Adolescents' Views on Preventing Youth Cannabis Marketing Exposure: A Concept Mapping Approach.

OBJECTIVE: The increasing number of states legalizing recreational cannabis use has raised growing concerns about exposure and access to cannabis for youth. The objective of this study was to develop an adolescent stakeholder-driven concept map toward identifying priority areas for preventing youth cannabis marketing influence. METHOD: This study used concept mapping, a validated research method that leverages both qualitative and quantitative approaches to integrate stakeholder input on complex topics. We recruited adolescents for the five steps of concept mapping: preparation, generation, structuring, representation, and interpretation. Analysis included hierarchical cluster analysis to develop a concept map representing approaches to protect youth from the influence of cannabis marketing, and youth focus groups to interpret the concept map. RESULTS: A total of 208 participants contributed to the study, including 74.0% females, 62.0% Caucasian, and 38.9% with previous cannabis use. There were 119 brainstorming items generated and sorted into a concept map that included 8 clusters. Clusters represented existing approaches, including education and regulation, and novel approaches, such as changing interpersonal communication and media norms around cannabis. Youth prioritized education-based approaches, including "showing both positive and negative effects of marijuana." CONCLUSIONS: This study leveraged adolescent input toward a stakeholder-driven concept map focused on prevention of youth cannabis use. Based on this concept map, there are existing and novel approaches to improve current efforts. The concept map brings adolescent voices forward to advance research, educational, and policy efforts.

Typology of Adolescents Exposed to Non-medical Cannabis Marketing and Associations with Consumption Patterns.

Latent class analysis (LCA) identified subtypes of cannabis marketing exposure among adolescents and assessed whether the classes were associated with three cannabis use outcomes: past 28-day use, poly-cannabis use, and symptoms of cannabis use disorder (CUD). Survey data were from 471 adolescents (aged 15-19 years) who lived in four states with legal non-medical cannabis in 2018. Measures included social media engagement and cannabis outcomes. LCA with robust maximum likelihood estimation identified latent classes. Chi-squared tests assessed whether empirically derived classes differed across demographics, and logistic regression tested associations with cannabis use outcomes. Three classes were identified: digitally engaged (35.5%), digitally unengaged (36.5%), and traditional (28.0%). Both digitally engaged and unengaged classes were exposed to marketing on social media platforms, but youth in the engaged class interacted with posts and brands. Class membership differed by age (χ2 = 14.89, p < 0.001) and school type, with the digitally engaged group older and not in school or in non-traditional schools (χ2 = 16.22, p=0.01). As compared to the traditional class, youth in the digitally engaged class had 10.63 times the odds of past 28-day cannabis use (95% CI: 5.25, 21.51), 7.84 times the odds of poly-cannabis use (95% CI: 3.54, 17.33), and 13.85 times the odds of symptoms of CUD (95% CI: 3.96, 48.48). Youth in the digitally engaged class had higher odds of all cannabis use behaviors than the traditional class. These findings point to the possible use of algorithmic marketing to adolescents and suggest a need for monitoring and possible restrictions on digital cannabis marketing.

Fertility rates in women with intellectual and developmental disabilities in Wisconsin Medicaid.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) face stigma and inequity surrounding opportunity and care during pregnancy. Little work has quantified fertility rates among women with IDD which prevents proper allocation of care. OBJECTIVE: Our objective was to cross-sectionally describe fertility patterns among women with and without intellectual and developmental disabilities (IDD) in 10-years of Medicaid-linked birth records. STUDY DESIGN: Our sample was Medicaid-enrolled women with live births in Wisconsin from 2007 to 2016. We identified IDD through prepregnancy Medicaid claims. We calculated general fertility-, age-specific-, and the total fertility-rates and 95% confidence intervals (95% CI) for women with and without IDD and generated estimates by year and IDD-type. RESULTS: General fertility rate in women with IDD was 62.1 births per 1000 women with IDD (95% CI 59.2, 64.9 per 1000 women) and 77.1 per 1000 for women without IDD (95% CI: 76.8, 77.4 per 1000 women). General fertility rate ratio was 0.81 (95% CI: 0.7, 0.9). Total fertility was 1.80 births per woman with IDD and 2.05 births per woman without IDD (rate ratio: 0.89 95% CI: 0.5, 1.5). Peak fertility occurred later for autistic women (30-34 years), compared with women with other IDD (20-24 years). CONCLUSION: In Wisconsin Medicaid, general fertility rate of women with IDD was lower than women without IDD: the difference was attenuated when accounting for differing age distributions. Results highlight the disparities women with IDD face and the importance of allocating pregnancy care within Medicaid.

