Cumulative Social Disadvantage and Medicinal Cannabis Use among Younger Adults in Rural Communities: A Mixed Methods Approach

Abstract

This mixed-methods study investigated the role of medicinal cannabis use among younger adults who live in rural communities and experience high levels of cumulative social disadvantage (CSD). Results are based on cross-sectional surveys and online interviews with 153 younger adults (18–35 years old) in rural California. We assessed participants’ levels of CSD (high, medium, and low) and examined associations with perceived general physical and mental health and with medicinal use of cannabis (MUC). Qualitative analyses were then conducted to better understand the roles of cannabis use in the lives of study participants with high versus low CSD. High CSD was associated with perceived poorer physical and mental health and with MUC, but not past month general cannabis use. Qualitative findings emphasized the significant role of MUC for rural young people with high CSD to reduce stress and manage physical and mental health. Findings suggest the need to address CSD inequities in rural communities, such as increasing access to health care, to reduce health inequities and the reliance on cannabis use for managing mental and physical health.

Keywords: Cumulative Social Disadvantage, Rural, Medicinal Cannabis Use, Health

INTRODUCTION

Low socioeconomic status has long been implicated in a number of health inequities (Ozga et al., 2021; Seabrook & Avison, 2012). Based on the cumulative disadvantage framework, this relationship is due in large part to the chronic stress associated with experiencing cumulative social disadvantage (CSD) (Dannefer, 2003; Pearlin et al., 2005; Schafer et al., 2011; Seabrook & Avison, 2012). These disadvantages often occur over the life course and across generations (Seabrook & Avison, 2012), and may include (a) increased risk of exposure to environmental and structural conditions that compromise health (e.g. air quality, workplace conditions), (b) reduced knowledge of and access to health information or health care (e.g. underinsured, hospital closures), and (c) persistent “hardships, demands, conflicts and frustrations” that undermine wellbeing by disrupting people’s everyday lives (e.g. job exploitation, family hardship) (Pearlin et al., 2005). Together, these CSDs are theorized to affect individual physical and mental health through variations in stress exposure and access to health care and related services.

Indeed, previous research has shown that CSD is related to adverse physical and mental health outcomes. In a national US study among adults, higher CSD, based on 47 deprivations across 6 domains (i.e., economic stability, neighborhood and physical environment, education, food security, community and social context, and healthcare system), was positively associated with poorer perceived overall health and functional activity limitation, based on age and the ability to perform a major activity (Hagan et al., 2023). Examining associations between CSD and cigarette smoking and cessation, another national study with US adults (aged 25 years or older) found that each additional disadvantage (e.g., current unemployment, low education) was associated with higher odds of smoking and lower odds of smoking cessation (Leventhal et al., 2019). In a study with high school seniors in Washington State, results showed lower perceived physical and emotional health outcomes among youth with high CSD compared to low or moderate CSD groups (Nurius et al., 2015). Similarly, a study in Finland found people aged 45 or older with greater CSD were more likely to be hospitalized due to ambulatory care-sensitive conditions (Lumme et al., 2020).

A research gap remains in that much of this prior research investigating associations between CSD and health outcomes has not considered the type of community where people live (rural vs. urban). People living in rural areas are more likely to experience high CSD due to factors related to their physical environment (e.g., access to health care services), low socioeconomic status (e.g., limited employment opportunities), and social factors (e.g., less social support) (Ozga et al., 2021; Richman et al., 2019). While previous research has investigated rural health inequities and structural, social, or personal factors contributing to these inequities, to our knowledge, no prior research has investigated the cumulative effects of personal (e.g., employment status, immigration status), social (e.g., social support, collective efficacy), and structural (e.g., access to health care) disadvantages and physical or mental health in people who live in rural areas. Based on available research and the cumulative disadvantage framework, we hypothesize that greater CSD will be associated with poorer perceived overall physical and mental health among people who live in rural communities.

In treating or managing poor physical or mental health conditions (e.g., anxiety, pain), medicinal use of cannabis (MUC) is common among adults (Asselin et al., 2022; Leung et al., 2022; Wallis et al., 2022). Here, MUC is used as a general term to refer to instances where people obtain a prescription of cannabis or cannabinoids to alleviate symptoms of or treat a medical condition or instances of self-medication, defined as use of cannabis for medical reasons without authorization or prescription (Leung et al., 2022). For younger adults who live in rural communities and experience higher CSD, MUC may play an important role in coping with chronic stress and related health issues, given limited access to physical and mental health care and services among other disadvantages in rural communities. However, to our knowledge, no prior research has focused on cannabis for medicinal use in younger adults who live in rural communities and experience high levels of CSD. Investigating MUC has important implications for understanding the role that cannabis use plays for younger adults who live in rural communities and how it relates to lived experiences with the cumulative disadvantages associated with rurality. If we do not understand cannabis use within the broader context of rural young people’s lives, we risk “mask[ing] the true nature of health risk, the causal mechanisms at play and appropriate interventions” that are needed to pursue health equity (Olstad & McIntyre, 2019).

