REU, Alm.del - 2017-18 - Endeligt svar på spørgsmål 857: Spm., om staten Colorado har et overblik over udviklingen i antallet af narkorelaterede indlæggelser på hhv. somatiske og psykiatriske behandlingstilbud, til justitsministeren

Retsudvalget 2017-18
REU Alm.del
Offentligt

Monitoring

Health Concerns

Related to Marijuana

in Colorado: 2016

Changes in Marijuana Use Patterns,

Systematic Literature Review,

and Possible Marijuana-Related

Health Effects

colorado.gov/cdphe/marijuana-health-report

REU, Alm.del - 2017-18 - Endeligt svar på spørgsmål 857: Spm., om staten Colorado har et overblik over udviklingen i antallet af narkorelaterede indlæggelser på hhv. somatiske og psykiatriske behandlingstilbud, til justitsministeren

Presented to the Colorado State Board of Health, the Colorado

Department of Revenue, and the Colorado General Assembly on Monday,

January 30, 2017 by the Retail Marijuana Public Health Advisory

Committee pursuant to 25-1.5-110, C.R.S.

This report has been reviewed by Larry Wolk, MD, MSPH, Executive

Director and Chief Medical Officer, Colorado Department of Public Health

and Environment

Retail Marijuana Public Health Advisory Committee

The Retail Marijuana Public Health Advisory Committee was established per Senate Bill 13-283 and 25-

1.5-110, C.R.S. Duties of the Committee are to review the currently available scientific literature and

data on health effects of marijuana use and data on patterns of marijuana use, on an ongoing basis.

This document summarizes health topics and data reviewed beginning in 2014 with updates conducted

through 2016. As a committee, we agree that reported findings reflect current science. Public health

messages were developed by the committee to accurately communicate scientific findings.

Recommendations reported were developed by the committee with the goal of protecting consumers of

marijuana and the general public.

25-1.5-110, C.R.S. Monitor health effects of marijuana

“The

department shall monitor changes in drug use patterns, broken down by county and race and

ethnicity, and the emerging science and medical information relevant to the health effects associated

with marijuana use. The department shall appoint a panel of health care professionals with expertise

in cannabinoid physiology to monitor the relevant information. The panel shall provide a report by

January 31, 2015, and every two years thereafter to the state Board of Health, the Department of

Revenue, and the General Assembly. The department shall make the report available on its web site.

The panel shall establish criteria for studies to be reviewed, reviewing studies and other data, and

making recommendations, as appropriate, for policies intended to protect consumers of marijuana or

marijuana products and the general public. The department may collect Colorado-specific data that

reports adverse health events involving marijuana use from the all-payer claims database, hospital

discharge data, and behavioral risk factors.”

HISTORY:

Source: L. 2013: Entire section added,

(SB 13-283), ch. 332, p. 1894, § 10,

effective

May 28.L. 2016: Entire section amended,

(SB 16-090), ch. 45, p. 107, § 1,

effective August 10.

Retail Marijuana Public Health Advisory Committee members

Chairman: Mike Van Dyke, PhD, CIH, Chief, Environmental Epidemiology, Occupational Health and

Toxicology Branch

Shireen Banerji, PharmD, DABAT, Clinical Manager, Rocky Mountain Poison Center

Laura Borgelt, PharmD, Associate Dean and Professor, Departments of Clinical Pharmacy and Family

Medicine, University of Colorado Anschutz Medical Campus

Russell Bowler, MD, PhD, Professor of Medicine, National Jewish Health and University of Colorado

Ashley Brooks-Russell, PhD, MPH, Assistant Professor, Colorado School of Public Health; Member, Injury

Prevention, Education and Research Program

Ken Gershman, MD, MPH, Manager, Medical Marijuana Research Grants Program Colorado Department

of Public Health and Environment

Heath Harmon, MPH, Director of Health Divisions, Boulder County Public Health

Rebecca Helfand, PhD, Director of Data and Evaluation, Office of Behavioral Health, Colorado

Department of Human Services

Sharon Langendoerfer, MD, Retired Pediatrician and Neonatologist, Denver Health Medical Center

Andrew Monte, MD, Emergency Medicine Physician, Medical Toxicologist, University of Colorado and

Rocky Mountain Poison and Drug Center

Kristina T. Phillips, PhD, Clinical Psychologist, Professor, School of Psychological Sciences, University of

Northern Colorado

Judith Shlay, MD, MSPH, Interim Director, Denver Public Health; Professor of Family Medicine,

University of Colorado School of Medicine

Christian Thurstone, MD, Psychiatrist and Medical Director of Addiction Services, Denver Health;

Associate Professor of Psychiatry, University of Colorado

George Sam Wang, MD, Assistant Professor of Pediatrics, Department of Pediatrics, Section of

Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus and

Children’s Hospital Colorado; Volunteer Faculty, Rocky Mountain Poison and Drug Center

Tista Ghosh, MD, MPH, Deputy Chief Medical Officer and Director of Health Programs, Colorado

Department of Public Health and Environment (Alternate Member)

Colorado Department of Public Health and Environment technical staff

Mike Van Dyke, PhD, CIH, Chief, Environmental Epidemiology, Occupational Health and Toxicology

Branch

Daniel I. Vigil, MD, MPH, Manager, Marijuana Health Monitoring and Research Program

Katelyn E. Hall, MPH, Statistical Analyst, Marijuana Health Monitoring and Research Program

Elyse Contreras, MPH, Coordinator, Marijuana Health Monitoring and Research Program

Rowena Crow, MD, Statistical Analyst, Marijuana Health Monitoring and Research Program

Additional authors

Amy Anderson Mellies, MPH, Health Data Analyst, Health Surveys and Evaluation Branch, Colorado

Department of Public Health and Environment

Lisa Barker, MPH, Retail Marijuana Health Monitoring, Colorado Department of Public Health and

Environment

Kevin Berg, MA, GIS Epidemiologist, Environmental Epidemiology, Colorado Department of Public

Health and Environment

Kirk Bol, MSPH, Manager, Vital Statistics and Disease Registry Branch, Colorado Department of Public

Health and Environment

Alvin C. Bronstein, MD, Rocky Mountain Poison Center; University of Colorado

Todd Carlson, MD, Internal Medicine Resident, University of Colorado

Teresa Foo, MD, MPH, Marijuana Clinical Guidelines Coordinator, Colorado Department of Public Health

and Environment; Clinical Instructor, University of Colorado

David Goff Jr., MD, PhD, FACP, FAHA, Dean and Professor, Colorado School of Public Health

Alison Grace Bui, MPH, Epidemiologist, Health Surveys and Evaluation Branch, Colorado Department of

Public Health and Environment

Christopher H. Domen, PhD, ABPP-CN, Assistant Professor, Department of Neurosurgery, University of

Colorado School of Medicine

Renee M. Johnson, PhD, MPH, Associate Professor, Department of Mental Health, Johns Hopkins

Bloomberg School of Public Health

Ashley Juhl, MSPH, Maternal and Child Health Epidemiologist, Health Surveys and Evaluation Branch,

Colorado Department of Public Health and Environment

Leonardo Kattari, MSW, Healthy Kids Colorado Survey Coordinator, Prevention Services Division,

Colorado Department of Public Health and Environment

Mike Kosnett, MD, MPH, Associate Clinical Professor, Division of Clinical Pharmacology and Toxicology,

Department of Medicine, University of Colorado School of Medicine, Department of Environmental and

Occupational Health, Colorado School of Public Health

Bruce Mendelson, MPA, Denver Office of Drug Strategy, University of Colorado

Madeline Morris, BS, Graduate Student, Colorado School of Public Health

Allison Rosenthal, MPH, Applied Epidemiology Fellow, Substance Abuse Mental Health Services

Administration and Council of State and Territorial Epidemiologists

Anne Schiffmacher, MPH, Maternal and Child Health Data Analyst, Health Surveys and Evaluation

Branch, Colorado Department of Public Health and Environment

Kim Siegel, MD, MPH, Occupational Medicine Resident, University of Colorado

Rickey Tolliver, MPH, Chief, Health Surveys and Evaluation Branch, Colorado Department of Public

Health and Environment

Michael F. Wempe, PhD, Associate Research Professor, Department of Pharmaceutical Sciences,

University of Colorado Anschutz Medical Campus

Other contributors

Alejandro Azofeifa, DDS, MSc, MPH

Shannon Barbare

Rio Chowdhury

Erin Flynn, MPH

Rachel K. Herlihy, MD, MPH

Diana Herrero, MS

Ali Maffey, MSW

Mark Salley

Megan Snow, MS, CHES

Jan Stapleman

Community Epidemiology and Program Evaluation Group, Colorado School of Public Health

Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey on Drug Use and

Health (NSDUH) analysis team

Public meeting attendees

Contact

[email protected]

Press contact

Mark Salley

Director, Office of Communicatoins

Colorado Department of Public Health and Environment

[email protected]

303-692-2013

Monitoring Health Concerns

Related to Marijuana in

Colorado: 2016

Table of Contents

Executive Summary

Section1: Monitoring Changes in Marijuana Use Patterns

Background and Summary of Key Findings

Behavioral Risk Factor Surveillance Survey (BRFSS)

Child Health Survey (CHS)

Healthy Kids Colorado Survey (HKCS)

Pregnancy Risk Assessment Monitoring System (PRAMS)

i - x

109

119

127

145

157

165

179

193

209

221

108

118

126

144

156

164

178

192

208

220

228

229

230 - 234

235 - 246

247 - 270

271 - 278

279 - 286

Section 2: Scientific Literature Review on Potential Health Effects of

Marijuana Use

Background and Summary of Key Findings

Systematic Literature Review Process

Marijuana Use Among Adolescents and Young Adults

Marijuana Use and Cancer

Marijuana Use and Cardiovascular Effects

Marijuana Dose and Drug Interactions

Marijuana Use and Driving

Marijuana Use and Gastrointestinal and Reproductive Effects

Marijuana Use and Injury

Marijuana Use and Neurological, Cognitive and Mental Health Effects

Marijuana Use During Pregnancy and Breastfeeding

Marijuana Use and Respiratory Effects

Unintentional Marijuana Exposures in Children

Section 3: Monitoring Possible Marijuana-Related Health Effects in Colorado

Background and Summary of Key Findings

Rocky Mountain Poison and Drug Center (RMPDC) Data

Colorado Hospital Association (CHA) Data

Retail Marijuana Public Health Advisory Committee 2015-2016 Membership

Roster

Glossary

Monitoring Health

Concerns Related to

Marijuana in

Colorado: 2016

Executive Summary

Retail Marijuana Public Health Advisory

Committee

Executive Summary

Retail Marijuana Public Health Advisory Committee Members

2015-2016

Chairman: Mike Van Dyke, PhD, CIH, Chief, Environmental Epidemiology, Occupational Health and

Toxicology Branch

Laura Borgelt, PharmD, Associate Dean and Professor, Departments of Clinical Pharmacy and Family

Medicine, University of Colorado Anschutz Medical Campus

Russell Bowler, MD, PhD, Professor of Medicine, National Jewish Health and University of Colorado

Shireen Banerji, PharmD, DABAT, Clinical Manager, Rocky Mountain Poison Center

Ashley Brooks-Russell, PhD, MPH, Assistant Professor, Colorado School of Public Health; Member, Injury

Prevention, Education and Research Program

Ken Gershman, MD, MPH, Manager, Medical Marijuana Research Grants Program Colorado Department

of Public Health and Environment

Heath Harmon, MPH, Director of Health Divisions, Boulder County Public Health

Sharon Langendoerfer MD, Retired Pediatrician and Neonatologist, Denver Health Medical Center

Andrew Monte, MD, Emergency Medicine Physician, Medical Toxicologist, University of Colorado and

Rocky Mountain Poison and Drug Center

Judith Shlay, MD, MSPH, Interim Director, Denver Public Health; Professor of Family Medicine,

University of Colorado School of Medicine

George Sam Wang, MD, Assistant Professor of Pediatrics, Department of Pediatrics, Section of

Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus and

Children’s Hospital Colorado; Volunteer Faculty, Rocky Mountain Poison and Drug Center

Rebecca Helfand, PhD, Director of Data and Evaluation, Office of Behavioral Health, Colorado

Department of Human Services

Kristina Phillips, PhD, Clinical Psychologist, Professor, School of Psychological Sciences, University of

Northern Colorado

Christian Thurstone, MD, Psychiatrist and Medical Director of Addiction Services, Denver Health;

Associate Professor of Psychiatry, University of Colorado

Tista Ghosh, MD, MPH, Deputy Chief Medical Officer and Director of Health Programs, Colorado

Department of Public Health and Environment (Alternate Member)

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Executive Summary

Introduction

When Colorado became one of the first two states in the nation to legalize retail marijuana, the

Colorado Legislature mandated that the Colorado Department of Public Health and Environment

(CDPHE) study the potential public health effects of marijuana. Though medical marijuana has been

legal in Colorado since 2000, it was largely viewed as an individual doctor/patient decision outside the

scope of public health policy. However, the legalization of retail (non-medical) marijuana and the

potential for greater availability of marijuana in the community prompted a closer look at potential

health effects on the population at large.

Legalized retail marijuana presents a paradigm shift, grouping marijuana with other legal substances

like alcohol, tobacco and prescription drugs, as opposed to illicit drugs like cocaine and heroin. As with

alcohol, tobacco and prescription drugs, misuse of marijuana can have serious health consequences.

The standard public health approaches to alcohol, tobacco and prescription drugs are to monitor use

patterns and behaviors, health care use, potential health effects, and emerging scientific literature to

guide the development of policies or consumer education strategies to prevent serious health

consequences. This report presents information on marijuana use patterns, potential health effects and

the most recent scientific findings associated with marijuana use, with a key objective of helping

facilitate evidence-based policy decisions and science-based public education campaigns.

In 25-1.5-110, C.R.S., the Colorado Department of Public Health and Environment (CDPHE) was given

statutory responsibility to:



“…

monitor changes in drug use patterns, broken down by county and race and ethnicity, and the

emerging science and medical information relevant to the health effects associated with marijuana

use.”

“…

appoint a panel of health care professionals with expertise in cannabinoid physiology to monitor

the relevant information.”

“…

collect Colorado-specific data that reports adverse health events involving marijuana use from

the all-payer

claims database, hospital discharge data, and behavioral risk factors.”



