WSLCB - Board Caucus
(July 26, 2022) - WA Young Adult Health Survey

Washington Young Adult Health Survey - WYAHS
[ Event Details ]

An expert on cannabis use by young adults provided results for the Washington Young Adult Health Survey before talking through education, prevention, and research topics of concern.

Here are some observations from the Tuesday July 26th Washington State Liquor and Cannabis Board (WSLCB) Board Caucus.

My top 3 takeaways:

  • Kilmer reviewed the latest WYAHS results and cannabis trends before speaking to areas which concerned him, like cannabis use disorder (CUD, audio - 17m, WSLCB video, TVW video, presentation).
    • Thanking Segawa, Kilmer began with the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) data from the 2020 National Survey of Drug Use and Health (NSDUH), commenting that 18-25 year olds reported the “most prevalent cannabis use” with 34.5% of that demographic having consumed cannabis in the prior year, compared to “26 and older, 16.3%.” After joking that he appreciated SAMHSA “putting me in an age group with 26 year olds,” he emphasized that while 18-25 year olds had the highest rate of cannabis use, “the majority do not use.” Mentioning that studies back to the 1980s “show that when people hear or think or believe that ‘everyone uses,’ they're more likely to start,” Kilmer added people were then “more likely to” continue and the perception of use can “even be a barrier to someone making a change.” He’d found that “opportunities to correct misperceived norms” required documenting what those norms were.
    • The WYAHS was conducted with the support of the Washington State Health Care Authority (WA HCA) Division of Behavioral Health and Recovery (DBHR). Kilmer noted Substance Use Disorder Prevention and Mental Health Promotion Section Manager Sarah Mariani was a “main contact” under a contract managed by Epidemiological Prevention Research and Evaluation Manager Sandy Salivaras Murphy. He acknowledged the rest of the WYAHS team:
    • The concept for the survey began following voter approval of Initiative 502 (I-502) in 2012, Kilmer explained, and researchers aimed to start collecting data before “the first retail store opened in July 2014.” Their first survey included “69% of the data collected before the first store opened its doors,” he said, and “the remaining 30.7% we collected into August” when “only 18 stores had opened statewide by July, only 31 had opened by August.” According to Kilmer, the information was intended “as a pre-time point for the implementation of legalization.”
    • Survey participants were recruited with “a combination of methods” like direct mail or online ads, rather than a “random sample.” He described how this approach allowed them “the ability to monitor data as they were coming in” which enabled the team “to modify strategies to recruit samples that were being underrepresented.” Kilmer asserted that this was “a strength because it has let us get data from people that otherwise might not have been identified.” Their results were further modified with U.S. Census data for Washington State resulting in “a weighted sample matched on gender, race, and geographic region,” he said. A positive he’d found was that the “weighted results are consistently very similar to the non-weighted.” Since the WYAHS was initiated, they’d collected “over 16,000 groups” of responses from individual 18-25 year olds, and “each year, we follow up with previous cohorts.”
      • Kilmer did not mention that participants who complete the online survey “will be paid $10 in the form of an Amazon.com gift card.”
    • Kilmer credited Katarina Guttmannova, a UW Adjunct Professor of Psychology, who “applied for and obtained a secondary data analysis grant” giving them “the opportunity to do a deeper dive into this very rich data set” than WA HCA funding alone would permit. Kilmer noted that Rhew had investigated “Associations of cannabis retail outlet availability and neighborhood disadvantage with cannabis use and related risk factors among young adults in Washington State,” finding that “living within 1-kilometer of at least one cannabis retail outlet was statistically significantly associated with any past year and at least monthly cannabis use as well as high perceived access to cannabis. Results using a 2-km buffer and census tract-level metrics for retail outlet availability showed similar findings. Neighborhood disadvantage was statistically significantly associated with at least weekly and at least daily cannabis use and with greater perceived acceptability of cannabis use.” Larimer, Guttmannova, and Kilmer himself also contributed to the paper.
    • Turning to research he’d led with “just shy of 13,000 young adults in Washington” while trying to “control for everything we could,” Kilmer concluded that “among young adults in Washington, particularly those of legal age, prevalences of cannabis use and cannabis use disorder symptomatology have increased since legalization.” He stated that in this “already at risk age group…it seems to be those with legal access who are driving these significant increases. Those over 21 are driving that significant finding for any past year use, at least monthly use, this is a significant difference for those over 21.” Kilmer was certain that cannabis could be addictive, saying CUD had “clear criteria” even as the nomenclature for the disorder had changed over time. He’d seen that “more were using, using frequently, and using in a degree that led to reporting more” CUD symptoms.
