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Associations between cannabis use and same-day health and substance use behaviors

Writer's picture: Jason BeckJason Beck

Irene De La Torre a k, Emily T. Hébert a b g, Krista M. Kezbers a, Danielle Walters a i, Zachary C. Pope a c, Bingjing Mao a h, Lizbeth Benson d, Dingjing Shi e j, Nadia Stanley a f, Michael S. Businelle


Abstract

Objective

Cannabis use has increased in the United States as states have legalized/decriminalized recreational and/or medicinal use. The primary aim of this study was to examine daily associations between cannabis use and health (physical activity [PA]) and substance use (alcohol consumption, cigarette use) behaviors.

Method

Data from a 28-day nationwide study that prompted daily ecological momentary assessments (EMAs) were used to assess daily cannabis use, moderate-to-vigorous PA (MVPA), alcohol containing drinks consumed, and cigarettes smoked. Only participants who reported cannabis use on at least one day during the study period were included in the analysis (N = 98). Generalized linear mixed models were used to examine associations between cannabis use and same-day health and substance use behaviors while adjusting for race, biological sex, and age.

Results

Daily cannabis use was positively associated with daily PA (p = 0.04, 3.31-minute higher PA duration on use vs. non-use days), number of alcohol containing drinks consumed (p = 0.01, 0.45 more drinks on use vs. non-use days), and number of cigarettes smoked (p = 0.01, 0.63 more cigarettes on use vs. non-use days).

Conclusions

This study was among the first to use EMAs to examine associations between daily cannabis use and same-day PA, alcohol consumption, and cigarette use. Overall, findings indicated that daily cannabis use is associated with higher engagement in these daily health and substance use behaviors. Further research is needed to understand mechanisms linking cannabis use with these and other behaviors.

Introduction

Cannabis, also known as marijuana, is the most frequently used federally illicit drug in the United States (U.S.) (Centers for Disease Control and Prevention, 2022b, Substance Abuse and Mental Health Services Administration, 2022). Attitudes towards cannabis use have become more positive as states have legalized cannabis for medicinal and recreational purposes (Hasin et al., 2019, Urits et al., 2021). The “Monitoring the Future Panel” study showed an overall 9 % increase in cannabis users between 2017 and 2022, with a 3 % increase in daily cannabis use among those aged 19–30 years and an 11 % increase in daily cannabis use among those aged 35–50 years over this same time period (Patrick et al., 2022). Despite these increases, research on how daily cannabis use relates to other behaviors is limited, partially due to continued federal regulations, research-related cannabis sourcing difficulties, and limited cannabis-related research funding (Cooper et al., 2021, Piomelli et al., 2019). Research examining associations between daily cannabis use and same-day health and substance use behaviors may yield important insights that could inform policy as well as multiple behavior change interventions. Current research on the relationship of cannabis use with common health and substance use behaviors is briefly reviewed below.

Daily PA improves cardiovascular, musculoskeletal, and psychological function (Bouchard et al., 2012, Miles, 2007, U.S. Department of Health and Human Services, 2018). Yet, insufficient PA remains a major public health issue leading to premature mortality, loss of function, and increased risk for multiple chronic diseases (Saunders et al., 2020). According to Behavioral Risk Factor Surveillance System data, only 25.3 % of U.S. adults report being physically active (CDC, 2023). Increasing PA is therefore important and can increase life expectancy (World Health Organization, 2018), partially by preventing the development of noncommunicable diseases (Lee et al., 2012). Examining how cannabis use may relate to PA is important in the context of health behavior promotion to ensure cannabis use is not precluding PA participation. Cross-sectional research that has examined relationships between cannabis use and PA has been mixed, with some studies finding that cannabis use may be associated with higher PA (Ong et al., 2021, YorkWilliams et al., 2019) and others finding that cannabis use may be associated with lower PA (Vidot et al., 2017). Scant research is available using more intensive survey methods to examine this relationship. Gibson et al. (2023) used an email-delivered daily diary to examine the relationship between cannabis use and exercise (i.e., planned, repetitive PA done for health-promoting purposes) over 30 days. Observations suggested cannabis users were no more likely to engage in exercise than non-users and that cannabis use days were no more likely to be associated with exercise engagement than non-use days. Using more intensive survey methods to examine how cannabis use is related to overall daily PA, and not the more specific concept of ‘exercise’, may therefore be critical for public health policy.

Alcohol is among the most frequently used substances in the U.S. and is a leading cause of preventable death nationwide behind tobacco, illicit drugs, and physical inactivity (Pilar et al., 2020, Centers for Disease Control and Prevention, 2022a, National Institute on Alcohol Abuse and Alcoholism, 2023, Substance Abuse and Mental Health Services Administration, 2022). Co-substance use is defined as the use of two substances on the same day or using two substances at the same time on any given day. Co-use of alcohol and cannabis is common and increasing (McCabe et al., 2021). Narrative reviews (Yurasek et al., 2017) and longitudinal analyses of cross-sectional survey data (Novak et al., 2016) have shown that cannabis use is associated with increased alcohol consumption and that individuals meeting cannabis use disorder criteria have heightened risk for alcohol use disorder (Stinson et al., 2006). Gunn et al. (2022) showed that co-use of cannabis and alcohol may be substitutionary (e.g., an individual using cannabis to help reduce alcohol consumption) or complementary (e.g., an individual using cannabis to increase the feelings of intoxication associated with alcohol consumption). Short-term studies evaluating the daily use of cannabis and alcohol have been completed. Lee et al. (2020) used SMS text-based online surveys to examine this relationship, observing that alcohol consumption was higher on days when cannabis was used relative to days with no cannabis use. This research group has also observed that days with simultaneous cannabis and alcohol use are also associated with a higher number of 1) hours feeling high and 2) consequences related to alcohol consumption (positive and negative) (Fairlie et al., 2023). However, these studies were conducted in community-based young adult samples. As cannabis use has increased among older populations (Patrick et al., 2022), investigating this relationship among older cohorts is important.

