The nature and characteristics of problem gaming, with a focus on ICD-11 diagnoses.

PURPOSE OF REVIEW: This review describes the diagnoses related to problem gaming that are included in ICD-11, published by the WHO in 2022. It summarizes the recent literature on the prevalence of Gaming Disorder, its structure, antecedents and comorbidities, and explores whether the range of diagnoses currently available adequately covers the range of experiences seen with problem gaming. RECENT FINDINGS: Overall, between 3 and 6% of the population worldwide are reported to have a gaming disorder as defined by ICD-11 or DSM-5. However, most studies are constrained by methodological issues such as nonrepresentative samples and the use of brief questionnaires to determine prevalence. ICD-11 Gaming Disorder is a psychometrically sound diagnosis. There is no diagnosis that currently captures the experience of harm from gaming, where the requirements for the diagnosis of Gaming Disorder are not reached. SUMMARY: There is evidence in support of the proposed new entity of 'Harmful Gaming', which encompasses mental and physical harm/impairment due to a repeated pattern of gaming, but where requirements for the diagnosis of Gaming Disorder are not met. Such a diagnosis would complete the spectrum of diagnoses available for problem or unhealthy gaming, similar to those for unhealthy substance use, and would provide a framework for a public health approach to reducing the overall harm from unhealthy gaming.

Alcohol use and alcohol use disorders in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Population-level alcohol use data are available from high-income countries, but limited research has been conducted in sub-Saharan Africa. This systematic review and meta-analysis aimed to summarize population-level alcohol use in sub-Saharan Africa. METHOD: Databases searched included PubMed, EMBASE, PsycINFO and AJOL, without language restrictions. Searches were also conducted in the Global Health Data Exchange (GHDx) and Google Scholar. Search terms encompassed 'substance' or 'substance-related disorders' and 'prevalence' and 'sub-Saharan Africa'. We included general population studies on alcohol use (including any use, high-risk alcohol use and alcohol use disorders) from 2018 onwards. Prevalence data for alcohol use among sub-Saharan African adolescents (10-17) and adults (18+) were extracted. Analyses included life-time and past 12- and 6-month alcohol use. RESULTS: We included 141 papers. Among adolescents, the life-time prevalence of alcohol use was 23.3% [95% confidence interval (CI) = 11.3-37.1%], 36.2% (CI = 18.4-56.1%) in the past year and 11.3% (CI = 4.5-20.4%) in the past 6 months. Among adolescents, 12-month prevalence of alcohol use disorder and alcohol dependence were 7.7% (CI = 0.0-27.8%) and 4.1% (CI = 1.4-7.9%), respectively. Among adults, the life-time prevalence of alcohol use was 34.9% (CI = 17.7-54.1%), 27.1% (CI = 5.0-56.4%) in the past year and 32.2% (CI = 19.8-46.0%) in the past 6 months. Among adults, the 12-month prevalence of alcohol use disorder and alcohol dependence were 9.5% (CI = 0.0-30.4%) and 4.3% (CI = 0.8-9.8%), respectively. The highest weighted life-time prevalence of alcohol use, 86.4%, was reported in Tanzania among adults. The highest weighted past 6-month prevalence of alcohol use, 80.6%, was found in Zambia among adolescents. CONCLUSION: Alcohol use patterns vary across countries and subregions within sub-Saharan Africa, and comprehensive population-level data on alcohol use remain scarce in numerous sub-Saharan African countries. The prevalence of alcohol use disorder is common among adolescents in sub-Saharan Africa.

Patterns of drug use among people who inject drugs: A global systematic review and meta-analysis.

