Vaping of Cannabis, Cannabidiol, and Synthetic Cannabis Among US Sexual Minority Youths
Abstract
This cross-sectional study investigates rates of vaping of cannabis, cannabidiol, and synthetic cannabis among US sexual minority youths.
Affiliations: Research and Education to Empower Adolescents and Young Adults to Choose Health (REACH) Lab, Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California; University of Pennsylvania, Annenberg School for Communication, Philadelphia; University of Pennsylvania, Leonard Davis Institute of Health Economics, Philadelphia; Abramson Cancer Center, Tobacco and Environmental Carcinogenesis Program, Philadelphia, Pennsylvania; Department of Psychiatry, Yale University School of Medicine, New Haven
License: Copyright 2023 Liu J et al. JAMA Network Open. CC BY 4.0 This is an open access article distributed under the terms of the CC-BY License.
Article links: DOI: 10.1001/jamanetworkopen.2023.29041 | PubMed: 37581889 | PMC: PMC10427937
Relevance: Moderate: mentioned 3+ times in text
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Introduction
Sexual minority youths, compared with heterosexual youths, reported higher past 30-day use in 2021 of alcohol (29.3% vs 21.6%), cannabis (25.6% vs 14.0%), e-cigarettes (26.2% vs 16.4%), and other tobacco (9.1% vs 4.6%).1 Higher rates of e-cigarette use among sexual minority youths may be associated with increased risk for vaping cannabis products.2 In particular, the 2019 e-cigarette, or vaping, product use–associated lung injury (EVALI) epidemic highlighted concerns of vaping illicit tetrahydrocannabinol (THC) oils.2 Thus, this study aimed to examine the rate of vaping cannabis among sexual minority youths.
Methods
This cross-sectional study used the 2022 National Youth Tobacco Survey (NYTS), a Centers for Disease Control and Prevention–collected data set on tobacco use behaviors among 28 291 US nationally representative middle and high school students (weighted response rate, 45.2%). Outcomes included past 30-day vaped (1) marijuana, including THC, THC concentrates, hash oil, or waxes; (2) cannabidiol (CBD) or CBD oils; and (3) synthetic marijuana or cannabinoids, such as K2 or spice. The factor of interest was sexual identity, which was assessed as “heterosexual (straight),” “lesbian or gay,” “bisexual,” and “not sure.” Covariates included school level, sex, race and ethnicity, past 30-day nicotine vaping and other tobacco use, familial e-cigarette use, and peer e-cigarette use (all self-reported). We conducted descriptive statistics for the population count and prevalence of cannabis vaping outcomes by sexual orientation from probability weights and assessed bivariate associations with Pearson χ2 test (Rao and Scott correction) and ran post hoc tests for differences between sexual orientation subgroups. We further ran a series of multivariable logistic regression models on the 3 vaping outcomes by sexual orientation, adjusting for covariates, and stratified by sex. We ran multivariable models interacting sexual orientation and race and ethnicity to explore the association of that intersectionality with outcomes. We considered P = .0167 (.05/3) as the level of statistical significance to adjust for multiple comparisons and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. We used the survey package in R statistical software version 1.1.456 (R Project for Statistical Computing) for analyses. This secondary data analysis of publicly available, deidentified data was deemed exempt from review by the Yale Institutional Review Board.
Results
Among 28 291 students (12.4% non-Hispanic Black, 26.9% Hispanic, 54.1% non-Hispanic White, and 6.6% non-Hispanic other race; 51.1% male; 56.2% high school students), 4.5% students identified as gay or lesbian, 11.8% as bisexual, and 9.9% as “not sure.” Among males and females, sexual minority youths (gay or lesbian and bisexual individuals) reported higher levels of past 30-day vaping of THC, CBD, and synthetic cannabis than their heterosexual peers (Table 1). Post hoc tests showed that there were significant differences between gay and lesbian youths and the not sure group for all 3 vaping outcomes and for bisexual youths and the not sure group for THC and CBD vaping. After adjusting for other covariates, bisexual youths were more likely vs heterosexual youths to report past 30-day THC vaping (adjusted odds ratio [aOR] = 1.61; 95% CI, 1.24-2.09) and CBD vaping (aOR, 1.99; 95% CI = 1.37-2.91) (Table 2). We found similar patterns when stratified by sex. There was no interaction between sexual orientation and race and ethnicity for any outcome for the overall sample or when stratified by sex.
