Trends and Factors Related to Blunt Use in Middle and High School Students, 2010–2020 Mohammad Ebrahimi Kalan, PhD,a Rime Jebai, MPH,a Zoran Bursac, PhD,b Lucy Popova, PhD,c Prem Gautam, MPH,a Wei Li, MPH,a Mohammed M. Alqahtani, MS,d Tanjila Taskin, MPH,a Leah L. Atwell, MPH,e Jennifer Richards, MPH,e Kenneth D. Ward, PhD,f Raed Behaleh, PhD,g Ziyad Ben Taleb, MD, MPH, PhDh

BACKGROUND AND OBJECTIVES: Blunt use is a popular mode of marijuana consumption among abstract adolescents in the United States, but little is known about how its prevalence has changed over time or factors associated with its use. With this study, we assessed trends and correlates of past (ever used but not in the past 30 days) and current (used in past 30 days) blunt use among adolescents in Florida. METHODS: We analyzed data from 2010–2020 cross-sectional, statewide representative Florida Youth Tobacco Surveys that comprised 461 706 middle and high schoolers using Joinpoint to calculateannualpercentagechange(APC)intheweightedprevalenceofpastandcurrentblunt use. A weighted multivariable regression model was developed by using 2019–2020 Florida Youth Tobacco Survey data to examine the factors associated with past and current blunt use. RESULTS: Whereas the prevalence of past (APC 5 5.32%)andcurrent(APC5 5.28%)bluntuse significantly decreased from 2010 to 2015, an increasing trend in current use prevalence (APC 5 14.91%) was observed from 2015 to 2018 and has been approximately constant ever since. Similar increasing trends were observed in current blunt use among female students (APC 5 14.92%), middle schoolers (19.57%), and non-Hispanic (NH) white students (APC 5 11.12%) from 2016 to 2020. Several factors were consistently associated with greater odds of both past and current blunt use for both middle and high schoolers, including older age, being NH Black (versus NH white), past and current use of cigarettes, electronic cigarettes, hookah, cigars, and ever vaping marijuana. CONCLUSIONS: Although blunt use among Florida youth decreased from 2010 to 2015, substantial increases were observed since 2015, suggesting that existing tobacco control programs should incorporate marijuana (and blunt) modules into existing tobacco and nicotine prevention programs.

WHAT’S KNOWN ON THIS SUBJECT: The popularity of a b Departments of Epidemiology and Biostatistics, Robert Stempel College of Public Health and Social Work, Florida blunt use as a common mode of marijuana consumption International University, Miami, Florida; cDepartment of Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, Georgia; dRehabilitation Science Program, School of Health Professions, among adolescents is a public health concern. e The University of Alabama at Birmingham, Birmingham, Alabama; Florida Department of Health, Tallahassee, WHAT THIS STUDY ADDS: In 2019–2020, blunt use was Florida; fSchool of Public Health, The University of Memphis, Memphis, Tennessee; gDepartment of Public Health reported by a large number of middle and high schoolers and Prevention Sciences, College of Education and Health Sciences, Baldwin Wallace University, Berea, Ohio; and hPublic Health Program, Department of Kinesiology, College of Nursing and Health Innovation, The University of in Florida, particularly among non-Hispanic Black Texas at Arlington, Arlington, Texas students. Students who used blunts either in the past or currently reported use of each tobacco product type DOI: https://doi.org/10.1542/peds.2020-028159 (cigarettes, electronic cigarettes, hookah, cigars, and Accepted for publication Mar 16 , 2021 smokeless tobacco). Address correspondence to Ziyad Ben Taleb, MD, MPH, PhD, Public Health Program, Department of Kinesiology, College of Nursing and Health Innovation, The University of Texas at Arlington, 411 S Nedderman Dr, Box 19407, Arlington, TX 76019-0407. E-mail: [email protected] To cite: Ebrahimi Kalan M, Jebai R, Bursac Z, et al. Trends and Factors Related to Blunt Use in Middle and High School PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Students, 2010–2020. Pediatrics. 2021;148(1):e2020028159 Copyright © 2021 by the American Academy of Pediatrics

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 148, number 1, July 2021:e2020028159 ARTICLE Substance use patterns among using data from Population not well established,23–25 the adolescents in the United States Assessment of Tobacco and Health, American Thoracic Society warns have changed drastically over the authors found that initiating that marijuana (and blunt) smoke past decade.1 According to 2018 e-cigarettes at wave 1 (2013–2014) can cause an asthma attack leading Monitoring the Future, a survey of was associated with subsequent to hospitalization and even death.26 50 000 eighth-, 10th-, and 12th- marijuana use in wave 2 Therefore, monitoring the grade students in the United States, (2014–2015), especially among prevalence of blunt use and how it opioid use frequency is at historic young adolescents aged 12 to 14 differs between adolescents with low, whereas vaping and marijuana years (ie, middle schoolers).13 These and without asthma is crucial for use are on the rise.2 In 2019, past studies suggest a bidirectional both clinical and regulatory (ever used but not in the past 30 association between using marijuana purposes. days) and current (used in the past (and blunts) and tobacco and 30 days) marijuana use rates among nicotine products. Taken together, Given that marijuana is the most % commonly used federally defined US high school students were 36.8 the coadministration of nicotine and 27 and 21.7%, respectively3,4; marijuana through blunt use among illicit drug among US youth and in marijuana is the second most adolescents may increase the light of shifting policies on marijuana (eg, Florida passed commonly used substance after likelihood of becoming dependent medical marijuana laws on alcohol.1 Cigar blunts have become a on both nicotine and marijuana (and – November 8, 2016, with effective popular mode of marijuana blunts)13 15 and can worsen the date on January 3, 2017; retail consumption among US respiratory symptoms, especially marijuana remains illegal as of adolescents.5,6 Blunts are cigars that among people with asthma.16,17 February 9, 2021),28 the landscape have been hollowed out and filled None of the abovementioned studies of marijuana and blunt use among with marijuana; cigar wrappers reported prevalence of blunt use adolescents might also change.29 contain quantifiable levels of and associated factors (eg, Adding to this, 26.2% of adolescents nicotine, thus exposing users to concomitant use of blunts and in the United States reported ever nicotine despite the removal of the tobacco, having asthma) by school vaping marijuana in 2018,30 which tobacco filler.7 level, leaving it for further coincides with the recent epidemic investigation. of e-cigarette- or vaping-associated Consistent with a potential lung injury.31 In addition, evidence dependence-producing effect, blunt Marijuana smoke contains many of shows higher rates of blunt use use is linked to the initiation of the same harmful chemicals and among young Black individuals, combustible cigarettes and other carcinogens as tobacco smoke, with – especially Black female youth, who tobacco and nicotine products.8 10 some at lower and others at higher are more likely to smoke marijuana Pooled data from 2 prospective concentrations.18 Recent research through blunts compared with other studies of adolescents in California identified new chemical compounds – race and/or ethnicity groups.32 34 and Connecticut found that past in blunt smoke that were not blunt users had significantly greater previously found in either tobacco Examining blunt use trends and how 19 odds of trying a combustible tobacco or marijuana smoke. As such, they differ by demographic factors product (cigarettes, nonblunt cigars, smoking blunts could expose users such as sex, race and/or ethnicity, and hookah) between baseline to a range of harmful chemicals, and tobacco and nicotine use among 11 (2013) and follow-up (2014). In potentially leading to negative middle and high schoolers is pivotal another prospective study, health outcomes (eg, impaired to a richer understanding of researchers found that adolescents short-term memory, symptoms of disparities and informing prevention 16,20,21 who had ever used a blunt at age 14 chronic bronchitis). and treatment interventions and were 20 times more likely to Additionally, a recent report from drug policies. In fact, changing become a current cigar user across a the US Youth Risk Behavior Survey landscape in marijuana consumption 2-year follow-up compared with (YRBS) reveals that during 2003 to (eg, access to various product adolescents who had never used a 2017, cigar and marijuana use (the features of cigars that make it easy blunt.5 Cross-sectional data from 4 combination usually used in blunts) for adolescents to manipulate them high schools in Connecticut and New was more common among to make blunts),35,36 a decrease in York found that blunt use was adolescents with asthma than perceived harmfulness of this drug, associated with concurrent use of without asthma.22 Although the as well as marijuana-specific policy electronic cigarettes (e-cigarettes).12 exact effects of marijuana use on settings (eg, decriminalization, In fact, in a recent prospective study adolescents with severe asthma are medicalization, and legalization)

Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 KALAN et al make it crucial to investigate the during the past 30-day” preceding tobacco, snuff, dip, snus, and trends in blunt use among the survey were classified as current dissolvable tobacco). For each of adolecnts.21,37,38 Therefore, we aim users. Therefore, the outcome these 5 products, participants were to (1) evaluate the trends in past variables for this study were defined asked, “Have you ever smoked/used and current blunt use among a as “past” use (“No; non-users” coded part or all of a (name of product)?” representative sample of Florida as “0” and “Yes” coded as “1”) and Responses to this question were yes adolescents from 2010 to 2020 and “current” use (“No; non-current or no. Those who answered yes but (2) identify factors associated with users” coded as “0” and “Yes” coded indicated not using the product in past and current blunt use as“1”). The FYTS included the blunt- the past 30 days were defined as employing 2019–2020 Florida Youth associated questions in the school past users, whereas those who Tobacco Surveys (FYTSs). surveys starting in 2010. answered yes and reported use of the product on “$1 day during the Demographic Characteristics and METHODS past 30-day” were classified as Asthma History current users. Ever use of e- Data Source and Study Sample Demographic characteristics include cigarettes to vape marijuana oil was Data were drawn from the age (years), sex, race and/or determined by asking “Have you 2010–2020 FYTS, a statewide cross- ethnicity (non-Hispanic [NH] white, ever used an electronic vapor sectional, school-based, pencil-and- NH Black, Hispanic, and NH other), product with marijuana oil or hash paper questionnaire administered to school level (middle or high oil?” Responses to this question public middle and high school schooler), and residential status were yes or no, with a yes response students in 67 Florida counties. (metro versus nonmetro or rural). indicating ever use. Details for FYTS are available County-level metropolitan status – Data Analysis elsewhere.39 41 The analytical associated with the sampled schools, sample in this study was limited to developed by the US Department of All analyses were weighted by using adolescents (aged 9–21 years) who Agriculture Economic Research SAS/STAT version 14.2 (SAS answered questions about blunt use Service, was dichotomized into the Institute, Inc, Cary, NC) survey (N 5 461 706 for trends analyses metro (code 1–3) and nonmetro or procedures (PROC SURVEYFREQ and during 2010–2020; N 5 33 038 for rural (code 4–9, which includes PROC SURVEYLOGISTIC) to account multivariable analyses during completely rural counties).41,42 We for survey design features, to offset 2019–2020). Institutional review defined asthma status using the nonresponse bias, and to be board approval was not required following questions. “Has a doctor representative of middle and high because of the deidentified nature of or nurse ever told you that you have schoolers in Florida. To examine the the publicly available data. This asthma?” Participants who factors associated with past and study followed the Strengthening responded yes to this question were current blunt use, we pooled data the Reporting of Observational considered as having “lifetime from the 2019 and 2020 FYTSs. Studies in Epidemiology (STROBE) asthma.” Those who answered yes Univariate differences across levels reporting guidelines. to the question “Do you still have of each independent variable asthma?” were considered having (demographic characteristics and Blunt Use 41,43 “current asthma.” Those who tobacco use) were examined by The definition of blunt use (as the answered “don’t know, no, or not Rao-Scott v2 tests for middle and outcome of the study) was explained sure” about whether they still have high schoolers. We applied weighted to the participants as follows: asthma were considered as not multivariable regression models “Sometimes people take tobacco out having asthma. adjusted for demographic and of a cigar and replace it with tobacco use variables for middle and marijuana. This is sometimes called Tobacco and/or Nicotine Product high schoolers to estimate adjusted Use a ‘Blunt.’” Next, participants were odds ratios (aORs) and 95% asked, “Have you ever smoked part Past and current (past 30-day) use confidence intervals (CIs) of past or all of a blunt?” Responses to this of 5 tobacco and/or nicotine and current blunt use. All question were yes or no. Those who products was assessed. These associations were considered answered yes but reported not products were cigarettes, significant at the a level of .05. We using blunts in the past 30 days e-cigarettes, hookah (ie, waterpipe), grouped our findings by school level were defined as past users, and cigars (cigars, little cigars, and (middle versus high schoolers) to those who answered yes and cigarillos, ie, nonblunt cigars), and provide a clear picture of risk reported using blunts on “$1 day smokeless tobacco (SLT) (chewing differences by age group and to

