The association between cannabis consumption and compliance with COVID-19 related barrier measures: prospective analyses from the French CONSTANCES cohort and SAPRIS survey

doi:10.21203/rs.3.rs-4939540/v1

Objective

To examine the association between the frequency of cannabis consumption and compliance with COVID-19 related barrier measures among adults in France between April and October 2020.

Methods

Data from the CONSTANCES cohort on 39,450 adults participating in the SAPRIS survey were analyzed. The associations between noncompliance with handwashing, wearing a mask and social distancing and the frequency of cannabis consumption in 2019 at two periods of time, wave 1 + 2 (confinement) and wave 3 (deconfinement), were examined using binary logistic regression adjusted for age, sex, education, marital status, accommodation, tobacco use, self-rated health, anxiety and depressive symptoms.

Results

Compared to not consuming cannabis during the last 12 months, consuming less than once per month was negatively associated with handwashing at wave 3 (Odds Ratio [95% Confidence Interval]) 1.46 [1.28–1.66], wearing a mask at wave 1 + 2 (1.26 [1.05–1.52]) and at wave 3 (1.60 [1.35–1.89]) and social distancing at wave 1 + 2 (1.32 [1.16–1.50]) and at wave 3 (1.55[1.32–1.83]). Consuming cannabis once per month or more was negatively associated with wearing a mask at wave 3 (1.41 [1.11–1.80]) and social distancing at wave 1 + 2 (1.27 [1.06–1.52]) and at wave 3 (1.57 [1.25–1.98]).

Conclusion

Cannabis consumption may be associated with less compliance with barrier measures.

Cannabis

handwashing

wearing a mask

social distancing

COVID-19

The Coronavirus Disease 2019 (COVID-19) pandemic has been among the most significant public health challenges in the past years. France is one of the European countries who were hit hard by the COVID-19 pandemic causing more than 150,000 deaths (1). In order to help mitigate the transmission of the SARS-CoV-2, like in many countries around the world, the national health authorities encouraged the adoption of barrier measures including handwashing, wearing a mask and social distancing (2, 3). Moreover, the French government has implemented three national lockdowns, the first ran from 17 March to 10 May 2020, the second from 30 October to 15 December 2020 and the third from 3 April to 3 May 2021. Everyday life has been impacted by the pandemic and lockdown on a socioprofessional, economic, behavioral, and psychological level (4–6).

Studies have reported changes in cannabis use patterns during the pandemic in France including both increases and decreases (5, 6). Cannabis is the most widely consumed illicit drug in the country with almost half of the population reporting lifetime use (7). Cannabis consumption is known to have deleterious consequences on the cardiorespiratory system (8, 9). Thus, cannabis users were at greater risk of SARS-CoV-2 infection and higher risk of clinical complications (10, 11). In addition, behavioral pathways may as well explain the greater possibility of contagion, for instance not adhering to the recommended barrier measures (12).

To the best of our knowledge, limited studies have addressed the factors associated with compliance with the barrier measures introduced during the COVID-19 pandemic (13–19) and only few have addressed substance use including cannabis (15–17). The cross-sectional study of Monnig et al. reported no association between cannabis and compliance to Centers for Disease Control and Prevention (CDC) guidelines for COVID-19 mitigation among 1,185 adults in the United States between June and July 2020. However, with a small sample size, the study may have lacked sufficient power to observe differences in compliance to CDC guidelines (16). The other studies evaluated the compliance to the use of masks and social distancing among adolescents and young adults. One study reported associations between vaping in the past 12 months (i.e. nicotine, cannabis or just flavoring) and less regular use of masks and less compliance to social distancing (17). Another study found no association between cannabis and compliance with COVID-19 related restrictions (15). Thus, the association between cannabis use and the compliance with to the barrier measures remains unclear.

Therefore, the present study aimed to examine the association between the frequency of cannabis consumption at baseline and the compliance with COVID-19 related barrier measures (i.e. handwashing, wearing a mask and social distancing) at follow-up among volunteers from the CONSTANCES cohort participating in the nested SAPRIS survey while taking into account several sociodemographic and clinical factors (20). CONSTANCES, is a French population-based cohort with a large random sample of around 220,000 adults. The present study is a longitudinal analysis of data from the SAPRIS survey that took place between the 6th of April 2020 and the 31st of October 2020. We also thought to examine two follow-up points, i.e. during the lockdowns and after the deconfinement. Our main hypothesis was that cannabis use could decrease the likelihood of complying to the barrier measures.

2.1. Population

The CONSTANCES cohort, a French population-based cohort study, includes around 220,000 participants aged 18–69 years enrolled between 2012 and 2019. Participants were randomly sampled among individuals covered by the general insurance scheme (85% of the French population). All participants gave informed consent to participate in the cohort (20). At baseline and then annually, participants are invited to complete self-administered questionnaires assessing sociodemographic factors, occupational conditions, and health-related behaviors including cannabis consumption. The CONSTANCES cohort study has received the authorization of the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés, CNIL) (Autorisation #910486, March 3, 2011) and the institutional review board of the National Institute for Medical Research (Inserm) (Authorization n°01–011 and n°21–842, September 7, 2021) and all methods were performed in accordance with the relevant guidelines and regulations. All the participants provided an informed consent.

