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Cannabis Vaping Among Youth and Young Adults: a Scoping Review

Cannabis Vaping Among Youth and Young Adults: a Scoping Review Purpose of Review The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults. Recent Findings Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same. Summary Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vap - ing for young people, along with risk factors and reasons for the same. Keywords Cannabis · Vaping · Health effects · Epidemiology · Etiology · Regulation Introduction These studies include information relevant to the epidemiol- ogy, health effects, etiology, marketing, and regulation of The purpose of this review was to describe the state-of-the- cannabis vaping and are applicable to young people less than literature regarding research specific to cannabis vaping 30 years old. among youth and young adults [1]. A recent meta-analysis found that among adolescents in the USA and Canada, life- time, past-12 month, and 30-day prevalence of cannabis vap- Methods ing increased by two- to seven-fold, from 2013 to 2020 [2 ]. Preference for cannabis products, therefore, may be shifting This review was conducted using methods consistent with from dried herb to cannabis oil (e.g., liquid tetrahydrocan- the Preferred Reporting Items for Systematic Review and nabinol (THC), the primary psychoactive component in can- Meta-Analysis for scoping reviews (PRISMA-ScR) [6]. A nabis) — and, given the emergence [3] and predominance scoping review was deemed appropriate, as it focuses on an of e-cigarette use among young people now [4, 5], from assessment of the potential size and scope of available litera- smoking to vaping cannabis. Here, we provide a summary ture. We categorize the available literature into relevant sub- of results from 202 original investigations on this topic (see topics and summarize the findings in the “ Results” section. Supplementary Table 2), published between 2007 and 2021. Search Strategy This article is part of the Topical Collection on Tobacco Addiction Our search strategy was informed by recent published * Melissa B. Harrell reviews of vaping among youth and young adults specific to Melissa.B.Harrell@uth.tmc.edu the impact that nicotine vaping has on subsequent cannabis [7] or combustible tobacco product use [8–11]. Consistent School of Public Health, University of Texas Health Science with these reviews, the following databases were searched Center at Houston (UTHealth), 1616 Guadalupe St., Suite 6.300, Austin, TX 78701, USA for studies: PubMed, Embase, and Web of Science. In addition, searches were conducted on the aforementioned Center for Research to Advance Community Health, UTHealth San Antonio, San Antonio, TX, USA Vol.:(0123456789) 1 3 218 Current Addiction Reports (2022) 9:217–234 reviews [7–11] and relevant summary reports [3, 12, 13] (e.g., nicotine, flavors only); studies whose participants for additional studies, too. Keywords included: e-cigarettes, were not youth or young adults; animal studies; and, vaping, ENDS, JUUL; cannabis, marijuana, THC, CBD; finally, articles that were not original research (e.g., edi- adolescents, young adults. Keywords used for each database torials, commentaries, and review articles). are provided in Supplementary Table 1. When available, we A total of 1801 articles were initially identified. After used subject headings (PubMed: MeSH; Embase: Emtree). removing 416 duplicates, 1385 titles and abstracts were Searches were conducted from January 2007 to December independently reviewed by at least 2 of the 6 co-authors 2021. The initial date was chosen as it coincides with the to determine their suitability for full-text screening. After appearance of the “modern” e-cigarette or vaping device on removing 927 articles at this stage, each of 458 articles the international market [14]. selected for full-text screening was again independently reviewed by at least 2 co-authors for inclusion. Any dis- Study Selection crepancies between reviewers were discussed among all co- authors until consensus was reached. Ultimately, 202 articles All studies retrieved through these searches were imported were deemed relevant. Figure 1 is the PRISMA flow diagram into software designed to support systematic reviews for this process. Supplementary Table 2 provides a list of ( https:// www . co vid ence. or g/) [15] and study selection these 202 articles. was done there. There were five inclusion criteria. First, we included studies that examined cannabis vaping as a central topic or had findings about cannabis vaping. Sec- Extraction ond, study participants were youth (12–18 years old) and/ or young adults (18–29 years old), or the study findings Data extracted from each study included the following: were relevant for young people (e.g., the unit of analysis study design; study sub-topic, including epidemiology, was advertisements, but study findings were relevant for health effects, etiology, marketing, and regulation; key youth and/or young adults). Third, studies were original findings about cannabis vaping within each sub-topic area; research; fourth, studies were full-text articles; and fifth, and, where relevant, study characteristics (e.g., location, the articles were written in English. The reasons for exclu- participants’ age). Typical of a scoping review, no formal sion included studies in which cannabis was not vaped, assessment of the quality of the eligible manuscripts was but only consumed in some other form; studies that only conducted, so information on the risk of bias that may be addressed vaping with substances other than cannabis inherent in each of these studies is not presented here. Fig. 1 PRISMA flo w diagram PubMed Embase Web Of Science Other Sources (n=204) (n=676) (n=863) (n=58) Total Results From Search (n=1801) Duplicates Removed (n=416) Titles And Abstracts Screened Irrelevant Articles Removed (n=1385) Full Text Reviewed (n=458) Excluded (n=256) Not full text (n=82) Wrong mode of marijuana consumption, or did not distinguish modes of marijuana use (n=104) Not original research, or a review (n=40) Adult population (n=21) Cannabis vaping not a central topic (n=6) Non-English (n=3) Final Articles Included (n=202) 1 3 Included Screening Identification Current Addiction Reports (2022) 9:217–234 219 past 30-day cannabis vaping observed among young adults Results (college students) from 2017 to 2018 was among the larg- est 1-year increase in any substance use ever recorded in Overview the history of MTF (> 40 years) [4]. From 2018 to 2019, a similar doubling in the prevalence of past 30-day canna- No studies that met the inclusion criteria were published bis vaping was also observed for youth (8th, 10th, and 12th from 2007 to 2013. From 2013 onwards, the rate of pub- grade) [16]. Frequent vaping (defined as using ≥ 10 times in lication increased exponentially, reaching a peak in 2020 the last month) increased significantly among high school (Supplementary Fig. 1) that was driven, in large part, by seniors from 2018 to 2019, too [17]. MTF data for young many articles (n = 70) on EVALI (e.g., case reports). Table 1 adults for 2021 were not available at this writing. (Note that provides a summary of the number of articles reviewed here, the MTF publications that these prevalence estimates are by study design and sub-topic. Most studies were specific to derived from report data on “vaping marijuana” questions health effects and etiology. measured in the vaping section of the survey [4, 16]. One recent study shows that there is some discordance in preva- Epidemiology lence estimates, if measures from the cannabis section on “using cannabis in a vaporizer” are used, instead [18]. Thus, National Estimates researchers must take care when considering how best to ask questions about cannabis vaping and where to place them on Annual prevalence estimates of cannabis vaping were avail- a survey instrument [19]. able from Monitoring the Future (MTF) from 2017 to 2021 Despite these alarming statistics, it is worth noting that, for youth (8th, 10th, and 12th grade) and from 2017 to 2021 for each year (2017 to 2020), behavioral measure, and age for young adults (college students) and are shown in Sup- group, the prevalence of cannabis vaping was less than the plementary Fig. 2 (lifetime use) and Supplementary Fig. 3 prevalence of nicotine vaping (data not shown) [4, 20–23]. (past 30-day use) [4]. Lifetime use increased rapidly for both For young adults, the prevalence of cannabis vaping was age groups from 2017 to 2020 then, for youth, declined in 20–30% less than that for nicotine vaping, while it was 2021. Among youth, lifetime prevalence rose from 8.5% in 50–60% less among youth. It is also worth reporting that 2017 to 20.1% in 2020, then decreased to 15.9% in 2021. from 2015 to 2018 (latest published data, among 12th grad- Among young adults, lifetime prevalence increased from ers only), cannabis smoking decreased, while cannabis 14.4% in 2017 to 34.6% in 2020. Notably, the doubling of vaping and the use of edibles increased [24]. From 2015 to 2018, for all students and among past-year cannabis users specifically, the prevalence of smoking cannabis was 2–3 Table 1 Frequency of studies by study design and research area times higher than the prevalence of vaping or use of edibles (n = 202) [24, 25]. Characteristic n (%) This comparison across substances (nicotine vs. cannabis) Study designs and modes of consumption (smoking vs. vaping vs. edibles)   Case-reports 44 (21.8%) helps to contextualize cannabis vaping among young people,   Case-series 28 (13.9%) demonstrating that, for now, it may not be as problematic   Randomized controlled trials 4 (2.0%) as other substance use behaviors. However, given observed   Observational 105 (52.0%) increases in recent years, efforts should continue to moni-     Cross-sectional 84 (41.6%) tor cannabis vaping among young people in the future, and     Cohort/longitudinal 21 (10.4%) assessing modes of consumption may be a helpful way to   Qualitative 18 (8.9%) guide prevention efforts [26]. Data on cannabis vaping are   Mixed methods 2 (1.0%) currently collected not only by MTF but also by the National   Meta-analysis 1 (0.5%) Youth Tobacco Survey (NYTS) (youth only) [27–29], the Research areas Behavioral Risk Factor Surveillance System (BRFSS)   Health effects 93 (46.0%) (young adults only) [30, 31], and the Population Assessment   Etiology 49 (24.3%) of Tobacco Use and Health (PATH) study (youth and young   Epidemiology 50 (24.8%) adults) [32]. Each surveillance system offers unique insights   Regulatory policy 17 (8.4%) into this phenomenon, given data it collects not only on can-   Marketing/advertising 11 (5.5%) nabis vaping but also on other substance use behaviors and modes of cannabis consumption, too. 1 2 Categories are mutually exclusive. Mixed methods studies were An analysis of PATH data from 2015 to 2016 for young cross-sectional + case series and longitudinal + qualitative. Catego- adults (18–24 years old), for example, showed that lifetime ries are mutually inclusive 1 3 220 Current Addiction Reports (2022) 9:217–234 or ever use of cigar products (e.g., cigarillos) to consume significant differences in the prevalence of past 30-day use cannabis (i.e., blunt use) was 3 times more common than of a vaporizer to heat dried herb were observed within coun- consuming cannabis by vaping or using a hookah to do so tries (England: 8.1% (2017), 12.5% (2018), 11.1% (2019); [32]. BRFSS surveys also include items on different modes Canada: 15.9% (2017), 19.3% (2018), 19.1% (2019); USA: of cannabis consumption (i.e., smoking, vaping, eating, and 20.6% (2017), 21.5% (2018), 23.0% (2019)). However, from dabbing) [30] and can be used to compare nicotine vaping 2017 to 2019, significant increases were observed for each and cannabis vaping [31]. Analyses of BRFSS data from country in the prevalence of past 30-day use of an e-cigarette 2018 showed past 30-day dual nicotine and cannabis vap- to vape oil or liquid (England: 9.0% (2017), 14.6% (2018), ing was as common among young adults as past 30-day 19.0% (2019); Canada: 12.9% (2017), 18.8% (2018), 25.9% cannabis vaping alone [31]. Analyses of NYTS data from (2019); USA: 24.2% (2017), 31.0% (2018), 52.1% (2019)). 