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 30, 2021 3 recommend school-based programs current blunt use for the same 6.17 to 11.86). Those who were to prevent blunts and tobacco and/ period ranged from 10.5% to 12.7% current blunt users (versus or nicotine product use. (Supplemental Table 4). As shown in noncurrent users) were more likely Supplemental Fig 2, the past and to be older (aOR 5 1.22; 95% CI, For the time trends analysis of the current use of blunt in Florida high 1.07 to 1.39), NH Black (versus NH annual estimated prevalence of schoolers had a similar pattern as white; aOR 5 2.36; 95% CI, 1.41 to blunt use from 2010 to 2020, we marijuana use in US high schoolers 3.94), Hispanic (versus NH white; used the Joinpoint Regression from 2011 to 2019. aOR 5 1.79; 95% CI, 1.23 to 2.59), software version 4.8.0.1 released by past users of e-cigarettes (aOR 5 44 the US National Cancer Institute. Trends Analyses 3.63; 95% CI, 2.22 to 5.91) and Joinpoint regression enables the As displayed in Fig 1 and hookah (aOR 5 2.32; 95% CI, 1.33 to user to test whether an apparent Supplemental Table 5, whereas the 4.07), current users of cigars (aOR 5 positive or negative change in trend prevalence of past (APC 5 5.32%; 4.93; 95% CI, 1.98 to 12.25) and is statistically significant by 95% CI, 7.9% to 2.7%) and cur- e-cigarettes (aOR 5 3.75; 95% CI, breaking the data into time rent (APC 5 5.28%;95% CI, 7.1% 2.58 to 5.45), and ever users of segments. For each time segment, to 3.4%) blunt use significantly de- e-cigarettes to vape marijuana oil we calculated the annual percentage creased from 2010 to 2015, increas- (aOR 5 8.54; 95% CI, 5.90 to 12.35). change (APC) in past and current ing trends in current use prevalence blunt use during that period and (APC 5 14.91%;95% CI, 0.5% to High School Students determined if the APC was 31.4%) were observed from 2015 to In the adjusted multivariable statistically different from 0 (no 2018 and has been approximately regression model as shown in Table trend).44 Joinpoint regression constant ever since. Similar increas- 2, those who were past blunt users analyses were stratified by sex, race, ing trends were observed in current (versus nonusers) were more likely and school level, providing the SE blunt use among female students to be older (aOR 5 1.15; 95% CI, for each annual prevalence estimate (APC 5 14.92%;95% CI, 1.1% to 1.08 to 1.23), NH Black (versus NH by using PROC SURVEYFREQ 30.7%), middle schoolers (19.57%; white; aOR 5 2.20; 95% CI, 1.76 to software. 95% CI, 2.3% to 39.8%), and NH 2.75), past users of cigars (aOR 5 white students (APC 5 11.12%;95% 3.10; 95% CI, 2.25 to 4.26), We examined potential modification CI, 2.0% to 21.1%) from 2016 to cigarettes (aOR 5 1.93; 95% CI, 1.50 (interaction) effects of sex and race 2020. Joinpoint models revealed no to 2.50), e-cigarettes (aOR 5 4.52; and/or ethnicity on outcomes of significant change for average APC 95%C, 3.71 to 5.50), and hookah interest (current and past blunt use) for past and current blunt use over- (aOR 5 3.00; 95% CI, 2.20 to 4.73), in multivariable regression models all and by sex, race and/or ethnicity, current users of e-cigarettes (aOR 5 (controlling for age and residence and school level (all P values >.05; 1.57; 95% CI, 1.27 to 1.93), and ever status) and stratified trends in blunt data not shown). users of e-cigarettes to vape use by sex and race (see marijuana oil (aOR 5 8.32; 95% CI, Supplemental Tables 6 and 7). We Middle School Students 6.88 to 10.06). Those who were also compared statewide blunt use In the adjusted multivariable current blunt users (versus with nationwide marijuana use us- regression model as shown in Table 1, noncurrent users) were more likely ing published data from the US those who were past blunt users to be NH Black (versus NH white; YRBS (2011–2019) among high (versus nonusers) were more likely aOR 5 1.92; 95% CI, 1.49 to 2.48), school students.4 to be older (aOR 5 1.32; 95% CI, past users of e-cigarettes (aOR 5 1.17 to 1.49), NH Black (versus NH 2.19; 95% CI, 1.66 to 2.90) and RESULTS white; aOR 5 2.52; 95% CI, 1.76 to hookah (aOR 5 2.06; 95% CI, 1.59 to 3.62), past users of cigars (aOR 5 2.66), current users of cigars (aOR 5 Descriptive Analyses of Sample 5.23; 95% CI, 2.93 to 9.34), 5.98; 95% CI,3.92to9.13),cigarettes Of the 461 706 respondents during cigarettes (aOR 5 2.14; 95% CI, 1.45 (aOR 5 1.80; 95% CI,1.11to2.91),e- 2010–2020, 50.7% were male, 56.9% to 3.14), e-cigarettes (aOR 5 8.01; cigarettes (aOR 5 3.04; 95% CI, 2.49 high schoolers, 41.2% NH white, 95% CI, 5.73 to 11.19), and hookah to 3.71), and hookah (aOR 5 3.62; 22.1% NH Black, 30.6% Hispanic, and (aOR 5 2.58; 95% CI, 1.40 to 4.73), 95% CI, 1.02 to 2.68), and ever users 6.2% NH other. As displayed in current users of e-cigarettes (aOR 5 of e-cigarettes to vape marijuana oil Supplemental Table 3, past blunt 1.50; 95% CI, 1.07 to 2.12), and ever (aOR 5 5.63; 95% CI, 4.56 to 6.96). use for 11 waves (2010–2020) users of e-cigarettes to vape Past users of blunt were more likely ranged from 19.6% to 20.0%, and marijuana oil (aOR 5 8.56; 95% CI, to report having lifetime asthma (aOR

Downloaded from www.aappublications.org/news by guest on September 30, 2021 4 KALAN et al FIGURE 1 Past and current blunt use prevalence among Florida youth from 2010 to 2020. A, Overall past blunt use. B, Overall current blunt use. C, Past blunt use by sex. D, Current blunt use by sex. E, Past blunt use by race and ethnicity. F, Current blunt use by race and ethnicity. G, Past blunt use by school type. H, Current blunt use by school type. a Indicates that the APC is significantly different from 0 at the a 5 .05 level.

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 30, 2021 5 TABLE 1 Estimated Prevalence and Association Between Demographic and Tobacco Use Status and Past or Current Blunt Use Among Middle School Students, FYTS, 2019–2020 Past Use Current Use aOR (95% CI)

