Given the relatively widespread approval for MM in the United States as well as high rates of patient interest and increasing utilization of medical marijuana in cancer patients in general, this data can prove useful for counseling gynecologic cancer patients on the efficacy and side effects of MM. Further larger prospective studies are needed to investigate specific formulations and indications in this patient population, but our data indicate that it is a safe and useful adjunct for symptom management among a diverse cohort of women with gynecologic cancer. Simultaneous alcohol and marijuana use is defined as using both substances within the same occasion, resulting in an overlap of their effects . SAM use is prevalent among young adults , including college students ; White et al., 2019. For example, one study among college students who reported use of alcohol and marijuana in the past year found high rates of past year , past 3-month , and past month SAM use . In addition to being prevalent, SAM use is associated with an increased risk of substance use and experiencing negative consequences related to use. Individuals who endorse SAM use exhibit greater frequency and quantity of alcohol use compared to those who only drink alcohol . Moreover, individuals that engage in SAM use are significantly more likely to experience negative consequences , including driving under the influence . An underlying question is whether these differences emerge because these two substances are used simultaneously or due to the concurrent consumption, even when they are not used in the same occasion/session. Research on SAM and concurrent alcohol and marijuana use suggest that although SAM use seems to have a more deleterious effect, both patterns of use contribute to increased vulnerability for young adults to experience negative consequences.
Among a sample of college students that reported use of alcohol and marijuana in the past year, Jackson et al. found that students that engaged in SAM use experienced more negative consequences than students that engaged in CAM use; yet, when examining each negative consequence and controlling for relevant variables , only blackouts were significantly different between students that endorsed SAM vs. CAM use. In another study among first year college students with prior alcohol use, Cummings et al. found that students who endorsed either SAM or CAM use engaged in greater alcohol use and experienced more alcohol-related negative consequences, including risky sexual behavior, than students who only drank alcohol. Students that endorsed SAM use also exhibited greater frequency of blackouts and academic problems than students that endorsed CAM use . In examining marijuana outcomes, Looby et al. found that among college students that endorsed using both alcohol and marijuana at least once in the past month, students who endorsed SAM use reported more marijuana use and negative consequences than students reporting CAM use. Moreover, Sokolovsky et al. obtained daily reports on alcohol and cannabis grow equipment use among college students that endorsed past year marijuana and alcohol use and found that on days featuring use of both substances, compared to days were alcohol or marijuana were used exclusively, young adult college students experienced more negative consequences. Most of the research on SAM or CAM use has been focused in NorthAmerica, particularly using U.S., samples. This is unfortunate, considering marijuana and alcohol use are pervasive behaviors worldwide . Cross-cultural research of these behaviors and associated harms is a remaining challenge, and may be especially relevant among countries with different consumption policies, as they could help to identify protective measures that could be implemented in the most vulnerable countries. For example, the legal age to access alcohol usually differs across countries . Marijuana policies differ even more between countries. In the U.S., laws determining legal status of marijuana, availability of marijuana, and acceptability of use vary from state to state, leading to differences in use and negative consequences . Further recreational marijuana use is legal.The purpose of the present study was to examine prevalence rates of CAM and SAM use across college students from seven countries.
Further, we examined CAM vs SAM use status as a predictor on variables of alcohol use, alcohol-related problems, marijuana use, and marijuanarelated problems and examined if these effects were similar across countries. In line with prior research, we expected that students who report SAM use compared to CAM use to report higher marijuana and alcohol use and more negative consequences. Comparing results across countries were largely exploratory and aimed to test the universality of our findings. Confirming the predicted results would emphasize simultaneous polysubstance use as an important risk process underpinning substance related problems. Participants were college students recruited to participate in an online survey from the U.S. , Argentina , Spain , Uruguay , England , Canada and South Africa between February 2019 and March 2020. A total of 9171 college students participated in the study . Across all sites, students completed the same core battery of measures translated into the native language. To minimize burden on participants, we utilized a planned missing data design which has been used in other large multi-site college student studies . Specifically, each participant received and completed a battery of core measures that focused on substance use , addictive behaviors , and a measure of mental health. After completing the core measures, each participant received a random sample of 12 measures from a larger pool that assessed rumination, personality , antisocial behavior, mindfulness, distress tolerance, self-regulation, emotion regulation, food addiction, subjective happiness, childhood trauma and experiences, and driving under the influence. Alcohol use was assessed using several indicators: an indicator of past 30-day alcohol use frequency, past 30-day frequency of getting drunk, past 30-day frequency of getting sick from drinking, past 30-day binge drinking frequency , an indicator of typical frequency of alcohol use, and an indicator of typical quantity of alcohol use. Participants were first presented with a visual guide about typical drinks , in order to help orient them to Standard Drink Units . We assessed typical alcohol frequency and quantity using a grid such that each day of the week was broken down into six 4-hour blocks of time and participants were asked to report at which times they consumed alcohol during a “typical week” in the past 30 days, as well as the number of standard drinks consumed during that time block. The measure was translated into Spanish for students in Argentina, Spain, and Uruguay. We calculated typical frequency of alcohol use by summing the total number of time blocks for which they reported using alcohol during the typical week .
