Comparative Toxicogenomics Database is a powerful tool to identify the potential mechanistic connections between environmental exposure and adverse health outcomes . We identified 22 insecticides in CTD – including 7 pyrethroids, 6 organophosphates, 4 organochlorines, 2 carbamates, 2 neonicotinoids, and fifipronil – and their association with 57 genes, 146 phenotypes, and the outcome of “Seizures”  in 621 computationally generated CGPD‐ tetramer constructs . Chlorpyrifos had the highest number of tetramers , followed by diazinon  and cypermethrin . Only two cannabinoids – cannabidiol and dronabinol – had curated information in CTD. Dronabinol was a synthetic form of Δ‐9‐tetrahydrocannabinol  approved by U.S. Food and Drug Administration  for the treatment of anorexia, nausea, and vomiting associated with AIDS and cancer chemotherapy . It was used as a surrogate to highlight the THC‐related bioactivity in this network analysis. We further generated 53 CGPD‐tetramers with cannabidiol, dronabinol, and seizure and identified 25 genes and 23 phenotypes . Nineteen genes and 9 phenotypes had connections to both cannabinoid and insecticide CGPD‐tetramers. The fifinding of shared genes and phenotypes was consistent with the fact that many anticonvulsant drugs and insecticides either worked through the same mechanism  or belonged to the same chemical class. Fig. 4 shows the 246 chemical‐gene interactions involved in forming the 621 CGPD‐ tetramers related to pesticides and seizure.Medical cannabis, like many pharmaceuticals and herbal medicines, are prone to contamination of metals, fungi, and pesticides during manufacturing and storage processes . While pharmaceutical contaminants are under robust U.S. FDA regulations , there is the lack of drug safety regulation of medical cannabis at the federal level. Thus, medical cannabis represents a potentially dangerous route of contaminant exposure to patients with susceptible conditions. Here, we surveyed the different approaches taken by the state‐level jurisdictions in the U.S. to regulate medical cannabis and pesticide residues. We show that  movement disorders are the most common neurological diseases qualified for medical use;  the number and action levels of regulated pesticides show great variation between jurisdictions; and  exposure to insecticides and cannabinoids affects the same set of signaling pathways that link to seizure.

In the contemporary cultural environment, cannabis is regarded by users and the society more generally as relatively risk free . An earlier study found that the representations of cannabis risks on social media forums were limited to concerns about driving and sleep effects . These “risks” were framed as avoidable and ephemeral drug‐induced impairments deriving from improper usage. No evidence of concerns was found about adulterated products as the social media representations naturalized cannabis as intrinsically medicinal. This unproblematic naturalization essentially mystifies the chemically‐intensive practices used in legal and illegalcultivation as well as the drug safety concerns of cannabis in medical use. The current study reveals a lack of clarity and consistent language in the listing of neurological diseases qualified for medical use. The culture transition of accepting cannabis as a medicinal plant, vertical grow rack together with the ambiguity of regulatory language for medical use, creates a potentially dangerous route of contaminant exposure to populations with existing vulnerability. The observed variation of pesticide action levels is indicative of the legal and scientific challenges in mitigating the human health risk of pesticide exposure in cannabis use. In the U.S., the pesticide residues of crops and vegetables are regulated under FIFRA . Yet, the illegal status of cannabis at the federal level means that individual states have to develop their own guidance and regulation. The published action levels reflect a variety of strategies taken by the regulatory agencies to approach this problem. Some agencies have developed specific sets of action levels to account for the differences in pesticide‐borne health risks due to the concentration effect of the cannabinoid extraction process  and the toxicokinetics of inhalational, dietary, and dermal exposures . Other agencies opt to impose more stringent action levels by applying the precautionary principle to mitigate such complex exposure scenarios with multiple risks and knowledge gaps . Implementing the U.S. EPA tolerances of food commodities in cannabis and cannabis‐derived products has the advantage of covering a large number of pesticide residues with relatively protective action levels. Yet, the U.S. EPA tolerances are not developed for commodities that are consumed in the inhalable form. Additionally, the effect of pyrolysis on pesticide residues – including the possibility of the generation of hydrogen cyanide – is largely unknown . The current study of CGPD‐tetramers highlights several pesticide groups that can disrupt multiple biological pathways. Several of these pathways are implicated in seizure, epilepsy, and other neurotoxic effects. For instance, exposure to organophosphate insecticides, carbamate insecticides, as well as cannabinoids can each be linked to oxidative stress and mitochondrial toxicity . Such oxidative stress and inflammation are linked to temporal lobe epilepsy through the MAPK pathway . Concomitant exposure to organophosphate insecticides and cannabinoids can also cause developmental neurotoxicity .

These pesticide groups may individually, or additively, produce neurotoxic effects though common mechanisms. For example, exposure to chlorpyrifos, diazinon, and dichlorvos all promotes seizure through cholinergic overstimulation. These organophosphate insecticides have been evaluated by the U.S. EPA as a common mechanism group.The present study is the first to examine the potential human health hazards of pesticidal contaminants on medical cannabis users. While previous studies have surveyed different classes of prevalent contaminants in cannabis, this study provides a proof of concept that  medical use of cannabis may unintentionally expose susceptible patients to harmful pesticides and  pesticidal contaminants, cannabinoids, and gene variants may disrupt the same set of biological functions that link to seizure disorders. A number of knowledge gaps remains to be addressed in order to mitigate pesticide‐borne health risks in medical cannabis, including  the exposure level of insecticide residues in medical patients;  the potential interaction of insecticides and cannabinoids and their adverse effects to human health; and  the health risk of cannabis use attributed to pesticide exposure and genetic variation. Such exposure and hazard information is crucial to our understanding of human health risk of cannabinoids and pesticides, which will support a health‐ protective national standard for cannabis pesticide regulations.With increasing medical cannabis use and rapidly changing cannabis laws, driving under the influence of cannabis  is a major public safety concern . Experimental studies show that acute cannabis intoxication can impair simulator and on-road driving performance as well as outcomes on a range of driving-related cognitive tasks. Recent cannabis use is also associated with a modest increase in crash risk and crash culpability. However, the focus of the literature to date has been on non-medical  cannabis and its acute effects in healthy volunteers. It is unclear whether these findings can be applied to patients who are using cannabis therapeutically. While the intention of medical cannabis use is to alleviate the symptoms associated with various chronic health conditions, rather than to produce intoxication, this doesn’t obviate the legitimate concerns that medical cannabis patients may be at a high risk of DUIC due to their cannabis use. In Australia, however, legal medical cannabis products are dominated by orally delivered oils, sprays and capsules, many of which contain only low or negligible amounts of THC and high amounts of CBD and are therefore unlikely to produce clinically relevant driving impairment.

Given that many medical conditions  can themselves impair driving, it is also conceivable that treating such conditions effectively will have a positive, or at least neutral, effect on driving performance. In a recent review of studies that assessed driving ability in patients with multiple sclerosis-related spasticity who were being treated with nabiximols , most patients reported an improvement in driving ability, most likely due to a reduction in spasticity and/or improved cognitive function. A number of studies to date have investigated the relationship between the introduction of medical cannabis laws in various U.S. states and traffic safety outcomes using data from the Fatality Analysis Reporting System. In most cases, medical cannabis laws had little effect on the prevalence of cannabis-positive driving and, in some cases, were associated with a reduction in traffic fatalities, possibly due to a decrease in the prevalence of driving under the influence of alcohol . This effect has not been entirely uniform, however, with one study reporting an increase in the prevalence of cannabis-positive drivers involved in fatal crashes in 3 out of the 12 U.S. states that were examined. Another study found an increase in cannabis-positive driving in Colorado, specifically following the commercial expansion of their medical cannabis industry in 2009. These data, while inconclusive, best trimming trays suggest that states with less restrictive cannabis laws and greater ease of access may be more susceptible to increases in DUIC prevalence. Given that many jurisdictions have only recently legalised medical cannabis, it may take more time for the impact of such changes on the prevalence of DUIC and cannabis-related crashes to become clear. There are some concerns that increased cannabis availability and changing social attitudes toward its use may affect perceptions of the risks associated with DUIC. A recent study found that >70% of medical cannabis patients in Michigan were driving while a “little high” or “very high”, with over half driving within two hours of using cannabis. The amount of cannabis used was positively associated with DUIC behaviour: respondents using more cannabis were more likely to drive within 2 hours of cannabis use and to self-report driving while intoxicated. In another survey of older drivers in Colorado, where both medical and non-medical cannabis use is legal, 9.3% reported driving within one hour of cannabis use. However, cannabis users were as likely as non-users to report having had a crash or citation. Recent Canadian government analysis indicated that 13.2% of cannabis users were driving within two hours of cannabis use, a proportion unchanged by the recent legalisation of access to non-medical cannabis. Driving within two hours of cannabis use was five times more likely among drivers who reported daily cannabis use.