Measuring Problematic Internet Use, Internet Gaming Disorder, and Social Media Addiction in Young Adults: Cross-sectional Survey Study.

BACKGROUND: Digital technology use is nearly ubiquitous among young adults; this use provides both benefits and risks. The risks of technology use include maladaptive technology use or technology addiction. Several conceptualizations of these addictions have emerged, each with its own assessment tools. These conditions include problematic internet use (PIU), internet gaming disorder (IGD), and social media addiction (SMA). These conditions have been associated with health outcomes such as problematic alcohol use, sleep disorders, and mental illness. These maladaptive technology conditions have been most commonly studied in isolation from each other. OBJECTIVE: The aim of this study is to examine PIU, IGD, and SMA together to better inform future research approaches and provider screening practices for young adults. METHODS: This cross-sectional survey study was conducted using Qualtrics panel-based recruitment and survey hosting. We recruited US young adults aged 18-25 years. The survey assessed PIU, IGD, and SMA. Survey measures also included assessments of problematic alcohol use, sleep, depression, and anxiety. We evaluated the frequency of and overlap in positive screening scores among PIU, IGD, and SMA and modeled each condition using multivariate logistic regression. Finally, we calculated sensitivity and specificity, as well as the positive predictive value and negative predictive value of the screening tools using the most prevalent maladaptive technology type. RESULTS: Our 6000 participants had an average age of 21.7 (SD 2.5) years. Of these 6000 participants, 3062 (51.03%) were female, 3431 (57.18%) were Caucasian, 1686 (28.1%) were in a 4-year college program, and 2319 (38.65%) worked full time. The mean PIU score was 3.5 (SD 3.1), and 53.58% (3215/6000) of participants met the criteria for PIU. The mean IGD score was 2.7 (SD 2.6), and 24.33% (1460/6000) of participants met the criteria for IGD. The mean SMA score was 7.5 (SD 5.7), and 3.42% (205/6000) met the criteria for SMA. Across all 3 maladaptive technology use diagnoses, there were varied associations with demographic variables and similar overlap with health outcomes. The sensitivity of PIU screening to detect IGD was 82% and to detect SMA was 93%, whereas the specificity and positive predictive value were much lower (37%-54% specificity; 6%-37% positive predictive value). CONCLUSIONS: This cross-sectional survey screened a large national sample of adolescents and young adults for PIU, IGD, and SMA to determine prevalence and overlap, demographic associations with each, and associations between these technology-related conditions and health outcomes. There was overlap across PIU, IGD, and SMA in some associated demographic variables and health outcomes. However, the patterns in the associated variables demonstrated unique qualities of each of these conditions.

Opioid Overdose Mortality Trends in Wisconsin, 2004-2019.

BACKGROUND: Opioid-related mortality in Wisconsin by race differs from national trends: Black Wisconsinites are nearly twice as likely as Whites to die by opioid overdose. These trends warrant further study by other demographic factors on the state level. METHODS: We characterize trends in mortality due to opioid overdose in Wisconsin using CDC WONDER data for 2004-2019 by race, age, and sex. ICD-10 (International Classification of Disease, Tenth Revision) codes were selected per national guidelines for identifying opioid-related overdose deaths. RESULTS: Opioid overdose mortality increased 415% during the study period. Black or African American and American Indian or Alaska Native populations had consistently higher risk than White populations, with an older age distribution. CONCLUSION: We identify inequities in opioid overdose mortality that have persisted over time in Wisconsin. Different age distributions by race may indicate different pathways to overdose and require further investigation to guide upstream mitigation strategies.

Cyber-ethnography of cannabis marketing on social media.

