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EDITORIAL

Use of marijuana or cannabis and driving is of significant public health concern (Huestis, 2015). The legalization of medical cannabis in two-thirds of states in the US and several countries has increased the number of its users. After the 2018 elections, a total of ten US states and the District of Columbia have legalized the non-medical/rec- reational use of cannabis and 20 states have pending bills (National Conference of State Legislatures, 2018). This poses challenges to pub- lic health, especially when it comes to driving under the influence of cannabis. Some epidemiological studies have shown that the risk of motor vehicle accidents increases almost two-fold after cannabis smok- ing (Hartman & Huestis, 2013). Acute effects of consuming cannabis result in euphoria, sedation, sometimes depression, and often changes in perception. Impaired driving is mainly related to cognitive and psy- chomotor impairments, altered reaction time and changes in perception along with the tendency to do lane weaving (Bondallaz et al., 2016). Combined use with alcohol is responsible for further deterioration in driving abilities. The use of cannabis in youth is also of concern with its effects on reckless driving under its influence (Cobb, Soule, Rudy, Sutter, & Cohn, 2018).

A study by Richer and Bergeron (2009) found that driving under the influence of cannabis was associated with both self-reported, as well as, observed risk taking and displaying negative emotions while driving. They also found that self-reported driving under the influence of canna- bis was associated with a greater risk of getting involved in motor vehi- cle accidents. An Australian simulation study on the effects of cannabis on driving by Lenne and colleagues (2010) found that increased doses of cannabis led to greater impairment compared to lower doses. The effects of cannabis on driving resulted in indulging in greater speeds and variability in lateral positions. An empirical study from New Zealand also concluded that the harms of driving under the influence of cannabis outweighed those of driving under the influence of alcohol (Fergusson, Horwood, & Boden, 2008). Another problem associated with cannabis

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and driving is evident from a Canadian study that found that a statis- tically significant percentage (35.0%) of the respondents in that study had driven a motor vehicle under the influence of cannabis compared to under the influence of alcohol (5%) which the study conjectured could be due to the lack of awareness or misperceptions about the effects of cannabis on the part of its users (McGuire, Dawe, Shield, Rehm, & Fischer, 2011).

However, establishing causal linkages between cannabis use and impaired driving is difficult. Some of these challenges are cannabinoid blood concentration levels from those with impaired driving and those without impaired driving are often not available for comparisons (the problem of good control groups). Often there is a presence of alco- hol and other drugs associated with cannabis use (polydrug use), so postmortem sampling is often not done due to legalities and the costs of estimating cannabinoid blood concentrations are often prohibitive (Huestis, 2015). Thus, effectual policy measures are difficult to for- mulate with regard to cannabis use. For example, no consensus exists on tetrahydrocannabinol (THC) blood concentration that impairs driv- ing. Some have proposed zero tolerance, others, levels of 1 μg/L, while others believe it should be 5μg/L and still others propose something in between (Huestis, 2015; Jones, Holmgren, & Kugelberg, 2008). Besides blood tests, some have even advocated tests of hair and repeat urine analyses to establish abstinence from cannabis use because of its long-term effects on driving (Bondallaz et al., 2016).

Studies have also looked at the determinants of driving under the influence of cannabis. In a qualitative study, done in Australia, utiliz- ing face-to-face interviews, Jones and colleagues (2006) found that increased certainty of harmful sequelae of marijuana, as opposed to the severity of punishment then, could result in a decrease in driving under the influence of cannabis. They also found that provision of facts related to risks offered almost no benefit in altering the behavior. The study reinforced the theory that behavior change is possible but requires a myriad of intrapersonal attitudinal changes, interpersonal factors and environmental constructs.

Both educational and policy approaches have a place in altering driv- ing under the influence of cannabis. Behavior change educational inter- ventions geared toward altering driving behavior under the influence of cannabis should utilize fourth generation models such as the integrative model of behavioral prediction (Fishbein, 2009) or multi-theory model of health behavior change (Sharma, 2015. 2017). According to the

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multi-theory model of health behavior change, the process of change is divided into initiation and sustenance or maintenance of the behavior. The first construct of the initiation model is participatory dialogue that entails underscoring advantages over disadvantages of behavior change through a two-way communication process. In operationalizing this construct, the advantages of quitting cannabis use with driving must be emphasized. The second construct of the initiation model is behavioral confidence that stems from both internal, as well as, external sources and serves to provide futuristic motivation for behavior change. In operationalizing this construct, the confidence level of the participants should be boosted so that they can abstain from cannabis use if they have to drive. The third construct of changes in physical environment pertains to obtainability, accessibility and availability of resources that support the behavior change. For operationalizing this construct, alter- natives such as utilization of a designated driver, use of Uber or Lyft or other such services if cannabis is to be used and other such measures to avoid combining cannabis and driving need to be in place.

