Both the cross-sectional and longitudinal studies highlight individual and socio-contextual factors that may shape HIV risk. Of note is in the emergence of brain imaging data to this body of literature. Thayer et al. found that network connectivity strength of the dorsal default mode network was associated with initial and longitudinal trajectories of alcohol use and that alcohol use was associated with sexual risk behaviors among court involved youth. Although these data are rare, they point to novel approaches for future research exploring associations between the experiences of alcohol use and interventions attempting to reduce alcohol use and associated sexual risk behaviors in adolescence. It is encouraging that over the past 5 years, there has been an increase in rigorous substance use and HIV -prevention intervention study designs, particularly with community supervised justice-involved youth who have the opportunity to engage in risk and practice prevention skills during the intervention period. Our own work demonstrates the many challenges to rigorously testing HIV -prevention interventions in court-based and other nondetention justice settings; thus, these recent studies that have enrolled larger samples and conducted rigorous randomized controlled trials show promise for bringing evidence-based substance use and HIV -prevention interventions to other juvenile justice populations and settings outside of detention. Despite these advances, however, dissemination and implementation of the few existing interventions has been limited. The field is also in need of development and testing of gender-responsive interventions as the unique risk profiles,growing indoor cannabis and needs of cisgender girls are supported by cross-sectional studies. Several limitations to the present review warrant mention. First, the findings are limited to what authors reported in each manuscript.
Additional study or intervention details that were unpublished were not requested by the authors or investigators. Second, our review intentionally did not include the few studies of substance use and justice involvement among HIV -positive youth; this is a growing and important area of future research that can inform the field in different ways about the intersection of substance use, HIV, and justice involvement.This review highlights numerous gaps in the literature and suggests many important areas for future research on the intersecting risks of HIV and substance use for justice-involved youth populations. First, in order to develop effective HIV -prevention strategies for this high risk population, it is necessary to identify optimal opportunities within the juvenile justice continuum to assess and intervene upon HIV risk behaviors. Identifying at-risk youth and developing and implementing HIV-prevention interventions at a youth’s earliest point of contact with the juvenile justice system could shift both their HIV- risk trajectories and stem the progression of illness and spread of disease, for example, screening youth for sexual and substance use risk behaviors at their first point of contact with the system, such as arrest or court intake appointments. Second, although the current body of literature reflects an expanded focus to include youth in a diverse array of juvenile justice settings, there remain several underrepresented juvenile justice populations. The field remains nascent with respect to efficacious prevention interventions for high -risk subgroups such as cisgender girls and sexual minority youth. There is a desperate need to develop and test interventions that are responsive to gender, sexual orientation, and gender identity in order to address the unique behavioral risks of these subgroups. Third, emerging biomedical HIV -prevention interventions are notably absent from the reviewed literature.
Questions examining pre-exposure prophylaxis awareness, acceptability, and uptake and adherence that are being asked with increasing regularity among other high-risk populations have yet to be studied among this at-risk group of youth. PrEP, a fixed-dose combination of two antiretroviral drugs, is efficacious in preventing the transmission of HIV. Clinical trials among HIV-negative individuals from high-risk groups suggests that when used correctly, PrEP can significantly reduce the risk of HIV acquisition. Given the high levels of engagement in sexual and substance use risk behaviors among justice-involved youth, PrEP and other emerging biomedical HIV-prevention technologies are a critical component of HIV-prevention efforts. Future research and intervention studies could, for example, examine justice-involved youth and emerging adults’ awareness and acceptability of, and access, uptake, and adherence to PrEP. Fourth, given the strong association between HIV risk behaviors and substance use among justice-involved youth, future research should focus on development, testing, and implementation of interventions that simultaneously reduce HIV risk and substance use. Fifth, the field must start to take advantage of developing and testing digital health risk -reduction interventions for this population to expand scale and impact. To date, there are no published digital health substance use and HIV/STI risk-reduction interventions for justice-involved youth. Lastly, the field is witnessing an increase in efficacious substance use and HIV -prevention interventions that now calls for novel implementation science trials with multiple different justice settings, such as the courts and probation, to understand how to effectively implement and sustain these interventions. Marijuana use has become increasingly normalized in the US and abroad. Since 1996, California has allowed marijuana for medical use. An additional 17 states and the District of Columbia have followed suit by either allowing medical marijuana use or legalizing recreation use of marijuana.Marijuana cigars or blunts refer to cannabis rolled with a shell from an inexpensive cigar called a blunt, although any commonly available inexpensive small cigars or cigarillos are likely to be used . Blunt wrappers, which are tobacco leaf rolling papers that come in sealed packages, are also sold for rolling blunts.