BACKGROUND: A better understanding of global patterns of drug use among people who inject drugs can inform interventions to reduce harms related to different use profiles. This review aimed to comprehensively present the geographical variation in drug consumption patterns among this population. METHODS: Systematic searches of peer reviewed (PsycINFO, Medline, Embase) and grey literature published from 2008-2022 were conducted. Data on recent (past year) and lifetime drug use among people who inject drugs were included. Data were extracted on use of heroin, amphetamines, cocaine, benzodiazepines, cannabis, alcohol, and tobacco; where possible, estimates were disaggregated by route of administration (injecting, non-injecting, smoking). National estimates were generated and, where possible, regional, and global estimates were derived through meta-analysis. RESULTS: Of 40,427 studies screened, 394 were included from 81 countries. Globally, an estimated 78.1 % (95 %CI:70.2-84.2) and 71.8 % (65.7-77.2) of people who inject drugs had recently used (via any route) and injected heroin, while an estimated 52.8 % (47.0-59.0) and 19.8 % (13.8-26.5) had recently used and injected amphetamines, respectively. Over 90 % reported recent tobacco use (93.5 % [90.8-95.3]) and recent alcohol use was 59.1 % (52.6-65.6). In Australasia recent heroin use was lowest (49.4 % [46.8-52.1]) while recent amphetamine injecting (64.0 % [60.8-67.1]) and recent use of cannabis (72.3 % [69.9-74.6]) were higher than in all other regions. Recent heroin use (86.1 % [78.3-91.4]) and non-injecting amphetamine use (43.3 % [38.4-48.3]) were highest in East and Southeast Asia. Recent amphetamine use (75.8 % [72.7-78.8]) and injecting heroin use (84.8 % (81.4-87.8) were highest in North America while non-injecting heroin use was highest in Western Europe (45.0 % [41.3-48.7]). CONCLUSION: There is considerable variation in types of drugs and routes of administration used among people who inject drugs. This variation needs to be considered in national and global treatment and harm reduction interventions to target the specific behaviours and harms associated with these regional profiles of use.

Regional and Country Prevalence Estimates of Unsafe Sex Among Adolescents in 68 Low-Income and Middle-Income Countries.

Prioritizing adolescent health is a public health priority to achieve the sustainable development goals, including reducing the risk of unsafe sex. Data on unsafe sex have remained scarce among adolescents in low-and middle-income countries (LMICs). To estimate the prevalence of unsafe sex in LMICs, we conducted secondary data analysis on the Global School-based Student Health Surveys among 244,863 students aged 13-17 years from 68 countries across five World Health Organization regions. The overall prevalence of ever had sex was 16.2%. The highest to lowest regional prevalence estimation of ever had sex was 30.5% (28.9-32.1) in the Americas, 28.6% (26.8-30.4) in Africa, 10.9% (9.2-12.6) in the Eastern Mediterranean, 9.6% (8.8-10.5) in South-East Asia, and 8.0% (6.8-9.1) in the Western Pacific. The highest prevalence of sexual intercourse before age 14 and practicing sexual intercourse without condom use were 36.5% (34.5-38.5) and 32.2% (30.1-34.3) in Africa, respectively. Findings suggest that current interventions are inadequate in promoting the uptake of safe sexual behaviors and an urgent intervention is needed.

A systematic review of second-hand smoking mass media campaigns (2002-2022).

BACKGROUND: Second-hand smoking (SHS) increases the risk of chronic disease in adults and poses a serious health threat to children. Mass media campaigns are instrumental in raising awareness and reducing SHS exposure. There is a need to identify recent SHS mass media campaigns and assess their sustainability in terms of knowledge, attitudes, and behavioural changes. This systematic review summarises the characteristics and outcomes of mass media campaigns on SHS prevention. METHODS: PubMed, Embase, Web of Science, and grey literature were searched in November 2022 for SHS campaigns implemented between 2016 and 2022. The eligibility criteria included campaigns on the dangers or effects of SHS with any target group, dissemination medium, study design, or language. The database search identified 1,413 peer-reviewed titles, of which 82 full-texts were screened, with 14 meeting the eligibility criteria. The grey literature search identified 9,807 sources, of which 61 were included. We extracted data on the campaign characteristics, metrics, and smoking-related outcomes. The JBI critical appraisal tool was used to assess the risk of bias of the included studies. RESULTS: We found 73 SHS campaigns conducted between 2002 and 2022, across 50 countries. The campaigns reached 378 million people. The reported recall rates range from 8 to 76%. Of the 11 studies that reported smoking-related outcomes, 10 reported increased knowledge in understanding SHS risks (73-85%), five reported an increased prevalence of smoke-free homes, and two reported an increase in number of participants persuading others to quit smoking. Two studies reported a decrease in overall smoking, whereas three studies observed a reduction in smoking in the presence of children. CONCLUSION: The available data provide some support for the effectiveness of SHS campaigns in reducing smoking behaviours in homes and around children. However, the certainty of evidence was low due to the lack of a control group and the substantial heterogeneity in the outcomes assessed. Future campaigns need comprehensive evaluation and reporting to reduce publication bias.

