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.