2017 and 2018 showed that cannabis vaping was especially In 2017, for all three countries, vaping herb or vaping oil/liq- common for students who frequently use (i.e., use ≥ 20 days uid was the least common modes of cannabis consumption; per month) e-cigarettes [27]. Surveillance data on lifetime yet, from 2017 to 2019, across all three countries, vaping or ever cannabis vaping on the 2016 [28], 2017 [29], and oil/liquid increased more than other modes of consumption 2018 [29] NYTS surveys are consistent with the sustained (vaping herb, smoking, and edible use) [51]. In addition, increase reported in MTF, too. Two published studies while nicotine vaping was also more prevalent than cannabis [33, 34] specifically examined the possible impact of the vaping across these countries [53], dual use was common COVID-19 epidemic on cannabis vaping among youth [52]; and, in 2018, past 30-day cannabis users in the USA and young adults. One study showed that individual use were more likely to report vaping cannabis than in Canada or increased, decreased, or stayed the same, depending on rel- England [53]. Findings from the COMPASS study in Canada evant risk factors (e.g., access, dependence) [33]. Another before legalization in 2018 showed that ingesting and/or vap- national study of more than 4000 adolescents and young ing cannabis were more often in addition to smoking can- adults showed only 6.8% of participants increased cannabis nabis, rather than as a replacement [49]. Follow-up studies vaping during the pandemic, while 37% reduced or quit can- from COMPASS that included data from 2017 to 2018 and nabis vaping, and 42.3% reported no change [34]. Though 2018–2019 showed multiple modes of cannabis consump- not explicitly stated by MTF, COVID-19 could be a reason tion (smoking, vaping, and/or ingesting) and increased fre- for the leveling-off of past 30-day cannabis vaping from quency of the same were more common among high school 2019 to 2021 among both age groups seen in MTF (Fig. 4). students after legalization in 2018 [54–56]. Other studies from Finland [48] and Germany [50] show cannabis vap- Estimates by State ing among young people, at < 10%, may be less prevalent in these European countries than in England [51] though The prevalence of cannabis vaping among young people differences between studies by age and year of data col- does vary by state, consistent with differences in local poli- lection make comparison difficult. Pooled estimates across cies regarding age restrictions on use [35–43]. More infor- 2016–2018 from one study of youth (14–15 years old) in mation is provided below (see “Regulation” section). Data New Zealand show cannabis vaping is less prevalent there, from the 2017 Healthy Kids Colorado survey, one of the too [57]. Less than 10% of students reported using canna- first states to legalize recreational cannabis use for adults, bis in the past 30-day days and, of these, only 7% reported showed that vaping was far less common as a mode of con- exclusive cannabis vaping; 90% reported smoking cannabis, sumption among youth than smoking or ingesting cannabis in contrast [57]. Estimates from other countries were not (i.e., edible use) [44]. NYTS data from Florida (2015) [45] located in this review. and North Carolina (2017) [46], where recreational cannabis use was and still is illegal, even for adults, showed 1 in 10 Use Trajectories high students reported cannabis vaping. Several studies reported on developmental trajectories of use International Estimates that describe the onset and progression of cannabis vaping across adolescence into young adulthood [58–63]. Several Several studies identified through this review provided of these studies focused on cannabis vaping only [60–63], estimates of cannabis vaping among young people from while others show cannabis vaping co-occurs with other other countries [47–53]. Data for 16 to 19 year-olds from substance use behaviors [58, 59]. Studies from California the International Tobacco Control Policy Evaluation (ITC) [60] and Texas [63] both show variability by sub-groups study showed cannabis vaping is more prevalent in the USA, of young people: some young people start cannabis vap- followed by Canada and England, consistent with regula- ing in adolescence, while others begin in young adulthood; tory policy in each country [51–53]. From 2017 to 2019, no and some trajectories escalate quickly, while others escalate 1 3 Current Addiction Reports (2022) 9:217–234 221 less rapidly. However, declines in use from adolescence into EVALI were provided in the articles, which aligned with young adulthood are generally not observed [60, 63]. Taken the broad case definition established by the CDC, which together, these studies suggest a strong, positive relationship includes (1) e-cigarette use or dabbing resin within 90 days between age and cannabis vaping that may (or may not) peak of symptom onset, (2) pulmonary infiltrate present on radio- in young adulthood. No studies reported on quit intentions graphs, (3) no evidence of pulmonary infection with mini- or behaviors, providing scope for future research. mum workup of a viral respiratory panel and influenza test- ing, and (4) no evidence of alternative plausible diagnosis Special Populations [4]. Studies highlighted a need to assess history of vaping use behaviors for patients with EVALI-like symptoms. Several studies reported on use in special populations The case series papers (n = 25) provided insight into pat- [64–69], like hospitalized adolescents [69], pregnant young terns of and risk factors for EVALI across individual patients adults [68], young adults with asthma [67], nightclub patrons [103–128, 137]. For example, among 160 patients reported [66], young people with inflammatory bowel disease [65], to the California Department of Public Health, the median and young people in substance use treatment centers [64]. age of participants was 27 years, 62% were male, and 46% The reader is directed to these publications for further infor- of patients were admitted to the intensive care unit [113]. mation. Data for all of these studies were collected between Among the vaping devices gathered from participants (87 2015 and 2020. devices from 24 patients), 56% contained THC, and vitamin E acetate was found in 84% of the THC vape products [113]. Health Eec ff ts Another case series of EVALI patients (n = 86) in Wiscon- sin and Illinois added to these findings by identifying Dank EVALI Vapes as a potential source of the contaminated cartridges; 66% of patients reported use of Dank Vapes [118]. In addi- In Spring 2019, reports of e-cigarette, or vaping, associ- tion to risk factors for EVALI, case series such as Kalin- ated lung injury (EVALI) began to emerge across the USA, insky et al. described treatment considerations and recom- with cases peaking in Summer 2019 [1, 2 ]. Cases were mendations [106]. Treatment recommendations for EVALI characterized by respiratory, gastrointestinal, and/or con- included (1) supportive respiratory support as needed (i.e., stitutional symptoms, including cough, difficulty breath- supplemental oxygen, ventilation), (2) antibiotics for severe ing, nausea, diarrhea, fever, chills, and/or weight loss [1, cases, per blood culture results, (3) antivirals until influenza 3]. To date, the Centers for Disease Control and Preven- is excluded (if symptoms occur during flu season), and (4) tion (CDC) has recorded 2807 EVALI cases and 68 deaths corticosteroids to treat lung inflammation. across 50 states, Puerto Rico and the US Virgin Islands. In the cross-sectional studies (n = 9), [126, 129 , The severity of EVALI varies, with the most severe cases 130–136] research highlighted demographic characteristics leading to extended ICU stays, lung transplants, and death of EVALI patients, substance use behaviors, and risk factors [1, 2 ]. Given the emergence of EVALI and the subse- for EVALI. Common risk factors across studies for EVALI quent research that implicated vitamin E acetate found in included younger age, cannabis vaping, higher frequency of some cannabis vape products in the outbreak, the majority cannabis vaping, the use of Dank Vapes (a brand of e-ciga- of studies investigating the health effects of cannabis vap- rettes only available on the black market), as well as obtain- ing (n = 93) focused on EVALI (n = 70), including 34 case ing products from informal sources. These findings are sup- reports [70–102], 25 case series [103–128], 8 cross-sectional ported by current evidence from the CDC; as of the last studies [129 , 130–136], 1 longitudinal study [137], and 1 update (data from January 14, 2020) [140], 76% of EVALI qualitative study [138]. One study included a case series patients were under 35 years of age. Blount et al. provided of EVALI patients and a cross-sectional analysis of vaping the strongest evidence on the link between vitamin E acetate devices; therefore, this was counted as both a case series and and development of EVALI; vitamin E acetate was found cross-sectional study [26]. in 94% of patients’ BAL (bronchoalveolar-lavage) fluid and The case series and case reports detailed symptoms at was in BAL fluid taken from the control participants [130]. diagnosis including respiratory, gastrointestinal, and con- stitutional symptoms; and information on the treatment and Other Health Issues outcomes of numerous patients with EVALI. Among the case reports (n = 34) [70–102, 139], 10 studies were ado- About 24.7% (n = 23) of the studies categorized under this lescent patients (12 to 17 year olds), and 23 involved young sub-topic examined other health effects of cannabis vap- adults (18 to 29 year olds); 31 of the 34 cases reported vap- ing, including oral health issues, other respiratory effects, ing THC or THC use was confirmed through urine analy - cardiotoxicity, and seizures [65, 141–162]. Young persons sis. Different diagnostic presentations of individuals with who vape cannabis with oral health issues presented with 1 3 222 Current Addiction Reports (2022) 9:217–234 conditions such as dental caries, erosions, and ulcerations and driving performance were similar for THC-dominant [147]. Case reports of teens who vape cannabis described cannabis and THC/CBD equivalent cannabis and, in some someone with daily use presenting with seizures [149] and cases, CBD may worsen THC-induced impairment. Another someone who vaped for the first time presented with myo- placebo-controlled randomized trial reported enhanced ver- cardial ischemia following chest pain [150]. One young bal episodic memory performance among those adminis- who vaped cannabis who presented with respiratory issues tered cannabidiol as compared to the placebo, while also had bronchiolitis (with mechanism distinct from EVALI) indicating that CBD may not impact attention or working [152]; while two cases who vaped cannabis were treated memory performance negatively as