The prevalence of cannabis use disorders in people who use medicinal cannabis: A systematic review and meta-analysis.

BACKGROUND: The prevalence of cannabis use disorders (CUDs) in people who use cannabis recreationally has been estimated at 22%, yet there is a dearth of literature exploring CUDs among people who use medicinal cannabis. We aimed to systematically review the prevalence of CUDs in people who use medicinal cannabis. METHODS: In our systematic review and meta-analysis, we followed PRISMA guidelines and searched three databases (PsychInfo, Embase and PubMed) to identify studies examining the prevalence of CUDs in people who use medicinal cannabis. Meta-analyses were calculated on the prevalence of CUDs. Prevalence estimates were pooled across different prevalence periods using the DSM-IV and DSM-5. RESULTS: We conducted a systematic review of 14 eligible publications, assessing the prevalence of CUDs, providing data for 3681 participants from five different countries. The systematic review demonstrated that demographic factors, mental health disorders and the management of chronic pain with medicinal cannabis were associated with an elevated risk of CUDs. Meta-analyses were conducted on the prevalence of CUDs. For individuals using medicinal cannabis in the past 6-12 months, the prevalence of CUDs was 29% (95% CI: 21-38%) as per DSM-5 criteria. Similar prevalence was observed using DSM-IV (24%, CI: 14-38%) for the same period. When including all prevalence periods and using the DSM-5, the prevalence of CUDs in people who use medicinal cannabis was estimated at 25% (CI: 18-33%). CONCLUSIONS: The prevalence of CUDs in people who use medicinal cannabis is substantial and comparable to people who use cannabis for recreational reasons, emphasizing the need for ongoing research to monitor the prevalence of CUDs in people who use medicinal cannabis.

Designing observational studies for credible causal inference in addiction research-Directed acyclic graphs, modified disjunctive cause criterion and target trial emulation.

Randomized controlled trials (RCTs) are considered the gold standard for causal inference. With a sufficient sample size, randomization removes confounding up to the time of randomization and allows the treatment effect to be isolated. However, RCTs may have limited generalizability and transportability and are often not feasible in addiction research due to ethical or logistical constraints. The importance of observational studies from real-world settings has been increasingly recognized in research on health. This paper provides an overview of modern approaches to designing observational studies that enable causal inference. It illustrates three key techniques, Directed Acyclic Graphs (DAGs), modified Disjunctive Cause Criterion and Target Trial Emulation, and discusses the strengths and limitations of their applications.

Participation in Australian drug treatment programs for individuals engaging in high-risk substance use: Data from a nationally representative sample.

INTRODUCTION: Substance use, including drugs, alcohol and smoking have a significant health, social and economic impact. We aim to assess the rate and factors associated with treatment access among individuals with high-risk substance use. METHOD: This study is a cross-sectional analysis of the 2019 Australian National Drug Strategy Household Survey (N = 22,015). Participants were persons with high-risk substance use based on the Alcohol, Smoking and Substance Involvement Screening Test-Lite (ASSIST-Lite) and current smokers. We measured self-reports of past 12-month engagement in a tobacco, alcohol or other drugs treatment program. RESULTS: Overall, 0.4% had high-risk drug use (0.3% cannabis, 0.1% meth/amphetamine or 0.1% opioids), 7.4% had high-risk alcohol use, and 14.0% currently smoked. Among high-risk users, past 12-month treatment access rates were 50.6% [22.3-78.9%] for opioids, 27.1% [8.1-46.1%] for meth/amphetamine, 14.5% [4.3-24.7%] for cannabis, 9.6% [8.1-11.0%] for alcohol and 11.7% [10.6-12.9%] for current smoking. The primary source of treatment support was information and education (12.7% drugs, 4.6% alcohol, 4.0% smoking), followed by counselling (6.7% drugs, 4.5% alcohol, 3.0% smoking). Online or internet support was accessed by 5.9% (drug) and 1.6% (alcohol) people with high-risk use. Psychological distress was associated with treatment access (drugs: odds ratio 3.03 [0.77-11.95], p = 0.111; alcohol: odds ratio 3.16 [2.20-4.56], p ≤ 0.001; smoking: odds ratio 1.95 [1.52-2.49], p ≤ 0.001). DISCUSSION AND CONCLUSIONS: The proportion of people engaging in risky substance use who had used treatment programs remains low, especially for alcohol. Public health strategies to scale up treatment access are warranted.

