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The Intersection of Tobacco, Legalised Marijuana and Electronic Vaporisers in Denver, Colorado Emily Anne Mcdonald,1 Lucy Popova,2 Pamela M Ling3

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The Intersection of Tobacco, Legalised Marijuana and Electronic Vaporisers in Denver, Colorado Emily Anne Mcdonald,1 Lucy Popova,2 Pamela M Ling3 Research paper Tob Control: first published as 10.1136/tobaccocontrol-2016-053091 on 3 October 2016. Downloaded from Traversing the triangulum: the intersection of tobacco, legalised marijuana and electronic vaporisers in Denver, Colorado Emily Anne McDonald,1 Lucy Popova,2 Pamela M Ling3 1Department of Anthropology, ABSTRACT rates of tobacco smoking (37%).3 More young City University of New York, Objective To explore the intersection of tobacco, adults have ever tried e-cigarettes (21.6%) com- John Jay College, New York, 4 New York, USA legalised marijuana and electronic vaporiser use among pared to other age groups. Rates of dual and poly 2Center for Tobacco Control young adults in the ‘natural laboratory’ of Colorado, the use are also high: in 2013, among US young adults Research and Education, first state with legalised retail marijuana. who smoked cigarettes in the past 30 days (16% of University of California, Methods We conducted semistructured interviews with the sample), 47% were current marijuana users.5 San Francisco, San Francisco, 32 young adults (18–26 years old) in Denver, Colorado, Given high rates of co-use of tobacco and mari- California, USA 6–9 3Division of General Internal in 2015 to understand the beliefs and practices related juana among young adults, as well as transfor- Medicine, Department of to the use of tobacco, marijuana and vaporisers. mations in the realm of policy and technology, Medicine, Center for Tobacco Results We found ambiguity about whether the phrase tobacco, marijuana and vaporisers are most effect- Control Research and ‘to smoke’ refers to the use of tobacco or marijuana ively studied in relationship to one another.10 Education, University of ‘ ’ California, San Francisco, products. Smoking marijuana blunts (emptied cigarillo or Referred to as the triangulum (Latin for triangle), San Francisco, California, USA tobacco wrap filled with marijuana) was common, but this approach reflects interest in the intersection of few interpreted this as tobacco use. Marijuana vaporisers tobacco, marijuana and electronic vaporiser use, Correspondence to were used to circumvent public consumption laws (eg, with implications for surveillance (eg, evaluating Professor Emily Anne while at work or when driving). Young adults considered tobacco and marijuana use, product taxonomies), McDonald, Department of Anthropology, City University secondhand tobacco smoke dangerous, but perceived policy (eg, smoke-free policies related to marijuana 11 12 of New York, John Jay College, secondhand marijuana smoke as benign. and e-cigarettes) and treatment (eg, effects of New York, NY 10019, USA; Discussion Using tobacco products as a delivery dual use on cessation).13 Several quantitative [email protected] method for marijuana (eg, blunts) might be increasing studies examined some aspects of the triangulum, and normalising tobacco use among young adults. including co-use of combustible tobacco and mari- copyright. Received 31 March 2016 14 Revised 20 July 2016 Surveillance should explicitly ask about use of tobacco juana, perceptions of comparative harm of Accepted 22 July 2016 products for marijuana. Marijuana vaporisers, often tobacco and marijuana,15 prevalence of vaporiser indistinguishable from nicotine vaporisers, may be used use among marijuana users16 17 and reasons for use to circumvent public consumption laws; communities of marijuana vaporisers.17 18 Two qualitative concerned about use of marijuana in public spaces studies examined the intersection of tobacco and should include vaporisers (for nicotine or marijuana) in marijuana by interviewing youth in Scotland.13 19 smoke-free regulations. Tobacco, marijuana and The data in the studies, however, were collected http://tobaccocontrol.bmj.com/ electronic vaporisers should be studied together, rather over a decade ago and do not reflect changing legal than separately. This approach is essential in informing and normative environments around marijuana or research and policy as more US states and countries the proliferation of vaporising devices. Several worldwide move to legalise marijuana. quantitative studies have addressed marijuana vaporisers use by adults, including Lee et al17 and Etter,18 but neither was designed to explore in INTRODUCTION depth why users choose to vaporise marijuana, or The legal landscape around marijuana in the USA is the social or policy contexts shaping vaporiser use. fi changing rapidly. Currently, medical marijuana is To the best of our knowledge, this is the rst legal in 25 states and Washington DC, with retail in-depth, qualitative investigation