These findings indicate a relatively high prevalence of DUIC, particularly among frequent cannabis users. While various U.S. states and Canada have relatively mature medical cannabis markets, other countries have introduced medical cannabis more recently, and with quite different regulatory models. Australia, for example, introduced laws permitting medical cannabis access in late 2016, and the roll out to patients has been relatively slow, despite overwhelming public support for patient access. At the same time, Australian States and Territories have expanded their roadside drug testing programmes, thereby increasing the likelihood that drivers will be randomly tested for the presence of THC in oral fluid. Although a positive test result can often lead to a criminal conviction and a driving ban, these laws do not currently differentiate between medical and non-medical cannabis use. It was therefore of interest to examine the attitudes, perceptions and driving-related behaviours of Australian medical cannabis users within this new and rapidly evolving context. Here, we describe the results of a survey that assessed DUIC behaviours in a convenience sample of medical cannabis users in Australia. These questions formed a sub-section of a larger online survey that examined the use of medical cannabis in the community and assessed consumer perspectives on the implementation of the Australian regulatory framework for prescribed medical cannabis . The term ‘medical cannabis’ as it is used here refers to any legal or illegal cannabis-based product being used to treat or alleviate the symptoms of a self-identified health condition. This does not imply that this treatment was recommended or prescribed by a health professional. Respondents were asked when they first tried cannabis and when they first began using it regularly for  medical reasons and for  any reason. Respondents were also asked how many days in the last 28 days they had used cannabis for medical reasons, how many times a day they typically used it and what percentage of their total cannabis use was considered medical. Additional survey questions asked about respondents’ primary method of cannabis use and type of cannabis used . Respondents were also asked how long it took after using medical cannabis until they felt  any effects,  peak effects and  no effects.In total, 1388 respondents completed and provided valid responses to the larger CAMS-18 survey. Of these, 909  completed the entire survey and 806  reported driving a motor vehicle in the past 12 months.

Data were weighted to consider the survey design including school and student nonresponse and oversampling of Non-Hispanic Black and Hispanic students. First, demographic characteristics of the study sample were described. Next, bivariate analyses with chi-square tests were performed to assess differences in participant demographics based on their current e-cigarette and marijuana use. Then, separate adjusted logistic regression analyses were conducted to assess the magnitude of the associations of e-cigarette and marijuana use with meeting the ‘5–2- 1-0′ recommendations and perceptions of weight status among all adolescents. For follow-up analyses, we excluded non-users and performed adjusted logistic regression analyses to assess current use group differences based on meeting the ‘5–2-1-0′ recommendations and perceptions of weight status. All logistic regression analyses adjusted for sex, race/ ethnicity, grade, combustible cigarette smoking, cigar smoking, and smokeless tobacco use. Results were considered significant when alpha value was < 0.05. Adjusted odds ratios  were calculated using the complex samples logistic regression procedure  in IBM SPSS Statistics 26 which accounts for the complex YRBS survey design including assigned stratum and primary sampling unit. The present study found about 10% of adolescents reported exclusive marijuana use, 5% reported exclusive e-cigarette use, and 7.4% reported dual use. Overall, about 1% of the sample met all the ‘5–2-1-0′ daily health guidelines. This finding is consistent with other research highlighting poor nutrition and a lack of exercise in American youth in general . Our findings indicated that when compared with non-users, exclusive users of e-cigarette were more likely to meet the ‘1′ physical activity recommendation outlined by the ‘5–2-1- 0′ guidelines. When compared with dual users, as posited, exclusive users of e-cigarette were more likely to meet the ‘2′ screen time recommendation.

Dunbar and colleagues  found that youth using e-cigarettes engaged in “healthier behaviors” compared to adolescents using combustible cigarettes. Thus, one potential explanation for our findings is that health-promoting and health-risk behaviors co-occur, and particularly, e-cigarette users may perceive ecigarettes as “healthy” compared to other drug use . Thus, educational efforts should focus on the health risks of vaping, and the risks associated with ingredients contained in e-cigarettes such as nicotine addiction that can harm the developing brain during adolescence U.S. DHHS, . Findings were mixed for the exclusive marijuana and dual user groups and the odds of meeting the ‘5–2-1-0′ recommendations when compared to non-users. Interestingly, exclusive cannabis grow set up users and dual users of e-cigarettes and marijuana were both more likely to meet the ‘5′ fruit and vegetable intake recommendation but less likely to meet the ‘0′ sugar-sweetened beverage recommendation. One potential reason for exclusive marijuana users and dual users having an increased likelihood to meet the ‘5′ recommendation could be that studies have linked marijuana use to increased appetite for high calorie/energy and palatable foods  such as sweet beverages like fruit juices; and 100% fruit juice was included in the fruit and vegetable intake response options. However, most 100% fruit juices have a high sugar content which would not “count” towards the ‘5’ category but would “count” towards not meeting the ‘0’ category. Thus, this issue needs further research. About one-third of adolescents in the present study perceived themselves as overweight, which is higher than the national prevalence of about one-fifth of adolescents being overweight . While there were no differences between non-users and current use groups, there were differences detected in the sub-analysis delimited to current use groups. Compared to dual users, adolescents who were exclusive marijuana users were more likely to perceive themselves as overweight. It is important to note that exclusive marijuana users were also at reduced odds to meet the ‘2′ screen time and ‘1′ physical activity recommendations compared to exclusive e-cigarette users. Thus, the increased likelihood of current marijuana users perceiving themselves as overweight may be related to low levels of physical activity as well as increased screen time and higher consumption of sugar-sweetened beverages.

Taken together, these results suggest that marijuana consumption could influence appetite —for healthy and unhealthy diet— and sedentary behaviors. Previous studies have reported that marijuana use influences food intake, appetite, and metabolism with both chronic and acute use leading to increased food consumption and visceral adiposity . Further, marijuana use has also been linked to reduced physical activity and increased screen time for non-educational purposes . This finding highlights the clustering of marijuana use with other unhealthy behaviors, therefore increasing the need for more awareness and education for youths, health care providers, and policy makers. In terms of education, adolescent current marijuana users may benefit from education about improved health behaviors, and the association between marijuana use and cardiovascular health. Several issues may have limited the generalizability of study findings. This study was cross-sectional and assessed perceptions at one timepoint using a survey with general questions that do not assess contextual factors such as socioeconomic status. Longitudinal research with the addition of qualitative data , and specific questions about health behaviors and socioeconomic indicators might provide more information about eating patterns and reasons why adolescents had low intake of fruits and vegetables, for instance. The YRBS is a school-based survey, and thus does not represent adolescents who are not enrolled in a school—a group that has a disproportionately higher number of adolescents who are at increased risk for substance use . Our study purpose was to understand the association of e-cigarette and marijuana use with adherence to the ‘5–2-1- 0′ guidelines among adolescents, thus, information about fruit and vegetable consumption and screen time were combined into a summary variable by the YRBS. Thus, for example, we were unable to examine whether a particular type of screen  was associated with meeting the obesity prevention guidelines due to the use of secondary data. Also, given that fruit juice was included in fruits and vegetables count, the data may not correctly reflect the sugar-sweetened beverage recommendation since not all youth are able to correctly identify if there is added sugar in their juices. Additionally, participants reported on their subjective judgment about their weight  and based on the distribution of responses, the variable was collapsed into “very/ slightly underweight and about the right weight” and “slightly and very overweight”. This categorization limited the study’s capacity for obtaining nuanced results on the collapsed subgroups.In sum, our findings show the majority of adolescents are not meeting the obesity prevention guidelines  and adolescent current marijuana users and dual users were less likely to meet obesity prevention guidelines. In order to assess risks for adolescent e-cigarette and marijuana use with healthy habits by adhering to the ‘5–2-1-0′ obesity prevention guidelines among adolescents, pediatricians and public health professionals should consider implementing screening tools with questions about use and adherence or nonadherence to healthy habits during encounters . Interventions have often been directed toward younger school-age youth;  thus, more research is needed to adapt interventions for adolescents and determine if these interventions are successful in influencing positive health behaviors.

Furthermore, education and training programs need to enhance knowledge of the health effects of e-cigarette products  and instruction on how to coach adolescents about healthy behaviors. Adding education to high school health curricula about the risks of e-cigarette and marijuana use and the need for healthy eating and physical activity to enhance cardiovascularhealth is important for adolescents who do or do not engage in healthrisking behaviors such as e-cigarette and marijuana use. In future studies, examining family factors, such as food availability at home and health behaviors of family members may shed light on ways that family health behaviors are related to adolescent health behaviors. Studies assessing the impact of interventions to teach adolescents about ‘5–2-1-0′ obesity prevention behaviors and how they impact health and motivate change in adolescent health are needed, as are studies investigating identification of e-cigarette and marijuana users and reducing their use of these drugs. Future research should seek to determine whether reducing use of e-cigarettes and marijuana results in increases in healthy eating and physical activity and reductions in screen time and consumption of sugar-sweetened beverages over time. Marijuana is the second most common psychotropic substance used in the United States after alcohol, with nearly 12 million young adults reporting marijuana use in the past year . While there is a declining trend of tobacco use in the United States, outdoor cannabis grow utilization is on the rise. Between 2002 and 2015, specifically among parents with children at home, marijuana use increased from 5% to 7%, while tobacco use decreased from 27% to 20%. A larger increase in marijuana use was seen in those who also smoke tobacco; during the same time period, marijuana use among tobacco smoking parents increased from 11% to 17% . When marijuana and tobacco smoking are combined, the harmful health effects may be potentiated.The National Institute on Drug Abuse survey found marijuana use is at a historic high among this demographic, with approximately 43% of persons reporting any prior marijuana use, and 6–11% of persons reporting daily use . Marijuana smoking is often perceived as less harmful than tobacco smoking, yet marijuana and tobacco smoke contain many of the same toxic chemicals and carcinogens . Secondhand marijuana smoke exposure in children has not been extensively studied, while the negative health effects of tobacco smoke are well documented. As the 2006 Surgeon General Report on involuntary exposure to tobacco smoke noted: tobacco smoke is clearly linked to several pediatric diseases with significant morbidity and mortality including otitis media, impaired lung function, lower respiratory illness, and sudden infant death syndrome . Because of the similarities between marijuana and tobacco, further research into the potential harmful effects of secondhand marijuana is of importance.

