ISSN 2691-7475 Health Policy Brief June 2020 The Changing Landscape: Tobacco and Marijuana Use Among Young Adults in California Ying-Ying Meng and Ninez A. Ponce ‘‘ In 2018, 1.66 million young adults in California were currently using SUMMARY: Use of tobacco products in any form and long-term recreational marijuanai use among young adults can be harmful to their health and well-being, according to the National Academies of Sciences, Engineering, and Medicine. This policy brief summarizes findings from the California Health Interview Survey (CHIS) that describe use of, reasons for, (e-cigarette), or marijuana product. Cigarette smoking, which had remained flat after a continued decade-long decline, was offset in 2018 by escalating use of e-cigarettes and marijuana among young adults: E-cigarette use climbed 48%, and marijuana use rose by 19% over one year. In 2018, only 1 in 5 young adults (19%) in the state reported using e-cigarettes at least one form and preferences for tobacco and marijuana use as a means of quitting, replacing, or reducing of cigarette, among young adults amid a changing policy cigarette smoking. Flavored cigarettes and e-cigarette, or landscape. In 2018, 1.66 million young adults (ages 18 to 25) in California were using at least e-cigarettes were popular, with nearly 8 in 10 young adults (77.8%) reporting that they were marijuana one form of cigarette, electronic cigarette vaping flavored e-cigarettes. ’’ products. Y oung adults are particularly at risk for harm and addiction, as the use of tobacco products in any form and long-term persons under 21 was prohibited in California; in addition, e-cigarettes became included in California’s smoke-free laws, thereby recreational marijuana use1 can be harmful prohibiting them in workplaces and many to their health and well-being.2 The use public spaces. In 2017, the cigarette tax was of electronic cigarettes (e-cigarettes) and raised from 87 cents to $2.87 per pack to marijuana among young adults can harm the disincentivize the purchasing behavior of developing brain, which continues to develop California’s smokers. Since 2019, some cities in until about age 25.3 Use in early adulthood California have banned the sale of e-cigarettes.4 also increases the risk of future addiction to other drugs.2, 3 In this policy brief, we focus on current use (that is, any use in the past 30 days) of Effective January 1, 2018, California legalized cigarettes, e-cigarettes, and marijuana among recreational marijuana for individuals ages Californians ages 18 to 25. We present overall 21 and over, but commensurately fortified trends in current use between 2017 and 2018, a policy environment that discouraged then present detailed data from 2018 on smoking and vaping. As of June 2016, the patterns of use by sociodemographic groups. sale of tobacco products and e-cigarettes to We also examine the use of flavored products such as menthol cigarettes and flavored i This policy brief uses the term “marijuana” rather than e-cigarettes, reasons for e-cigarette use, “cannabis” because Califonia Health Interview Survey respondents were asked about “marijuana.” and modes of marijuana consumption. The 2 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1 Trends in Current Use of Cigarettes, E-Cigarettes, or Marijuana, Adults Ages 18-25, California, 2017 and 2018 36.3%* Any Use 1.66 million 30.8% 28.5%* Marijuana 1.3 million 23.9% 14.9%* E-cigarette 682,000 10.1% 7.6% 6.9% Cigarette 314,000 2017 2018 Source: 2017 and 2018 California Health Interview Surveys * Differences between 2017 and 2018 were statistically significant at p<=0.05. ‘‘ Current e-cigarette use climbed by 48% and current marijuana use population-based insights on young adults give us an important picture of cigarette, e-cigarette, and marijuana use and behaviors, informing the design of policies aimed at curbing use of these products by young adults. Trends in Tobacco and Marijuana Use Use by Age, Gender, Race/Ethnicity, and Income Exhibit 2 presents patterns of current use of cigarettes, e-cigarettes, and marijuana by age, gender, race/ethnicity, and income. •Young adults ages 18-20 are smoking rose by 19% In 2018, 1.66 million young adults (ages 18- cigarettes at significantly lower rates 25) in California were currently using at least (4.6%) than young adults ages 21-25 among young one form of cigarette, e-cigarette, or marijuana (8.6%). adults between products: 314,000 smoked cigarettes, 682,000 •A wide