Based on this charge, CDPHE has appointed a 14-member committee, the Retail Marijuana Public

Health Advisory Committee (RMPHAC), to review scientific literature on the health effects of marijuana

and Colorado-specific health outcome and use pattern data. Members of this committee (see Retail

Marijuana Public Health Advisory Committee membership roster) consist of individuals in the fields of

public health, medicine, epidemiology and medical toxicology who demonstrate expertise related to

marijuana through their work, training or research. This committee was charged with the duties as

outlined in C.R.S. 25-1.5-110

to “…

establish criteria for studies to be reviewed, reviewing studies and

other data, and making recommendations, as appropriate, for policies intended to protect consumers

marijuana or marijuana products and the general public.”

The committee began meeting in May

2014 and in January 2015 published the first edition of this report. The overall goal of the committee

was to implement an unbiased and transparent process for evaluating scientific literature as well as

marijuana use and health outcome data. The committee was particularly interested in ensuring quality

information is shared about the known physical and mental health effects associated with marijuana

use

–

and also about what is unknown at present. The official committee bylaws are included in the

Appendix, Retail Marijuana Public Health Advisory Committee Bylaws.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

iii

Executive Summary

Monitoring changes in marijuana use patterns

This report includes detailed information about marijuana use patterns in Colorado that has been

gathered using several prominent population-based surveys. These surveys are:

1. The Behavioral Risk Factor Surveillance System survey, a survey of adults sponsored by the U.S.

Centers for Disease Control and Prevention (CDC).

2. The Child Health Survey, a survey of adults with children ages 1-14 years old in their home about

the children’s health and environment.

3. The Healthy Kids Colorado Survey of middle and high school students, a collaboration of CDPHE,

Colorado Department of Education, and Colorado Department of Human Services.

4. The Pregnancy Risk Assessment Monitoring System survey, a survey of women who recently gave

birth.

The data available at this time cannot answer all of the important questions about whether or how

marijuana use patterns may be changing as a result of legalization. However, they do provide

important insights into marijuana use in adults and vulnerable populations such as pregnant women,

youth, and those with racial, ethnic, and sexual orientation disparities. A summary of key trends:

Encouraging trends



For adults and adolescents, past-month marijuana use has not changed since legalization either in

terms of the number of people using or the frequency of use among users.

Based on the most comprehensive data available, past month marijuana use among Colorado

adolescents is nearly identical to the national average.

We have not identified any

new

disparities in marijuana use by age, gender, race, ethnicity or

sexual orientation since legalization.

Daily or near-daily marijuana use among adults is much lower than daily or near-daily alcohol or

tobacco use. Among adolescents, past month marijuana use is lower than past month alcohol use.

Trends to continue monitoring



About 6 percent of pregnant women use marijuana while pregnant. This percentage is higher

among those with unintended pregnancies as well as younger mothers or those with less education.

At least 14,000 children in Colorado are at risk of accidentally eating marijuana products that are

not safely stored and at least 16,000 are at risk of being exposed to secondhand marijuana smoke

in the home.

More than 5 percent of high school students use marijuana daily or near daily. This rate has

remained stable since at least 2005.

Past month marijuana use among adults in Colorado is higher than the national average. In

Colorado, one in four adults age 18-25 reported past month marijuana use and one in eight use

daily or near-daily. These numbers have been consistent since legalization.

There continue to be disparities in marijuana use based on race/ethnicity for adolescents and

sexual orientation for both adults and adolescents.

While past month marijuana use among adults and adolescents was stable for most regions in

Colorado, adult use in the Northwest Colorado region increased from 2014 to 2015.

More than 1-in-3 adolescents who use marijuana first use it by age 14, supporting prevention

efforts aimed at children before they enter ninth grade.



Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Executive Summary

Scientific literature review on potential health effects

of marijuana use

The committee used a standardized systematic literature review process to search and grade the

existing scientific literature on health effects of marijuana. Findings were synthesized into evidence

statements that summarize the quantity and quality of supporting scientific evidence. These evidence

statements were classified as follows:



Substantial evidence - indicates robust scientific findings that support an association between

marijuana use and the outcome.

Moderate evidence - indicates that scientific findings support an association between marijuana

use and the outcome, but these findings have some limitations.

Limited evidence - indicates modest scientific findings that support an association between

marijuana use and the outcome, but these findings have significant limitations.

Mixed evidence - indicates both supporting and non-supporting scientific findings for an association

between marijuana use and the outcome with neither direction dominating.

Body of research failing to show an association - indicates that the topic has been researched

without evidence of an association; is further classified as a limited, moderate or substantial body

of research.

Insufficient evidence - indicates that the outcome has not been sufficiently studied to conclude

whether or not there is an association between marijuana use and the outcome.



The committee also translated these evidence statements into plain language so the public can

understand them when used in public health messages. In addition, the committee was asked to

develop public health recommendations based on potential concerns identified through the review

process and to articulate research gaps based on common limitations of existing research. All of these

were presented to the full committee during open public meetings that offered opportunities for

stakeholder input. Final statements, recommendations, and research gaps were formally approved by a

majority vote of the committee.

An important note for all key findings is that the available research evaluated the

association

between

marijuana use and potential adverse health outcomes. This

association

does not prove the marijuana

use alone

caused

the effect. Despite the best efforts of researchers to account for confounding

factors, there may be other important factors related to

causality

that were not identified. In

addition, marijuana use was illegal everywhere in the United States prior to 1996. Research funding,

when appropriated, was commonly sought to identify adverse effects from marijuana use. This legal

fact introduces both funding bias and publication bias into the body of literature related to marijuana

use. Another limitation of the available research data is that most studies did not or could not measure

the THC level (potency) of marijuana used by subjects, nor which other cannabinoids were present.

There are diverse products now available in Colorado, many of which are likely higher in potency than

the marijuana used by study subjects for much of the literature reviewed.

The Retail Marijuana Public Health Advisory Committee recognizes the limitations and biases inherent

in the published literature and made efforts to ensure the information reviewed and synthesized is

reflective of the current state of medical knowledge. Where information was lacking

–

for whatever

reason

–

the committee identified this knowledge gap and recommended further research. This

information will be updated as new research becomes available.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Executive Summary

Marijuana use among adolescents and young adults

The committee reviewed

the relationships between adolescent and young adult marijuana use and

cognitive abilities, academic performance, mental health and future substance use. Weekly marijuana

use by adolescents is associated with impaired learning, memory, math and reading, even 28 days after

last use. Weekly use is also associated with failure to graduate from high school. Adolescents and young

adults who use marijuana are more likely to experience psychotic symptoms as adults, such as

hallucinations, paranoia, delusional beliefs and feeling emotionally unresponsive. Evidence shows that

marijuana users can become addicted to marijuana and that treatment for marijuana addiction can

decrease use and dependence. Additionally, marijuana users who quit have lower risks of cognitive and

mental health outcomes than those who continue to use.

Marijuana use and cancer

The committee reviewed

different forms of cancer relative to marijuana use, as well as the chemicals

released in marijuana smoke and vapor. Strong evidence shows that marijuana smoke contains many of

the same cancer-causing chemicals found in tobacco smoke. However, there is conflicting research for

whether or not a higher cumulative level of marijuana smoking is associated with lung cancer. Limited

evidence suggests an association between marijuana use and both testicular and prostate cancers. On

the other hand, the limited evidence available concerning cancers of the bladder, head and neck

suggests that they might not have any association with marijuana use.

Marijuana use and cardiovascular effects

The committee reviewed

myocardial infarction, stroke and death from cardiovascular causes, relative

to marijuana use. There is a moderate level of scientific evidence that marijuana use increases risk for

some forms of stroke in individuals younger than 55 years of age, and more limited evidence that

marijuana use may increase risk for heart attack. Research is lacking concerning other cardiovascular

events and conditions, including death.

Marijuana dose and drug interactions

The committee reviewed

THC (tetrahydrocannabinol, the main psychoactive component of marijuana)

levels relative to marijuana dose and method of use, the effects of secondhand marijuana smoke, drug-

drug interactions involving marijuana, and relationships between marijuana and opioid use. One very

important finding is that it can take up to four hours after consuming an edible marijuana product to

reach the peak THC blood concentration and feel the full effects. There is credible evidence of

clinically important drug-drug interactions between marijuana and multiple medications, including

some anti-seizure medications and a common blood-thinner. Data about potential interactions are

lacking for many drugs at this time and likely to evolve substantially over coming years. Finally, there

is some evidence that opioid pain medication overdose deaths are lower in states with legal medical

marijuana than would be expected based on trends in states without legal medical marijuana. There is

conflicting evidence for whether or not marijuana use is associated with a decrease in opioid use

among chronic pain patients or individuals with a history of problem drug use.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Executive Summary

Marijuana use and driving

The committee reviewed

driving impairment and motor vehicle crash risk relative to marijuana use, as

well as evidence indicating how long it takes for impairment to resolve after marijuana use. They

found that the risk of a motor vehicle crash increases among drivers with recent marijuana use.

Furthermore, the higher the blood THC level, the higher the motor vehicle crash risk. In addition, using

alcohol and marijuana together increases impairment and the risk of a motor vehicle crash more than

using either substance alone. For less than weekly marijuana users, using marijuana containing 10

milligrams or more of THC is likely to impair the ability to safely drive, bike, or perform other safety-

sensitive activities. Less than weekly users should wait at least six hours after smoking or eight hours

after eating or drinking marijuana to allow time for impairment to resolve.

Marijuana use and gastrointestinal or reproductive effects

The committee reviewed

gastrointestinal diseases, particularly cyclic vomiting, and infertility or

abnormal reproductive function. Evidence shows that long-time, daily or near daily marijuana use is

associated with cyclic vomiting, which has been called cannabinoid hyperemesis syndrome. In such

cases, stopping marijuana use may relieve the vomiting. There is conflicting research for whether or

not marijuana use is associated with male infertility or abnormal reproductive function, and research is

lacking on female reproductive function related to marijuana use.

Marijuana use and injury

The committee reviewed

workplace, recreational and other non-driving injuries, burns from hash-oil

extraction or failed electronic smoking devices, and physical dating violence. Evidence shows that

marijuana use may increase the risk of workplace injury while impaired, but is unclear for other types

of non-driving related injury. There have been many reports of severe burns resulting from home-

extraction of butane hash-oil leading to explosions, and cases of electronic smoking devices exploding,

leading to trauma and burns. Concerning dating violence, adolescent girls who use marijuana may be

more likely to commit physical violence against their dating partners, and adolescent boys who use

marijuana may be more likely to be victims of physical dating violence.

Marijuana use and neurological, cognitive and mental health effects

The committee reviewed

the potential relationships between marijuana use and cognitive impairment,

mental health disorders and substance abuse. Strong evidence shows that daily or near daily marijuana

users are more likely to have impaired memory lasting a week or more after quitting. An important

acute effect of THC is psychotic symptoms, such as hallucinations, paranoia and delusional beliefs

during intoxication. These symptoms are worse with higher doses. Daily or near daily marijuana use is

associated with developing a psychotic disorder such as schizophrenia. Finally, evidence shows that

marijuana users can become addicted to marijuana and that treatment for marijuana addiction can

decrease use and dependence.

Marijuana use during pregnancy and breastfeeding

The committee

reviewed adverse birth outcomes, effects of prenatal marijuana use on exposed

offspring later in childhood or adolescence and effects of marijuana use by a breastfeeding mother.

Biological evidence shows that THC passes through the placenta to the fetus, so that the unborn child

is exposed to THC if the mother uses marijuana, and that THC passes through breast milk to a

breastfeeding child. Marijuana use during pregnancy may be associated with an increased risk of heart

defects or stillbirth. Stronger evidence was found for effects that are seen months or years after birth

if a child’s mother used marijuana while pregnant with the child. These include decreased growth and

impaired cognitive function and attention. Decreased academic ability or increased depression

symptoms may also occur.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

vii

Executive Summary

Marijuana use and respiratory effects

The committee

reviewed respiratory diseases like chronic obstructive pulmonary disorder (COPD),

chronic bronchitis and asthma, respiratory infections and lung function relative to smoked marijuana.

They also reviewed potential health effects of vaporized marijuana. Strong evidence shows an

association between daily or near-daily marijuana use and chronic bronchitis. Additionally, daily or

near daily marijuana use may be associated with bullous lung disease and pneumothorax in individuals

younger than 40 years of age. Research is lacking concerning any possible association between

marijuana use and COPD, emphysema or respiratory infections. Smokers who switch from marijuana

smoking to marijuana vaporizing may have fewer respiratory symptoms and improved pulmonary

function. Finally, a notable effect of acute use is a short-term improvement in lung airflow.

Unintentional marijuana exposures in children

The committee

reviewed unintentional marijuana exposure relative to marijuana legalization and

child-resistant packaging. They found strong evidence that more unintentional marijuana exposures of

children occur in states with increased legal access to marijuana, and that the exposures can lead to

significant clinical effects requiring hospitalization. Additionally, evidence shows that child resistant

packaging prevents exposure to children from potentially harmful substances, such as THC.

Monitoring possible marijuana-related health effects

This report includes detailed information about population-based health effects of legalized marijuana

in Colorado, using two primary public health datasets:

1. Exposure calls to the Rocky Mountain Poison and Drug Center, typically used as a surrogate data

source to determine the potential for adverse health effects from exposure to chemicals and drugs.

2. Hospital and emergency department data provided by the Colorado Hospital Association, which

collects data from participating hospitals in the state of Colorado.

The data presented here provide important insights into the yearly volume, trends over time and

nature of marijuana exposure calls to the poison center among different age groups and the rates of

hospitalizations and emergency department visits for which a marijuana-related billing code was used.

A summary of key trends:

Encouraging trends



Marijuana exposure calls to the poison center appear to be decreasing since 2015, including

unintentional exposures in children ages 0-8 years.

The overall rate of emergency department visits with marijuana-related billing codes dropped 27

percent from 2014 to 2015 (2016 data is not available yet).

Trends to continue monitoring



Marijuana exposure calls to the poison center continue to be higher in years after medical

marijuana commercialization (2010-2016) than in previous years (2000-2009), including calls about

children 0-8 years old with unintentional marijuana exposure.

Edible marijuana products were involved in about 40 percent of marijuana exposure calls to the

poison center. For children 0-8 years old, calls about edible marijuana were twice as common as

calls about smokeable marijuana.