To address this existing research gap, we used a mixed-methods approach to investigate the role of MUC among younger adults who live in rural communities and experience high levels of CSD. First, we quantitatively examined the association between levels of CSD and MUC among younger rural adults. To cope with chronic stress and related health issues and given limited access to health care and services and other disadvantages in rural communities, we hypothesize that CSD will be positively associated with MUC in younger adults who live in rural communities. Since people who experience high levels of CSD can use both medicinal and recreational cannabis, we examined general cannabis use as well as self-reported medicinal use. Then, to better understand the role of cannabis use in the context of CSD for these participants, we compared cannabis-related narrative data, obtained through in-depth qualitative interviews, between participants of high versus low levels of CSD.

Study Area

The current study used data collected from younger adults who lived in California’s rural North State. Importantly, the experiences and concerns of residents in this region resemble other conservative rural areas throughout the United States, where residents believe that state governments insufficiently address or ignore rural concerns (Davis, 1952; Laufer, 2022; Tickner & Fiorini-Jenner, 2006) and where health-related inequities are prominent. For example, data from 2018–2020 suggest the region’s crude death rate was 1,112.19 deaths per 100,000 people, considerably higher than the California death rate (719.7) (County Health Status Profiles – County Health Status Profiles 2022, n.d.). In terms of cannabis legalization, California became the first state to allow medicinal cannabis use in 1996 (the Compassionate Use Act) and as of November 2016, California legalized cannabis to be used recreationally by adults (Proposition 64). Findings of this study can inform prevention efforts addressing health inequities in rural communities, and shed light on the differential roles of medicinal versus recreational uses of cannabis.

METHODS

Participants

This study is based on data from two federally and state funded studies with overlapping aims conducted contemporaneously from April 2021-March 2023 by the same research team. Both studies explored social and structural conditions related to various forms of substance use in the lives of younger adults (18–35 years old) in California’s rural “North State.” Twelve north central and northeastern counties comprise this region: Butte, Colusa, Glenn, Lassen, Modoc, Plumas, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Yuba counties. All counties are defined as rural by the Rural County Representatives of CA (Counties | Rural Counties, n.d.). Of these counties, nine are considered noncore, the most rural designation available by the National Center for Health Statistics. The remaining three are considered small metro due to a single urbanized region with a population of at least 50,000 people (Data Access – Urban Rural Classification Scheme for Counties, 2023). We did not include volunteers from those counties who lived in an urbanized region that was considered by local community advisors to be significantly culturally different from the rest of the county.

The study is based on data collected from 153 participants across both studies who lived in this area. Participation in each study involved completing a 30-minute online survey with a $20 honorarium, followed by an online in-depth qualitative interview lasting up to two hours with a $50 honorarium. Of study participants, 57 completed two interviews, one for each study (n=210 interviews total). Participants were 18–35 years old, with a mean of 25.4 years. The sample was predominantly White (69.9%), and more women (56.2%) than men (42.5%) participated. About 15% of the sample reported their race/ethnicity as Latinx, and 10% of the sample reported more than one racial or ethnic identity. Additional selected sample characteristics are in Table 1.

Table 1.

Selected Sample Characteristics and Study Outcomes (N=153)

N (%)
Mean (SD)
Range

Age

25.36 (4.89)
18–35

Female
86 (56.21)

Racial or ethnic identities

 Native Hawaiian/Pacific Islander
0 (0.00)

 Asian
1 (0.65)

 Hispanic/Latinx
23 (15.03)

 American Indian/Alaska Native
2 (1.31)

 Black/African American
2 (1.31)

 No Hispanic/Latinx White
107 (69.93)

 Other
2 (1.31)

 Multi-race
16 (10.46)

College education or higher
23 (15.03)

Currently working
97 (63.40)

Insecure housing, lifetime
78 (50.98)