Web respondents to the CONSTANCES cohort were invited to take part in the nested SAPRIS “Santé, pratiques, relations et inégalités sociales en population générale pendant la crise COVID-19” survey and responded to at least one of the 5 waves (21). The SAPRIS survey was approved by the French Institute of Health and Medical Research ethics committee (approval #20–672 dated March 30, 2020). The participants responded to wave 1 between the 6th of April 2020 till the 4th of May 2020, to wave 2 between the 30th of April 2020 till the 15th of June 2020 and to wave 3 between the 29th of June 2020 till the 31st of October 2020. The barrier measures were assessed at wave 1, 2 and 3 of the SAPRIS survey. In the present study, wave 1 and wave 2 were combined because they overlap and represent the first lockdown while wave 3 was during the deconfinement.

Our population was restricted to participants who responded to both waves 1 and 2 of the SAPRIS survey and to the CONSTANCES 2019 annual questionnaire (n = 39,450). We excluded those who did not report the frequency of their cannabis consumption in 2019 (n = 247). Among the 39,203 participants, 33,017 responded to the wave 3 of the SAPRIS survey. Then, for each barrier measure we excluded those who had missing data. For the barrier measure “wearing a mask”, we further excluded those who reported not having masks, used scarfs and not going out (n = 5,621 at wave 1 + 2 and n = 49 at wave 3). For the barrier measure “social distancing”, we further excluded those who reported not meeting anyone and not going out (n = 835 at wave 1 + 2 and n = 15 at wave 3). Thus, for the barrier measure “hand washing”, 38,480 and 32,844 participants were included in the analyses of wave 1 + 2 and wave 3, respectively. Participants included in the analyses for the barrier measure “wearing a mask” were 32,862 for wave 1 + 2 and 32,788 for wave 3. Finally, for the barrier measure “social distancing”, 37,647 and 32,822 participants were included in the analyses of wave 1 + 2 and wave 3, respectively (Fig. 1).

2.2. Cannabis use at baseline

The last annual questionnaire of the CONSTANCES cohort before the pandemic was 2019. The frequency of cannabis consumption, self-reported at the 2019 annual questionnaire, was considered and categorized as follows: 1) no consumption during the last 12 months; 2) less than once a month; 3) once per month or more.

2.3. Barrier measures at follow-up

The adoption of barrier measures including handwashing, wearing a mask and social distancing were assessed at wave 1, 2 and 3 of the SAPRIS survey.

Handwashing

At wave 1 and wave 2 of the SAPRIS survey, handwashing was assessed using the following question: “Do you wash your hands with soap or with hand sanitizer when returning to your home?” and was categorized as follows: 1) yes, systematically after each outing, 2) not after each outing or never. At wave 3, hand hygiene was assessed using the following question: “Since deconfinement, do you wash your hands with soap or with hand sanitizer when returning to your home?” and was categorized as follows: 1) yes, systematically after each outing, 2) not after each outing or never.

Wearing a mask

At wave 1 and wave 2 of the SAPRIS survey, wearing a mask was assessed using the following question: “Do you wear a mask when you go outdoors?” and was categorized as follows: 1) yes, systematically on every outing, 2) during certain outings or never no risk or no need. At wave 3, wearing a mask was assessed using the following question: “Since deconfinement, do you wear a mask when you go outdoors?” and was categorized as follows: 1) yes, systematically on every outing, 2) during certain outings or never no risk or no need.

Social distancing

At all waves of the SAPRIS survey, social distancing was assessed via the following question: “Were you able to keep more than one-meter distance from the people you met outside your home?” and was categorized as follows: 11) yes, everyone or almost everyone, 2) no.

The first category for each barrier measure was considered as complying with the barrier measure and the second was considered as not complying with the barrier measure.

If participants reported not complying with at least one of the three barrier measures, they were considered as not complying with the barrier measures. At wave 1 and wave 2, if participants reported not complying with the barrier measure at one of the waves, they were considered as not complying with the barrier measure.

2.4. Covariables

We considered the following sociodemographic factors: age in 2019, sex, education, marital status, accommodation.

Sex and education were considered at enrollment in the CONSTANCES cohort. Education was measured as a categorical variable on the International Standard Classification of Education 2011 (level 0–8) and introduced as a continuous variable in the analyses since we assumed that this variable is an ordinal representation of underlying sets of continuous units (i.e. years of education) (22, 23). Marital status was considered at wave 1 of the SAPRIS survey. Accommodation was assessed at wave 2 with the following question “Currently, were do you live? 1) in an apartment or a house with access to an open space, 2) in an apartment or a house without access to an open space.