While there is a dearth of specific messaging regarding marijuana, many organizations have highlighted the negative consequences of tobacco smoke and have created policy statements. The American Academy of Pediatrics  states, “tobacco is unique among consumer products in that it severely injures and kills when used exactly as intended .” There is no safe level of tobacco smoke exposure, as it poses harm from the moment of conception. The AAP suggests pediatricians counsel caregivers who smoke about smoking cessation, as well as provide advice to all children and adolescents regarding tobacco dangers before they initiate use. This brief article is a sub-analysis of a larger research study that consisted of a cross-sectional survey of a convenience sample of 1500 caregivers presenting with their children to a Pediatric Emergency Department in Colorado. Surveys were administered to caregivers between December 2015 and July 2017, several years after Colorado had legalized recreational marijuana use. Caregivers who met inclusion criteria were English or Spanish speaking, 21 to 85 years-old, presenting to the Pediatric ED with their child. Exclusion criteria included caregivers of all of the following: critically ill children, medically complex children, children over 11 years-old , children utilizing medical marijuana, and children previously incorporated in this study. The hospital’s Institutional Review Board approved this study. This work has been carried out in accordance with The Code of Ethics of the World Medical Association  and prioritized patient privacy and safety. Caregivers were approached after presentation to the Pediatric ED by study investigators or trained research assistants. Once informed consent was obtained, participants were asked to complete the survey during wait times. Surveys were available in English and Spanish and were self-administered on a tablet. Responses were directly uploaded to a password protected REDCap database to maintain confidentiality. The survey asked questions regarding demographics, medical history of the child, and caregiver tobacco and marijuana habits. The specific question regarding marijuana use was, “Does anyone who lives in your home or who primarily cares for your child use marijuana ?” When respondents indicated marijuana use, the survey then asked several follow up questions such as type and frequency of use. The survey further prompted every caregiver indicating marijuana use to answer the question: “Has your child’s pediatrician ever asked or counseled you about marijuana?” The caregivers could respond with either “yes,” “no,” or “unsure.” Not much is known about the effects of secondhand marijuana smoke on children.

All the interviews were conducted face-to-face by trained research assistants and lasted approximately 40 min. A parking stage is a well-organized, precise location that registers and allows commercial motorcycle riders to park and wait for passengers. To avoid recall bias, we did not consider cases that could not be invited and interviewed within 14 days after the crash due to poor health conditions or other reasons. Controls were commercial motorcycle riders who reported no history of RTI that led to hospital attendance within the past six months. Recruitment of controls was done at 90 purposefully selected parking stages between December 2018 to March 2019. The parking stages were selected across the five municipalities of Dar es Salaam City Council and included parking stages located at the trunk and collector roads. There are variations in the size of parking stages: those located along the trunk roads have a large number of riders compared to those found in collector roads. This sampling approach was used to ensure that controls were representative of commercial motorcycle riders in the city. At the parking stages, all riders were approached, informed about the study and consented to participate in the study. We recruited about 20% of the riders at each parking stage. We assigned numbers  on a piece of paper and asked riders to choose a number. Compensation of a 1$ voucher was given to riders who participated. Of 413 eligible controls, 13  declined to participate for various reasons, ending up with a total of 400 controls. In total, our study population included 564 commercial motorcycle riders operating within the city of Dar es Salaam, aged 18 years and above . The controls were interviewed face-to-face by trained research assistants. The interviews took place at parking stages and lasted approximately 40 min. The sample size was calculated using OpenEpi version 3.0 statistical software for unmatched case-control study . We aimed to detect an OR of at least 1.8 for being a case, with significant level , at 95% confidence interval, power of 80%, and a ratio of one case to two controls, assuming the prevalence of alcohol consumption among commercial motorcycle riders to be the same  as that of males in the general population .

A minimum sample size of n = 495  was required. After adding 10% non-response rate, the total of 550 sample size was required.The Alcohol Use Identification Test  was used to assess alcohol consumption. The AUDIT is a screening tool developed by the World Health Organization  for assessing alcohol consumption,cannabis grow supplies drinking behaviour and alcohol-related problems . The first three questions in the AUDIT questionnaire are used to measure the frequency of alcohol consumption, the number of standard drinks containing alcohol on a typical day when drinking, and the frequency of heavy drinking. The next three questions covered: symptoms of alcohol dependence, impaired control due to overdrinking, increased salience due to drinking, and morning drinking. The last four questions focus on: harmful alcohol use, guilt after drinking, blackouts, and alcohol-related injuries associated with drinking. All ten items of AUDIT scores were summed up and classified into four categories: non-drinker , normal consumption , risky drinker  and possible alcohol dependence. However, due to the small number of participants with AUDIT scores of 16 and above, the cut-off points of AUDIT scores were revised into three categories; nondrinker , normal consumption , and risky drinker . Missing values for AUDIT scores were imputed using means scores of individual with an assumption that the values were missing at random on less than two items of the scale. Psychoactive drug use was assessed by asking whether the participants had used any drugs in the past 12 months If they responded yes, there were follow-up question as about which psychoactive drug  they had used. The cases were comparatively younger than the controls, with a mean age of 27.8 and 29.5 years, respectively . More than half  of the cases were single, while 59.3% of the controls were married. The cases had a lower level of education and less driving experience compared to the controls. About 39.0% of the cases and 35.5% of the controls reported never having possessed a motorcycle driving license. Regarding the work-related factors, the cases reported working more hours per day compared to the controls. More than half of the cases reported earning a higher daily income compared to 18% among the controls. Nearly 82% of cases reported high risky driving behaviour compared to controls . This study adds to the existing evidence that there is an increased risk of RTIs among commercial motorcyclist riders who report alcohol consumption in sub-Saharan Africa . Our analysis showed an almost six times increased odds of RTIs among commercial motorcyclist riders who reported risky drinking compared to non-drinkers.

The effect decreased to 2.41 times when adjusted for sociodemographic characteristics, work-related factors and risky driving. The decreased effect of alcohol consumption in the fully adjusted model indicates that some of the effect may be due to other risk factors of RTIs Unlike the increased risk of RTIs among riders with risky drinking behaviour, the odds of RTIs was non-significant among commercial motorcycle riders reporting normal alcohol consumption compared to non-drinkers. Furthermore, our findings showed that alcohol consumption in the past year was not significantly associated with the risk of RTIs. This could probably be explained by the fact that alcohol consumption in the past year is a less sensitive measure as it includes both riders who reported normal alcohol consumption and those who fall into the risky drinker category. Evidence from other studies suggested that alcohol consumption and marijuana use are directly or indirectly associated with other risky driving behaviours. In this study we also noted high prevalence of risky driving behaviour in both cases and controls. As motorcycle use is becoming an increasingly important means of transportation in Tanzania , the high prevalence of risky driving behaviour is particularly concerning. Our study shows that most cases were younger, unmarried, and had a lower level of education. These findings are consistent with other studies that have shown an association with increased motorcycle RTIs and sociodemographic factors, notably young age, male sex, and low education level . Only six out of ten motorcycle riders are reported to have ever possessed motorcycle driver’s license even though possession of license is mandatory in Tanzania .Approximately two-thirds of study participants reported working for>13 h a day, suggesting a higher number of working hours in this group of riders. Our findings are consistent with findings from a previous study on risk factors for RTIs among commercial motorcyclists in Uganda by Tumwesigye et al. ,which showed that alcohol consumption was associated with increased risk of RTIs among commercial motorcycle riders , The measurement we have used,the AUDIT is an indirect measure of alcohol consumption which does not measure the effects of the actual intake of alcohol consumption, i.e. level of intoxication at the time of RTIs; instead, it measures the frequency and amount of alcohol consumption to predict the pattern of alcohol use and disorder and hence its influence on the driving ability, directly or indirectly through other mechanisms. Also, studies have shown that drivers with hazardous alcohol consumption are more likely to drink and drive  Previous studies have reported that alcohol intake negatively affects attention and increases the likelihood of sensory and motor dysfunction such as loss of balance and increase in reaction time .

Since balance and coordination are important for motorcycle riders, both novice and experienced motorcycle riders are more susceptible to the effect of alcohol consumption than other motor vehicle drivers . In addition to the impairment of driving performance, alcohol consumption has been shown to be associated with other risky driving behaviours such as speeding, failure to use a helmet, and not having a motorcycle driving license . Moreover, high alcohol consumption has been reported to be associated with non-compliance with traffic rules such as violating the traffic lights, carrying two or more passengers and using cellphones while driving . Our findings show that, even after considering risky driving behaviour, risky drinking was still associated with higher odds of RTIs, emphasizing the need to develop interventions to reduce risky alcohol consumption among these riders. Another important finding revelead that there was a doubling odds of RTIs among riders who reported marijuana use compared to nonusers. Congruent to the observation obtained in a longitudinal study of a cohort of motor vehicle drivers in New Zealand , which showed that statistically significant association disappeared after controlling for risky driving behaviour, cannabis grow facility driving licensure and driving experience. Studies have suggested that increased risk of RTIs observed with marijuana use might appear to reflect the characteristics of drivers who are often young men and prone to engage in risk-taking behaviour . In addition, the studies which have found an association have observed it among drivers who reported to have driven while under the influence of marijuana but not with merely the use . Cognitive studies have reported a plausible biological mechanism of impaired driving performance among marijuana users . However, there has been inconsistent evidence on whether marijuana use increases the incidence of a crash and subsequent injuries in epidemiological and experimental studies . It has been suggested that the mechanism through which marijuana use does not increase crash risk despite neurophysiologic impairments is that marijuana users tend to overestimate their impairment and consequently employ compensatory strategies . Furthermore, driving and simulation studies have revealed that drivers who use marijuana/cannabis tend to decrease their speed, attempts fewer overtakes, and increase their following distance . Moreover, in studies that reported driving impairment, marijuana use was associated with impairment of automatic driving functions of which drivers could not compensate for, and the risk of which increased with increasing doses . On the other hand, other psychoactive drugs such as opiates, stimulants inhalant, and zopiclone have been associated with a higher risk of RTIs . At both the individual and societal level, alcohol consumption and psychoactive drug use represent a severe threat to road traffic safety . Studies have shown that the effects of alcohol consumption increase in dose-related fashion and are more pronounced with complex integrative functions, which is the opposite pattern from that seen for marijuana use . Combining marijuana with alcohol might eliminate the ability to use coping strategies effectively, leading to impairment at lower doses than when either drug is used alone . Our study showed that it is not uncommon among commercial motorcyclists to consume alcohol and use marijuana; 15% of cases and 7.3% of controls reported using both alcohol and marijuana in the past year. However, we did estimate an effect for this combination as data could not differentiate between combined use of alcohol and marijuana at the same time from using them at separate occasions. A notable limitation of our study was that data were self-reported and subject to social desirability bias. Globally, injured victims tend to underreport socially sensitive issues such as alcohol consumption and psychoactive drug use , and a similar observation was documented in Tanzania .