Rao-Scott Rao-Scott Past Blunt Use: Current Blunt Use: Total Yes NoP Yes No P Yes Versus No Yes Versus No Total, N (weighted %) 30 338 3220 (9.2) 29 818 (90.8) <.0001 2003 (5.7) 30 762 (94.3) <.0001 Age, mean ± SDa 12.7 ± 6.8 13.3 ± 7.7 12.6 ± 6.5 <.0001 13.3 ± 7.8 12.6 ± 6.6 <.0001 1.32 (1.17–1.49)b 1.22 (1.07 to 1.39)b Sex, n (weighted %) .1077 .1683 Male 16 311 (50.7) 1528 (8.8) 14 783 (91.2) — 936 (5.4) 15 224 (94.6) — Referent Referent Female 16 350 (49.3) 1633 (9.5) 14 717 (90.5) — 1021 (5.9) 15 220 (94.1) — 0.97 (0.75–1.27) 0.85 (0.61 to 1.17) Race, n (weighted %) <.0001 <.0001 NH white 14 004 (37.5) 1172 (7.7) 12 832 (92.3) — 667 (4.2) 13 251 (95.8) — Referent Referent NH Black 5014 (20.7) 627 (11.7) 4387 (88.3) — 388 (7.3) 4579 (92.7) — 2.52 (1.76–3.62)b 2.36 (1.41 to 3.94)b Hispanic 10 386 (35.4) 1098 (9.6) 9288 (90.4) — 748 (6.6) 9544 (93.4) — 1.22 (0.90–1.66) 1.79 (1.23 to 2.59)b NH other 2938 (6.4) 281 (9.0) 2657 (91.0) — 175 (5.1) 2742 (94.9) — 1.38 (0.88–2.16) 1.79 (0.97 to 3.30) Past use of cigars, <.0001 <.0001 n (weighted %) No 31 369 (96.0) 29 138 (93.0) 2231 (7.0) — 1269 (4.0) 29 859 (96.0) — Referent Referent Yes 1508 (4.0) 952 (61.3) 556 (38.7) — 709 (46.0) 789 (54.0) — 5.23 (2.93–9.34)b 1.73 (0.98 to 3.06) Current use of cigars, <.0001 <.0001 n (weighted %) No 32 033 (98.1) 2644 (7.9) 29 378 (92.1) — 1439 (4.3) 30 454 (95.7) — Referent Referent Yes 721 (1.9) 522 (70.6) 199 (29.4) — 530 (74.2) 179 (25.8) — 1.43 (0.53–3.88) 4.93 (1.98 to 12.25)b Past use of cigarettes, <.0001 <.0001 n (weighted %) No 30 325 (93.3) 1817 (6.1) 28 508 (93.9) — 1082 (3.6) 29 000 (96.4) — Referent Referent Yes 2567 (6.7) 1386 (52.3) 1181 (47.7) — 911 (35.0) 1632 (65.0) — 2.14 (1.45–3.14)b 1.39 (0.92 to 2.10) Current use of cigarettes, <.0001 <.0001 n (weighted %) No 32 202 (98.3) 2759 (8.2) 29 443 (91.8) — 1566 (4.7) 30 411 (95.3) — Referent Referent Yes 669 (1.7) 437 (64.9) 232 (35.1) — 412 (62.7) 246 (37.3) — 0.78 (0.31–1.96) 1.87 (0.79 to 4.41) Past use of e-cigarettes, <.0001 <.0001 n (weighted %) No 26 722 (82.1) 633 (2.6) 26 089 (97.4) — 379 (1.5) 26 132 (98.5) — Referent Referent Yes 6811 (17.9) 2574 (39.7) 3614 (60.3) — 1614 (25.0) 4522 (75.0) — 8.01 (5.73–11.19)b 3.63 (2.22 to 5.91)b Current use of e-cigarettes, <.0001 <.0001 n (weighted %) No 29 701 (91.0) 1502 (5.1) 28 199 (94.9) — 633 (2.2) 28 921 (97.8) — Referent Referent Yes 3082 (9.0) 1688 (50.8) 1394 (49.2) — 1349 (40.9) 1702 (59.1) — 1.50 (1.07–2.12)b 3.75 (2.58 to 5.45)b Past use of hookah, <.0001 <.0001 n (weighted %) No 31 686 (96.7) 2409 (7.0) 29 277 (93.0) — 1339 (3.8) 30 124 (96.2) — Referent Referent Yes 968 (3.3) 696 (68.2) 272 (31.8) — 567 (54.5) 390 (45.5) — 2.58 (1.40–4.73)b 2.32 (1.33 to 4.07)b Current use of hookah, <.0001 <.0001 n (weighted %) No 31 951 (98.4) 2707 (8.0) 29 244 (92.0) — 1538 (4.5) 30 241 (95.5) — Referent Referent Yes 477 (1.6) 365 (73.4) 112 (26.6) — 350 (66.7) 116 (33.3) — 1.51 (0.54–4.22) 1.57 (0.64 to 3.87) Past use of SLT, <.0001 <.0001 n (weighted %) No 31 570 (97.1) 2596 (8.0) 28 974 (92.0) — 1513 (4.6) 29 826 (95.4) — Referent Referent Yes 1201 (2.9) 585 (48.6) 616 (51.4) — 455 (41.0) 732 (59.0) — 0.96 (0.49–1.89) 1.01 (0.52 to 1.96) Current use of SLT, <.0001 <.0001 n (weighted %) No 32 076 (98.6) 2810 (8.3) 29 266 (91.7) — 1595 (4.7) 30 370 (95.3) — Referent Referent Yes 538 (1.4) 350 (69.3) 188 (30.7) — 367 (73.2) 158 (26.8) — 1.39 (0.89–2.16) 2.60 (0.91 to 7.46) Has ever vaped marijuana <.0001 <.0001 oil, n (weighted %) No 13 331 (83.4) 905 (6.2) 12 426 (93.8) — 490 (3.5) 12 765 (96.5) — Referent Referent Yes 1439 (16.6) 1179 (79.8) 260 (20.2) — 915 (63.6) 510 (36.4) — 8.56 (6.17–11.86)b 8.54 (5.90 to 12.35)b Lifetime asthma, <.0001 <.0001 n (weighted %) No 23 937 (80.6) 2063 (7.9) 21 874 (92.1) — 1243 (4.8) 22 531 (95.2) — Referent Referent Yes 5558 (19.4) 712 (12.1) 4846 (87.9) — 457 (7.8) 5066 (92.2) — 1.04 (0.68–1.60) 0.95 (0.53 to 1.69)

Downloaded from www.aappublications.org/news by guest on September 30, 2021 6 KALAN et al TABLE 1 Continued Past Use Current Use aOR (95% CI)

Rao-Scott Rao-Scott Past Blunt Use: Current Blunt Use: Total Yes NoP Yes No P Yes Versus No Yes Versus No Currently has asthma, <.0001 <.0001 n (weighted %) No 26 156 (88.5) 2326 (8.3) 23 830 (91.7) — 1395 (5.0) 24 586 (95.0) — Referent Referent Yes 3301 (11.5) 452 (12.7) 2849 (87.3) — 309 (9.1) 2973 (90.9) — 1.19 (0.69–2.05) 1.28 (0.67 to 2.46) Residence, .0040 .0019 n (weighted %) Urban 24 835 (94.3) 2322 (9.2) 22 513 (90.8) — 1406 (5.6) 23 212 (94.4) — 1.13 (0.77–1.65) 1.08 (0.69 to 1.70) Nonurban 6422 (5.7) 734 (12.0) 5688 (88.0) — 481 (8.0) 5898 (92.0) — Referent Referent For some variables, because of missing values, the sum is not equal to the overall sample. —, not applicable. a Weighted mean ± SD. b aORs indicating P < .05.