no significant effects for nontuberculous mycobacteria (NTM) infection [153]. were found for those outcomes [159]. Health effects associ- Another case report of a young person who vaped cannabis ated with cannabis vaping among youth and young adults oil described symptoms of catatonia, mania, and psycho- are summarized in Table 2. sis supposedly induced by previous cannabis vaping [151]. Cases of eosinophilic pneumonitis, synthetic cannabinoid Etiology intoxication, Torsades de pointes, and cardiac arrest were reported among youth who vaped various forms of mari- This review identified 48 studies that reported on the etiol- juana [155, 160–162]. A qualitative study which interviewed ogy of cannabis vaping [3, 21, 24, 28, 29, 31, 33, 43, 47, 50, cannabis vaping youth reported participants describing the 64, 163–196, 197 , 198–200]; most of these studies were physical health effects ranging from respiratory, oral, nau- cross-sectional ones (Table 1). The most commonly stud- sea, and appetite related and headaches [157]. ied correlates were biological sex; age or grade level; race/ Other observational studies examined subjective effects, ethnicity; socio-economic status (SES); other tobacco use, functioning (physical, social, and mental), and respiratory including nicotine vaping (i.e., e-cigarette use); and other effects such as bronchitis and wheezing [ 65, 144–146, 156]. modes of cannabis use (e.g., smoking). Consistent findings An intensive longitudinal study on subjective cannabis are summarized here. Across studies, cannabis vaping was intoxication and modes of administration found that par- more common among males than females [21, 24, 28, 29, ticipants reported higher intoxication on the days they used 47, 170, 173, 178, 179, 182, 185, 198, 200], and among only bongs than the days they used only vapes [158]. older youth (e.g., high school compared to middle school Experimental studies examined the effects of vapor- students) in most studies [21, 29, 47, 163, 167, 198], and ized cannabis on cognition, psychomotor performance, and among young adults compared to older adults [31, 50]. Can- physiological pain [141–143]. In a double-blind crossover nabis vaping was also more common among Hispanic youth study, Wilsey et al. examined analgesic efficacy of vapor - compared with non-Hispanic White [28, 163, 167, 190] or ized cannabis by comparing medium dose, low dose, and Black [21, 28, 167, 190, 198] youth. Some studies showed placebo treatment [142]. Subjects reported greater pain relief that Black youths were more likely to vape cannabis relative (measured by visual analog scale and Patient Global Impres- to White youth [64, 163], while other studies showed the sion of Change) by using cannabis compared to placebo, reverse [21, 24, 198, 200]. Studies showed greater socio- while results were almost similar for low and high dose. economic status (SES) may be a risk factor for cannabis vap- Spindle et al. examined acute dose effects of smoked and ing [24, 47, 64, 170, 182]. E-cigarette use with nicotine only vaporized cannabis in a double-blind, crossover study [141]. or flavors [28, 29, 163, 166, 172–174, 180, 186, 197 , 198, They reported higher peak concentrations of THC in blood 200], as well as use of cigarettes, cigars, hookah, and smoke- and stronger drug effects for pharmacodynamic outcomes less tobacco [21, 28, 29, 50, 163, 166, 174, 178, 179, 186, (subjective drug effects, cognitive and psychomotor perfor - 195, 197 , 199] is associated with greater odds of cannabis mance) by using vaporized cannabis as compared to equal vaping. Former cannabis use, susceptibility to use cannabis, doses of smoked cannabis. In another double-blind, crosso- and peer use of cannabis, via vaping and other forms of ver study, Arkell et al. examined the effects of vaporized cannabis consumption (e.g., ingesting, smoking), have also THC-dominant cannabis (containing 11% THC and < 1% been shown to be related to greater odds of cannabis vaping CBD), THC/CBD equivalent cannabis (containing 11% [21, 169, 170, 173, 175, 179, 180, 184, 200]. Greater access THC and 11% CBD), and placebo (containing < 1% THC/ to both e-cigarettes [33, 167, 197 ] and cannabis [167]; and CBD) on driving and cognitive performance [143]. Com- parent, sibling, and peer cannabis vaping [28, 64, 166, 180, pared to placebo, cognitive performance was impaired by 197 ] are associated with cannabis vaping. both cannabis types, especially by the THC/CBD equiva- Other less studied correlates of cannabis vaping included lent. Both cannabis types had little effect on driving per - alcohol use [170, 174, 197 , 198, 200], non-medical pre- formance, except for a car-following task, where increased scription use [174], and illicit drug use [170, 188]; greater lane weaving was reported for both types of cannabis. The impulsivity [174, 179] and attention-related factors authors conclude that adverse effects specific to cognitive (e.g., inattention, perseverance) [174]; openness to new 1 3 Current Addiction Reports (2022) 9:217–234 223 Table 2 Health effects, risk factors and reasons associated with cannabis vaping among youth and young adults Health effects of cannabis vaping:   • Symptoms (bronchiolitis, bronchitis, wheezing, nontuberculous mycobacteria infection)   • Respiratory gastrointestinal symptoms   • Constitutional symptoms (cough, difficulty breathing, nausea, diarrhea, fever, chills, and/or weight loss)   • Oral health issues (dental caries, erosions, ulcerations)   • Myocardial ischemia   • Mental health (psychosis, mania, catatonia)   • Pain relief   • Impaired cognitive performance Risk factors or correlates of cannabis vaping:   • Male sex   • Older age (older youth or young adults relative to older adults)   • Hispanic and Black race/ethnicity compared to White   • Greater socio-economic status, greater parental education level   • E-cigarette use with nicotine or flavors   • E-cigarette use for reason trendy/cool   • E-cigarette marketing exposure   • Low disapproval of nicotine vaping   • Other cannabis use (spliffs, blunts, pipes, bidis)   • Medical cannabis use   • Vaping cannabis in a vehicle   • Obtaining cannabis from dispensaries or recreational retailers versus friend and family   • Susceptibility to cannabis use   • Low disapproval of smoking cannabis regularly   • Other tobacco use (cigarette, cigars, hookah, smokeless tobacco)   • Alcohol use or binge drinking   • Non-medical use of prescription stimulant use or prescription opioids   • Other illicit drug use   • Easy access to e-cigarettes and cannabis   • Lower perceived addictiveness of e-cigarettes   • Lower perceived risk of cannabis use   • Living with peers, parents, siblings who use cannabis   • Endorsement by peers   • Presence in social network   • School-related factors (urban or suburban, low grade point average, skipped class, delinquent behavior)   • Sensation seeking   • Presence among social networks   • Greater impulsivity and inattention (ADHD impulsivity)   • Negative/positive urgency   • Lack of perseverance   • Openness to new experiences   • Psychiatric symptoms (conduct problems, depressive symptoms, anhedonia, psychotic experiences)   • Canadian immigration status Reasons for cannabis vaping:   • To get high   • Safer than smoking, combustion   • Healthier than smoking   • Less discomfort/irritation compared with smoking   • Reduce or quit cigarette smoking, other combustible tobacco, or cannabis   • Control dosage   • Maintain sustained high   • Experimentation   • Mixing with flavors   • Friend use   • Looks trendy/cool   • Enjoyment   • Stress relief   • Relaxation   • Sleep improvement   • Mood improvement   • Efficient   • Discreetness   • Convenience   • Circumvent smoking bans   • Cheaper than smoked cannabis   • Easily concealed experiences [182] and sensation seeking [170, 189]; psychi- marketing (see “Marketing” section, below) [179]; school atric symptoms (e.g., depressive symptoms, conduct prob- urbanicity (urban and suburban being greater risk versus lems) [174, 182]; delinquent behavior [196]; low grade point rural) [24, 198]; using cannabis in a vehicle [170]; obtaining average and skipping class [167]; internalizing and external- cannabis from dispensaries or recreational retailers versus izing problems [197 , 198]; more exposure to e-cigarette from friends and family [171]; low disapproval of nicotine 1 3 224 Current Addiction Reports (2022) 9:217–234 vaping [167] and of smoking cannabis regularly, [182] lower platforms including e-liquid vendor online sites [202], the perceived risk of cannabis use [167]; lower perceived addic- Google Play Store [203], YouTube [204, 205], Instagram tiveness of e-cigarettes [163]; and earlier age of initiation of [206–209], and Twitter [210, 211]. Together, these studies cannabis use, in any form [170, 200]. showed that content was primarily promotional, with very Seven studies reported on youth and young adults’ rea- little prevention, cessation, or health messaging. In 2020, sons for cannabis vaping [50, 178, 181–183, 187, 193]. in an effort to combat COVID-19, South Africa restricted Reasons included that vaping cannabis is safer, healthier, tobacco and e-cigarette product sales over a 5-month period. and/or less physically irritating than cigarettes or com- Studying this, Agaku et al. showed that among 2661 e-liq- bustible tobacco; to reduce or quit smoking cigarettes or uids marketed by online vendors, about 29% were canna- other combustible tobacco products, as well as cannabis; bidiol (CBD) liquids, primarily fruit and tobacco-flavored to control dosage or amount of cannabis consumed and/or [202]. During the restriction period, online vendors com- to maintain a sustained high; experimentation; mixing with monly promoted CBD liquids instead of nicotine-containing flavors; friends’ use; because cannabis vaping is “trendy” e-liquid, salts, and concentrates [202]. Meacham et al. iden- and “cool”; because it is enjoyable; stress relief; relaxation; tified 79 Google Play Store applications that were related sleep improvement; mood improvement; and its discreetness to vaping, three of which were specific to cannabis vaping, or ability to circumvent smoking bans. One study reported with the remaining specific to nicotine or unspecified [203 ]. a reason that may deter young adults from cannabis vaping, Applications were commonly categorized as “tools and life- namely that vaping may be less safe than other forms of style,” “health and fitness,” and “social” and included do- consuming cannabis [181]. it-yourself content for creating e-liquids and coils, games, Four studies reported on youth and young adults’ harm social networking, purchasing e-cigarette products, smoking perceptions of cannabis vaping [176, 177, 181, 191]. One cessation services, pairing with e-cigarettes to adjust dos- study reported that young adults perceived combustible (e.g., age and temperature, and e-cigarette cessation [203]. Yang smoked, via a joint or pipe) cannabis as more harmful than et al. identified 214 YouTube videos over a 1-year period in vaporized cannabis; however, chemicals (e.g., butane) used 2014–2015 related to cannabis vaping [204]. Most videos make cannabis concentrates were thought to be a source were generated and shared by lay persons and included per- of harm [181]. Another study reported that most partici- sonal experiences and tips, instructions, and product reviews pants perceived using e-cigarettes to vape cannabis to be related to cannabis vaping — although 21% of videos were just as harmful or more harmful than joint use. Studies also clearly marketing