The frequency of self-reported marijuana use among the cases in our study was lower  than what was observed in a cross-sectional survey among trauma patients at the national hospital in Tanzania. The disparities between the findings of our study and this survey could be attributed to the difference in the measurement used. In the trauma patients survey, the psychoactive drug use, including marijuana use, was measured through urine analysis, which is more reliable as compared to self-reports. Also, self-reported measurements may suffer from specific drawbacks due to the way the respondents choose to reply, the answers may be exaggerated or the respondents may be too embarrassed to report a certain behaviours. To address this bias our study following recommendations from previous studies, in particular by guaranteeing anonymity among respondents, clearly defining their roles and the purpose of the data collection and prefacing of questions . Our study included only the commercial motorcycle riders who could be interviewed within 14 days from the date of the RTIs so as to minimize recall biases.

However, we have to keep in mind that a certain cannabinoid invention can be referred into more than one patent category. For instance, cannabinoids are highly hydrophobic by nature and thus they have low bio-availability in the human body. As a result, a new class of cannabinoid-glycosides has been created,whose representatives are produced through enzymatic glycosylation. This novel strategy led to increased aqueous solubility of the target cannabinoids and resulted in four patents . Recently a new method of producing one or more cannabosides by feeding an insect a cannabinoid was patented . These new classes of cannabinoid glycosides generated vast structural diversity and have greatly improved water solubility,enabling new pharmaceutical formulations, and multiple administration routes .The discovery of the genes encoding glycosyl transferases may belong to different categories of the cannabinoid patent family, that is, genes, enzymes, delivery technology, etc.The exponential enhancement of the patent number during recent years in the diverse areas of cannabinoid applications is indicative of the increased commercial interest in this class of natural compounds.The various pharmaceutical applications will continue to shape primarily the the path of the future invention cannabinoids. Pain management remains a major challenge in orthopedics.Surgeons employ a multitude of strategies to combat this challenge,including multimodal pain regimens and preoperative opioid counseling.1e3 A recent review of medical cannabis  in orthopedic surgery proposed that MC may provide an additional pain management option for patients with chronic pain.Chronic pain,defined as pain that fails to respond to traditional pain control regimens and lasts greater than 3 to 6 months, is one of the most widely recognized indications for MC use and has been reported to be the primary indication for MC use in two-thirds of patients presenting to MC dispensaries in the northeast.

MC use has become more widespread in recent years and is currently legal in 36 states and 4 United Sates territories.This has been paralleled by a decreased perceived risk of marijuana grow system use reported in a nationwide survey of United States citizens from 2002to 2014.7 However, limited evidence exists on MC use in orthopedic surgery and on patient perspectives of this novel therapeutic. One descriptive qualitative study of spinal cord injury patients found that patients used MC when other pain management strategies failed and when they had both initiative and connections to educate themselves on MC use.Heng et al investigated musculoskeletal trauma patients’ opinions on MC and found that most patients thought it could be effective in treating musculoskeletal pain.However, there is an overall paucity of research on hand and upper-extremity patient perspectives on MC. This patient population may differ from other orthopedic conditions in that many present electively, it includes conditions with a mix of acute and chronic pain and includes patients of a wide age range.The purpose of this study was to evaluate hand and upperextremity patient perspectives of MC and its use in treating common hand and upper-extremity musculoskeletal conditions. We further sought to identify the prevalence of patients already using MC in this patient population, perceived barriers to MC use, and opinions on the legality of cannabis. We hypothesized that most patients would consider using MC for common orthopedic conditions,and that older patients would be more reluctant to use MC compared to younger patients. Institutional review board approval was obtained prior to initiation of this anonymous cross-sectional survey study. From October 2020 to January 2021, all patients who were at least 18years old and presenting for an office visit at a metropolitan academic institution with clinic sites across New Jersey and Pennsylvania were asked to participate in this study.

All patients presented with a hand or upper-extremity complaint to 1 of 3 board certified,fellowship-trained orthopedic hand and upper-extremity surgeons.Medical cannabis is legal in both states where the survey was conducted, with New Jersey legalizing MC in 2010 and Pennsylvania in 2016. Patients completed a survey that was created by the  study investigators regarding patient opinions of MC, including opinions of its legality, safety, costs, and potential barriers for use.Medical cannabis was defined in the survey as any publicly available legal MC product, which included topical, inhalational, andoral cannabis products. All survey responses were collected and stored electronically , with no identifying patient information collected as part of the survey. During the study period, 937 clinic patients were solicited to participate in the study.Categorical data were presented as counts and percentages andanalyzed using chi-square tests. Statistical significance was set at P< .05. The present study identified numerous findings regarding hand surgery patient perspectives of MC. The majority  of patients reporting to hand and upper-extremity orthopedic surgery outpatient offices would consider using MC for chronic pain control or for pain associated with many common orthopedic conditions. As MCuse increases throughout the United States and as more MC research continues to emerge, it is important for surgeons to understand how patients perceive these substances and what factors may represent barriers to use.Most patients in our study reported that they would consider using MC for a variety of acute and chronic orthopedic pain conditions and believed it could effectively treat musculoskeletal pain.This is consistent with other orthopedic patient populations’ beliefs on the utility of MC. In a survey of orthopedic trauma patients, 81%believed cannabis can be used as a medication, and 78% believed it could be used to treat acute pain.9 In a study of elective surgery patients at a large academic center, inclusive of both orthopedic and nonorthopedic procedures, most patients believed MC could beat least somewhat effective for postoperative pain  and chronic pain , and most patients  would use MC if prescribed by a physician.The positive patient response to MC as a potential pain controloption brings into question the clinical effectiveness of MC in treating musculoskeletal pain. In multiple prior studies, cannabis users subjectively reported that cannabis provided effective pain relief.Of orthopedic trauma patients who used RC during recovery, 90% believed that it reduced their pain symptoms, and81% believed it reduced the amount of opioids they required.

Similarly, a survey of MC users, most being treated for chronicpain, revealed that 75% believed MC was effective in treating their pain and positively impacted their quality of life.5 Further, a study of orthopedic surgery patients found that preoperative RC users had lower pain scores and improved lower-extremity activity scores compared to non-cannabis users.Though most orthopedic surgery patients in the literature believe that MC is an effective treatment for pain, multiple review articles conclude that only low to moderate-quality evidence exists to support pain reduction with MC. These reviews also call for additional research on the safety, efficacy, and dosing of MC prior to making definitive conclusions on MC for pain management.To date, cannabis research has been limited by the federal classification of cannabis as a Schedule 1 substance, which has presented many barriers for researchers to perform high quality clinical trials.In our cohort, 74.7% of patients believed MC to be safe for treating orthopedic conditions and 74% of patients agreed or strongly agreed that MC was safer than prescription opioids for common pain conditions. While opioids are associated with many adverse outcomes including overdose and death, cannabis is likely perceived as safer as it is not associated with either of these critical major side effects.14 Despite this, other side effects of cannabis use must be considered. Cannabis use has been linked to negative mental health illnesses ,impaired cognition, and increased rates of cardiovascular and cerebrovascular events.There is also a reported increased risk of motor vehicle collisions, including fatal accidents, in the acute setting following cannabis use.Negative consequences of cannabis use have also been described in total joint arthroplasty,although the evidence is inconsistent. One study reported no difference in short-term outcomes in primary total kneearthroplasty with cannabis use,while another reported an increased risk of revision associated with cannabis use disorder.However, these studies are limited by the mixed inclusion of both MC and RC use.Lastly, the impact of cannabis use onanesthesia should be considered. A recent review of the perioperativec are of cannabis users highlighted increased incidence of hyperre active airway, intra operative hypothermia, and cerebrovascular ischemic events.These studies are limited by the federal classification of cannabis as a Schedule 1 substance,and further studies are needed to better inform patients on the risks and benefits of MC.Interestingly, despite our cohort’s support for MC use as an alternative to opioids, only 26% believed MC could be used as a treatment for opioid use disorder. There is limited and contradictory evidence on the effects of cannabis vertical farming on opioid use. One population level study found lower average opioid overdose mortality rates in states with legalized MC.Another study of orthopedicsurgeons prescribing opioids to Medicare Part D patients found a decrease in opioid prescriptions in states with legal MC.Most studies on the impact of cannabis on opioid use in postoperative patients focus on the effect of preoperative RC use on perioperative and postoperative opioid requirements. Increased postoperativeopioid requirements have been reported for orthopedic trauma patients. and total joint arthroplasty patients who were RCusers.In contrast, other studies reported no difference inopioid requirements for RC users among total joint arthroplasty patients and elective surgery patients, inclusive of orthopedic and nonorthopedic proceduresNone of these studies reported specifically on the effects of legal MC use on opioid requirements.

