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IUMSP Institut universitaire de médecine sociale et préventive, Lausanne Tell me what you smoke and I'll tell you where you'll end: tobacco, cannabis and.

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Presentation on theme: "IUMSP Institut universitaire de médecine sociale et préventive, Lausanne Tell me what you smoke and I'll tell you where you'll end: tobacco, cannabis and."— Presentation transcript:

1 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne Tell me what you smoke and I'll tell you where you'll end: tobacco, cannabis and adolescents Joan-Carles Suris, MD, PhD Université de Lausanne, Switzerland

2 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 2 Four youths… Youth 1Youth 2Youth 3Youth 4 Age16 TobaccoNo Yes CannabisNoYesNoYes Which one are you the most worried about? Which is the second one you are the most worried about?

3 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 3 Outline  Some epidemiological data  Theories  Tobacco and cannabis  Ups and downs (controversies)  Predictor factors  Trajectories (TREE cohort)

4 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 4 Some epidemiological data

5 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 5 Smoking at least once a week, 15 year-olds Source: HBSC 2006

6 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 6 Cannabis in the last 30 days, 15 year-olds Source: HBSC 2006

7 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 7 Girls: current cannabis/tobacco 15 year-olds Source: HBSC 2006

8 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 8 Boys: current cannabis/tobacco, 15 year-olds Source: HBSC 2006

9 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 9 Last 30 days, Spain, year-olds

10 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 10 Theories

11 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 11 Gateway theory (Kandel, 1975) No use Tobacco and/or Alcohol CannabisOther illegal drugs Reverse gateways (Patton et al., 2005) No use CannabisTobacco

12 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 12 Tobacco and cannabis

13 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 13 21% of cannabis users declared never having smoked cigarettes Cannabis-only adolescents showed better functioning than those who also used tobacco. Compared with abstainers, they were more socially driven and did not seem to have psychosocial problems at a higher rate.

14 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 14 Ontario Child Health Study (OCHS) Tobacco onlyCannabis onlyTobacco & cannabis Physical health- Life satisfaction- Personal income - Years of education- Depression- Georgiades & Boyle, J Child Psychology Psychiatry, 2007

15 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 15  Pure joints are too strong  Pure joints do not burn correctly  It is too expensive to smoke pure joints

16 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 16 Evidence now indicates that nicotine dependence and persistent cigarette smoking may be the main public health consequences of cannabis use Agrawal et al., Drug & Alcohol Dependence, 2008

17 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 17 Ups and downs (controversies)

18 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 18 Is it just a ‘phase’? In contrast to users of tobacco and alcohol, most cannabis users quit using cannabis relatively early in their adult lives. Sidney S, BMJ, 2003

19 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 19 Between the ages of 18 and 24 about three-quarters of the sample did not use marijuana (47%) or used it only infrequently (28%) Schulenberg et al., J Drug Issues, 2005

20 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 20 For many young people, some or even frequent marijuana use appears to be developmentally limited and not associated with difficulties with the transition to adulthood Schulenberg et al., J Drug Issues, 2005

21 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 21 The progression to higher usage categories during the follow-up period is more frequent than to lower categories Perkonigg et al., Addiction, 1999

22 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 22 While many young people moderate their cannabis use patterns during adolescence, the impact of moderation on later regular/dependent use may be limited, particularly among adolescents initially reporting regular cannabis use Swift et al., Addiction, 2009

23 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 23 Although the use of cannabis is not harmless, the current knowledge base does not support the assertion that it has any notable adverse public health impact in relation to mortality. Sidney S, BMJ, 2003

24 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 24 Predictor factors

25 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 25 The life-event effect At age years, married respondents and those who were parents were overrepresented in the Decreased and Abstain groups Schulenberg et al., J Drug Issues, 2005

26 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 26 Early alcohol dependence may be a selective risk factor, discriminating those with a long-term risk of chronic use from those who stop using cannabis after adolescence or early adulthood Perkonigg et al., Addiction, 2008 Alcohol

27 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 27 Youth who had never tried cannabis at baseline were found to be most likely to be classified as non-users at follow-up (82%) and regular users classified with considerable use at baseline are also likely to remain in the same group (54%) Perkonigg et al., Addiction, 1999 Prior use

28 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 28 A dose-response effect Overall the probability of stopping cannabis use decreases fairly consistently with increased frequency of use at baseline. This pattern seems to suggest a “dose- response” relationship: the higher the baseline use, the higher the probability of continued and heavier use at follow-up Perkonigg et al., Addiction, 1999