a specific brand or product [204]. Over a reported uncertainty about the safety and harms of canna- 4-month period in 2018, Ramamurthi et al. identified 18,200 bis vaping compared to other forms of use [177, 191]. One “stealth vaping” YouTube videos that touted numerous dis- study reported that youth and young adult cannabis vapers creetly designed e-cigarettes like JUUL’s USB-like device, had lower odds of perceiving harm from daily cannabis use to enable discreet vaping of nicotine and cannabis, espe- in any form, when compared to never cannabis users [176]. cially by youth [205]. E-cigarettes in these videos resembled Risk factors and reasons for use associated with cannabis pens, smart phones and other electronics, and even asthma vaping among youth and young adults are summarized in inhalers [205]. Over a 2-week period in 2014, Cavazos-Rehg Table 2. et al. identified over 400,000 Instagram posts with cannabis- related hashtags [206]. Of a random sample of 5000 of these posts, 2136 were explicitly about cannabis (generally) [206]. Marketing About 9% (187/2136) of cannabis-related posts were adver- tisements, many of which (43%; 80/187) promoted devices A growing body of literature shows e-cigarette marketing or tools to use cannabis including advertising vape pens to is prevalent, largely unregulated, and is an important risk use cannabis (13%; 10/80) [206]. Majmundar et al. iden- factor for e-cigarette use among youth and young adults, tified 1775 Instagram posts with the hashtag #kandypens especially [201]. This review identified 11 studies that exam- posted over a 1-month period in 2018, and about 32% of ined marketing and/or other types of messaging about using these posts referenced using cannabis-related solutions in e-cigarettes and the relation to vaping cannabis-related sub- Kandy Pens [207]. These posts were made and distributed by stances. These studies primarily focused on digital media laypersons, vendors, KandyPen’s official Instagram account, (i.e., internet and social media), which is highly utilized by vaping advocates or enthusiasts, and influencers [207]. Cza- e-cigarette manufacturers and other promoters due to lax plicki et al. identified over 50,000 JUUL-related Instagram regulations, low cost, and access to vast and diverse young posts over 2 ½ months in 2018, prior to JUUL Lab’s vol- audiences. untary actions limiting their own youth-oriented Instagram Most studies (n = 10) were descriptive content analyses content in May 2018, and over 6 months following these of messaging about vaping cannabis on varied digital media self-imposed restrictions in 2018 [208]. Cannabis-content 1 3 Current Addiction Reports (2022) 9:217–234 225 in JUUL-related posts was identified as a common theme, states where recreational cannabis use is legal [62]. Canada and one that grew in prominence over time in 2018 [208]. legalized recreational marijuana use for adults in 2018. Kostygina et al. identified cannabis vaping themes in JUUL- One study reinforced that legalization does not appear to related Instagram posts over 2 ½ months in 2018. Cross- strengthen barriers to obtaining cannabis for underage youth promotion of JUUL with cannabis products was a prominent [55]. Increases in multimodal use of cannabis (e.g., smok- theme in commercial posts, and youth use of JUUL with ing, vaping, and/or ingesting) among underage youth were marijuana was a prominent theme in organic, non-commer- observed after legislation was passed [54, 56]. cial posts [209]. Two studies of e-cigarette-related tweets Readers are referred to a summary [35] that describes the posted in 2019 identified cannabis vaping as a prominent regulatory and marketing environment related to legalization theme, for example, cannabis vaping was discussed on Twit- of adult-use cannabis in 11 legalized states. This paper noted ter as “the real problem” causing the EVALI outbreak [210, that regulatory approaches vary substantially but most states 211]. set standards on (1) quantity; (2) eligibility for purchase; (3) Only one study reported statistically significant longitudi- transportation; (4) retail setting; and (5) how cannabis can be nal associations between marketing via numerous channels grown, packaged, sold, distributed, and promoted. Regula- including digital media and cannabis vaping [179]. Kreitz- tory approaches include rules and guidelines for cannabis berg et al. reported increased odds of using e-cigarette prod- vaping products, including establishing quantity limits for ucts with cannabis 1-year later among 3720 college students THC concentrates as well as requiring labels to state the who self-reported increased exposure to e-cigarette advertis- same and whether concentrates have been tested for contam- ing via eight channels: gas/convenience stores, drug stores, inants. Strong enforcement efforts are necessary, as studies grocery stores; liquor stores; bars or clubs; music events; report that many underage youth and young adults success- radio or internet radio; online; magazines or newspapers; fully purchase their devices online or from vape shops [222]. and billboards [179]. Regulation Discussion As of May 2021, a total of 36 states and 4 US territories From 2013 forward, consistent with increases in cannabis allow for medical use of cannabis products and 18 states, 2 vaping among young people [2 ], the available research lit- US territories, and the District of Columbia have legalized erature on this topic has grown exponentially. We hope this adult-use (recreational) cannabis [212]. Of note, two states review provides a timely summary of the state-of-the-knowl- (South Dakota and Mississippi) passed ballot initiatives by edge, in ways that inform development of preventive inter- popular vote to legalize cannabis use (medical and adult- ventions and provides direction for future studies. Clearly, use in South Dakota; medical-only in Mississippi) in 2020; surveillance of cannabis vaping among young people should however, these ballot initiatives were overturned by the State continue. It would be beneficial for efforts to continue to Supreme Court in each state [212]. Most states set no legal collect information that informs comparisons by substance age restrictions for medical cannabis, though all require a (e.g., THC, CBD vs. nicotine) and method (e.g., vaping vs. prescription from a credentialed medical professional and for smoking) of use, so that other streams of research (e.g., on minors to use under the supervision of their guardian. Legal health effects) can anchor appropriately into this informa- age for purchase of adult-use cannabis is 21 years of age in tion. Although reports of EVALI have declined over time, a all legalized states, territories, and the District of Columbia body of literature is starting to emerge regarding the other [212]. health effects of cannabis vaping. To date, little research Several articles explored cannabis vaping prevalence has examined its impact on gastrointestinal issues, despite a among youth and young adults by state-level cannabis reg- larger body of evidence on the same for cannabis smoking ulatory policy [213 , 214–219]. Across the USA, studies [65, 141–153]. More studies of the impact of cannabis vap- show the prevalence of any form of cannabis consumption ing on cognition, affect, and behavior will also be useful, among young people, including for cannabis vaping, is con- given limited research to date. Preventive interventions can sistently higher in legalized states, relative to prohibition benefit from the information summarized here, which high- states [213 , 220, 221]. One study also showed that among lights important target audiences that can benefit given their youth who had ever used cannabis, those living in a legalized higher prevalence of use (e.g., older youth, young adults; state initiated cannabis vaping at a slightly earlier age than Hispanic youth) and risk factors (e.g., reasons for use, risk those in prohibition states (mean age = 15.3 vs. 15.4 years; perceptions) that could be relevant to the development of p < 0.01) [42]. Another study showed that cannabis vap- program or communication campaign content. ing (and other forms of cannabis consumption) was more Overall, there is a dearth of research on marketing of and/ prevalent among young adults compared to older adults in or other types of messaging about cannabis vaping. More 1 3 226 Current Addiction Reports (2022) 9:217–234 study; personal fees from XX is a consultant in litigation involving the research is needed to describe the various channels through vaping industry, outside the submitted work. Sumbe A. reports grants which cannabis vaping is promoted especially via the ever- from NIH/NCI, during the conduct of the study. Dr. Case has nothing expanding world of digital media, as well as the content to disclose. Dr. Mantey reports grants from NIH/NCI, during the con- and source of messages about cannabis vaping. Although duct of the study; personal fees from XX is a consultant in litigation involving the vaping industry, outside the submitted work. Swan. S Apple, Facebook, and many popular, digital media compa- reports grants from NIH/NCI, during the conduct of the study. nies have self-imposed policies against tobacco, e-cigarette, cannabis, and other drug use, some studies have shown these Human and Animal Rights and Informed Consent This article does not are lacking in preventing youth and young adults’ exposure contain any studies with human or animal subjects performed by any of the authors. to tobacco and other substance use-related content via these media [223]. Additionally, there are no federal restrictions on digital marketing to curb commercial e-cigarette mar- Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- keting, at least. The nine studies identified in this review tion, distribution and reproduction in any medium or format, as long suggest e-cigarette — and particularly cannabis vaping — as you give appropriate credit to the original author(s) and the source, marketing and other promotional messaging appear to be provide a link to the Creative Commons licence, and indicate if changes critical factors contributing to the explosion of cannabis were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated vaping among youth and young adults. otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a Conclusions copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . As the regulatory environment for cannabis products con- tinues to open up not only across many states in the USA but also in other countries like Uruguay, Canada, Mexico, References and South Africa, the need for research and intervention specific to youth and young adults will become increasingly Papers of particular interest, published recently, have relevant. The research to-date clearly shows that cannabis been highlighted as: vaping among young people is consistently higher in set- • Of importance tings where use is legal for those over the age of 21 years. Therefore, additional methods for preventive interventions 1. Grant MJ, Booth A. A typology of reviews: an analysis of 14 will be necessary in the future, and development of these review types and associated methodologies. Health Info Libr J. 2009;26(2):91–108. must be informed by etiologic research. 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Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Supplementary Information The online version contains supplemen- Center for Chronic Disease Prevention and Health Promotion, tary material available at https://doi. or g/10. 1007/ s40429- 022- 00413-y . Office on Smoking and Health, 2016. 4. Schulenberg JE, Patrick ME, Johnston LD, O’Malley PM, Bachman JG, Miech RA. Monitoring the future national survey Funding Research reported in this paper was supported by grant results on drug use, 1975–2020: Volume II, college students and number [R01-CA239097] from the National Cancer Institute and by adults ages 19–60. Ann Arbor: Institute for Social Research, the Career Development Program — National Cancer Institute/NIH The University of Michigan. 2021. Available at http://monit or ing Grant — National Cancer Institute/NIH Grant T32/CA057712 (author: thefu ture. org/ pubs. html# monog raphs. DSM). 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Cannabis Vaping Among Youth and Young Adults: a Scoping Review

