Author ORCID Identifier

https://orcid.org/0000-0002-1677-1171

Year of Publication

2020

Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation

College

Graduate School

Department

Public Policy and Administration

First Advisor

Dr. Edward T. Jennings, Jr.

Second Advisor

Dr. Jeffery Talbert

Abstract

I am devoted to health policy research, especially tackling the opioid crisis, and evaluating marijuana laws and newly emerging issues associated with legal recreational drugs. Opioid overdose in the United States continues to jeopardize public health. Meanwhile, the majority of states have legalized medical marijuana and one third of them further liberalized recreational marijuana. Marijuana liberalization, although originally independent of the growing opioid crisis, may be a harm reduction approach to the crisis because marijuana may be a substitute for opioids in pain management at a relatively lower risk. However, marijuana liberalization may also lead to marijuana-related harms, such as marijuana-related emergency department visits. Moreover, e-cigarette use has been rising among youth and young adults at an alarming rate and led to the current outbreak of lung diseases.

My dissertation consists of three papers: “Paper 1: The Impact of Medical and Recreational Marijuana Laws on Opioid Prescribing in Employer-Sponsored Health Insurance,” “Paper 2: The Impact of Medical Marijuana Smoking Ban on Emergency Department Visits Related to Marijuana and Opioid Use,” and “Paper 3: Marijuana Use in E-Cigarettes among U.S. Youth.”

Paper 1 Abstract:

Marijuana may provide an alternative for pain management at a relatively lower risk of addiction and virtually no risk of overdose. Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2009 and 2015, I studied the effects of medical and recreational marijuana laws on opioid prescribing in employer-sponsored health insurance. I used a differences-in-differences (DD) approach and found that the implementation of medical marijuana laws (MML) and recreational marijuana laws (RML) reduced morphine milligram equivalents (MME) per enrollee by 7% and 13%, respectively. The reduction associated with medical marijuana laws was largely in people aged 55-64, while the reduction associated with recreational marijuana laws was mainly in people aged 45-54. My findings suggest that both medical and recreational marijuana laws have the potential to reduce opioid prescribing in the privately-insured population, especially for the middle-aged population and pain patients.

Paper 2 Abstract:

Medical marijuana liberalization has been spreading across U.S. states and empirical studies have found that medical marijuana and prescription opioids may be substitutes, yet no study has examined the impact of medical marijuana smoking bans on marijuana- and opioid-related emergency department visits, despite the fact that people historically prefer to smoke marijuana for medical purposes, and most marijuana-related emergency department visits were associated with Cannabinoid hyperemesis caused by smoking marijuana. The purpose of this study is to examine the impact of smoking bans by analyzing a nationally representative sample of the privately-insured population.

Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2011 and 2016, I employed a differences-in-differences (DD) quasi-experimental design to examine the differences in marijuana- and opioid-related ED visits between states with medical marijuana smoking bans and states without such bans. I aggregated the data at the state/month level.

I found that state medical marijuana laws with smoking bans were associated with a decrease in the number of marijuana-related ED visits by -3.289 per month (95% CI=-5.453, -1.125), which can be translated to a 16.3 percent decrease. State medical marijuana laws with smoking bans were associated with a decrease in the number of opioid-related ED visits by -3.808 per month (95% CI=-6.703, -0.913). The combination of medical marijuana laws with smoking bans and legal dispensaries was consistently associated with decreases in marijuana- and opioid-related ED visits among all ages.

The findings suggest that medical marijuana laws with smoking bans coupled with legal dispensaries may improve the safety of marijuana use without compromising the accessibility of marijuana.

Paper 3 Abstract:

Non-nicotine substances, including marijuana and THC concentrates, can be used in e-cigarettes. By 2014, e-cigarettes had replaced traditional combusted tobacco products, such as cigarettes, and become the most prevalently used nicotine products among US youth. E-cigarette use among US youth continues to grow rapidly. State liberalization of medical and recreational marijuana makes marijuana more accessible and further reduces public perceived riskiness associated with marijuana use. Previous research has documented youth concurrent use of nicotine and other substances in e-cigarettes.

I used data from the 2016, 2017 and 2018 National Youth Tobacco Survey (NYTS), a nationally representative sample of US 6 to 12 grade students to examine the trend of marijuana use in e-cigarettes as well as behavioral and environmental factors associated with marijuana use in e-cigarettes.

I found that marijuana vaping increased among high school students but not among middle school students from 2016 to 2018. Being male was at greater odds of marijuana vaping. Compared to White non-Hispanic students, Hispanic students were at greater odds of marijuana vaping, while other non-Hispanic students were at lower odds of marijuana vaping. High school students were at greater odds of marijuana vaping than middle school students. The odds of marijuana vaping increased among high-school Hispanic females and among other non-Hispanic males from 2017 to 2018. The odds of marijuana vaping increased among high-school black females and among middle-school Hispanic females from 2016 to 2017. Both high-school Hispanic females and males were increasingly more likely to vape marijuana from 2016 to 2018 after controlling for behavioral and environmental factors. The odds of marijuana vaping continuously increased among those who did not report flavors as one of the reasons of using e-cigarettes from 2016 to 2018, among those who did not report less cost as one of the reasons of using e-cigarettes from 2016 to 2018, and among those who did not report less harmfulness as one of the reasons of using e-cigarettes from 2016 to 2018.

My findings suggest that E-cigarette policy may need to focus on the increase in marijuana vaping among Black and Hispanic female students, and Hispanic students in general. Banning flavored e-cigarettes may not reduce marijuana vaping among youth. Lower cost and less perceived harmfulness associated with e-cigarette use may not be associated with the trend of marijuana vaping among youth.

Digital Object Identifier (DOI)

https://doi.org/10.13023/etd.2020.136

Funding Information

The research was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998 (2017- 2018). The content is solely the responsibility of the author and does not necessarily represent the official views of the NIH.

Available for download on Saturday, August 13, 2022

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