Table 1. : Respondent Characteristics
| Characteristic | Overall (N = 28 291) | Heterosexual (n = 18 740 [73.8%])zld230153t1n1 | Gay and lesbian (n = 1146 [4.5%])zld230153t1n1 | Bisexual (n = 3002; 11.8%)zld230153t1n1 | Not sure (n = 2547; 9.9%)zld230153t1n1 | χ2zld230153t1n2 | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Unweighted No. | Weighted % | Unweighted No. | Weighted % | Unweighted No. | Weighted % | Unweighted No. | Weighted % | Unweighted No. | Weighted % | ||
| Past 30-d cannabis vapingzld230153t1n3 | |||||||||||
| Marijuanazld230153t1n4 | 2273 | 8.2 | 1291 | 7.2 | 142 | 14.4 | 387 | 12.8 | 134 | 0.9 | <0.001 |
| CBD or CBD oils | 841 | 2.9 | 425 | 2.2 | 62 | 6.4 | 150 | 4.8 | 66 | 2.3 | <0.001 |
| Synthetic marijuana or cannabinoidszld230153t1n5 | 402 | 1.4 | 191 | 1.0 | 41 | 4.4 | 60 | 2.1 | 33 | 1.1 | <0.001 |
| Sex | |||||||||||
| Male | 14 375 | 51.1 | 10 801 | 57.6 | 426 | 39.2 | 558 | 19.1 | 1040 | 40.4 | <0.001 |
| Female | 13 692 | 48.9 | 7907 | 42.4 | 700 | 60.8 | 2393 | 80.9 | 1473 | 59.6 | |
| Grade level | |||||||||||
| Middle school | 12 041 | 43.8 | 7541 | 41.2 | 457 | 37.9 | 1274 | 41.9 | 1461 | 58.2 | <0.001 |
| High school | 16 118 | 56.2 | 11 172 | 58.8 | 679 | 62.1 | 1722 | 58.1 | 1075 | 41.8 | |
| Race and ethnicityzld230153t1n6 | |||||||||||
| Hispanic | 7458 | 26.9 | 4707 | 25.2 | 308 | 28.8 | 816 | 28.0 | 722 | 27.7 | 0.103 |
| Non-Hispanic Black | 3383 | 12.4 | 2195 | 11.9 | 150 | 13.8 | 350 | 11.7 | 274 | 10.6 | |
| Non-Hispanic White | 13 501 | 54.1 | 9413 | 56.0 | 567 | 51.5 | 1466 | 54.5 | 1094 | 53.1 | |
| Non-Hispanic otherzld230153t1n7 | 3171 | 6.6 | 2089 | 6.8 | 99 | 5.9 | 312 | 5.8 | 367 | 8.6 | |
| Past-30-d other tobacco usezld230153t1n8 | |||||||||||
| None | 25 950 | 94.8 | 17 794 | 95.8 | 1007 | 87.2 | 2749 | 93.4 | 2416 | 96.6 | <0.001 |
| Any | 1569 | 5.2 | 830 | 4.2 | 125 | 12.8 | 221 | 6.6 | 100 | 3.4 | |
| Past 30-d nicotine vaping | |||||||||||
| None | 25 801 | 92.6 | 17 340 | 93.2 | 1014 | 89.2 | 2640 | 90.8 | 2428 | 95.9 | <0.001 |
| Any | 2070 | 7.4 | 1236 | 6.8 | 115 | 10.8 | 297 | 9.2 | 98 | 4.1 | |
| Household e-cigarette use | |||||||||||
| No | 21 377 | 86.5 | 15 731 | 88.0 | 858 | 77.3 | 2270 | 79.1 | 2145 | 88.1 | <0.001 |
| Yes | 3338 | 13.5 | 2167 | 12.0 | 232 | 22.7 | 612 | 20.9 | 285 | 11.9 | |
| Perceived peer e-cigarette use | |||||||||||
| None | 4904 | 18.8 | 3490 | 18.1 | 180 | 13.5 | 392 | 12.0 | 843 | 31.2 | <0.001 |
| Any | 21 600 | 81.2 | 15 242 | 81.9 | 966 | 86.5 | 2610 | 88.0 | 1704 | 68.8 | |
Sexual identity was assessed with the question “Which of the following best describes you?” with responses of “heterosexual (straight),” “lesbian or gay,” “bisexual,” and “not sure.” Sexual identity totals to 25 435 due to missing values.
χ2 values were obtained through Pearson χ2 test with Rao and Scott correction. Post hoc tests were conducted.
Past-30-day vaping cannabis was assessed with the questions “Have you vaped any of the following substances during the past 30 days?” and separate items for “marijuana (also called pot, weed, or cannabis), including THC, THC concentrates, hash oil, or waxes,” “CBD or CBD oils,” and “synthetic marijuana or cannabinoids, such as K2 or spice” (not mutually exclusive). Totals for past-30-day cannabis across sexual identity groups do not total to overall due to missing values from sexual identity.
Marijuana (also called pot, weed, or cannabis), includes THC, THC concentrates, hash oil, or waxes.
Includes as K2 or spice.
