Opinion Editorial

(Maansi Bansal-Travers, PhD, Andrew Hyland, PhD, Cheryl Rivard, MPH, F.J.C., Jidong Huang, PhD, and Dianne Barker, MHS, unpublished data, January 2014). This implies that taxing ENDS at rates comparable to cigarettes would be highly effective in deterring youths’ initiation of ENDS use but at the same time would discourage many current smokers from switching to ENDS. At the other extreme, failing to levy a tax on ENDS would keep their prices relatively low, which could lead to youths’ experimentation with ENDS and subsequent progression to conventional cigarette smoking. This suggests that governments that decide to levy taxes on ENDS should at the same time adopt significant increases in their other tobacco taxes so that the prices of cigarettes and other combusted tobacco products rise relative to prices for ENDS. Such a policy would have

the benefit of deterring initiation of all tobacco use, including ENDS use, among young people while increasing cessation among current tobacco users, at least in part by encouraging substitution to ENDS. To date, only Minnesota levies an excise tax on ENDS, with similar taxes under consideration in several others states (Camille K. Gourdet, JD, MA, Jamie F. Chriqui, PhD, and F.J.C., unpublished data, November 2013). While much remains to be learned about the public health benefits and/or consequences of ENDS use, their exponential growth in recent years, including their rapid uptake among youths, makes it clear that policy makers need to act quickly. Adopting the right mix of policies will be critical to minimizing potential risks to public health while maximizing the potential benefits.

Author Affiliation: Institute for Health Research and Policy, University of Illinois at Chicago, Chicago.

a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics .2013.5488.

6. Schripp T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air. 2013;23(1):25-31.

Corresponding Author: Frank J. Chaloupka, PhD, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 W Roosevelt, Room 558, Chicago, IL 60608 ([email protected]).

2. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among US adults, 2010-2011. Nicotine Tob Res. 2013;15(9):1623-1627.

7. Americans for Nonsmokers' Rights Foundation. US state and local laws regulating the use of electronic cigarettes. http://www.no-smoke.org /pdf/ecigslaws.pdf. Accessed February 16, 2014.

Published Online: March 6, 2014. doi:10.1001/jamapediatrics.2014.349.

3. Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tob Res. 2013;15(10):1787-1791.

8. International Agency for Research on Cancer. Effectiveness of Tax and Prices Policies for Tobacco Control. Lyon, France: International Agency for Research on Cancer; 2012.


Conflict of Interest Disclosures: None reported. REFERENCES 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents:

4. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382(9905):1629-1637. 5. Abrams DB. Promise and peril of e-cigarettes: can disruptive technology make cigarettes obsolete? JAMA. 2014;311(2):135-136.

Driving After Marijuana Use The Changing Face of “Impaired” Driving Mark Asbridge, PhD

Whitehill et al1 share the findings of a survey of 315 first-year college students who report having driven after using marijuana and/or alcohol and being a passenger of a driver who had used these substances. They found that among first-year Related article page 618 college students who had used marijuana in the past month, a substantial proportion reported driving after using marijuana (43.9% of male and 8.7% of female students). Of particular interest, although a higher proportion of students had drunk alcohol in the past month, rates of driving were much lower after drinking than after marijuana use. Study findings speak to the changing nature of impaired driving and bring needed attention to the issue of marijuana use before getting behind the wheel.

Measuring the Prevalence of Driving After Marijuana Use Driving after marijuana use is not a new issue and has been a focus of study since the 1980s. Reports on the prevalence of 602

driving after marijuana use have emerged from the United States, Canada, Australia, New Zealand, and many European nations, drawing on respondent self-reports, police records, hospital registries, and coroner data on drivers involved in crashes. Three observations can be drawn from this research. First, in many jurisdictions, the prevalence of driving after marijuana use has risen in recent years.2-4 Second, driving after marijuana use is particularly problematic for younger populations, in which observed rates are considerably higher than in adults.2,4,5 Finally, it is apparent that, in certain populations, rates of driving after marijuana use parallel and sometimes surpass rates of drinking and driving.4,5 O’Malley and Johnston,2 looking at the 2011 data from the “Monitoring the Future” study, noted that 12.4% of US high school seniors reported driving after using marijuana at least once in the preceding 2 weeks compared with 8.7% who reported driving after drinking alcohol. In thinking about this issue, key questions persist beyond the question of prevalence: Does marijuana impair

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Editorial Opinion

driving ability? Does it increase the likelihood of a motor vehicle crash? What effect does the consumption of alcohol concurrently with marijuana have on the risk of a crash? Finally, what approaches are available to regulate or prevent driving after marijuana use?

