The websites used to determine the locations of medical marijuana dispensaries and delivery services were obtained by conducting a comprehensive search of such databases available on the web and by asking dispensary owners where they advertise their services. These websites provide the most up-to-date information on locations of dispensaries as some offer free listing services for new dispensaries with a pay option to continue the listing . To determine how well these on-line sources correspond with other sources of data , we conducted a premise assessment of all the dispensaries in one of the 50 cities in March, 2013. Lists of dispensaries were compiled from the sources above and from official city lists. Of the 51 dispensaries identified, only 16 were opened and operating. All of these dispensaries were identified using the on-line sources used in the current study. The official city list accounted for the dispensaries that were no longer in operation. Counts of dispensaries were denominated by the total length of roadways within cities to provide a representation of the functional access to these businesses . A strength of our study is that we calculate these densities for the entire city; thus while the count of dispensaries may not be perfectly accurate, rolling hydro tables cities with contrasting levels of dispensaries can still be differentiated. This variable was standardized for analyses.Multilevel logistic regression analyses were conducted with HLM version 7 software to adjust for clustering of observations within cities .
Although some outlets were nested within the same block group, 74% of the block groups in the current study had only one outlet within it. We therefore examined two-level models with outlets nested within cities . Intraclass correlations were .29 and .31 for whether blunt cigars, small cigars or cigarillos were for sale and whether blunt wrappers were for sale, respectively. These intraclass correlation values suggest that observations within the cities were not independent and indicate the value of including cities as a random second-level unit. Prevalence of adult marijuana or hashish users, medical marijuana dispensary or private cultivation policy and density of medical marijuana dispensaries and delivery services were included as city-level variables in all models . Availability of blunt cigars, small cigars or cigarillos , availability of blunt wrappers , outlet type and outlet block group demographic variables were included at the outlet-level . In each model, variables at both levels were entered simultaneously. Results of multilevel analyses to examine correlates of availability of tobacco products associated with blunts use are provided in Table 2. At the outlet level, results indicated significant associations between the type of the outlet and availability. Specifically, compared with small markets, availability of tobacco products associated with use of blunts was significantly higher in convenience stores, smoke/tobacco shops and liquor stores.
The associations with smoke/tobacco shops was in particular higher; 91% and 93% of these outlets sold blunt cigars, small cigars or cigarillos and blunt wrappers, respectively. None of the outlets’ block group demographics were associated with availability of blunt wrappers and only percent of Whites was positively associated with availability of blunt cigars, small cigars or cigarillos at the store. Controlling for outlet type and block group demographics, higher city prevalence of adult marijuana or hashish use was associated with greater availability of blunt wrappers. It was only marginally associated with availability of blunt cigars, small cigars or cigarillos. Also, policy that permits medical marijuana dispensaries or private cultivation was positively associated with availability of tobacco products associated with blunts. Density of medical marijuana dispensaries and delivery services per city, however, was negatively and strongly associated with greater availability of these products at places where tobacco products are typically sold.The current study examined social factors associated with availability of tobacco products for blunts. Other studies have shown that the tobacco industry aggressively markets specific products, such as menthol cigarettes, in low-income communities and communities of color . This may not be the case for blunts and blunt wrappers.
Results of our study indicate, that for the most part, availability of tobacco products associated with blunts was similar in neighborhoods with different socioeconomic status and racial and ethnic composition. Focusing on socioeconomic status, these results are less expected given the associations between some low socioeconomic indicators and use of blunts . Our results regarding racial and ethnic composition are consistent with recent findings that blunt smoking appears to be practiced among a growing number of racial/ethnic groups . Moreover, our finding about the positive association between percent of Whites and availability of cigars at the store is consistent with results of a recent study that cigar use including big cigars, cigarillos, and little cigars has increased among White non-Hispanic men aged 18 to 25 years . Additionally, our findings suggest that convenience stores, smoke/tobacco shops and liquor stores may provide greater availability of tobacco products associated with blunts than do other types of stores that sell tobacco. Because previous studies have shown that exposure to and availability of drugs increase drug use and abuse , policies that limit young people retail access to these products may help to reduce use of blunts and therefore related problems such as cannabis and tobacco dependence and smoking-related diseases . Interestingly, all three community-level factors related to marijuana use and access to medical marijuana were found associated with availability of tobacco products associated with blunts. Specifically, higher prevalence of marijuana/hashish use and policy that permits medical marijuana dispensaries and private cultivation were positively associated with availability of tobacco products for blunts in tobacco outlets. Density of medical marijuana dispensaries and/or delivery services, however, reduced odds of availability of these products. Possible explanations of these results include considering community norms and physical demand. Focusing on the associations between medical marijuana policy and availability, it is possible that community norms that support marijuana use may affect medical marijuana policy which in turn may increase availability of tobacco products associated with blunts. Using structural equations modeling, our previous studies indicated that community norms were directly related to tobacco and alcohol policies . Community-level prevalence of adult marijuana/hashish use was another important factor. Community-level prevalence of adult marijuana may simply be a proxy of community norms. In this case, higher rates of marijuana use contribute to more acceptability of marijuana which affects policy and availability. However, it is also possible that increased acceptability of marijuana affects policy and access to marijuana which in turn increases rates of marijuana/hashish users in the community. A recent study found higher odds of marijuana use in states that legalized medical marijuana . The cross-sectional design of the current study limits our understanding of these relationships. Future studies should explore these potential mediation effects and its relationships to youth and adults marijuana and blunts use. We also found that greater density of medical marijuana dispensaries and delivery services reduced odds of availability of tobacco products associated with blunts. These relationships may be explained by economic equilibrium theory . That is, tobacco stores may service demand for products associated with marijuana use when supply through medical marijuana dispensaries and delivery services is low. Also, vertical horticulture tobacco stores that sell products associated with blunts and medical marijuana dispensaries and delivery services may serve different types of marijuana users and therefore emerge in different types of business. Some research suggests that blunts use is a distinct subcultural formation associated with hip hop or rap music and with distinct configuration of rituals, jargon, and drug use norms . Results of this study should be considered in light of several limitations. First, the cross sectional design of the study limited our ability to make directional inferences about relationships between the community-level factors and availability.