Due to the tobacco content in the wrapper leaf, smoking marijuana cigars may be considered as concurrent use of marijuana and tobacco. In this paper, we use the term “blunts” to talk about marijuana cigars and the term “blunt cigars” to talk about the inexpensive tobacco cigar that is typically used to make the marijuana cigars. Blunt cigars are cheap, frequently available at urban convenience stores, typically pre-cut with a blunt tip , and sold singly or in small packs of five. The present study examines factors associated with availability of tobacco products commonly used for blunts. Epidemiological surveys indicate that blunts are most commonly used by emerging adults , and that their use is generally increasing across all age groups. In 2005, 3.5% of all American youth aged 12–17 years were estimated to have used blunts in the past month , and a study among young adults aged 18-25 reported that between 2005 and 2008 past month blunts use ranged between 9% and 10.1% . By comparison, in 2011, 4.1% of youth aged 12–17 years, 11% of young adults aged 18-25years, 4.2% of adults aged 26-34 years and 1% of adults aged 35 or older reported using blunts in the past month , 2013. A recent study reported a moderate increase in the annual prevalence of blunt smoking among respondents aged 12-34 years old from 12% in 2004 to 14% in 2010 . Other studies indicate that blunt smoking appears to be practiced among a growing number of racial/ethnic groups , such as Southeast Asian youth and young adults in California . Previous studies have found that, compared to other intake forms of marijuana, smoking blunts is more associated with male gender, low GPA, poor school attachment, not attending college, not working, and living in low income areas . Also, blunts smokers may have greater odds of being dependent on cannabis and tobacco and are at risk for smoking-related diseases . While tobacco remains the leading cause of preventable and premature death,vertical farming killing an estimated 443,000 Americans each year , risks associated with marijuana use include impaired respiratory, cardiovascular and cognitive functioning and reduced mental health, as well as impaired driving ability and impaired function in school and at work . Blunts availability is likely to increase blunts use and problems associated with marijuana and tobacco use in local neighborhoods. Previous research suggests that exposure to and availability of drugs increase drug use and abuse . However, very little is known about availability of tobacco products associated with use of blunts. Studying the associations between neighborhood characteristics and availability of tobacco products used for blunts may help to identify areas at risk for blunts use and help policymakers and community advocates make better decisions about allocation of prevention resources. Analyzing 2000-2003 data from the National Survey on Drug Use and Health , Golub and colleagues showed that more than half of past-30-day marijuana users also reported current use of blunts. Among current blunts users, over two-thirds reported no current use of cigars, indicating blunts smokers may not define this practice as tobacco use. Similarly, a recent study suggested that young people recognize blunts as a form of marijuana use but do not recognize it as cigar use . Qualitative studies have also shown that youths may not consider blunts smoking to be a form of cigar use at all . These studies suggest the importance of studying the relationships between availability of tobacco products associated blunts use and societal-level influences related to normalization of marijuana use. Increased recognition of “recreational drug use” and increased support for legalizing some forms of marijuana use may contribute to normalization of marijuana and therefore to availability of products associated with blunts use.
Societal-level influences related to normalization of marijuana use in the community may include rates of adult marijuana use. Recent studies have found that prevalence of adult drinking or smoking in the community are associated with increased underage drinking and youth cigarette smoking . These studies suggested that the level of adult drug use in the community reflect both community drug norms and availability. Medical marijuana policy and availability should also be considered as social influences related to normalization of marijuana. Our previous studies indicated that tobacco and alcohol policies were directly related to community norms . Although blunts smoking and use of other forms of marijuana may be seen as different practices , medical marijuana dispensaries might increase availability and ease of access to marijuana. Also, medical marijuana dispensaries may indirectly affect general acceptability of marijuana in the community. The present study focuses on the associations between availability of tobacco products for blunts and social factors including neighborhood demographics, community-level marijuana use, medical marijuana policy and access to medical marijuana dispensaries and delivery services. This study used data from access surveys conducted at 1,000 tobacco outlets in 50 California cities with populations between 50,000 and 500,000. The sampling procedures for the 50 cities are described elsewhere in detail . This sample was a purposive geographic sample intended to maximize validity with regard to the geography and ecology of the state. Twenty randomly selected tobacco outlets in each city were surveyed. The sampling procedures for the tobacco outlets and survey procedures are also described in detail . The current study is based on data from 943 outlets with data for at least one of the outcome variables. In each city, data for the study were available for between 14 and 20 outlets . The selected tobacco outlets in each city were surveyed by two research assistants. At each outlet, a single research assistant attempted to purchase a pack of cigarettes and conducted a brief observation. After leaving the outlet, the research assistants recorded outlet data on a standardized form including whether blunt cigars, small cigars or cigarillos and blunt wrappers were for sale. Institutional review board approval was obtained prior to study implementation. Although California allows medical marijuana use, the state leaves regulations regarding the distribution of medical marijuana to patients up to local jurisdictions. Some localities have banned the distribution of marijuana through storefront dispensaries, have strict regulations on cultivation sites, have density restrictions on dispensaries, or some combination. Between June 2012 and July 2012, local city ordinances and policies around distribution and cultivation of marijuana were reviewed to determine whether the city permitted medical marijuana dispensaries or private cultivation in its jurisdiction. Cities were coded as allowing or not allowing medical marijuana storefront dispensaries and/or private cultivation within city boundaries. The density of medical marijuana dispensaries and delivery services is a measure of physical availability of medical marijuana in each of the 50 cities. Delivery services are an alternative means for users to obtain medical marijuana. These services can be available in any of the 50 cities, but are often more available in cities that do not allow distribution through dispensaries.