5 1.27; 95% CI, 1.01 to 1.62) which might have increased the study, even with a considerable compared with nonusers. appeal and experimentation among increase in current blunt use among adolescents.29,46 As of March 7, NH white individuals in 2016–2020, As shown in Supplemental Tables 6 2021, 37 states and the District of Black individuals had the highest through 7, our analyses revealed no Columbia have legalized the use of prevalence of blunt use over 11 effect modifications between sex marijuana for medical purposes, years (2010–2020). Several factors and race and/or ethnicity on past or including 12 states with retail may drive race disparities in blunt current blunt use both in trends and marijuana laws (although marijuana use. African Americans may prefer multivariable models (all P > .05). remains illegal under the federal blunts to joints (marijuana wrapped law).28 Substantial changes in in a cigarette paper that does not DISCUSSION marijuana policy that include contain nicotine) because a blunt This study revealed that during 11 provisions for medical and/or retail can hold more marijuana inside it use make it pivotal to monitor its and is inexpensive, burns more years (2010–2020), the proportion use trends in any form (eg, blunt) slowly, and is easier to transport of self-reported past and current among adolescents to inform policy and conceal.33,34,48 Moreover, cigars blunt use by Florida adolescents makers and clinicians (particularly have been historically and heavily decreased 5 APC points per year in pediatricians) to make effective marketed to the Black community 2010–2015 (from 19% to 16% for tailored interventions to curb by the tobacco industry through past users and from 10.5% to 8.5% marijuana use. targeted advertising49,50 and for current users) and then sponsored music events.51 More increased 15 APC points per year in During 2019–2020, the use of blunts importantly, Black individuals are 2015–2017 (from 8.5% to 13.6% to consume marijuana was reported more likely than other racial groups only for current blunt use), which by 11.8% (estimated 344 000) of to have friends who smoke was more pronounced in middle middle and high schoolers in blunts.21,33,34,48 Prevention schoolers than in high schoolers and Florida, with higher rates among NH programs to reduce blunt use remained almost constant ever since Black students and co-users of among adolescents and prevent – (during 2018 2020). These trends tobacco and nicotine products. The subsequent co-use of tobacco and of blunt use follow the same pattern trends of past and current blunt use marijuana must address the racial observed in trends of marijuana use were roughly parallel for NH Black disparities in blunt use, especially among a national sample of US high and NH white adolescents, with when Black adolescents have 4 schoolers from 2011 to 2019. This higher prevalence of use among NH decreased access to substance use reversal trend in blunt use coincides Black adolescents in recent years. treatment compared with white with legalizing medical marijuana Recent studies reported that being adolescents.52 consumption in Florida in 2017,28 Black (compared with other races) which may have further facilitated was a strong predictor of co-use of Our analysis revealed that despite accessibility for adolescents.21,45 marijuana and tobacco among young similar downward trends in past Another possible reason is the low adults, which is likely because of the and current blunt use among males perceived risk of marijuana use high prevalence of blunt use among and females in 2010–2016, a among adolescents in recent years, this minority population.21,47 In our substantial increase in current blunt

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 30, 2021 7 TABLE 2 Estimated Prevalence and Association Between Demographic and Tobacco Use Status and Past or Current Blunt Use Among High School Students, FYTS, 2019–2020 Ever Use Current Use aOR (95% CI) Rao- Rao- Scott Scott Past Blunt Use: Current Blunt Use: Total Yes NoP Yes No P Yes Versus No Yes Versus No Total, N (weighted %) 31 687 8822 (27.5) 22 865 (72.5) <.0001 5488 (16.6) 26 025 (83.4) <.0001 Age, mean ± SDa 16.1 ± 9.7 16.3 ± 9.6 16.0 ± 9.6 <.0001 16.3 ± 10.3 16.0 ± 9.5 <.0001 1.15 (1.08–1.23)b 1.06 (0.99 to 1.13) Sex .0001 .7377 Male 15 290 (50.4) 4125 (26.1) 11 165 (72.9) — 2707 (16.7) 12 465 (83.3) — Referent Referent Female 16 124 (49.6) 4614 (28.9) 11 510 (27.1) 2719 (16.5) 13 352 (83.5) 1.03 (0.87–1.21) 0.93 (0.78 to 1.11) Race, n (weighted %) <.0001 .1239 NH white 14 359 (38.7) 4133 (29.2) 10 226 (70.8) — 2492 (16.9) 11 799 (83.1) — Referent Referent NH Black 5107 (21.3) 1507 (28.4) 3600 (71.6) — 946 (17.6) 4127 (82.4) — 2.20 (1.76–2.75)b 1.92 (1.49 to 2.48)b Hispanic 9463 (33.6) 2479 (25.4) 6984 (74.6) — 1566 (15.7) 7846 (84.3) — 0.87 (0.72–1.06) 1.02 (0.84 to 1.25) NH other 2426 (6.5) 607 (24.3) 1819 (75.7) — 418 (16.3) 1994 (83.7) — 0.78 (0.56–1.10) 0.82 (0.55 to 1.23) Past use of cigars, <.0001 <.0001 n (weighted %) No 28 185 (90.3) 6160 (22.2) 22 025 (77.8) — 3492 (12.5) 24 557 (87.5) — Referent Referent Yes 3346 (9.7) 762 (23.6) 2584 (76.4) — 1938 (54.0) 1391 (46.0) — 3.10 (2.25–4.26)b 0.98 (0.75 to 1.27) Current use of cigars, <.0001 <.0001 n (weighted %) No 29 923 (95.8) 7487 (25.1) 22 436 (74.9) — 4175 (13.7) 25 666 (86.3) — Referent Referent Yes 1516 (4.2) 1227 (79.3) 289 (20.7) — 1232 (79.2) 265 (20.8) — 1.41 (0.91–2.19) 5.98 (3.92 to 9.13)b Past use of cigarettes, <.0001 <.0001 n (weighted %) No 27 028 (87.3) 5597 (21.5) 21 431 (78.5) — 3283 (12.3) 23 605 (87.7) — Referent Referent Yes 4586 (12.7) 3201 (68.6) 1385 (31.4) — 2190 (46.1) 2367 (53.9) — 1.93 (1.50–2.50)b 1.21 (0.97 to 1.50) Current use of cigarettes, <.0001 <.0001 n (weighted %) No 30 425 (97.1) 7912 (26.1) 22 513 (73.9) — 4653 (15.1) 25 629 (84.9) — Referent Referent Yes 1129 (2.9) 859 (71.7) 270 (28.3) — 801 (67.6) 314 (32.4) — 1.05 (0.61–1.80) 1.80 (1.11 to 2.91)b Past use of e-cigarettes, <.0001 <.0001 n (weighted %) No 19 311 (61.8) 1594 (9.0) 17 717 (91.0) — 928 (5.3) 18 284 (94.7) — Referent Referent Yes 12 301 (38.2) 7201 (57.3) 5100 (43.7) — 4540 (34.9) 7691 (65.1) — 4.52 (3.71–5.50)b 2.19 (1.66 to 2.90)b Current use of e-cigarettes, <.0001 <.0001 n (weighted %) No 24 816 (79.1) 4043 (16.8) 20 773 (83.2) — 1855 (7.8) 22 874 (92.2) — Referent Referent Yes 6679 (20.9) 4716 (67.9) 1963 (32.1) — 3589 (49.7) 3049 (50.3) — 1.57 (1.27–1.93)b 3.04 (2.49 to 3.71)b Past use of hookah, <.0001 <.0001 n (weighted %) No 28 539 (89.3) 6498 (21.8) 22 041 (78.2) — 3671 (11.9) 24 744 (88.1) — Referent Referent Yes 2775 (10.7) 2136 (73.0) 639 (27.0) — 1663 (53.5) 1097 (46.5) — 3.00 (2.20–4.11)b 2.06 (1.59 to 2.66)b Current use of hookah, <.0001 <.0001 n (weighted %) No 30 109 (96.3) 7753 (25.4) 22 356 (74.6) — 4501 (14.3) 25 493 (85.7) — Referent Referent Yes 1057 (3.7) 828 (75.0) 229 (25.0) — 797 (68.9) 256 (31.1) — 0.81 (0.48–1.37) 1.62 (1.02 to 2.68)b Past use of SLT, <.0001 <.0001 n (weighted %) No 29 546 (95.3) 7455 (25.6) 22 091 (74.4) — 4454 (14.9) 24 957 (85.1) — Referent Referent Yes 1976 (4.7) 1290 (64.9) 686 (35.1) — 975 (50.7) 984 (49.3) — 1.08 (0.71–1.66) 1.08 (0.75 to 1.54) Current use of SLT, <.0001 <.0001 n (weighted %) No 30 479 (97.9) 8083 (26.6) 22 396 (73.4) — 4783 (15.3) 25 612 (84.7) — Referent Referent Yes 940 (2.1) 637 (66.6) 303 (33.4) — 630 (69.9) 300 (30.1) — 0.34 (0.18–0.64) 1.03 (0.57 to 1.87) Has ever vaped marijuana <.0001 <.0001 oil, n (weighted %) No 11 405 (53.4) 1943 (16.5) 9462 (83.5) — 1010 (8.6) 10 348 (91.4) — Referent Referent Yes 4895 (46.6) 4204 (85.0) 691 (15.0) — 3118 (61.2) 1754 (38.8) — 8.32 (6.88–10.06)b 5.63 (4.56 to 6.96)b Lifetime asthma, <.0001 .0007 n (weighted %) No 23 034 (79.5) 6094 (26.4) 16 940 (73.6) — 3691 (15.6) 19 255 (84.4) — Referent Referent Yes 5958 (20.5) 1841 (30.2) 4117 (69.8) — 1150 (18.2) 4791 (81.8) — 1.27 (1.01–1.62)b 1.06 (0.82 to 1.38)