In addition, the following clinical factors were considered: tobacco use, self-rated health, anxiety and depressive symptoms.

Tobacco use, “non-smoker or occasional smoker” or “daily smoker” was considered at the 2019 CONSTANCES annual follow-up questionnaire. Self-rated health from 1 = “Very good” to 8 = “Very Poor” was reported at wave 1 of the SAPRIS survey and was analyzed as a continuous variable (24). Anxiety and depressive symptoms were self-reported at wave 1 of the SAPRIS survey with the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder Assessment (GAD-7) scales, respectively (25, 26). The total scores for both questionnaires were analyzed as continuous variables.

2.5. Statistical analyses

First, descriptive analyses were performed for the compliance with the barrier measures at wave 1 + 2 and at wave 3 according to the frequency of cannabis use. Frequencies and percentages were presented for categorical variables. Mean and standard deviation were presented for continuous variables.

Second, for each wave, multivariable analyses were performed using logistic regression to examine the association between the frequency of cannabis consumption at baseline and not complying with each barrier measure at follow-up, while using “not consuming during the last 12 months” as the reference category for the independent variable. The dependent variables were handwashing at wave 1 + 2, wearing a mask at wave 1 + 2, social distancing at wave 1 + 2, not adhering to at least one of the three barrier measures at wave 1 + 2, handwashing at wave 3, wearing a mask at wave 3, social distancing at wave 3 and not adhering to at least one of the three barrier measures at wave 3. Odds ratio (OR) with 95% confidence intervals (95%CI) were calculated. Two sets of adjustments were considered: a model adjusted for age and sex and a model that was further adjusted for education, marital status, accommodation, tobacco use, self-rated health, anxiety and depressive symptoms.

Third, as sensitivity analyses, we wanted to examine in depth whether barrier measures were associated with cannabis use independently of tobacco use (27). Interactions between the frequency of cannabis consumption and tobacco use were tested and stratified analyses were performed in the case of a significant interaction.

Among the included participants, the prevalence of missing data for the covariables ranged from 0.2% for marital status to 6.3% for the anxiety and depressive symptoms, with a mean percentage of missing data of 2.0%. Missing data were handled by multiple imputations in 10 different datasets, and the results were based on a combined dataset (28). Analyses were performed using IBM SPSS Statistics for Windows v.21 and a two-sided value of p < 0.05 was considered statistically significant.

3.1. Participants’ characteristics

At waves 1 + 2, 7,852/38,480 (20.4%), 26,471/32,862 (80.5%) and 20,502/37,647 (54.5%) participants reported not washing their hands after every outing, not wearing a mask at every outing and not complying with social distancing, respectively. A total of 33,643/36,164 (93.0%) did not adhere to at least one of the three barrier measures at waves 1 + 2. At wave 3, 11,700/32,844 (35.6%), 24,138/32,788 (73.6%) and 3,176/32,822 (9.7%) participants reported not washing their hands after every outing, not wearing a mask at every outing and not complying with social distancing, respectively. A total of 26,260/32,810 (80.0%) participants did not adhere to at least one of the three barrier measures at wave 3. Among participants who reported consuming cannabis less than once per month at baseline, 97.4% and 90.7% participants did not adhere to at least one of the three barrier measures at waves 1 + 2 and at wave 3, respectively. Among those who reported consuming cannabis once per month or more at baseline, 95.8% and 88.9% participants did not adhere to at least one of the three barrier measures at wave 1 + 2 and at wave 3, respectively. Participants' characteristics according to non-compliance with the barrier measures at follow-up are presented in Table 1.

