Marijuana

INTRODUCTION

The relationship between sexually transmitted diseases (STDs) and marijuana use has been presented consistently in the literature; however, many of these studies do not deal with incarcerated populations (1-4). The studies that do examine inmate populations are conducted outside of the United States, do not look specifically at soon-to-be-released inmate populations, and do not consider prior incarceration history (5-9).

Individuals under the jurisdiction of corrections systems, who are on probation or parole, numbered six million (three percent of all U. S. adults) (10). Prison populations have doubled during the past decade since drug-related offenses and the "war on drugs" became the major contribution to those being sentenced to prison. The millions of incarcerated people, many of whom are illicit drug users, are among the most difficult to reach with critical health prevention services.

Adequate understanding and treatment for substance users with a history of incarceration requires that researchers examine traits and practices that may impact both individual and community health, especially in view of the evidence indicating the multiple risk factors that incarcerated populations may display (11,12).

This problem is compounded by institutional policies designating condoms as contraband. This is a major concern since primary risk factors for HIV are substance use, having unprotected sex, and having sex with multiple partners. These activities, along with other identified risk factors such as intravenous drug use (IVDU), needle-sharing (13), and tattooing (11) are indisputably occurring in prisons and jails regardless of prohibitions against all of these activities.

In addition to these risks, substance use (especially marijuana consumption) is also a problem for inmate populations and has been well documented in the scientific literature (14-20). Inmates report using a wide range of drugs, including heroin, methadone, cocaine, marijuana, amphetamines, or barbiturates at some point in their lives without a doctor's prescription and outside of a treatment program (15,20). The most commonly used drugs include marijuana and cocaine; tobacco and alcohol are also widely used (19,21). According to a study by Hser et al. (5), approximately 66.9% reported tobacco use, 22.1% reported alcohol use, 35.5% reported marijuana use, 19.4% reported cocaine use, and 10.3% reported crack use. Moreover, age and gender interact to influence how addiction develops. For example, younger males are more likely to have marijuana dependence; women initiate alcohol and marijuana use significantly later in life than their male cohorts, but begin using cocaine earlier in the course of their addiction (22). The nature of the drug dependency also influences the perceived need for treatment. Research conducted by Lo and Stephens (19) found that individuals dependent on cocaine or opiates perceived that they had a need for drug treatment; while those dependent on marijuana did not share this perception.

High rates of drug use are common prior to incarceration (19,21,23), and there is evidence that drug use also occurs during incarceration as well (16,24). However, the majority of studies have examined the relationship between substance use and criminal behavior and have not explored the relationship between substance use and HIV/AIDS risk behavior in this population. Conklin et al. (21) examined HIV risk perception in a sample of newly incarcerated inmates and found that, although rates of HIV testing were high, HIV risk perception was low among both male and female inmates.

The primary purpose of this study was to determine associations between measures of prior incarceration and marijuana use with self-reported HIV/AIDS risk behaviors among a sample of soon-to-be-released adult male inmates. Such information can assist in targeting inmates who may be most likely to benefit from intervention activities prior to their release back into the community.

Study Site and Sample

The current study delivered a health education intervention to soon-to-be-released adult male inmates. Eligibility for this study required that inmates be at a point between 60 and 90 days prior to release from the facility and returning to the metropolitan area of a major southeastern city. Participants were recruited from a population of inmates at three medium security correctional institutions for men located in middle Georgia and a transitional center located in a major southeastern city. Pilot testing of interview materials was conducted in a fifth medium security facility not included in the baseline.

Data Collection

Data were collected at baseline (prior to implementing the intervention), at release, and at three, six, and nine months postrelease. However, only baseline data are presented in the current study, and these data were collected from August 2000 to December 2001. Trained interviewers and peer educators collected data inside the correctional facility. After explaining the purpose of the study and obtaining written informed consent, the interviewer reviewed the data collection instrument with each participant. The instrument was written on a fourth grade reading level and, as noted previously, pretested prior to actual data collection. Inmates received monetary incentives and personal kits (including materials related to the intervention) when participating in the follow-up interviews.

Approximately 230 inmates had agreed to enroll in the study. Most of the sample were African American (n = 160, 69%), with approximately 26% (n = 60) and less than 5% (n = 10), respectively, reporting their ethnicity as white and Hispanic. The mean total number of years incarcerated reported by inmates for their lifetime was 8.94 years (SD = 14.13). Nearly similar proportions of the sample of inmates indicated that they had attended high school but did not finish (38%, n = 87) or had graduated from high school and received their GED (35%, n = 82). The remaining respondents reported attending vocational, trade, or technical school or at least starting college (27%, n = 39). More than 34% of participants noted their income prior to incarceration at or below $19,000 annually, with another 21.46% (n = 34) making from $20,000 to $29,000 annually before their most recent arrest. Forty-four percent reported earning more than $29,000 annually prior to incarceration.

