A receiver-operating characteristic curve analysis was used to investigate possible cut points on the NIAAA two-question screen score for detecting a CUD diagnosis . We defined the optimal cut point as the point at which the sum of sensitivity and specificity was maximized. Test characteristics were calculated at each potential cut-point and the area under the curve was used to provide an assessment of the overall accuracy of the screen in predicting CUD, lifetime tobacco use and other drug use. Additional analyses were conducted by sex, race, and ethnicity for the combined sample of middle and high school students.The demographics of the sample with respect to a CUD diagnosis, lifetime tobacco use, and lifetime drug use, are presented in Table 2. Of the 4,834 participants who completed the baseline survey, 97.5%, 99% and 96% of participants completed enough questions to obtain CUD diagnoses, lifetime tobacco use, and lifetime other drug use, respectively. Older teens were more likely to have a CUD , report lifetime tobacco , and lifetime drug use than younger teens. Females were more likely to report lifetime use of tobacco than males. Table 3 presents whether a participant received a DSM-5 diagnosis of a CUD on the DISC by categories of the NIAAA two-question screen. NIAAA two-question screen risk category was significantly associated with CUD diagnosis as well as lifetime tobacco use, with a generally increasing trend from non-drinker to high risk. The same was true of most of the other drugs, with the exception of PCP and crystal methamphetamine. Among middle school students, a DSM-5 diagnosis of CUD , lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk on the NIAAA two-question screen. Among high school students, dry rack cannabis the accompanying tables to Figures 1, 2, and 3 indicate that a DSM-5 diagnosis of CUD, lifetime tobacco use, and lifetime drug use was predicted optimally by any drinking days in the past year.

Any drinking days for high school students indicates a classification of lower risk on the NIAAA two-question screen. However, the lower risk classification for high school students is functionally equivalent to the moderate risk classification in middle school, i.e. any drinking days in the past year. For both males and females, to detect a CUD, the optimal cutoff was classification of moderate risk or higher for middle school students and lower risk or higher for high school students on the NIAAA two-question screen. The same held true regardless of race and ethnicity, either Hispanic/Latino or non-Hispanic/Latino. Since there is no low risk category for middle school students, this finding functionally translates to increased risk for a CUD for any adolescent reporting drinking at all in the past year.Although experimentation with alcohol is normative developmentally, this finding suggests nonetheless that alcohol use during adolescence may be associated with and predictive of other potential problems, including CUDs. For both males and females, lifetime tobacco use and lifetime drug use were most strongly associated with the classification of moderate risk for middle school students and lower risk for high school students on the NIAAA two-question screen The same held true for race and ethnicity, either Hispanic/Latino or non-Hispanic/ Latino, with one exception. For Asian participants, lifetime drug use was predicted best by classification as moderate risk on the NIAAA two-question screen for high school students, and high risk for middle school students. Like the finding with CUD, these results suggest that any drinking in the past year is related to not only higher risk for significant marijuana use but also tobacco and other drug use. Interestingly, for Asian participants, drinking more substantially was necessary to increase the odds of tobacco and other drug use.This study found, in a large sample of adolescent patients seen in a PED, endorsement of any drinking in the past year was positively associated with a CUD, lifetime cigarette smoking, and lifetime use of other drugs.

This association was found for both males and females, adolescents of Hispanic and non-Hispanic ethnicity, and White, Black, Asian, American Indian/Alaskan Native, Native Hawaiian or other Pacific Islander, or adolescents of more than one race, with one exception. For Asian participants, lifetime drug use was more strongly related to a classification as moderate risk, rather than lower risk, on the NIAAA two-question screen for high school students and high risk for middle school students. It is unclear why this finding, which implies a protective factor, is specific to Asians. Further, among Asians, it is unclear why it was specific to drug use and not a CUD or tobacco use. Although these findings could be a reflection of genetic 49, familial, and/or cultural factors, these results are based on only 8 youth endorsing lifetime drug use so these findings need to replicated before any further speculation is warranted. It is also important to note that endorsement of any drinking in the past year, which translates to an NIAAA two question screen lower risk classification for high school students and moderate risk classification in middle school students, is still associated with other drug use. There is a strong need for PED-based screening as adolescent PED patients report high levels of drug use and mental health problems. Further, high school dropouts, who commonly use the PED for healthcare20 and cannot be reached in schools,g, are more likely report alcohol and drug misuse relative to their school-attending peers 19.While there is a need, a PED screen must be brief, easy to administer and require minimal staff training. Adolescents may also be more willing to admit to alcohol use rather than marijuana, tobacco, or other drug use. Being identified as being at moderate or high risk for alcohol useon the NIAAA two-question screen may provide an opening for a PED staff person to probe further about tobacco and other drug use There are several limitations to this study. First, the sample is not representative of the general population because it is limited to adolescents being treated in a PED. Similarly, patients who did not speak English or Spanish, did not have a parent present or lacked a telephone/address were excluded from the study. Third, the friend’s alcohol use question was not used to determine individual risk assessment. This variable may have provided valuable information about a teen’s risk level. Fourth, the measures were collected by self report so we do not know how the screen will perform if the questions were asked directly of teens by a health care provider. Lastly, given the strong correlation between tobacco and marijuana use, it is possible that a screen for cigarette smoking might be equally useful in predicting drug use as the NIAAA two-question screen. Despite these limitations, study findings suggest that a simple question about alcohol use in the past year can provide valuable clues about tobacco, marijuana, and other drug use. More research is necessary to better understand the use of the NIAAA two-question screen in the PED including how to increase its sensitivity, e.g. if combined with another brief screen. A commercialized marijuana market has not been open anywhere in the world long enough to reliably evaluate the effectiveness of programs designed to minimize use or evaluate the health consequences of the kind of increased use expected to follow legalization. Using the precautionary principle, governments could learn from past and present regulatory successes and failures in tobacco control, and use this knowledge to inform the policy making process for retail marijuana. Legalizing medical and retail marijuana markets, without adequate evidence supporting marijuana’s therapeutic benefit, roll bench opens the door to multinational corporations—including the tobacco companies—that could market retail marijuana products as medicinal and safe. 