Table 1

Characteristics of participants according to not complying with barrier measures at wave 1 + 2 and at wave 3. (SAPRIS survey, metropolitan France, 2020)
	Wave 1 + 2 Not complying with				Wave 3 Not complying with
	Handwashing	Wearing a mask	Social distancing	At least one	Handwashing	Wearing a mask	Social distancing	At least one
	38,480	32,862	37,647	36,164	32,844	32,788	32,822	32,810
N%	7,852 (20.4%)	26,471 (80.6%)	20,502 (54.5%)	33,643 (93.0%)	11,700 (35.6%)	24,138 (73.6%)	3,176 (9.7%)	26,260 (80.0%)
Frequency of Cannabis consumption in 2019
Not during the last 12 months	7,421(20.3%)	25,111 (80.3%)	19,255 (53.7%)	31,905 (92.8%)	11,005 (35.2%)	22,825 (73.0%)	2,841 (9.1%)	24,855 (79.5%)
Less than once per month	280 (22.4%)	917 (87.6%)	839 (69.3%)	1,161 (97.4%)	470 (45.3%)	879 (85.4%)	225 (21.8%)	941 (90.7%)
Once per month or more	151 (23.9%)	443 (83.1%)	408 (66.8%)	577 (95.8%)	225 (43.0%)	434 (83.5%)	110 (21.1%)	464 (88.9%)
Age in 2019	51.54 (± 13.70)	50.67 (± 13.27)	49.33 (± 13.34)	50.69 (± 13.34)	51.35 (± 13.54)	50.40 (± 13.23)	44.18 (± 12.82)	50.44 (± 13.26)
Sex
Men	4,822 (25.5%)	13,258 (83.2%)	9,851 (53.1%)	16,704 (94.0%)	7,082 (44.0%)	12,624 (78.7%)	1,412 (8.8%)	13,650 (84.9%)
Women	3,030 (15.5%)	13,213 (78.0%)	10,648 (55.8%)	16,939 (92.1%)	4,618 (27.6%)	11,514 (68.8%)	1,764 (10.5%)	12,610 (75.3%)
Education ^a
Level 0–1	49 (22.4%)	133 (74.6%)	92 (43.2%)	174 (90.1%)	63 (33.1%)	120 (63.1%)	10 (5.3%)	130 (69.5%)
Level 2	224 (19.1%)	722 (74.6%)	525 (45.7%)	952 (89.2%)	363 (35.9%)	667 (66.1%)	59 (5.8%)	734 (72.7%)
Level 3–4	2049 (22.9%)	5,999 (79.2%)	4,264 (48.6%)	7,619 (91.4%)	2,909 (38.1%)	5,410 (71.1%)	605 (7.9%)	5,933 (77.8%)
Level 5–6	3060 (20.4%)	10,388 (80.4%)	8,056 (54.8%)	13,176 (93.1%)	4,532 (35.3%)	9,326 (72.7%)	1,204 (9.3%)	10,173 (79.2%)
Level 7–8	2470 (18.8%)	9,228 (82.3%)	7,565 (58.9%)	11,722 (94.2%)	3,833 (34.3%)	8,615 (77.3%)	1,298 (11.6%)	9,290 (83.2%)
Marital status
Married or civil partnership	5,466 (20.6%)	18,720 (80.7%)	13,372 (51.3%)	23,150 (92.5%)	8,096 (35.5%)	16,525 (72.6%)	1,773 (7.7%)	17,980 (79.0%)
Single, divorced or widowed	2,386 (20.0%)	7,751 (80.2%)	7,130 (61.5%)	10,493 (94.1%)	3,604 (35.8%)	7,613 (75.8%)	1,403 (13.9%)	8,280 (82.3%)
Accommodation
With access to an exterior	7,506 (21.2%)	24,618 (80.9%)	18,506 (53.3%)	31,003 (92.9%)	11,069 (36.3%)	22,290 (73.3%)	2,757 (9.0%)	24,275 (79.7%)
Without access to an exterior	346 (11.4%)	1,853 (76.4%)	1,996 (68.1%)	2,640 (93.5%)	631 (26.4%)	1,848 (77.8%)	419 (17.6%)	1,985 (83.4%)
Tobacco use in 2019
Non-smoker or occasional smoker	7,273 (20.4%)	24,600 (80.5%)	18,863 (54.2%)	31,120 (92.9%)	10,739 (35.3%)	22,295 (73.4%)	2,847 (9.4%)	24,241 (79.8%)
Daily smoker	579 (20.0%)	1,871 (80.5%)	1,639 (57.8%)	2,523 (93.8%)	961 (39.3%)	1,843 (75.8%)	329 (13.5%)	2,019 (82.8%)
Self-rated health ^b	2.18 (± 1.17)	2.10 (± 1.12)	2.14 (± 1.13)	2.13 (± 1.14)	2.16 (± 1.15)	2.10 (± 1.12)	2.08 (± 1.13)	2.12 (± 1.13)
Anxiety symptoms ^c	2.67 (3.43)	2.93 (± 3.51)	3.21 (± 3.63)	3.01 (± 3.57)	2.67 (± 3.35)	2.92 (± 3.51)	3.69 (± 4.08)	2.96 (± 3.56)
Depressive symptoms ^d	3.23 (3.71)	3.25 (± 3.60)	3.60 (± 3.79)	3.35 (± 3.70)	3.19 (± 3.62)	3.30 (± 3.64)	4.33 (± 4.32)	3.35 (± 3.71)
^a Based on the International Standard Classification of Education. ^b Self-rated health from 1= “very good” to 8= “very poor”. ^c Measured using the 7-item Generalized Anxiety Disorder Assessment (GAD-7). ^d Measured using the 9-item Patient Health Questionnaire (PHQ-9).

3.2. Association between the frequency of cannabis use at baseline and not complying to at least one of the three barrier measures at follow-up

Participants consuming cannabis less than once per month at baseline were more likely not to comply with at least one of the three barrier measures at waves 1 + 2 with OR = 1.65 95%CI (1.15–2.38) after adjustment for age and sex (Table 2). This association remained significant after further adjustment for sociodemographic and clinical factors OR = 1.60 95%CI (1.12–2.30) (Table 3). Cannabis consumption once per month or more at baseline was not significantly associated with not complying with at least one of the barrier measures at wave 1 + 2.