and significant male-female 2017 and used (vaped) e-cigarettes, and 1.3 million difference is seen in e-cigarette use (9.3 2018. ’’ used marijuana. After a decade-long decline in smoking, there was no statistically significant change in cigarette use between 2017 and percentage points), with male e-cigarette use nearly double female e-cigarette use. Any use of cigarettes, e-cigarettes, or 2018 (Exhibit 1). In contrast, there was marijuana is also significantly higher for escalating use of e-cigarettes and marijuana. males than females. Between 2017 and 2018, current e-cigarette use (vaping) climbed by 48% among young •Young adults who are white have higher adults, and current marijuana use rose by 19%. rates of cigarette and e-cigarette use than The proportion of young adults currently those who are Latinx. Approximately 27% using any of these products increased by 18% of young adult Latinx, whites, and Asians between 2017 and 2018 (Exhibit 1). use marijuana. UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Sociodemographic Patterns of Current Use of Cigarettes, E-Cigarettes, and Marijuana, Exhibit 2 Adults Ages 18-25, California, 2018 Any Use of Percent of Cigarettes/ Population Cigarette E-Cigarette Marijuana E-Cigarettes/ Ages 18-25 Marijuana Total 6.9% 14.9% 28.5% 36.3% Age 18-20 43% 4.6%a 16.7% 27.0% 35.9% 21-25 57% 8.6% 13.6% 29.6% 36.6% Gender Male 51% 7.8% 19.5% 31.8% 40.9% Female 49% 5.9% 10.2%b 25.1% 31.6%b Race/Ethnicity* Latinx 30% 4.9%c 10.4%c 27.1% 32.1% White 27% 10.5% 19.0% 27.6% 38.4% Asian 17% NR 16.0% 27.1% 35.4% African American 5% NR NR 38.1% 43.6% Other Single 21% NR 16.4% 30.8% 38.9% Race/Multiracial Income as % of Federal Poverty Level 0-200% FPL 43% 8.0% 10.1%d 27.1% 33.0% >200% FPL 57% 6.0% 18.5% 29.5% 38.8% Source: 2018 California Health Interview Survey a Significantly different from 21-25-year-olds at p<=0.05. NR: Not reported due to instability of estimate. b Significantly different from males at p<=0.05. * Race tabulation is based on the UCLA Center for Health Policy c Significantly different from whites at p<=0.05. Research tabulation “racehp2_p1,” which classifies multiracial d Significantly different from income >200%FPL at p<=0.05. individuals and Latinx individuals according to their reported primary race identification. Other Single Race/Multiracial includes individuals who report Other Race, American Indian/ Alaska Native, Native Hawaiian/Pacific Islander, or more than one race. Estimates for American Indian/Alaska Native and Native Hawaiian/Pacific Islander were unstable for reporting. •Only e-cigarette rates differ significantly by income: Young adults with incomes at or below 200% of the federal poverty level (FPL) use e-cigarettes at lower rates than young adults with incomes greater than 200% FPL. Among young adult current marijuana users, 81% reported smoking marijuana with a joint, bong, or pipe, followed by vaping at 47%, use of a blunt at 43%, eating or drinking at 35%, and dabbing at 23%. Preferences by gender are comparable, with the exception that more young women ‘‘ Marijuana users tend to use multiple methods of consumption, with only Multiple Methods of Marijuana Use than young men significantly eat/drink 22.2% of young Marijuana users tend to use multiple methods of consumption, with only 22.2% marijuana (45% vs. 28%). We also examined preferences of marijuana use by age and found adult current of young adult current users reporting that that methods of marijuana use among young users reporting they use a single method. The many methods adults ages 18-20 are similar to the methods that they use a of consuming marijuana include smoking, vaporizing, dabbing, eating, or drinking. Dabs contain a higher concentration of used by those ages 21-25. single method. ’’ marijuana that can be smoked or vaped. 