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Medical Marijuana Laws and Marijuana Use among U.S. Adolescents: Evidence from Michigan Youth Risk Behavior Surveillance Data

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Title: Medical Marijuana Laws and Marijuana Use among U.S. Adolescents: Evidence from Michigan Youth Risk Behavior Surveillance Data
Language: English
Authors: Chen, Xinguang, Yu, Bin (ORCID 0000-0001-6941-8083), Stanton, Bonita, Cook, Robert L., Chen, Ding-Geng, Okafor, Chukwuemeka
Source: Journal of Drug Education. Mar-Jun 2018 48(1-2):18-35.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
Peer Reviewed: Y
Page Count: 18
Publication Date: 2018
Document Type: Journal Articles
Reports - Research
Education Level: High Schools
Secondary Education
Descriptors: Marijuana, Drug Therapy, Correlation, Laws, Adolescents, Drug Use, Risk, High School Students, Student Attitudes, Surveys, Trend Analysis, Comparative Analysis
Geographic Terms: Michigan
DOI: 10.1177/0047237918803361
ISSN: 0047-2379
Abstract: Research findings are inconsistent regarding a positive association between the passage of state medical marijuana laws (MML) and the adolescent access and the use of marijuana. We utilized a novel analytical approach to examine this issue with multiyear data from the 1997-2013 Youth Risk Behavior Surveillance System of the State of Michigan. After controlling for the historically declining trend in marijuana use prior to the passages of MML in Michigan, we found that marijuana use among adolescents had increased subsequent to the passage of state MML. The study findings suggest the need for considering the increased risk of marijuana use in adolescents, as more states have implemented laws permitting marijuana use.
Abstractor: As Provided
Number of References: 54
Entry Date: 2018
Accession Number: EJ1196780
Database: ERIC
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  Value: <anid>AN0133201552;jdr01mar.18;2018Nov27.10:57;v2.2.500</anid> <title id="AN0133201552-1">Medical Marijuana Laws and Marijuana Use Among U.S. Adolescents: Evidence From Michigan Youth Risk Behavior Surveillance Data </title> <p>Research findings are inconsistent regarding a positive association between the passage of state medical marijuana laws (MML) and the adolescent access and the use of marijuana. We utilized a novel analytical approach to examine this issue with multiyear data from the 1997–2013 Youth Risk Behavior Surveillance System of the State of Michigan. After controlling for the historically declining trend in marijuana use prior to the passages of MML in Michigan, we found that marijuana use among adolescents had increased subsequent to the passage of state MML. The study findings suggest the need for considering the increased risk of marijuana use in adolescents, as more states have implemented laws permitting marijuana use.</p> <p>Keywords: medical marijuana laws; adolescents; marijuana use; YRBS; Michigan</p> <p>A large and increasing number of adolescents and young adults use marijuana, exerting a significant public health burden globally ([<reflink idref="bib37" id="ref1">37</reflink>]; World Health Organization, 2017). Policies and regulations represent one of the evidence-based approaches to prevent marijuana use among adolescents ([<reflink idref="bib40" id="ref2">40</reflink>]). However, a number of developed countries including Australia, Canada, Germany, Italy, Netherlands, and Spain have established different types of laws and regulations decriminalizing the use of marijuana products ([<reflink idref="bib14" id="ref3">14</reflink>],[<reflink idref="bib15" id="ref4">15</reflink>]; [<reflink idref="bib16" id="ref5">16</reflink>]; [<reflink idref="bib29" id="ref6">29</reflink>]; [<reflink idref="bib35" id="ref7">35</reflink>]). In the United States, laws were first passed in California in 1996 to permit marijuana use for medical purposes. To date, 29 of the 50 U.S. states and the District of Columbia have passed state medical marijuana laws (MML). Although these laws differ from one state to another with regard to the detailed provisions, they all make it legal to use marijuana for a set of specified medical conditions ([<reflink idref="bib19" id="ref8">19</reflink>]).</p> <hd id="AN0133201552-2">Regulation of Marijuana in the United States</hd> <p>For people living in states with MML, it is legal to use marijuana for medical purposes. To support marijuana use for medical purposes, MML in most states also includes provisions permitting their citizens to possess, distribute, and cultivate marijuana ([<reflink idref="bib40" id="ref9">40</reflink>]). Proponents of the medical use of marijuana argue that cannabidiol, an anti-psychoactive ingredient in marijuana, could be beneficial for health ([<reflink idref="bib44" id="ref10">44</reflink>]). Research data indicate that cannabidiol can help control negative emotions and relieve pain ([<reflink idref="bib5" id="ref11">5</reflink>]; [<reflink idref="bib22" id="ref12">22</reflink>]; [<reflink idref="bib27" id="ref13">27</reflink>]). Findings from this line of research provide the neurobiological and pharmacological arguments for legalizing marijuana for medical use ([<reflink idref="bib34" id="ref14">34</reflink>]; [<reflink idref="bib50" id="ref15">50</reflink>]).</p> <p>Although marijuana use has become legal in the states with marijuana laws, marijuana remains regulated by federal laws as a Schedule I illicit drug (i.e., high potential for abuse, no currently accepted medical use, and lack of accepted safety guidelines for use) ([<reflink idref="bib13" id="ref16">13</reflink>]). Research attributes the negative effect of marijuana to tetrahydrocannabinol, a primary psychoactive ingredient of marijuana ([<reflink idref="bib3" id="ref17">3</reflink>]). Exposure to marijuana is associated with a number of negative consequences including neurocognitive impairment, unsafe driving, tobacco smoking, alcohol consumption, unprotected sex, and delinquent behaviors ([<reflink idref="bib21" id="ref18">21</reflink>]; [<reflink idref="bib25" id="ref19">25</reflink>]; [<reflink idref="bib26" id="ref20">26</reflink>]; [<reflink idref="bib42" id="ref21">42</reflink>]; [<reflink idref="bib48" id="ref22">48</reflink>]).