Table 2

Association between the frequency of cannabis consumption and not complying with barrier measures at wave 1 + 2 and at wave 3 adjusted for age and gender. (logistic regression, SAPRIS survey, metropolitan France, 2020)
	Wave 1 + 2 Not complying with			At least one of the 3 barrier measures at wave 1 + 2	Wave 3 Not complying with			At least one of the 3 barrier measures at wave 3
	Handwashing	Wearing a mask	Social distancing	At least one of the 3 barrier measures at wave 1 + 2	Handwashing	Wearing a mask	Social distancing	At least one of the 3 barrier measures at wave 3
	38,480	32,862	37,647	36,164	32,844	32,788	32,822	32,810
N%	7,852 (20.4%)	26,471 (80.5%)	20,502 (54.5%)	33,643 (93.0%)	11,700 (35.6%)	24,138 (73.6%)	3,173 (9.7%)	26,260 (80.0%)
Frequency of Cannabis consumption in 2019	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)
Not during the last 12 months	REF	REF	REF	REF	REF	REF	REF	REF
Less than once per month	1.07 (0.93–1.24)	1.22 (1.01–1.48)	1.44 (1.27–1.64)	1.65 (1.15–2.38)	1.46 (1.28–1.66)	1.69 (1.41–2.02)	1.76 (1.50–2.06)	1.87 (1.50–2.31)
Once per month or more	1.13 (0.94–1.37)	0.87 (0.69–1.10)	1.36 (1.14–1.62)	1.09 (0.73–1.64)	1.28 (1.07–1.53)	1.47 (1.16–1.86)	1.84 (1.48–2.29)	1.54 (1.17–2.04)
Age	1.00 (0.99-1.00)	0.97 (0.97–0.98)	0.97 (0.97–0.97)	0.96 (0.96–0.96)	1.00 (1.00–1.00)	0.98 (0.98–0.98)	0.95 (0.95–0.96)	0.98 (0.98–0.98)
Sex
Men	REF	REF	REF	REF	REF	REF	REF	REF
Women	0.53 (0.51–0.56)	0.68 (0.64–0.72)	1.06 (1.02–1.10)	0.67 (0.62–0.73)	0.49 (0.46–0.51)	0.57 (0.54–0.60)	1.13 (1.05–1.22)	0.51 (0.49–0.54)