29 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 29 Association between adolescent and young adult cannabis use Weekly+ at age 24Dependent at age 24 No use Occasional use11 Weekly use Daily use waves waves Late reported use11 Early reported use Swift et al., Addiction, 2008

30 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 30 Tobacco It appears that adolescent tobacco use accounts for much of the distal association between adolescent cannabis use and adult outcomes Georgiades & Boyle, J Child Psychology Psychiatry, 2007

31 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 31 Male gender, regular cannabis use (weekly), persistent antisocial behavior, and persistent cigarette smoking independently predicted cannabis dependence Coffey et al., Br J Psychiatry, 2003 Tobacco & Cannabis

32 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 32 Simultaneous users of tobacco and cannabis are an especially vulnerable population Agrawal et al., Drug Alcohol Dependence, 2009 Tobacco & Cannabis

33 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 33 Trajectories (TREE cohort)

34 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 34 Methods  Data were drawn from the TREE cohort (www.tree-ch.ch)www.tree-ch.ch  A longitudinal study of a representative sample of Swiss youth surveyed yearly from 2001 (T1, N=5528, mean age 16.7 years) to 2007 (T7, N=3979, mean age 22.7 years).  According to their use of tobacco and/or cannabis at T1 (N=1955), subjects were divided in 4 groups:  Those using cannabis only (N=45, 2.3%)  Those using tobacco only (N=518, 26.5%)  Those using both substances (N=360, 18.4%)  Those using neither (N=1032, 52.8%)

35 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 35 Methods (2)  Outcome variables at T7 were:  Smoking: No Occasionally Daily  Cannabis use: No Occasional (less than weekly) Regular (weekly or more)  We performed a multinomial logistic regression using the group neither as the reference category and controlling for age, gender and alcohol use at T1

36 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 36 Results Cannabis only at T1 (N=45) Tobacco only at T1 (N=518) Tobacco & Cannabis at T1 (N=560) Occasional tobacco at T7 1,18 [0,54/2,60] 3,91 [2,42/6,33] 5,29 [2,50/11,18] Daily tobacco at T7 1,88 [0,59/3,97] 17,73 [11,24/27,96] 16,37 [8,22/32,62] Occasional cannabis at T7 4,57 [1,44/14,52] 1,27 [0,49/3,28] 4,62 [1,55/13,79] Regular cannabis at T7 6,31 [1,74/22,82] 1,76 [0,54/5,75] 15,83 [4,57/54,84] (Controlling for age, gender and alcohol use at T1)

37 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 37 Results: Cannabis only at age 16 Cannabis only 49% 28% 16% 7% Cannabis only Abstinent Tobacco only Tobacco & Cannabis Age

38 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 38 Tobacco & Cannabis Cannabis only Abstinent Tobacco only Tobacco & Cannabis Results: Tobacco & Cannabis at age 16 11% 44% 42% 4% Age

39 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 39 Results: Tobacco only at age 16 Tobacco only 21% 66% 12% Cannabis only Abstinent Tobacco only Tobacco & Cannabis Age 1%

40 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 40 Results: Abstinent at age 16 Abstinent 73% 23% 3% 1% Cannabis only Abstinent Tobacco only Tobacco & Cannabis Age

41 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 41  At age 16 they are already in a substance use trajectory  Occasional/recreational cannabis use can often be a phase, but…  The use of both substances is the one with worse outcomes  Between ages 16 and 22, it is more frequent to go from cannabis to tobacco than the other way around [Some] take home messages

42 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 42  Alcohol is an important predictor factor  Life events are also an important predictor factor (both ways)  Having faith in the future is a protective factor  Age solves (almost!) everything [Some] take home messages (2)

43 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 43 Let’s return to our four youths… Youth 1Youth 2Youth 3Youth 4 Age16 TobaccoNo Yes CannabisNoYesNoYes Which one are you the most worried about? Has the second one you are the most worried about, changed ?

44 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 44 “Can these findings be used to recommend a ‘safe’ level of adolescent cannabis use with regard to later problematic use? Although regular adolescent cannabis users appear to have an elevated long-term risk of problematic cannabis compared to their less regularly using peers, occasional adolescent use per se clearly does not preclude the outcomes at age 24. It would be irresponsible to promote such use as ‘safe’” Swift et al., Addiction, 2008

45 IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 45


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