The impact of legal cannabis availability on cannabis use and health outcomes: A systematic review.

BACKGROUND: For alcohol, regulating availability is an effective way to reduce consumption and harm. Similarly, the higher availability of medical cannabis dispensaries has been linked to increased cannabis consumption and harm. For recreational cannabis markets, such a link is suspected but still poorly understood. METHODS: A systematic literature review (PROSPERO registration number 342357) was conducted on 1 July 2022 in common libraries (Medline, Web of Science, PsycInfo, Psyndex, CINAHL, Embase, SCOPUS, Cochrane) for publications since 2012. Studies linking variations in the availability of legal cannabis products to behavioral outcomes (cannabis use or related health indicators) were included, while studies focusing solely on the legalization of medical cannabis were excluded. The risk of bias was assessed using an adapted version of the Newcastle-Ottawa-Scale. RESULTS: After screening n = 6,253 studies, n = 136 were selected for full-text review, out of which n = 13 met the inclusion criteria, reporting on n = 333,550 study participants and n = 855,630 presentations to emergency departments. All studies were conducted in North America, with the majority from Western US states. Using longitudinal (n = 1), cross-sectional (n = 4), or repeated cross-sectional (n = 8) study designs, an increased availability of legal cannabis was linked to increased current cannabis use and health-related outcomes (vomiting, psychosis, or cannabis-involved pregnancies), regardless of the indicator employed to measure availability (proximity or density) among both adults and adolescents. The positive correlation between cannabis availability and consumption is most pronounced among those groups who have been less exposed to cannabis before legalization. The association between the availability of legal cannabis and risky use indicators was less consistent. CONCLUSIONS: Groups who have been least exposed to cannabis before legalization may be most susceptible to increased availability. In jurisdictions with legal cannabis markets, restrictions on the number of legal cannabis retailers, especially in densely populated areas, appear warranted.

Parameters for Change in Offline Gambling Behavior After the First COVID-19 Lockdown in Germany.

Introduction: In spring 2020, the first nationwide lockdown in response to the spreading COVID-19 pandemic came into effect in Germany. From March to May, gambling venues, casinos, and betting offices were forced to close. This study explores how land-based gamblers respond to short-term closures of higher-risk forms of gambling. Which gamblers are particularly susceptible to switching to online gambling? Which are more likely to use the lockdown as an opportunity to quit or pause gambling? Potential parameters for these switching or cessation processes are identified using multivariate multinomial logistic regression analysis. Methods: The research questions are analyzed on the basis of quantitative data. For this purpose, a survey was conducted among members of a comparatively large German online access panel ("PAYBACK panel"). The sample of analysis consisted of 612 gamblers who had participated in at least one higher-risk form of gambling and had done so exclusively offline before the first lockdown (January and February 2020). Results: A total of 37.1% of sports bettors ceased participation in higher-risk forms of gambling, compared to 64.1% of casino gamblers. Switching to online gambling, on the other hand, was a rather rare event, regardless of the form of gambling: the proportions differ between 7.7% (slot machines) and 10.9% (sports betting). In the multivariate model female gender, younger age, and a lower frequency of gambling before the first lockdown were found to be significant factors for quitting (instead of continuing) higher-risk offline gambling forms. Secondly, the analysis revealed that individuals with more pronounced cognitive distortions had an increased risk of switching to online gambling rather than staying offline. Discussion: A key finding of this study is that the temporary closure of offline venues does not result in a significant shift towards the online market. Instead, the results of this study show that these short, temporary closures of gambling venues were an appropriate opportunity to give individual groups of gamblers the opportunity to reflect, reduce or quit gambling. It is worth considering implementing such temporary closures as a preventive measure in the future - this should be investigated in advance in further evaluation studies.

Controlled administration of cannabis to mitigate cannabis-attributable harm among recreational users: a quasi-experimental study in Germany.