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Underage Use Exhibit 3 Main Reasons for Current Use of Underage young adults (ages 18-20) E-Cigarettes, Adults Ages 18-25, California, 2018 in California are subject to tobacco and marijuana purchase restrictions. In 2018, of the 314,000 young adults who reported Quit, replace, currently smoking cigarettes, 89,000 or reduce were underage smokers. Of the 682,000 Other reason cigarettes 23% young adults who reported currently using 19% e-cigarettes, 326,000 were underage; of the 1.3 million young adults who reported currently using marijuana, 527,000 were Social reasons, underage. enjoyment, curiosity 58% Conclusions Over the period from 2017 to 2018, California saw a tremendous increase in e-cigarette and marijuana use among young Source: 2018 California Health Interview Survey adults, while cigarette smoking remained flat. Significant differences by gender, race/ ‘‘ ethnicity, and income were observed in e-cigarette use. Over three- Surge in E-Cigarette Use E-cigarettes had the largest increase (48%) in California’s trends in cigarette and e-cigarette quarters of use between 2017 and 2018 (Exhibit 1) and smoking are parallel to those observed young adult had significant differences in use by gender, nationwide.3 What stands out in our findings e-cigarette users race/ethnicity, and income in 2018 (Exhibit 2). for California’s young adults ages 18-25 is the following: used flavored Of the 682,000 young adults who were current •1.66 million of 4.6 million (36%) young e-cigarettes in e-cigarette users in 2018, fewer than 1 in 5 ’’ adults in California reported current use of (19%) reported using e-cigarettes for quitting, 2018. replacing, or reducing cigarette smoking at least one form of cigarette, e-cigarette, or marijuana product in 2018. (Exhibit 3). A majority (58%) of young adults reported social reasons, enjoyment, and curiosity •Among young adults, e-cigarette use as top reasons for vaping. surged by 48% in a one-year period between 2017 and 2018. Preference for Flavored/Menthol Products Among e-cigarette users, 19% reported Almost 4 in 10 (36.8%; 116,000) young vaping to quit, reduce, or replace cigarettes. adults who were currently smoking cigarettes in 2018 usually smoked menthol cigarettes. •Flavored products were popular among Of these 116,000 menthol cigarette smokers, young adult current tobacco users. about 30% (34,000) were underage users Among current e-cigarette users, 8 in 10 (ages 18-20). reported vaping flavored products. Young adults preferred vaping flavored Among current cigarette users, 4 in e-cigarettes—candy, fruit, and other flavors. 10 reported usually smoking menthol Among current young adult e-cigarette users cigarettes. in 2018, over three-quarters (77.8%, or about •Marijuana use among young adults 531,000) used flavored e-cigarettes. increased by 19% between 2017 and 2018. UCLA CENTER FOR HEALTH POLICY RESEARCH 5 •Underage use (i.e., use among those ages 18-20) was substantial for e-cigarettes and marijuana. About half (48%; 326,000) of young adult current e-cigarette users were underage. e-cigarettes that would become effective in 2021.6 A new statewide tax on e-cigarettes could discourage consumption, based on the evidence concerning cigarette taxes and their effectiveness in reducing cigarette consumption.7 ‘‘ About 326,000 young adult current e-cigarette users and more More than half a million (40%; 527,000) Crafting policies that encompass the than half a current marijuana users were underage. e-cigarette market, where products and flavors are rapidly changing, presents million current Policy Recommendations challenges. Since laws on e-cigarettes are marijuana users In this changing smoking environment where young adults are experimenting with tobacco, e-cigarettes, and marijuana, policies new, there are fewer studies that rigorously measure the effectiveness of policies such as bans on flavored products or prohibition ’’ were underage. that affect the access and social environments of the sale of e-cigarettes. Nevertheless, of all three products should be considered the alarming growth in the use of flavored together. Policies need to ensure that young e-cigarettes among young adults has led adults do not switch from one product to to policies that ban all flavored nicotine another because of differential prices, access, products. In addition to the e-cigarette tax, and availability across products.5 Governor Newsom’s administration has signaled that it supports eliminating the sale Additionally, state and local jurisdictions of all flavored tobacco products as of January must engage and mobilize diverse 1, 2021.6 stakeholders in developing and implementing policy approaches and interventions. In the absence of a current statewide ban, Engaging with diverse stakeholders is more than 80 local California communities an important process that can promote have passed restrictions on the sale of equity and reduce health disparities, flavored tobacco products.8 Some California ensuring that policies and interventions jurisdictions have gone further, with several are culturally