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Springer Journals
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Copyright © The Author(s) 2022
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2196-2952
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10.1007/s40429-022-00413-y
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Abstract

Purpose of Review The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults. Recent Findings Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same. Summary Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vap - ing for young people, along with risk factors and reasons for the same. Keywords Cannabis · Vaping · Health effects · Epidemiology · Etiology · Regulation Introduction These studies include information relevant to the epidemiol- ogy, health effects, etiology, marketing, and regulation of The purpose of this review was to describe the state-of-the- cannabis vaping and are applicable to young people less than literature regarding research specific to cannabis vaping 30 years old. among youth and young adults [1]. A recent meta-analysis found that among adolescents in the USA and Canada, life- time, past-12 month, and 30-day prevalence of cannabis vap- Methods ing increased by two- to seven-fold, from 2013 to 2020 [2 ]. Preference for cannabis products, therefore, may be shifting This review was conducted using methods consistent with from dried herb to cannabis oil (e.g., liquid tetrahydrocan- the Preferred Reporting Items for Systematic Review and nabinol (THC), the primary psychoactive component in can- Meta-Analysis for scoping reviews (PRISMA-ScR) [6]. A nabis) — and, given the emergence [3] and predominance scoping review was deemed appropriate, as it focuses on an of e-cigarette use among young people now [4, 5], from assessment of the potential size and scope of available litera- smoking to vaping cannabis. Here, we provide a summary ture. We categorize the available literature into relevant sub- of results from 202 original investigations on this topic (see topics and summarize the findings in the “ Results” section. Supplementary Table 2), published between 2007 and 2021. Search Strategy This article is part of the Topical Collection on Tobacco Addiction Our search strategy was informed by recent published * Melissa B. Harrell reviews of vaping among youth and young adults specific to Melissa.B.Harrell@uth.tmc.edu the impact that nicotine vaping has on subsequent cannabis [7] or combustible tobacco product use [8–11]. Consistent School of Public Health, University of Texas Health Science with these reviews, the following databases were searched Center at Houston (UTHealth), 1616 Guadalupe St., Suite 6.300, Austin, TX 78701, USA for studies: PubMed, Embase, and Web of Science. In addition, searches were conducted on the aforementioned Center for Research to Advance Community Health, UTHealth San Antonio, San Antonio, TX, USA Vol.:(0123456789) 1 3 218 Current Addiction Reports (2022) 9:217–234 reviews [7–11] and relevant summary reports [3, 12, 13] (e.g., nicotine, flavors only); studies whose participants for additional studies, too. Keywords included: e-cigarettes, were not youth or young adults; animal studies; and, vaping, ENDS, JUUL; cannabis, marijuana, THC, CBD; finally, articles that were not original research (e.g., edi- adolescents, young adults. Keywords used for each database torials, commentaries, and review articles). are provided in Supplementary Table 1. When available, we A total of 1801 articles were initially identified. After used subject headings (PubMed: MeSH; Embase: Emtree). removing 416 duplicates, 1385 titles and abstracts were Searches were conducted from January 2007 to December independently reviewed by at least 2 of the 6 co-authors 2021. The initial date was chosen as it coincides with the to determine their suitability for full-text screening. After appearance of the “modern” e-cigarette or vaping device on removing 927 articles at this stage, each of 458 articles the international market [14]. selected for full-text screening was again independently reviewed by at least 2 co-authors for inclusion. Any dis- Study Selection crepancies between reviewers were discussed among all co- authors until consensus was reached. Ultimately, 202 articles All studies retrieved through these searches were imported were deemed relevant. Figure 1 is the PRISMA flow diagram into software designed to support systematic reviews for this process. Supplementary Table 2 provides a list of ( https:// www . co vid ence. or g/) [15] and study selection these 202 articles. was done there. There were five inclusion criteria. First, we included studies that examined cannabis vaping as a central topic or had findings about cannabis vaping. Sec- Extraction ond, study participants were youth (12–18 years old) and/ or young adults (18–29 years old), or the study findings Data extracted from each study included the following: were relevant for young people (e.g., the unit of analysis study design; study sub-topic, including epidemiology, was advertisements, but study findings were relevant for health effects, etiology, marketing, and regulation; key youth and/or young adults). Third, studies were original findings about cannabis vaping within each sub-topic area; research; fourth, studies were full-text articles; and fifth, and, where relevant, study characteristics (e.g., location, the articles were written in English. The reasons for exclu- participants’ age). Typical of a scoping review, no formal sion included studies in which cannabis was not vaped, assessment of the quality of the eligible manuscripts was but only consumed in some other form; studies that only conducted, so information on the risk of bias that may be addressed vaping with substances other than cannabis inherent in each of these studies is not presented here. Fig. 1 PRISMA flo w diagram PubMed Embase Web Of Science Other Sources (n=204) (n=676) (n=863) (n=58) Total Results From Search (n=1801) Duplicates Removed (n=416) Titles And Abstracts Screened Irrelevant Articles Removed (n=1385) Full Text Reviewed (n=458) Excluded (n=256) Not full text (n=82) Wrong mode of marijuana consumption, or did not distinguish modes of marijuana use (n=104) Not original research, or a review (n=40) Adult population (n=21) Cannabis vaping not a central topic (n=6) Non-English (n=3) Final Articles Included (n=202) 1 3 Included Screening Identification Current Addiction Reports (2022) 9:217–234 219 past 30-day cannabis vaping observed among young adults Results (college students) from 2017 to 2018 was among the larg- est 1-year increase in any substance use ever recorded in Overview the history of MTF (> 40 years) [4]. From 2018 to 2019, a similar doubling in the prevalence of past 30-day canna- No studies that met the inclusion criteria were published bis vaping was also observed for youth (8th, 10th, and 12th from 2007 to 2013. From 2013 onwards, the rate of pub- grade) [16]. Frequent vaping (defined as using ≥ 10 times in lication increased exponentially, reaching a peak in 2020 the last month) increased significantly among high school (Supplementary Fig. 1) that was driven, in large part, by seniors from 2018 to 2019, too [17]. MTF data for young many articles (n = 70) on EVALI (e.g., case reports). Table 1 adults for 2021 were not available at this writing. (Note that provides a summary of the number of articles reviewed here, the MTF publications that these prevalence estimates are by study design and sub-topic. Most studies were specific to derived from report data on “vaping marijuana” questions health effects and etiology. measured in the vaping section of the survey [4, 16]. One recent study shows that there is some discordance in preva- Epidemiology lence estimates, if measures from the cannabis section on “using cannabis in a vaporizer” are used, instead [18]. Thus, National Estimates researchers must take care when considering how best to ask questions about cannabis vaping and where to place them on Annual prevalence estimates of cannabis vaping were avail- a survey instrument [19]. able from Monitoring the Future (MTF) from 2017 to 2021 Despite these alarming statistics, it is worth noting that, for youth (8th, 10th, and 12th grade) and from 2017 to 2021 for each year (2017 to 2020), behavioral measure, and age for young adults (college students) and are shown in Sup- group, the prevalence of cannabis vaping was less than the plementary Fig. 2 (lifetime use) and Supplementary Fig. 3 prevalence of nicotine vaping (data not shown) [4, 20–23]. (past 30-day use) [4]. Lifetime use increased rapidly for both For young adults, the prevalence of cannabis vaping was age groups from 2017 to 2020 then, for youth, declined in 20–30% less than that for nicotine vaping, while it was 2021. Among youth, lifetime prevalence rose from 8.5% in 50–60% less among youth. It is also worth reporting that 2017 to 20.1% in 2020, then decreased to 15.9% in 2021. from 2015 to 2018 (latest published data, among 12th grad- Among young adults, lifetime prevalence increased from ers only), cannabis smoking decreased, while cannabis 14.4% in 2017 to 34.6% in 2020. Notably, the doubling of vaping and the use of edibles increased [24]. From 2015 to 2018, for all students and among past-year cannabis users specifically, the prevalence of smoking cannabis was 2–3 Table 1 Frequency of studies by study design and research area times higher than the prevalence of vaping or use of edibles (n = 202) [24, 25]. Characteristic n (%) This comparison across substances (nicotine vs. cannabis) Study designs and modes of consumption (smoking vs. vaping vs. edibles)   Case-reports 44 (21.8%) helps to contextualize cannabis vaping among young people,   Case-series 28 (13.9%) demonstrating that, for now, it may not be as problematic   Randomized controlled trials 4 (2.0%) as other substance use behaviors. However, given observed   Observational 105 (52.0%) increases in recent years, efforts should continue to moni-     Cross-sectional 84 (41.6%) tor cannabis vaping among young people in the future, and     Cohort/longitudinal 21 (10.4%) assessing modes of consumption may be a helpful way to   Qualitative 18 (8.9%) guide prevention efforts [26]. Data on cannabis vaping are   Mixed methods 2 (1.0%) currently collected not only by MTF but also by the National   Meta-analysis 1 (0.5%) Youth Tobacco Survey (NYTS) (youth only) [27–29], the Research areas Behavioral Risk Factor Surveillance System (BRFSS)   Health effects 93 (46.0%) (young adults only) [30, 31], and the Population Assessment   Etiology 49 (24.3%) of Tobacco Use and Health (PATH) study (youth and young   Epidemiology 50 (24.8%) adults) [32]. Each surveillance system offers unique insights   Regulatory policy 17 (8.4%) into this phenomenon, given data it collects not only on can-   Marketing/advertising 11 (5.5%) nabis vaping but also on other substance use behaviors and modes of cannabis consumption, too. 1 2 Categories are mutually exclusive. Mixed methods studies were An analysis of PATH data from 2015 to 2016 for young cross-sectional + case series and longitudinal + qualitative. Catego- adults (18–24 years old), for example, showed that lifetime ries are mutually inclusive 1 3 220 Current Addiction Reports (2022) 9:217–234 or ever use of cigar products (e.g., cigarillos) to consume significant differences in the prevalence of past 30-day use cannabis (i.e., blunt use) was 3 times more common than of a vaporizer to heat dried herb were observed within coun- consuming cannabis by vaping or using a hookah to do so tries (England: 8.1% (2017), 12.5% (2018), 11.1% (2019); [32]. BRFSS surveys also include items on different modes Canada: 15.9% (2017), 19.3% (2018), 19.1% (2019); USA: of cannabis consumption (i.e., smoking, vaping, eating, and 20.6% (2017), 21.5% (2018), 23.0% (2019)). However, from dabbing) [30] and can be used to compare nicotine vaping 2017 to 2019, significant increases were observed for each and cannabis vaping [31]. Analyses of BRFSS data from country in the prevalence of past 30-day use of an e-cigarette 2018 showed past 30-day dual nicotine and cannabis vap- to vape oil or liquid (England: 9.0% (2017), 14.6% (2018), ing was as common among young adults as past 30-day 19.0% (2019); Canada: 12.9% (2017), 18.8% (2018), 25.9% cannabis vaping alone [31]. Analyses of NYTS data from (2019); USA: 24.2% (2017), 31.0% (2018), 52.1% (2019)). 