</p> <hd id="AN0133201552-3">MML in Michigan</hd> <p>In Michigan, the topic of medical marijuana use was initiated in 2000 by the Ann Arbor Libertarians, but no local legislation regarding medical marijuana use was passed until 2004 when voters in Detroit first approved a city MML. Following Detroit, several Michigan cities passed municipal MML between 2004 and 2007 ([<reflink idref="bib39" id="ref23">39</reflink>]). Michigan enacted its state MML in November 2008 after years of statewide public debate and voting ([<reflink idref="bib38" id="ref24">38</reflink>]). The Michigan MML includes four major provisions: (a) patient registry/ID card, (b) regulation of medical practice, (c) regulations of possession and limits, and (d) legal defense and protection of users.</p> <hd id="AN0133201552-4">Evaluation Challenges and Inconsistent Findings</hd> <p>Some previous studies assessed the impact of medical marijuana legalization on marijuana abuse, but no consistent conclusions have been reached. Several studies have found no association between MML and marijuana abuse with data collected from different populations, including adolescents and adults from the general population, juveniles from the criminal justice system, and patients from medical care facilities ([<reflink idref="bib20" id="ref25">20</reflink>]; [<reflink idref="bib32" id="ref26">32</reflink>]; [<reflink idref="bib41" id="ref27">41</reflink>]; [<reflink idref="bib46" id="ref28">46</reflink>]). Several other studies have detected a negative relationship among adolescents ([<reflink idref="bib23" id="ref29">23</reflink>]; [<reflink idref="bib32" id="ref30">32</reflink>]). A third group of studies found mixed results with positive associations for some subpopulation groups (e.g., juveniles, young children) and no associations for others (e.g., adolescents in the general population) ([<reflink idref="bib47" id="ref31">47</reflink>]; [<reflink idref="bib51" id="ref32">51</reflink>]; [<reflink idref="bib53" id="ref33">53</reflink>]).</p> <p>One explanation for the inconsistent findings from different studies could be the complexity in assessing the effect of MML on marijuana abuse ([<reflink idref="bib17" id="ref34">17</reflink>]; [<reflink idref="bib47" id="ref35">47</reflink>]). Passage of state MML differs from implementation of an intervention trial in a number of ways. Unlike an intervention trial, no state is randomized to pass MML. As a result, no real comparison group can be scientifically established as a control to detect the effect of MML. This difference also makes commonly used statistical methods ineffective for detecting both the within- and between-group differences. Furthermore, since the passage of MML is a public process, information regarding marijuana legislation in one state can easily be spread to other states, including the states without MML. Information diffusion therefore reduces validity of the non-MML states serving as controls to assess the between-state difference ([<reflink idref="bib8" id="ref36">8</reflink>]; [<reflink idref="bib17" id="ref37">17</reflink>]; [<reflink idref="bib33" id="ref38">33</reflink>]; [<reflink idref="bib47" id="ref39">47</reflink>]). Finally, a state MML is enacted in a specific year, completing the legislation takes time, often lasting for several years. This timing factor must be considered in a study to evaluate the effect of MML.</p> <hd id="AN0133201552-5">Purpose of This Study</hd> <p>In this study, we proposed a new analytical approach considering the evaluation challenges described earlier and applied it in evaluating the potential impact of state MML on adolescent marijuana use in Michigan. As described earlier, adolescents are highly vulnerable to marijuana, and no consistent conclusion has been reached regarding the relationship between MML and adolescent marijuana use. The state legislation on marijuana use for medical purposes and YRBS data in Michigan provide an opportunity to examine the issue. The goal of this study is to provide empirical data for decision makers and the general public to strengthen current adolescent drug use prevention while legalizing marijuana use, and to inform future research on detailed mechanisms between MML and adolescent marijuana abuse.</p> <hd id="AN0133201552-6">Materials and Methods</hd> <p></p> <hd id="AN0133201552-7">Data Sources and Study Population</hd> <p>Data used for this study were derived from the Michigan Youth Risk Behavior Survey (YRBS), 1997–2013 (<ulink href="http://www.cdc.gov/healthyyouth/data/yrbs/data.htm">http://www.cdc.gov/healthyyouth/data/yrbs/data.htm</ulink>). Survey participants were students in grades 9 to 12, selected using a two-stage cluster random sampling method. First, schools were selected with probability proportionate to enrollment size from the school sampling frame in which all public schools were included. Second, classes within the participating schools were selected randomly; data from all students in the selected classes were included. Students completed the self-administered questionnaire ([<reflink idref="bib6" id="ref40">6</reflink>]). The study was approved by the university Institutional Review Board.</p> <hd id="AN0133201552-8">Measurement</hd> <p></p> <hd id="AN0133201552-9">Never-users</hd> <p>This variable was defined as those students who reported never having used marijuana. Participants were coded as never-users if they selected "0 times" to the question: "During your lifetime, how many times have you used marijuana?" with seven answer options (0 times, 1 or 2 times, 3–9 times, 10–19 times, 20–39 times, 40–99 times, and 100 or more times).</p> <hd id="AN0133201552-10">Current users</hd> <p>Participants were coded as current marijuana users if they reported any use of the drug in their lifetime, and also having used it at least one time in the past 30 days, based on their responses to the question: "During the past 30 days, how many times did you use marijuana?" Answer options to this question include 0 times, 1–2 times, 3–9 times, 10–19 times, 20–39 times, and 40 or more times.