What is the hype on #MedicinalCannabis in the United States? A content analysis of medicinal cannabis tweets.

INTRODUCTION: Medicinal cannabis is now legal in 44 US jurisdictions. Between 2020 and 2021 alone, four US jurisdictions legalised medicinal cannabis. The aim of this study is to identify themes in medicinal cannabis tweets from US jurisdictions with different legal statuses of cannabis from January to June 2021. METHODS: A total of 25,099 historical tweets from 51 US jurisdictions were collected using Python. Content analysis was performed on a random sample of tweets accounting for the population size of each US jurisdictions (n = 750). Results were presented separately by tweets posted from jurisdictions where all cannabis use (non-medicinal and medicinal) is 'fully legalised', 'illegal' and legal for 'medical-only' use. RESULTS: Four themes were identified: 'Policy', 'Therapeutic value', 'Sales and industry opportunities' and 'Adverse effects'. Most of the tweets were posted by the public. The most common theme was related to 'Policy' (32.5%-61.5% of the tweets). Tweets on 'Therapeutic value' were prevalent in all jurisdictions and accounted for 23.8%-32.1% of the tweets. Sales and promotional activities were prominent even in illegal jurisdictions (12.1%-26.5% of the tweets). Fewer than 10% of tweets were about intoxication and withdrawal symptoms. DISCUSSION AND CONCLUSION: This study has explored if content themes of medicinal cannabis tweets differed by cannabis legal status. Most tweets were pro-cannabis and they were related to policy, therapeutic value, and sales and industry opportunities. Tweets on unsubstantiated health claims, adverse effects and crime warrants continued surveillance as these conversations could allow us to estimate cannabis-related harms to inform health surveillance.

How much cannabis is used in a joint in Australia? An experimental investigation into use by potency and frequency.

INTRODUCTION: Cannabis use is highly prevalent in Australia, yet current survey metrics measure tetrahydrocannabinol (THC) exposure with limited accuracy. Often survey items measure cannabis quantity by assuming specific modes of use (i.e., 'how many joints do you use?'), which fail to capture variations in cannabis use and the diverse modes of use (e.g., joints, cones, spliffs). This study investigated how much cannabis is used in these modes of administration in an Australian sample. METHODS: Participants (N = 31, Mage = 25.77; 51% university students) completed the Roll a Joint Paradigm in which they rolled joints, spliffs and packed cones as they would typically, using oregano as 'cannabis.' Participants then prepared each again but with cannabis of higher or lower potency. RESULTS: The amount of cannabis used across different modes of administration was variable: joints (range 0.10-1.25 g), spliffs (range 0.12-1.21 g) and cones (range 0.03-0.41 g). Participants who used cannabis daily rolled three times the amount of cannabis into a joint. DISCUSSION AND CONCLUSIONS: The amount of cannabis used in common modes of administration may be highly variable. Daily use may be associated using larger quantities of cannabis. Titration attempts based on potency were not proportional or consistent across modes of administration. The results indicate people may adjust the quantity of cannabis based on perceived potency, however, not proportional to THC concentration. Inconsistency in the amount of cannabis used based on potency and within different modes of administration may represent a problem for self-report metrics which ask participants to report cannabis use in joints.

Prevalence and correlates of positive parental attitudes towards cannabis use and use intention in Australia during 2016 and 2019.