Table 3

Association between the frequency of cannabis consumption and not complying with barrier measures at wave 1 + 2 and at wave 3 adjusted for sociodemographic and clinical factors. (logistic regression, SAPRIS survey, metropolitan France, 2020)
	Wave 1 + 2 Not complying with			At least one of the 3 barrier measures at wave 1 + 2	Wave 3 Not complying with			At least one of the 3 barrier measures at wave 3
	Handwashing	Wearing a mask	Social distancing	At least one of the 3 barrier measures at wave 1 + 2	Handwashing	Wearing a mask	Social distancing	At least one of the 3 barrier measures at wave 3
	38,480	32,862	37,647	36,164	32,844	32,788	32,822	32,810
N%	7,852 (20.4%)	26,471 (80.5%)	20,502 (54.5%)	33,643 (93.0%)	11,700 (35.6%)	24,138 (73.6%)	3,173 (9.7%)	26,260 (80.0%)
Frequency of Cannabis consumption in 2019	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)
Not during the last 12 months	REF	REF	REF	REF	REF	REF	REF	REF
Less than once per month	1.12 (0.97–1.29)	1.26 (1.05–1.52)	1.32 (1.16–1.50)	1.60 (1.12–2.30)	1.46 (1.28–1.66)	1.60 (1.35–1.89)	1.55 (1.32–1.83)	1.74 (1.40–2.15)
Once per month or more	1.16 (0.96–1.41)	0.95 (0.74–1.20)	1.27 (1.06–1.52)	1.09 (0.72–1.66)	1.19 (0.99–1.43)	1.41 (1.11–1.80)	1.57 (1.25–1.98)	1.42 (1.07–1.89)
Age	0.99 (0.99-1.00)	0.97 (0.97–0.98)	0.98 (0.98–0.98)	0.96 (0.96–0.96)	0.99 (0.99-1.00)	0.98 (0.98–0.99)	0.96 (0.96–0.96)	0.98 (0.98–0.98)
Sex
Men	REF	REF	REF	REF	REF	REF	REF	REF
Women	0.53 (0.50–0.56)	0.71 (0.67–0.75)	1.02 (0.97–1.06)	0.68 (0.62–0.74)	0.49 (0.47–0.51)	0.58 (0.55–0.61)	1.07 (0.99–1.16)	0.52 (0.49–0.55)
Education ^a	0.92 (0.89–0.95)	1.01 (0.98–1.05)	1.11 (1.08–1.14)	1.06 (1.01–1.11)	0.94 (0.91–0.97)	1.10 (1.07–1.13)	1.06 (1.01–1.11)	1.11 (1.07–1.14)
Marital status
Married or civil partnership	REF	REF	REF	REF	REF	REF	REF	REF
Single, divorced or widowed	1.05 (0.99–1.11)	0.97 (0.91–1.04)	1.32 (1.26–1.38)	1.20 (1.09–1.32)	1.08 (1.02–1.14)	1.15 (1.09–1.22)	1.45 (1.34–1.58)	1.20 (1.12–1.28)
Accommodation
With access to an open space	REF	REF	REF	REF	REF	REF	REF	REF
Without access to an open space	0.46 (0.41–0.52)	0.67 (0.61–0.75)	1.47 (1.35–1.60)	0.83 (0.70–0.98)	0.59 (0.53–0.65)	1.08 (0.97–1.20)	1.45 (1.29–1.64)	1.03 (0.92–1.16)
Tobacco use in 2019
Non-smoker or occasional smoker	REF	REF	REF	REF	REF	REF	REF	REF
Daily smoker	0.94 (0.85–1.04)	0.97 (0.86–1.08)	0.96 (0.89–1.05)	1.00 (0.84–1.18)	1.14 (1.04–1.24)	1.03 (0.93–1.14)	1.12 (0.98–1.28)	1.09 (0.97–1.22)
Self-rated health ^b	1.02 (0.99–1.04)	0.90 (0.88–0.92)	1.02 (1.00-1.04)	0.91 (0.88–0.94)	1.01 (0.99–1.03)	0.91 (0.89–0.93)	0.96 (0.93–0.99)	0.92 (0.90–0.94)
Anxiety symptoms ^c	0.95 (0.94–0.96)	0.96 (0.95–0.97)	1.00 (0.99–1.01)	0.96 (0.95–0.98)	0.95 (0.94–0.95)	0.96 (0.95–0.97)	1.00 (0.99–1.01)	0.96 (0.95–0.97)
Depressive symptoms ^d	1.03 (1.02–1.04)	1.00 (0.99–1.01)	1.01 (1.01–1.02)	1.01 (0.99–1.03)	1.03 (1.02–1.04)	1.01 (1.00-1.02)	1.03 (1.01–1.04)	1.02 (1.01–1.03)
^a Based on the International Standard Classification of Education. ^b Self-rated health from 1= “very good” to 8= “very poor”. ^c Measured using the 7-item Generalized Anxiety Disorder Assessment (GAD-7). ^d Measured using the 9-item Patient Health Questionnaire (PHQ-9).

Participants consuming cannabis less than once per month and once per month or more were more likely not to comply with at least one of the three barrier measures at wave 3 after adjustment for age and sex with OR = 1.87 95%CI (1.50–2.31) and OR = 1.54 95%CI (1.17–2.04), respectively (Table 2). These associations persisted after further adjustment for sociodemographic and clinical factors with OR = 1.74 95%CI (1.40–2.15) and OR = 1.42 95%CI (1.07–1.89) for cannabis consumption less than once per month and once per month or more, respectively (Table 3).

Having a higher education level, being single, separated or divorced were significantly associated with not complying with at least one of the barrier measures at wave 1 + 2 OR = 1.06 95%CI (1.01–1.11) and OR = 120 95%CI (1.09–1.32), respectively. The association persisted at wave 3 OR = 1.11 95%CI (1.07–1.14) and OR = 1.20 95%CI (1.12–1.28), respectively. Being older, women, not having access to an open space at home, poorer self-rated health and higher score for anxiety symptoms were negatively associated with not complying with at least one of the barrier measures at wave 1 + 2 OR = 0.96 95%CI (0.96–0.96), OR = 0.68 95%CI (0.62–0.74), OR = 0.83 95%CI (0.70–0.98), OR = 0.91 95%CI (0.88–0.94), OR = 0.96 95% CI (0.95–0.98), respectively. At wave 3, all the associations persisted except for not having access to an open space at home. In addition, a higher score of depressive symptoms was significantly associated with not complying with at least one of the barrier measures at wave 3 OR = 1.02 95%CI (1.01–1.03) (Table 3).

3.3. Association between the frequency of cannabis use at baseline and compliance with handwashing at follow-up

The frequency of cannabis use at baseline was not significantly associated with handwashing at wave 1 + 2.

Participants consuming cannabis less than once per month at baseline were more likely not to wash their hands after every outing at wave 3 with OR = 1.46 95%CI (1.28–1.66) after adjustment for age and sex (Table 2) and after further adjustment for sociodemographic and clinical factors OR = 1.46 95%CI (1.28–1.66) (Table 3). Participants consuming cannabis once per month or more at baseline were more likely not to wash their hands after every outing at wave 3 with OR = 1.28 95%CI (1.07–1.53) after adjustment for age and sex (Table 2). This association did not persist after further adjustment for sociodemographic and clinical factors (Table 3).

