birth) .17 .02 −.02 0.61 1.33 −.11* 1.01 0.82
White Race .13 −.13 .15 1.77 1.11 .08 0.92 0.73
Free/Reduced-Price Lunch Eligibility .00 −.13 −.19* 1.05 1.49 .08 0.82 1.33
Year 1 variable corresponding to Year 2 outcome of interest .60*** .34** .35*** 4.17 .44*** 3.34*** 3.49***
R2 of the entire model .48 .29 .31 .23 .12 .24 .10 .12
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Note. Analyses used complete data at Y2. Results of the two dichotomous outcomes (sleep duration variables, binge drinking and cigarette use status) are based on binary logistic regressions, and thus Nagelkerke R2 and odds ratios are reported; Results from all other variables are based on linear regressions, R2 and standardized coefficients are reported.

a

Lifetime abstainers of the substance coded as missing.

b

Model did not control for Year 1 variable corresponding to Year 2 outcome of interest due to the lifetime measurement timeframe.

*

p < .05.

**

p < .01.

***

p < .001.

Several ancillary analyses were conducted. Group comparison analyses compared those who used cannabis for sleep aid to those who used cannabis but not for sleep aid to clarify descriptive differences restricted to cannabis-using adolescents. Regression analyses were additionally conducted: (a) with all available data (N=407) using Mplus (Muthén & Muthén, 2018) and maximum likelihood estimation with robust standard errors with all available data to assess impact of Y2 attrition; (b) with sleep aid effects moderated by male sex (female=reference) and race (Black, Asian, and Multiracial [White=reference]; other races notably omitted due to insufficient sample size [n=12 total]) in separate models; (c) additionally controlling for depression and anxiety symptoms to explore the impact of cannabis sleep aid use over and above these covariates; (d) additionally controlling for general cannabis use to clarify the unique risk profile of cannabis sleep aid use relative to general cannabis use; and (e) alternatively exploring effects of general cannabis use (versus sleep aid).

Results

Year 1 (Y1) Descriptive Analyses

On average, the complete sample reported subclinical levels of depression (M=1.53 [SD=1.69]) and anxiety (M=1.53 [SD=1.73]) symptoms at Y1. Students endorsing lifetime cannabis use Y1 (n=105; 26%) reported using 3–9 times during the past year (M=2.54 [SD=2.14]) and subthreshold dependence symptoms (M=1.80 [SD=2.57]; 4% of the complete sample met clinical threshold). Students endorsing lifetime alcohol use at Y1 (n=172; 42%) reported drinking 1–2 times in the past year (M=1.32 [SD=1.25]) and 6% of the complete sample reported past 2-week binge drinking. At Y1, 11% of the complete sample reported lifetime history of cigarette use. Students endorsed subclinical insomnia symptoms (M=8.18 [SD=5.14]; 12% met clinical threshold) at Y1, with insufficient sleep durations reported by 51% for weekdays and 34% for weekends.

Group Comparisons by Cannabis Sleep Aid Use

Group comparisons of students reporting Y1 lifetime cannabis sleep aid use (n=33; 8% of sample) versus those who did not (n=374; 92% of sample) across Y1 and Y2 variables are presented in Table 1. Compared to non-using peers, students who used cannabis for sleep aid reported (a) higher socioeconomic status at Y1; (b) more severe depression and anxiety symptoms (although sub-clinical threshold) at Y1; (c) more frequent cannabis use and more severe cannabis dependence symptoms at Y1 and Y2 (among students endorsing lifetime cannabis use); (d) more frequent past-year alcohol use at Y1 and Y2 (among students endorsing lifetime alcohol use) and greater likelihood of past-2-week binge drinking at Y2 (but not at Y1, p=.054); and (e) greater likelihood of lifetime cigarette use status at Y1 and Y2. Groups did not differ in terms of any other sociodemographic characteristics at Y1 (ps=.14–.95) or insomnia symptoms or sleep durations at Y1 or Y2 (ps=.38–.90).