We calculated typical quantity of alcohol use by summing the total number of SDUs consumed across time blocks during the typical week. To make accurate comparisons across countries, the total number of SDUs consumed were transformed into grams of alcohol taking into account country specific SDU rates based on grams of alcohol . Marijuana use was assessed using several indicators: an indicator of past 30-day marijuana use frequency, an indicator of typical frequency of marijuana use, and an indicator of typical quantity of marijuana use. Participants were presented with a visual guide showing different amounts of marijuana in grams.The measure was translated into Spanish for students in Argentina, Spain, and Uruguay. Specifically, each day of the week was broken down into six 4-hour blocks of time , and participants were asked to report at which times they used marijuana during a “typical week” in the past 30 days as well as the quantity of grams consumed during that time block. We calculated typical frequency of marijuana use by summing the total number of time blocks for which they reported using during the typical week . We calculated typical quantity of marijuana use by summing the total number of grams consumed across time blocks during the typical week . Students who reported consuming both alcohol and marijuana at least once in the past 30-days were asked to report how often their alcohol and marijuana use was simultaneous. Specifically, these students were instructed to “indicate in the last 30 days how often you used alcohol and marijuana simultaneously ”. Students were instructed to enter zero days if they did not use these substances simultaneously. In order to make comparisons between students endorsing CAM vs. SAM use, students that reported at least one day of simultaneous use were coded as the SAM use group and students that reported never engaging in simultaneous use in the past 30-days were coded as the CAM use group. To test study aims, mobile grow system we first examined differences in prevalence rates of distinct alcohol/marijuana use patterns across countries. Significant differences in prevalence rates across countries were determined by differences in proportions using a Z-test with a Bonferroni correction. Next, we compared alcohol and marijuana use and consequences among students reporting past 30-day CAM vs. SAM use using a series of regression models.
Most outcomes were best treated as highly skewed and over dispersed count variables. These outcomes were modeled using negative binomial regression . The two exceptions were alcohol and marijuana quantity consumption variables, which were best modeled as log-transformed in ordinary least squares regression models. For both negative binomial and log transformed outcomes, unstandardized regression coefficients can be exponentiated to ease interpretation. In negative binomial models, exponentiation results in a Rate Ratio , which is interpreted as the predicted percent change in the count for a 1-unit change in the predictor. Similarly, an exponentiated unstandardized regression coefficient from a logtransformed outcome can carry a similar interpretation with one additional step. That is, if you subtract 1 from the exponentiated value, the result is a decimal that is interpreted as the percent change in the outcome for a 1-unit change in the predictor. Typically, the RRs and the exponentiated log-transformed unstandardized regression coefficients minus 1 are multiplied by 100, for interpretation yielding a percent. In all models described above we controlled for age and gender and used a binary predictor comparing CAM to SAM use. For models predicting marijuana/alcohol problems, marijuana/alcohol frequency of use was entered as a covariate. We ran two sets of models. The first set of models included the entire analytic sample . The second set of models utilized a mixture modeling framework with a known class specification to run a type of multi-group analysis across countries to allow for the estimation of separate effects for each country within the same model. All models were run in Mplus version 8 . For analyses that include at least one count outcome, the default estimator is maximum likelihood with robust standard errors and missing data is handled using full information maximum likelihood, both are best practices for handling non-normal count data with missing data .
Finally, due to the large number of statistical tests and our relatively large sample size we chose to use 99% confidence intervals to indicate significance. Note that for RRs CIs should not include 1 to be considered statistically significant and for the 1- exponentiated unstandardized regression coefficients the CIs should not include 0 to be considered statistically significant. The aim of the present research was to study CAM and SAM use prevalence among young adult college students from seven different countries and examine if CAM vs SAM use status predicted different alcohol and marijuana related outcomes. We also explored if those associations were consistent across countries from three different continents. Descriptive results showed that among college students that reported lifetime use of both alcohol and marijuana, students from the U.S., Canada, South Africa, Argentina, and Uruguay reported a higher prevalence of consuming both drugs during the last 30 days compared to only consuming alcohol. Comparably, students from Spain and England reported a higher prevalence of alcohol only consumption compared to use of both drugs. These differences could be explained in part by the current marijuana policies in Spain and England , which have higher access restrictions than the other countries sampled. In fact, among all the countries included in the research, the only country in which the recreational use of marijuana is completely illegal is in England. Similarly, in Spain the marijuana consumption is only permitted in the private sphere. Among students who reported both alcohol and marijuana use during the last 30 days, the results showed similar prevalence rates of SAM vs CAM that have been found in a previous sample of U.S. students .