Background: New approaches are required to slow down or reverse increasing trends of levels of delta-9-tetrahydrocannabinol (THC) and cannabis-attributable hospitalizations in Germany. Legal access to cannabis may constitute one viable effective policy response; however, available evidence does not suffice to inform a regulation model for Germany. The proposed study aims to reduce harm for cannabis users through legal access to herbal cannabis through pharmacies. Protocol: A quasi-experimental study comparing cannabis users with legal access to herbal cannabis (Berlin, intervention group) to those without legal access (Hamburg, control group) (total N=698). As the primary outcome, we hypothesize that: 1) illegal THC consumption will reduce by at least 50% in the intervention group and 2) total THC exposure in the intervention group will be reduced by at least 10% lower than that of the control group, taking into account baseline values. Secondary outcomes comprise measures of frequency of use, THC-impaired driving, and mode of administration. Paired t-tests and multilevel regression models will be performed for statistical analyses. Discussion: This study proposal is currently being reviewed by the 'Federal Institute for Drugs and Medical Devices' - the body responsible for approving research studies on classified substances, including cannabis. Upon approval and prior to the start of the study, a full ethical review will be undertaken. Results may inform a regulation model for Germany and other jurisdictions and are expected to deepen the understanding of the effects of legal access to cannabis. Pre-registration: German Clinical Trials Register (DRKS), DRKS00020829.

Profiles of childhood adversities in pathological gamblers - A latent class analysis.

Despite of high rates of adverse childhood experiences (ACEs) in pathological gamblers, researchers have rarely studied which types of ACEs often co-occur and how these profiles of ACEs are related to current psychopathology. We aimed to identify profiles of ACEs in pathological gamblers and examined how these profiles were related to gambling-related characteristics and current general psychopathology. In 329 current or lifetime pathological gamblers, diagnosed with the Composite Diagnostic Interview for DSM-IV, 10 types of ACEs were measured using the Adverse Childhood Experiences Questionnaire. Global psychopathology was assessed using the Symptom Checklist SCL-27. ACE profiles were identified using latent class analysis. Differences between ACE profiles in gambling-related characteristics and global psychopathology were analyzed using MANOVA. We found that four out of five gamblers (n=257, 78.1%) reported at least one ACE. Four distinct ACE profiles were identified: 'Low ACE', 'High ACE', 'Physical and emotional abuse', and 'Neglect'. The number of the fulfilled pathological gambling criteria and the severity of current global psychopathology differed between the ACE profiles: Gamblers with a 'High ACE' profile fulfilled more pathological gambling criteria and showed a more severe current psychopathology than gamblers of the 'Low ACE' profile. Gamblers with a 'Physical and emotional abuse' or an 'Emotion neglect' profile showed an intermediate severity of psychopathology. Our findings indicate that four different ACE profiles can be distinguished in pathological gamblers that differed in their gambling-related characteristics and current psychopathology. Systematic assessment of profiles of ACEs in pathological gamblers may inform about the severity of current global psychopathology that might be important to be addressed in addition to gambling-specific treatment.

Do Simulated Gambling Activities Predict Gambling with Real Money During Adolescence? Empirical Findings from a Longitudinal Study.

As technology has developed, the international gambling market has changed markedly in recent years. The supply of internet-based gambling opportunities has become ever more significant. At the same time, the introduction of new gambling opportunities always brings a demand for evidence-based scientific evaluation, with regard to the associated risks of addiction. Simulated internet gambling, which is the focus of this study, represents a relatively new product group located at the interface between gambling and computer gaming. Concerns have been raised in scientific literature, especially with regard to the adolescent age group, as to whether participation in simulated internet gambling directly promotes recruitment to the world of monetary gambling, as defined in the gateway hypothesis. The research design was based on a standardized, representative longitudinal survey (over a 1-year period) with a total of 1178 school pupils from Northern Germany (M = 13.6 years; 47.5% male). It must be borne in mind that 12% of the adolescents belonged to the subgroup of "onset gamblers" and first reported experience with monetary gambling at the second stage of surveying. Logistic regression analysis demonstrates that this migration process is fostered by (1) participation from home in simulated gambling on social networks and (2) significant exposure to advertising (relating to both simulated and monetary gambling). Within the subgroup of simulated internet gamblers, variables such as particular patterns of use (including breadth and depth of involvement with simulated internet gambling, certain motives for participation, and microtransactions) do not serve as significant predictors. Despite this, important needs for action for the purposes of prevention and research can be identified.