3.4. Association between the frequency of cannabis use at baseline and compliance with wearing a mask at follow-up

Participants consuming cannabis less than once per month were more likely not to wear a mask at every outing at waves 1 + 2 with OR = 1.22 95%CI (1.01–1.48) after adjustment for age and sex (Table 2) and after further adjustment for sociodemographic and clinical factors OR = 1.26 (1.05–1.52) (Table 3). Consuming cannabis once per month or more at baseline was not significantly associated with wearing a mask at wave 1 + 2 (Tables 2 and 3).

Participants consuming cannabis less than once per month and those declaring consuming cannabis once per month or more at baseline were more likely not to wear a mask on every outing at wave 3 after adjustment for age and sex with OR = 1.69 95%CI (1.41–2.02) and OR = 1.47 95%CI (1.16–1.86), respectively (Table 2). These associations persisted after further adjustment for sociodemographic and clinical factors with OR = 1.60 95%CI (1.35–1.89) and OR = 1.41 95%CI (1.11–1.80) for cannabis consumption less than once per month and once per month or more, respectively (Table 3).

3.5. Association between the frequency of cannabis use at baseline and compliance with social distancing at follow-up

Participants consuming cannabis less than once per month and those declaring consuming cannabis once per month or more at baseline were more likely not to comply with social distancing at waves 1 + 2 after adjustment for age and sex with OR = 1.44 95%CI (1.27–1.64) and OR = 1.36 95%CI (1.14–1.62), respectively (Table 2). These associations persisted after further adjustment for sociodemographic and clinical factors with OR = 1.32 95%CI (1.16–1.50) and 1.27 95%CI (1.06–1.52) for cannabis consumption less than once per month and once per month or more, respectively (Table 3).

Participants consuming cannabis less than once per month and those declaring consuming cannabis once per month or more at baseline were more likely to not comply with social distancing at wave 3 after adjustment for age and sex with OR 1.76 95%CI (1.50–2.06) and OR 1.84 95%CI (1.48–2.29), respectively (Table 2). These associations persisted after further adjustment for sociodemographic and clinical factors with OR = 1.55 95%CI (1.32–1.83) and 1.57 95%CI (1.25–1.98) for cannabis consumption less than once per month and once per month or more, respectively (Table 3).

In sensitivity analyses, significant interactions were found between cannabis consumption and tobacco use for wearing a mask (p = 0.048) and not complying with at least one of the barrier measures at wave 3 (p = 0.033). Stratified analyses are presented in the Supplemental Table 1.

The aim of this study was to evaluate the association between the frequency of cannabis consumption at baseline and compliance with COVID-19 related barrier measures at follow-up (i.e. handwashing, wearing a mask and social distancing) while considering several sociodemographic and clinical factors among a large national population-based cohort. We also thought to examine two follow-up points, i.e. during the lockdowns and after the deconfinement. Compared to not consuming cannabis during the last 12 months, consuming cannabis less than once per month was negatively associated with respecting at least one of the three barrier measures at wave 1 + 2 and at wave 3. It was as well negatively associated with wearing a mask and social distancing and wave 1 + 2 and at wave 3, and handwashing at wave 3. Consuming cannabis once per month or more was negatively associated with complying with at least one of the three barrier measures at wave 3. It was also negatively associated with social distancing at wave 1 + 2 and at wave 3 and with wearing a mask at wave 3.

The prevalence of compliance with barrier measures in the present study especially for handwashing and wearing a mask were in line with those of CoviPrev, a cross-sectional survey among the general adult population living in metropolitan France(1, 13). In addition, being younger, a man, having a poorer self-rated health and a lower score for anxiety symptoms were associated with lower compliance with barrier measures, consistent with results from previous studies in France and other countries (13, 16). The observed associations between cannabis use and barrier measures in the present study were in line with Oliver et al.’s findings for wearing a mask and social distancing (17) and were in contrast with other previous studies (15, 16). However, the previous studies included smaller samples (15–17) or evaluated the associations only among adolescents and young adults (15, 17). In addition, Oliver et al. did not examine specifically the association between cannabis use and compliance with barrier measures but rather vaping whether nicotine, cannabis or just flavoring. To the best of our knowledge, this is the first study to observe less compliance with the three barrier measures among cannabis users during confinement and deconfinement periods. This could be explained by the effects of cannabis on attention and decreased perception of risks (29). Another hypothesis, could be that cannabis users may come from poorer socioeconomic conditions beyond their educational level which was as well associated with lower likelihood of compliance with COVID-19 related barrier measures (30).

These associations between cannabis and barrier measures persisted even when adjusting for tobacco use knowing that tobacco and cannabis co-use is a common practice (31). This finding suggests that cannabis consumption is a specific indicator that goes beyond the role of tobacco. Moreover, after stratifying for tobacco use, the associations persisted only among participants who were not daily smokers. The persistence of association without daily smoking could be useful to draw hypotheses such as the specific effects of cannabis on the brain, and the specific social behaviors of cannabis users (29).