The overall rate of hospitalizations with marijuana-related billing codes has increased each year

since 2008.



Monitoring Health Concerns Related to Marijuana in Colorado: 2016

viii

Executive Summary



Among young adults (ages 18-25 years) in 2014 and 2015, about 8 percent of all hospitalizations and

2 percent of all emergency department visits had a marijuana-related billing code. This was higher

than the rate among other age groups, and likely reflects the higher rate of marijuana use in this

age group.

Disparities in hospitalizations and emergency department visits also existed by sex and race, with

higher rates among males and blacks across all time periods.

Hospitalizations with marijuana-related billing codes are nine times more likely to have a primary

mental health diagnosis compared to those without marijuana-related billing codes.



These data should be interpreted carefully, keeping in mind that observed increases have many

potential explanations including:

changes in the amount or type of marijuana use in Colorado,

changes in physician screening or reporting related to marijuana, increased honesty in reporting

marijuana use to health care providers after legalization, and changes in coding practices by hospitals

and emergency departments. In addition, possible marijuana-related cases accounted for 3 percent of

hospitalizations and less than 1 percent of emergency department visits in Colorado in 2015. More data

and time are needed to determine if the observed increases are a direct and sustained result of

changes in Colorado marijuana use.

Public health recommendations

The committee made a number of public health recommendations interspersed throughout this report.

It recommends Colorado support research to fill important gaps in public health knowledge and

continue improving and standardizing data about marijuana use history and health effects in public

health surveillance, medical care settings and research.

Collection and in-depth analysis of data regarding marijuana use should be continued using population-

based surveys such as the Behavioral Risk Factors Surveillance System, the Healthy Kids Colorado

Survey and Pregnancy Risk Assessment Monitoring System. Colorado also should continue to develop,

improve and expand tools to monitor marijuana use patterns, such as CDPHE’s Cannabis Users’ Survey

on Health.

CDPHE should continue using poison center and hospital data to monitor trends in potential marijuana

health effects and assess the impact over time, especially among groups with higher rates of marijuana

use. For the poison center, this includes implementing a surveillance protocol currently being

developed and conducting more detailed data collection and analysis of unintentional marijuana

exposures, especially in children under 9 years old. In order to better assess potential health impacts,

data on hospitalizations and emergency department visits related to marijuana should be further

explored. This includes continuing analysis of primary diagnoses in relation to marijuana-related billing

codes and targeted projects like CDPHE’s

collaboration to evaluate ski-related

injuries and marijuana.

In addition, improved testing methods and documentation are needed in relation to motor vehicle

crashes and driving under the influence of drugs (DUID). Evaluation of death certificate

and coroner’s

report data should continue, to determine how it can best be used in monitoring for potential

marijuana-related deaths.

Public education on potential health effects of marijuana is important, particularly related to the

effects of use during pregnancy, adolescent use, driving after using and unsafe storage around

children. Dispensaries and industry should continue to partner with public health to disseminate

education about these topics of highest concern. Education for health care providers on the known

health effects of marijuana use may encourage more open dialogue between providers and patients.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Executive Summary

Research gaps

Important research gaps related to the population-based health effects of marijuana use were

identified during the literature and data review process. These research gaps were based on common

limitations of existing research, exposures or outcomes not sufficiently studied, or issues important to

public education or policymaking. These research gaps provide an important framework for continuing

to prioritize research related to marijuana use and public health.

The committee strongly recommends

that Colorado support research to fill these important gaps in public health knowledge. While outside

the scope of this committee’s duties, the committee also recognizes that more research is needed on

the potential therapeutic benefits of marijuana.

A common theme among the research gaps was the need for studies with better defined marijuana-use

histories and practices. This should include frequency, amount, potency, and method of marijuana use,

length of abstinence, and a standardized method for documenting cumulative lifetime marijuana

exposure. A key need is to separately evaluate effects for less frequent users versus daily or near-daily

users. Researchers should consider evaluating separately by age group, sex or other characteristics

when the health effect being studied could differ among groups - for example, by age for

cardiovascular effects or by sex for mental health effects.

Research gaps particularly important to public health and safety include: 1) Additional research using

marijuana with THC levels consistent with currently available products; 2) Research on impairment in

marijuana users who use more than weekly and may have developed tolerance; 3) Research to identify

improved testing methods for impairment either through alternate biological testing methods or

physical tests of impairment; and 4) Research to better characterize the

pharmacokinetics/pharmacodynamics, potential drug interactions, health effects, and impairment

related to newer methods of marijuana use such as edibles and vaporizing as well as other

cannabinoids such as cannabidiol (CBD).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1

Monitoring Changes in

Marijuana Use

Patterns

Retail Marijuana Public Health Advisory

Committee

Section 1: Monitoring Changes in Marijuana Use Patterns in Colorado

Background

The Colorado Department of Public Health and Environment (CDPHE) was given statutory (In 25-1.5-

110, C.R.S.) responsibility to:



“… monitor changes in drug use patterns, broken

down by county and race and ethnicity, and the

emerging science and medical information relevant to the health effects associated with marijuana

use.”

Patterns of drug use are typically determined by using population-based surveys that ask specific

questions about substance use. Colorado has created and manages several population-based surveys to

assess the prevalence of a variety of health conditions and behaviors of specific populations. In

addition, there are a few national surveys that collect state level data on marijuana use. The data

from these surveys are compiled here to meet the reporting requirements set forth in 25-1.5-110,

C.R.S. These data also have been presented to the Retail Marijuana Public Health Advisory Committee,

which was charged with the duties outlined in 25-1.5-110,

C.R.S. to “…establish criteria for studies to

be reviewed, reviewing studies and other data, and making recommendations, as appropriate, for

policies intended to protect consumers of marijuana or marijuana products and the

general public.”

Reviewing marijuana use patterns in Colorado provides important insight to the committee members as

they consider public health recommendations.

Data sources

Adult use: Behavioral Risk Factor Surveillance System (BRFSS)

The Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey of adults ages 18 years

and older, sponsored by the U.S. Centers for Disease Control

and Prevention (CDC). It is the nation’s

premier system of health-related telephone surveys that collect data from U.S. residents regarding

their health-related risk behaviors, chronic health conditions and safety practices. CDPHE, in a

cooperative agreement with CDC, manages and administers BRFSS in Colorado. In 2014 and 2015,

Colorado added questions on marijuana use to the state-level BRFSS.

Marijuana in homes with children: Child Health Survey (CHS)

The Child Health Survey (CHS) is a telephone survey conducted among respondents to the BRFSS Survey

who have children ages 1-14 in their home. Adult respondents answer questions about their children

and the home environment. This annual survey provides data on a wide range of health issues and risk

factors affecting children and youth in Colorado. Since 2014, questions about marijuana use and

storage in the home have been included in the survey.

Adolescent and young adult use: Healthy Kids Colorado Survey (HKCS)

The Healthy Kids Colorado Survey (HKCS) collects health information from public high school and

middle school students. It is a voluntary, anonymous survey, completed by students individually in their

classrooms and parents are notified ahead of time. HKCS is a collaboration of CDPHE, Colorado

Department of Education and Colorado Department of Human Services. This survey includes the

questions on the national Youth Risk Behavioral Surveillance Survey (YRBSS). HKCS has included

questions on marijuana since 1999.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Monitoring Changes in Marijuana Use Patterns in Colorado

Adolescent and adult use: National Survey on Drug Use and Health (NSDUH)

The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks national and state

level data on tobacco, alcohol, marijuana, and illicit drug use through the National Survey on Drug Use

and Health (NSDUH). This survey is completed by in-person

interview at the respondent’s home, and

includes one or two residents who are at least 12 years old. Although the survey design differs from

BRFSS and HKCS, it can be used for comparisons of state and national marijuana use estimates. This

report does not have a NSDUH-specific chapter, but NSDUH data are included for comparison in the

BRFSS and HKCS chapters.

Use during pregnancy: Pregnancy Risk Assessment Monitoring System (PRAMS)

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a mailed survey of women who recently

gave birth. It is sponsored by the Centers for Disease Control and Prevention (CDC). It provides data not

available from other sources about pregnancy and the first few months after delivery, and allows CDC

and states to monitor changes in maternal and child health indicators, such as unintended pregnancy,

prenatal care, breastfeeding, infant health, smoking and alcohol use. In 2014, Colorado added

questions about marijuana use before, during and after pregnancy to the state-level PRAMS.

Each of these surveys only collects self-reported information, so there is no way to confirm whether

each respondent has answered truthfully. These types of surveys have been validated in various

studies, which indicate most people do answer truthfully. Consistency in methodology from year to

year for each of the surveys provides confidence that trends over time can be effectively monitored.

Key details about all five surveys

Survey

BRFSS

CHS

HKCS

NSDUH

PRAMS

Population and ages studied

Adults age 18 and up

Parents of children age 1-14

Adolescents and young adults age 11-18

Adolescents and adults age 12 and up

Pregnant and recently pregnant women

Years

2014-2015

1999-2015

1971-2015

2014

Data collection method

Telephone survey

In-school paper survey

In-person, at home survey

Mailed paper survey

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Monitoring Changes in Marijuana Use Patterns in Colorado

Summary of key findings

The most prominent findings from all surveys are described below. For additional results and details,

see the individual chapters for BRFSS (page 9), CHS(page 29), HKCS (page 39) and PRAMS (page 63).

Trends in adult marijuana use in Colorado

In 2015, BRFSS data showed an estimated 13% of Colorado adults ages 18 and up had used marijuana in

the past-month. The NSDUH estimate for past-month use differs, at 17%. However, neither survey

showed a statistical change from 2014 to 2015. According to NSDUH data, adult use in Colorado

continued to be higher than the national average, which was 8%. BRFSS in 2015 showed past-month

adult marijuana use in Colorado was highest among those 18-25 years old (26%); males (17%); and those

who reported gay, lesbian, bisexual or other sexual orientation (37%). None of these groups saw a

statistical change in use between 2014 and 2015. Northwest Colorado saw an increase in past-month

use from 2014 (10%) to 2015 (16%), while other regions had no statistical change.

In 2015, 6% of adults reported using marijuana daily or near-daily. This was lower than daily or near-

daily alcohol (22%) or tobacco use (16%). Of 18- to 25-year old marijuana users, 50% report using daily

or near-daily (13% of all 18- to 25-year olds). Among adult past-month marijuana users, 79% smoke, 30%

“vape” and 33% use edibles. Respondents could report using more than one method, which 50% of users

did. Finally, approximately 2% of adults drove a vehicle in the past 30 days after using marijuana.

Trends in adolescent marijuana use in Colorado

HKCS results from 2015 indicate approximately 21% of Colorado high school students had used

marijuana in the past-month. This is not statistically different from 2013 (20%) and is nearly identical

to national estimates from YRBSS (22%). From 2005-2015, past-month use fluctuated between

approximately 20% and 25%, with no clear trend. The most recent NSDUH data for high school age

adolescents (14- to 17-year olds) is from 2012-2014 and shows 17% past-month use. This compares with

the 2013 HKCS estimate of 19%. According to HKCS in 2015, past-month adolescent marijuana use was

nearly identical among males and females (21%). Comparing grade levels, use was highest among

juniors (26%) and seniors (28%). As with adults, students identifying as gay, lesbian, or bisexual were

more likely to report past-month use (35%) than those identifying as heterosexual (20%). Use is higher

among Hispanics (24%) and multiple or other races (28%) than among whites (20%).

In 2015, past-month marijuana use among high school students in Colorado (21%) was lower than past-

month alcohol use (30%) and higher than past-month tobacco use (9%). Smoking marijuana is the most

popular method of use among high school students, with 87% reporting it as their usual method of use.

Edibles dropped from 5% in 2013 to 2% in 2015. In 2015, 27% of past-month high school users (more than

5% of all high school students) used daily or near-daily. Concerning age of first use, 41% of high school

seniors who had ever used marijuana said they first used it by age 14 or before and another 43% had

first used by age 16. 2015 data also showed that 8% of Colorado middle school students had ever used

marijuana and 4% used within the past-month.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Monitoring Changes in Marijuana Use Patterns in Colorado

Marijuana in Colorado homes with children

In 2015, CHS data showed 8% of adults with children 1-14 years old in the home had marijuana or

marijuana products in or around the home. In 82% of these homes, marijuana was stored safely, while

in 18% it was potentially stored unsafely. It is estimated that approximately 14,000 homes in Colorado

with children 1-14 years old had marijuana in the home with potentially unsafe storage.

For 2014 and 2015 together, 3% of adults with children 1-14 years old in the home reported marijuana

being used inside the home. Of these, 83% reported the marijuana was smoked, vaporized, or dabbed.

It is estimated that approximately 16,000 homes in Colorado had children 1-14 years old with possible

exposure to secondhand marijuana smoke or vapor in the home.

Trends in marijuana use during pregnancy and breastfeeding in Colorado

PRAMS results from 2014 show 11% of new mothers had used marijuana shortly before their pregnancy

and 6% of new mothers used it during their pregnancy. By comparison, 13% used alcohol and 6% used

tobacco during pregnancy. A 2016 article reported use during pregnancy was approximately 4%

nationally (see PRAMS chapter for details), an estimate that is not statistically different from PRAMS

results for Colorado. According to PRAMS, use during pregnancy in Colorado was statistically higher

among women 20-24 years old (13%) than among women 25-34 years old (4%) or women 35 years old or

older (3%). It also was higher among women with less than a 12

-grade education (16%) than among

women with some college (4%). Use during pregnancy was lower among women who intended to

become pregnant (4%) than women with unintended pregnancies (9%). Finally, approximately 5% of new

mothers used marijuana after pregnancy when they were also breastfeeding.

Discussion

The citizens of Colorado exhibit behaviors much more complex than any survey can capture. Currently

available data cannot answer all the important questions we have about whether or not marijuana use

patterns are changing as a result of legalization. The data presented here provide important insights

into marijuana use in adults as well as vulnerable populations such as pregnant women; youth; and

those with racial, ethnic and sexual orientation disparities.

Encouraging trends



For adults and adolescents, past-month marijuana use has not changed since legalization either in

terms of the number of people using or the frequency of use among users.

Based on the most comprehensive data available, past-month marijuana use among Colorado

adolescents is nearly identical to the national average.

We have not identified any

new

disparities in marijuana use by age, gender, race, ethnicity or

sexual orientation since legalization.