    • Speaking to trends “in the two years that followed,” Kilmer remarked that there had been “a statistically significant difference when we look across cohorts anywhere” in adult use of cannabis since retail stores began opening in Washington. “We've been able to say for years that most young adults in Washington don't report cannabis use,” he said, but “in 2021, that changed, we were over 50% said at least once in the past year that they reported cannabis use” and that similar increases in past monthly or weekly use had been driven by increased use by adults 21-25 allowed to access cannabis legally.
    • Kilmer moved to issues of perceptions and social norms around cannabis, commenting that “We ask people ‘what is the typical person your age in Washington do, what does their cannabis use look like?’”
      • What he’d found was “a troubling increase” in young adults believing most people in their age group used cannabis, and now “over 68% thought the typical person their age used weekly or more,” even though the reported proportion of 18-25 year olds consuming cannabis that frequently was 21.62%. Because “misperception matters,” Kilmer remained worried about increased use.
      • As to where young adults under 21 were obtaining cannabis, he noted a “decreasing trend in getting it from friends and we've seen a decreasing trend in getting it from someone with a medical marijuana card.” However, the survey showed increasing occurrences of paying someone else to buy for them, accessing cannabis through their parents, and even stealing from retail outlets “which was a new finding that theft especially during the last two years” of 2020 and 2021. 
      • Young adults over 21 bought cannabis from legal retail stores as they became available, he indicated, and access decreased “from all other sources.”
      • With “parent-based opportunities,” Kilmer said education on “everything from addiction potential to academic outcomes to mental health risks associated with cannabis use including high potency cannabis use can be noteworthy.”
    • Driving following cannabis use had been declining, Kilmer told the board, though he still found rates to be “at relatively uncomfortably high levels.” He said that when I-502 had been enacted, only one study had “looked at five nanograms of [tetrahydrocannabinol] THC per milliliter of blood, which is our state's per se limit.” Kilmer claimed that “the research that's come out since then have said when smoked, people might want to wait six to eight hours” before driving, or wait 8-12 hours after consuming a cannabis edible. WYAHS results showed a declining trend from “almost half” of consumers driving within three hours “down to the point where a little over a third say they’ve driven at least once” within three hours of use within the past year.
    • For medical cannabis use, Kilmer had seen “no significant differences in any past year use, nor overall categories of use, yet perceptions of medical use are increasing significantly.” With other substances, the survey revealed a “significant decreasing trend in at least once per year” use of alcohol, cigarettes, non-prescribed pain relievers, and opiates, he stated. Moreover, “perceived risk of two drinks every day is going up,” but Kilmer remained concerned about a decreasing perception of risk of cannabis as harmful, having heard the sentiment that “it's just weed, it's natural” or “it's safer than alcohol” when there were health risks “especially with high potency cannabis.” The ninth year of WYAHS data would be released later in 2021, he commented.
  • Board members asked about topics including CUD, impaired driving, cannabis “normalization,” treatment, research funding, and synthesized cannabinoids.
    • Board Member Jim Vollendroff, drawing on his background in substance prevention, thanked Kilmer and expressed his appreciation that “we're having these types of discussions with the board." He asked if WYAHS results were showing increases in CUD or cannabis consumption overall. Kilmer replied that “both of those are going up” but researchers were getting more “reliable, valid measures for cannabis use” that weren’t merely changing “the word ‘alcohol’ to ‘cannabis’” to make it “a marijuana survey.” WYAHS didn’t detect more than daily use, but he was confident “not only that more people are using, but those that are using are using more frequently, and endorsing more symptoms associated with cannabis use disorder” (audio - 2m, WSLCB video, TVW video).
    • Next, Vollendroff inquired what the CUD designation was based on. Kilmer answered it was self-reported symptoms designated by “endorsing items associated with cannabis use disorder.” He emphasized no diagnosis could be made based on survey results alone, but the results indicated symptomatology was increasing (audio - 1m, WSLCB video, TVW video).