MEASURES

Sociodemographic and Background Variables

The measures used in this study and their psychometric properties are detailed in Table 1. The survey instrument contained items assessing sociodemographic and other background characteristics of participants. These variables included ethnicity, marital status, education, income prior to incarceration, and incarceration history. The variable of prior incarceration was represented by a dichotomous response item worded "Was this your first time being incarcerated?" (1 = yes, 2 = no).

Condom Use

Condom use was assessed with two questions. The first question was dichotomous ("yes," "no") and asked, "When you had sex, did you use a protective barrier (condom or dental dam)?" The second question asked, "When you had sex, how often would you say you used a protective barrier (condom or dental dam)?" The response categories for this question were: "all of the time," "more than half of the time," "about half of the time," "less than half of the time," and "never."

Health Self-Efficacy

Health self-efficacy was assessed by asking the participant to indicate how confident he was that he could perform a health-related behavior after being released from prison. Degree of confidence was ranked using a number from 0 to 100 ("not at all confident" to "very confident").

Sexual Behavior

Sexual behavior as it relates to alcohol use was assessed by asking the participant to indicate how likely it is that he could successfully perform each behavior after a few drinks of alcohol. Likelihood was assessed using a scale ranging from 0 to 100 ("not at all likely" to "very likely").

Health Practices

Behavior associated with healthy practices was assessed using a scale to indicate how likely the participant felt that he could successfully perform each after being released from prison. Degree of likelihood was assessed using a percentage from 0 to 100 ("not at all likely" to "very likely").

Condom Self-Efficacy

This measure assessed behavior associated with condom self-efficacy (e.g., "I can always put a condom on (myself/partner) so that it will not slip or break"). Degree of confidence was assessed using a number from 0 to 10 ("not at all sure I can" to "completely sure I can't").

Drug Use Avoidance

Using the same response format as the condom self-efficacy measure, each participant was asked to indicate how sure he was that he would not use any of the following drugs when released from prison: marijuana, powdered cocaine, crack, inhalants, heroin/opium, LSD/acid/hallucinogens, speed/uppers, claradine, downers/tranquilizers, PCP/Angel Dust, and Ecstasy/other designer drugs.

Marijuana Use

Sexual behavior as related to marijuana use was assessed by asking the participant to indicate how likely it is that he could successfully perform each behavior after using marijuana. Participants responded by using a scale numbering from 0 to 100 ("not at all likely" to "very likely").

Analysis

Participant data collected revealed completed surveys from 208 of the 230. Analyses presented herein also involved calculating two multiple logistic regression models to test the study hypothesis. The general model specified self-reported marijuana use as an outcome with selected demographic variables including ethnicity, age, education, and income prior to incarceration as predictor variables. Ethnicity and income are measured in several ways. First, ethnicity was measured in terms of black, white, and other, and education as dichotomous (above high school vs. high school degree or less). Ethnicity was also isolated in two dichotomous outcomes (African American/black vs. white and other vs. white). Income, on the other hand, was measured singularly and by the following categories (< $20,000 vs. > $40,000, < $40,000 vs. > $60,000, and < $60,000 vs. > $60,000). In addition, income was dichotomized into: less than $20,000 vs. greater than $60,000; less than $40,000 vs. greater than $60,000; and less than $60,000 vs. greater than $60,000. All measures were entered independently into the estimated equations.

Findings

In Table 2, measures of the relationship between the selected independent and dependent variables are presented. Significant bivariate associations were recorded for age, education, and sexual self-expectation with respect to reincarceration. Specifically, the less education reported, the more likely study participants were to have been incarcerated more than once. In comparison, both substance use and condom use more than half of the time were strongly correlated with sexual behavior and condom self-efficacy. However, substance use and condom self-efficacy were inversely related. Self-reported substance use was also related to marijuana use, with condom use being associated with drug use avoidance less than half of the time.

Table 3 provides results from the regression models outlined in the analysis section. As indicated, age was significantly associated with marijuana use as an outcome in both equations [Wald = 17.7, p < .001]. This was the only variable significantly associated with predicting self-reported marijuana use. The other demographic variables did not reflect any differences between inmate responses with respect to blacks vs. whites and those individuals who had gone beyond high school vs. those with a high school degree or less.