appropriate and are tailored enacting policies in 2019 that placed a to the needs of the target communities. moratorium or outright prohibition on Diverse stakeholders can also provide input the sale and distribution of e-cigarettes. to ensure that enforcement of policies will These jurisdictions include San Francisco, not contribute to systemic oppression of Sacramento, Los Angeles, Manhattan Beach, priority populations. These actions will also and Morro Bay, among others.4 increase the community buy-in and public support essential for the development, Apply effective local policies equitably implementation, and enforcement of policies. throughout the state’s diverse communities. Following are some policy approaches that Before the adoption of major statewide California should take to ensure that policies policies, cities and counties in California are equitably applied throughout California’s had been at the forefront of adopting local diverse communities. tobacco control policies.9, 10 However, according to a recent report of the American Adopt new and effective policies to curtail Lung Association (ALA), in 2018, about 50% the surge of emerging products. of Californians still lived in communities State and local governments could implement unprotected by at least some of these policy approaches and interventions for policies.10 Further, some studies highlight e-cigarettes and marijuana that have proved the inherent inequities in the geography of effective in tobacco control. Governor Gavin smoke-free policy coverage, as well as the Newsom has proposed a nicotine tax on known geographic clustering of tobacco 6 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ It is important to ensure that effective local policies are applied retailers and advertising in more vulnerable neighborhoods.11-13 Therefore, it is important to ensure that effective local policies are applied equitably throughout California. Local jurisdictions and states can set minimum floor price laws (MFPLs) for all •prohibiting the sale of tobacco products at retailers with pharmacy services; •capping and winnowing the number of retailers to whom the total number of tobacco retail licenses may be issued within a geographic area, and allowing only one new license for every three that equitably tobacco products, prohibit the sale of any are not renewed or that are revoked due to tobacco product (e.g., a pack of cigarettes) throughout enforcement violations; and ’’ for less than the set price, and pair MFPLs California. with minimum pack sizes. The policy could •prohibiting license issuance and future also prohibit the redemption of coupons, renewal for any tobacco retailer within price discounts, and other price promotions. 1,000 feet of a school. Studies have suggested that setting MFPLs and restricting price promotions may prevent Enforce the existing laws and policies. youth from uptaking tobacco.14-16 Equally important to the adoption of new policies is the enforcement of existing Cities, counties, and colleges and universities policies at both the local and state levels. can implement population-level strategies to The findings described in this brief on the reduce smoking and the social acceptability underage use of cigarettes, e-cigarettes, of smoking among young adults. A report and marijuana show that enforcement of of the U.S. surgeon general reached this existing laws and policies could be further conclusion: “Coordinated, multicomponent strengthened. Local jurisdictions could interventions that combine mass media regulate suppliers by preventing unlicensed campaigns, price increases including those retailers and underage sales of cigarettes, that result from tax increases, school-based e-cigarettes, and marijuana. Regulation by policies and programs, and statewide or licensing ordinances could include: community-wide changes in smoke-free policies and norms are effective in reducing •requiring tobacco and marijuana retailers to the initiation, prevalence, and intensity of pay an annual fee covering administration smoking among youth and young adults.”17 and enforcement efforts; Given the current smoking environment, it is •requiring all retailers to obtain a license to also important to explicitly include e-cigarettes sell tobacco or marijuana, with the license and marijuana in smoke-free policies—for renewed annually; example, in the smoke-free policies of multi- • considering any violation of a state, local, unit housing, schools, and