    • Vollendroff wanted to know if Kilmer had a “hypothesis” for the reported decrease in young adults driving following cannabis use. “It’s really hard to know,” Kilmer observed, pointing to a grant “looking exactly at that” underway by Brittney Hultgren, UW Acting Assistant Professor of Psychiatry, CSHRB faculty, and researcher. He said she’d studied “driving under the influence of alcohol, of cannabis, of both, and also people’s willingness to be a passenger in a car with people who have been using.” He felt the state had "done what it can" to educate the public, and complemented public safety efforts like increased impaired driving patrols on April 20th. “We’ve heard people subjectively say that as potency has gone up they've realized…’I'm not good to drive,’” and that “people hypothesize a number of different things” but Hultgren’s research was something officials should follow “for a future opportunity” (audio - 1m, WSLCB video, TVW video).
    • Then, Vollendroff wondered about “public information campaigns.” He complimented posters for a campaign he’d seen on a trip to New York and was curious about their effectiveness. Kilmer remarked that Washington Association for Substance Abuse and Violence Prevention (WASAVP)  Co-Vice President Mike Graham-Squire had used WYAHS data to create “a norms campaign in King County” called Most Steer Clear which highlighted how most young adults in that county weren’t using cannabis and “most aren’t driving under the influence.” Kilmer felt this educated young adults and reinforced positive social expectations, as knowledge alone didn’t “always change behavior.” If the goal was to “change behavior through a public health campaign, you need behavior change strategies embedded in that,” he explained (“scare tactic-y stuff, not so helpful”). Kilmer spoke favorably about using QR codes to make it convenient for people to learn more after encountering an ad (audio - 2m, WSLCB video, TVW video).
    • Vollendroff was grateful to see campaigns “leading with the information that most young people are not using” and felt it was “super important to continue to emphasize that.” Another of his questions involved the availability of “mini-grants” for “things like public campaigns, or the work that you're doing.” Kilmer favored additional funding for “timely, immediate, emerging issues” but found the process for federal grants took too long, and “by the time you get the funding, the issue is passed.” If new grants were executed faster and “data-driven,” he believed they could “advance our understanding or the science around an issue, those are incredible and…can be very, very valuable.” He felt there were researchers who would partner with local leaders to get information “out there in the real world.” He credited Guttmannova’s supplemental grant with helping WYAHS data reach more people than the survey would have otherwise. Vollendroff promised to follow up with Kilmer on the topics he’d raised (audio - 3m, WSLCB video, TVW video).
    • Board Member Ollie Garrett shared her gratitude with Kilmer and said his “information was very valuable” (audio - <1m, WSLCB video, TVW video).
    • Board Chair David Postman was also thankful for Kilmer’s perspective. His first question involved perceptions around cannabis use “where people seem to think in their own cohort a lot more people are using than report they are using,” postulating it was evidence of “a concern of…kind of cultural acceptance.” Kilmer argued that during the 1980s “a number of researchers showed that people tend to way overestimate the percentage of people that engage in a behavior, and they believe that those that do, do it more than they actually do.” The more pronounced that misperception was, he said, “the more [likely] people were to use,” including consumption when there were “consequences.” His simple explanation for this was: “it's how we work as people.” In a circumstance where “people smell weed they're like, ‘well, I forgot we're in Washington’…or in an apartment building, or a residence hall in a college campus. Someone's using on the floor” leads to a perception that “everyone's using here and the fact that it persists” could engender an attitude of “permissibility.” He noted things which could influence perceptions around permissibility included “billboards, public use, storefronts, signs…things done visibly and publicly that send a potential mixed message, all of that can come into play” (audio - 4m, WSLCB video, TVW video).
    • Postman followed up by asking about potential public health benefits to “normalizing something like cannabis” and setting social expectations like there were for alcohol. Kilmer replied that "we talk about norms and destigmatizing very differently,” with normalizing tending to mean “majority behavior.” Besides annual cannabis use as documented in the 2021 WYAHS survey, he stressed that “most people aren’t using” cannabis, and that the majority of 18-25 year olds around the state weren’t. Kilmer said that normalizing had a different meaning to him: “what's been clear is that in the eight years following the implementation of legalization…it's been so rapidly evolving, the products are evolving, the potencies evolving, laws and rules are evolving, what can be done and not done with advertising is evolving. All of that is changing.” This left him uncertain how to “normalize something that's a moving issue," but comparisons with alcohol policy making suggested that a variety of strategies were needed. “Yes, prevention is part of it, but there's also policies, enforcement of those policies” and education, treatment, and “recovery support.” He concluded that “it's a big package deal” (audio - 2m, WSLCB video, TVW video).