Cigarette smoking contributes to approximately 480,000 annual deaths in the U.S. (Carter et al., 2015). Smoking increases the likelihood of developing lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease (Chen and Boreham, 2002, Fabbri, 2016, Walser et al., 2008). Individuals who smoke cigarettes are more likely to use cannabis than individuals who do not smoke cigarettes (Goodwin et al., 2018, Schauer et al., 2017). Cannabis use is also associated with decreased smoking cessation, increased smoking relapse, and increased cigarette smoking initiation (Weinberger et al., 2020). In a 28-day long study of daily cannabis and tobacco use assessed via an automated phone system, Wilhelm et al. (2020) observed combustible tobacco use (cigarette, cigar, hookah/waterpipe tobacco, e-cigarettes) was significantly more likely to occur following cannabis use among young adult co-users. In a 21-day study of this relationship using SMS text-based surveys, Berg et al. (2019) observed young adults were more likely to smoke cigarettes if they also used cannabis. However, similar to literature on daily cannabis use and alcohol consumption, investigating the relationship between daily cannabis use and cigarette smoking among older samples would extend the literature base.

There is a clear need for prospective investigations into how daily cannabis use is associated with same-day health and substance use behaviors. Ecological momentary assessments (EMA) can be used to assess an individual’s daily engagement in these behaviors in a more ecologically valid manner and in a way subject to less recall bias than traditional survey-based methods (Businelle et al., 2024b, Shiffman et al., 2008). Given the high percentage of smartphone ownership across sociodemographic categories (Pew Research Group, 2024), smartphone-based EMA represents a survey delivery methodology with the necessary reach to complete larger, geographically-diverse investigations that gather more generalizable data. Smartphone-based EMA investigations on the associations of daily cannabis use with same-day health and substance use behaviors among cannabis users across the U.S. could therefore allow for more precise estimates of these associations. This could increase the potential to inform future multiple behavior change interventions—particularly within study designs that seek to use smartphone-based methods to deliver the right intervention to the right person at the correct time (e.g., just-in-time adaptive interventions).

The current study examined associations between daily cannabis use and same day: 1) PA, 2) alcohol consumption, and 3) cigarette smoking. Specifically, smartphone-based EMAs were used to examine within- and between-person associations of cannabis use with same-day: 1) moderate-to-vigorous PA (MVPA), 2) number of alcohol containing drinks consumed, and 3) number of cigarettes smoked. Owing to mechanistic research suggesting that the acute impact of cannabis use on the endocannabinoid and dopaminergic systems may heighten the psychological reward associated with PA (Laksmidewi & Soejitno, 2021), it was hypothesized that MVPA would be higher 1) on cannabis use vs. non-use days and 2) among more vs. less frequent cannabis users. Similarly, it was hypothesized that the number of alcohol containing drinks consumed and cigarettes smoked would be higher 1) on cannabis use vs. non-use days and 2) among more vs. less frequent cannabis users.

Section snippets

Material and methods

The current manuscript was constructed per the Journal Article Reporting Standards for Quantitative Research in Psychology (Applebaum et al., 2018). We report how we determined our sample size, all data exclusions (if any), all manipulations, and all study measures.

Descriptive Statistics

A total of 98 participants met inclusion criteria for the current secondary data analyses. Table 1 provides descriptive information on participant sociodemographic characteristics and variables of interest.

Same-day associations between cannabis use and MVPA

Table 2 provides results from unadjusted and adjusted models examining same-day associations between cannabis use and MVPA. In the adjusted model, daily cannabis use was positively associated with MVPA (p = 0.04), with participants reporting an additional 3.31 more minutes of MVPA/day on

Discussion

This study is among the first to use EMA data to examine associations between cannabis use and same-day MVPA, alcohol consumption, and cigarettes smoked. The observed positive between- and within-person associations between cannabis use and MVPA aligned with our hypothesis and prior cross-sectional observations that people who use cannabis (vs. non-users) tend to report more minutes of weekly PA (YorkWilliams et al., 2019) and have higher accelerometer-measured light PA and MVPA (Ong et al.,

Conclusions

Observations from the current study indicated that cannabis use was related to increased same-day MVPA, alcohol consumption, and cigarettes smoked. The use of EMA to gather data on these behaviors has two implications. First, the enhanced ecological validity and reduced recall bias that smartphone-based EMA affords allowed for more precise estimates of the same-day associations between cannabis use and these health and substance use behaviors across a nationwide sample. Health professionals

CRediT authorship contribution statement

Irene De La Torre: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptualization. Emily T. Hébert: Writing – review & editing, Visualization, Methodology, Formal analysis, Data curation, Conceptualization. Krista M. Kezbers: Writing – review & editing, Project administration, Investigation, Data curation, Conceptualization. Danielle Walters: Writing – review & editing, Investigation, Data curation. Zachary C. Pope: Writing – review & editing. Bingjing Mao:

Funding

Programming and technological support was provided through the mobile health shared resource of the Stephenson Cancer Center via an NCI Cancer Center Support Grant (P30CA225520). Data analysis and manuscript preparation were additionally supported through R00DA046564, and through the Oklahoma Tobacco Settlement Endowment Trust grant R22-02.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Dr. Michael S. Businelle is the primary inventor of the InsightTM mHealth Platform, which was used to develop the Exemplar app. Businelle receives royalties related to the InsightTM Platform, but he did not receive royalties in this case because he was the study PI. All other authors declare that they have no conflicts of interest].

Acknowledgements

We would like to acknowledge all those that participated in this study.


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