Daily or near-daily marijuana use among adults is much lower than daily or near-daily alcohol or

tobacco use. Among adolescents, past month marijuana use is lower than past month alcohol use.

Trends to continue monitoring



About 6 percent of pregnant women choose to use marijuana while pregnant. This percentage is

higher among those with unintended pregnancies as well as younger mothers or those with less

education.

At least 14,000 children in Colorado are at risk of accidentally eating marijuana products that are

not safely stored, and at least 16,000 are at risk of being exposed to secondhand marijuana smoke

in the home.



Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Monitoring Changes in Marijuana Use Patterns in Colorado



More than 5 percent of high school students use marijuana daily or near daily. This rate has

remained stable since at least 2005.

Past-month marijuana use among adults in Colorado is higher than the national average. In

Colorado, one in four adults ages 18-25 reported past-month marijuana use and one in eight use

daily or near-daily. These numbers have been consistent since legalization.

There continued to be disparities in marijuana use based on race/ethnicity for adolescents and

sexual orientation for both adults and adolescents.

While past-month marijuana use among adults and adolescents was stable for most regions in

Colorado, adult use in the Northwest Colorado region increased from 2014 to 2015.

More than 1-in-3 adolescents who use marijuana first use it by age 14, supporting prevention

efforts aimed at children before they enter ninth grade.



Recommendations and future directions

1. Continue assessing prevalence of marijuana use via large Colorado-based surveys including the

Pregnancy Risk Assessment Monitoring System, Healthy Kids Colorado Survey, and the Behavioral

Risk Factor Surveillance System. Data from surveys identify trends in use patterns that can be used

to inform and target education and prevention strategies. National surveys do not have a sufficient

Colorado sample size to fully address patterns of use by age, race/ethnicity, and any county or

regional catchment. Continued surveys using the same methodology can act as a feedback loop to

ensure marijuana policies and education campaigns are effective.

2. Continue to develop, improve and expand tools to monitor marijuana use patterns. Results from

the Cannabis Users Survey on Health (CUSH) will be reported in spring 2017. CUSH is a survey

created by CDPHE to gather more detailed information about adult marijuana use, including

methods, amounts and frequency of use; reasons for using; how it is purchased or obtained;

concurrent use with other substances; and any adverse effects experienced. CDPHE is collaborating

with other states and national organizations to expand use of this survey to other states.

3. Continue in-depth analyses of existing survey data to assess risk and protective factors for

marijuana use, including changes in the perception of harm from marijuana use.

4. Continue collaboration with other state and national agencies to identify data that might add

additional detail on use patterns in specific populations or geographic areas in the state.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1

Monitoring Changes in

Marijuana Use

Patterns

Chapter 1

Behavioral Risk Factor

Surveillance System (BRFSS)

2014-2015 Survey Results

Retail Marijuana Public Health Advisory

Committee

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Authors

Daniel I. Vigil, MD, MPH

Manager

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Katelyn E. Hall, MPH

Statistical Analyst

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Elyse Contreras, MPH

Coordinator

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Amy Anderson Mellies, MPH

Health Data Analyst

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Alison Grace Bui, MPH

Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Rickey Tolliver, MPH

Chief

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Mike Van Dyke, PhD, CIH

Chief

Environmental Epidemiology, Occupational Health, and Toxicology Branch, Colorado Department of

Public Health and Environment

Reviewer

Shireen Banerji, PharmD, DABAT

Clinical Manager, Rocky Mountain Poison Center

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

The BRFSS survey and marijuana use in Colorado

The Behavioral Risk Factor Surveillance System (BRFSS) collects data on adult, individual-level

behavioral health risk factors associated with leading causes of premature mortality and morbidity. It is

the nation’s premier system of health-related

telephone surveys that collect state data about U.S.

residents regarding their health-related risk behaviors, chronic health conditions, and safety practices.

By collecting behavioral health risk data at the state and local level, BRFSS has become a powerful tool

for targeting and building health promotion activities.

Colorado participates in BRFSS using core and optional

modules, and it is able to add ‘state-added’

questions to customize data collection to topics most relevant to Coloradans. In 2014 and 2015

Colorado added questions on marijuana use to the BRFSS (Table 1).

These questions have begun to

give insight into marijuana use patterns among Colorado’s adult population.

For additional survey details and information about analysis methods, see Appendix B.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Survey questions

Table 1. Behavioral Risk Factor Surveillance System questions asked of Colorado

adults about marijuana use and methods of marijuana use, 2014-2015.

1. Have you ever used marijuana or hashish? (all respondents were asked)

a. Yes

b. No

c. Don't Know/Not Sure

2014/2015

2. How old were you the first time you used marijuana or hashish? (only ever users 2014/2015

were asked)

a. Age: _______

b. Don't Know/Not Sure

3. During the past 30 days on how many days did you use marijuana or hashish?

(only ever users were asked)

a. Number of Days: ________

b. None

c. Don't Know/Not Sure

2014/2015

4. During the past 30 days, how many times did you drive a car or other vehicle

2014/2015

when you had been using marijuana or hashish? (only current users were asked)

a. Number of days ________

b. Don't Know/Not Sure

5. On the days that you did use marijuana, how many times per day did you use it 2015

on average? (only current users were asked)

a. Number of times: ________

b. None

c. Don't know/Not sure

6. During the past 30 days, how did you use marijuana? For each of the following

methods please say YES if it does apply or NO if it does not apply or Don't

know/Not sure. (only current users were asked)

a. Was it vaporized? (e-cigarette-like vaporizer)

b. Was it smoked? (in a joint, bong, pipe, blunt)

c. Was it eaten in food? (in brownies, cakes, cookies, candy)

d. Was it consumed in a beverage? (tea, cola, alcohol)

e. Was it dabbed?

f. Was it used in some other way? _______________ (specify)

2015

The National Survey on Drug Use and Health

The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks national and state

level data on tobacco, alcohol, marijuana, and illicit drugs including non-medical use of prescription

drugs through the National Survey on Drug Use and Health (NSDUH).

National and Colorado past 30 day

marijuana use estimates from the NSDUH survey were compared with the Colorado BRFSS past 30 day

marijuana use estimate (Figure 2).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Definitions

Current use

–

having used marijuana or hashish on at least one day in the past 30 days (answered at

least ‘1 day in the past 30 days’ on question 3) (Table 1)

Dabbing

–

a method of marijuana use where a "dab" (small amount) of marijuana concentrate is placed

on a pre-heated surface, creating concentrated marijuana vapor to be inhaled.

Daily or near daily use

- having used marijuana or hashish on twenty to thirty days in the past 30 days

(answered ‘20-30 days in the past 30 days’ on question 3) (Table 1)

Ever use

–

having used marijuana or hashish at least

once in their lifetime (answered ‘Yes’ on question

1) (Table 1)

Monthly use

- having

used marijuana or hashish on one to three days in the past 30 days (answered ‘1-3

days in the past 30 days’ on question 3) (Table 1)

Vaping (vaporization of marijuana)

- a method of marijuana use where marijuana vapor, rather than

smoke, is inhaled. Marijuana flower or concentrate is heated in a vaporizing device (vaporizer) to a

temperature below the point of combustion, to produce vapor.

Weekly use

- having used marijuana or hashish on four to nineteen days in the past 30 days (answered

‘4-19 days in the past 30 days’ on question 3) (Table 1)

How to interpret survey results

Respondents to the BRFSS survey are a sample of Colorado adults. The percent of survey respondents

selecting a specific answer might not be exactly the same as if all adults in Colorado were surveyed.

Therefore, the survey results are estimates, and each has a range of possible values (also called margin

of error, confidence interval, or 95% CI). These ranges are very important when comparing two

estimates, and the following terms are used throughout this report:

‘Not statistically different’-

Typically, if the ranges of possible values

overlap

for two different survey

results (like two different years, or male vs. female), we cannot be confident that there is a true

difference between the two (also called ‘not statistically significant.’) In some cases, an additional

statistical test is done to confirm.

‘Statistically higher’ or ‘statistically lower’-

If the ranges of possible values

do not overlap

for two

different results, we CAN be confident that there is a true difference between the two (also called

‘statistically significant.’)

On the figures in this report, these ranges of possible values are indicated by black bars. In footnotes,

they are referred to by the statistical term ‘95% CI.’

Results

Results are displayed in Figures 1-13 below.

Trends in marijuana use in Colorado

Ever marijuana use among Colorado adults was estimated at 49.3% in 2015. Survey results indicated

that there were no statistical differences in ever marijuana use from 2014 (48.8%) to 2015 (49.3%).

Current marijuana use among adults was estimated at 13.4% from 2015 BRFSS (Figure 1). The 2015

NSDUH estimate for current use was statistically higher, at 17.1% (Figure 2). Neither survey showed a

statistical difference in current use from 2014 to 2015 (Figure 2). NSDUH estimates of current

marijuana use among Colorado adults from 2006-2015 were statistically higher than the national

estimates for adult current marijuana use for each year (Figure 2). Monthly, weekly, and daily or near

daily marijuana use among adults in 2015 was 3.5%, 3.6%, and 6.3% respectively. In both 2014 and

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

2015, daily or near daily marijuana use was statistically higher than monthly or weekly marijuana use

(Figure 3). Comparing across years within each level of use, there were no statistical differences

between 2014 and 2015 (Figure 3). In 2015, 2.1% of adults drove a vehicle in the past 30 days when

using marijuana (Figure 4). This was not statistically higher than in 2014 (2.5%).

Current marijuana use in Colorado by age, gender, race & ethnicity, and sexual

orientation

In both 2014 and 2015, current marijuana use was lower among adults 35 years and older (9.3%, 10.3%)

than among those 18-25 (27.5%, 26.1%) or 26-34 years of age (19.8%, 18.3) (Figure 5). Comparing across

years within each age category, there were no statistical differences between 2014 and 2015 (Figure

5). In both 2014 and 2015, current marijuana use was higher among males (17.2%, 16.9%) than females

(10.0%, 10.0%) (Figure 6). Comparing across years within each gender, there were no statistical

differences in current marijuana use from 2014 to 2015 (Figure 6). There also were no statistical

differences in current marijuana use estimates from 2014 to 2015 within any of the race/ethnicity

groups: Hispanic, White, Black, Multiracial, or Other Race (Figure 7). In both 2014 and 2015, current

marijuana use was higher among those who reported Gay, Lesbian, Bisexual, or Other sexual

orientation (30.1%,36.9%) compared to those who reported Heterosexual orientation (12.9%, 12.4%)

(Figure 8). Comparing across years within each sexual orientation category, there were no statistical

differences in current marijuana use from 2014 to 2015 (Figure 8).

Current marijuana use in Colorado by region

In 2015, the range of current marijuana use was 11.2% to 17.0% across regions compared to 10.3% to

15.1% in 2014. The Northwest region of Colorado had a statistical increase in current marijuana use

from 10.3% in 2014 to 16.0% in 2015 (Figure 9). There were no statistical differences in current

marijuana use from 2014 to 2015 in all other regions (Figure 9).

Daily or near daily marijuana use in Colorado

In both 2014 and 2015, daily or near daily marijuana use (6.0%, 6.3%) among adults was lower than

daily or near daily alcohol (22.8%, 21.8%) or tobacco use (15.9%, 15.6%) (Figure 10). Comparing across

years within each substance, there were no statistical differences between 2014 and 2015 (Figure 10).

In both 2014 and 2015, daily or near daily marijuana use was lower among adults 35 years and older

(3.6%, 4.8%) than among those 18-25 (13.3%, 13.1%) or 26-34 years of age (9.9%, 8.4%) (Figure 11).

Comparing across years within each age group, there were no statistical differences in daily or near

daily marijuana use between 2014 and 2015 (Figure 11).

Methods of marijuana use

Data on methods of use were only available for 2015. Dabbing was reported less among current users

aged 35 years and older (7.0%) than among those 18-25 (36.0%) or 26-34 (25.2%) years of age (Figure

12). There were no statistical differences between age groups in the number of adults who smoked,

vaporized, or ate/drank marijuana (Figure 12). Approximately half of adults who currently use

marijuana reported using it through multiple methods (49.9%), which was statistically higher than all

other reported methods of marijuana use (Figure 13). Only smoked (40.4%) was the next most

commonly reported method of use after multiple methods followed by only vaporized (5.8%), only

ate/drank (3.6%) and only dabbed (0.3%) in the past 30 days (Figure 13).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 1. Ever and current marijuana use among Colorado adults (18+ years),

2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Ever Use was marijuana use at least once in a lifetime. Current Use is defined as marijuana use at least once in the past 30

days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Ever marijuana use among Colorado adults (18+ years) was not statistically different from 2014

to 2015.

Current marijuana use (marijuana use at least once in the past 30 days) among adults was not

statistically different from 2014 to 2015.

Ever marijuana use 2014 vs. 2015:

= 0.15, p=0.7017

Current marijuana use 2014 vs. 2015:

= 0.07, p=0.7922

For an

explanation of terms, see “How to interpret survey results”

above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.1.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 2. Current marijuana use among adults (18+ years): NSDUH 2006-2015 and

BRFSS 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Daily or Near Daily Use is defined as using 20-30

days in the past 30 days (marijuana or alcohol) or reporting everyday or

someday use (smoking tobacco).

‡Data Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health (NSDUH)

2006-2014. Colorado Behavioural Risk Factors Surveillance System (BRFSS) 2014-2015

Major findings



BRFSS estimated current marijuana use among Colorado adults was not statistically different from

2014 to 2015.

NSDUH estimated current marijuana use among Colorado adults was not statistically different from

2014 to 2015.

In 2015, the NSDUH estimate for current marijuana use among Colorado adults was statistically

higher than the BRFSS estimate.

NSDUH estimates of current marijuana use among Colorado adults from 2006-2015 were statistically

higher than the national estimates for adult current marijuana use for each year.

Current marijuana use (BRFSS): 2014 13.6% (95% CI 12.4-14.8%), 2015 13.4% (95% CI 12.3-14.5%)

Current marijuana use (NSDUH): 2014 15.2% (95% CI 13.1-17.5%), 2015 17.1% (95% CI 15.0-19.5%)

Current marijuana use: 2014 BRFSS 13.6% (95% CI 12.4-14.8%), 2014 NSDUH 15.2% (95% CI 13.1-17.5%), 2015 BRFSS 13.4% (95% CI

12.3-14.5%), 2015 NSDUH 17.1% (95% CI 15.0-19.5%)

See Appendix B, Table B.2 for Colorado & National NSDUH estimates from 2006-2015

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.2.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 3. Monthy, weekly, and daily or near daily marijuana use among Colorado

adults (18+ years), 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Monthy use was using marijuana 1-3

days in the past 30 days, weekly use was using marijuana 4-19 days in the past 30 days, and

daily or near daily use was using marijuana 20 or more days in the past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



In both 2014 and 2015, daily or near daily marijuana use among adults was statistically higher than

monthly or weekly marijuana use.

