True or false—putting ice in a bong makes smoking safer?
Turns out, a lot of cannabis consumers think so. Twenty-three percent of the hundreds of people who took a survey at the University of Michigan’s annual Hash Bash incorrectly identified ice as a way to lower health risks when consuming cannabis. Meanwhile, only 38 percent endorsed not mixing cannabis with tobacco as a harm reduction strategy.
Evidence supports many real ways to be safer when consuming cannabis: Wait six hours before driving a car, for example. Use a vaporizer instead of smoking. Don’t smoke while pregnant. But in a country just getting used to the idea of legal cannabis, truth can mix with myth and misperceptions in advice that is often spread through word of mouth. A government-level approach that focuses on evidence-based harm reduction, experts say, would reduce the uncertainty.
Abstinence-only has long been the de facto message for public safety campaigns around drugs—from Nancy Reagan’s “Just Say No” campaign and the subsequent Drug Abuse Resistance Education program (D.A.R.E.) to the National Youth Anti-Drug Media Campaign. But emerging research suggests that a harm-reduction approach could be more useful. Harm reduction is a technique increasingly implemented for users of opioids and other substances that focuses on educating users and providing them with safer ways to consume a substance rather than pushing them to stop completely. Opioid substitution maintenance therapy and needle exchange programs, for example, have been shown to reduce overdoses and increase rates of cessation.
When it comes to cannabis, Colorado’s “Responsibility Grows Here” is an example of a public health campaign that incorporates information on state laws with harm reduction elements, like tips from “Meg the Budtender” on consuming edibles, cautions for pregnant and breastfeeding moms, and talking points for parents. Cannabis Wire spoke with Jessica Kruger of the University of Buffalo’s Department of Community Health and Health Behavior, who conducted the Hash Bash study and published the findings in the journal Health Promotion Practice this May. She said that more states should take a public safety approach that focuses on harm reduction and education. (This conversation has been lightly edited for clarity.)
Sophie Putka, Cannabis Wire: Could you tell me briefly about your background with regard to cannabis?
Jessica Kruger, University of Buffalo: My venture into cannabis studies actually started because I was researching the “drunchies,” the drunk munchies. Through our research of the drunchies, I made an offhand comment to one of my collaborators and said, “Ah, now we’ve got to prove the munchies.” And we looked at each other and said, “Oh, no one’s done that before.” So we had to figure out a way to see if we could prove the age-old legend of the munchies. And, in fact, we did this through going to Hash Bash and having people fill out a survey about their cannabis use, but also about their eating habits. We found that, on average, people said that they ate less healthily when they were using. We also, as part of that, had them choose an incentive—and our incentive was food, so for taking this survey they could choose between chips or a mandarin orange. And, you guessed it, more people chose chips who also said that they didn’t eat as healthy while high. So this got us down the road of studying cannabis use. And as a health educator and a public health professional, I think the way that we have been looking at cannabis for decades has been abstinence-based. And we know that that doesn’t work. With this paper we really wanted to look at harm reduction, and harm reduction typically is seen with drugs such as heroin and other more harmful substances. The premise of harm reduction is that we’re not asking people to stop, because in some cases, that’s not realistic. But in fact we want them to use it more healthfully, so we want them to be safe while using. With legalization and medical use, we really want people to be healthy while they use cannabis. And so with this study, we really wanted to look at the level of knowledge around harm reduction, and to see if people were using these harm reduction strategies.
Cannabis Wire: Can you tell me a bit about how you conducted the survey?
Jessica Kruger: We used the population at Hash Bash, which is held in Ann Arbor, Michigan. I think it’s a really nice representation of cannabis enthusiasts, and enthusiasts are probably some of the most knowledgeable. We also asked people where they get their information, and, sadly in some cases, most of the information is word of mouth. And I think that’s because there isn’t a lot of research yet on cannabis, cannabinoids, CBD, and THC harm reduction strategies. So we looked at the literature. Fischer et al in 2017 reviewed a lot of the literature out there and looked at strategies for lower risk. They found that vaping rather than smoking, avoiding driving within six hours of using cannabis, avoiding mixing cannabis with tobacco, avoiding cannabis use while pregnant, and using cannabis strains with high CBD to THC ratios were all scientifically healthier strategies. But then we also started looking on a lot of websites, how they said to be safer, and their techniques were not supported by empirical evidence. Some were saying things like use a pipe with a longer stem, things not supported [empirically], yet supported by word of mouth. Just as we do every year at Hash Bash, we created a survey. We asked about knowledge about amounts of CBD, THC within someone’s cannabis, and on harm reduction techniques.