of the triangulum ‘ ’ on September 30, 2021 by guest. Protected (‘recreational’) marijuana legalised in four states in the natural laboratory of Colorado. We inter- and Washington DC. On 1 January 2014, viewed young adults in Colorado to understand Colorado became the first state to legally sell retail how they use, perceive and ascribe meaning to marijuana to people 21 years or older. Shifting reg- various tobacco, marijuana and vaporiser products. ulations have been accompanied by technological innovations, including electronic vaporisers for METHODS tobacco and marijuana. These developments are Collaboration likely to transform use of these substances, espe- As part of the State and Community Tobacco cially among young adults. Control (SCTC) research initiative (http://www. Nationally, young adults have the highest rates of sctcresearch.org), this project was developed in stra- current (past 30 days) marijuana use, with 18.9% tegic partnership with Denver Public Health and aged 18–25 years using in 2013, compared to 7.1% Jefferson County Public Health departments in aged 12–17 years and 5.5% aged ≥26 years.1 Colorado. Beginning in early 2014, we worked To cite: McDonald EA, According to 2014 data, almost 30% of young with local agencies to identify research questions Popova L, Ling PM. Tob adults in Colorado reported current marijuana that would advance policy solutions and practice. – Control 2016;25:i96 i102. use.2 Young adults also have the highest current These questions were further refined iteratively i96 McDonald EA, et al. Tob Control 2016;25:i96–i102. doi:10.1136/tobaccocontrol-2016-053091 Research paper Tob Control: first published as 10.1136/tobaccocontrol-2016-053091 on 3 October 2016. Downloaded from throughout the data collection period. Local agencies provided Ninety-one per cent of participants had ever smoked a staff to recruit participants, assisted with interviewing, provided tobacco cigarette; 56% smoked 100 cigarettes or more; 97% space for interviews and engaged key stakeholders in reviewing ever smoked marijuana and 44% were daily marijuana smokers. early findings. Table 1 shows rates of use of each product as collected in our intake questionnaire. Three-quarters (75%) of participants Study recruitment reported dual use of tobacco and marijuana in the past 30 days, Participants were recruited using flyers placed in marijuana dis- while 19% reported only marijuana use and 6% only tobacco pensaries, vape shops, cafes, stores and on bulletin boards at use in the past 30 days. Sixty-nine per cent of participants had — community colleges in the Denver Metro area. Online recruit- used all three products combustible tobacco, marijuana and — ment was conducted through Craigslist and posting on vaporisers (for nicotine or marijuana) in the past 30 days. Facebook. Inclusion criteria included being 18–26 years old and current use (past month) of at least one of the three products Themes fl (marijuana, tobacco or electronic vaporisers). Prospective parti- Participants highlighted uidity between use of tobacco, mari- fl fl ‘ ’ cipants were screened and enrolled in the study via telephone juana and vaporisers. Re ecting this uidity, the terms smoke ‘ ’ by trained research staff. We attempted to interview all 32 and to be a smoker were used to describe either tobacco or enrolled participants twice, in order to allow conversations to marijuana use in ways that left unclear which substance was develop more deeply. Twenty-four completed both interviews. referred to. While dual and poly use was our primary focus, Participants were compensated $35 for the first interview and some participants also reported co-use through merging pro- $65 for the second. Each participant gave written consent. All ducts, including use of tobacco wraps (blunts) or little cigars/ study protocols were approved by the Committee on Human cigarillos to smoke marijuana and the use of tobacco cigarettes ‘ ’ Research at the University of California, San Francisco. to extend the effects of marijuana. Vaporising devices were used to consume either nicotine or marijuana concentrates, with such devices nearly indistinguishable in appearance. Data collection Participants remarked upon the increasing popularity of Semistructured interviews were conducted between January and ‘vaping’, expanded interest in vaporisers for nicotine and mari- August 2015 by six trained interviewers (three PhDs, one juana products and the convenience of vaporisers for use in MD and two MPHs), following a standard interview guide. public spaces. Interviews were conducted individually (one participant with In some contexts, participants clearly distinguished between one or more interviewers) in public places (coffee shops, librar- tobacco, marijuana and vaping, as they did when discussing the ies) or in meeting rooms in local health departments. Before risks of secondhand smoke. Participants viewed secondhand each interview, participants
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