One study of total hip arthroplasty and total knee arthroplasty patients treated after surgery with dronabinol,a synthetic prescription cannabinoid, in addition to a standard multimodal painregimen found a lower mean length of stay and lower average opioid use.Further studies are required to elucidate the impact of multimodal pain regimens inclusive of MC on opioid requirements in orthopedic surgery patients.Cost was reported by nearly 50% of our patients as a potential barrier for MC use, and over 70% reported the cost as either“expensive” or “not affordable.” A previous study of MC users also revealed the most common negative aspect of MC use was the associated cost, where patients reported spending over $2,000 per year on MC.5 The cost of MC varies by state and by specific product and is challenging to study, given the heterogeneity of the required quantity. A recent study by the Minnesota Department of Health found that the average 30-day cost per patient using MC to treat pain was $314 in 2019.35 Over 90% of patients in our cohort, greater than the number of patients that endorsed a willingness to use MC,supported insurance coverage for MC. Currently, no insurance companies cover MC.Together, these findings support advocacy for policies that support patient access to MC.This study has several limitations. First, MC use remains controversial, and this may limit our patients’ willingness to report MC use and provide honest opinions on MC. We attempted to minimize this bias through collecting data anonymously, but this bias may still be present. The controversy behind MC may have impacted which patients responded to our survey, and thus, despite our favorable response rate of 72.5%, we cannot rule out non-responsebias affecting our findings. Additionally, this study is conducted with patients presenting to outpatient hand and upper extremity clinics in 2 states in which MC has been legalized for at least 4 years, therefore limiting the generalizability of study findings for patients in states where MC has been recently legalized or where it remains illegal. We defined MC as any legal MC product in our study survey , but investigating patient responses to specific MC products could be explored further in future studies. Further, our patient population consists of predominantly patients with health insurance, which limits the generalizability of study findings. Lastly, our study is limited in that we do not collect information on the patients’ current pain levels, chronicity of symptoms, or RC use status, which could affect patient willingness to use MC. These variables may act as con-founders of patient perception of MC, and these relationships should be explored further in future studies.This study found that most hand and upper-extremity orthopedic patients presenting to outpatient offices would consider using MC, and most perceive it as a safe treatment option for common orthopedic conditions. Moreover, 10% of survey participants were already using MC. One of the major barriers to MC use is the financial cost.

Tetrahydrocannabivarin,6-Hydroxymelatonin,and Delta9-Tetrahydrocannabinol had the highest binding scores, indicating that they could inhibit Plasmodium tubulin and thus interfere with malaria cycle progression. This study could not find a significant correlation be- tween the physicochemical properties of the compounds and the binding affinities of the compounds to Plasmodium tubulin.However, 6-hydroxymelatonin and delta9-Tetrahydrocannabinol were found to have favourable drug description properties thereby suggesting a role of these compounds as drug leads. This claim is supported by the fact that tetrahydrocannabinol has a higher binding affinity than other cannabinoids, as demonstrated in the current study. However, to the best of our knowledge, there is no literature to support the potential anti-malarial activity of tetrahydrocannabivarin. Judging by the available computational data and evidence from literature, tetrahydrocannabinol and tetrahydrocannabivarin could berec- ommended as possible anti-malarial drug leads targeting αβtubulin. The amino acids interaction of the cannabinoids and vinblastine with the tubulin protein differed significantly with each compound. This reflects the diversity of physicochemical properties of the compounds. However, certain amino acids ASN99, ALA97, ALA247 and CYS353 were found to participate in the interaction for more than one ligand tested. Cannabis sativa L. is one of the earliest known cultivated plants since agricultural farming started around10,000 years ago . It is a multi-purpose crop plant with diverse agricultural and industrial applications ranging from the production of paper, wood, and fiber, to potential use in the medicinal and pharmaceutical industries. The first-ever report to reveal the prospects of C. sativa L. as a medicinal plant was already published in 1843 and described the use of plant extracts to treat patients suffering from tetanus, hydrophobia, and cholera .

However, the first chemical constituent identified was oxy-cannabis, isolated cannabinoid,and fully identified in 1940 was cannabidiol   followed by tetrahydro cannabinol  and cannabigerol  in 1964, and cannabichromene  in 1966. Identification of THC later led to an understanding of the endocannabinoid system followed by the discovery of the first cannabinoid receptor  in 1988 . CB1 receptor acts as a homeostatic regulator of neurotransmitters for pain relief mechanisms, but the same mode of action was responsible for intoxicating effects from cannabinoids’ excessive use.Thus, the understanding of mode of action of CB1 receptor raised concerns about the adverse effects of cannabis use. Consequently, the plant was removed from the medicinal category and recategorized exclusively to the category of drug-type plants.Cultivation and use of cannabis plants for recreational,medical, and industrial use were strictly banned and severely limited the scientific research in the field. Owing to strict legal regulations, the plant remained unexplored for its incredible potential in drug discovery for an extended period until it was legalized for medical use first in California and later in many countries around the globe. Extensive research followed legalization to explore the chemo-diversity of cannabinoids for potential clinical value. In total, more than one thousand compounds—278 cannabinoids, 174 terpenes, 221 terpenoids, 19 flavonoids, 63 flavonoidglycosides, 46 polyphenols, 92 steroids—have been identified . Nearly 278 of these compounds are cannabinoids and classified as phytocannabinoids to distinguish them from endocannabinoids.Cannabimimetic drugs binding toCB1-receptors in the endocannabinoid system can also be found in algae, bryophytes, and monilophytes . The major cannabinoids in cannabis include THC, CBD, and CBC, their precursor CBG and cannabinol.To date, 10 CBN-type, 17CBG-type, 8 CBD-type, and 18 THC-type cannabinoids have been isolated . Cannabigerolic acid , a CBG-type cannabinoid, is the central precursor for the biosynthesisof psychoactive THC, mobile vertical rack non-psychoactive CBD, and CBC .Cannabinoid biosynthesis in plants occurs in specialized biosynthetic organs called glandular trichomes on female flowers and leaves. Several studies use metabolic profiling of trichomes to demonstrate variation in trichome size, density, and relative concentration of cannabinoids . However, the genetic mechanisms underlying the developmentalchanges in trichomes and consecutive cannabinoid content are still unknown. Apart from natural and chemical biosynthesis methods , heterologous biosynthesis of cannabinoids has also been reported .

However, the considerable amount of side products is still one of the major bottlenecks  in cannabinoid production.This review highlights the latest research developments and challenges in cannabis plant sciences, the roleof trichomes as biosynthetic sites, with a special focus on plant biology. In addition, we discuss the existing legal practices with patent information for the C. sativa L. We also discuss the new potential use of cannabinoids for COVID-19 treatment. Finally, we address the available genomic and transcriptomic resources and discuss their potential toward the genetic improvement of cannabis. Overall, we provide the first in depth review of diverse aspects of C. sativa L. from traditional medicinal use to genomics insights and research perspective to broad industrial applications. Scientific endeavors to experiment, observe, and understand the diverse medicinal applications of cannabis were still in the early stages. However, 1900s witnessed a series of legal regulation in the direction of the criminalization of cannabis. Cannabis was starting to be categorized into the list of narcotic drugs and Poisons Rules including the Pure Food and Drug Act  pushed for stricter measures for cannabis distribution. Later International opium Convention  called for measures to regulate Indian hemp. Exports unless exclusively for medical or scientific purposes or European hemp  were banned. Uniform State Narcotic Drug Act , Geneva Trafficking Conventions  resulted in criminalizing the cultivation, possession, manufacture, and distribution of cannabis derivatives. Marihuana Tax Act levied heavy taxes on the possession and selling of cannabis, excluding medical, and industrial use. As a consequence, the cultivation and procurement of cannabis for research purpose became increasingly difficult and severely limited the research of medicinal cannabis during this era . During the second period , cannabis research suffered major restrictions owing to legal regulations in the first two decades until the identification of the first cannabinoid—cannabidiolic acid in 1954 , isolation of the most psychoactive component of cannabis, the THC in 1964 . Isolation of the THC, discovery of CB1 , and CB2  receptors, followed by the Compassionate Investigational New Drug program  paved the way for decriminalization laws. The discovery of endocannabinoid and the role of cannabis in the medicinal field have been reviewed in  As a consequence a steep surge was observed in the number of cannabis-related articles from 445 articles and25 reviews during 1937–1964 to nearly 8,888 articles and 773 reviews during 1964–1996 , although with a short period of decline between 1973 and 1982. Finally, the third period began with the historical Compassionate Use Act of 1996 in California approving medical cannabis. Post legalization, cannabis has been extensively explored for its diverse potential in the pharmaceutical and medicinal industries. During the third period, cannabis research witnessed an unprecedented growth with nearly 67,777 articles, 13,202 reviews, and 493 preprints ,of which 97.01%articles were published in the last two decades since 2000  and the first draft of the cannabis genome in 2011  in this era were the two major accomplishments that exponentially accelerated the research development.