Downloaded from www.aappublications.org/news by guest on September 30, 2021 8 KALAN et al TABLE 2 Continued Ever Use Current Use aOR (95% CI) Rao- Rao- Scott Scott Past Blunt Use: Current Blunt Use: Total Yes NoP Yes No P Yes Versus No Yes Versus No Currently has asthma, .0004 <.0001 n (weighted %) No 25 982 (90.1) 6991 (26.7) 18 991 (73.3) — 4186 (15.6) 21 705 (84.4) — Referent Referent Yes 2938 (9.9) 918 (31.2) 2020 (68.8) — 625 (20.1) 2306 (79.9) — 0.89 (0.63–1.25) 1.10 (0.77 to 1.57) Residence, .7663 .6386 n (weighted %) Urban 24 089 (96.2) 6800 (28.2) 17 289 (71.8) — 4195 (17.1) 19 756 (82.9) — Referent Referent Nonurban 5807 (3.8) 1582 (27.7) 4225 (72.3) — 1029 (17.6) 4750 (82.4) — 0.99 (0.79–1.23) 0.85 (0.67 to 1.08) For some variables, because of missing values, the sum is not equal to the overall sample. —, not applicable. a Weighted mean ± SD. b aORs indicating P < .05. use was observed among female user. This is not surprising because cigarettes, among this vulnerable adolescents in 2016–2020 (15 marijuana is the most commonly age group. percentage points per year; from used illicit substance among 7.3% to 13.0%). This trend merits adolescents in the United States,27 This study has some limitations. The serious attention, especially because which also coincided with a high cross-sectional nature of this study female marijuana (including blunt) prevalence of current e-cigarette use does not allow us to deduce users are more vulnerable to mental among middle schoolers (4.7%) and causality or determine the health disorders such as depression high schoolers (19.6%) in 2020.56 In temporality of the observed and have a greater likelihood to addition, we found that, among high associations. Further research using develop marijuana addiction than schoolers, past blunt users were longitudinal studies is warranted to male users.53,54 This is concerning more likely to report having lifetime investigate the temporality relation because results from the 2019 YRBS asthma. Although the scope of our between blunt use and other revealed no significant sex study cannot rule out any potential tobacco products and whether it difference in the current use of likelihood of reverse causality (ie, leads to some health issues such as marijuana among high schoolers individuals with asthma use asthma. Moreover, there was no (male 5 22.5% versus female 5 marijuana to relieve symptoms), information regarding the type and 20.8%).4 Taken together, these according to the American Thoracic brand of blunt wraps used to smoke findings highlight the need for a Society, smoking marijuana (and marijuana. Although traditionally, better understanding of factors blunt) can cause an asthma attack blunts are made of tobacco leaves 57 associated with marijuana use with dire consequences (eg, and contain nicotine, some among female adolescents. Such hospitalization and even death).26 marijuana consumers, especially understanding will help in Therefore, the co-use of blunts and those who are not tobacco and/or developing sex-specific prevention vaping marijuana among nicotine users, buy prerolled campaigns and interventions aimed adolescents, as well as having nicotine-free blunt wraps (eg, at curbing blunt use among lifetime asthma among past blunt natural palm leaf style wraps) with 6 adolescents, especially in light of users, raises a serious concern about a variety of available flavors. shifting policies on marijuana detrimental health effects and calls Therefore, surveys like the FYTS, (eg, legalized recreational use).28,46 for rapid regulatory actions to curb YRBS, and National Youth Tobacco this potential epidemic among Survey should include a question or In addition to smoking blunts, adolescents, especially in light of the questions distinguishing the type of e-cigarette vaping has become a recent tragic e-cigarette- or vaping- blunt wrap used and whether it popular way to consume associated lung injury outbreak.31 contains nicotine. Finally, the tetrahydrocannabinol oil and other Most importantly, there is an urgent findings of our study may not substances.30,55 This notion was in need to incorporate educational generalize to states beyond Florida agreement with our findings, which elements regarding the harms of and to adolescents who are not revealed that both middle and high marijuana consumption among enrolled in school. Nonetheless, to schoolers who vaped marijuana adolescents into prevention the best of our knowledge, this is using an e-cigarette device had >15- campaigns that are aimed at curbing the first study used to examine the fold odds of being a current blunt tobacco products, especially e- co-use of blunts and various tobacco

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 30, 2021 9 products among a large sample of and help public health practitioners students who participated in the adolescents in the United States in designing school-based FYTS. using time trend analyses. prevention programs (eg, educating adolescents about the harms of CONCLUSIONS tetrahydrocannabinol and nicotine ABBREVIATIONS on the developing brain and Current use of blunts was reported – aOR: adjusted odds ratio respiratory health).58 60 Such by a large number of Florida APC: annual percentage change regulations and programs are students, has increased over time CI: confidence intervale-cigarette, urgently needed and can provide a (especially among female students), electronic cigarette substantial contribution to the and was particularly prevalent FYTS: Florida Youth Tobacco health of the next generations. among NH Black individuals, and co- Survey users of tobacco products such as NH: non-Hispanic ACKNOWLEDGMENTS cigarettes, e-cigarettes, hookah, SLT: smokeless tobacco cigars, and SLT. Our findings can We thank the Florida Department YRBS: Youth Risk Behavior inform future regulatory actions (eg, of Health for providing 2019 Survey incorporating marijuana [and blunt] FYTS data. We also acknowledge modules into existing tobacco and/ all middle and high school or nicotine prevention programs)