BACKGROUND: Since 2012, several states have legalized non-medical cannabis, and cannabis businesses have used social media as a primary form of marketing. There are concerns that social media cannabis exposure may reach underage viewers. Our objective was to identify how cannabis businesses cultivate an online presence and exert influence that may reach youth. METHODS: We chose a cyber-ethnographic approach to explore cannabis retailers on social media. We searched cannabis retailers with Facebook and Instagram presence from Alaska, Oregon, Colorado, and Washington, and identified 28 social media business profiles. One year of content was evaluated from each profile. In-depth, observational field notes were collected from researchers immersed in data collection on business profiles. Field notes were analyzed to uncover common themes associated with social media cannabis marketing. RESULTS: A total of 14 businesses were evaluated across both Facebook and Instagram, resulting in 14 sets of combined field notes. A major theme was Normalization of Cannabis, involving both Broad Appeal and Specific Targeting. CONCLUSIONS: It is concerning that Normalization of Cannabis by cannabis businesses may increase cannabis acceptability among youth. In a digital world where the majority of youth are spending time online, it is important for policymakers to examine additional restrictions for cannabis businesses marketing through social media.

Cannabis Marketing and Problematic Cannabis Use Among Adolescents.

OBJECTIVE: Health consequences of commercializing nonmedical cannabis remain unclear, but data suggest that youth may encounter unintended risks. This study examined whether cannabis marketing exposure and engagement are associated with problematic cannabis use among adolescents. METHOD: The analytic sample included 172 lifetime cannabis users (15-19 years old) who lived in one of six states with legalized nonmedical cannabis in 2018. Predictors included having exposure to or engagement with cannabis marketing on Facebook or Instagram, seeing cannabis billboards, owning/likely to own cannabis-branded merchandise, and reporting a favorite cannabis brand. Logistic regression assessed whether these predictors were associated with weekly cannabis use, high-intensity cannabis use, and cannabis use disorder (CUD). RESULTS: Adolescents who saw billboards rarely/sometimes had 5 times the odds of CUD, whereas youth who saw them most/all of the time had 7 times the odds of weekly use and 6 times the odds of CUD. Adolescents who owned/were likely to own branded merchandise had nearly 23 times the odds of weekly use, and those with a favorite brand had 3 times the odds of weekly use and CUD. Adolescents who reported seeing promotions on Instagram rarely/sometimes had 85% lower odds of weekly use, and those who saw them most/all of the time had 93% lower odds. CONCLUSIONS: The ways cannabis businesses market their products, especially branding, may affect patterns of underage cannabis use. Future research should test whether these associations persist in longitudinal designs. In the interim, states should consider an approach that offers youth additional means to protect them from cannabis marketing.

Tanning Misinformation Posted by Businesses on Social Media and Related Perceptions of Adolescent and Young Adult White Non-Hispanic Women: Mixed Methods Study.

BACKGROUND: Indoor ultraviolet (UV) tanning is common and consequential, increasing the risk for cancers including melanoma and basal cell carcinoma. At-risk groups include adolescents and young adults, who often report beliefs about benefits of tanning. Adolescent and young adults are also among the most ubiquitous social media users. As previous studies support that content about tanning is common on social media, this may be a way that young women are exposed to influential content promoting tanning, including health misinformation. OBJECTIVE: The purpose of this study was to evaluate health misinformation promoted by indoor tanning businesses via social media and to understand young women's perceptions of this misinformation. METHODS: This mixed methods study included (1) retrospective observational content analysis of indoor tanning salons' content on Facebook over 1 year and (2) qualitative interviews with a purposeful national sample of 46 White non-Hispanic women, age 16 to 23 years, who had recently tanned indoors. We assessed experiences with tanning businesses' posted content on social media through interviews. We used the constant comparative approach for qualitative analyses. RESULTS: Content analysis findings included data from indoor tanning businesses (n=147) across 50 states, yielding 4956 total posts. Among 9 health misinformation topics identified, the most common was the promotion of UV tanning as a safe way to get Vitamin D (n=73, 1.5%). An example post was "Stop by Body and Sol to get your daily dose of Vitamin D." Another misinformation topic was promoting tanning for health benefits (n=31, 0.62%), an example post was "the flu is not a season, it's an inability to adapt due to decreased sun exposure…" A total of 46 participants completed interviews (age: mean 20 years, SD 2). Almost all participants (45/46, 98%) used Facebook, and 43.5% (20/46) followed an indoor tanning business on social media. Approximately half of participants reported seeing social media posts from tanning salons about Vitamin D, an example of a participant comment was "I have [seen that] a few times..." Among the participants, approximately half believed it was safe to get Vitamin D from indoor UV tanning; a participant stated: "I think it is a valid benefit to UV tanning." CONCLUSIONS: Despite the low frequency (range 0.5%-1.5%) of social media posts promoting health misinformation, participants commonly reported viewing these posts, and their perceptions aligned with health misinformation. Health education campaigns, possibly using social media to target at-risk populations, may be an innovative approach for tanning prevention messages.