</p> <p>Demographic variables were age (in years), gender (male/female), and race (White, Black and others). These variables were used to characterize the sampled participants and their variations at different years of survey.</p> <hd id="AN0133201552-11">Statistical Analysis</hd> <p>We employed a historical trend analysis approach to test the hypothesis that the passage of MML in Michigan is associated with increased marijuana use among adolescents. The principle of our method is the same as the interrupted time series analysis commonly used in analyzing the effect of policy change ([<reflink idref="bib26" id="ref41">26</reflink>]; [<reflink idref="bib36" id="ref42">36</reflink>]). We hypothesized the existence of a turning point associated with MML after which the increasing trend in the number of youth reporting never having used marijuana slows down and the declining trend in the number of current marijuana users levels off. We detected linear trends before and after MML using a linear regression model, followed by a piecewised testing method ([<reflink idref="bib4" id="ref43">4</reflink>]) to statistically locate the turning point.</p> <p>The statistical analysis was conducted at both the aggregate level and the individual level. At the aggregate level, the prevalence rates of current use and never-use for each survey year were estimated. The PROC SURVEYMEANS in SAS was used to compute the prevalence rates considering the sampling design. The time trends before and after the state MML were modeled with two separate linear regression models, and the differences in the two regression slopes were assessed using Z test.</p> <p>At the individual level, current user (y/n) and never-user (y/n) were modeled separately using the PROC GENMOD in SAS with the survey year as the predictor variable. The survey year was first modeled as a continuous variable to capture the linear trends prior to and post state MML. A noninclusive 95% confidence interval between the two regression slopes was used as evidence of significant difference. The survey year was further modeled as a categorical variable to quantify the association between MML and marijuana use.</p> <p>Mathematical rotations were conducted to control confounding from the declining historical trend in marijuana use prior to the passage of MML. The continuous declining trend makes the conventional pre–post comparison ineffective, resulting in contradictory conclusions even if the MML might have stopped the declining trends in adolescent marijuana use. The rotation method was used to help overcome this limitation by turning overall time trends in the two marijuana-use measures during 1997–2013 such that the slope became zero for the period prior to the state MML.</p> <p>Our effort to locate one or more non-MML states to serve as a control failed because none of these states showed a trend similar to that of Michigan regarding marijuana use before 2008 (Appendix Figure A1). Therefore, no single state can be employed as a control to assess MML for Michigan. The advantages of the historical analytical approach we used were (a) building on historical trend, rather than being biased by it; (b) utilizing multi-wave survey data of one state to test the study hypothesis; and (c) taking advantage of a self-control design to assess within-state differences in marijuana use before and after MML while controlling confounders ([<reflink idref="bib21" id="ref44">21</reflink>]). This method has been used to evaluate tobacco control programs at the state level ([<reflink idref="bib9" id="ref45">9</reflink>]).</p> <hd id="AN0133201552-12">Results</hd> <p></p> <hd id="AN0133201552-13">Characteristics of the Study Sample</hd> <p>Data from nine waves of YRBS survey for a total of 29,426 participants aged 12–17 years were included. Among the total sample (Table 1), 48.33% were male and 69.24% were White, 16.02% Black, and 14.74% other races.</p> <p>Graph</p> <p>Sample Characteristics of the YRBS Participants, 1997–2013, Michigan, USA.</p> <p> <ephtml> <table frame="hsides"><tr><th rowspan="2">Year</th><th rowspan="2">Total (%)</th><th align="center" colspan="2">Gender</th><th align="center" colspan="3">Race</th></tr><tr><th align="center">Male (%)</th><th align="center">Female (%)</th><th align="center">White (%)</th><th align="center">Black (%)</th><th align="center">Others (%)</th></tr><tr><td>1997</td><td align="center">3,616 (12.29)</td><td align="center">1,657 (45.82)</td><td align="center">1,959 (54.18)</td><td align="center">1,471 (41.02)</td><td align="center">1,748 (48.75)</td><td align="center">367 (10.23)</td></tr><tr><td>1999</td><td align="center">2,481 (8.43)</td><td align="center">1,171 (47.20)</td><td align="center">1,310 (52.80)</td><td align="center">1,935 (79.43)</td><td align="center">293 (12.03)</td><td align="center">208 (8.54)</td></tr><tr><td>2001</td><td align="center">3,262 (11.09)</td><td align="center">1,554 (47.64)</td><td align="center">1,708 (52.36)</td><td align="center">2,408 (74.62)</td><td align="center">399 (12.36)</td><td align="center">420 (13.02)</td></tr><tr><td>2003</td><td align="center">3,138 (10.66)</td><td align="center">1,551 (49.43)</td><td align="center">1,587 (50.57)</td><td align="center">2,180 (70.03)</td><td align="center">407 (13.07)</td><td align="center">526 (16.90)</td></tr><tr><td>2005</td><td align="center">2,965 (10.08)</td><td align="center">1,368 (46.14)</td><td align="center">1,597 (53.86)</td><td align="center">2,145 (72.81)</td><td align="center">313 (10.62)</td><td align="center">488 (16.56)</td></tr><tr><td>2007</td><td align="center">3,171 (10.78)</td><td align="center">1,581 (49.86)</td><td align="center">1,590 (50.14)</td><td align="center">2,264 (72.49)</td><td align="center">253 (8.10)</td><td align="center">606 (19.40)</td></tr><tr><td>2009</td><td align="center">3,051 (10.37)</td><td align="center">1,552 (50.81)</td><td align="center">1,499 (49.13)</td><td align="center">2,229 (74.20)</td><td align="center">309 (10.29)</td><td align="center">466 (15.51)</td></tr><tr><td>2011</td><td align="center">3,854 (13.10)</td><td align="center">1,886 (48.94)</td><td align="center">1,968 (51.06)</td><td align="center">2,854 (75.11)</td><td align="center">391 (10.29)</td><td align="center">555 (14.61)</td></tr><tr><td>2013</td><td align="center">3,888 (13.21)</td><td align="center">1,901 (48.89)</td><td align="center">1,987 (51.11)</td><td align="center">2,634 (68.86)</td><td align="center">543 (14.20)</td><td align="center">648 (16.94)</td></tr><tr><td>Total</td><td align="center">29,426 (100.00)</td><td align="center">14,221 (48.33)</td><td align="center">15,205 (51.67)</td><td align="center">20,120 (69.24)</td><td align="center">4,656 (16.02)</td><td align="center">4,284 (14.74)</td></tr></table> </ephtml> </p> <hd id="AN0133201552-14">Prevalence Rates of Current Marijuana Users and Never-Users</hd> <p>Table 2 indicates that the prevalence of current marijuana use among Michigan adolescents showed a spike in 2009 and, correspondingly, the prevalence of never-users showed a dip in 2009. This result was true for the overall sample and by sex and racial groups.</p> <p>Graph</p> <p>Estimated Prevalence, % (95% CI) of Adolescent Marijuana Use, 1997–2013 YRBS Data, Michigan, United States.</p> <p> <ephtml> <table frame="hsides"><tr><th rowspan="2">Year</th><th align="center" rowspan="2">Total</th><th align="center" colspan="2">Gender</th><th align="center" colspan="3">Race</th></tr><tr><th align="center">Male</th><th align="center">Female</th><th align="center">White</th><th align="center">Black</th><th align="center">Others</th></tr><tr><td colspan="2">Current users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> 1997</td><td align="center">28 [25, 32]</td><td align="center">32 [27, 36]</td><td align="center">25 [20, 29]</td><td align="center">28 [23, 32]</td><td align="center">28 [21, 34]</td><td align="center">34 [27, 42]</td></tr><tr><td> 1999</td><td align="center">26 [23, 30]</td><td align="center">30 [26, 34]</td><td align="center">23 [19, 27]</td><td align="center">25 [22, 29]</td><td align="center">30 [19, 40]</td><td align="center">29 [22, 37]</td></tr><tr><td> 2001</td><td align="center">24 [22, 27]</td><td align="center">25 [22, 28]</td><td align="center">24 [20, 27]</td><td align="center">25 [22, 28]</td><td align="center">21 [16, 26]</td><td align="center">22 [19, 26]</td></tr><tr><td> 2003</td><td align="center">24 [20, 28]</td><td align="center">26 [20, 31]</td><td align="center">23 [20, 26]</td><td align="center">24 [19, 28]</td><td align="center">27 [20, 35]</td><td align="center">24 [20, 28]</td></tr><tr><td> 2005</td><td align="center">19 [16, 22]</td><td align="center">20 [16, 24]</td><td align="center">18 [15, 20]</td><td align="center">18 [15, 21]</td><td align="center">22 [17, 28]</td><td align="center">26 [21, 32]</td></tr><tr><td> 2007</td><td align="center">18 [16, 21]</td><td align="center">20 [17, 23]</td><td align="center">17 [14, 20]</td><td align="center">18 [15, 21]</td><td align="center">20 [16, 24]</td><td align="center">20 [15, 26]</td></tr><tr><td> 2009</td><td align="center">21 [19, 23]</td><td align="center">22 [19, 25]</td><td align="center">20 [17, 22]</td><td align="center">21 [18, 23]</td><td align="center">21 [14, 28]</td><td align="center">25 [20, 31]</td></tr><tr><td> 2011</td><td align="center">19 [16, 21]</td><td align="center">22 [19, 25]</td><td align="center">16 [13, 19]</td><td align="center">19 [16, 21]</td><td align="center">18 [11, 24]</td><td align="center">20 [15, 25]</td></tr><tr><td> 2013</td><td align="center">18 [16, 19]</td><td align="center">19 [17, 21]</td><td align="center">17 [15, 19]</td><td align="center">18 [16, 19]</td><td align="center">18 [13, 22]</td><td align="center">21 [16, 26]</td></tr><tr><td colspan="2">Never-users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> 1997</td><td align="center">52 [47, 57]</td><td align="center">49 [44, 54]</td><td align="center">54 [48, 61]</td><td align="center">53 [47, 59]</td><td align="center">46 [39, 53]</td><td align="center">48 [39, 57]</td></tr><tr><td> 1999</td><td align="center">53 [50, 57]</td><td align="center">50 [46, 54]</td><td align="center">56 [52, 61]</td><td align="center">54 [50, 58]</td><td align="center">48 [37, 60]</td><td align="center">51 [44, 58]</td></tr><tr><td> 2001</td><td align="center">56 [52, 60]</td><td align="center">55 [50, 59]</td><td align="center">58 [54, 62]</td><td align="center">56 [51, 60]</td><td align="center">60 [53, 67]</td><td align="center">53 [47, 59]</td></tr><tr><td> 2003</td><td align="center">56 [51, 60]</td><td align="center">53 [49, 58]</td><td align="center">58 [53, 63]</td><td align="center">57 [52, 61]</td><td align="center">50 [41, 59]</td><td align="center">56 [51, 62]</td></tr><tr><td> 2005</td><td align="center">62 [58, 66]</td><td align="center">60 [54, 65]</td><td align="center">64 [60, 69]</td><td align="center">65 [61, 69]</td><td align="center">50 [42, 59]</td><td align="center">54 [47, 61]</td></tr><tr><td> 2007</td><td align="center">64 [61, 68]</td><td align="center">62 [57, 67]</td><td align="center">67 [62, 71]</td><td align="center">65 [61, 70]</td><td align="center">61 [54, 68]</td><td align="center">60 [54, 67]</td></tr><tr><td> 2009</td><td align="center">63 [61, 66]</td><td align="center">62 [58, 66]</td><td align="center">65 [62, 68]</td><td align="center">64 [61, 67]</td><td align="center">62 [57, 68]</td><td align="center">60 [55, 66]</td></tr><tr><td> 2011</td><td align="center">66 [62, 69]</td><td align="center">62 [58, 65]</td><td align="center">70 [65, 74]</td><td align="center">68 [64, 71]</td><td align="center">61 [51, 70]</td><td align="center">61 [55, 67]</td></tr><tr><td> 2013</td><td align="center">67 [65, 70]</td><td align="center">66 [63, 69]</td><td align="center">69 [66, 72]</td><td align="center">69 [66, 71]</td><td align="center">62 [53, 71]</td><td align="center">65 [59, 71]</td></tr></table> </ephtml> </p> <p>1 Note. Michigan passed its state medical marijuana laws in November 2008. CI = confidence interval.