America Addresses Two Epidemics – Cannabis and Coronavirus and their Interactions: An Ecological Geospatial Study
Authors: Reece Albert Stuart , Hulse Gary Kenneth 
Published: April 2020

AbstractImportanceCovid-19 infection has major international health and economic impacts and risk factors for infection are not completely understood. Cannabis smoking is linked with poor respiratory health, immunosuppression and multiple contaminants. Potential synergism between the two epidemics would represent a major public health convergence. Cigarettes were implicated with disease severity in Wuhan, China.ObjectiveIs cannabis use epidemiologically associated with coronavirus incidence rate (CVIR)?DesignCross-sectional state-based multivariable study.SettingUSA.Primary and Secondary Outcome MeasuresCVIR. Multivariable-adjusted geospatially-weighted regression models. As the American cannabis epidemic is characterized by a recent doubling of daily cannabis use it was considered important to characterize the contribution of high intensity use.ResultsSignificant associations of daily cannabis use quintile with CVIR were identified with the highest quintile having a prevalence ratio 5.11 (95%C.I. 4.90-5.33), an attributable fraction in the exposed (AFE) 80.45% (79.61-81.25%) and an attributable fraction in the population of 77.80% (76.88-78.68%) with Chi-squared-for-trend (14,782, df=4) significant at P<10−500. Similarly when cannabis legalization was considered decriminalization was associated with an elevated CVIR prevalence ratio 4.51 (95%C.I. 4.45-4.58), AFE 77.84% (77.50-78.17%) and Chi-squared-for-trend (56,679, df=2) significant at P<10−500. Monthly and daily use were linked with CVIR in bivariate geospatial regression models (P=0.0027, P=0.0059). In multivariable additive models number of flight origins and population density were significant. In interactive geospatial models adjusted for international travel, ethnicity, income, population, population density and drug use, terms including last month cannabis were significant from P=7.3×10−15, daily cannabis use from P=7.3×10−11 and last month cannabis was independently associated (P=0.0365).Conclusions and RelevanceData indicate CVIR demonstrates significant trends across cannabis use intensity quintiles and with relaxed cannabis legislation. Recent cannabis use is independently predictive of CVIR in bivariate and multivariable adjusted models and intensity of use is interactively significant. Cannabis thus joins tobacco as a SARS2-CoV-2 risk factor.Article SummaryStrengths and Limitations of this StudyPopulation level was used for the large datasets employed relating to international travel, Covid-19 rates and drug exposure.Nationally representative datasets were employed for drug use and exposureA Broad range of covariates was considered including socioeconomic, demographic, drug use, Covid-19 incidence and international travel.Advanced geospatial modelling techniques were used to analyze data.Higher resolution geospatial data was not available to this study.NoteThe following files were submitted by the author for peer review, but cannot be converted to PDF.You must view these files (e.g. movies) online.3Key PointsQuestionSince cannabis is immunosuppressive and is frequently variously contaminated, is its use associated epidemiologically with coronavirus infection rates?FindingsGeospatial analytical techniques were used to combine coronavirus incidence, drug and cannabinoid use, population, ethnicity, international flight and income data. Cannabis use and daily cannabis use were associated with coronavirus incidence on both bivariate regression and after multivariable spatial regression with high levels of statistical significance. Cannabis use quintiles and cannabis legal status were also highly significant.MeaningSignificant geospatial statistical associations were shown between cannabis use and coronavirus infection rates consistent with immunomodulatory mechanistic reports and environmental exposure concerns.BMJI, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence.The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open Access articles. 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