Vaccination Discussion among Parents on Social Media: A Content Analysis of Comments on Parenting Blogs.

Despite the effectiveness of vaccines, parents are increasingly opting for non-medical exemption. For health advice on such topics, many parents are now more likely to look to online communities than rely on medical expertise. There is scant literature outlining how parents contribute to online discussion of vaccination. The purpose of this study was to analyze parent vaccination opinions expressed online. Using a codebook adapted from previous research, content analysis was conducted to evaluate comments on parenting blog posts related to vaccination. Variables included stance, argument rhetoric, and accuracy of information. Comments recognized as aggressive or accusatory were recorded into an "attack" category. Descriptive statistics were used to assess trends in comment content. Nine blogs were included, from which 244 comments were analyzed. The most common argument rhetoric was providing, requesting, or evaluating source credibility for both pro- and anti-vaccine comments (24% and 36%). 25% of comments were considered inaccurate health information; 27% fell into the "attack" category, of which 60% were pro-vaccination. The high percentage of "attack" comments and inaccurate information is evidence that blog comments may not be reliable for information-seeking parents. Clinicians should use this data to understand anti-vaccination arguments in efforts to improve vaccine communication.

Exposure to Cannabis Marketing in Social and Traditional Media and Past-Year Use Among Adolescents in States With Legal Retail Cannabis.

PURPOSE: The objective of this study was to examine adolescents' self-reported exposure to cannabis marketing in states with legalized cannabis and its association with past-year cannabis use. METHODS: We conducted a cross-sectional, online panel survey of 469 adolescents aged 15-19 years residing in four states with legal retail cannabis for adult use. Adolescents self-reported exposure to cannabis marketing on social or traditional media (i.e., outdoor or print) and past-year cannabis use. Logistic regression generated estimated odds of youths' past-year cannabis use by marketing exposure after adjusting for demographic factors and cannabis-related social norms. RESULTS: Exposure to cannabis marketing on Facebook, Twitter, and Instagram was associated with increased odds of past-year cannabis use of 96% (95% confidence interval [CI]: 15%-234%), 88% (95% CI: 11%-219%), and 129% (95% CI: 32%-287%), respectively. Odds of past-year cannabis use increased by 48% (95% CI: 16%-87%) with each additional social media platform where adolescents reported exposure. CONCLUSIONS: Despite restrictions that prohibit cannabis advertising on social media, adolescents are exposed to cannabis marketing via social media, and this exposure is associated with recent cannabis use. States should consider further regulation of cannabis marketing on social media.

Active cannabis marketing and adolescent past-year cannabis use.

METHODS: Data are from an online survey of 482 adolescents (aged 15-19 years) living in states with legalized retail cannabis. Youth were asked about their engagement with cannabis promotions, including whether they liked/followed cannabis businesses on social media (Facebook, Twitter, and Instagram), had a favorite cannabis brand, or could see themselves owning/wearing a cannabis-branded product. Youth also self-reported cannabis use in the past year. We used logistic regression with a Bonferroni correction to compare the odds of cannabis use among youth with different levels of engagement with cannabis promotions and brands after controlling for demographics. RESULTS: After adjusting for several possible confounders, youth who liked or followed a cannabis business on at least one social media platform had 5 times higher odds of past-year cannabis use (aOR = 5.00, 95% CI: 2.47, 10.09, p < 0.001). Youth who thought it was likely that they would own or wear cannabis-branded merchandise (aOR = 6.93, 95% CI: 4.45, 10.78, p < 0.001) or who had a favorite cannabis brand (aOR = 7.98, 95% CI: 4.90, 13.00, p < 0.001) had nearly 8 times greater odds of past-year cannabis use. CONCLUSION: Youth who engage with cannabis promotions and brands had higher odds of past-year cannabis use. Jurisdictions with retail cannabis may want to consider restrictions to limit youth engagement with cannabis promotions.