Comparative Analysis of Potential Risk Factors for at-Risk Gambling, Problem Gambling and Gambling Disorder among Current Gamblers-Results of the Austrian Representative Survey 2015.

Background: The risk of developing a problem gambling behavior is distributed unequally among the population. For example, individuals who report stressful life events, show impairments of mental health or belong to a socio-economically deprived group are affected more frequently by gambling problems. The aim of our study is to investigate whether these risk factors are equally relevant for all gambling groups (social = 0 DSM-5 criteria, at risk = 1 DSM-5 criterion, problem = 2-3 DSM-5 criteria, disordered = 4-9 DSM-5 criteria). Methods: Of a total of 10,000 participants in the representative gambling survey in Austria in 2015, 4,082 individuals reported gambling during the last 12 months and were allocated to the four gambling groups according to DSM-5. With social gamblers as the reference group, relevant risk factors for the other three groups were identified by means of bi- and multivariate multinomial logistic regression. Results: Significant risk factors for gambling disorder are at-risk alcohol use (OR = 4.9), poor mental health (OR = 5.9), young age (≤26 years, OR = 2.1), a low level of formal education (OR = 2.4), having grown up with a single parent (OR = 2.5), parents with addiction problems (OR = 2.3) and belonging to the working class (OR = 2.9). Risk factors for problem gambling are parents with addiction problems (OR = 3.8), poor mental health (OR = 2.6) and a young age (OR = 2.2). With regard to at-risk gambling, only growing up with a single parent was relevant (OR = 2.4). Conclusion: Overall, the results of this study suggest, that the number and the influence of the included risk factors differ between gambling problem groups. Apparently, the development of severe gambling problems is to a lesser extent facilitated by specific risk factors than by their cumulative presence. Therefore, future prevention and treatment measures should place a particular focus on individuals who have experienced growing up in a difficult family situation, have poor mental health, suffer from substance-related problems or have a low level of formal education.

Prevalence of problem gambling among the prison population in Hamburg, Germany.

Despite the increasing research in gambling, the prevalence of problem gambling in the criminal justice population is rarely investigated, especially in Europe. Given the lack in knowledge the Hamburg study aimed at identifying the prevalence of problem gambling in the whole regional prison population. For this purpose two major approaches were used: a 10 months long-term screening of pre-trial detainees at prison entry through the Lie/Bet Questionnaire, and full-scale survey of inmate personnel records of prisoners being in prison on a defined reporting date. Based on 792 valid screening files 6.6 % of the pre-trial detainees were positive on the Lie/Bet Questionnaire, and these problem gamblers were male only. Among the 1,236 inmate personnel records reviewed in 7.3 % the records indicated problem gambling (90 prisoners). This indication was found in 7.5 % males and 3.6 % females. For almost half of the prisoners with problem gambling their prison sentence was related to their gambling behavior (46.7 %). These results are representative for the regional prison population, and the first of its kind in Europe.

Learning by doing: 'initiated abstinence', a school-based programme for the prevention of addiction. Results of an evaluation study.

The objective of the study was to find out whether the school-based prevention programme 'Initiated abstinence' is suitable to induce pupils to change their consumer behavior and attitudes. The participants of the prevention programme commit themselves 'per contract' to abstain from or considerably reduce their consumption of at least one of their currently used substances (e.g. sweets, cigarettes) or media (TV, computer games) for a period of 2 weeks. The main goal of the programme is to sharpen their problem and health consciousness concerning addiction and pleasure seeking. The programme was evaluated by a longitudinal study. At three given times, the 12- to 15-year-old pupils of the experimental classes were interviewed by standardized self-completion questionnaires (n = 2,267). The control classes were submitted to two surveys (n = 586). The study was carried out in the areas of Innsbruck (Austria), Schleswig-Holstein (Germany) and South Tyrol (Italy). Not all pupils were able to keep their intentions submitted in their contract, but 4 of 5 pupils had at least one positive experience with the renunciation (82%). There were 'overall effects': The actual renunciation of the pupils was much higher than stated in their agreement. The experimental group showed significant reduction effects for pupils, who had successfully reduced or stopped use of a substance or medium. In a further step, it should be explored whether the programme is suitable also for older groups, i.e. for pupils older than 15 years. Moreover, the long-term effects of the programmes should be tested.