</p> <hd id="AN0133201552-15">Trends in Marijuana Use Pre- and Post-MML</hd> <p>Figure 1 depicts the time trend of current marijuana use for the total sample. The prevalence rate showed an overall declining trend from 28.20% in 1997 to 18.75% in 2005 with an interruption during 2001–2003 prior to the approval of the Detroit MML in 2004. The declining trend slowed from 2005 to 2007, followed by a sudden increase with a peak rate of 20.67% in 2009 before it started to decline, ending at 18.22% in 2013. Results from piecewise testing indicate that the turning point of the overall trend was 2006.</p> <p>Changes in the prevalence of current marijuana use among Michigan adolescents and the passage of medical marijuana laws in five local cities and Michigan state. The two dashed straight lines describe the linear trends before and after MML in Michigan and were derived by fitting the prevalence rates to a linear model during the two periods, respectively. Data source: 1997–2013 Michigan YRBS.</p> <p>Graph</p> <p>Figure 2 shows the time trends of the prevalence of adolescents who reported having never used marijuana. Consistent with the findings in Figure 1, up to 2005, there was a progressive increase in this rate; and the speed of increase started to slow down from 2005 to 2007, followed by an obvious drop during the 2007–2009 before a growing trend resumed, but with a flatter slope. Results from the piecewise test indicated that the turning point of the two trends also occurred in 2006.</p> <p>Changes in the prevalence of marijuana never-users among Michigan adolescents before and after the medical marijuana laws in Michigan. The two dashed straight lines describe the linear trends before and after MML in Michigan and were derived by fitting the prevalence rates to a linear model during the two periods, respectively. Data source: 1997–2013 Michigan YRBS.</p> <p>Graph</p> <hd id="AN0133201552-16">Comparison of the Trend of Marijuana Use Measures Pre- and Post-MML</hd> <p>A comparison of the β coefficients of the two linear regression lines of the current marijuana user trend (the upper panel of Table 3) indicates a significant decrease in the reduction of current marijuana use after MML. As there were no YRBS data in 2006, the detected turning point, we used both 2005 and 2007 as the turning points to test the effect statistically. When 2007 was used as the turning point, the β coefficient [95% confidence interval] was −.0567 [−.0576, −.0559] for the trend from 1997 to 2007, and −.0114 [−.0131, −.0097] after 2007, which was statistically significant. A similar result was observed when the year 2005 was used as the turning point. Results from the lower panel of Table 3 indicate significant reductions in the growing trend of the proportion of never-users after the state MML, regardless as to whether year 2005 or 2007 was used as the turning point.</p> <p>Graph</p> <p>Comparison of the Trends in Marijuana Use Among Michigan Adolescents Before and After the Passage of the State Medical Marijuana Laws: Results From the Aggregate Level Analysis.</p> <p> <ephtml> <table frame="hsides"><tr><th rowspan="2">Marijuana users</th><th align="center" rowspan="2">Β</th><th align="center" rowspan="2">SE</th><th align="center" colspan="2">95% CI</th></tr><tr><th align="center">Lower</th><th align="center">Upper</th></tr><tr><td>Current users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> Trend prior to MML up to 2007</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td>  Trend before MML</td><td align="center">−0.0567</td><td align="center">0.0004</td><td align="center">−0.0576</td><td align="center">−0.0559</td></tr><tr><td>  Trend after MML</td><td align="center">−0.0114</td><td align="center">0.0009</td><td align="center">−0.0131</td><td align="center">−0.0097</td></tr><tr><td> Trend prior to MML up to 2005</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td>  Trend before MML</td><td align="center">−0.0551</td><td align="center">0.0006</td><td align="center">−0.0562</td><td align="center">−0.0540</td></tr><tr><td>  Trend after MML</td><td align="center">−0.0114</td><td align="center">0.0009</td><td align="center">−0.0131</td><td align="center">−0.0097</td></tr><tr><td>Never-users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> Trend prior to MML up to 2007</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td>  Trend before MML</td><td align="center">0.0528</td><td align="center">0.0004</td><td align="center">0.0521</td><td align="center">0.0535</td></tr><tr><td>  Trend after MML</td><td align="center">0.0237</td><td align="center">0.0007</td><td align="center">0.0223</td><td align="center">0.0251</td></tr><tr><td> Trend prior to MML up to 2005</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td>  Trend before MML</td><td align="center">0.0471</td><td align="center">0.0005</td><td align="center">0.0461</td><td align="center">0.0480</td></tr><tr><td>  Trend after MML</td><td align="center">0.0237</td><td align="center">0.0007</td><td align="center">0.0223</td><td align="center">0.0251</td></tr></table> </ephtml> </p> <p>2 Note. The two β coefficients of marijuana use indicators for the two comparison periods were estimated by fitting a linear model of the data for the corresponding periods assuming a binary distribution of marijuana use. The difference in the β between the two comparison periods was judged with the 95% CI, with no inclusion of the two CIs as the indication of statistical significance at p < .05 level (two-sided). CI = confidence interval; MML = medical marijuana laws; SE = standard error.</p> <hd id="AN0133201552-17">Associations Assessed at the Individual Level</hd> <p>Results in the upper panel of Table 4 indicate that after rotating the prevalence of marijuana use over time such that the trend for the period before MML became flat, there were significant positive relationships between MML and current marijuana use in all survey years. When year 2007 was used as the reference, the rotated model coefficient was .2718 (odds ratio [OR] = 1.31) in 2009, .2240 (OR = 1.25) in 2011, and .2893 (OR = 1.34) in 2013, p < .01 for all. A stronger association was observed when year 2005 was used as the reference.