Comparing across years within each level of use, there were no statistical differences between

2014 and 2015.

In 2014: daily/near daily 6.0% (95% CI 5.2-6.9%), monthly 4.2% (95% CI 3.5-4.8%), weekly 3.4% (95% CI: 2.8-4.0%). In 2015:

daily/near daily 6.3% (95% CI 5.5-7.2%), monthly 3.5% (95% CI 2.9-4.0%), weekly 3.6 (95% CI 3.0-4.2%).

Monthly, weekly and daily/near daily use 2014 vs. 2015:

= 2.56, p=0.4636

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.3.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 4. Colorado adults (18+ years) who drove a vehicle when using marijuana in

the past 30 days, 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



The prevalence of Colorado adults who drove a vehicle when using marijuana in the past 30 days

was not statistically different from 2014 to 2015.

Drove a vehicle when using marijuana, 2014 vs. 2015:

= 1.26, p=0.2609

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.4.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 5. Current marijuana use among Colorado adults (18+ years) by age

categories, 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Current marijuana use was statistically lower among adults 35 years and older than among adults

18-25 years or 26-34 years of age in both 2014 and 2015.

Comparing across years within each age category, there were no statistical differences between

2014 and 2015.

In 2014: 35+ years 9.3% (95% CI 8.3-10.3%), 26-34 years 19.8% (95% CI 16.3-23.4%), 18-25 years 27.5% (95% CI 22.6-32.3%). In

2015: 35+ years 10.3% (95% CI 9.3-11.2%), 18-25 years 26.1% (95% CI 21.2-31.0%), 26-34 years 18.3% (95% CI 14.7-21.9%).

Current use 2014 vs. 2015: 18-25 years

= 0.15, p=0.6974; 26-34 years

= 0.36, p=0.5470; 35 years and older

= 1.97,

p=0.1607.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.5.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 6. Current marijuana use among Colorado adults (18+ years) by gender,

2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days.

‡Data Source:

Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Current marijuana use was statistically higher among male adults compared to female adults in

both 2014 and 2015.

Comparing across years within each gender, there were no statistical differences in current

marijuana use from 2014 to 2015.

In 2014: males 17.2% (95% CI 15.4-19.1%), females 10.0% (95% CI 8.6-11.4%). In 2015: males 16.9% (95% CI 15.1-18.6%), females

10.0% (95% CI 8.7-11.4%).

Current use 2014 vs. 2015: adult males

= 0.07, p=0.7846; adult females

= 0.003, p=0.9509.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.6.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 7. Current marijuana use among Colorado adults (18+ years) by race and

ethnicity, 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



There were no statistical differences in estimates of current marijuana use from 2014 to 2015

within any of the race/ethnicity groups: Hispanic, White, Black, Multiracial, or Other Race.

Current use 2014 vs. 2015: Hispanic

= 0.14, p=0.7087; multiracial

= 0.57, p=0.4516; other

= 2.30, p=0.1298; white non-

Hispanic

= 0.02, p=0.8845; black

= 3.45, p=0.0633.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.7.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 8. Current marijuana use among Colorado adults (18+ years) by sexual

orientation, 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Current marijuana use was higher among those who reported Gay, Lesbian, Bisexual, or Other

sexual orientation compared to those who reported Heterosexual orientation in both 2014 and

2015.

Comparing across years within each sexual orientation category, there were no statistical

differences in current marijuana use from 2014 to 2015.



In 2014: Gay, Lesbian, Bisexual, or Other 30.1% (95% CI 21.7-38.4%), Heterosexual 12.9% (95% CI 11.8-14.1%). In 2015: Gay,

Lesbian, Bisexual, or Other 36.9% (95% CI 28.1-45.8%), Heterosexual 12.4% (95% CI 11.4-13.5%).

Current use 2014 vs. 2015: heterosexual adults

= 0.41, p=0.5226;

gay, lesbian, bisexual, or other sexual orientation adults Χ

1.23, p=0.2669.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.8.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 9. Current marijuana use among Colorado adults (18+ years) by regions,

2014-2015.

Produced by: EEOHT, CDPHE 2016.

†Black bars indicate margins of error (95%

Confidence Intervals).

‡Current Use was marijuana use at least once in the past 30 days.

§Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Current marijuana use among adults in Colorado’s Northwest region was

statistically higher in 2015

than in 2014.

There were no statistical differences in estimates of current marijuana use from 2014 to 2015

within the other regions of Colorado: Southwest, Denver-Boulder, South Central, Southeast, or

Northeast.

Current use among adults in the Northwest Region in 2014 vs. 2015:

= 4.91, p=0.027

Current use 2014 vs. 2015:

Southwest Region Χ

= 0.89, p=0.3457; Denver-Boulder

Region Χ

= 1.91 p=0.1664; South Central

Region Χ

= 0.48, p=0.487;

Southeast Region Χ

= 0.11, p=0.742;

Northeast Region Χ

0.09, p=0.765.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.9.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 10. Daily or near daily use of alcohol, tobacco, and marijuana among

Colorado adults (18+ years) 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Daily or Near Daily Use is defined as

using 20-30 days in the past 30 days (marijuana or alcohol) or reporting everyday or

someday use (smoking tobacco).

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



The prevalence of daily or near daily marijuana use among Colorado adults was statistically lower

than daily or near daily alcohol or tobacco use in both 2014 and 2015.

Comparing across years within each substance, there were no statistical differences between 2014

and 2015.

In 2014: Marijuana 6.0% (95% CI 5.2-6.9%), Alcohol 22.8% (95% CI 21.2-24.5%), Tobacco 15.9% (95% CI 14.7-17.1%). In 2015:

Marijuana 6.3% (95% CI 5.5-7.2%), Alcohol 21.8% (95% CI 20.4-23.3%), Tobacco 15.6% (95% CI 14.6-16.7%).

For an explanation of terms,

see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.10.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 11. Daily or near daily marijuana use among Colorado adults (18+ years) by

age categories, 2014-2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Daily or near daily was using marijuana 20 or more days in the

past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Daily or near daily marijuana use was statistically lower among adults 35 years and older than

among those 18-25 or 26-34 years of age in both 2014 and 2015.

Comparing across years within each age group, there were no statistical differences in daily or near

daily marijuana use between 2014 and 2015.

In 2014: 35+ years 3.6% (95% CI 3.0-4.3%), 18-25 years 13.3% (95% CI 9.4-17.2%), 26-34 years 9.9% (95% CI 7.1-12.6%). In 2015:

35+ years 4.8% (95% CI 4.1-5.5%), 18-25 years 13.1% (95% CI 9.3-17.0%), 26-34 years 8.4% (95% CI 5.7-11.1%).

Current use 2014 vs. 2015: 18-25 years

= 0.22, p=0.8991; 26-34 years

= 0.63, p=0.729; 35 years and older

= 5.86,

p=0.0534.

For an

explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.11.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 12. Methods of marijuana use among Colorado adults (18+ years) who

reported current use, by age categories, 2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30 days. Use of more than one method may have been

reported in the

past 30 days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Reported dabbing marijuana in the past 30 days was statistically lower among Colorado adults aged

35 years and older than among those 18-25 or 26-34 years of age.

There were not statistical differences between age groups within those that smoked, vaporized, or

ate/drank marijuana.

Dabbed: 18-25 years 36.0% (95% CI 25.3-46.7%), 26-34 years 25.2% (95% CI 14.5-35.9%), 35+ years 7.0% (95% CI 4.2-9.8%).

Smoked: 18-25 years 89.5% (95% CI 83.1-95.9%), 26-34 years 86.9% (95% CI 78.6-95.2%), 35+ years 78.9% (95% CI 75.1-82.8%).

Vaporized: 18-25 years 34.8% (95% CI 24.1-45.5%), 26-34 years 36.4% (95% CI 25.4-47.5%), 35+ years 29.7% (95% CI 25.0-34.5%).

Ate/drank: 18-25 years 37.9% (95% CI 27.2-48.6%), 26-34 years 39.1% (95% CI 28.1-50.1%), 35+ years 33.5% (95% CI 28.7-38.2%).

For an explanation

of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.12.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

Figure 13. Methods of marijuana use among Colorado adults (18+ years) who

reported current use, 2015.

Produced by: EEOHT, CDPHE 2016.

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use was marijuana use at least once in the past 30

days.

‡Data Source: Colorado Behavioral Risk Factor Surveillance System 2015.

Major findings



Approximately half of adults who currently use marijuana use it through multiple methods.

The prevalence of Colorado adults who used marijuana multiple methods in the past 30 days was

statistically higher than those who only smoked, only vaporized, only ate/drank, and only dabbed

in the past 30 days.

Multiple methods 49.9% (95% CI 45.4-54.5%), Only Smoked 40.4% (95% CI 36.0-44.8%), Only Vaporized 5.8% (95% CI 3.6-8.0%),

Only Ate/Drank 3.6% (95% CI 2.3-4.9%), Only Dabbed 0.3% (95% CI 0.0-0.6%).

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix B. For data, see

Appendix B, Table B.13.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Behavioral Risk Factor Surveillance System (BRFSS)

References

1. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: Annual

Survey Data. http://www.cdc.gov/brfss/annual_data/annual_data.htm. Accessed October 7,

2016.

2. Colorado Department of Public Health and Environment. Colorado Health and Environmental Data:

Adult Health Data: Behavioral Risk Factor Surveillance System.

http://www.chd.dphe.state.co.us/topics.aspx?q=Adult_Health_Data. Accessed October 7, 2016.

3. Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and

Health. https://nsduhweb.rti.org/respweb/homepage.cfm.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1

Monitoring Changes in

Marijuana Use

Patterns

Chapter 2

Child Health Survey (CHS)

2014-2015 Survey Results

Retail Marijuana Public Health Advisory

Committee

Section 1: Child Health Survey (CHS)

Authors

Daniel I. Vigil, MD, MPH

Manager

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Katelyn E. Hall, MPH

Statistical Analyst

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Elyse Contreras, MPH

Coordinator

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Ashley Juhl, MSPH

Maternal and Child Health Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Anne Schiffmacher, MPH

Maternal and Child Health Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Allison Grace Bui, MPH

Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Rickey Tolliver, MPH

Chief

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Mike Van Dyke, PhD, CIH

Chief

Environmental Epidemiology, Occupational Health, and Toxicology Branch, Colorado Department of

Public Health and Environment

Reviewer

Ashley Brooks-Russell, PhD, MPH

Assistant Professor

Injury Prevention, Education and Research Program, Colorado School of Public Health

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

The CHS survey and marijuana-related behaviors in Colorado

Since 2004, the Colorado Department of Public Health and Environment has conducted the Child Health

Survey (CHS). This annual survey provides data on a wide range of health issues and risk factors

affecting children and youth in Colorado for children ages 1-14. The CHS is conducted as a telephone

survey among respondents to the Behavioral Risk Factor Surveillance System (BRFSS) Survey who have

children ages 1-14 years old. Data from the CHS help to identify areas where education, resources to

assist parents, policy changes or other data-informed actions can

improve the health of Colorado’s

children.

Since 2014, questions about marijuana use and storage in the home have been included in the survey

(Table 1). The presence of marijuana in or around the home was evaluated using question 1, and was

asked of

all survey participants. Participants who answered ‘YES’ to this question were asked how their

marijuana is stored, in question 2. Marijuana being used in the home was evaluated using question 3,

and was asked of all survey participants. Participants who answered

‘YES’ to this question were asked

how the marijuana was used inside the home in question 4. Results enable CDPHE to estimate the

number of children in Colorado who may be exposed to secondhand marijuana smoke or unintentional

ingestion due to unsafe storage of marijuana products in the home.

For additional survey details and information about analysis methods, see Appendix C.

Survey questions

Table 1. Child Health Survey questions about marijuana storage or use in or

around the home, 2014-2015.

1. Is there any marijuana or marijuana product in or around your home right now?

Yes

2. Where is the marijuana that is currently in or around your home being stored? For each of the

following methods please say yes if it does apply or no if it does not apply.

In a childproof container or packaging

In a locked container such as a cabinet, drawer or safe

In a location your child cannot access (such as out of reach)

Someplace else? (specify)

3. During the past 30 days, has anyone- including yourself, used marijuana or hashish inside your home?

Yes

4. How was the marijuana that was used inside your home consumed? For each of the following methods

please say yes if it does apply or no if it does not apply.

It was vaporized (e-cigarette-like vaporizer)

It was smoked (in a joint, bong, pipe, blunt)

It was eaten in food (in brownies, cakes, cookies, candy)

It was consumed in a beverage (tea, cola, alcohol)

It was used in some other way (specify)

It was dabbed

(response option was added in 2015)

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Definitions

Dabbing

–

a method of marijuana use where a "dab" (small amount) of marijuana concentrate is placed

on a pre-heated surface, creating concentrated marijuana vapor to be inhaled.

Possible exposure to second-hand marijuana smoke or vapor within the home

- defined by

combining three responses from question 4:

it was vaporized; it was smoked;

and

it was dabbed.

Dabbing was added as a response in 2015; therefore, this category could be underrepresented in 2014

because respondents who dabbed within the home may have indicated

it was used in some other way.

Safe storage of marijuana

- defined by combining three responses from question 2:

in a childproof

container or packaging; in a locked container such as a cabinet, drawer, or safe;

and

in a location your

child cannot access.

The response

someplace else

was considered potentially unsafe storage and a risk

for unintentional ingestion.

Vaping (vaporization of marijuana)

- a method of marijuana use where marijuana vapor, rather than

smoke, is inhaled. Marijuana flower or concentrate is heated in a vaporizing device (vaporizer) to a

temperature below the point of combustion, to produce vapor.

How to interpret survey results

Respondents to the Child Health Survey are a sample of Colorado adults with children 1-14 years old.