Dr Ebrahimi Kalan, Ms Jebai, and Drs Ben Taleb and Bursac conceptualized and designed this study, undertook the analyses for this study, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Popova, Mr Li, Mr Gautam, Mr Alqahtani, Ms Taskin, and Drs Ward and Behaleh had input in the study design and critically reviewed the manuscript for important intellectual content; Ms Atwell and Ms Richards contributed in data acquisition and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES and the uptake of cigars. JAMA Netw 10. Patton GC, Coffey C, Carlin JB, Sawyer SM, 1. G€uneylioglu D, Yilmaz A, Bilgin S, Open. 2019;2(12):e1917001 Lynskey M. Reverse gateways? Frequent Bayram U, Akkaya E. Factors affecting 6. Sifaneck SJ, Johnson BD, Dunlap E. cannabis use as a predictor of tobacco delays in diagnosis and treatment of Cigars-for-blunts: choice of tobacco initiation and nicotine dependence. – pulmonary tuberculosis in a tertiary products by blunt smokers. JEthn Addiction. 2005;100(10):1518 1525 care hospital in Istanbul, Turkey. Med Subst Abuse. 2005;4(3–4):23–42 11. Mayer ME, Kong G, Barrington-Trimis JL, Sci Monit. 2004;10(2):CR62–CR67 7. Delnevo CD, Bover-Manderski MT, McConnell R, Leventhal AM, Krishnan- 2. Farah MG, Rygh JH, Steen TW, Selmer R, Hrywna M. Cigar, marijuana, and blunt Sarin S. Blunt and non-blunt cannabis Heldal E, Bjune G. Patient and health use among US adolescents: are we use and risk of subsequent combusti- care system delays in the start of accurately estimating the prevalence of ble tobacco product use among adoles- tuberculosis treatment in Norway. cigar smoking among youth? Prev Med. cents. Nicotine Tob Res. – BMC Infect Dis. 2006;6:33 2011;52(6):475–476 2020;22(8):1409 1413 3. Demissie M, Lindtjorn B, Berhane Y. 8. McDonald EA, Popova L, Ling PM. 12. Camenga DR, Kong G, Cavallo DA, et al. Patient and health service delay in the Traversing the triangulum: the intersec- Alternate tobacco product and drug diagnosis of pulmonary tuberculosis in tion of tobacco, legalised marijuana use among adolescents who use Ethiopia. BMC Public Health. 2002;2:23 and electronic vaporisers in Denver, electronic cigarettes, cigarettes only, and never smokers. J Adolesc Health. 4. Jones CM, Clayton HB, Deputy NP, et al. Colorado. Tob Control. 2016;25(suppl 1): – Prescription opioid misuse and use of i96–i102 2014;55(4):588 591 alcohol and other substances among 9. Peters EN, Schauer GL, Rosenberry ZR, 13. Dai H, Catley D, Richter KP, Goggin K, – high school students Youth Risk Pickworth WB. Does marijuana “blunt” Ellerbeck EF. Electronic cigarettes and Behavior Survey, United States, 2019. smoking contribute to nicotine expo- future marijuana use: a longitudinal – MMWR Suppl. 2020;69(1):38 46 sure?: preliminary product testing of study. Pediatrics. 2018;141(5):e20173787 5. Audrain-McGovern J, Rodriguez D, nicotine content in wrappers of cigars 14. Rogers SM, Harrell MB, Chen B, Alexander E, Pianin S, Sterling KL. Asso- commonly used for blunt smoking. Springer A, Loukas A, Perry CL. Multi- ciation between adolescent blunt use Drug Alcohol Depend. 2016;168:119–122 directional pathways of tobacco and

Downloaded from www.aappublications.org/news by guest on September 30, 2021 10 KALAN et al marijuana use, including comorbid use, Effects of Cannabis and Cannabinoids: 36. Kong G, Cavallo DA, Goldberg A, LaVallee among a population-based cohort of The Current State of Evidence and Rec- H, Krishnan-Sarin S. Blunt use among adolescents in Texas: a six-wave cross- ommendations for Research. Washing- adolescents and young adults: inform- lagged model. Addict Behav. 2021; ton, DC: National Academies Press; 2017 ing cigar regulations. Tob Regul Sci. – 115:106771 26. American Thoracic Society. Smoking 2018;4(5):50 60 15. Ream GL, Benoit E, Johnson BD, Dunlap marijuana and the lungs. Patient Educ 37. Trapl ES, Koopman Gonzalez SJ, Cofie L, E. Smoking tobacco along with marijua- 2017;195(3):5–P6 Yoder LD, Frank J, Sterling KL. Cigar na increases symptoms of cannabis 27. National Institute on Drug Abuse. Moni- product modification among high dependence. Drug Alcohol Depend. toring the Future 2018 survey results. school youth. Nicotine Tob Res. 2008;95(3):199–208 2018. Available at: https://www. 2018;20(3):370–376 16. Tashkin DP. Effects of marijuana smok- drugabuse.gov/drug-topics/ 38. Bailey JA, Epstein M, Roscoe JN, ing on the lung. Ann Am Thorac Soc. trends-statistics/monitoring-future. Oesterle S, Kosterman R, Hill KG. 2013;10(3):239–247 Accessed November 30, 2019 Marijuana legalization and youth mari- 17. Tetrault JM, Crothers K, Moore BA, 28. ProCon. Legal medical marijuana states juana, alcohol, and cigarette use and Mehra R, Concato J, Fiellin DA. Effects and DC (as of February 9, 2021). 2021. norms. Am J Prev Med. 2020;59(3): – of marijuana smoking on pulmonary Available at: https://medicalmarijuana. 309 316 function and respiratory complications: procon.org/legal-medical-marijuana- 39. Trapl ES, Koopman Gonzalez SJ. a systematic review. Arch Intern Med. states-and-dc/. Accessed March 1, 2021 Attitudes and risk perceptions toward 2007;167(3):221–228 29. CerdaM,WallM,FengT,etal.Asso- smoking among adolescents who modi- 18. McLaren J. National cannabis strategy ciation of state recreational marijua- fy cigar products. Ethn Dis. – consultation paper: September 2005. na laws with adolescent marijuana 2018;28(3):135 144 2005. Available at: https://www. use. JAMA Pediatr. 2017;171(2): 40. Ebrahimi Kalan M, Bursac Z, Behaleh R, danaonline.org/documents/ 142–149 et al. Nicotine-naïve adolescents who National_Cannabis_Strategy_ 30.BenTalebZ,KalanME,BahelahR, live with tobacco products users, 2018 Consultation_Paper.pdf. Accessed Boateng GO, Rahman M, Alshbool FZ. Florida Youth Tobacco Survey. J Addict March 7, 2021 Vaping while high: factors associated Dis. 2021;39(2):265–269 19. Klupinski TP, Strozier ED, Makselan SD, with vaping marijuana among youth in 41. Florida Health Department. Florida et al. Chemical characterization of mar- the United States. Drug Alcohol Depend. Youth Tobacco Survey. 2021. Available ijuana blunt smoke by non-targeted 2020;217:108290 at: www.floridahealth.gov/statistics- chemical analysis. Inhal Toxicol. 31. Werner AK, Koumans EH, Chatham- and-data/survey-data/florida-youth- 2020;32(4):177–187 Stephens K, et al; Lung Injury Response survey/florida-youth-tobacco-survey/ 20. Moir D, Rickert WS, Levasseur G, et al. Mortality Working Group. Hospitaliza- index.html. Accessed January 10, 2021 A comparison of mainstream and side- tions and deaths associated with EVALI. 42. Choi K, Bernat D. E-cigarette use among – stream marijuana and tobacco ciga- NEnglJMed.2020;382(17):1589 1598 Florida youth with and without asthma. rette smoke produced under two 32. Chen-Sankey JC, Mead-Morse EL, Le D, AmJPrevMed.2016;51(4):446–453 et al. Cigar-smoking patterns by race/ machine smoking conditions. Chem Res 43. Porter L, Duke J, Hennon M, et al. – ethnicity and cigar type: a nationally Toxicol. 2008;21(2):494 502 Electronic cigarette and traditional representative survey among U.S. 21. Ladegard K, Thurstone C, Rylander M. cigarette use among middle and high adults. AmJPrevMed.2021;60(1): Marijuana legalization and youth. school students in Florida, 2011-2014. 87–94 Pediatrics. 2020;145(suppl 2):S165–S174 PLoS One. 2015;10(5):e0124385 33. Montgomery L, Bagot K. Let’sbe 22. Everett Jones S, King BA, Leroy Z. 44. Reid KM, Forrest JR, Porter L. Tobacco blunt: consumption methods matter Trends in the use of cigarettes, cigars, product use among youths with and among black marijuana smokers. J and marijuana among students with without lifetime asthma - Florida, 2016. Stud Alcohol Drugs. 2016;77(3): and without asthma, 2003-2017. JAsth- MMWR Morb Mortal Wkly Rep. 451–456 ma. 2020;57(4):391–397 2018;67(21):599–601 34. Montgomery L, Heidelburg K, Robinson 23. Lee MH, Hancox RJ. Effects of smoking 45. Surveillance Research Program; US C. Characterizing blunt use among twit- cannabis on lung function. Expert Rev National Cancer Institute. Joinpoint ter users: racial/ethnic differences in Respir Med. 2011;5(4):537–546, quiz 547 trend analysis software. 2020. Available use patterns and characteristics. Subst at: https://surveillance.cancer.gov/ 24. Self TH, Shah SP, March KL, Sands CW. Use Misuse. 2018;53(3):501–507 Asthma associated with the use of co- joinpoint/. Accessed Nov 15, 2020 35. Azofeifa A, Mattson ME, Schauer G, et caine, heroin, and marijuana: a review al. National estimates of marijuana use 46. Shi Y. The availability of medical of the evidence. JAsthma.2017;54(7): and related indicators National survey marijuana dispensary and adolescent – – 714 722. on drug use and health, United States, marijuana use. Prev Med. 2016;91:1 7 25. National Academies of Sciences, Engi- 2002–2014. MMWR Surveill Summ. 47. Montgomery L, Mantey D. Racial/ethnic neering, and Medicine. The Health 2016;65(11):1–25. differences in prevalence and