Prospective Analyses

Regression results relating Y1 cannabis sleep aid use with Y2 substance use and sleep are presented in Table 2. Y1 cannabis sleep aid use was associated with (a) greater Y2 cannabis dependence symptoms, but not with Y2 past-year cannabis frequency (p=.44; among students endorsing lifetime cannabis use); (b) more frequent Y2 binge drinking in past 2 weeks, but not with Y2 past-year alcohol frequency (p=.40; among students endorsing lifetime alcohol use); and (c) greater likelihood of Y2 lifetime cigarette; but not (d) any Y2 sleep outcomes at Y2 (ps=.69–.75).

Ancillary Analyses

First, compared to cannabis-using participants who denied sleep aid use, those who used cannabis for sleep aid reported higher socioeconomic status (χ2[1] = 5.84, p=.02, OR = 0.28) and heavier substance use at T1 (cannabis, drinking, and cigarette use; ps=.00–.049) and T2 (cannabis and cigarette use; ps=.00–01); groups did not differ by other demographics or sleep problems (ps>.05). Second, sensitivity analyses of all available data (N=407) yielded patterns of significance for cannabis sleep aid effects consistent with main regression analyses of complete data only (n=363), with one exception: the effect of cannabis sleep aid use on cannabis dependence symptoms became marginally significant (b=1.20, SE=0.67, p=.07, β=1.20). Third, ancillary regression analyses demonstrated that associations of cannabis sleep aid use with substance and sleep outcomes did not significantly differ by sex (ps=.08–.97) or race (ps=.06–.99). Fourth, significance patterns of main results remained consistent when additionally controlling for baseline depression and anxiety symptoms (except cannabis dependence symptoms became marginal; b=1.13, SE=0.57, p=.05, B=0.24) and past-year cannabis use frequency (except cannabis sleep aid use no longer predicted past-2-week binge drinking; b=1.23, SE=1.01, p=.22, OR=3.43). Lastly, ancillary regression analyses revealed that past-year cannabis use frequency (regardless of sleep motive) was associated with past-year cannabis (b=0.70, SE=0.10, p<.001, B=.63) and alcohol (b=0.21, SE=0.09, p=.02, B=.33) frequencies over one year, but not with other substance (ps=.29–.67) or sleep (ps=.48–.90) outcomes.

Discussion

This novel characterization of cannabis sleep aid among high school students contributes to the literature on co-occurring substance use and sleep problems during this critical developmental period. Students who used cannabis for sleep aid (8% of sample) reported greater depression, anxiety, and substance use compared to non-using peers, but groups did not differ in terms of insomnia symptoms or sleep durations. Over one year, cannabis sleep aid use was associated with increased cannabis dependence symptoms, binge drinking frequency, and cigarette use, but not with past-year cannabis and alcohol use frequencies, insomnia symptoms, or sleep durations. Thus, cannabis sleep aid use during adolescence may contribute to the development of substance use/problems over time, without the intended benefit of sleep improvement.

Prevalence and Characteristics

Current findings offer preliminary characterization of cannabis sleep aid use among high school students. Cannabis was more prevalent than alcohol for sleep aid in this sample (7% cannabis only, 1% alcohol only, and 1% cannabis and alcohol), consistent with college literature (albeit lower prevalence rates; Goodhines, Gellis, Ansell, et al., 2019; Goodhines, Gellis, Kim, et al., 2019). The lower prevalence rate observed in this high school sample potentially reflects onset in later stages of development and/or discrepancies between college-attending versus general community samples, albeit requiring replication. Students endorsing lifetime cannabis sleep aid use in this sample were characterized by higher socioeconomic status (possibly attributable to greater cannabis access given lesser financial barrier; see Devenish et al., 2017), greater depression and anxiety symptoms and heavier substance use, but not by other demographic variables (age, sex, race, or ethnicity; consistent with narrowing cannabis use gaps observed in Miech et al., 2020) or sleep problems/durations.