The percent of survey respondents selecting a specific answer might not be exactly the same as if all

adults with children 1-14 years old in Colorado were surveyed. Therefore, the survey results are

estimates, and each has a range of possible values (also called margin of error, confidence interval, or

95% CI). These ranges are very important when comparing two estimates, and the following terms are

used throughout this report:

‘Not statistically different’-

Typically, if the ranges of possible values

overlap

for two different survey

results (like two different years, or male vs. female), we cannot be confident that there is a true

difference between the two (also called ‘not statistically significant.’) In some cases, an additional

statistical test is done to confirm.

‘Statistically higher’ or ‘statistically lower’-

If the ranges of possible values

do not overlap

for two

different results, we CAN be confident that there is a true difference between the two (also called

‘statistically significant.’)

On the figures in this report, these ranges of possible values are indicated by black bars. In footnotes,

they are referred to by the statistical term ‘95% CI.’

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Results

Results are displayed in Figures 1-3 below.

Marijuana in or around the home and safe storage

In 2015, 7.9% of adults with children 1-14 years old in the home reported having marijuana or

marijuana products in or around the home (Figures 1 & 2). In 82.2% of these homes, marijuana was

stored safely, while in 17.8% the marijuana was potentially stored unsafely (Figure 2). It was estimated

that approximately 14,000 homes in Colorado with children 1-14 years old had marijuana in the home

with potentially unsafe storage.

Comparing across years, there were no statistical differences from 2014 to 2015 in the prevalence of

marijuana or marijuana products in or around the home (6.9%, 7.9%; Figure 1) or safe storage in homes

with marijuana (86.0%, 82.2%; Figure 2). There were no differences in marijuana being in or around the

home by child’s age, highest household education, or household income,

or difference from 2014 to

2015 (data not shown).

Marijuana used inside the home and secondhand smoke exposure

For 2014 and 2015 together, 3.2% of adults with children 1-14 years old in the home reported

marijuana being used inside the home (Figure 3). Of these, 83.2% reported the marijuana was smoked,

vaporized, or dabbed (Figure 3). It was estimated that approximately 16,000 homes in Colorado had

children 1-14 years old with possible exposure to secondhand marijuana smoke or vapor in the home.

Comparing across years, there were no statistical differences from 2014 to 2015 in the prevalence of

marijuana being used inside the home (3.9%, 2.6%; Figure 1).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Figure 1. Presence of marijuana in or around the home or used in the home where

children live, 2014-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Data Source:

Colorado Child Health Survey 2014-2015 a call-back survey from BRFSS for adults with children 14 years old or

younger in the home.

Major findings



The prevalence of marijuana or marijuana products in or around homes where children live was not

statistically different between 2014 and 2015.

The prevalence of marijuana being used inside homes where children live was not statistically

different between 2014 and 2015.

Marijuana or marijuana products in or around the home: 2014 6.9% (95% CI 4.9-8.9%), 2015 7.9% (95% CI 4.9-10.9%)

Marijuana used inside the home: 2014 3.9% (95% CI 2.4-5.4%), 2015 2.6% (95% CI 0.8-4.4%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix C. For data, see

Appendix C, Table C.1.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Figure 2. Percent of adults with children and marijuana in or around the home

who store their marijuana in a safe place, 2014-2015.

2014

Marijuana in or around the home

Marijuana storage in or around the home

2015

Marijuana in or around the home

Marijuana storage in or around the home

Produced by: EEOHT, CDPHE 2016

*Statistically different due to non overlapping 95% confidence intervals (95% CI).

†Black bars indicate margins of error (95% Confidence Intervals)

‡Data Source: Colorado Child Health Survey 2014-2015

a call-back survey from BRFSS for adults with children 14 years or younger

in the home.

§Safe storage included a childproof container, a locked container, or a location a child cannot access.

Major findings:



The prevalence of marijuana being stored safely in homes where children live was not statistically

different between 2014 and 2015.

Marijuana safe storage: 2014 86.0% (95% CI 76.4-95.6%), 2015 82.2% (95% CI 70.1-94.2%)

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Figure 3. Methods of marijuana use among adults with children in the home, 2014-

2015 (years combined).

2014-2015

Marijuana use in the home

Methods of marijuana use in the home

Produced by: EEOHT, CDPHE 2016

*Statistically different due to non overlapping 95% confidence intervals (95% CI).

†Black bars indicate margins of error (95% CI)

‡Dabbing

was added as a response in 2015.

§ Data Source: Colorado Child Health Survey 2014-2015 a call-back survey from BRFSS for adults with children 14 years or younger

in the home.

Major findings



Among adults who use marijuana in a home where children live, the prevalence of

‘smoked,

vaporized or dabbed’ was statistically

higher than ‘ate or drank’.

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix C. For data, see

Appendix C, Table C.2.

For 2014-2015 combined years: smoked, vaporized or dabbed 83.2% (95% CI 64.3-100.0%), ate or drank 24.0% (95% CI 5.2-42.7%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix C. For data, see

Appendix C, Table C.3.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

References

1. Colorado Department of Public Health and Environment. Maternal and Child Health Data, Colorado

Child Health Survey Data. 2016;

http://www.chd.dphe.state.co.us/topics.aspx?q=Maternal_Child_Health_Data. Accessed January 1,

2017.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Child Health Survey (CHS)

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1

Monitoring Changes in

Marijuana Use

Patterns

Chapter 3

Healthy Kids Colorado Survey

(HKCS)

2005-2015 Survey Results

Retail Marijuana Public Health Advisory

Committee

Section 1: Healthy Kids Colorado Survey (HKCS)

Authors

Daniel I. Vigil, MD, MPH

Manager

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Katelyn E. Hall, MPH

Statistical Analyst

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Elyse Contreras, MPH

Coordinator

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Amy Anderson Mellies, MPH

Health Data Analyst

Health Surveys and Evaluation, Colorado Department of Public Health and Environment

Leonardo Kattari, MSW

Healthy Kids Colorado Survey Coordinator

Prevention Services, Colorado Department of Public Health and Environment

Kevin Berg, MA

GIS Epidemiologist

Environmental Epidemiology, Colorado Department of Public Health and Environment

Rickey Tolliver, MPH

Chief

Health Surveys and Evaluation, Colorado Department of Public Health and Environment

Mike Van Dyke, PhD, CIH

Chief

Environmental Epidemiology, Occupational Health, and Toxicology, Colorado Department of Public

Health and Environment

Reviewer

Ashley Brooks-Russell, PhD, MPH

Assistant Professor

Injury Prevention, Education and Research Program, Colorado School of Public Health

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

The HKCS survey and marijuana use in Colorado

The Healthy Kids Colorado Survey (HKCS) collects health information in the fall of odd years from

public high school and middle school students. It is a voluntary, anonymous survey, and parents are

notified ahead of time. HKCS is a collaboration of the Colorado Department of Public Health and

Environment (CDPHE), the Colorado Department of Education, and the Colorado Department of Human

Services, who recognized the need to gather critical data while minimizing the student survey requests

to Colorado schools. Both state and regional data are available to provide schools and communities

with information to support effective strategies to protect the health and promote academic

achievement of Colorado youth. This survey also fulfills Colorado’s reporting requirement

for the CDC-

sponsored Youth Risk Behavioral Surveillance Survey (YRBS)

and ensures Colorado data can be

compared to both national data and data from other states. HKCS provides data on a wide range of

health issues and risk factors affecting children and youth including: nutrition, physical activity, safety

behaviors, mental health, alcohol, tobacco and other substance use, and sexual behaviors (high school

only). The survey has included questions on marijuana since 1999.

This report includes results from

2005-2015 for high school and 2011-2015 for middle school.

For additional survey details and information about analysis methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Survey questions

Table 1. Healthy Kids Colorado Survey questions asked of middle school and high

school students about whether they use marijuana, when they use it and how they

use it, 2005-2015.

Not all questions were included in all years and not all questions were asked of both middle school and

high school students.

1. During your life, how many times have you used marijuana?

0 times

1 or 2 times

3 to 9 times

10 to 19 times

20 to 39 times

40 to 99 times

100 or more times

2. How old were you when you tried marijuana for the first time?

I have never tried marijuana

8 years old or younger

9 or 10 years old

11 or 12 years old

13 or 14 years old

15 or 16 years old

17 years old or older

3. During the past 30 days, how many times did you use marijuana?

0 times

1 or 2 times

3 to 9 times

10 to 19 times

20 to 39 times

40 or more times

4. During the past 30 days, how did you use marijuana? (Select all that apply.)

did not use marijuana during the past 30 days

smoked it

ate it (in an edible, candy, tincture or other food)

used a vaporizer

dabbed it*

used it in some other way

5. During the past 30 days, how did you usually use marijuana? (Select only one response.)

did not use marijuana during the past 30 days

smoked it I ate it (in an edible, candy, tincture or other food)

used a vaporizer

dabbed it*

used it in some other way

The response option of “I dabbed it” was added in 2015

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

The National Survey on Drug Use and Health

The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks national and state

level data on tobacco, alcohol, marijuana, and illicit drugs including non-medical use of prescription

drugs through the National Survey on Drug Use and Health (NSDUH).

Colorado past 30 day marijuana

use estimates from the NSDUH survey were compared with the Colorado HKCS past 30 day marijuana

use estimates (Figure 2).

Definitions

Current use

–

Having used marijuana at least once in the past 30 days (any answer

other than ‘0 times’

on question 3) (Table 1)

Dabbing

–

a method of marijuana use where a "dab" (small amount) of marijuana concentrate is placed

on a pre-heated surface, creating concentrated marijuana vapor to be inhaled.

Ever use

–

having used marijuana at least once in their lifetime (any answer other

than ‘0 times’ on

question 1) (Table 1)

Tried marijuana before age 13

–

answered

‘11 or 12 years old’, ‘9 or 10 years old’, or ‘8 years

old or

younger’ on question 2

(Table 1)

Vaping (vaporization of marijuana)

- a method of marijuana use in which marijuana vapor, rather than

smoke, is inhaled. Marijuana flower or concentrate is heated in a vaporizing device (vaporizer) to a

temperature below the point of combustion, to produce vapor.

How to interpret survey results

Respondents to the Healthy Kids Colorado Survey are a sample of Colorado high school and middle

school students. The percent of survey respondents selecting a specific answer might not be exactly

the same as if every student in Colorado were surveyed. Therefore, the survey results are estimates,

and each has a range of possible values (also called margin of error, confidence interval, or 95% CI).

These ranges are very important when comparing two estimates, and the following terms are used

throughout this report:

‘Not statistically different’-

Typically, if the ranges of possible values

overlap

for two different survey

results (like two different years, or male vs. female), we cannot be confident that there is a true

difference between the two (also called ‘not statistically significant.’) In some cases, an additional

statistical test is done to confirm.

‘Statistically higher’ or ‘statistically lower’-

If the ranges of possible values

do not overlap

for two

different results, we CAN be confident that there is a true difference between the two (also called

‘statistically significant.’)

On the figures in this report, these ranges of possible values are indicated by black bars. In footnotes,

they are referred to by the statistical term ‘95% CI.’

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Results

Results are displayed in Figures 1-13 and Maps 1-2 below.

Trends in marijuana use in Colorado

Survey results from 2015 indicate that approximately 38% of Colorado high school students report

having ever used marijuana and 21% report use in the past 30 days (Figures 1 & 3). These estimates are

similar to national estimates of ever and current marijuana use among high school students (Figure 1).

From 2005-2015, estimates of current marijuana use among Colorado high school students have

fluctuated between approximately 20% and 25% (Figures 1 & 3). From 2005 to 2013, the HKCS estimates

of current marijuana use among high school students in Colorado were higher than the NSDUH

estimates for current marijuana use among high school aged adolescents. However, the difference

became smaller in 2013, at 19.7% on HKCS and 17.4% on NSDUH (Figure 2). Among Colorado middle

school students in 2015, an estimated 7.6% had ever used marijuana and an estimated 4.4% reported

currently using marijuana (Figure 3). Current marijuana use among high school students in Colorado has

remained below current alcohol use from 2005 to 2015 and above current tobacco smoking from 2011

to 2015. Current alcohol use and tobacco smoking among high school students in Colorado has trended

downward since 2005, while current marijuana use has remained stable (Figure 4). In both 2013 and

2015, current marijuana use among Colorado 9

graders (13.7%, 12.4%) was statistically lower than

among 10

graders (19.0%, 18.8%), which was statistically lower than among 11

graders (22.1%, 26.3%)

(Figure 5).

Marijuana use among Colorado high school students by gender, race & ethnicity,

and sexual orientation

Current marijuana use among male high school students in 2013 (21.5%) was statistically higher than

among female students (17.7%), but current use for both genders was nearly identical in 2015 (21.4%,

21.0%) (Figure 6). Current marijuana use among middle school students was not statistically different

between males and females in 2013 (5.3%, 4.8%) or 2015 (3.8%, 5.2%) (Figure 7). Prevalence of current

marijuana use and age of first use varied among students of different races and ethnicities (Figures 8 &

11). The percent of white non-Hispanic students who tried marijuana before age 13 was statistically

lower than among black, Hispanic, or multiple or other race students (Figure 11). Prevalence of

marijuana use also varied among students with different sexual orientation. In both 2013 and 2015,

estimated current use of marijuana among students identifying as gay, lesbian, or bisexual (39.7%,

34.9%) was statistically higher than the estimated current use among students identifying as

heterosexual (17.7%, 19.5%) (Figure 9). In 2015, a large portion of high seniors reported first trying

marijuana at ages 13-14 years old (27.0%) and 15-16 years old (43.1%) compared to younger ages and 17

and older (Figure 10).

Methods and frequency of marijuana use in Colorado

In 2015, 87% of high school students who currently used marijuana reported that smoking was their

usual method of use

–

much higher than edibles (2%), vaping (5%), or other methods of use (6%) (Figure

12). More than one-third of high school or middle school students who reported current marijuana use

in 2015 had used once or twice in the past 30 days, while approximately 27% of high school students

and 20% of middle school students had used 20 or more times in the past 30 days (Figure 13). The

estimates of marijuana use at each frequency level fluctuated from 2005 to 2015, with no notable

trends (Figure 14).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Marijuana use also varies greatly

by Health Statistics Region (HSR). Some of Colorado’s larger counties

represent a single HSR, but for smaller or less populated areas, several counties may be represented by

a single HSR (Maps 1 & 2). In both 2013 and 2015, health statistics regions 7 (Pueblo County 32.0%,

30.1%) and 9 (Dolores, San Juan, Montezuma, La Plata, and Archuleta Counties 24.6%, 26.2%) were

statistically higher than the state prevalence (19.7%, 21.2%) for current marijuana use among high

school students. For all but one HSR, current marijuana use among high school students in 2015 was not

statistically different from 2013. Health statistics region 10 (Montrose, Delta, Gunnison, Ouray,

Hinsdale, and San Miguel Counties) did have statistically lower current marijuana use among high

school students in 2015 (17.5%) than in 2013 (26.7%) (Map 2).