To further investigate the most researched field, the journals of cannabis articles were categorized into scientific and social areas.The journals related to social, law, and policy-based studies were merged into the subject category of social research. Although the majority of broad scientific subjects were grouped into the following seven major categories: medicinal,pharmaceutical-comprised of pharmacology, pharmaceuticals, drug, toxicology, and chemical studies,neurosciences-comprised of neurological, brain-related, psychiatry, psychology, and cognitive studies,  biochemistry-included biotechnology,microbiology,immunology,virology,andbiochemistry,genomics-grouped genetical and genomic studies,plant biology-included plant sciences, agricultural, botanical aspects, plant-pathogen and environment studies, and lastly,bio informatics. Journals that could not be classified into either of the aforementioned categories or social research categories were excluded from downstream evaluation. The Scientific subject areas  were further compared for the corresponding number of articles and journals. A distinct pattern was observed for the Clinical aspects of cannabis which remained a major focus since the very beginning with nearly 94.76% published articles including 64.51% articles in medicinal subject areas, 19.55% in pharmaceutical sciences, and 10.70% in neuro sciences. In contrast, plant biology and agricultural sciences comprised only 2.62% of articles, followed by 0.71% genomics, and 0.07% bio informatics-based cannabis research. Genomics and bio-informatics are relatively new subjects growing at a fast pace since the release of the first Cannabis draft genome in 2011 together. Recent advances in sequencing technologies have further propelled genomic and transcriptomic studies with the purpose of dissecting the regulatory networks. The growth of genomic data in public space has met with the fast-paced development of bio-informatics tools for data analysis. In addition, ongoing developments of machine-learning and artificial intelligence based genomic tools will facilitate genetic-level understanding of cannabis metabolism for the selective breeding of genetically modified cannabis with improved metabolic traits. Physiological, morphological, and developmental aspects of Cannabis are key in understanding the plant growth patterns and chemical profiles. However, plant growth and function are substantially influenced byabiotic factors and nutrient availability. Although botanical aspects , plant architecture,and florogenesis of female C. sativa plants  with detailed trichomemorphogenesis  provided crucial insight into plant biology. However, it also became increasingly important to determine the effect of abiotic factors on Cannabis growth and chemical yield, especially for large-scale commercial breeding programs. Hence, in-depth analysis of the effect of soil fertilization, salinity, temperature, and light conditions, as well as nutrient and water use efficiency is key in establishing industrial-scale systems for the cultivation of hemp and marijuana varieties.The first available records about the mineral nutrition of hemp plants were published by Tibeau et al.,in 1936 . Later in 1944, Clarence H Nelson published the effect of varying soil temperature on hemp growth .

The first publication with a detailed response of greenhouse cultivated cannabis to nitrogen, phosphorus , and potassium  was published in 1977 . Furthermore, two parallel reports by HMGet al., in 1995 discussed the impact of nitrogen fertilization on sex expression in hemp ,vertical grow rack and the effect of temperature on leaf and canopy formation . Importantly, most physiological studies in the second and third period  were published for hemp with a focus on photosynthetic response and biomass yield with varying conditions such as temperature, water availability, nitrogen, and mineral nutrition . However, the first study to assess the chemical response of hemp plants was published in 1997.Since the physiological response of drug-type medical cannabis plants may differ from hemp plants owing to the distinct genetic and chemical differences. Hence, a clear understanding of optimum factors for medical cannabis is inevitable for the efficient cultivation of plants with desired chemical composition. Among the first few studies that addressed medical cannabis, photosynthetic response to photon flux densities,temperature, and CO2 conditions were published by Chandra et al., in 2008 and 2011 . Bernstein and the group further addressed the growth and chemical response of medical cannabis to mineral nutrition especially N, P, and K . Saloner and Bernstein  reported optimum N concentration at 160 mg L_1, N with lower levels showed several symptoms inducing necrosis and growth retardation while the higher levels impacted in reducing concentrations of THCA and CBDA. Shiponi and Bernstein  showed a negative association of cannabinoid concentrations and yield with increasing P supply. Saloner et al. further  determined genotype-dependent effect of K nutrition on medical cannabis reporting 240 ppm K detrimental for the genotype Royal Medic and stimulant for Desert Queen genotype while 15 ppm K was insufficient for both genotypes. Further in 2019 Bernstein et al.  discussed the combined effect of NPK nutrition upon cannabinoid concentration. In addition to soil nutrients, heavy metal uptake potential of hemp varieties has also been thoroughly investigated by multiple reports in past years . Industrial hemp varieties of C. sativa have also been shown to grow in soils contaminated with heavy metals and reported for heavy metal accumulation. Several field projects have assessed the phytoremediation potential of hemp plants for the reclamation of contaminated and radioactive soils. Cannabis cultivars are classified into drug-type  fiber-type  and neutral plants with distinct cannabinoid constitutions. Drug-type cultivars with THC/CBD ratioR10 are classified as chemotype I, while those with THC/CBD ratio ranging from 0.2 to 10 are grouped as chemotype II.In contrast, fiber-type cultivars with THC/CBD ratio <0.2 are categorized as chemotype III. Chemotype IValso has low THC contents but with the potent percentage of CBG. Furthermore, the chemotypes producing very little to almost zero cannabinoid compounds  are grouped as chemotype V -was first described byMandolino et al. . Apart from cannabinoid  content, drug and fiber-type plants have significant genetic variation. Sawleret al., 2015 described that marijuana is genetically inclined toward ‘‘sativa’’ and hemp have a similarity with the ‘‘indica’’ type . Moreover, each plant type has unique applications differentiating them from each other. For example, the fiber-type “hemp’’ plant has mostly food and industrial applications,including production dietary products, hemp oil, seeds, and fiber, while the ‘‘marijuana’’ drugtype plant is used exclusively for medicinal and recreational purposes.Despite such a huge genetic and application diversity, both types of cannabis plants were categorized as‘‘Scheduled 1 drug’’ according to the ‘‘Controlled Substances Act’’ in 1970 . These restrictions had a serious impact on the research preventing the scientific community to study the potential of diverse yielding traits for hemp. However, after 44 years in 2014 the ‘‘agricultural act section 7606’’ was implemented which distinguish hemp from marijuana .

Additional research is needed to understand YA exposure to pro-tobacco and cannabis marketing across a wider range of marketing platforms. Further, tobacco products are marketed online largely via organic social media posts not labeled as advertising . Since respondents were asked generally about seeing ads “when using the internet,” we were unable to disentangle the various types of online marketing YA saw. Fifth, patterns of media consumption vary among YA , and heavy media users may recall more tobacco and cannabis marketing than light media users. While respondents were able indicate if they did not use the Internet or if they did not watch TV/movies at all, we were otherwise unable to account for the frequency or timing of their Internet or TV/ movie consumption. Sixth, these data are from a cohort of YA from Southern California, and so may not reflect national or regional trends in perceived marketing exposure. However, the sample was similar to population characteristics of Los Angeles, CA in terms of race/ethnicity and educational attainment . To reduce survey burden, respondents were not asked to report on all characteristics that may potentially be related to substance use . Finally, small sample sizes in some of the sociodemographic subgroups  and in some of the specific products marketed resulted in wide confidence intervals on some of our estimates, and also precluded us from testing sociodemographic differences in viewing marketing across the various products.  Binge drinking  is mainly observed in adolescents and young adults, and concerns two thirds of college students in France . BD is usually defined as a pattern of alcohol consumption characterized by intermittent periods of heavy drinking over a short period of time and periods of abstinence .This specific pattern of consumption is frequently associated with the use of cannabis , which is the most consumed illicit substance in Europe, with 31% of French students reportedly having smoked it at least once in their lives .

Both BD and cannabis use have harmful consequences , making them a major public health issue. The focus must therefore be on BD and its association with cannabis use. The neuropsychological impairments induced by BD have been extensively documented in the scientific literature . This problematic drinking pattern can lead to brain atrophy in the prefrontal,vertical grow system temporal and parietal cortices, as well as in the hippocampus, inducing executive and memory disorders . BD mainly impairs executive functions, with increased impulsivity and a lack of cognitive control related to frontal dysfunction . Memory impairments have also been reported , but less consistently than executive disorders.Chronic cannabis consumption can also lead to brain damage, especially in hippocampal  and prefrontal regions , resulting in episodic memory impairment  and executive deficits . According to these studies, using cannabis in addition to BD leads to potentially more severe cognitive consequences. To sum up, the aforementioned studies describe common memory and executive impairments among BD and cannabis consumers. Although the cognitive deficits seem to be similar in nature, they appear to differ in severity, depending on which substance is used. Memory impairments are reported more than executive deficits in chronic cannabis users , with the opposite pattern for BD . Their combined use could therefore lead to memory and executive dysfunctions of the same severity, owing to an additive effect. Despite the frequency of alcohol and cannabis use among students, few studies have explored the additive effect of BD and cannabis use on neuropsychological deficits. To our knowledge, only two studies have so far been conducted among adolescents and young adults , and none with a sample made up solely of college students. Compared with young adults with a history of light and controlled substance use, poorer executive functioning and verbal episodic memory abilities have been observed in young BD and cannabis co-users. In Winward et al. ’s study, BD and cannabis co-use was associated with the executive and episodic memory impairments found in single-substance users , but co-users also had specific working memory impairments that are not observed in single users. Overall, these two studies suggest that the consumption of both substances has an additive effect on neuropsychological deficits, and encourage further research to examine co-use in college students and identify the characteristics of those who exhibit the poorest neuropsychological performances.

This knowledge is essential for designing appropriate prevention measures. Thus, for the first time in college students, the present study aimed to  improve understanding of the additive effect of BD and cannabis use on neuropsychological functioning, and  describe the profiles of student users who are at the greatest risk of neuropsychological deficits. Based on the literature, we first expected to observe executive and episodic memory deficits in college students who engage in BD, whether they smoked cannabis or not. Second, we expected to observe an additive effect of BD and cannabis use in students, resulting in more severe memory and executive function impairments than in BD students who did not consume cannabis. Finally, we expected to find a gradient of severity of neuropsychological impairments among BD students, with those who consumed cannabis grow equipment performing more poorly. Neuropsychological impairments were assessed with the Brief Evaluation of Alcohol-Related Neuropsychological Impairments . This test was specifically designed to screen for cognitive and motor deficits in patients with alcohol use disorders . It contains five subtests: verbal episodic memory , alphabetical span, assessing verbal working memory , alternating verbal fluency, assessing flexibility abilities , five complex figures, assessing visuospatial abilities , and ataxia, assessing balance . The BEARNI yields six scores: five subscores and a total score . The BEARNI is a screening tool that facilitates referral for a more detailed neuropsychological assessment. As low drinking does not lead to neuropsychological deficits, participants in the LD group with moderate impairments  were excluded from the statistical analysis. First, participants’ raw BEARNI scores were transformed into z scores. A z score was computed for each BEARNI subtest, based on the mean and standard deviation of the LD group . Second, we calculated a linear mixed model, with BEARNI subtest z score as a within-participants variable, group as between-participants variable, and participant as a random component. Sex , age, Fagerstr¨om score, and BD score were included as covariates, to control for their effects.