At waves 1 + 2 and wave 3, the associations were almost unchanged except for handwashing, although the context has changed enormously as can be seen from the prevalence of declarations of compliance with social distancing between these two periods, the role of cannabis in compliance to barrier measures remains significant. It is also important to note that at the beginning of the pandemic, there was a shortage of face masks in France. Moreover, we observed no dose-dependent effect, but rather a threshold effect (no consumption in the last 12 months, versus at least one consumption). This raises the question of the specificity of cannabis, or whether we rather measured a social category effect. Anyway, cannabis use before a pandemic might indicate a decreased likelihood of complying with barrier measures, whatever the mechanisms underlying this association. In addition to population-bases prevention strategies, this finding might suggest some benefit to more targeted prevention campaigns among cannabis users, at least among those who are followed by caregivers do to their cannabis use disorder or other comorbidities.

This study had some limitations. First, our findings cannot be generalized as the participants of the CONSTANCES cohort although randomly selected, are not representative of the general French population. Volunteers in a cohort may be different from the general population. They tend to be healthier, have higher education levels and better socioeconomic status, and consume fewer substances (32). Moreover, SAPRIS survey was limited to participants who had access to Internet thus, introducing a potential selection bias. Second, we cannot draw a causal conclusion because although prospective, it was an observational study and unmeasured factors such as personality traits may have an impact on the association between cannabis use and compliance with barrier measures. Third, cannabis consumption may have changed between its assessment and the measure of the outcomes. Nevertheless, the present study was a prospective population-based cohort study with a large sample size that allowed to control for various sociodemographic and health-related variables.

In conclusion, the results of this study suggest significant associations between cannabis consumption and compliance to COVID-19 related barrier measures at both lockdowns and deconfinement periods. They underline the need for awareness campaigns regarding the importance of compliance with barrier measures that should be reinforced among the general population and particularly among cannabis users without stigmatizing them. This would be important not only to prevent the COVID-19 transmission but also in case of new infectious emergence, especially while considering the increased risk of complications among cannabis users in case of respiratory infections. Future research should consider the role of socioeconomic status when evaluating the association between cannabis use and compliance with barrier measures.

Ethical statement

The CONSTANCES cohort study has received the authorization of the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés, CNIL) (Autorisation #910486, March 3, 2011) and the institutional review board of the National Institute for Medical Research (Inserm) (Authorization n°01–011 and n°21–842, September 7, 2021) and all methods were performed in accordance with the relevant guidelines and regulations. The SAPRIS survey was approved by the French Institute of Health and Medical Research ethics committee (approval #20–672 dated March 30, 2020). All the participants provided an informed consent.

Competing Interests

Guillaume Airagnes has received speakers and/or consulting fees from Pfizer, Lundbeck and Pierre Fabre. However, these entities did not have any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Rita El Haddad, Emmanuel Wiernik, Sofiane Kab and Marie Zins report no conflicts of interest.

Funding

This project has received public funding from the Fonds de lutte contre les addictions managed by the Assurance Maladie, as part of a call for projects issued by the Institut de Recherche en Santé Publique (A21027LS). The Constances Cohort benefits from a grant from ANR (ANR-11-INBS- 0002) and is partly funded by MSD and L’Oréal. However, these funding sources had no role in the design of the study, the collection and analysis of data or decision to publish.

Author Contribution

R.E.H and G.A conceived and designed the analysis. R.E.H performed the analysis and wrote the main manuscript. R.E.H, E.W, S.K, M.Z and G.A contributed to the study design, interpretation of the findings and critically revised the manuscript. All authors approved the final version of the paper.

Acknowledgement

The authors thank the "Population-based Epidemiologic Cohorts Unit” (Cohortes épidémiologiques en population), Université de Paris Cité, INSERM, Paris Saclay University, UVSQ", UMS 011, which designed and manages the Constances Cohort Study. They also thank the National Health Insurance Fund (“Caisse nationale d’assurance maladie”, CNAM) and its Health Screening Centres (“Centres d’examens de santé"), which are collecting a large part of the data, as well as the National Old-Age Insurance Fund (Caisse nationale d’assurance vieillesse) for its contribution to the constitution of the cohort, ClinSearch, Asqualab and Eurocell, which are conducting the data quality control.

Data Availability

Data are available upon reasonable request.

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Competing interest reported. Guillaume Airagnes has received speakers and/or consulting fees from Pfizer, Lundbeck and Pierre Fabre. However, these entities did not have any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Rita El Haddad, Emmanuel Wiernik, Sofiane Kab and Marie Zins report no conflicts of interest.

SupplementalTables120824.docx

The association between cannabis consumption and compliance with COVID-19 related barrier measures: prospective analyses from the French CONSTANCES cohort and SAPRIS survey

Status:

Version 1

Abstract

Figures

1. Introduction

2. Methods