2017 and 2018 showed that cannabis vaping was especially In 2017, for all three countries, vaping herb or vaping oil/liq- common for students who frequently use (i.e., use ≥ 20 days uid was the least common modes of cannabis consumption; per month) e-cigarettes [27]. Surveillance data on lifetime yet, from 2017 to 2019, across all three countries, vaping or ever cannabis vaping on the 2016 [28], 2017 [29], and oil/liquid increased more than other modes of consumption 2018 [29] NYTS surveys are consistent with the sustained (vaping herb, smoking, and edible use) [51]. In addition, increase reported in MTF, too. Two published studies while nicotine vaping was also more prevalent than cannabis [33, 34] specifically examined the possible impact of the vaping across these countries [53], dual use was common COVID-19 epidemic on cannabis vaping among youth [52]; and, in 2018, past 30-day cannabis users in the USA and young adults. One study showed that individual use were more likely to report vaping cannabis than in Canada or increased, decreased, or stayed the same, depending on rel- England [53]. Findings from the COMPASS study in Canada evant risk factors (e.g., access, dependence) [33]. Another before legalization in 2018 showed that ingesting and/or vap- national study of more than 4000 adolescents and young ing cannabis were more often in addition to smoking can- adults showed only 6.8% of participants increased cannabis nabis, rather than as a replacement [49]. Follow-up studies vaping during the pandemic, while 37% reduced or quit can- from COMPASS that included data from 2017 to 2018 and nabis vaping, and 42.3% reported no change [34]. Though 2018–2019 showed multiple modes of cannabis consump- not explicitly stated by MTF, COVID-19 could be a reason tion (smoking, vaping, and/or ingesting) and increased fre- for the leveling-off of past 30-day cannabis vaping from quency of the same were more common among high school 2019 to 2021 among both age groups seen in MTF (Fig. 4). students after legalization in 2018 [54–56]. Other studies from Finland [48] and Germany [50] show cannabis vap- Estimates by State ing among young people, at < 10%, may be less prevalent in these European countries than in England [51] though The prevalence of cannabis vaping among young people differences between studies by age and year of data col- does vary by state, consistent with differences in local poli- lection make comparison difficult. Pooled estimates across cies regarding age restrictions on use [35–43]. More infor- 2016–2018 from one study of youth (14–15 years old) in mation is provided below (see “Regulation” section). Data New Zealand show cannabis vaping is less prevalent there, from the 2017 Healthy Kids Colorado survey, one of the too [57]. Less than 10% of students reported using canna- first states to legalize recreational cannabis use for adults, bis in the past 30-day days and, of these, only 7% reported showed that vaping was far less common as a mode of con- exclusive cannabis vaping; 90% reported smoking cannabis, sumption among youth than smoking or ingesting cannabis in contrast [57]. Estimates from other countries were not (i.e., edible use) [44]. NYTS data from Florida (2015) [45] located in this review. and North Carolina (2017) [46], where recreational cannabis use was and still is illegal, even for adults, showed 1 in 10 Use Trajectories high students reported cannabis vaping. Several studies reported on developmental trajectories of use International Estimates that describe the onset and progression of cannabis vaping across adolescence into young adulthood [58–63]. Several Several studies identified through this review provided of these studies focused on cannabis vaping only [60–63], estimates of cannabis vaping among young people from while others show cannabis vaping co-occurs with other other countries [47–53]. Data for 16 to 19 year-olds from substance use behaviors [58, 59]. Studies from California the International Tobacco Control Policy Evaluation (ITC) [60] and Texas [63] both show variability by sub-groups study showed cannabis vaping is more prevalent in the USA, of young people: some young people start cannabis vap- followed by Canada and England, consistent with regula- ing in adolescence, while others begin in young adulthood; tory policy in each country [51–53]. From 2017 to 2019, no and some trajectories escalate quickly, while others escalate 1 3 Current Addiction Reports (2022) 9:217–234 221 less rapidly. However, declines in use from adolescence into EVALI were provided in the articles, which aligned with young adulthood are generally not observed [60, 63]. Taken the broad case definition established by the CDC, which together, these studies suggest a strong, positive relationship includes (1) e-cigarette use or dabbing resin within 90 days between age and cannabis vaping that may (or may not) peak of symptom onset, (2) pulmonary infiltrate present on radio- in young adulthood. No studies reported on quit intentions graphs, (3) no evidence of pulmonary infection with mini- or behaviors, providing scope for future research. mum workup of a viral respiratory panel and influenza test- ing, and (4) no evidence of alternative plausible diagnosis Special Populations [4]. Studies highlighted a need to assess history of vaping use behaviors for patients with EVALI-like symptoms. Several studies reported on use in special populations The case series papers (n = 25) provided insight into pat- [64–69], like hospitalized adolescents [69], pregnant young terns of and risk factors for EVALI across individual patients adults [68], young adults with asthma [67], nightclub patrons [103–128, 137]. For example, among 160 patients reported [66], young people with inflammatory bowel disease [65], to the California Department of Public Health, the median and young people in substance use treatment centers [64]. age of participants was 27 years, 62% were male, and 46% The reader is directed to these publications for further infor- of patients were admitted to the intensive care unit [113]. mation. Data for all of these studies were collected between Among the vaping devices gathered from participants (87 2015 and 2020. devices from 24 patients), 56% contained THC, and vitamin E acetate was found in 84% of the THC vape products [113]. Health Eec ff ts Another case series of EVALI patients (n = 86) in Wiscon- sin and Illinois added to these findings by identifying Dank EVALI Vapes as a potential source of the contaminated cartridges; 66% of patients reported use of Dank Vapes [118]. In addi- In Spring 2019, reports of e-cigarette, or vaping, associ- tion to risk factors for EVALI, case series such as Kalin- ated lung injury (EVALI) began to emerge across the USA, insky et al. described treatment considerations and recom- with cases peaking in Summer 2019 [1, 2 ]. Cases were mendations [106]. Treatment recommendations for EVALI characterized by respiratory, gastrointestinal, and/or con- included (1) supportive respiratory support as needed (i.e., stitutional symptoms, including cough, difficulty breath- supplemental oxygen, ventilation), (2) antibiotics for severe ing, nausea, diarrhea, fever, chills, and/or weight loss [1, cases, per blood culture results, (3) antivirals until influenza 3]. To date, the Centers for Disease Control and Preven- is excluded (if symptoms occur during flu season), and (4) tion (CDC) has recorded 2807 EVALI cases and 68 deaths corticosteroids to treat lung inflammation. across 50 states, Puerto Rico and the US Virgin Islands. In the cross-sectional studies (n = 9), [126, 129 , The severity of EVALI varies, with the most severe cases 130–136] research highlighted demographic characteristics leading to extended ICU stays, lung transplants, and death of EVALI patients, substance use behaviors, and risk factors [1, 2 ]. Given the emergence of EVALI and the subse- for EVALI. Common risk factors across studies for EVALI quent research that implicated vitamin E acetate found in included younger age, cannabis vaping, higher frequency of some cannabis vape products in the outbreak, the majority cannabis vaping, the use of Dank Vapes (a brand of e-ciga- of studies investigating the health effects of cannabis vap- rettes only available on the black market), as well as obtain- ing (n = 93) focused on EVALI (n = 70), including 34 case ing products from informal sources. These findings are sup- reports [70–102], 25 case series [103–128], 8 cross-sectional ported by current evidence from the CDC; as of the last studies [129 , 130–136], 1 longitudinal study [137], and 1 update (data from January 14, 2020) [140], 76% of EVALI qualitative study [138]. One study included a case series patients were under 35 years of age. Blount et al. provided of EVALI patients and a cross-sectional analysis of vaping the strongest evidence on the link between vitamin E acetate devices; therefore, this was counted as both a case series and and development of EVALI; vitamin E acetate was found cross-sectional study [26]. in 94% of patients’ BAL (bronchoalveolar-lavage) fluid and The case series and case reports detailed symptoms at was in BAL fluid taken from the control participants [130]. diagnosis including respiratory, gastrointestinal, and con- stitutional symptoms; and information on the treatment and Other Health Issues outcomes of numerous patients with EVALI. Among the case reports (n = 34) [70–102, 139], 10 studies were ado- About 24.7% (n = 23) of the studies categorized under this lescent patients (12 to 17 year olds), and 23 involved young sub-topic examined other health effects of cannabis vap- adults (18 to 29 year olds); 31 of the 34 cases reported vap- ing, including oral health issues, other respiratory effects, ing THC or THC use was confirmed through urine analy - cardiotoxicity, and seizures [65, 141–162]. Young persons sis. Different diagnostic presentations of individuals with who vape cannabis with oral