    • Postman wanted to know if some consumption trends were reflective of the fact that young adults were “getting more comfortable with” legal cannabis access. Kilmer interrupted to say that federal data on cannabis use had been collected for “over 20 years” and that in his research “we do everything we can to boost the reliability and validity” of self-reported numbers. He emphasized that his team had a “federal certificate of confidentiality which even protects their data from subpoena.” This gave him “a lot of faith in people being honest in their data” and that “people have historically always been comfortable disclosing, in a confidential survey, their marijuana use” (audio - 1m, WSLCB video, TVW video).
    • Postman was curious if there was a way to “overlay” data about individuals seeking treatment with WYAHS data. Kilmer told Postman that was possible, though "it would be complicated because there are other factors at play" (audio - 1m, WSLCB video, TVW video).
    • Postman then asked about educational campaigns about CUD, to which Kilmer answered he wasn’t aware of any. He stated that researchers had considered how to “reach people that might not seek treatment” and thought one option was to have every visit to a healthcare provider include a mandatory survey to screen for CUD, “that alone is an educational tool.” Kilmer speculated that “a lot of what people are coming in for…could either be caused, by or made worse, by their cannabis use,” since “a lot of the reasons that college students report use of cannabis are actually symptoms of withdrawal. And so we've realized the opportunity to let people know that if a person has a cannabis use disorder the potential for withdrawal when they stop or make a change in their use, is a possibility” (audio - 1m, WSLCB video, TVW video).
    • The last question from Postman involved research funding: “if you had the opportunity to go seek funding from the legislature…what would it be?” Kilmer responded that while he didn’t have a specific project in mind, "we've learned a lot more about high-potency products,” his team was getting better at analyzing collected data, “and we'd be thrilled to do something.” Postman pointed out that Vollendroff was “working on a briefing for…on our own budget, where the cannabis money goes” which could “help us…set a baseline of knowledge” (audio - 2m, WSLCB video, TVW video).
    • In closing, Vollendroff asked for Kilmer’s final thoughts on three topics: a New York Times article indicating “teens are getting sick from high potency THC levels,” delta-8-THC which he’d seen “in the news a lot,” and mental health associations with cannabis (audio - 4m, WSLCB video, TVW video).
      • Kilmer bragged that the “most cited tool” in the article Vollendroff had mentioned was the consensus report on risks associated with higher potency cannabis products he and others had authored, and the article had been reprinted by the Seattle Times.
      • He noted that delta-8-THC had been added to the WYAHS “this year” to hopefully inform researchers if use of the synthesized cannabinoid was “as widespread as we’re hearing.”
      • As for mental health, Kilmer indicated that the Washington State Prevention Research Subcommittee had found that "the more frequent the use" of high-potency cannabis, the more “it's associated with a range of different mental health concerns.” Daily use of high-potency products meant “odds of developing a psychotic disorder go up 4.8 to 5.8 times over people who do not use at all,” he said. Kilmer was aware of research that “showed more anxiety with the use of high-potency cannabis.” 
      • Citing Christine Lee, Research Professor of Psychiatry and Behavioral Sciences and CSHRB Associate Director, Kilmer stated that some college students had reported using cannabis for things like “depressed mood, anxiety, appetite problems, headaches, and sleep problems” which he identified as withdrawal symptoms of CUD. He felt it was possible that those reporting using cannabis to treat anxiety were in fact “resuming substance use making withdrawal symptoms stop.” Kilmer then mentioned research by University of Queensland professor Wayne Hall who “showed, years ago, for our college coalition, [research on] depression and suicide risk. He said ‘we do not pretend to think one drives the other, but if one is present we want to assess the other two.’” He was certain that “something's going on with cannabis use disorder, depression, and suicide risk.”
    • Postman thanked Kilmer, encouraging him to return once he’d seen more delta-8-THC data, and thanked Segawa for arranging the visit. He anticipated "more conversations like this” in the future (audio - 1m, WSLCB video, TVW video).

Information Set