INTRODUCTION: With recent policy changes around medicinal cannabis in Australia, there is concern about the influence of changing norms of cannabis use on adults who are actively parenting. METHODS: This repeated cross-sectional population study used National and Drug Strategy and Household Surveys to estimate the changes and correlates of cannabis-related attitudes (support of legalisation, approve of regular use, would try or use if legal) among Australian parents from 2016 to 2019. RESULTS: The estimated proportion of parents who supported legalisation and approved regular cannabis use increased significantly. Parents who would try cannabis if it was legal grew from 5.9% (95 %CI: 5.2, 6.7) to 8.1% (95 %CI: 7.2, 9.0). Parents who said they would use cannabis more often increased from 1.6 (95 % CI: 1.2, 1.9) to 2.9 (95 %CI: 2.4, 3.4), an 81% jump in the three years. The strongest associations were observed between a very high level of psychological distress and regular smoking and drinking. For example, people with a very high level of psychological distress were 2.16 times (95 %CI: 1.42, 3.28) and 2.48 times (95 %CI: 1.61, 3.83) more likely to approve legalisation and regular cannabis use, respectively. Daily drinking was associated with higher odds of trying cannabis (OR = 1.66; CI: 1.25-2.20). DISCUSSION AND CONCLUSION: The proportion of parents who would try or use cannabis more often represents a sizeable pool of potential new and frequent users. This highlights the need for education and intervention strategies for parents who use cannabis and care for young children. The associations between mental health and substance use suggest that more research is needed to understand the impact of legalisation on vulnerable groups.

Global, regional, and country-level coverage of testing and treatment for HIV and hepatitis C infection among people who inject drugs: a systematic review.

BACKGROUND: People who inject drugs are disproportionately affected by HIV and hepatitis C virus (HCV) infections, while there is little global data on HIV and HCV testing and treatment coverage of this population. We conducted a systematic review to evaluate country-level, regional, and global coverage of HIV and HCV testing and treatment among people who inject drugs. METHODS: We did a systematic review, and searched bibliographic databases (MEDLINE, Embase, and PsycINFO) and grey literature for studies published between Jan 1, 2017, and April 30, 2022, that evaluated the proportion of people who inject drugs who received testing or treatment for HIV or HCV. For each country, we estimated the proportion of people who inject drugs tested for HIV antibodies in the past 12 months (recent), people who inject drugs ever tested for HCV antibodies and HCV RNA, people who inject drugs with HIV currently receiving antiretroviral therapy, and people who inject drugs with HCV ever receiving HCV antiviral treatment. Regional and global estimates, weighted by the population size of people who inject drugs, were generated where sufficient data were available. This study is registered with PROSPERO (CRD42020173974). FINDINGS: 512 documents reported data eligible for analyses, including 337 peer-reviewed articles, 27 conference abstracts or presentations, and 148 documents from grey literature or supplementary searches. Data of recent HIV antibody testing were available for 67 countries and ever having had HCV antibody testing were available for 49 countries. Globally, an estimated 48·8% of people who inject drugs were recently tested for HIV antibodies (95% uncertainty interval [UI] 43·3-54·2%; range 0·9-86·0%), and 47·1% had ever been tested for HCV antibodies (95% UI 43·4-51·0%; range 0·0-93·3%). HCV RNA testing data were available from three countries. Coverage of HIV antibody testing was high (>75%) in four countries and for HCV antibody testing in 15 countries. The estimated uptake of current HIV treatment (18 countries) ranged from 2·6% to 81·9%, and the estimated uptake of ever having HCV treatment (23 countries) ranged from 1·8% to 88·6% across countries. Uptake of HIV treatment was high in two countries, and of HCV treatment in one country. INTERPRETATION: HIV and HCV testing and treatment uptake among people who inject drugs was highly variable, and suboptimal in most countries. Strategies to improve access to HIV and HCV care among people who inject drugs and the availability of public health surveillance are urgently required. FUNDING: Australian National Health and Medical Research Council and UK National Institute for Health and Care Research Health Protection Research Unit in Behavioural Science and Evaluation.

Adolescent Exposure to Online Advertisements and Promotions for Tobacco Products on the Internet-A Cross-Sectional Analysis of the Global Youth Tobacco Surveys.