Cumulative social disadvantage

6.93 (4.97)
0–21

Perceived general physical health

3.13 (1.07)
1–5

Perceived general mental health

2.57 (1.21)
1–5

Any past month cannabis use
120 (78.43)

Current medicinal cannabis use
38 (24.84)

Procedures

Participants were recruited using a multi-tiered strategy involving online and radio advertising, outreach to local organizations, ‘on the street’ recruitment efforts, and participant referrals (limited to three to reduce sampling bias). Interested volunteers were screened online or in-person to determine eligibility. Eligibility criteria included being between 18–35 years old and either currently living in the study area or having previously lived there for multiple years and only moved within the past year. All participants had experience with tobacco and/or alcohol use based on the original study for which they were recruited. Participants received a unique link to complete the study consent form and confidential online survey in advance of the interview. Survey instruments for both studies included the same demographic, community, and basic substance use questions.

Upon completing their survey, participants were scheduled for an online interview conducted via Zoom. Given problems with internet connectivity in rural communities (California’s Digital Divide, n.d.), we conducted some interviews by phone. Interviewers verbally reviewed consent procedures with participants and answered any remaining questions prior to interviews. The interview instruments for both studies contained many of the same questions though diverged in their more in-depth inquiries about the specific substance of interest. Interviewers wrote up field notes immediately following each interview summarizing the participants’ background, interview content related to study aims, and preliminary analytical ideas about the data. All interviews were audio recorded, professionally transcribed, and reviewed by interviewers for accuracy. Study procedures were approved by our organization’s Institutional Review Board.

Measures

Levels of cumulative social disadvantage (CSD).

A CSD measure was created using several survey items assessing social disadvantages in the following domains: (a) economic stability, (b) education, (c) neighborhood & physical environment, (d) food security, (e) community & social context, and (f) health care (Hagan et al., 2023). On average, participants reported 6.9 social disadvantages across these domains (SD= 4.9), range 0–21 (Table 1). Using a tertile, levels of CSD were defined as low (0–4 social disadvantages), medium (5–8 social disadvantages), and high (9 or more social disadvantages). Table 2 includes the specific survey items used by domain, how disadvantage was coded, and the percent of participants who reported a social disadvantage per each survey item.

Table 2.

Cumulative Social Disadvantage: Survey Items Used by Domains and Coding

Topic
Survey Item
Response Options
CSD Coding
N (%) of CSD

Economic Stability Domain

Employment
Are you currently employed?
1. Full-Time (Working 35 hours/week or more; including self-employed)
2. Part-time (Working less than 35 hours/week; including self-employed)
3. Unemployed, but looking for a job
4. Neither employed nor looking for a job
5. On disability
3 or 5 = CSD
35 (22.88)

Economic Hardship
In the past 12 months, has there been a time when your household:

Did not pay the full amount of rent or mortgage.
Yes/No
Yes=CSD
31 (20.26)

Was evicted from your home for not paying rent or mortgage.
Yes/No
Yes=CSD
2 (1.31)

Did not pay the full amount of the gas or electricity bill.
Yes/No
Yes=CSD
41 (26.80)

Had a phone disconnected because payments were not made.
Yes/No
Yes=CSD
35 (22.88)

Had someone in your household who needed to go to see a doctor or go to the hospital but didn’t go.
Yes/No
Yes=CSD
39 (25.49)

Education Domain

Education
What is the highest grade of school you have completed?
1. Less than high school
2. High school graduate
3. GED or equivalent
4. Some college
5. Associate degree
6. Bachelor’s degree
7. Some post graduate
8. Post graduate degree
9. Other (specify)
1=CSD
6 (3.92)

Neighborhood & Physical Environment Domain

Lifetime Insecure Housing
Please indicate whether you have spent at least one night in any of the following places at any point in your life. These questions are about housing security, so please do not count recreational activities in your answers.

In a shelter (emergency shelter, DV shelter, homeless shelter)
Yes/No
Yes=CSD
15 (9.80)

In a temporary housing program?
Yes/No
Yes=CSD
13 (8.50)

On the street or anywhere outside (e.g. park, sidewalk; NOT including recreational camping)?
Yes/No
Yes=CSD
28 (18.30)

Temporarily staying with a friend or family member (crashing) because you had nowhere else to go.
Yes/No
Yes=CSD
73 (47.71)

In a public place not intended for sleeping (e.g. bus station, car, abandoned building).
Yes/No
Yes=CSD
35 (22.88)

In a welfare or voucher hotel/motel.
Yes/No
Yes=CSD
15 (9.80)