Including these covariates allowed for a more precise assessment of the effects of our variable of interest on the BEARNI test, by providing estimated means of BEARNI subtests across the three groups, with the covariate effects in the model kept constant. To compare neuropsychological profiles between groups, we used the contrast method recommended by Cohen et al. . More specifically, we use two Helmert contrasts to test our hypotheses. The first contrast  compared the LD group with the set of binge drinkers , thereby allowing us to test the overall effect of substance use on neuropsychological impairments . The second contrast  compared the BD group with the BDC group, allowing us to assess the additive effect of BD and cannabis use on neuropsychological impairments . Regarding the hypotheses set out in the Introduction, we expected the LD group to perform better than both BD and BDC, with no difference between BD and BDC on executive functioning . As for memory, we expected LD to perform better than both BD and BDC, and BD to perform better than BDC . Finally, we further explored the heterogeneity of the users’ profiles by carrying out two analyses on the BD set . First, to examine the hypothesis of the additive effect in greater depth, we explored the distribution of the two groups’ executive and memory scores. Second, we performed a k-means clustering analysis including the BEARNI subscores. This revealed greater impairment in BDC than in BD. The algorithm was constrained to separate the users into two groups, and we assumed that one contained the less impaired profiles, and the other contained the more impaired profiles. This analysis allowed us to identify BD and BDC participants who were more or less cognitively impacted , and to pinpoint their specific characteristics  regarding alcohol , tobacco , and cannabis  consumption patterns, as well as anxiety  and depression . The purpose of these analyses was thus to identify at-risk consumer profiles. We ran individual analyses to examine whether scores indicated a gradient of severity. We predicted that the BDC group would have more severe cognitive impairments than the BD group. Performances of BD and BDC participants on the BEARNI flexibility and episodic and working memory subtests were heterogeneous . Results showed a gradient of severity, specifically for the episodic memory subtest. Most BD participants had better scores than BDC, who performed more poorly, but the expected gradient was not found for working memory and flexibility subtests. The separation was not linear: BD and BDC overlapped on both the lowest and highest scores. A few BD participants performed more poorly than other BD, and some of the BDC had preserved performances when others had more severe impairments. This outcome encouraged us to go further to understand the factors that could explain the heterogeneity of cognitive performances found here. This was the first study to seek to  improve understanding of the additive effect of college students’ BD and cannabis use on their neuropsychological functioning, and  describe the profiles of student users who are most at risk of neuropsychological deficits.

Results showed that college students who engaged in binge drinking behavior with  or without  cannabis use performed consistently more poorly than LD on all the cognitive domains we assessed . An additive effect of BD and cannabis use was specifically observed on flexibility, episodic memory and working memory, when BD and BDC groups were contrasted. Individual analyses revealed heterogeneous gradients of cognitive impairment severity between BD and BDC. Finally, cluster analyses highlighted more severe neuropsychological deficits in users who frequently consumed tobacco and who had a high level of anxiety. The present study revealed negative effects of combined alcohol and cannabis use on episodic memory, executive functions, visuospatial skills, ataxia, and working memory in college students. With the exception of ataxia, this observation was in accordance with previous studies conducted among adolescents and young adults identified as BD  or cannabis users . Ataxia is not usually described in BD, but is regularly reported in alcohol use disorder  and cannabis use . We hypothesized that BD combined with cannabis use results in more severe memory and flexibility impairments, and results confirmed that BDC students did indeed have greater episodic memory, flexibility and working memory deficits than BD students. As shown in Winward et al. ’s study, combine use seemed to have a negative effect on working memory. However, contrary to their observations, we also found impaired working memory in BD without cannabis use. Flexibility and working memory abilities rely on the prefrontal cortex and cerebellum, which are rich in cannabinoid receptors, thus making them very sensitive to the neurotoxic effects of cannabis . Although other studies conducted in BD have not always clearly reported executive impairments encompassing flexibility and working memory abilities , cannabis use seems to heighten the negative effect of BD on executive functions. Moreover, the deleterious additive effect on episodic memory in the BDC group is consistent with the literature on chronic cannabis users , as well as with our hypothesis. This specific additive effect could be due to the peculiar neurotoxic effects of cannabis on the hippocampus . The hippocampus is a node of the brain network responsible for episodic memory abilities , and is rich in cannabinoid receptors . An additive effect on episodic memory could interfere with scores on flexibility and working memory subtests, as these are not purely executive tasks, but also rely on memory abilities. Further examination is needed, using executive tasks that do not involve memory, in order to disentangle the impact of these results. This study also deepened our understanding of the specific BDC neuropsychological profile in college students. Individual score analyses showed a gradient of severity, with a larger proportion of BDC students having poorer episodic memory performances than BD, despite greater heterogeneity than expected. Even among young students, this pattern indicates that adding cannabis consumption to BD mostly affects memory abilities. Together, these two products have an even more harmful effect on the developing brain than BD without cannabis . We expected this gradient of severity to be particularly marked for the working memory subtest, on which BDC performed more poorly overall than single-substance users, as reported by Winward et al. . Surprisingly, the gradient was more mixed and nonlinear for working memory and flexibility, but these subscores still indicated an additive effect of BD and cannabis use. These results point to a significant additive effect of cannabis when consumed with BD, although this does not necessarily lead to new additional impairments. Nevertheless, the present study highlighted heterogeneity, with some BD students having unexpectedly poor performances, and some BDC students having preserved performances. This prompted us to focus on variables that might help us identify the clinical profile of BD college students who are most at risk of developing neuropsychological impairment.

The potential risk of contaminants in artisanal cannabis preparations,in addition to the variability in cannabinoid content and labeling accuracy , are legitimate concerns for consumer safety. Although the samples collected in the current study were intended for the treatment of seizures in children with epilepsy,it is possible that any individual seeking ‘CBD-rich’ artisanal products for treatment of a medical condition could be susceptible to purchasing contaminated products. The use of artisanal products accessed without prescription evades the necessary medical and regulatory oversight to ensure the patient’s suitability for medicinal cannabis  and subsequent monitoring for safety and adverse events. Such products are unlikely to be optimized for safety or efficacy, indicating a need for improved patient access to safe, quality-controlled prescribed products from licensed manufacturers. Cannabis consumption is estimated at 192 million users in 2018 which equals 3.9 per cent of the world community aged between 15 and 64 years.

Cannabis grow lights use represents the most commonly illicit drug intake worldwide, with around 3.8% one-year prevalence worldwide and 5% in North Africa .Cannabis use may lead to adverse health effects such as heart attacks, brain development issues, lung tissues damage and psychiatric comorbidities ; It is also responsible for the decline of cannabis users’ living conditions and other social consequences such as poor schooling or week work performance , family violence stigmatisation, social discrimination and criminality. In addition,cannabis users, victims of social discrimination, are often challenged by many health system challenges such as poor and inequitable access to healthcare, qualified human resource shortage and lack of social and assistance to quit drug use . Recently, ensuring timely access to medical care and adequate support and assistance for cannabis users has become an important concern for policy makers and health system stakeholders.More specifically, increased attention has been placed in using information and communication technologies  to promote access to quality health care services for cannabis users and help them overcome major health system barriers  and better connect with appropriate health services.Available evidence supports the effectiveness of mobile health technologies in improving patients adherence to treatment and ensuring better symptom monitoring by health professionals .

For technology users, m-Health or mobile health is the visible part of ICT iceberg. It is defined as “medical and public health practices relying on mobile devices, such as cell phones, patient monitoring systems, personal digital assistants and other wireless devices” . m-Health has benefited from the rise of digital technologies and the emergence of increasingly innovative and intuitive portable technological tools. m-Health interventions range from sending simple text messages,to complex telemedicine practices using connected mobile devices  and m-Health applications associated or not with sensors.Over 340 mobile and ready-to-wear devices are made available to users around the world , and more than 325,000 m-Health applications are currently available on the main commercial virtual stores “Google app” and “Apple iOS” , this number estimated at 160,000 in 2015, has doubled after two years with more than 200 mobile apps added every day . m-Health intervention have proved appropriate in managing chronic diseases , by allowing useful functionalities for both patients, and health workers.Therefore, m-Health interventions may play a key role in the fight against cannabis grow tent intake issues.

However, little evidence exists on the functionality, usability and effectiveness of m-Health intervention for cannabis use addiction. In response, we carried out a scoping review that aims at exploring technical and functional characteristics of available m-Health-apps intended for non-medical Cannabis Use and Dependence . We aimed more specifically to  identify mobile applications used as m-Health interventions,describe their characteristics and  discuss evaluation outputs of CUD-focused apps. The rest of the paper is structured as follows. Section 2 presents the research methodology. General, technical and functional characteristics of CUD m-Health intervention apps are provided in Section 3 along with evaluation approaches. These results are discussed in Section 4 in terms of usability. The conclusions are included in Section 5.Frequent cannabis use in adolescence has been shown to increase the risk for mental health conditions such as depression, anxiety, and psychotic symptoms, and has potential consequences on brain development, especially in cognition, memory, and problem-solving.  

The focus of this piece will be on herbal medical cannabis, not pharmaceutical cannabis-based medicines , as the safety considerations for herbal cannabis are less clear in the current literature. However, many of the considerations presented below can be applied to both. Data from Health Canada showed that the majority of people  reporting cannabis use for medical purposes did not have a government authorization for its use, and were acquiring their cannabis through non-medical sources . The lack of healthcare professional  guidance can be problematic in medically complex patients, particularly those with chronic conditions and polypharmacy. Here, we summarize safety considerations for patients being considered for medical cannabis. Although some HCPs do not support the use of medical cannabis based on current evidence, mobile grow system many patients will use cannabis to improve their symptoms.