Marijuana promotions on social media: adolescents' views on prevention strategies.

BACKGROUND: Youth exposure to positive marijuana messages increases their risk of marijuana use. Since Washington State legalized recreational marijuana in 2012, marijuana businesses have used social media business pages to promote their products. Regulations to prevent youth access and targeting by marijuana businesses on social media in Washington State are absent. The purpose of this study was to engage youth in conceptualizing prevention approaches to limit youth exposure to marijuana business promotions on social media. METHODS: Towards our goal of generating novel prevention approaches and promoting youth interaction to build ideas, we used focus groups. Adolescents ages 15-20 years in Washington State were recruited through purposeful sampling to achieve a diverse sample from six schools across two counties. During focus groups, trained facilitators used a semi-structured guide to prompt discussion about marijuana business presence on social media. In the latter half of focus groups, facilitators showed example social media posts from marijuana businesses. All focus groups were audio recorded and manually transcribed. Qualitative analysis was conducted using the constant comparative method. RESULTS: A total of 32 adolescents with average age 17 years (SD = 0.6), 71% female, 43.8% Asian and 21.9% mixed race, participated in 5 focus groups. Recommendations for prevention focused in two main thematic areas. First, participants supported policies to restrict underage access to marijuana social media pages, an example quote was: "you have access to [the social media page] without being 21 and I think that's a problem." Second, participants proposed regulation of content that marijuana companies can post on social media, an example quote was: "I'm thinking they shouldn't be allowed to use children or anything associated with children and the memes that they post." CONCLUSIONS: Our findings indicate two strategies to limit youth exposure to marijuana content on social media. These specific strategies represent potential avenues to revise state policies and test the effectiveness of these approaches for states that permit recreational marijuana.

Social Media Posts by Recreational Marijuana Companies and Administrative Code Regulations in Washington State.

Importance: Recreational marijuana use was legalized in the state of Washington in 2012, and the Washington Administrative Code (WAC) 314-55-155 was implemented to limit the exposure of youths to marijuana advertisements. Objectives: To evaluate the content of social media posts by marijuana companies and to assess the compliance of these posts with WAC regulations. Design, Setting, and Participants: In a cross-sectional study, a content analysis of 1027 social media posts was conducted to identify and assess compliance of WAC regulations with the business pages of recreational marijuana companies located on Facebook and Twitter platforms in the state of Washington from December 1, 2015, through November 30, 2016. Main Outcomes and Measures: Application of coding based on WAC regulations to focus on the prohibition of language that promoted the overconsumption of marijuana, that described its curative or therapeutic benefits, or that was designed to appeal to youths; and the requirements for warnings about intoxication, driving, health risks, and age restrictions for marijuana. Results: Of the 1027 posts on Facebook and Twitter from business pages of 6 marijuana companies, Facebook followers ranged from 342 to 1592 persons and Twitter followers ranged from 374 to 2915 persons per company. Findings for WAC regulations included 17 posts (1.7%) that encouraged overconsumption; 137 posts (13.3%) that promoted therapeutic benefits; and 9 posts (0.01%) that appealed to youths. Requirements for warnings addressing intoxication, driving, health risks, and age restrictions were present on 110 posts (10.7%). Some businesses repeatedly violated particular regulations; 7 of 17 (41.2%) posts encouraging overconsumption derived from 1 marijuana company. Conclusions and Relevance: Most social media posts by marijuana companies were consistent with WAC regulations that prohibit particular messages, but few companies provided required warning messages. Findings can be used toward implementation strategies for marijuana prevention to address these influential media messages.