Jail or prison.
Yes/No
Yes=CSD
25 (16.34)

In a foster care placement
Yes/No
Yes=CSD
20 (13.07)

Food Security Domain

Food availability
Which statement best describes the food eaten in your household in the past month? (Choose 1)
1. We had enough of the kind of food we want
2. We had enough food, but not always the kinds of food we want to eat
3. We sometimes did not have enough food
4. We often did not have enough food
5. No answer
3 or 4 = CSD
36 (23.53)

Community & Social Context Domain

Immigration
What country were you born in?
1. United States
2. Other country (specify)
2=CSD
6 (3.92)

Collective Efficacy
The next questions are about the area where you live in. How much do you agree or disagree with the following statements?

People around here are willing to help each other.
1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly Disagree
4 or 5 = CSD
30 (19.87)

This is a close-knit neighborhood area
1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly Disagree
4 or 5 = CSD
36 (23.84)

People in the area where I live cannot be trusted
1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly Disagree
1 or 2 = CSD
43 (28.48)

People in this area where I live generally do not get along with each other
1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly Disagree
1 or 2 = CSD
21 (14.09)

People in this area where I live do not share the same values
1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly Disagree
1 or 2 = CSD
47 (31.13)

Social Support
How often is each of the following types of support available to you if you need it?

Someone to help with daily chores if you were sick.
1 (none of the time) to 5 (all of the time)
1 or 2 = CSD
44 (28.76)

Someone to do something enjoyable with.
1 (none of the time) to 5 (all of the time)
1 or 2 = CSD
31 (20.26)

Someone to turn to for suggestions about how to deal with a personal problem.
1 (none of the time) to 5 (all of the time)
1 or 2 = CSD
33 (21.57)

Someone to love and make you feel wanted.
1 (none of the time) to 5 (all of the time)
1 or 2 = CSD
34 (22.22)

Access to a Vehicle
Is there a car or motorcycle you are able to use almost anytime you want?
Yes/No
No = CSD
33 (21.57)

Health Care Domain

Health insurance
Are you currently covered by any of these health insurance plans (select one)?
1. None
2. MediCal
3. Medicare
4. Healthy Families
5. Private Insurance (through employer)
6. Private insurance (self-employed)
1=CSD
28 (18.30)

Delayed Medical Care
There are many reasons people delay getting medical care. In the past 12 months, have you delayed getting care for any of the following reasons?

Did not have transportation.
Yes/No
Yes=CSD
26 (16.99)

You live in a rural area where distance to the health care provider is too far.
Yes/No
Yes=CSD
27 (17.65)

You were nervous about seeing a health care provider.
Yes/No
Yes=CSD
54 (35.29)

You could not get time off work.
Yes/No
Yes=CSD
19 (12.42)

Could not get childcare.
Yes/No
Yes=CSD
10 (6.54)

You provide care to an adult and could not leave them.
Yes/No
Yes=CSD
2 (1.31)

Could not afford the copay.
Yes/No
Yes=CSD
24 (15.69)

Your deductible was too high/or could not afford the deductible.
Yes/No
Yes=CSD
23 (15.03)

You had to pay out of pocket for some or all of the procedure.
Yes/No
Yes=CSD
30 (19.61)

Other
Yes/No
Yes=CSD
10 (6.54)

Perceived General Health.

To assess their perceived general health, participants were asked to separately rate their physical and mental health as excellent, very good, good, fair, or poor. “Excellent” was coded 1 and “Poor” was coded as 5.

General and Medicinal Use of Cannabis.

Current general cannabis use (medicinal and/or recreational) was measured using participants’ responses to 3 questions asking the number of days they (a) smoked marijuana, (b) used a cannabis concentrate, and (c) used cannabis edibles in the past 30 days. We used responses to these survey items to assess any past 30-day cannabis use. MUC was assessed by asking participants to self-report if they use cannabis for a medical condition with response options of yes or no.

Qualitative Interview Guide.

Both studies’ guides began with a series of questions about the participant’s background and daily life (i.e., occupational, family, and housing situations). The next section elicited narratives regarding the participant’s local area, including resources, reputation, and community composition. Then, the interview guides included a section on the participant’s identities and reflections on how their identities impacted their life.

The guides then shifted to discussions of substance use, focusing on either alcohol or tobacco, depending on study aims, with additional questions about lifetime use of any other substances, including the details, contexts, and reasons for this use. With the high prevalence of past month cannabis use in the study sample (78.43%), narratives related to cannabis were common. The final sections of the interview guides centered on the participant’s perceptions of pressing issues in their community before a short wrap-up section for any final thoughts or feedback.