Indeed, the tobacco companies seriously considered entering the marijuana market in the late 1960s when legalization for medical use seemed a real possibility. The history of tobacco and alcohol control shows that these companies use aggressive marketing strategies and political tactics to increase and sustain tobacco and alcohol use, including wielding their economic and political power to fight effective public health regulations. A key impediment to the development and implementation of effective public health policies is the existence of a wealthy, sophisticated, and politically powerful industry that recognizes the threats to their profitability that effective government regulation to minimize use and sales represents. This history illustrates the risks of corporate capture of the marijuana market.The harms of marijuana do not currently approach those of tobacco or alcohol, likely as a result of the fact that marijuana is illegal in most places, with the result that widespread regular heavy marijuana use is uncommon, and few users become lifetime marijuana smokers. It is also likely that the individual-level risks of cannabis use are underestimated. The specific levels of both population and individual risks will depend on how use patterns change in the new legalized market. It is, for example, possible that marijuana could turn out to be as harmful as tobacco if marijuana use patterns eventually resemble current tobacco use. Marijuana is used by tobacco smokers separately or in combination with tobacco in various forms including “spliffs,” cigarettes that contain a combination of marijuana and tobacco. Dual users may also smoke blunts or marijuana flower wrapped inside tobacco leaves, cigars or cigarillos, or “blunt chase”—the act of following marijuana smoking with cigarette smoking. This pattern in particularly common among African American in the United States . Electronic cigarettes establish another link between marijuana and tobacco, as open-system e-cigarettes may be used equally for delivering tetrahydro cannabinol and/or nicotine. Co-use of marijuana and tobacco presents undesirable effects, such as difficulty in quitting both substances. Nonsmoking youth and young adults who use marijuana are more likely to start using tobacco and suffer nicotine addiction. The fact that co-use of marijuana with tobacco and alcohol is common makes it difficult to quantify the health effects of marijuana alone or the possible synergistic effects with these other substances. This situation may change as marijuana use increases and tobacco use declines. The technical difficulties of precisely quantifying the magnitudes of particular health effects of marijuana use in isolation should not be interpreted as affirmative evidence for benign or safe effects of marijuana use.Regardless of whether marijuana is more or less harmful than tobacco or alcohol, it is not harmless. Marijuana smoke has a similar toxicity profile as tobacco smoke, and the California Environmental Protection Agency has identified marijuana as a cause of cancer. One minute exposure to secondhand marijuana smoke significantly impairs vascular function in ways that increase the risk for cardiovascular disease. Case-control studies conducted in Europe have found associations between smoking highly potent marijuana flower with an increased risk of cardiovascular disease, heart attack, and stroke in young adults. Acute risks associated with marijuana and marijuana product use can include anxiety, panic attacks, and paranoia. Generally, adolescents with a personal or family history of schizophrenia are the most at risk for psychotic symptoms. There is strong evidence to support preventing marijuana use in adolescence. Compared to those who began use in adulthood, adolescents were more likely to develop psychosis. 75 Developing psychosis and psychotic symptoms may be made worse through regular and frequent use. The direction of causality is not clear; it is possible that teens use marijuana to deal with the onset of schizophrenia and its associated health problems. Youth are regularly exposed to protobacco messaging through a wide variety of media channels, including static tobacco advertising on newspapers and magazines, retail outlets, the Internet, and on television or in the movies. Marketing activities of tobacco industry are a key factor in leading young people to take up tobacco, keeping some users from quitting, and achieving greater consumption among users. The 201257 and 201421 US Surgeon General reports concluded that tobacco industry promotional activities, including branding, imagery, event sponsorship, and marketing campaigns, cause the onset and progression to smoking among young people. NCI’s smoking and health monograph, The Role of the Media in Promoting and Reducing Tobacco Use, had earlier found a causal relationship between tobacco marketing exposure and youth smoking. Even minimal exposure to tobacco advertising positively influenced youth attitudes and perceptions on smoking, as well as smoking intentions among youth.93, p. 16 Causal effects of tobacco marketing on smoking may be stronger among youth than adults as youth are also more likely to be brand loyal. 57, p. 522 and are more susceptible to tobacco industry marketing. Youth susceptibility to smoking, experimentation, and current use varies by the source of pro-tobacco media.