It is important for each HCP to be able to assess cannabis safety for any patient using from legal or illicit sources. When initiating a patient on medical cannabis a host of factors should be considered . Prior to cannabis initiation, clinicians recommending cannabis  should screen for potential precautions, contraindications, and drug interactions . Further, we encourage the use of validated questionnaires such as General Anxiety Disorder-7 , Patient Health Questionnaire-9 , and Brief Pain Inventory , as these tools can help clinicians to monitor response to therapy and evaluate the risk versus benefit during follow-up. After assessing potential precautions, contraindications, and drug interactions, clinicians should weigh the overall risk vs benefit of medical cannabis use in each patient. Each of these factors could influence the process of initiation and titration. Route of administration and chemovar  selection should be considered taking into account the individual patients safety considerations . Following selection, a low-dose, slow titration strategy should be encouraged . Each patient will commonly require an individualized approach.

The risks and benefits of cannabis should be assessed for each patient. Clinicians should screen for the following considerations and comorbidities that may influence patient safety . Cannabis has the potential of being contaminated with microorganisms. Patients who are immunocompromised  have a higher infection risk when exposed to contaminated cannabis.Cannabis products from a regulated source are always preferred for these patients. Many immuno compromised patients take medications that may interact with cannabis.Caution should be taken when used with a calcineurin inhibitor  as CBD may increase toxicity.CBD may also worsen the efficacy of programmed cell death protein 1  inhibitors, also known as immune checkpoint inhibitors . There is preliminary evidence THC could inhibit the proliferation of lymphocytes and suppress CD8 T-cell and cytotoxic T lymphocyte cytolytic activity . As such,mobile vertical rack both CBD and THC could potentially interfere with immunotherapy in cancer patients. Interactions between monoclonal antibody therapies  and cannabis are unlikely, although it is important to note that no formal drug interaction trials have yet to be completed.

Evidence suggests the predominant impact of cannabis on impairment is mostly due to THC . In patients who work in safety sensitive occupations, defined as one “in which incapacity due to impairment could result in direct and significant risk of injury to the employee, others or the environment”  , or partake in safety-sensitive activities like driving, risk of impairment is an important consideration. It is generally recommended patients using THC should not drive or engage in safety-sensitive activities for at least 4 hours after inhalation, 6 hours after oral ingestion, or 8 hours, if euphoria is experienced . . There is an increasing body of evidence supporting that daily medical cannabis users tend to be more tolerant to the impairing effects of THC . It has previously been demonstrated that at a dose of 0.5 mg/kg THC, daily users did not display acute impairment on most neurocognitive impairment tasks, except for a decrease in impulse control at high THC concentrations  . A review of the duration of impairment found that within 4 hours after THC inhalation, and 6-8 hours if ingestd orally, medical cannabis users were no longer impaired . In contrast, a recent RCT showed that following CBD inhalation of 13.75 mg there was no indiction of neurocognitive impairment, including for measures of driving performance .

We tested whether the proportional hazards assumption was met in all analyses using the ASSESS statement in PROC PHREG with the option PH . We conducted multiple imputation by fully conditional specification with the number of imputations set to 20 to account for covariates with missing data, based on the assumption those missing covariates were missing at random . We then conducted multivariable survival analysis based on the fully imputed datasets. Reducing early initiation of cannabis use is key to preventing negative long-term health and associated psychosocial consequences . In this large sample of first-time JIY, rates of early onset cannabis use were high and 15 % of youth newly initiated cannabis use in the year following first justice contact. Youth’s internal distress, affect dysregulation, and positive expectancies about cannabis use drove new initiation, even after accounting for known associated factors . The justice system largely focuses on interventions to address co-occurring mental health and delinquent behavior, primarily through group or family-based intervention, but our data suggest there is a critical and unique window of opportunity to prevent grow lights for cannabis use initiation among youth by addressing internalizing symptoms, teaching emotion regulation skills, and modifying expectancies.

Such interventions can be brief and feasible to implement within existing individual-based court and justice-related services . Since adolescent cannabis use can be associated with future worse public health and legal outcomes, developing effective brief primary prevention interventions for JIY is critical; these are not mutually exclusive from essential development and empirical testing of structural-level public health and legal policy interventions to delay or reduce JIY substance use. Only two studies have tested brief interventions to reduce substance use among justice-involved or diverted truant populations . Spirito and colleagues  tested the preliminary efficacy of a combined family-based  and individual adolescent based brief motivational enhancement therapy  intervention ; the latter targeting adolescent substance use related attitudes, beliefs and norms and demonstrating feasibility, acceptability and reductions in youth cannabis use at 3 month follow-up . Dembo and colleagues  tested the efficacy of a brief intervention  with youth and parents  compared to youth-only BI and Standard Truancy Services in reducing cannabis use and sexual risk behavior over 12 months.

No significant intervention effects were found; however, the authors note certain subgroups showed differential response to the intervention . Although mixed in success, both studies addressed individual level factors commonly associated with increased likelihood of substance use among JIY . Our data suggest with first-time JIY who have not initiated use, a brief individual youth intervention targeting internalizing symptoms, emotion regulation skills, and grow cannabis use expectancies is important for future intervention development and testing. Single session interventions  are a cost-effective and feasible way to address youth internalizing symptoms  and increase access to mental health interventions for underserved  youth . SSIs focused on motivational enhancement therapy for sexual risk reduction  have been feasible and acceptable to deliver to large numbers of detained youth . The concept of SSIs has yet to be explored for substance use prevention among JIY, but our study suggests a SSI addressing internalizing symptoms, emotion regulation, and cannabis use expectancies and intentions may be efficacious in delaying or preventing cannabis use initiation, both of which have significant positive public health implications .

SSIs could also be developed to shift expectancies and intentions about continued use for those with early onset, who are at greater risk for worse outcomes due to being younger upon first using and greater likelihood of continued use and consequences. Our results suggest incorporating alcohol use content might also be important for those already using cannabis at first-time justice contact. SSIs are also likely more feasible to implement within real-world settings already serving JIY  and have strong potential to address a highly concerning gap in access to substance use intervention for community-supervised JIY . One possible approach for substance use SSIs is motivational interviewing , a communication technique used to reduce alcohol and cannabis use among school-mandated college students  and in two studies of general substance using adolescent populations ; however, the limited data available suggest MI for universal prevention may not be as effective .

However, human research studies are lacking on concurrent e-cigarette and cannabis use and COVID-19-related health outcomes.Research has linked respiratory symptoms or disease with adult current e-cigarette use,current cannabis combustible smoking and vaping , and lifetime e-cigarette and cannabis use.College student e-cigarette use and cannabis smoking and vaping reached historical highs between 2017 and 2019.Currently, 22% and 14% of students report past 30-day nicotine and cannabis vaping, respectively . Over one-in-four  students report current cannabis use including other routes of administration,with 1-in-17  reporting daily cannabis use. While current dual use of e-cigarettes and combustible cigarettes has been associated with increased risk of COVID-19 symptoms and diagnosis among 13–24-year-olds , less is known about COVID-19-related risks associated with concurrent e-cigarette and cannabis grow tray use. Given the high prevalence of e-cigarette and cannabis use among college students,research is needed to assess the associations between concurrent use and COVID-19-related outcomes.

This investigation assessed whether current e-cigarette and cannabis use was associated with COVID-19 symptomatology, testing, and diagnosis among college student current e-cigarette users. We hypothesized concurrent users of e-cigarettes and cannabis would be at increased odds of experiencing COVID-19 symptoms and having a prior positive COVID- 19 diagnosis compared with exclusive e-cigarette users. Additionally, we assessed whether frequency of e-cigarette and cannabis use was associated with COVID-19 symptoms, testing, and diagnosis. We hypothesized that when compared to infrequent exclusive e-cigarette users, intermediate or daily exclusive e-cigarette users as well as infrequent, intermediate, and frequent concurrent e-cigarette and cannabis users would be at increased odds of reporting COVID-19 symptoms and diagnosis. Based on COVID-19 random selection testing policies at each university during the study period, we posited there would be no difference in COVID-19 testing between the exclusive e-cigarette and concurrent use groups.

Data are from a cross-sectional, online survey conducted October- December 2020. Participants were college students  ages 18–26 years from four geographically diverse, large U.S. public universities  who reported current e-cigarette use. Institutional review boards  at each university independently vetted and approved all study procedures by November 2020; data collection occurred after respective IRB approval. Students at each university had the option to complete their coursework online, vertical grow system in-person, or a hybrid model. Students residing in university housing/ residences were allowed to remain on each of the respective campuses during the data collection period. COVID-19 testing programs at each of the four respective campuses were similar and required randomly selected students to undergo testing. Eligible participants were recruited by disseminating emails via campus-wide listservs and undergraduate and graduate course listservs. Participant recruitment strategically took place at least over one month into the fall semester due to the study’s aim of capturing past 30-day behavior during the academic year.

Solicitations sought students between the ages of 18–26 who “vape or use e-cigarettes” and were currently on campus. The recruitment email included a website link to a survey hosted on Qualtrics , and stated the estimated completion time was 10 minutes. Potential participants were provided with a research information sheet which they needed to acknowledge prior to proceeding to the survey. The information sheet reinforced the recruitment email’s information.However, sample size calculations using a 95% confidence interval , 100,000-population size, and a conservative 50–50 split considering the population is relatively varied , assert a minimum of 383 completed surveys were needed to have sufficient power for statistical analysis. This study provides evidence college student e-cigarette users who concurrently use cannabis in the past 30-days are at greater likelihood of experiencing COVID-19 symptoms and having a positive COVID-19 diagnosis, compared with exclusive e-cigarette users.