Analytical Approach

We used descriptive statistics to characterize the sample. One-way ANOVA tests were used to examine if perceived general physical health and perceived general mental health were different for groups with different CSD levels. Tukey post-hoc tests were then used to assess the significance of differences between pairs of group means. Also, chi-squared tests were performed to examine the relations between CSD levels and any past month general cannabis use as well as any current cannabis use for medical conditions. Qualitative analyses were then conducted to better understand the roles of cannabis use in the lives of rural younger adults and explore how these roles may be contextualized by CSD experiences.

Using ATLAS.ti, we coded interview transcripts using a structured codebook, to organize the large dataset into analytically meaningful segments for subsequent analyses. The codebook was developed collaboratively by the research team, and designed to include codes suitable for capturing general descriptive topical areas (e.g., “Health/Illness”), theoretically-informed topics identified in the literature on rural substance use (e.g., “Isolation”), and topical domains inductively identified as important by participants during data collection (e.g., “Religion/Spirituality”).

For the current study, authors JP and ES identified all narrative data referencing cannabis use by conducting a text search for cannabis-related terms within all data captured under the “Other Substances” code. The list of 25 search terms included common names for and modes of cannabis use (e.g., “weed,” “cannabis,” “marijuana,” “joint*,” etc.) and was revised to include other unique terms used by participants (e.g., “chops”). We then grouped interview transcripts into high CSD and low CSD categories in order to set up our analysis to identify cross-group comparisons, a “powerful tool for identifying patterns” and developing more formal explanatory hypotheses in qualitative data analysis (Bernard & Ryan, 2010). Authors JP and TA conducted independent explorations of the data, paying close attention to similarities and differences between the high and low CSD groups. The research team met regularly to discuss theoretical patterns produced by the analysis that may explain the processes connecting MUC with high CSD.

RESULTS

Quantitative Results

Sample characteristics and descriptives of study outcomes are included in Table 1. Results of a one-way ANOVA found a statistically significant difference between CSD groups in perceived general physical health [F (2,149) = 7.32, p = .001]. A Tukey post-hoc test revealed that perceived general physical health was significantly poorer in the high CSD group (M=2.8, SD=1.1) compared to the low CSD group (M=3.5, SD=0.9). There were no statistically significant differences between the medium versus high CSD groups. Similarly, there was a statistically significant difference between groups, as determined by one-way ANOVA, when assessing perceived general mental health [F (2,149) = 16.9, p < .001]. A Tukey post-hoc test revealed that perceived general mental health was statistically significantly poorer in the high CSD group (M=1.9, SD=0.9) compared to the medium CSD (M=2.5, SD=1.2) or low CSD groups (M=3.2, SD=1.2).

While no associations were found between CSD levels and any general past month cannabis use in a chi-squared test [X2 (2, N = 153) = 2.9, p = .238], results showed that the relationship between CSD levels and any current use of cannabis for a medical condition was significant [X2 (2, N = 146) = 13.8, p = .001]. Participants with high CSD (41.2%) were more likely than participants of medium (28.6%) or low CSD (9.4%) to report current MUC. To better understand the role of MUC for participants with high CSD, we compared cannabis-related narrative data between participants of high versus low levels of CSD.

Qualitative Results

Though interview instruments were not designed to explore the role of MUC in participants’ lives, discussions of cannabis nevertheless emerged. While some similarities existed between high and low CSD groups of participants (e.g., cannabis use as normalized, fun), interviews also suggested key differences that may reveal important mechanisms linking CSD with MUC. High CSD participants emphasized cannabis use as an individual-level practice and a routinized part of their everyday lives. Specifically, many high CSD participants noted the importance of cannabis for managing their mental health. For example, V, a 24-year-old woman, who was unhoused for three years and is currently recovering from a decade-long heroin addiction and on parole, living with her mom while struggling to secure employment, described:

“… for a lot of years, I was on prescription medications. But truthfully, I cannot stand pills. I hate taking pills. I hate the way they taste in my mouth. I hate how they feel in my throat. And they scare me because there are a lot of possible negative effects of any medication. So, I actually have my medical card for marijuana, and I prefer to use it as a medication for my anxiety and my depression.”