In the sustenance model, the first construct is that of changes in social environment that pertains to social support from family, friends and others. In operationalizing this construct, the cannabis user needs to solicit help from significant people in their life who can provide both tangible and intangible supports to avoid combining cannabis use with driving. The second construct in sustenance model is that of practice for change which entails constantly thinking about the behavior change exemplified by reflective action and active reflection. In order to opera- tionalize this construct, the cannabis user has to reinforce the belief sys- tem coupled with skills to avoid combining cannabis use with driving. The final construct in the sustenance model is that of emotional trans- formation in which emotions, particularly negative ones, are converted into goals of healthy behavior change. In operationalizing this con- struct the cannabis user has to develop goals for avoiding a combination of cannabis with driving. So, drug education can play a substantial role in addressing this public health problem of cannabis use and driving.

Manoj Sharma, MBBS, Ph.D. MCHES® Editor, Journal of Alcohol & Drug Education Professor, Behavioral & Environmental Health School of Public Health Jackson State University 350 W. Woodrow Wilson Drive Jackson, MS 39213 (601) 979-8850 (Phone)

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(601) 979-1434 (Fax) [email protected] (E-mail)

&

Manoj K. Mohata, MD Correctional Psychiatrist [email protected] (E-mail)

REFERENCES

Bondallaz, P., Favrata, B., Chtiouid, H., Fornarie, E., Maederf, P., & Giroud, C. (2016). Cannabis and its effects on driving skills. Forensic Science International, 268, 92-102.

Cobb, C. O., Soule, E. K., Rudy, A. K., Sutter, M. E., & Cohn, A. M. (2018). Patterns and correlates of tobacco and cannabis co-use by tobacco prod- uct type: Findings from the Virginia Youth Survey. Substance Use and Misuse, 53(14), 2310-2319.

Fergusson, D. M., Horwood, L. J., & Boden, J. M. (2008). Is driving under the influence of cannabis becoming a greater risk to driver safety than drunk driving? Findings from a longitudinal study. Accident Analysis and Prevention, 40, 1345-1350.

Fishbein, M. (2009). An integrative model for behavioral prediction and its application to health promotion. In R. J. Diclemente, R. A. Crosby, & M. C. Kegler (Eds.), Emerging theories in health promotion practice and research (2nd ed., pp. 215-234). San Francisco: Jossey-Bass.

Hartman, R. L. & Huestis, M. A. (2013). Cannabis effects on driving skills. Clinical Chemistry, 59(3), 478-492.

Huestis, M. A. (2015). Cannabis-impaired driving: A public health and safety concern. Clinical Chemistry, 61(10), 1223-1225.

Jones, A. W., Holmgren, A., & Kugelberg, F. C. (2008). Driving under the influence of cannabis: A 10-year study of age and gender differences in the concentrations of tetrahydrocannabinol in blood. Addiction, 103, 452–461.

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Jones, C., Donnelly, N., Swift, W., & Weatherburn, D. (2006). Preventing cannabis users from driving under the influence of cannabis. Accident Analysis and Prevention, 38, 854-861.

Lenne, M. G., Dietze, P. M., Triggs, T. J., Walmsley, S., Murphy, B., & Redman, J. R. (2010). The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accident Analysis and Prevention, 42, 859-866.

McGuire, F., Dawe, M., Shield, K/D., Rehm, J. & Fischer, B. (2011). Driving under the influence of cannabis or alcohol in a cohort of high-frequency cannabis users: Prevalence and reflections on current interventions. Canadian Journal of Criminology and Criminal Justice, 53 (2), 247-259.

National Conference of State Legislatures. (2018). Marijuana overview. Retrieved from http://www.ncsl.org/research/civil-and-criminal-justice/ marijuana-overview.aspx

Richer, I., & Bergeron, J. (2009). Driving under the influence of cannabis: Links with dangerous driving, psychological predictors, and accident involvement. Accident Analysis and Prevention, 41, 299-307. Sharma, M. (2015). Multi-theory model (MTM) for health behavior change. Webmed Central Behaviour, 6(9), WMC004982. Retrieved from http://www.web- medcentral.com/article_view/4982

Sharma, M. (2017). Theoretical foundations of health education and health promotion. (3rd ed., pp. 250-262) Burlington, MA: Jones and Bartlett.

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