</p> <p>Graph</p> <p>Positive Associations Between MML and Risk of Current Marijuana Use Among Adolescents in Michigan: Results From the Individual Level Data Analysis.</p> <p> <ephtml> <table frame="hsides"><tr><th rowspan="2">Year</th><th align="center" colspan="2">2007 as the turning year</th><th align="center" colspan="2">2005 as the turning year</th></tr><tr><th align="center">Rotated</th><th align="center">Original (SE)</th><th align="center">Rotated</th><th align="center">Original (SE)</th></tr><tr><td>Current users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> 1997</td><td align="center">−0.0133</td><td align="center">0.5402 (.0052)**</td><td align="center">0.0537</td><td align="center">0.4773 (.0051)**</td></tr><tr><td> 1999</td><td align="center">0.0080</td><td align="center">0.4508 (.0053)**</td><td align="center">0.0702</td><td align="center">0.3879 (.0052)**</td></tr><tr><td> 2001</td><td align="center">0.0242</td><td align="center">0.3563 (.0053)**</td><td align="center">0.0816</td><td align="center">0.2934 (.0052)**</td></tr><tr><td> 2003</td><td align="center">0.1253</td><td align="center">0.3467 (.0052)**</td><td align="center">0.1779</td><td align="center">0.2838 (.0051)**</td></tr><tr><td> 2005</td><td align="center">−0.0478</td><td align="center">0.0629 (.0054)**</td><td align="center">Reference</td><td align="center">Reference</td></tr><tr><td> 2007</td><td align="center">Reference</td><td align="center">Reference</td><td align="center">0.0043</td><td align="center">−0.0629 (.0054)**</td></tr><tr><td> 2009</td><td align="center">0.2718**</td><td align="center">0.1611 (.0054)**</td><td align="center">0.3100**</td><td align="center">0.0982 (.0053)**</td></tr><tr><td> 2011</td><td align="center">0.2240**</td><td align="center">0.0026 (.0054)**</td><td align="center">0.2574**</td><td align="center">−0.0603 (.0053)**</td></tr><tr><td> 2013</td><td align="center">0.2893**</td><td align="center">−0.0428 (.0057)**</td><td align="center">0.3179**</td><td align="center">−0.1057 (.0056)**</td></tr><tr><td>Never-users</td><td align="center" /><td align="center" /><td align="center" /><td align="center" /></tr><tr><td> 1997</td><td align="center">0.0028</td><td align="center">−0.5007 (.0045)**</td><td align="center">−0.0423</td><td align="center">−0.3975 (.0044)**</td></tr><tr><td> 1999</td><td align="center">−0.0399</td><td align="center">−0.4427 (.0045)**</td><td align="center">−0.0731</td><td align="center">−0.3395 (.0044)**</td></tr><tr><td> 2001</td><td align="center">−0.0489</td><td align="center">−0.3510 (.0045)**</td><td align="center">−0.0702</td><td align="center">−0.2478 (.0044)**</td></tr><tr><td> 2003</td><td align="center">−0.1488</td><td align="center">−0.3502 (.0044)**</td><td align="center">−0.1582</td><td align="center">−0.2470 (.0043)**</td></tr><tr><td> 2005</td><td align="center">−0.0025</td><td align="center">−0.1032 (.0044)**</td><td align="center">Reference</td><td align="center">Reference</td></tr><tr><td> 2007</td><td align="center">Reference</td><td align="center">Reference</td><td align="center">−0.0057</td><td align="center">0.1032 (.0044)**</td></tr><tr><td> 2009</td><td align="center">−0.1208**</td><td align="center">−0.0201 (.0045)**</td><td align="center">−0.0945**</td><td align="center">0.0831 (.0045)**</td></tr><tr><td> 2011</td><td align="center">−0.0899**</td><td align="center">0.1115 (.0045)**</td><td align="center">−0.0517**</td><td align="center">0.2147 (.0044)**</td></tr><tr><td> 2013</td><td align="center">−0.1462**</td><td align="center">0.1559 (.0047)**</td><td align="center">−0.0961**</td><td align="center">0.2591 (.0046)**</td></tr></table> </ephtml> </p> <p>3 Note. Age, sex, and race were included as covariates to account for their variations in the study sample across years. The rotation of the estimated coefficients was made by setting the slope = 0 for a linear trend before 2007 and 2005, respectively. SE = standard error.**P<0.001.</p> <p>Likewise, results in the lower panel of Table 4 indicate a significant negative association between MML and never-users when either 2005 or 2007 was used as the reference year.</p> <hd id="AN0133201552-18">Discussion</hd> <p>The growth in marijuana use among adolescents since 2005 has emerged as a significant health challenge in the United States (Johnston, O'Malley, Bachman, & Schulenberg, 2011). Furthermore, this challenge is accompanied by a growing number of states that permit marijuana use through state legislature. In this study, we examined the association between MML and risk of marijuana use among middle and high school students in Michigan using the YRBS data. Findings of this study provide new evidence underscoring the need for further research to understand the mechanisms underpinning the complex relationship between MML and adolescent marijuana use. The data suggest a possible need for strengthening drug use prevention programs simultaneous with efforts advocating for legalization of marijuana through state legislature.</p> <p>Findings from our analysis showed a significant and positive association between MML and adolescent marijuana use, including increased risk of marijuana initiation and current use and declines in the number of never-users. The effect peaked at 2009 and the risk remained significant through 2013 when the most recent survey data were available. Findings of this study are consistent with and support those from several reported studies that MML can increase the risk of marijuana use ([<reflink idref="bib12" id="ref46">12</reflink>]; [<reflink idref="bib43" id="ref47">43</reflink>]; [<reflink idref="bib49" id="ref48">49</reflink>]; [<reflink idref="bib53" id="ref49">53</reflink>]) but contradict those reporting a protective effect ([<reflink idref="bib23" id="ref50">23</reflink>]) or no effect at all ([<reflink idref="bib11" id="ref51">11</reflink>]; [<reflink idref="bib18" id="ref52">18</reflink>]; [<reflink idref="bib24" id="ref53">24</reflink>]; [<reflink idref="bib28" id="ref54">28</reflink>]; [<reflink idref="bib51" id="ref55">51</reflink>]).