PURPOSE: Although many countries have banned tobacco advertising on traditional media platforms, the tobacco industry actively promotes their products via online channels. Adolescents are at high risk of exposure due to spending substantial time online. We examined the prevalence of adolescent exposure to online tobacco advertisements and promotions. METHODS: We analyzed data from the Global Youth Tobacco Surveys (GYTS; 2013-2018; average response rate = 76.8%). We included 15 countries in four regions that measured self-reported exposure to tobacco advertising on the internet in the past month (N = 111,356, adolescents aged 11-18): Region of the Americas (Argentina, Costa Rica, Cuba, Ecuador, Panama, Paraguay, Peru), African (Mauritius, Zimbabwe), European (Czech Republic, Turkey), and the Western Pacific (Micronesia, Macao, Papua New Guinea, Samoa). We calculated the prevalence of online exposure to tobacco advertising by past-month cigarette use. RESULTS: Prevalence of adolescent exposure to online advertisements for tobacco products ranged from 18.2%-34.3% and 12.3%-34.4% for tobacco advertisements that "looked fun or cool". Exposure to online tobacco product advertisements was prevalent across countries, including those with advertising bans in place, and included adolescents who have never smoked (14.4%-28.4% exposed to any, 9.1%-31.0% exposed to fun or cool advertisements). Reporting seeing tobacco advertising online that looked fun or cool was positively associated with the prevalence of past-month smoking (r = 0.64, p = .010). DISCUSSION: A substantial proportion of adolescents in countries that have banned tobacco advertising are still exposed to advertisements for tobacco products online. Internet tobacco advertising needs better enforcement to prevent adolescent tobacco use and uptake worldwide.

Factors Associated with Trust in Public Authorities Among Adults in Norway, United Kingdom, United States, and Australia Two Years after the COVID-19 Outbreak.

Objectives: This study aimed to examine the levels of trust in information provided by public authorities 2 years after the COVID-19 outbreak and to examine factors associated with trust. Methods: Using a cross-national approach, online survey data was collected from four Western countries-Australia, Norway, the United Kingdom, and the United States of America. Differences in reports of very low or low levels of trust were examined by age, gender, area of residence, and the highest level of education in the four countries. Results: Levels of trust in the public authorities' information were highest among Norwegian respondents and lowest among U.K. respondents. Lower levels of trust in public authorities were found among males, individuals living in rural or remote areas, and those with lower levels of education. Conclusion: The outcomes contribute to knowledge regarding differences between socio-demographic groups and countries regarding the levels of trust people have in public authorities' information concerning a crisis, such as COVID-19. Strategies to promote trust in societies in different countries could consider these socio-demographic differences.

Promotions of vaping products near schools and central business district: A descriptive cross-sectional study.

ISSUES ADDRESSED: The increase of youth vaping in Australia has raised concerns, especially with increasing promotions of vaping products. We observed the visibility of vaping products near high-adolescent-traffic areas. METHODS: We examined stores within walking distance of high schools and the central business district (CBD) in Brisbane, Australia, observing the number and proportion of stores selling or displaying vaping products. Using an observational approach, we analysed advertisements and open displays of vaping products at tobacconists, vape stores, and convenience stores. RESULTS: We identified 61 eligible stores located near schools or in the CBD. Overall, 20% of stores displayed vaping products externally, with higher proportions among vape stores (78%) compared to tobacconists (36%). Additionally, 46% of stores had visible interior displays, with vape stores (89%) displaying them more frequently than tobacconists (71%). Among the 28 stores displaying vaping products, 57% included warnings, one store featured only flavoured products, and 25% showcased nicotine-containing products. Youth-appealing features were present in all but one store, with cartoons (61%) as the most common feature. CONCLUSION: Vapes were displayed near high schools and in the city, often featuring youth-appealing features, such as colours and flavours. SO WHAT?: The exposure to such promotions could normalise vaping and contribute to increased youth uptake. Continued monitoring of vaping product promotions is essential, particularly considering recent policy changes.