Marijuana use in Colorado by region

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 1. Prevalence of ever and current marijuana use for high school students in

Colorado (HKCS) compared to the national prevalence (YRBS), 2005-2015.

36.9

19.7

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Ever Use is defined as marijuana use at least one time during a student's lifetime and Current

Use is defined as marijuana use at

least once in the past 30 days.

‡Data Source:

Colorado estimates are from the Healthy Kids Colorado Survey (HKCS) and United States estimates are from the

Youth Risk Behavioral Surveillance System survey. Note: Data for the year 2007 was not included due to low sample size.

Major findings



HKCS estimates for both ever and current marijuana use in Colorado have had no statistical

difference from the YRBS national estimates from 2005 through 2015, except for current use in

2013.

In 2013, the HKCS estimate of current marijuana use among high school students in Colorado was

statistically lower than the YRBS national estimate.

Comparing 2015 HKCS estimates with 2013, there was no statistical difference in current use or

ever use among Colorado high school students.

The 2015 HKCS estimates for both ever and current marijuana use among high school students in

Colorado were nearly identical to the 2015 YRBS national estimates.



In 2013: HKCS estimate for Colorado 19.7%, (95% CI 18.7-20.6%), YRBS national estimate 23.4% (95% CI 21.3-25.7%).

Current marijuana use in Colorado (HKCS): 2013 19.7% (95% CI 18.7-20.6%), 2015 21.2% (95% CI 19.7-22.7%). Ever marijuana use

in Colorado (HKCS): 2013 36.8% (95% CI 35.4-38.3%), 2015 38.0% (95% CI 36.0-40.0%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.1.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 2. Prevalence of current marijuana use for high school aged adolescents in

Colorado, 2005-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once

in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2005-2015

and National Survey on Drug Use and

Health (NSDUH) for 2004-2014 ages 14-17. Both are for Colorado only.

Major findings



From 2005 to 2013, the HKCS estimates of current marijuana use among high school students in

Colorado were higher than the NSDUH estimates for current marijuana use among high school aged

adolescents in Colorado. However, the difference became smaller in 2013.

NSDUH data was a 3-year aggregate 2012-2014. For data, see Appendix D, Table D.2.

For statistical methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 3. Prevalence of ever and current marijuana use for high school and middle

school students in Colorado, 2005-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Ever Use is defined as marijuana use at least one time

during a student's lifetime and Current Use is defined as marijuana use at

least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2005-2015.

Data for the year 2007 was not included

due to low sample size. Data for middle school marijuana use was not collected before 2011.

Major findings



Among Colorado high school students, over the years 2005 to 2015, estimates of current marijuana

use have fluctuated between 19.7% and 24.8%. None of these estimates were statistically different

from each other.

Among Colorado high school students, over the years 2005 to 2015, estimates of having ever used

marijuana have fluctuated between 36.9% and 42.6%. None of these estimates were statistically

different from each other.

Among Colorado middle school students in 2015, an estimated 4.4% were currently using marijuana

and an estimated 7.6% had ever used marijuana. Between 2011 and 2015, none of the estimates

were statistically different.



For data, see Appendix D, Table D.3.

For statistical methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 4. Prevalence of current marijuana use for high school students in Colorado

compared to current alcohol use and tobacco smoking in Colorado, 2009-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2005-2015.

Note: Data for the year 2007 was not

included due to low sample size.

Major findings



The prevalence of current marijuana use among high school students in Colorado has remained

statistically higher than current tobacco smoking from 2011 through 2015 and has remained

statistically lower than current alcohol use from 2009 through 2015.

Current alcohol use was statistically lower in 2015 compared to 2009.

Current tobacco smoking was statistically lower in 2015 compared to 2013 and in 2013 compared to

2011.

Current marijuana use has remained stable from 2009 through 2015 with the prevalence of current

marijuana use among high school students ranging from 19.7%-24.8%.



Current

alcohol use: 2015 30.2% (95% CI 28.3-32.2%), 2009 40.8% (95% CI 35.8-46.0%)

Current tobacco use: 2015 8.6% (95% CI 7.7-9.5%), 2013 10.7% (95% CI 10.0-11.4%), 2011 15.7% (95% CI 12.8-19.0%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.4.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 5. Prevalence of current marijuana use for high school and middle school

students in Colorado by grade, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



In both 2013 and 2015, estimates of current marijuana use among Colorado students in each grade

level trended upward from 6

through 12

grade, with current use higher in older grades than

younger grades.

In both 2013 and 2015, estimated current use among Colorado 9

graders was statistically lower

than among 10

graders, and current use among 10

graders was statistically lower than among

graders.

Estimated current use among Colorado 11

graders was statistically higher in 2015 than it was in

2013. There was not a statistical difference in current use among all other grades between 2013

and 2015.



In 2013: 9

graders 13.7% (95% CI 12.3-15.1%), 10

graders 19.0% (95% CI 17.7-20.3%), 11

graders 22.1% (95% CI 20.6-23.5%); In

2015: 9

graders 12.4% (95% CI 10.0-14.7%), 10

graders 18.8% (95% CI 16.3-21.3%), 11

graders 26.3% (95% CI 23.8-28.7%)

Current use among Colorado 11

graders: 2015 26.3% (95% CI 23.8-28.7%), 2013 (22.1%, 95% CI: 20.6%-23.5%).

For an explanation

of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.5.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 6. Prevalence of current marijuana use for high school students in Colorado

by gender, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



The estimate of female high school students in Colorado who reported current marijuana use in

2015 was statistically higher than in 2013.

Estimates for current marijuana use among male high school students in Colorado were nearly

identical in 2013 and 2015.

Colorado female high school students current marijuana use: 2013 17.7% (95% CI 16.6-18.8%), 2015 21.0% (95% CI 19.3-22.6%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.6.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 7. Prevalence of current marijuana use for middle school students in

Colorado by gender, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least

once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



Current marijuana use was not statistically different between 2013 and 2015 for either male or

female middle school students in Colorado.

Males: 2013 5.3% (95% CI 4.1-6.5%), 2015 3.8% (95% CI 1.3-6.2%); Females: 2013 4.8% (95% CI 3.8-5.9%), 2015 5.2% (95% CI 1.7-

8.6%)

For an explanation

of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.7.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 8. Prevalence of current marijuana use for high school students in Colorado

by race/ethnicity, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as

marijuana use at least once in the past 30 days.

‡Hispanic includes respondents who selected “Hispanic” for ethnicity and “white” for race. Those who selected “Hispanic” for

ethnicity and a non-white race are included under

“multiple or other race”.

AI: American Indian, AN: Alaska Native, NH: Native Hawaiian, PI: Pacific Islander.

§Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



In both 2013 and 2015, current marijuana use was statistically lower among Asian high school

students than among white, Hispanic, black, and multiple or other race students.

In both 2013 and 2015, current marijuana use was statistically higher among multiple or other race

high school students than among white students.

In 2013, current marijuana use was also statistically higher among Hispanic, black and American

Indian/Alaskan Native high school students than among white students.

For data, see Appendix D, Table D.8.

For an explanation of terms, see “How

to interpret survey results”

above. For statistical methods, see Appendix

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 9. Prevalence of current marijuana use among high school students in

Colorado by sexual orientation, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS)

prevalence estimates for 2013-2015.

Major findings



In 2013 and 2015, current use of marijuana among students identifying as gay, lesbian or bisexual,

was statistically higher than estimated current use among students identifying as heterosexual.

In 2013: gay, lesbian, or bisexual students 39.7% (95% CI 36.5-42.9%), heterosexual students 17.7% (95% CI 16.7-18.7%). In 2015:

gay, lesbian, or bisexual students 34.9% (95% CI 30.4-39.4%), heterosexual students 19.5% (95% CI 17.8-21.1%).

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.9.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 10. Age of first marijuana use among high school seniors in Colorado who

reported ever using marijuana, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana

use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



In 2015, among high school seniors who had used marijuana at least once in the past, an estimated

84.4% of them first used by age 16 or before, 41.3% first used by age 14 or before, and 14.3% first

used by age 12 or before.

Age of first marijuana use followed a similar pattern among high school seniors surveyed in 2013

who reported ever using marijuana.



First used by age 12 includes the “Less than 9” (2.7%), “9-10” (2.4%) and “11-12” (9.2%),

totaling 14.3%; first used by age 14

includes those plus “13-14” (27.0%), totaling 41.3%; first used by age 16 includes those plus “15-16” (43.1%),

totaling 84.4%

For data, see Appendix D, Table D.10.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 11. Prevalence of high school students in Colorado who tried marijuana

before age 13 by race/ethnicity, 2013-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Hispanic includes respondents who selected “Hispanic” for ethnicity and “white” for race. Those who selected “Hispanic” for

ethnicity and a non-white race

are included under “multiple or other race”.

AI: American Indian, AN: Alaska Native, NH: Native Hawaiian, PI: Pacific Islander.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



In both 2013 and 2015, the estimated percent of white students who first tried marijuana before

age 13 was statistically lower than among black, Hispanic, and multiple or other race students.

In 2013, the estimated percent of Asian students who first tried marijuana before age 13 was

statistically lower than among black, Hispanic, American Indian/Alaskan Native and multiple or

other race students.

For an explanation of terms,

see “How

to interpret survey results”

above. For statistical methods, see Appendix

D. For data,

see Appendix D, Table D.11.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 12. Usual methods of marijuana use among high school students in Colorado

who reported current marijuana use, 2011-2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡In 2015 the 'Other' category included 'Other' and 'Dabbing.'

§Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2011-2015.

Major findings



A large majority of high school students who currently use marijuana report that smoking is their

usual method of use, as compared to edibles, vaping or other methods of use.

The percentage of high school students who reported usually using edibles was statistically lower in

2015 compared to 2013.

Usually use edibles: 2013 5.2% (95% CI 4.2-6.1%), 2015 2.1% (95% CI 1.2-3.0%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D. For data, see

Appendix D, Table D.12.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 13. Frequency of marijuana use among high school and middle school

students in Colorado who reported current marijuana use, 2015.

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2013-2015.

Major findings



In 2015, among high school students currently using marijuana, an estimated 35.8% used it once or

twice in the past 30 days, while 26.8% used it 20 or more times.

Among middle school students currently using marijuana, an estimated 40.3 % used once or twice in

the past 30 days and 19.8% used 20 or more times.

20 or more times includes “20-39” (8.3%) and “40 or more” (18.5%), totaling 26.8%

20 or more times includes “20-39” (8.7%) and “40 or more”

(11.1%), totaling 19.8%

For statistical methods, see Appendix D. For data, see Appendix D, Table D.13.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Figure 14. Frequency of marijuana use among high school students in Colorado,

2005-2015.

5.3

Produced by: EEOHT, CDPHE 2016

*Black bars indicate margins of error (95% Confidence Intervals).

†Current Use is defined as marijuana use at least once in the past 30 days.

‡Data Source: Healthy Kids Colorado Survey (HKCS) prevalence estimates for 2005-2015.

Note: Data for the year 2007 was not

included due to low sample size.

Major findings



The estimated percent of Colorado high school students using marijuana at each frequency level

fluctuated for surveys from 2005 to 2015, with no notable trends.

For data, see Appendix D, Table D.14.

For statistical methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Map 1. Prevalence of current marijuana use among high school students in

Colorado, 2013

Major findings



In 2013, health statistic regions 7 (Pueblo County, 32.0%), 10 (Montrose, Delta, Gunnison, Ouray,

Hinsdale, and San Miguel Counties, 26.7%), 20 (Denver County, 26.6%), 17 (Gilpin, Clear Creek,

Park, and Teller Counties, 25.1%), 9 (Dolores, San Juan, Montezuma, La Plata, and Archuleta

Counties, 24.6%), and 13 (Lake, Chaffee, Fremont, and Custer Counties, 22.9%), were statistically

higher than the 2013 Colorado state estimate of current use among high school students of 19.7%.

In 2013:

HSR 7 - 32.0% (95% CI 25.7-38.4%), HSR 10 - 26.7% (95% CI 22.3-31.0%), HSR 20 - 26.6% (95% CI 22.5-30.8%), HSR 17 -

25.1% (95% CI 21.9-28.3%), HSR 9 - 24.6% (95% CI 20.9-28.3%), HSR 13

–

22.9% (95% CI 21.2-24.7%), all of Colorado - 19.7% (95% CI

18.7-20.6%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

Map 2. Prevalence of Current Marijuana Use among High School Students in

Colorado, 2015

Major findings



In 2015, health statistics regions 7 (Pueblo County, 30.1%) and 9 (Dolores, San Juan, Montezuma, La

Plata, and Archuleta Counties, 26.2%) were statistically higher than the 2015 Colorado state

estimate of current use among high school students of 21.2%.

Current marijuana use in health statistics region 10 (Montrose, Delta, Gunnison, Ouray, Hinsdale,

and San Miguel Counties) was statistically lower in 2015 (17.5%) than it was in 2013 (26.7%).

For all other health statistics regions, current use in 2015 was not statistically different from

current use in 2013.



In 2015: HSR 7 - 30.1% (95% CI 27.1-33.2%), HSR 9 - 26.2% (95% CI 24.7-37.7%), all of Colorado - 21.2% (95% CI 19.7-22.7%)

HSR 10: 2013 - 26.7% (95% CI 22.3-31.0%), 2015 - 17.5% (95% CI12.7-22.3%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix D.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Healthy Kids Colorado Survey (HKCS)

References

1. Centers for Disease Control and Prevention. Youth Risk Behavioral Surveillance System.

Adolescent

and School Health

http://www.cdc.gov/healthyyouth/data/yrbs/.

2. Colorado Department of Public Health and Environment. Adolescent Health Data, Healthy Kids

Colorado Survey.