Multiple explanations may be posited for unexpected null group differences in sleep problems. Students who use cannabis for sleep aid may successfully manipulate sleep with substances to prevent subjective sleep problems (thereby precluding observable group differences), consistent with “safety behavior” per cognitive insomnia theory (Harvey, 2005) and limited adult experimental literature suggesting some potential benefit to sleep onset latency (Babson et al., 2017). However, future controlled polysomnographic research is needed to further clarify potential therapeutic effects of cannabis for adolescent sleep. Alternatively, students using cannabis for sleep aid may use cannabis for numerous perceived motives, regardless of subjective sleep problems. Overall, findings suggest cannabis sleep aid use among adolescents may be indicative of a general tendency toward substance use, as opposed to an attempted remedy for sleep problems specifically.

Longitudinal Consequences/Benefits of Cannabis

Although cannabis sleep aid use was not associated with increases in past-year frequency of cannabis, it was associated with increased cannabis dependence symptoms. Thus, cannabis sleep aid use may increase susceptibility to cannabis dependence symptoms over time, regardless of interim use frequency. With repeated cannabis sleep aid use over time, students may develop a greater perceived need or lesser perceived control over their cannabis use, suggesting increased use after high school with increased freedom and cannabis access. Additional underlying risk mechanisms may be considered, such as possible sleep-related diurnal impairment to impulse-regulatory processes (Peach & Gaultney, 2013) following sleep aid use. Sleep-related diurnal functional impairment has been shown to increase susceptibility to negative drinking consequences among college students (Goodhines, Zaso, et al., 2019), and alcohol/cannabis sleep aid use has been associated with increased negative drinking consequences directly (despite no change in alcohol use over time; Goodhines, Gellis, Kim, et al., 2019). Preliminary current findings highlight dependence symptoms as a potential consequence of adolescent cannabis sleep aid use necessitating further investigation.

Consistent with hypotheses, cannabis sleep aid use was associated with increases in other substance use over time. Although cannabis sleep aid use was not associated with increases in annual frequency of drinking (among students endorsing lifetime use), it was associated with greater likelihood of recent binge drinking one year later (after controlling for binge drinking at Year 1) and lifetime cigarette use, suggesting cannabis sleep aid use may be associated with increased vulnerability to risk behavior. Prospective alcohol findings may reflect the infrequent and opportunistic nature of adolescent drinking (Windle, 2016), which promotes binge drinking due to limited alcohol availability, as opposed to stable drinking patterns (such as consistent alcohol frequency). Cannabis sleep aid use demonstrated a one-year risk profile notably distinct from general cannabis use, which was associated only with past-year alcohol use frequency. Overall, adolescent cannabis sleep aid use (over and above general cannabis use) may be indicative of other substance-related risk across development.

Consistent with hypotheses and longitudinal college findings (Goodhines, Gellis, Kim, et al., 2019), cannabis sleep aid use was not associated with changes in subjective sleep problems over time. This null association notably remained when exploring prospective outcomes of general cannabis use (that is, not specifically for sleep aid), suggesting that cannabis use among this high school sample may not benefit or harm sleep over one year. Although experimental evidence suggests cannabis has a predictable impact on sleep (i.e., proximally-reduced sleep onset latency but impaired sleep quality over time; Babson et al., 2017), generalizability to adolescents remains uncertain. Current null results may be attributable to subjective and prospective nature of assessment, necessitating replication. Alternatively, it is possible that adolescents experience unique sleep-related responses to pre-sleep cannabis use and may be more resilient to sleep-related consequences observed among adults. Adolescence may be premature for detection of theorized substance-related risk conferred by sleep problems (Brower, 2003), or development of substance use problems due to cannabis self-medication, as this risk process may occur over longer periods of time or at later developmental stages. Regardless, current results suggest cannabis sleep aid behavior among adolescents neither harms nor benefits sleep over one year.

