Tobacco products are used as a delivery method for marijuana because of convenience and/or to facilitate sharing, even when tobacco products are not explicitly desired. Therefore, tobacco consumption may increase and become normalised even in the absence of the desire to use tobacco. Second, as noted previously,participants reported using traditional tobacco cigarettes to extend the ‘high’ of marijuana consumption, particularly because of tobacco’s comparatively lower cost. Third, participants did not uniformly agree whether the use of tobacco products for consuming marijuana ‘counted’ as using tobacco. This may lead to a significant under-reporting of current tobacco use. For example, the participant who reported using tobacco products 3 days of the last 30 on the questionnaire revealed during his interview that he used tobacco wrappers for marijuana 30 days out the past 30 . It was not until specifically asked about his method of marijuana consumption that it became evident he was a daily tobacco user. Tobacco researchers should be aware that tobacco products used to consume marijuana may not be reported as tobacco use, and should specifically ask about the use of blunt wraps and cigarillos for marijuana consumption. While this issue has been raised before,with at least one nationally representative survey asking about cigarillos for marijuana consumption,seedling grow rack it has not been widely adopted and will become increasingly critical as marijuana is more widely legalised.
Some participants used the same vaporiser for both products , while others reported owning devices for each. Although past studies showed that vaping was less common than smoking marijuana among a convenience sample of adults,given the rapid growth of the marijuana vaporiser industry and the growing popularity of electronic vaporisers, especially in states with legalised medical marijuana,it is essential to study perceptions and practices related to electronic vaporisers for marijuana. Reduced odour was frequently mentioned in the appeal of marijuana vaporisers, cited as advantageous when consuming marijuana in public spaces . Those wishing to vaporise marijuana in public may benefit from the broader normalisation of nicotine vaporising , as the similar appearance of the devices may make it difficult for the passers-by or law enforcement to identify which product is being consumed. This was experienced negatively by some participants who exclusively vaporise nicotine, as they felt falsely identified as marijuana users. Communities concerned about the use of marijuana in public spaces should consider including all vaporisers in smoke-free regulations to prevent this confusion. Additionally, there is a concern that growing popularity of vaping, for tobacco and marijuana, might renormalise smoking.Participants clearly differentiated between secondhand tobacco and secondhand marijuana smoke. Many were quick to cite the dangers of tobacco, including secondhand smoke, and enforced rules determining where combustible tobacco could and could not be used in their own spaces. In contrast, marijuana smoke was largely regarded as benign, neutral or even pleasant. Few participants expressed concern about secondhand marijuana smoke, or limited where combustible marijuana could be used. This was, in part, due to the subjective experiences of marijuana smoke being much ‘milder’ than tobacco smoke, and dissipating more quickly. Participants also reported that aerosol produced by vaporisers , whether nicotine or marijuana, smelled less strongly than combustible smoke, and generally allowed its use indoors. This is in contrast to a study in Georgia that found 83% of surveyed college students adopted smoke-free policies for marijuana and 86% for tobacco in their homes.State policies around legal marijuana might affect young adults’ personal smoke-free rules.
Our participants reported that smoking combustible marijuana indoors was often the only viable option available. Colorado law prohibits the use of marijuana in public places . Since many of our participants lived in lower income, multi-unit housing, they did not often have private outdoor spaces where they could legally smoke marijuana. Their choice, therefore, was either to break the law and smoke marijuana in an outdoor public space, or, following the law, smoke combustible marijuana in indoor, home spaces. Furthermore, ‘no smoking’ signs in housing units and other spaces were sometimes unclear, with young adults unsure whether prohibitions were limited to tobacco or included marijuana. Current research indicates that secondhand marijuana smoke contains many of the same chemicals as secondhand tobacco smoke and some in greater concentrations with recent studies demonstrating that secondhand marijuana smoke has negative cardiovascular effects similar to tobacco smoke.Non-smokers exposed to secondhand marijuana smoke had detectable levels of THC and metabolites, with levels increasing when higher potency marijuana was used.Non-smokers exposed to cannabis smoke for 60 min in an unventilated room had detectable levels of THC in blood following the exposure, increased heart rate, mild to moderate self-reported sedative drug effects and performed worse on a cognitive test.As normalisation of marijuana use continues, it is important to monitor the effects of normalisation on tobacco use, perceptions and smoke-free spaces. Smoke-free policies should cover all products, including combustible marijuana and electronic vaporisers for tobacco and marijuana. Signs and information signalling smoke-free policies should be adapted to clearly include marijuana smoke where applicable. Information about harmful effects of secondhand tobacco smoke was found to be a deterrent to smoking initiation and a motivator for cessation for youth.Studies should explore messaging around the negative effects of secondhand marijuana smoke. As a qualitative study, our relatively small sample provides insight into how some young adults in Colorado integrate tobacco, marijuana and vaporiser use.
