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 À5.32%)andcurrent(APC5 À5.28%)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. Full article can be found online at www.pediatrics.org/cgi/doi/10.1542/2020-028159 aDepartments of Epidemiology and bBiostatistics, Robert Stempel College of Public Health and Social Work, Florida WHAT’S KNOWN ON THIS SUBJECT: The popularity of International University, Miami, Florida; cDepartment of Health Policy and Behavioral Sciences, School of Public blunt use as a common mode of marijuana consumption d Health, Georgia State University, Atlanta, Georgia; Rehabilitation Science Program, School of Health Professions, among adolescents is a public health concern. The University of Alabama at Birmingham, Birmingham, Alabama; eFlorida Department of Health, Tallahassee, Florida; fSchool of Public Health, The University of Memphis, Memphis, Tennessee; gDepartment of Public Health WHAT THIS STUDY ADDS: In 2019–2020, blunt use was and Prevention Sciences, College of Education and Health Sciences, Baldwin Wallace University, Berea, Ohio; and reported by a large number of middle and high schoolers h Public 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 DOI: https://doi.org/10.1542/peds.2020-028159 currently reported use of each tobacco product type (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 To cite: Nedderman Dr, Box 19407, Arlington, TX 76019-0407. E-mail: [email protected] 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 Downloaded from www.aappublications.org/news by guest on September 29, 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,