health issues presented with 1 3 222 Current Addiction Reports (2022) 9:217–234 conditions such as dental caries, erosions, and ulcerations and driving performance were similar for THC-dominant [147]. Case reports of teens who vape cannabis described cannabis and THC/CBD equivalent cannabis and, in some someone with daily use presenting with seizures [149] and cases, CBD may worsen THC-induced impairment. Another someone who vaped for the first time presented with myo- placebo-controlled randomized trial reported enhanced ver- cardial ischemia following chest pain [150]. One young bal episodic memory performance among those adminis- who vaped cannabis who presented with respiratory issues tered cannabidiol as compared to the placebo, while also had bronchiolitis (with mechanism distinct from EVALI) indicating that CBD may not impact attention or working [152]; while two cases who vaped cannabis were treated memory performance negatively as no significant effects for nontuberculous mycobacteria (NTM) infection [153]. were found for those outcomes [159]. Health effects associ- Another case report of a young person who vaped cannabis ated with cannabis vaping among youth and young adults oil described symptoms of catatonia, mania, and psycho- are summarized in Table 2. sis supposedly induced by previous cannabis vaping [151]. Cases of eosinophilic pneumonitis, synthetic cannabinoid Etiology intoxication, Torsades de pointes, and cardiac arrest were reported among youth who vaped various forms of mari- This review identified 48 studies that reported on the etiol- juana [155, 160–162]. A qualitative study which interviewed ogy of cannabis vaping [3, 21, 24, 28, 29, 31, 33, 43, 47, 50, cannabis vaping youth reported participants describing the 64, 163–196, 197 , 198–200]; most of these studies were physical health effects ranging from respiratory, oral, nau- cross-sectional ones (Table 1). The most commonly stud- sea, and appetite related and headaches [157]. ied correlates were biological sex; age or grade level; race/ Other observational studies examined subjective effects, ethnicity; socio-economic status (SES); other tobacco use, functioning (physical, social, and mental), and respiratory including nicotine vaping (i.e., e-cigarette use); and other effects such as bronchitis and wheezing [ 65, 144–146, 156]. modes of cannabis use (e.g., smoking). Consistent findings An intensive longitudinal study on subjective cannabis are summarized here. Across studies, cannabis vaping was intoxication and modes of administration found that par- more common among males than females [21, 24, 28, 29, ticipants reported higher intoxication on the days they used 47, 170, 173, 178, 179, 182, 185, 198, 200], and among only bongs than the days they used only vapes [158]. older youth (e.g., high school compared to middle school Experimental studies examined the effects of vapor- students) in most studies [21, 29, 47, 163, 167, 198], and ized cannabis on cognition, psychomotor performance, and among young adults compared to older adults [31, 50]. Can- physiological pain [141–143]. In a double-blind crossover nabis vaping was also more common among Hispanic youth study, Wilsey et al. examined analgesic efficacy of vapor - compared with non-Hispanic White [28, 163, 167, 190] or ized cannabis by comparing medium dose, low dose, and Black [21, 28, 167, 190, 198] youth. Some studies showed placebo treatment [142]. Subjects reported greater pain relief that Black youths were more likely to vape cannabis relative (measured by visual analog scale and Patient Global Impres- to White youth [64, 163], while other studies showed the sion of Change) by using cannabis compared to placebo, reverse [21, 24, 198, 200]. Studies showed greater socio- while results were almost similar for low and high dose. economic status (SES) may be a risk factor for cannabis vap- Spindle et al. examined acute dose effects of smoked and ing [24, 47, 64, 170, 182]. E-cigarette use with nicotine only vaporized cannabis in a double-blind, crossover study [141]. or flavors [28, 29, 163, 166, 172–174, 180, 186, 197 , 198, They reported higher peak concentrations of THC in blood 200], as well as use of cigarettes, cigars, hookah, and smoke- and stronger drug effects for pharmacodynamic outcomes less tobacco [21, 28, 29, 50, 163, 166, 174, 178, 179, 186, (subjective drug effects, cognitive and psychomotor perfor - 195, 197 , 199] is associated with greater odds of cannabis mance) by using vaporized cannabis as compared to equal vaping. Former cannabis use, susceptibility to use cannabis, doses of smoked cannabis. In another double-blind, crosso- and peer use of cannabis, via vaping and other forms of ver study, Arkell et al. examined the effects of vaporized cannabis consumption (e.g., ingesting, smoking), have also THC-dominant cannabis (containing 11% THC and < 1% been shown to be related to greater odds of cannabis vaping CBD), THC/CBD equivalent cannabis (containing 11% [21, 169, 170, 173, 175, 179, 180, 184, 200]. Greater access THC and 11% CBD), and placebo (containing < 1% THC/ to both e-cigarettes [33, 167, 197 ] and cannabis [167]; and CBD) on driving and cognitive performance [143]. Com- parent, sibling, and peer cannabis vaping [28, 64, 166, 180, pared to placebo, cognitive performance was impaired by 197 ] are associated with cannabis vaping. both cannabis types, especially by the THC/CBD equiva- Other less studied correlates of cannabis vaping included lent. Both cannabis types had little effect on driving per - alcohol use [170, 174, 197 , 198, 200], non-medical pre- formance, except for a car-following task, where increased scription use [174], and illicit drug use [170, 188]; greater lane weaving was reported for both types of cannabis. The impulsivity [174, 179] and attention-related factors authors conclude that adverse effects specific to cognitive (e.g., inattention, perseverance) [174]; openness to new 1 3 Current Addiction Reports (2022) 9:217–234 223 Table 2 Health effects, risk factors and reasons associated with cannabis vaping among youth and young adults Health effects of cannabis vaping:   • Symptoms (bronchiolitis, bronchitis, wheezing, nontuberculous mycobacteria infection)   • Respiratory gastrointestinal symptoms   • Constitutional symptoms (cough, difficulty breathing, nausea, diarrhea, fever, chills, and/or weight loss)   • Oral health issues (dental caries, erosions, ulcerations)   • Myocardial ischemia   • Mental health (psychosis, mania, catatonia)   • Pain relief   • Impaired cognitive performance Risk factors or correlates of cannabis vaping:   • Male sex   • Older age (older youth or young adults relative to older adults)   • Hispanic and Black race/ethnicity compared to White   • Greater socio-economic status, greater parental education level   • E-cigarette use with nicotine or flavors   • E-cigarette use for reason trendy/cool   • E-cigarette marketing exposure   • Low disapproval of nicotine vaping   • Other cannabis use (spliffs, blunts, pipes, bidis)   • Medical cannabis use   • Vaping cannabis in a vehicle   • Obtaining cannabis from dispensaries or recreational retailers versus friend and family   • Susceptibility to cannabis use   • Low disapproval of smoking cannabis regularly   • Other tobacco use (cigarette, cigars, hookah, smokeless tobacco)   • Alcohol use or binge drinking   • Non-medical use of prescription stimulant use or prescription opioids   • Other illicit drug use   • Easy access to e-cigarettes and cannabis   • Lower perceived addictiveness of e-cigarettes   • Lower perceived risk of cannabis use   • Living with peers, parents, siblings who use cannabis   • Endorsement by peers   • Presence in social network   • School-related factors (urban or suburban, low grade point average, skipped class, delinquent behavior)   • Sensation seeking   • Presence among social networks   • Greater impulsivity and inattention (ADHD impulsivity)   • Negative/positive urgency   • Lack of perseverance   • Openness to new experiences   • Psychiatric symptoms (conduct problems, depressive symptoms, anhedonia, psychotic experiences)   • Canadian immigration status Reasons for cannabis vaping:   • To get high   • Safer than smoking, combustion   • Healthier than smoking   • Less discomfort/irritation compared with smoking   • Reduce or quit cigarette smoking, other combustible tobacco, or cannabis   • Control dosage   • Maintain sustained high   • Experimentation   • Mixing with flavors   • Friend use   • Looks trendy/cool   • Enjoyment   • Stress relief   • Relaxation   • Sleep improvement   • Mood improvement   • Efficient   • Discreetness   • Convenience   • Circumvent smoking bans   • Cheaper than smoked cannabis   • Easily concealed experiences [182] and sensation seeking [170, 189]; psychi- marketing (see “Marketing” section, below) [179]; school atric symptoms (e.g., depressive symptoms, conduct prob- urbanicity (urban and suburban being greater risk versus lems) [174, 182]; delinquent behavior [196]; low grade point rural) [24, 198]; using cannabis in a vehicle [170]; obtaining average and skipping class [167]; internalizing and external- cannabis from dispensaries or recreational retailers versus izing problems [197 , 198]; more exposure to e-cigarette from friends and family [171]; low disapproval of nicotine 1 3 224 Current Addiction Reports (2022) 9:217–234 vaping [167] and of smoking cannabis regularly, [182] lower platforms including e-liquid vendor online sites [202], the perceived risk of cannabis use [167]; lower perceived addic- Google Play Store [203], YouTube [204, 205], Instagram tiveness of e-cigarettes [163]; and earlier age of initiation of [206–209], and Twitter [210, 211]. Together, these studies cannabis use, in any form [170, 200]. showed that content was primarily promotional, with very Seven studies reported on youth and young adults’ rea- little prevention, cessation, or health messaging. In 2020, sons for cannabis vaping [50, 178, 181–183, 187, 193]. in an effort to combat COVID-19, South Africa restricted Reasons included that vaping cannabis is safer, healthier, tobacco and e-cigarette product sales over a 5-month period. and/or less physically irritating than cigarettes or com- Studying this, Agaku et al. showed that among 2661 e-liq- bustible tobacco; to reduce or quit smoking cigarettes or uids marketed by online vendors, about 29% were canna- other combustible tobacco products, as well as cannabis; bidiol (CBD) liquids, primarily fruit and tobacco-flavored to control dosage or amount of cannabis consumed and/or [202]. During the restriction period, online vendors com- to maintain a sustained high; experimentation; mixing with monly promoted CBD liquids instead of nicotine-containing flavors; friends’ use; because cannabis vaping is “trendy” e-liquid, salts, and concentrates [202]. Meacham et al. iden- and “cool”; because it is enjoyable; stress relief; relaxation; tified 79 Google Play Store applications that were related sleep improvement; mood improvement; and its discreetness to vaping, three of which were specific to cannabis vaping, or ability to circumvent smoking bans. One study reported with the remaining specific to nicotine or unspecified [203 ]. a reason that may deter young adults from cannabis vaping, Applications were commonly categorized as “tools and life- namely that vaping may be less safe than other forms of style,” “health and fitness,” and “social” and included do- consuming cannabis [181]. it-yourself content for creating e-liquids and coils, games, Four studies reported on youth and young adults’ harm social