For example, prevalence of adult marijuana/hashish use can be a proxy of community norms or it can be a result of availability of marijuana and marijuana products through density of medical marijuana dispensaries and delivery services. Also, the study included only selected tobacco outlets in midsized cities. Including rural communities and a larger sample of tobacco outlets may help to more closely explore the relationships between neighborhood demographics and availability. Third, it is possible that our community-level measures do not capture societal level influences related to normalization of marijuana use comprehensively. Other studies should include other variables related to popular culture and more direct measures of adult beliefs. Finally, information about individuals’ blunts use in these communities was not available for the study. Prevalence of blunt smoking in regions of California is unknown. Such information is only available from of a qualitative study of Southeast Asian Americans in two communities in San Francisco Bay Area. In that study, 62% of youth and young adults and 10% of adults reported lifetime blunts use . This limits our understanding of the relationships among community norms, medical marijuana policy, availability of tobacco products associated with blunts and actual blunts use. Despite these limitations, results of this study suggest the important role that community norms that support marijuana use or legalization of medical marijuana and medical marijuana policy may play in increasing availability of tobacco products associated with blunts. Since blunts have become popular over time and expanded into growing number of racial/ethnic groups , these results may be of particular importance to different communities in California and elsewhere. Tobacco and marijuana policymakers should be aware of the larger social contexts of blunts use and availability and the importance of considering societal-level influences related to normalization of marijuana use to reduce blunts use and/or other forms of concurrent use of tobacco and marijuana. Similarly, results of this study also suggest the importance of studying blunts use and availability within the larger social contexts of marijuana use, related policies and community norms to better inform policies to reduce blunts use and/or other forms of concurrent use of tobacco and marijuana.Approximately 2.4 billion people worldwide rely on burning biomass fuels, including wood, crop residue, coal, and animal dung for household cooking and heating. These fuels are often burned indoors in simple stoves in often poorly ventilated rooms, emitting substantial amounts of pollutants including particulate matter, carbon monoxide, and polycyclic aromatic hydrocarbons, all components of household air pollution . It is estimated that HAP from biomass fuel is responsible for more than 1.8 million premature deaths and 60.9 million disability-adjusted life-years annually, with the greatest burden experienced in low- and middle-income countries. Women and children have the highest levels of exposure to HAP since they traditionally tend to daily household chores, including cooking and spending time in kitchens. Exposure to biomass smoke during childhood has been shown to impact lung function and increase risk of acute lower respiratory infections. However, less is known about the rates of allergic sensitization and subsequent risk of atopy, which is the tendency to develop allergic diseases such as allergic rhinitis, eczema, and allergic asthma, among children who are exposed to biomass smoke early in childhood.Prior studies focusing on outdoor air pollution suggest that exposure to traffic-related air pollution early in life may enhance the risk of aeroallergen sensitization and increase the risk of developing allergic diseases at older ages. Diesel exhaust, in particular, has been found to enhance risk of aeroallergen sensitization and promote development of allergic asthma. Environmental tobacco smoke exposure early in life has also been associated with the development of allergic sensitization in children. Studies that investigated cooking-related biomass smoke exposure in children have also found it to be associated with elevated risks of asthma, rhinitis, and other respiratory illnesses. There are, however, limited data regarding the relationship between HAP, aeroallergen sensitization, and atopy in pediatric populations. A cross-sectional study conducted in rural Bavaria in southern Germany in a cohort of school-aged children from 9 to 11 years old found that children living in households using coal or wood for heating were less atopic and less likely to be sensitized towards aeroallergens than children living in households with other forms of heating. In a large study of Finnish children, there was also a negative association between wood stove heating and allergic rhinoconjunctivitis; however, this association disappeared after adjusting for other factors in the residential environment. In another population of children in Spain, the use of a biomass energy source for cooking and indoor heating was not associated with atopic dermatitis. Contrastingly, for children in rural Guatemala, a previous study suggested that the use of an open fire for cooking may be an important risk factor for asthma symptoms and severity later in life.