outdoor dining areas. or federal tobacco law to be a violation of Evidence suggests that both the prevalence the license; and of and the disparities in cigarette smoking •creating financial deterrents (e.g., fines and might benefit from a reduction in tobacco penalties) for violations, as well as license retailer density, particularly in metropolitan suspension and revocation. areas.16, 18-20 These strategies include preventing clustering of tobacco retailers by: •prohibiting the issuance of a new tobacco retail license within 1,500 feet of an existing tobacco retailer; UCLA CENTER FOR HEALTH POLICY RESEARCH 7 In addition to the policy approaches Author Information above, investments in state tobacco control Ying-Ying Meng, DrPH, is a senior research programs that promote education and scientist and co-director of the Chronic Disease Program at the UCLA Center for Health Policy cessation assistance for young adults have also Research. Ninez A. Ponce, PhD, is director at the been found to be effective. Such programs UCLA Center for Health Policy Research, principal can include educational initiatives targeting investigator of the California Health Interview young adults and aiming to increase Survey, and a professor at the UCLA Fielding School awareness about the potential harm of using of Public Health. cigarettes, e-cigarettes, and marijuana.21 Funder Information In sum, strategies and policy options can be Support for this policy brief was provided by the designed and tailored based on the smoking California Tobacco Control Program, California Department of Public Health. This content is and vaping preferences and behaviors of young solely the responsibility of the authors and does not adults, as described in this policy brief. In necessarily represent the official views of the funder. addition to state policies, all California cities and counties have the legal authority to enact Acknowledgments policies concerning the use of cigarettes, The authors wish to thank Todd Hughes; AJ e-cigarettes, and marijuana. By monitoring and Scheitler, EdD; and Riti Shimkhada, PhD, of the considering the numbers and demographics UCLA Center for Health Policy Research for their review and comments. The authors also thank Zebry of users, their preferences, and the types of Jiang, MS; Eileen Zhou, MS; Florence Tse; Andrew use across cigarette, e-cigarette, and marijuana Juhnke, MPH; and Maia Smith, PhD, for their products, policies could be formulated to help statistical programming and data support. For their prevent access to these products for the 4.6 assistance with the publication of this policy brief, million young adults residing in the state. the authors thank Tiffany Lopes, Venetia Lai, and Elaiza Torralba. Data Source and Methods Data for this policy brief were drawn from the Suggested Citation 2018 California Health Interview Survey (CHIS) in Meng YY, Ponce NA. 2020. The Changing Landscape: conjunction with data from the 2017-2018 CHIS Tobacco and Marijuana Use Among Young Adults in annual data files. California. Los Angeles, Calif.: UCLA Center for The California Health Health Policy Research. Interview Survey (CHIS) In this policy brief, we used the responses to several covers a wide array of questions to define current users. Specifically, during Endnotes health-related topics, the CHIS 2017 and 2018 survey cycles, CHIS asked 1 National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis including health insurance adult respondents: “Have you ever used any type and Cannabinoids: The Current State of Evidence and coverage, health status of e-cigarette, vape pen, or e-hookah, such as Blu, Recommendations for Research. Washington, D.C.: The and behaviors, and access NJOY, or Vuse, or any larger devices for vaping, National Academies Press. to health care. It is based sometimes called vapes, tanks, or mods?” Among 2 National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2014. on interviews conducted those who responded positively, a follow-up question The Health Consequences of Smoking—50 Years of Progress: continuously throughout was asked: “During the past 30 days, on how many A Report of the Surgeon General. Atlanta, Ga.: Centers for the year with respondents days did you use electronic cigarettes?” Disease Control and Prevention. 