Viral Vaping: A systematic review and meta analysis of e-cigarette and Tobacco-Related social media content and its influence on youth behaviours and attitudes.

AIMS: E-cigarette and tobacco-related content on social media continues to rise from lax restrictions on both personal and promotional posts. This content has been linked to various mechanisms of increased e-cigarette and tobacco use (i.e., lower risk perceptions and increased susceptibility). This study aimed to synthesis the association between exposure to e-cigarette and tobacco-related content and youth behaviours and attitudes. METHODS: A comprehensive search was conducted on PubMed, Scopus, PsycINFO and Web of Science. Studies published post-2004 reporting effect estimates for exposure or engagement with e-cigarette or tobacco content on social media and behaviour or attitude outcomes were included. RESULTS: Thirty-two studies (N = 274,283, aged 9 to 25 years) were included for synthesis. Meta-analyses revealed significant associations between engagement with tobacco content and use (OR 2.21; 95% CI = 1.27-3.82, p =.005; I2 = 96.4%), exposure to tobacco content and never users' lower risk perceptions (OR 0.68; 95% CI = 0.49-0.91; p =.011; I2 = 78.2%), and exposure to e-cigarette content and use (OR 1.37; 95% CI = 0.99-1.88; p = 0.058; I2 = 64.4%). There was no observed relationship between exposure to tobacco content and ever users' risk perceptions (OR 0.83; 95% CI = 0.61-1.13; p =.231; I2 = 83.5%). Qualitative synthesis found significant associations between tobacco exposure and increased current use and pro-tobacco attitudes; e-cigarette exposure and increased susceptibility and lower risk perceptions; tobacco engagement and increased susceptibility; e-cigarette engagement and increased use; dual exposure and increased susceptibility; and dual engagement and increased dual use. Mixed findings were identified for the influence of e-cigarette exposure on attitudes, tobacco exposure on susceptibility, dual exposure on dual use behaviours, and dual engagement on dual susceptibility. CONCLUSIONS: Findings suggest an association between exposure and engagement to e-cigarette or tobacco products on social media and use or pro-use attitudes among youth. Further substantive research in the area of youth-specific use and attitudes following exposure and engagement with e-cigarette and tobacco content is needed to quantify this association.

Illicit drug use and violence.

This chapter reviews evidence on the relationship between illicit drug use and violence, specifically cannabis, stimulant drugs, and opioids. It summarizes findings of systematic reviews of evidence on cannabis, stimulant drugs, and opioids. It also examines evidence from epidemiological studies of drug use among violent offenders and of violence among persons who use drugs, intervention studies, animal studies, human laboratory studies, and human neuroimaging studies. More studies have examined cannabis because of its higher prevalence of use. There is an association between cannabis use and violence, suggestive evidence of a dose-response relationship between the frequency of cannabis use and violence, and a stronger association in persons with psychoses. There is similar emerging evidence on stimulant use and violence, but evidence on opioids is very limited. There is limited and mixed evidence from intervention studies that reducing drug use reduces violence. Animal and human studies provide potential biological explanations for these associations. The association between cannabis use and violence is most consistent but limited by study heterogeneity and lack of control for potential confounders. It is unclear whether these associations are causal or reflect reverse causation or the effects of confounding.

Longitudinal association between exposure to e-cigarette advertising and youth e-cigarette use in the United States.