Colorado Health and Environmental Data

2015;

http://www.chd.dphe.state.co.us/topics.aspx?q=Adolescent_Health_Data, 2016.

3. Substance Abuse and Mental Health Services Administration. Population Data / NSDUH.

https://www.samhsa.gov/data/population-data-nsduh/2015.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1

Monitoring Changes in

Marijuana Use

Patterns

Chapter 4

Pregnancy Risk Assessment

Monitoring System (PRAMS)

2014 Survey Results

Retail Marijuana Public Health Advisory

Committee

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Authors

Daniel I. Vigil, MD, MPH

Manager

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Katelyn E. Hall, MPH

Statistical Analyst

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Elyse Contreras, MPH

Coordinator

Marijuana Health Monitoring and Research Program, Colorado Department of Public Health and

Environment

Ashley Juhl, MSPH

Maternal and Child Health Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Anne Schiffmacher, MPH

Maternal and Child Health Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Allison Grace Bui, MPH

Epidemiologist

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Rickey Tolliver, MPH

Chief

Health Surveys and Evaluation Branch, Colorado Department of Public Health and Environment

Mike Van Dyke, PhD, CIH

Chief

Environmental Epidemiology, Occupational Health, and Toxicology Branch, Colorado Department of

Public Health and Environment

Reviewer

Laura Borgelt, PharmD

Associate Dean and Professor

Departments of Clinical Pharmacy and Family Medicine, University of Colorado Anschutz Medical

Campus

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

The PRAMS survey and marijuana use in Colorado

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a survey sponsored by the Centers for

Disease Control and Prevention (CDC). The survey asks new mothers questions about their pregnancy

and their new baby. It provides data not available from other sources about pregnancy and the first

few months after delivery, and allows CDC and the states to monitor changes in maternal and child

health indicators, such as unintended pregnancy, prenatal care, breastfeeding, infant health, smoking

and alcohol use. These data can be used to identify groups of women and infants at high risk for health

problems, to monitor changes in health status, and to measure progress toward goals in improving the

health of mothers and infants.

In 2014, PRAMS in Colorado asked about marijuana use before, during

and after pregnancy (Table 1).

For additional survey details and information about analysis methods, see Appendix E.

Survey questions

Table 1.

Pregnancy Risk Assessment Monitoring System question about marijuana use,

2014.

1. During any of the following time periods, did you use marijuana or hashish (hash)? For each time

period, say No if you did not use then or say Yes if you did.

During the 3 months before I got pregnant.

During the first 3 months of my pregnancy.

During the last 3 months of my pregnancy.

At any time during my most recent pregnancy.

Since my baby was born.

Don’t know/don’t remember

Definitions

Using marijuana during pregnancy

was defined by combining three responses:

during the first 3

months of my pregnancy; during the last 3 months of my pregnancy;

and

at any time during my most

recent pregnancy.

Using marijuana and breastfeeding after delivery

was defined as answering

‘Yes’

to using marijuana

since my baby was born

AND answering

‘Yes’

to one of two breastfeeding questions:

Did you ever

breastfeed or pump breastmilk to feed your new baby;

Are you currently breastfeeding or feeding

pumped milk to your new baby.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

How to interpret survey results

Respondents to the PRAMS survey are a sample of Colorado women who recently gave birth. The

percent of survey respondents selecting a specific answer might not be exactly the same as if all

Colorado women who recently gave birth were surveyed. Therefore, the survey results are estimates,

and each has a range of possible values (also called margin of error, confidence interval, or 95% CI).

These ranges are very important when comparing two estimates, and the following terms are used

throughout this report:

‘Not statistically different’-

Typically, if the ranges of possible values

overlap

for two different survey

results (like two different years, or male vs. female), we cannot be confident that there is a true

difference between the two (also called ‘not statistically significant.’) In some cases, an additional

statistical test is done to confirm.

‘Statistically higher’ or ‘statistically lower’-

If the ranges of possible values

do not overlap

for two

different results, we CAN be confident that there is a true difference between the two (also called

‘statistically significant.’)

On the figures in this report, these ranges of possible values are indicated by black bars. In footnotes,

they are referred to by the statistical term ‘95% CI.’

Results

Results are displayed in Figures 1-5 below.

In 2014, among new mothers in Colorado, marijuana use before pregnancy (11.2%) was statistically

lower than use of tobacco (16.9%) or alcohol (66.7%) before pregnancy (Figure 1). During pregnancy,

alcohol use (12.8%) was statistically higher than use of tobacco (6.4%) or marijuana (5.7%) (Figure 2). A

2016 article estimated that 3.9% of pregnant women in the United States overall used marijuana during

pregnancy (data not shown).

This was not statistically different from the PRAMS estimate of 5.7% for

Colorado.

Marijuana use before pregnancy (11.2%) was statistically higher than use during pregnancy (5.7%) or use

by breastfeeding mothers after delivery (4.5%) (Figure 3). There was no statistical difference between

use during pregnancy and use by breastfeeding mothers after delivery. Marijuana use during pregnancy

was statistically higher among women with an unintended pregnancy (9.1%) than among women who

intended to become pregnant (4.0%) (Figure 4).

When marijuana use during pregnancy was compared among different demographics, both education

and age showed statistical differences, while race/ethnicity did not. Use during pregnancy was

statistically higher among women with less than a 12

grade education (15.7%) than among women

with some college (4.1%) (Figure 5). It was also statistically higher among women 20-24 years old

(12.6%) than among women 25-34 years old (4.3%) or women 35 years old or older (2.7%) (Figure 5).

There were no statistical differences in marijuana use during pregnancy by race/ethnicity (Figure 5).

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Figure 1. Colorado women who reported using substances before pregnancy,

2014.

Produced by: EEOHT, CDPHE 2016

*95% confidence intervals do not overlap.

†Black bars indicate margins of error (95% Confidence Intervals).

‡Data Source: Colorado Pregnancy Risk Assessment Monitoring System 2014.

Major findings



The prevalence of marijuana use before pregnancy among women who recently gave birth was

statistically lower than use of tobacco or alcohol before pregnancy.

2014 substance use before pregnancy: alcohol 66.7% (95% CI 63.4-69.9%), tobacco 14.4% (95% CI 14.4-19.4%), marijuana 11.2%

(95% CI 9.0-13.3%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix E. For data, see

Appendix E, Table E.1.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Figure 2. Colorado women who reported using substances during pregnancy, 2014.

Produced by: EEOHT, CDPHE 2016

*95% confidence intervals do not overlap.

†Black bars indicate margins of error (95% Confidence Intervals).

‡Tobacco and alcohol use was during the last 3 months of pregnancy.

§Data Source: Colorado Pregnancy Risk Assessment Monitoring System 2014.

Major findings



The prevalence of alcohol use during pregnancy was statistically higher than use of tobacco or

marijuana during pregnancy. The use of marijuana was not statistically different from use of

tobacco.

2014 substance use during pregnancy: alcohol 12.8% (95% CI 10.5-15.0%), tobacco 6.4% (95% CI 4.8-8.1%), marijuana 5.7% (95%

CI 4.2-7.2%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix E. For data, see

Appendix E, Table E.2.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Figure 3. Colorado women who reported using marijuana before, during, and after

pregnancy, 2014.

Produced by: EEOHT, CDPHE 2016

*95% confidence intervals do not overlap.

†Black bars indicate margins of error (95% Confidence Intervals).

‡Data Source: Colorado Pregnancy Risk Assessment Monitoring System

2014.

Major findings



The prevalence of marijuana use before pregnancy was statistically higher than use during

pregnancy or use by breastfeeding mothers after delivery. There was no statistical difference

between use during pregnancy and use by breastfeeding mothers after delivery.

2014 marijuana use: before pregnancy 11.2% (95% CI 9.0-13.3%), during pregnancy 5.7% (95% CI 4.2-7.2%), by breastfeeding

mothers after delivery 4.5% (95% CI 3.1-5.9%)

For an explanation

of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix E. For data, see

Appendix E, Table E.3.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Figure 4. Colorado women who reported using marijuana during pregnancy by

intention to become pregnant, 2014.

Produced by: EEOHT, CDPHE 2016

*95% confidence intervals do not overlap.

†Black bars indicate margins of error (95% Confidence Intervals).

‡Data Source: Colorado Pregnancy Risk Assessment Monitoring System 2014.

Major findings



The prevalence of marijuana use during pregnancy was statistically higher among women with an

unintended pregnancy than among women who intended to become pregnant.

2014 marijuana use during pregnancy, by intention to become pregnant: intended pregnancy 4.0% (95% CI 2.3-5.7%), unintended

pregnancy 9.1% (95% CI 6.0-12.3%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix E. For data, see

Appendix E, Table E.4.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

Figure 5. Colorado women who reported using marijuana during pregnancy by maternal

education (a), age (b), and race (c), 2014.

(a) Maternal Education

(b) Maternal Age

Produced by: EEOHT, CDPHE 2016

†Black bars indicate margins of error (95% Confidence Intervals).

‡Data Source: Colorado Pregnancy Risk Assessment Monitoring System 2014.

Major Findings



The prevalence of marijuana use during pregnancy was statistically higher among women with less

than a 12

grade education than among women with some college.

The prevalence of marijuana use during pregnancy was statistically higher among women 20-24

years old than among women 25-34 years old or women 35 years old or older.

There were no statistical differences in marijuana use during pregnancy by race/ethnicity.

2014 marijuana use during pregnancy, by education: <12 years 15.7% (95% CI 6.9-24.5%), 12 years 6.3% (95% CI 3.2-9.5%), >12

years 4.1% (95% CI 2.6-5.5%)

2014 marijuana use during pregnancy, by maternal age: 15-19 years old 14.0% (95% CI 3.9-24.1%), 20-24 years old 12.6% (95% CI

7.2-18.0%), 25-34 years old 4.3% (95% CI 2.5-6.1%), 35 years or older 2.7% (95% CI 0.6-4.9%)

2014 marijuana use during pregnancy, by race/ethnicity: White/non-Hispanic 6.4% (95% CI 4.4-8.4%), Black 8.7% (95% CI 0.0-

22.5%), Hispanic 3.4% (95% CI 0.7-6.2%), Other 5.9% (95% CI 1.1-10.8%)

For an explanation of terms, see “How

to interpret survey results” above. For statistical methods, see Appendix E. For data, see

Appendix E, Table E.5.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 1: Pregnancy Risk Assessment Monitoring System (PRAMS)

References

1. Centers for Disease Control and Prevention. PRAMS. 2016; https://www.cdc.gov/prams/,

https://www.cdc.gov/prams/.

2. Colorado Department of Public Health and Environment. Pregnancy Risk Assessment Monitoring

System. https://www.colorado.gov/pacific/cdphe/pregnancysurvey.

3. Volkow ND, Compton WM, Wargo EM. The Risks of Marijuana Use During Pregnancy.

JAMA.

2017;317(2):129-130.

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 2

Scientific Literature

Review on Potential

Health Effects of

Marijuana Use

Retail Marijuana Public Health Advisory

Committee

Section 2: Scientific Literature Review on Potential Health Effects of Marijuana Use

Background

The Colorado Department of Public Health and Environment (CDPHE) was given statutory (25-1.5-110,

C.R.S.) responsibility to:

• “…monitor changes in drug use patterns, broken down by county and race and ethnicity, and the

emerging science and medical information relevant to the health effects associated with marijuana

use.”

• “…appoint a panel of health care professionals with expertise

in cannabinoid physiology to monitor

the relevant information.”

Based on this charge, CDPHE appointed a 14-member committee, the Retail Marijuana Public Health

Advisory Committee, to review scientific literature on the health effects of marijuana. Members of this

committee (see Appendix, Retail Marijuana Public Health Advisory Committee Membership Roster) are

individuals in the fields of public health, medicine, epidemiology, and medical toxicology who

demonstrate expertise related to marijuana through their work, training or research. This committee

was charged with the duties as outlined in 25-1.5-110 C.R.S.

to “...establish

criteria for studies to be

reviewed, review studies and other data, and make recommendations, as appropriate, for policies

intended to protect consumers of marijuana or marijuana products and the general public.”

The committee has met since May 2014 to complete these duties. The overall goal was to implement an

unbiased and transparent process for evaluating scientific literature and data on marijuana use and

health outcomes. The committee was particularly interested in ensuring quality information is shared

about the known physical and mental health effects associated with marijuana use

–

and also about

what is unknown at present. The official bylaws of this committee are included in Appendix A, Retail

Marijuana Public Health Advisory Committee By-laws.

The committee used a standardized systematic literature review process to search and grade the

existing scientific literature on health effects of marijuana. Findings were synthesized into evidence

statements that summarize the quantity and quality of scientific evidence supporting an association

between marijuana use and a health outcome. These evidence statements were classified as follows:

•

Substantial evidence

indicates robust scientific findings that support an association between

marijuana use and the outcome.

Moderate evidence

indicates scientific findings support an association between marijuana use

and the outcome, but these findings have some limitations.

Limited evidence

indicates modest scientific findings that support an association between

marijuana use and the outcome, but these findings have significant limitations.

Mixed evidence

indicates both supporting and non-supporting scientific findings for an

association between marijuana use and the outcome, with neither direction dominating.

Body of research failing to show an association

indicates the topic has been researched without

evidence of an association; is further classified as a

limited, moderate

substantial

body of

research.

Insufficient evidence

indicates the outcome has not been sufficiently studied to conclude

whether or not there is an association between marijuana use and the outcome.

•

Monitoring Health Concerns Related to Marijuana in Colorado: 2016

Section 2: Scientific Literature Review on Potential Health Effects of Marijuana Use

The committee also translated these evidence statements into plain language so they are

understandable to the general public for future use in public health messaging. In addition, the

committee was asked to develop public health recommendations based on potential concerns identified

through the review process and to articulate research gaps based on common limitations of existing

research. All these were presented to the full committee during open public meetings with

opportunities for stakeholder input. Final statements, recommendations and research gaps were

formally approved by a majority vote of the committee.

The topics for review were originally chosen in 2014 based on recently published peer-reviewed

publications outlining the potential health effects of marijuana use, and public health priorities

identified from key informant interviews of local public health officials across Colorado, including in

urban, rural, and resort communities. Additional topics added in 2015 and 2016 were based on

committee and stakeholder suggestions. Key findings for each topic are presented below. More detailed

findings including literature citations are included in each of the individual chapters.

An important note for all key findings is the available research evaluated the