Next, adjusted odd ratios (AORs) and beta coefficients were computed to examine the association between the selected demographic variables and marijuana use. As indicated in Table 4, age again was evinced to be significantly related to self-reported marijuana use. In addition, data indicate that the more money inmates reported they earned, the more likely they were to use marijuana. In fact the rate tended to increase as the comparison models increased. For example, inmates who reported making more than $60,000 a year were 1.2 times more likely to report marijuana use than inmates that reported annual incomes of $20,000 or less. Thus, inmates reporting income prior to incarceration of less than $20,000 annually were similar to inmates reporting a yearly income greater than $60,000. In comparison, those who reported more than $60,000 yearly were 2.3 times more likely to use marijuana than inmates making less than $60,000 annually prior to incarceration. This suggests that inmates who reported an annual income of more than $60,000, although not statistically significant, were more likely to report marijuana use compared to inmates reporting less than $60,000 annually. In summary, individuals with higher incomes prior to incarceration tended to self-report higher levels of marijuana use.

CONCLUSION

This article summarizes the relationship between an inmate's history of prior incarceration and self-reported HIV/AIDS risk behaviors and marijuana use. In our findings, we detail that marijuana use by inmates is unrelated to a history of prior incarceration, overall substance use, and condom use less than one half the time. However, although not significant, we did notice that as self-reported marijuana use increased, less than half the time condom use increased. This finding is consistent with other studies on inmate populations (6).

We also observed that substance use as a HIV/AIDS risk behavior was significantly associated with other risky sexual practices and condom self-efficacy. In fact, condom self-efficacy was inversely proportional to reported substance use, meaning higher levels of substance use resulted in lower occurrences of belief in using a condom. Moreover, we noted some differences between first time offenders and those with a history of prior incarceration. Our findings support that this difference may include demographic variables such as education and age as well as sexual self-expectations. This may mean that sexual risk taking and associated behaviors may develop among this population as a function of length of time or familiarity of being incarcerated.

Consequently, there is a need for specific and recommended guidance for prevention models, especially those that are peer-based, to maximize the utility of risk reduction efforts. These interventions may even need to take into consideration inmate experience with being incarcerated. This approach is also consistent for the finding that self-reported substance use behavior (universal measure inclusive of alcohol) was related to sexual risk practices, and reduced levels of condom use self-efficacy and marijuana use.

It is essential that health education and prevention specialists working with correctional populations understand how inmates vary with respect to substance use problem behaviors, and whether or not these differences can be used to impact behaviors so as to reduce the occurrence of problem behaviors. It is our contention that future health promotion efforts with inmate populations should also include educating correctional staff. Future research should examine these variables further and include other variables like history of deviant behavior and perceived risk (25).

Although our study proffered valuable insight with respect to soon-to-be-released adult male inmates, it has limitations. First, there are some concerns with the low alpha calculated for the condom use scale. This may be a function of the measurement of the question or of self-report biases that are common in sex behavior research. In addition, we did not look at measures to discern whether self-reported marijuana use was a function of living in an urban or rural area. This data may play some role in our findings, since Warner and Leukefeld (26) indicated that inmates from rural areas tend to report higher rates of lifetime drug use. Still, we acknowledge that these findings are limited with respect to validity in summary due to the nature of self-report measures. In addition, there may be some limited causation due to the implementation of a Latin Square Design, since the design is of a correctional nature. Regardless. we feel that our study provides valuable insight on marijuana use risk behaviors by inmates since many studies often do not use current inmates and may be prohibited from collecting information on high risk behaviors.

Although inmates are a population at risk for infectious diseases such as HIV/AIDS, hepatitis, and tuberculosis, very little progress has been made with respect to understanding what factors contribute to increased risk of transmission among selected inmate subgroups. The bottom line is that prisons and jails are ideal settings for health promotion activities that service the needs of high-risk populations like inmates. Understanding substance use behaviors and prior incarceration history provides critical information that may assist in controlling the spread of infectious diseases and counteracting substance use behaviors.

ACKNOWLEDGMENT

This research was funded by the National Institute on Drug Abuse grant 1 R01 DA 122331-01-A1.

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Torrance Stephens, Ph.D., * Ronald Braithwaite, Ph.D., and Corey Tiggs

Rollins School of Public Health and Center for Health Disparities Research, Emory University, Atlanta, Georgia, USA

* Correspondence: Torrance Stephens, Ph.D., Rollins School of Public Health and Center for Health Disparities Research, Emory University, 1518 Clifton Rd., Atlanta, GA 30322, USA; Fax: (404) 727-1369; E-mail: tstephe@sph.emory.edu.

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