Clinical Implications

Findings of this study may inform efforts to reduce potential harms associated with cannabis sleep aid use within the context of rapidly-changing cannabis legislation (Hammond et al., 2020) and decreasing perceived harmfulness among adolescents (Miech, 2020). Health psychology research may inform recommendations for systemic harm reduction via regulatory policy regarding cannabis prescription and marketing (such as Devylder et al., 2021; Fischer et al., 2020) specifically as a sleep aid. Regarding prevention, caregiver education for discussing and monitoring adolescent cannabis use (such as recommendations from the American Academy of Pediatrics; Ryan & Ammerman, 2017) may be advantageous given the demonstrated protective role of parental monitoring in adolescent cannabis use (Haas et al., 2018). Recommendations for individual clinical intervention remain precluded by insufficient empirical support for therapeutic cannabis effects on sleep (for a review, see Choi et al., 2020), however, current findings warrant further intervention development on intersectionality between sleep, substance use, and mood.

Limitations and Future Directions

Findings should be interpreted considering limitations. First, despite analytic control for key sociodemographic variables, findings may not generalize to non-school-attending adolescents, other geographic locations, heterogeneous socioeconomic groups, non-English speaking students, or clinical sleep/substance samples. Second, single-item assessment of sleep aid use precludes explication of (a) timing of use (e.g., at bedtime), (b) primary motivation for use (i.e., sleep aid versus other motives, such as social), (c) dosage, administration method, or type of cannabis product used (which may yield differential effects; Freeman & Lorenzetti, 2020), and simultaneous polysubstance use for sleep-wake manipulation (e.g., caffeine). Third, given between-group differences in those who did and did not complete the study, note that results may not generalize to older adolescents with heavier cannabis use and/or co-occurring mental health symptoms. Fourth, outcomes assessed herein notably represent varied assessment timeframes (consistent with literature recommendations informed by psychometric validation), thereby precluding comparative conclusions across outcomes. Lastly, causal inferences remain speculative given correlational design.

Current results may inform future research. First, future studies may consider over-sampling high school students who use cannabis for sleep aid for a larger comparison group and more robust conclusions regarding characteristics of students using cannabis for sleep aid, including possible sociodemographic protective and risk factors. Second, future studies may investigate (a) longitudinal risk mechanisms underlying adolescent sleep aid use (e.g., involving emotion dysregulation, consistent with Edwards et al., 2015) and (b) event-level, within-person associations of sleep aid use with precipitants and proximal consequences unique to daily adolescent life. Third, ongoing explication of potential risk mechanisms underlying the observed association of cannabis sleep aid use with increases in cannabis dependence symptoms over time is needed (such as mediation by sleep-related functional impairment).

Conclusions

This novel study contributes to the sparse literature on adolescent cannabis use for sleep aid by providing subsample characterization in terms of substance use and sleep patterns. Results indicate that adolescent cannabis sleep aid use is aligned with general substance use behavior, such that it is associated with increased dependence symptoms over time, without the intended benefit of sleep improvement. Although replication is needed, these findings may assist the identification of youth at risk for later substance use problems during adolescence.

Highlights.

  • Eight percent of high school students endorsed lifetime cannabis use for sleep aid

  • Cannabis sleep aid use characterized by general substance use, not sleep problems

  • Cannabis sleep aid use associated with cannabis dependence symptoms one year

  • Cannabis sleep aid use not associated with intended sleep benefits over one year

  • Results may assist identification of youth at risk for later substance use problems

Funding:

Research reported in this publication was supported by National Institutes of Health grants R15AA022496, R01AA027677, and F31 DA050435. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Declarations of interest: none.

Contributor Information

Patricia A. Goodhines, Department of Psychology, Syracuse University, Syracuse, NY 13244.

Amelia V. Wedel, Department of Psychology, Syracuse University, Syracuse, NY 13244.

Fatima Dobani, Department of Psychology, Syracuse University, Syracuse, NY 13244..

Michelle J. Zaso, Clinical and Research Institute on Addictions, University at Buffalo – The State University of New York, Buffalo, New York, USA.

Les A. Gellis, Department of Psychology, Syracuse University, Syracuse, NY 13244.

Aesoon Park, Department of Psychology, Syracuse University, Syracuse, NY 13244..

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