Marijuana, Driving Ability, and Crash Risk In addressing the first two questions we can draw on a large body of laboratory and experimental research involving driving simulators, as well as observational studies that assess crash risk in naturalistic settings. The primary psychoactive component in cannabis is tetrahydrocannabinol (THC), which typically produces euphoria, relaxation, and changes in perception at low doses; at higher doses, it can lead to deficits in attention span and memory, psychomotor function, and pain relief.6 In terms of driving ability, the results of simulator and laboratory studies are generally consistent: at higher doses, cannabis impairs the psychomotor skills necessary for safe driving.7,8 Berghaus and Guo9 performed a systematic review and meta-analysis of 60 laboratory studies and concluded that marijuana causes impairment of every aspect of performance connected with safe driving. Using standardized measures of driving performance, drivers under the influence of marijuana perform poorly on skills such as vehicle tracking, reaction time, attention, variability in speed and headway, and lateral control.9,10 Marijuana is commonly detected in injured or fatally injured drivers,3,10,11 yet such data do not tell us whether marijuana contributed to, or was responsible for, the crash. For that information we must rely on studies using epidemiologic designs (eg, case-control, culpability, or casecrossover designs), in which the proportion of drivers testing positive for marijuana is compared between those involved in a crash (cases) and a sample of crash-free drivers (controls). We can then estimate the relative contribution of marijuana to crash risk, holding known confounders constant. Recent systematic reviews and meta-analyses have considered this question12,13 and drew similar conclusions: marijuana use before driving roughly doubles the likelihood of a subsequent motor vehicle crash. However, heterogeneity was observed across study findings regarding how marijuana exposure status was measured (blood, urine, or self-report) and the nature of the crash (fatal or causing injury or property damage). Findings were more robust when acute or “recent” marijuana consumption was measured in blood rather than in urine, where the presence of THC metabolites may be evident for days or weeks after consumption with no clear relationship to driver impairment. The consumption of alcohol in conjunction with marijuana adds further complication, with important implications for road safety. When marijuana is used in conjunction with alcohol, the estimated crash risk is higher than for either substance alone, suggesting the presence of a synergistic effect.7,11,14 This is particularly important for drivers who consume each substance at levels below the legal threshold for impairment. Such drivers may believe they are using in moderation, but considerable impairment is experienced when substances are combined.

Regulating Driving After Marijuana Use Legislation regulating driving after marijuana use has been enacted in much of the United States and in Canada, Australia, New Zealand, and many parts of Western Europe. These policies vary regarding how marijuana-impaired drivers are identified, the methods used to determine legal impairment, and the resulting punishment (criminal charges or administrative sanctions, such as fines or license suspension). Detection takes 2 forms: an observation of driver impairment while the driver is behind the wheel (suspicion or probable cause) or a random stop or spot check (assessed without specific cause). Likewise, determination of driver impairment may be behavioral, wherein marijuana must be proved to have caused impairment, or physical, through the presence of per se limits. A per se limit sets a threshold that a measured amount of a substance present in the body must not exceed (for alcohol, a common per se limit is a blood alcohol concentration of ≥0.08 g/mL). Per se blood serum THC limits for driving under the influence of marijuana have been set between 0.001 and 0.005 μg/mL (to convert to micromoles per liter, multiply by 3.180) in the United States, with similar levels internationally. An expert panel has suggested setting a per se limit between 0.007 and 0.01 μg/mL.15 Many countries have established a zero tolerance per se law, wherein the presence of any amount of marijuana in blood, urine, or saliva, constitutes impairment. These approaches have also been combined in some jurisdictions; Canada, for example, relies on detection through the observation of driver behavior, followed by the use of specially trained police officers (drug recognition experts) to determine impairment by drugs, with final confirmation via fluid sample (blood or urine). What remains to be determined is the preferred policy approach; better evidence of the effectiveness of marijuana and driving legislation is needed.

Going Forward Besides legislation, much work remains to be done to change social norms regarding the acceptability of using marijuana in the context of driving. Key to this goal is the increased education and awareness of varying stakeholders in public health, transportation, and justice, as well as the general public, particularly young persons, among whom misconceptions about the impairing effects of marijuana on driving are common. Physicians and other health care professionals must also be encouraged to actively remind patients of the increased risk of driving after marijuana use. The need for action and cultural change is only solidified by recent legislative changes in 2 US states (Colorado and Washington) legalizing the sale and possession of marijuana for nonmedical use, as well as the ongoing implementation of medical marijuana laws in many US states. The implications for road safety and public health are great. As we learned from our multipronged efforts to combat drinking and driving, it took many years before the desired effects of legislation were realized. By focusing energy on the problem of driving after marijuana use and drawing on our successes and failures in responding to drinking and driving, we may not have to wait as long this time to realize change.


