Route of administration (ROA) for cannabis often refers to the overall way that cannabis is delivered into the human body, such as through inhalation, oral-mucosal/sublingual, or topical and transdermal applications (Bruni et al., 2018). Delivery method often refers to the specific method used to deliver cannabis, such as smoking, edibles, vaporization, tinctures, topical applications, and oil extracts (Bruni et al., 2018). The term cannabis administration will be used as an umbrella term, encompassing both ROA and delivery method for this paper. Along with legalization changes, a multibillion-dollar cannabis industry produces high-potency herbal cannabis products, a growing number of boutique species, and novel delivery methods such as the e-pen vaping device. Higher concentrations of THC, averaging above 60%, available as high potency concentrates via the e-pen vaping device and various extracts, are more harmful in terms of addiction potential, psychosis, and cognitive impairment (Davenport, 2021; El Sohly et al., 2016; Englund et al., 2017; Murray et al., 2016). Although legalization has led to rapid growth, there is limited research regarding how these factors have affected perceptions of risks and benefits and patterns of cannabis use (Russell et al., 2018), especially for women.

Some adverse side effects of cannabis use may be prevented by using less harmful forms of administration while still preserving the identified therapeutic effect (Tashkin, 2017). For example, smoking cannabis has been associated with acute and chronic bronchitis and other respiratory problems (Loflin & Earleywine, 2015; Tashkin, 2017; Tetrault et al., 2007). Some medical professionals have discouraged use of combusted cannabis inhalation and instead recommend forms of administration that do not involve smoking, such as vaporization (Fischer et al., 2017; Loflin & Earleywine, 2015). Further, individuals who use traditional forms of vaporizations to consume cannabis have reported fewer adverse respiratory symptoms than those who predominantly smoke cannabis (Loflin & Earleywine, 2015).

Some research has indicated that individuals who use medical cannabis utilize vaporization or ingestion methods significantly more than those who use cannabis recreationally, with those who use recreationally more likely to utilize inhalation methods (Sznitman, 2017). However, other research has indicated that 92% of individuals who use cannabis recreationally and 82% of those who use cannabis medically reported smoking cannabis flower the last time they used cannabis (Pacula et al., 2016). Some studies have shown medical cannabis users prefer non-inhalation forms, such as tinctures, edibles, and topicals, which may avoid the hazards commonly associated with inhalation and have a slower time to onset, less euphoria, and longer-lasting effects (MacCallum & Russo, 2018). Self-reported reasons for choosing vaporization or oral forms of administration include fewer perceived health risks and stronger subjective drug effects as compared to smoking (Lee et al., 2016).

While just under half of adults and over half of adolescents report consuming cannabis edibles (Knapp et al., 2019; Schauer et al., 2016; Steigerwald et al., 2018), there are documented inconsistencies and inaccuracies in product labeling regarding THC and CBD content in edibles (Cao et al., 2016; MacCoun & Mello, 2015; Vandrey et al., 2015). Further, medical cannabis dosage for edibles has not yet been specified by the U.S. Food and Drug Administration due to its Schedule 1 status (FDA; Barrus et al., 2017). Additionally, higher rates of edible consumption have been associated with adverse psychiatric and cardiovascular outcomes (Health Canada, 2018) and increased risk for CUD (Cerda et al., 2019). Research also suggests that higher concentrations of THC, which are available as high potency concentrates for consumption via a vape pen or e-cigarette device, are more harmful in terms of addiction potential (including CUD), psychosis, and cognitive impairment (Cerda et al., 2019; El Sohly et al., 2016; Englund et al., 2017; Murray et al., 2016).

While research has indicated that men use a greater number of forms of cannabis administration than women (Baggio et al., 2014), women are increasingly being targeted with advertising for feminized versions of cannabis products, such as vaginal suppositories and topical products, and claims for symptom relief that are not supported by empirical evidence. This lack of empirical evidence supporting safety and efficacy for such products may lead to unintentional harmful cannabis use by women. Additionally, due to socio-cultural norms, women may choose more “feminine” cannabis products or forms of administration, even when those products lack established evidence for safety, tolerance, and efficacy.

Overall, for participants who reported using any type of cannabis (n = 199), smoking was the preferred form of administration (62.1%), followed by edibles (25.3%), vaporizing in any form (7.4%), tinctures and concentrates (3.2%), and topicals (2.1%). Women who reported using any form of cannabis to treat chronic pain reported using from 1 to 6 different forms of administration (see Table 4).

Present findings revealed that racial and sexual identity were covariates for choice of cannabis administration for women, indicating that these factors may play a role in women’s decisions regarding the choice of cannabis delivery method. Additionally, while some studies have suggested that individuals who use medical cannabis are more likely to utilize vaporization or ingestion than those who use recreational cannabis (Sznitman, 2017), other research indicates that smoking has traditionally been the most utilized delivery method overall (Pacula et al., 2016). Present results indicated that both medical and recreational cannabis users preferred smoking as their primary choice of administration. These results contradict some past research indicating that those who use medical cannabis are more likely to avoid delivery methods involving inhalation (MacCallum & Russo, 2018).

Present results also indicated that edibles are the second most prevalent choice for cannabis administration for women who use any form of cannabis. Studies have suggested that individuals may choose edibles as one way to avoid cannabis use stigma since edibles can be consumed more discreetly than many forms of inhalation (Barrus et al., 2017). However, edibles often have inconsistent and sometimes inaccurate content labeling for THC and CBD concentration and are metabolized differently than when cannabis is consumed via inhalation, primarily due to the delayed onset of drug effect with ingestion (Cao et al., 2016; MacCoun & Mello, 2015; Vandrey et al., 2015). Further, the FDA has yet to regulate medical cannabis dosage for edibles due to its Schedule 1 status (Barrus et al., 2017). There is an urgent need to more comprehensively understand how women with chronic pain utilize different forms of cannabis administration and the extent to which specific delivery methods are associated with differential cannabis use outcomes.