BACKGROUND AND AIM: E-cigarette marketing strategies are targeting and appealing to youth, particularly through social media. This study examined the longitudinal relationship between recalled exposure to e-cigarette advertisements on social media and across five traditional advertising mediums, and e-cigarette use, a year later. DESIGN: Weighted regression analyses of waves 4 (W4; 2017), 4.5 (W4.5; 2018) and 5 (W5; 2019) from the Population Assessment of Tobacco and Health Study. SETTING: United States. PARTICIPANTS: Youth aged 12-17 years at W4 or W4.5 (N = 16,671). MEASUREMENTS: We examined the association between past 30-day recalled exposure to six different e-cigarette advertisement mediums (gas stations/convenience stores, social media/websites, newspaper/magazines, radio, billboard, TV) in W4.5 and past 30-day and past 12-month e-cigarette use in W5, while controlling for W4 e-cigarette use and covariates such as sociodemographic variables, academic performance, peer cigarette/e-cigarette use and other substance use. Associations between recalled exposure (W4.5) and lifetime use (W5) among e-cigarette naïve youth at W4.5 (N = 8,914) were also assessed. FINDINGS: Past 12-month and past 30-day e-cigarette use was significantly associated with recalled exposure to e-cigarette advertisement on social media/websites (aOR = 1.65 [99.17 %CI = 1.36,1.99; aOR = 1.49 [99.17 %CI = 1.13, 1.97]) and gas stations/convenience stores (aOR = 1.33; [99.17 %CI = 1.11,1.58]; aOR = 1.27 [99.17 %CI = 1.03,1.58]). Exposure to e-cigarette advertisement on social media/websites (aOR = 1.35 [99.17 %CI = 1.04,1.74]) and gas stations/convenience stores (aOR = 1.67 [99.17 %CI = 1.31,2.13]) was significantly associated with lifetime e-cigarette use among baseline youth who were e-cigarette naïve. CONCLUSIONS: Exposure to e-cigarette advertisement on social media/websites and gas stations/convenience stores was associated with youth e-cigarette use a year later. Stricter restrictions on marketing in these mediums is needed to limit youth exposure to e-cigarette marketing messages if we are to reduce e-cigarette use.

Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies.

OBJECTIVE: To systematically review and synthesise the findings of modelling studies on the population impacts of e-cigarette use and to identify potential gaps requiring future investigation. DATA SOURCE AND STUDY SELECTION: Four databases were searched for modelling studies of e-cigarette use on population health published between 2010 and 2023. A total of 32 studies were included. DATA EXTRACTION: Data on study characteristics, model attributes and estimates of population impacts including health outcomes and smoking prevalence were extracted from each article. The findings were synthesised narratively. DATA SYNTHESIS: The introduction of e-cigarettes was predicted to lead to decreased smoking-related mortality, increased quality-adjusted life-years and reduced health system costs in 29 studies. Seventeen studies predicted a lower prevalence of cigarette smoking. Models that predicted negative population impacts assumed very high e-cigarette initiation rates among non-smokers and that e-cigarette use would discourage smoking cessation by a large margin. The majority of the studies were based on US population data and few studies included factors other than smoking status, such as jurisdictional tobacco control policies or social influence. CONCLUSIONS: A population increase in e-cigarette use may result in lower smoking prevalence and reduced burden of disease in the long run, especially if their use can be restricted to assisting smoking cessation. Given the assumption-dependent nature of modelling outcomes, future modelling studies should consider incorporating different policy options in their projection exercises, using shorter time horizons and expanding their modelling to low-income and middle-income countries where smoking rates remain relatively high.

The implementation and public health impacts of cannabis legalization in Canada: a systematic review.

AIMS: We provide a narrative summary of research on changes in cannabis arrests, cannabis products and prices, cannabis use and cannabis-related harm since legalization. METHODS: We systematically searched for research on the impacts of cannabis legalization in Canada in PubMed, Embase, Statistics Canada and government websites and Google Scholar, published between 2006 and 2021. RESULTS: Cannabis legalization in Canada has been followed by substantial reductions in cannabis-related arrests and cannabis prices. It has also increased adults' access to a diverse range of cannabis products, including edibles and extracts. The prevalence of cannabis use among young adults has increased, but there have been no marked increases or decreases in use among high school students or changes in the prevalence of daily or near-daily use. Legalization has been associated with increased adult hospital attendances for psychiatric distress and vomiting, unintentional ingestion of edible cannabis products by children and hospitalizations for cannabis use disorders in adults. There is conflicting evidence on whether cannabis-impaired driving has increased since legalization. There is suggestive evidence that presentations to emergency departments with psychoses and cannabis use disorders may have increased since legalization. CONCLUSIONS: Legalization of cannabis in Canada appears to have reduced cannabis arrests and increased access to a variety of more potent cannabis products at lower prices. Since 2019, recent cannabis use in Canada has modestly increased among adults but not among adolescents. There is evidence of increased acute adverse effects of cannabis among adults and children.