While these experiences may not be representative, this work begins to shed light on how these products are used and made sense of alongside one another. Further in-depth qualitative work is needed to document the complexities of perceptions of tobacco and marijuana in distinct legal contexts , and examine differences between perceptions of medical and retail marijuana in relationship to tobacco. More work is also needed to understand those who primarily vaporise nicotine, those who vaporise marijuana and those who use both. The SCTC research initiative addresses high-priority gaps in tobacco control research through collaboration between academic researchers and local tobacco control agencies and community organisations. Legalisation of marijuana is one area that is highly salient for many state and community tobacco programmes because of its potential to affect use and perceptions of tobacco. Moreover, tobacco control experts within agencies are frequently tasked with recommending marijuana policies or educating citizens about rules of use and potential health effects. Tobacco, marijuana and vaporisers are most effectively studied together and future research should address perceptions of comparative harm of these products; social, political and health effects of their use; and adequate measurement of use patterns, especially when products are combined. Finally, tobacco programmes and policies should take into account emerging research on the complexities of this triangulum, particularly in the context of marijuana legalisation.In an era where burnout is common, it can be difficult to provide empathic care to patients. There may be a tendency to resort to pharmacotherapy as a replacement to psychodynamic or empathic approaches. This may be appealing as an easy fix, especially in the primary care setting where most non-acute psychiatric care is administered. Throughout their medical education, students are taught methods to narrow differential diagnoses to direct appropriate medical therapy. In addition to the science of medicine, students are often instructed to practice the art of medicine, which can be summarized with the quote, “cure sometimes, relieve often, comfort always.” When tasked with growing patient censuses and increasingly complex demands, it is often more efficient to operate on heuristic diagnostic principles. In the case of physical illnesses,greenhouse growing racks where diagnostic findings and historical contexts are often manifest in undeniable objective criteria, the decisions for specific treatment approaches are more easily communicated to and understood by patients. Similarly, physical sensations such as chest pain or nausea are readily understood and thus empathized with. In contrast, many mental illnesses have subtle and usually intangible qualities. Can you truly empathize with patients that possess sensations and realities which are different from that of your own? Part of establishing empathy is noticing one’s biases towards patients. As often as patients come into healthcare practices bearing their own biases towards physicians and the healthcare system, providers also label patients well before understanding the full spectrum of their story. This naturally stems from the desire of physicians to classify patients through symptom association. For example, we are taught that cardiac patients often present with exertional, crushing chest pain just as we learn by association that borderline patients often employ splitting as a defense mechanism. By consciously recognizing our biases during patient encounters, we can more avidly develop therapeutic alliances and avoid barriers to treatment. This brief primer will impart students a set of empathic approaches for psychiatric patients. Students will understand how poignant symptoms manifest in the context of DSM-V diagnoses. Broadly, this primer is split into two convergent approaches: 1) recognition of transference counter transference responses with concrete examples of facilitating positive transference reactions, and 2) reconciliation of patient and provider goals for therapy. Through these examples, students will be able to go beyond a formal diagnosis and gain deeper insight into how a patient’s mental health impacts and is impacted by their current situation. To achieve that end, students will be taught to recognize key features of the interview from a holistic point of view. After the initial presentation, we will be addressing a patient’s medical, psychiatric, and psychosocial circumstances. Students are encouraged to actively reflect on their own implicit biases and reactions to the initial and subsequent presentations of the patient. Appropriate DSM-V diagnostic criteria have been provided for reference within each case. Treatment options and differential diagnoses are not covered in this primer, but students are encouraged to read further. Finally, after the patient is presented, key notes on empathic approaches or goal reconciliation will be addressed. In the following cases, students will be instructed on methods to establish a common therapeutic alliance through awareness of the potential differences in patient and provider goals.
By examining the priorities of both patient and provider goals in conjunction, it is possible to then restructure treatment plans agreeable to both parties. Given that most psychiatric treatment modalities require patient cooperation and buy-in, this would likely result in better long-term follow up and patient outcomes. In medical school, students are taught primarily how to recognize, diagnose, and treat medical conditions. Combined with most medical students’ predilections towards helping others, this largely leads to rescue fantasy, in which treatments are often pushed to “fix” the condition without other considerations. Besides, who wouldn’t want to recover from their disease, or at least have symptomatic relief? Instead of discussing risks, benefits, and alternatives for treatment modalities as soon as possible, this writer encourages medical students to inquire about the unique individual goals of each patient. In general, patients present to physicians largely of their own volition. By directly asking the patient about his or her agenda early in the encounter, students can then tailor the approach accordingly. For example, in the outpatient setting, it is often useful to preface the history and intake with overarching questions such as, “Is there anything in specific that you want to achieve during this visit?” In the case of patients with multiple goals, it may be helpful to follow up with, “What would you say your primary or most important objective is?” or “If you had to rank these goals in order of preference, where would you place each?” In the inpatient setting, especially for patients without clear goal-directed thinking or future orientation, one may have to be more creative in eliciting concrete goals. One could try asking in the following way, “If we had a magic wand and could fix any one problem right now, what would you want?” Likewise, throughout the patient interview and interaction process, students learn to adjust their internal priorities for treatment goals. In general, this is in concordance to the acuity and severity of the underlying problem and balanced by prognostic factors and complications. One powerful tool to help convince patients to adhere to our provider priorities is concessions. By “giving in” to patient desires, especially ones that are relatively simple to accommodate, one can garner patient trust and buy-in. A provider’s professional knowledge allows for an accurate assessment of the plausibility of a patient’s goals in the patient’s psychosocial context.