Cannabis Wire: What was the makeup of respondents at Hash Bash?
Jessica Kruger: Out of 472 respondents, 60% were male or identified as men, and the mean age was 30. We got a range from 18 to 77. So we had a pretty large standard deviation. Education levels varied. And, you know, although it’s held on a college campus, only 35% were currently a student. We did have a majority white or European American—about 60% of the population. So this isn’t representative of all cannabis users, but we feel that we have a decently representative sample of cannabis users at Hash Bash, which is nice. We basically gave them a list of strategies and if they endorsed those strategies. Do they think these reduce harm? We asked them “Do you use these strategies?” And then we broke the strategies into five that were evidence based and five that were not. We really want to drive home the fact that there are safer ways to use. The top strategy that people actually endorsed was “avoid using while pregnant,” so 42% endorsed that, and of the women who answered that question, 36% said that they actually followed that. So that’s good. And I think that’s in part from some of the educational campaigns that exist, like what’s in Colorado.
Cannabis Wire: Is there anything else that jumped out at you?
Jessica Kruger: Just the lack of knowledge around this topic, and I never want to say this in a bad way, that it paints cannabis users as uneducated, because that’s not the case. I think it’s the fact that they just don’t have access to some of this information. Because many people are getting it from word of mouth. Or the Internet, versus some peer reviewed sources, which are sometimes not accessible. People are beginning to build up some of this knowledge and I hope that as legalization continues throughout this country, there will be an emphasis on the educational component. But it was surprising to see how many people were using non-evidence based practices.
Cannabis Wire: Is there anything that you think people might not know about unexpected effects or harms that cannabis can cause?
Jessica Kruger: I think there is a perception that it’s definitely a safer drug. And if you look at the literature, that’s very much supported. But just because something’s safer, doesn’t mean it’s completely safe. Why not be proactive in using this substance as safely as possible, that causes the least amount of harm to you? We know that anything that’s combusted or smoked can have detrimental effects on your lungs. So you can mitigate some of those risks by using a vape. And it is important to know what’s in the product that you’re using, the dosage. That’s an important way to think about it—not that this is far less harmful than other substances, but how can I use it in a way that’s safer, and take ownership of your health in that way.
Cannabis Wire: Are you involved in any other ways of education or harm reduction, or are you advising states and districts in any capacity?
Jessica Kruger: Oh, I wish I could. One of my interest areas is incarceration and public health. I teach a course on the harmful effects of incarceration. A huge component is the war on drugs and the challenges that come with our legal system, and the current scheduling of cannabis is a main topic that I like to focus on. With current events, the injustices that have been occurring and continue to occur with people of color, especially around drug use, is something that’s absolutely deplorable. In focusing on some of the areas where public health can intervene, I’d love to be able to help states and other districts talk about some of these issues and be more like Colorado or some of these states that are not scared to have the conversations about using more safely. It’s hard and it will take time because we’re so used to the abstinence-based approach. This research, I hope, pushes forward the fact that we really need, in legalization measures and funding efforts, to fund these educational campaigns.
Cannabis Wire: When I think of cannabis consumers, it’s rare for someone to say, “Okay, let me go read about how to be safer about this.” Not a lot of people are going to seek out this information. How do you reach people with this kind of education, and parents as well?
Jessica Kruger: I wish I knew that million dollar question. I think it’s by doing things with popular media, like talking to you today and getting things out to where people can digest them. I’m under no illusion that users are going to read my scientific article. That’s just not how it works. It’s educating everyone along the way. It would be great to be able to have that conversation with your budtender, where they can talk about, “Hey, have you thought about using this in a vape or have you thought about using this in another mode? Because we know that this can be a little less harmful on your lungs.” With this article, our goal is to push public health professionals to think about cannabis the same way that they think about harm reduction with other substances. How can we help people to use safer and how can we get this message out? How do we connect people to resources about cannabis, and do it in a way that is easy to access and not locked away in some journal article that six people read.