Available responses for race were American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White. Available responses for ethnicity were Hispanic, Latino, Latina, or of Spanish origin (Mexican, Mexican American, Chicano, or Chicana; Puerto Rican; Cuban; and another Hispanic, Latino, Latina, or Spanish origin) or not of Hispanic, Latino, Latina, or Spanish origin. Race and ethnicity were asked in separate questions and combined by ignoring race responses from individuals who responded yes to Hispanic, Latino, Latina, or of Spanish origin.
Non-Hispanic other includes non-Hispanic Asian, non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Other Pacific Islander, and multiple non-Hispanic races (respondents could choose more than 1 listed race).
Other tobacco use includes combustible cigarettes, cigars or cigarillos, smokeless tobacco, hookahs, roll-your-own cigarettes, pipes, snus, dissolvable tobacco, bidis, heated tobacco products, and nicotine pouches (does not include nicotine vaping).
Abbreviation: CBD, cannabidiol.
Table 2. : Association of Sexual Identity With Cannabis Vaping Outcomes
| Sexual identity | Past 30-d THC vapingzld230153t2n1 | Past 30-d CBD vapingzld230153t2n1 | Past 30-d synthetic cannabis vapingzld230153t2n1 | |||
|---|---|---|---|---|---|---|
| aOR (95% CI) | P valuezld230153t2n2 | aOR (95% CI) | P valuezld230153t2n2 | aOR (95% CI) | P valuezld230153t2n2 | |
| Overall (N = 28 291) | ||||||
| Sexual orientation | ||||||
| Heterosexual | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| Gay or lesbian | 1.56 (1.01-2.41) | .04 | 1.87 (0.96-3.65) | .07 | 2.26 (0.91-5.60) | .08 |
| Bisexual | 1.61 (1.24-2.09) | <.001 | 1.99 (1.37-2.91) | <.001 | 1.83 (0.90-3.75) | .10 |
| Not sure | 1.23 (0.84-1.78) | .28 | 1.64 (0.97-2.79) | .07 | 1.90 (1.03-3.50) | .04 |
| Males (n = 14 375) | ||||||
| Sexual orientation | ||||||
| Heterosexual | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| Gay or lesbian | 1.74 (0.78-3.90) | .18 | 2.50 (0.81-7.70) | .11 | 3.81 (1.19-12.20) | .03 |
| Bisexual | 2.13 (1.35-3.36) | .001 | 3.67 (1.65-8.17) | .002 | 3.10 (1.11-8.67) | .03 |
| Not sure | 1.38 (0.68-2.81) | .27 | 1.83 (0.82-4.08) | .14 | 2.14 (0.90-5.08) | .08 |
| Females (n = 13 692) | ||||||
| Sexual orientation | ||||||
| Heterosexual | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| Gay or lesbian | 1.42 (0.89-2.28) | .14 | 1.51 (0.75-3.05) | .25 | 1.29 (0.48-3.48) | .61 |
| Bisexual | 1.43 (1.02-2.01) | .04 | 1.56 (1.12-2.18) | .009 | 1.38 (0.66-2.88) | .39 |
| Not sure | 1.13 (0.67-1.90) | .66 | 1.53 (0.74-3.17) | .25 | 1.55 (0.67-3.60) | .31 |
Models were adjusted for grade level (middle or high school), sex (male or female), race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, and non-Hispanic other), any past 30-day use of other tobacco (none or any), household e-cigarette use (yes or no), any past 30-day nicotine vaping (none or any), and perceived peer e-cigarette use (none or any).
The statistical cutoff of the P value was .016 (.05/3), adjusted for multiple comparisons.
Abbreviations: aOR, adjusted odds ratio; CBD, cannabidiol; NA, not applicable; THC, tetrahydrocannabinol.
Discussion
In this cross-sectional study, sexual minority youths, particularly bisexual youths, were more likely to vape THC and CBD, as was found in a California sample.3 It is well-documented that minority stress (eg, stress from sexual orientation–based discrimination) is associated with youth substance use,4 which may be consistent with vaping cannabis.
This study has several limitations, such as self-report bias and an observational, cross-sectional nature, which cannot establish causal inference. This study did not assess dose and frequency. There may be unmeasured confounders, such as alcohol and other substance use, which the NYTS does not include. Despite these limitations, preliminary evidence from this study may inform future prevention strategies directed at reducing substance use disparities among sexual minority youth.
References
- 1Centers for Disease Control and Prevention. Explore youth risk behavior survey questions—United States, 2021. Accessed June 26, 2023. https://yrbs-explorer.services.cdc.gov/
- Cannabis vaping: understanding the health risks of a rapidly emerging trend.. Paediatr Child Health., 2020. [DOI | PubMed]
- E-cigarette, cigarette, and cannabis use patterns as a function of sexual identity in a sample of Southern California young adults.. Addict Behav Rep., 2021. [DOI | PubMed]
- A systematic review of the aetiology of tobacco disparities for sexual minorities.. Tob Control., 2013. [DOI | PubMed]