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 30, 2021 11 correlates of blunt smoking among communities. Am J Public Health. cigarettes to vaporize cannabis. adolescents. J Psychoactive Drugs. 2014;104(4):e1 Pediatrics. 2015;136(4): – – 2018;50(3):195 205 52. Ganz O, Rose SW, Cantrell J. Swisher 611 616 48. Cohn A, Johnson A, Ehlke S, Villanti AC. Sweets “Artist Project”: using musical 57. Miech RA, Patrick ME, O’Malley PM, Characterizing substance use and events to promote cigars. Tob Control. Johnston LD, Bachman JG. Trends in mental health profiles of cigar, blunt, 2018;27(e1):e93–e95 reported marijuana vaping among US and non-blunt marijuana users from 53. Alegria M, Carson NJ, Goncalves M, adolescents, 2017-2019. JAMA. the National Survey of Drug Use and – Keefe K. Disparities in treatment for 2020;323(5):475 476 Health. Drug Alcohol Depend. substance use disorders and co-occur- 58. King Palm. Flavors. Available at: https:// 2016;160:105–111 ring disorders for ethnic/racial minori- kingpalm.com/product-category/flavors/. 49. Montgomery L, Plano Clark VL, Twitty D, ty youth. J Am Acad Child Adolesc Accessed January 7, 2021 Budney AJ, Prochaska JJ, Winhusen T. Psychiatry. 2011;50(1):22–31 Is it “loud” enough?: a qualitative inves- 59. Meier MH, Caspi A, Ambler A, et al. tigation of blunt use among African 54. Calakos KC, Bhatt S, Foster DW, Persistent cannabis users show American young adults [published on- Cosgrove KP. Mechanisms underlying neuropsychological decline from child- line ahead of print August 3, 2020]. J sex differences in cannabis use. Curr hood to midlife. Proc Natl Acad Sci USA. Ethn Subst Abuse. Addict Rep. 2017;4(4):439–453 2012;109(40):E2657– E2664 50. Cantrell J, Kreslake JM, Ganz O, et al. 55. Ridenour TA, Lanza ST, Donny EC, Clark 60. Yuan M, Cross SJ, Loughlin SE, Leslie Marketing little cigars and cigarillos: DB. Different lengths of times for FM. Nicotine and the adolescent advertising, price, and associations progressions in adolescent substance brain. J Physiol. 2015;593(16): with neighborhood demographics. involvement. Addict Behav. 2006; 3397–3412 – Am J Public Health. 2013;103(10): 31(6):962 983 61. Meruelo AD, Castro N, Cota CI, Tapert – 1902 1909 56. Morean ME, Kong G, Camenga DR, SF. Cannabis and alcohol use, and the 51. Sheehan DM. Marketing little cigars Cavallo DA, Krishnan-Sarin S. High developing brain. Behav Brain Res. and cigarillos in African American school students’ use of electronic 2017;325(pt A):44–50

Downloaded from www.aappublications.org/news by guest on September 30, 2021 12 KALAN et al Trends and Factors Related to Blunt Use in Middle and High School Students, 2010−2020 Mohammad Ebrahimi Kalan, Rime Jebai, Zoran Bursac, Lucy Popova, Prem Gautam, Wei Li, Mohammed M. Alqahtani, Tanjila Taskin, Leah L. Atwell, Jennifer Richards, Kenneth D. Ward, Raed Behaleh and Ziyad Ben Taleb Pediatrics originally published online June 14, 2021;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2021/06/11/peds.2 020-028159 References This article cites 53 articles, 6 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2021/06/11/peds.2 020-028159#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:med icine_sub Substance Use http://www.aappublications.org/cgi/collection/substance_abuse_sub Smoking http://www.aappublications.org/cgi/collection/smoking_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 30, 2021 Trends and Factors Related to Blunt Use in Middle and High School Students, 2010−2020 Mohammad Ebrahimi Kalan, Rime Jebai, Zoran Bursac, Lucy Popova, Prem Gautam, Wei Li, Mohammed M. Alqahtani, Tanjila Taskin, Leah L. Atwell, Jennifer Richards, Kenneth D. Ward, Raed Behaleh and Ziyad Ben Taleb Pediatrics originally published online June 14, 2021;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2021/06/11/peds.2020-028159

Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2021/06/11/peds.2020-028159.DCSupplemental

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