</p> <p>According to our analysis, the passage of MML in Michigan was associated with increased risk of marijuana use among adolescents in Michigan. Along with the process of passing the state MML, the historically declining trend in adolescent marijuana use leveled off; and the numbers of adolescent marijuana user rated increase after the MML were passed. U.S. Census data indicated that there were 535,452 students in grades 9 to 12 in Michigan during the 2008–2009 school year. The increase in marijuana use due to MML might have resulted in an estimated 25,541 additional students who initiated marijuana use in the year 2009 alone. If this study finding can be verified using data from other states, the states with either extant MML or considering legislation to pass MML for adults should consider concomitant legislation to prevent potential increased marijuana accessibility to adolescents. Consideration should be given to developing or intensifying extant public health policies and health education programs for adolescent marijuana uses prevention to consider MML-related changes in harm perception and attitudes toward marijuana after marijuana legalization and decriminalization.</p> <p>Several mechanisms have been proposed to explain the association between MML and marijuana use among adolescents. MML may increase the risk of marijuana use by increasing the availability and the accessibility of the drug to adolescents ([<reflink idref="bib7" id="ref56">7</reflink>]; [<reflink idref="bib33" id="ref57">33</reflink>]; [<reflink idref="bib41" id="ref58">41</reflink>]; [<reflink idref="bib45" id="ref59">45</reflink>]; [<reflink idref="bib47" id="ref60">47</reflink>]; [<reflink idref="bib52" id="ref61">52</reflink>]). In addition, information spread at the public debate on marijuana through the mass media prior to enactment of MML legislation may make adolescents less likely to perceive marijuana as harmful ([<reflink idref="bib18" id="ref62">18</reflink>]; [<reflink idref="bib28" id="ref63">28</reflink>]). Finally, MML passage may also increase peer approval, attitudes, and social norms regarding marijuana use ([<reflink idref="bib30" id="ref64">30</reflink>]; [<reflink idref="bib31" id="ref65">31</reflink>]). Additional studies are needed to examine these mechanisms.</p> <p>Consistent with the findings of this study, the American Academy of Child and Adolescent Psychiatry has issued a statement expressing concerns about the negative effects of medical marijuana on youth. "Medicalization" of marijuana has distorted the perception of the known risks and purported benefits of this drug ([<reflink idref="bib1" id="ref66">1</reflink>]). Likewise, in 2015, the American Academy of Pediatrics reaffirmed its opposition to legalizing marijuana ([<reflink idref="bib2" id="ref67">2</reflink>]). Findings from newly published studies indicate that increasing numbers of adolescents are now initiating marijuana use ([<reflink idref="bib10" id="ref68">10</reflink>]). No MML in any of the 29 states in the United States contain components to prevent marijuana abuse among adolescents either by strengthening current drug use prevention programs or establish new prevention programs. To effectively reduce the risk of increased drug use among U.S. adolescents, consideration should be given to the increasing current drug-use prevention efforts across the country, particularly the states with states laws legalizing marijuana use.</p> <hd id="AN0133201552-19">Limitations</hd> <p>There are limitations to this study. First, we analyzed data from only one state—Michigan. Caution is needed if generalizing these findings to other states. Second, the YRBS is conducted every other year, preventing us from assessing the MML on an annual basis, particularly during 2004–2008 when several local municipalities passed their MML prior to the statewide legislation. Third, marijuana use was measured using self-reported data. Misreport cannot be ruled out without biomarker validation, such as tetrahydrocannabinol from urine drug testing. Finally, this analysis was essentially a pre- and postcomparison by design with the years when MML were established as the only comparison variable. Many other factors may also be associated with adolescent marijuana use, such as changes in attitudes toward, and perceived harm of, marijuana; social influences and peer approval of marijuana use, and availability and accessibility to marijuana after enactment of MML and discrimination of marijuana use. Despite these limitations, findings of this study provide useful data supporting further research to address these factors, to enhance our understanding of the relationship between MML and marijuana use, and to inform efficient marijuana legislation and prevision adolescent drug-use prevention.</p> <p>No state without a MML (overall and by individual states) whose prevalence of adolescent marijuana use showed the same historical trends as Michigan up to 2008, estimated with the state Youth Risk Behavior Survey data. Data source: the 1997–2013 YRBS.</p> <p>Graph</p> <hd id="AN0133201552-20">Declaration of Conflicting Interests</hd> <p>The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</p> <hd id="AN0133201552-21">Funding</hd> <p>The authors received no financial support for the research, authorship, and/or publication of this article.</p> <hd id="AN0133201552-22">Author Biographies</hd> <p>Xinguang Chen, MD, PhD, FACE, professor in the Department of Epidemiology, University of Florida. Dr. Chen's research focuses on social capital and health, mental health, substance use and abuse. His interests also include Quantum Behavior Change theory and catastrophic statistics, and innovative analytical methods and models for public health and global health research.</p> <p>Yu Bin, MD, MPH, a doctoral student in the Department of Epidemiology, University of Florida. His research focuses on acculturation, mental health, substance use and abuse, HIV-related risk behaviors among vulnerable populations.</p> <p>Bonita Stanton, MD, professor of Pediatrics and Founding Dean, Hackensack Meridian School of Medicine at Seton Hall University. Her research over the last three decades has been focused on the community in settings across the globe.