3 U.S. Department of Health and Human Services. from more than 20,000 E-Cigarette Use Among Youth and Young Adults: A Report of California households. Similar sets of questions were asked about cigarette the Surgeon General. Rockville, Md.: Office of the Surgeon smoking and marijuana use. However, the questions General. CHIS is a collaboration differed. For marijuana use, the question was: “Have 4 American Nonsmokers’ Rights Foundation. 2020. States and Municipalities With Laws Regulating Use of Electric between the UCLA Center you ever, even once, tried marijuana or hashish in Cigarettes. for Health Policy Research, any form?” Then, to determine marijuana current 5 Saffer H, Dench DL, Grossman M, et al. 2019. California Department of use, CHIS asked the question: “How long has it been E-Cigarettes and Adult Smoking: Evidence From Minnesota. Public Health, California since you last used marijuana or hashish in any form?” Working Paper 26589. Cambridge, Mass.: National Bureau of Economic Research. Department of Health Care To define current cigarette smoking, respondents who 6 State of California. 2020. 2020-2021 State of California Services, and the Public answered yes to the CHIS question, “Altogether, have Budget Summary. Health Institute. For more you smoked at least 100 or more cigarettes in your 7 Chaloupka FJ, Straif K, Leon ME. 2011. Effectiveness of information about CHIS, entire lifetime?” were asked: “Do you now smoke Tax and Price Policies in Tobacco Control. Tobacco Control 20(3):235. please visit chis.ucla.edu. cigarettes every day, some days, or not at all?” UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 8 Campaign for Tobacco-Free Kids. June 1, 2020. States and Localities That Have Restricted the Sale of Flavored Tobacco Products. 9 Francis JA, Abramsohn EM, Park HY. 2010. Policy- Driven Tobacco Control. Tobacco Control 19 Suppl The UCLA Center 1(Suppl_1):i16-20. for Health Policy Research 10 American Lung Association in California. 2018. is part of the State of Tobacco Control 2018 - California Local Grades. UCLA Fielding School of Public Health. Oakland, Calif.: American Lung Association in California. 11 Hood NE, Bernat DH, Ferketich AK, et al. 2014. Community Characteristics Associated With Smokefree Park Policies in the United States. Nicotine & Tobacco Research 16(6):828-835. 12 Lowrie C, Pearson AL, Thomson G. 2018. Inequities in Coverage of Smokefree Outdoor Space Policies Within the United States: School Grounds and The analyses, interpretations, conclusions, Playgrounds. BMC Public Health 18(1):736. and views expressed in this policy brief are 13 Huang J, King BA, Babb SD, et al. 2015. those of the authors and do not necessarily Sociodemographic Disparities in Local Smoke-Free represent the UCLA Center for Health Policy Law Coverage in 10 States. American Journal of Public Research, the Regents of the University Health 105(9):1806-1813. of California, or collaborating 14 McLaughlin I, Pearson A, Laird-Metke E, et al. organizations or funders. 2014. Reducing Tobacco Use and Access Through Strengthened Minimum Price Laws. American Journal PB2020-4 of Public Health 104(10):1844-1850. Copyright © 2020 by the Regents of the University of California. All Rights Reserved. 15 Golden SD, Farrelly MC, Luke DA, et al. 2016. Comparing Projected Impacts of Cigarette Floor Editor-in-Chief: Ninez A. Ponce, PhD Price and Excise Tax Policies on Socioeconomic Disparities in Smoking. Tobacco Control 25 (Suppl 1):i60. 16 Slater SJ, Chaloupka FJ, Wakefield M, et al. 2007. Phone: 310-794-0909 The Impact of Retail Cigarette Marketing Practices Fax: 310-794-2686 on Youth Smoking Uptake. Archives of Pediatrics & Email: chpr@ucla.edu Adolescent Medicine 161(5):440-445. healthpolicy.ucla.edu 17 National Center for Chronic Disease, PaHP, Office on Smoking and Health. 2012. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, Ga.: Centers for Disease Control and Prevention. 18 Ackerman A, Etow A, Bartel S, et al. 2017.Reducing the Density and Number of Tobacco Retailers: Policy Solutions and Legal Issues. Nicotine & Tobacco Research 19(2):133-140. 19 Ribisl KM, Luke DA, Bohannon DL, et al. 2017. Reducing Disparities in Tobacco Retailer Density by Banning Tobacco Product Sales Near Schools. Nicotine & Tobacco Research 19(2):239-244. 20 Myers AE, Hall MG, Isgett LF, et al. 2015. A Comparison of Three Policy Approaches for Tobacco Retailer Reduction. Preventive Medicine 74:67-73. 21 Farrelly MC, Loomis BR, Kuiper N, et al. 2014. Are Tobacco Control Policies Effective in Reducing Young Adult Smoking? Journal of Adolescent Health 54(4):481-486. Read this publication online