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Opinion Editorial

ARTICLE INFORMATION Author Affiliation: Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. Corresponding Author: Mark Asbridge, PhD, Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Fourth Floor, Halifax, Nova Scotia, B3H 1V7, Canada ([email protected]). Published Online: May 12, 2014. doi:10.1001/jamapediatrics.2014.83. Conflict of Interest Disclosures: None reported. REFERENCES 1. Whitehill JM, Rivara FP, Moreno MA. Marijuana-using drivers, alcohol-using drivers, and their passengers: prevalence and risk factors among underage college students [published online May 12, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5300. 2. O’Malley PM, Johnston LD. Driving after drug or alcohol use by US high school seniors, 2001-2011. Am J Public Health. 2013;103(11):2027-2034. 3. Mura P, Chatelain C, Dumestre V, et al. Use of drugs of abuse in less than 30-year-old drivers killed in a road crash in France: a spectacular

increase for cannabis, cocaine and amphetamines. Forensic Sci Int. 2006;160(2-3):168-172.

Australia: NHMRC Road Accident Research Unit; 1995:295-300.

4. Asbridge M, Poulin C, Donato A. Motor vehicle collision risk and driving under the influence of cannabis: evidence from adolescents in Atlantic Canada. Accid Anal Prev. 2005;37(6):1025-1034.

10. Romano E, Pollini RA. Patterns of drug use in fatal crashes. Addiction. 2013;108(8):1428-1438.

5. Fergusson DM, Horwood LJ, Boden JM. Is driving under the influence of cannabis becoming a greater risk to driver safety than drink driving? findings from a longitudinal study. Accid Anal Prev. 2008;40(4):1345-1350. 6. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374 (9698):1383-1391. 7. Bates MN, Blakely TA. Role of cannabis in motor vehicle crashes. Epidemiol Rev. 1999;21(2):222-232. 8. Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend. 2004;73(2):109-119. 9. Berghaus G, Guo BL. Medicines and driver fitness: findings from a meta-analysis of experimental studies as basic information to patients, physicians, and experts. In: Koedan CN, McLean AJ, eds. Proceedings of the 13th International Conference on Alcohol, Drugs, and Traffic Safety, August 13-18, 1995. Adelaide,

11. Laumon B, Gadegbeku B, Martin JL, Biecheler MB; SAM Group. Cannabis intoxication and fatal road crashes in France: population based case-control study. BMJ. 2005;331(7529):1371-1377. 12. Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34(1):65-72. 13. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536. 14. Longo MC, Hunter CE, Lokan RJ, White JM, White MA. The prevalence of alcohol, cannabinoids, benzodiazepines and stimulants amongst injured drivers and their role in driver culpability, II: the relationship between drug prevalence and drug concentration, and driver culpability. Accid Anal Prev. 2000;32(5):623-632. 15. Grotenhermen F, Leson G, Berghaus G, et al. Developing limits for driving under cannabis. Addiction. 2007;102(12):1910-1917.

School Nursing Beyond Medications and Procedures Howard L. Taras, MD

Children spend 6 to 7 hours per day, 180 days per year in school in the United States. While education is the chief purpose, consideration for children’s health is a significant role of schools. Like math and reading, students need to be taught how Related article page 642 to have an optimally healthy life. We want each student to return home at the end of the day at least as healthy as when he or she arrived. School-age children, especially adolescents, young students, and those developmentally immature, are more apt than are adults to share pathogens through close contact and shared body fluids. Children with special health care needs are integrated into regular school and classroom settings where medications and medical procedures are delivered. Numerous health conditions manifest first as behavioral and educational problems. Many students have suboptimal access to primary and secondary health care, making schools the first place where their underlying physical and mental illnesses become apparent. The staffing of school health-related services is the subject of a study by Wang and colleagues1 in this issue of JAMA Pediatrics. In any economic evaluation of health interventions or resources, the specific outcomes that are measured are critical.2 The effects of improved school attendance on parents’ and schools’ budgets were measured in this article. Ad604

ditional beneficial outcomes of school nursing services need to be assessed. These plausibly include the cost-benefit of higher graduation rates, improved grades and standardized test scores, reduced use of community emergency services, better compliance with prescribed medical management, reduced transmission of infectious diseases, and earlier diagnoses and treatment. The authors recognize that they omitted school nursing roles that require the most training and creativity. These omitted roles may turn out to be the most costbeneficial to society. Great variation exists among and within states for how school districts staff their health-related services. In some counties, school health staffing and resources are responsibilities of public health departments. In most locales, school health programs are organized entirely from within the educational sector, where they compete for the same dollars that can be used for instruction and educational infrastructure. During the past decade and longer, fluctuations in school budgets have necessitated that districts modify their models of health service provision, a circumstance that is disruptive to health program planning. For example, many schools that once may have been staffed by full-time, certified, registered school nurses may now be staffed by unlicensed assistive personnel (UAP) operating under the indirect supervision of a nurse. If

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Driving after marijuana use: the changing face of "impaired" driving.

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