networking, purchasing e-cigarette products, smoking perceptions of cannabis vaping [176, 177, 181, 191]. One cessation services, pairing with e-cigarettes to adjust dos- study reported that young adults perceived combustible (e.g., age and temperature, and e-cigarette cessation [203]. Yang smoked, via a joint or pipe) cannabis as more harmful than et al. identified 214 YouTube videos over a 1-year period in vaporized cannabis; however, chemicals (e.g., butane) used 2014–2015 related to cannabis vaping [204]. Most videos make cannabis concentrates were thought to be a source were generated and shared by lay persons and included per- of harm [181]. Another study reported that most partici- sonal experiences and tips, instructions, and product reviews pants perceived using e-cigarettes to vape cannabis to be related to cannabis vaping — although 21% of videos were just as harmful or more harmful than joint use. Studies also clearly marketing a specific brand or product [204]. Over a reported uncertainty about the safety and harms of canna- 4-month period in 2018, Ramamurthi et al. identified 18,200 bis vaping compared to other forms of use [177, 191]. One “stealth vaping” YouTube videos that touted numerous dis- study reported that youth and young adult cannabis vapers creetly designed e-cigarettes like JUUL’s USB-like device, had lower odds of perceiving harm from daily cannabis use to enable discreet vaping of nicotine and cannabis, espe- in any form, when compared to never cannabis users [176]. cially by youth [205]. E-cigarettes in these videos resembled Risk factors and reasons for use associated with cannabis pens, smart phones and other electronics, and even asthma vaping among youth and young adults are summarized in inhalers [205]. Over a 2-week period in 2014, Cavazos-Rehg Table 2. et al. identified over 400,000 Instagram posts with cannabis- related hashtags [206]. Of a random sample of 5000 of these posts, 2136 were explicitly about cannabis (generally) [206]. Marketing About 9% (187/2136) of cannabis-related posts were adver- tisements, many of which (43%; 80/187) promoted devices A growing body of literature shows e-cigarette marketing or tools to use cannabis including advertising vape pens to is prevalent, largely unregulated, and is an important risk use cannabis (13%; 10/80) [206]. Majmundar et al. iden- factor for e-cigarette use among youth and young adults, tified 1775 Instagram posts with the hashtag #kandypens especially [201]. This review identified 11 studies that exam- posted over a 1-month period in 2018, and about 32% of ined marketing and/or other types of messaging about using these posts referenced using cannabis-related solutions in e-cigarettes and the relation to vaping cannabis-related sub- Kandy Pens [207]. These posts were made and distributed by stances. These studies primarily focused on digital media laypersons, vendors, KandyPen’s official Instagram account, (i.e., internet and social media), which is highly utilized by vaping advocates or enthusiasts, and influencers [207]. Cza- e-cigarette manufacturers and other promoters due to lax plicki et al. identified over 50,000 JUUL-related Instagram regulations, low cost, and access to vast and diverse young posts over 2 ½ months in 2018, prior to JUUL Lab’s vol- audiences. untary actions limiting their own youth-oriented Instagram Most studies (n = 10) were descriptive content analyses content in May 2018, and over 6 months following these of messaging about vaping cannabis on varied digital media self-imposed restrictions in 2018 [208]. Cannabis-content 1 3 Current Addiction Reports (2022) 9:217–234 225 in JUUL-related posts was identified as a common theme, states where recreational cannabis use is legal [62]. Canada and one that grew in prominence over time in 2018 [208]. legalized recreational marijuana use for adults in 2018. Kostygina et al. identified cannabis vaping themes in JUUL- One study reinforced that legalization does not appear to related Instagram posts over 2 ½ months in 2018. Cross- strengthen barriers to obtaining cannabis for underage youth promotion of JUUL with cannabis products was a prominent [55]. Increases in multimodal use of cannabis (e.g., smok- theme in commercial posts, and youth use of JUUL with ing, vaping, and/or ingesting) among underage youth were marijuana was a prominent theme in organic, non-commer- observed after legislation was passed [54, 56]. cial posts [209]. Two studies of e-cigarette-related tweets Readers are referred to a summary [35] that describes the posted in 2019 identified cannabis vaping as a prominent regulatory and marketing environment related to legalization theme, for example, cannabis vaping was discussed on Twit- of adult-use cannabis in 11 legalized states. This paper noted ter as “the real problem” causing the EVALI outbreak [210, that regulatory approaches vary substantially but most states 211]. set standards on (1) quantity; (2) eligibility for purchase; (3) Only one study reported statistically significant longitudi- transportation; (4) retail setting; and (5) how cannabis can be nal associations between marketing via numerous channels grown, packaged, sold, distributed, and promoted. Regula- including digital media and cannabis vaping [179]. Kreitz- tory approaches include rules and guidelines for cannabis berg et al. reported increased odds of using e-cigarette prod- vaping products, including establishing quantity limits for ucts with cannabis 1-year later among 3720 college students THC concentrates as well as requiring labels to state the who self-reported increased exposure to e-cigarette advertis- same and whether concentrates have been tested for contam- ing via eight channels: gas/convenience stores, drug stores, inants. Strong enforcement efforts are necessary, as studies grocery stores; liquor stores; bars or clubs; music events; report that many underage youth and young adults success- radio or internet radio; online; magazines or newspapers; fully purchase their devices online or from vape shops [222]. and billboards [179]. Regulation Discussion As of May 2021, a total of 36 states and 4 US territories From 2013 forward, consistent with increases in cannabis allow for medical use of cannabis products and 18 states, 2 vaping among young people [2 ], the available research lit- US territories, and the District of Columbia have legalized erature on this topic has grown exponentially. We hope this adult-use (recreational) cannabis [212]. Of note, two states review provides a timely summary of the state-of-the-knowl- (South Dakota and Mississippi) passed ballot initiatives by edge, in ways that inform development of preventive inter- popular vote to legalize cannabis use (medical and adult- ventions and provides direction for future studies. Clearly, use in South Dakota; medical-only in Mississippi) in 2020; surveillance of cannabis vaping among young people should however, these ballot initiatives were overturned by the State continue. It would be beneficial for efforts to continue to Supreme Court in each state [212]. Most states set no legal collect information that informs comparisons by substance age restrictions for medical cannabis, though all require a (e.g., THC, CBD vs. nicotine) and method (e.g., vaping vs. prescription from a credentialed medical professional and for smoking) of use, so that other streams of research (e.g., on minors to use under the supervision of their guardian. Legal health effects) can anchor appropriately into this informa- age for purchase of adult-use cannabis is 21 years of age in tion. Although reports of EVALI have declined over time, a all legalized states, territories, and the District of Columbia body of literature is starting to emerge regarding the other [212]. health effects of cannabis vaping. To date, little research Several articles explored cannabis vaping prevalence has examined its impact on gastrointestinal issues, despite a among youth and young adults by state-level cannabis reg- larger body of evidence on the same for cannabis smoking ulatory policy [213 , 214–219]. Across the USA, studies [65, 141–153]. More studies of the impact of cannabis vap- show the prevalence of any form of cannabis consumption ing on cognition, affect, and behavior will also be useful, among young people, including for cannabis vaping, is con- given limited research to date. Preventive interventions can sistently higher in legalized states, relative to prohibition benefit from the information summarized here, which high- states [213 , 220, 221]. One study also showed that among lights important target audiences that can benefit given their youth who had ever used cannabis, those living in a legalized higher prevalence of use (e.g., older youth, young adults; state initiated cannabis vaping at a slightly earlier age than Hispanic youth) and risk factors (e.g., reasons for use, risk those in prohibition states (mean age = 15.3 vs. 15.4 years; perceptions) that could be relevant to the development of p < 0.01) [42]. Another study showed that cannabis vap- program or communication campaign content. ing (and other forms of cannabis consumption) was more Overall, there is a dearth of research on marketing of and/ prevalent among young adults compared to older adults in or other types of messaging about cannabis vaping. More 1 3 226 Current Addiction Reports (2022) 9:217–234 study; personal fees from XX is a consultant in litigation involving the research is needed to describe the various channels through vaping industry, outside the submitted work. Sumbe A. reports grants which cannabis vaping is promoted especially via the ever- from NIH/NCI, during the conduct of the study. Dr. Case has nothing expanding world of digital media, as well as the content to disclose. Dr. Mantey reports grants from NIH/NCI, during the con- and source of messages about cannabis vaping. Although duct of the study; personal fees from XX is a consultant in litigation involving the vaping industry, outside the submitted work. Swan. S Apple, Facebook, and many popular, digital media compa- reports grants from NIH/NCI, during the conduct of the study. nies have self-imposed policies against tobacco, e-cigarette, cannabis, and other drug use, some studies have shown these Human and Animal Rights and Informed Consent This article does not are lacking in preventing youth and young adults’ exposure contain any studies with human or animal subjects performed by any of the authors. to tobacco and other substance use-related content via these media [223]. Additionally, there are no federal restrictions on digital marketing to curb commercial e-cigarette mar- Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- keting, at least. The nine studies identified in this review tion, distribution and reproduction in any medium or format, as long suggest e-cigarette — and particularly cannabis vaping — as you give appropriate credit to the original author(s) and the source, marketing and other promotional messaging appear to be provide a link to the Creative Commons licence, and indicate if changes critical factors contributing to the explosion of cannabis were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated vaping among youth and young adults. otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a Conclusions copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . 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Journal

Current Addiction ReportsSpringer Journals

Published: Sep 1, 2022

Keywords: Cannabis; Vaping; Health effects; Epidemiology; Etiology; Regulation

References