</p> <p>Robert L. Cook, MD, MPH, professor of Epidemiology and Medicine, and Director of the SHARC Center for Translational HIV Research at the University of Florida. His research focuses on the relationships of alcohol and marijuana use on health outcomes in diverse populations, including persons with HIV infection.</p> <p>Ding-Geng (Din) Chen, PhD, a fellow of American Statistical Association and the Wallace Kuralt distinguished professor at the University of North Carolina at Chapel Hill. He has more than 150 referred professional publications and co-authored and co-edited 23 books on clinical trial methodology, meta-analysis and public health applications.</p> <p>Chukwuemeka Okafor, PhD, MPH, is a postdoctoral research fellow in the Division of Infectious Diseases and Department of Family Medicine, David Geffen School of Medicine at UCLA. His current research is focused on behavioral risk factors - particularly substance use - that are associated with health indicators in persons living with or at-risk for HIV infection.</p> <ref id="AN0133201552-23"> <title> References </title> <blist> <bibl id="bib1" idref="ref66" type="bt">1</bibl> <bibtext> American Academy of Child & Adolescent Psychiatry. (2012). AACAP medical marijuana policy statement. 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  Label: Title
  Group: Ti
  Data: Medical Marijuana Laws and Marijuana Use among U.S. Adolescents: Evidence from Michigan Youth Risk Behavior Surveillance Data
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Chen%2C+Xinguang%22">Chen, Xinguang</searchLink><br /><searchLink fieldCode="AR" term="%22Yu%2C+Bin%22">Yu, Bin</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6941-8083">0000-0001-6941-8083</externalLink>)<br /><searchLink fieldCode="AR" term="%22Stanton%2C+Bonita%22">Stanton, Bonita</searchLink><br /><searchLink fieldCode="AR" term="%22Cook%2C+Robert+L%2E%22">Cook, Robert L.</searchLink><br /><searchLink fieldCode="AR" term="%22Chen%2C+Ding-Geng%22">Chen, Ding-Geng</searchLink><br /><searchLink fieldCode="AR" term="%22Okafor%2C+Chukwuemeka%22">Okafor, Chukwuemeka</searchLink>
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Drug+Education%22"><i>Journal of Drug Education</i></searchLink>. Mar-Jun 2018 48(1-2):18-35.
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  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 18
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2018
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22High+Schools%22">High Schools</searchLink><br /><searchLink fieldCode="EL" term="%22Secondary+Education%22">Secondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Marijuana%22">Marijuana</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Therapy%22">Drug Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Laws%22">Laws</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Use%22">Drug Use</searchLink><br /><searchLink fieldCode="DE" term="%22Risk%22">Risk</searchLink><br /><searchLink fieldCode="DE" term="%22High+School+Students%22">High School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Surveys%22">Surveys</searchLink><br /><searchLink fieldCode="DE" term="%22Trend+Analysis%22">Trend Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Michigan%22">Michigan</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/0047237918803361
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0047-2379
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Research findings are inconsistent regarding a positive association between the passage of state medical marijuana laws (MML) and the adolescent access and the use of marijuana. We utilized a novel analytical approach to examine this issue with multiyear data from the 1997-2013 Youth Risk Behavior Surveillance System of the State of Michigan. After controlling for the historically declining trend in marijuana use prior to the passages of MML in Michigan, we found that marijuana use among adolescents had increased subsequent to the passage of state MML. The study findings suggest the need for considering the increased risk of marijuana use in adolescents, as more states have implemented laws permitting marijuana use.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
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  Label: Number of References
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  Data: 54
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2018
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1196780
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1196780
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/0047237918803361
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 18
        StartPage: 18
    Subjects:
      – SubjectFull: Marijuana
        Type: general
      – SubjectFull: Drug Therapy
        Type: general
      – SubjectFull: Correlation
        Type: general
      – SubjectFull: Laws
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Drug Use
        Type: general
      – SubjectFull: Risk
        Type: general
      – SubjectFull: High School Students
        Type: general
      – SubjectFull: Student Attitudes
        Type: general
      – SubjectFull: Surveys
        Type: general
      – SubjectFull: Trend Analysis
        Type: general
      – SubjectFull: Comparative Analysis
        Type: general
      – SubjectFull: Michigan
        Type: general
    Titles:
      – TitleFull: Medical Marijuana Laws and Marijuana Use among U.S. Adolescents: Evidence from Michigan Youth Risk Behavior Surveillance Data
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            NameFull: Chen, Xinguang
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            NameFull: Yu, Bin
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            NameFull: Chen, Ding-Geng
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            NameFull: Okafor, Chukwuemeka
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            – TitleFull: Journal of Drug Education
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