Another participant, Mary, a 30-year-old mother of five who cleans houses for a living, explained that due to a long custody battle with her abusive ex-partner, she had to move away from her family support system to a town with few resources, where it is harder for her to access the food, community connection, and mental health support she needs. Mary shared that cannabis was a critical part of managing not only her mental state, as she navigates stress, poverty, and past traumas, but also the pain and inflammation caused by celiac disease:

“… it really helps me with my stomach. Because my celiac disease f*#$ing governs my entire life, and I hate it. And it’s the one thing on the planet – Like, whether it’s a salve that I rub on my stomach or something that I take orally that has THC or CBD in it, or most of the time both – but smoking is … instant relief for me as far as my inflammation and my pain goes in my gut. So, it’s very beneficial for me. Definitely, cannabis is my go-to for things. …I’m constantly pent up and constantly stressed and constantly inflamed. … it’s a constant fight for me every day.”

Notably, high CSD participants rarely emphasized the intoxicating effects of cannabis nor the sociability of cannabis use. Cannabis generally was described as an important way to cope with anxiety and depression, as well as other health ailments like chronic pain, seizures, and insomnia. While a few low CSD participants described MUC, overall, their narratives were different from those of the high CSD participants in their relative indifference towards cannabis use. Specifically, a few participants who identified as low CSD and discussed regular use of cannabis were more likely than the high CSD participants to emphasize the pleasures associated with using cannabis both in terms of sociability as well as physiologically (i.e., intoxication). For example, Alex, a 23-year-old woman, who’s employed and living with a housemate for company, explained that she prefers cannabis to alcohol as a pleasurable way to unwind at the end of the day: “I really enjoy smoking weed when I get off work or in the evening. It’s kind of like my 5 o’clock moment. Instead of a glass of wine, I have that.” Similarly, Shelley, a 23-year-old woman living with her family until she starts graduate school, explained: “I smoke marijuana…. It’s nothing for medical reasons. Recreational use. That would be the fancy way of saying I like doing it.”

Also, among the low CSD group, some narratives suggested only occasional uses of cannabis as well as a relative lack of interest in cannabis. For example, Dylan, a 23-year-old man who was attending a prestigious university online, explained of his previous cannabis use: “I never really enjoyed it. It was just kind of, all of my friends are doing it, so I would do it too. It wasn’t like something that I was super, super big into.”

DISCUSSION

This study explored the role of MUC among rural younger adults with different levels of CSD. Similar to previous studies (Hagan et al., 2023; Leventhal et al., 2019; Lumme et al., 2020; Nurius et al., 2015), quantitative results showed that perceived general physical and mental health were significantly poorer in the high versus low CSD groups. Extending these findings, quantitative results also showed that people experiencing high CSD were more likely to report MUC compared to people with low CSD, possibly to treat or manage their poorer physical and mental health conditions. The results showing no associations between CSD levels and past month general cannabis use emphasize the unique role of MUC among younger adults living in rural communities and experiencing high levels of CDS due to personal (e.g., employment status), social (e.g., social support), and structural (e.g., access to health care) disadvantages contributing to health inequities in rural areas.

To better understand this observed relationship, we conducted a comparative qualitative analysis of interviews grouped by high versus low CSD participants to interpret the roles of cannabis use in the lives of younger rural adults and explore how these roles may be contextualized by CSD experiences. Our analysis identified a noteworthy pattern by group, illustrative of the way in which the role of cannabis may be shaped by the social and structural conditions surrounding people’s lives in rural communities. High CSD participants rarely emphasized the intoxicating effects of cannabis but generally emphasized the importance of cannabis use for coping with daily stressors or managing chronic illnesses, supporting the relationship we observed in analysis of the survey data. Notably, much of California’s North State region is a Health Provider Shortage Area (HPSA), a designation that refers to regions and populations with shortages in both primary and mental health care (Kirsch, 2023). This lack of accessible mental and physical health care in the North State, combined with additional social disadvantages that compound one’s vulnerability to illness and ability to seek out care, may situate cannabis as an attractive palliative for coping with chronic health challenges for people with high CSD. Conversely, low CSD participants, who also experience barriers to health care services, are likely afforded other privileges, including financial, material, and social capital (e.g., wealth, health insurance, social support) (Jennifer Sherman, 2006; Sherman, 2021) that expose them to fewer health challenges (e.g., lower risk of chronic and mental illnesses) as well as help them to secure access to care despite living in a HPSA (e.g., ability to drive long distances to care, internet access for telehealth). As a result, low CSD participants who use cannabis may do so, not because they feel it is instrumental for surviving the day-to-day, but instead because it is fun (Bunton & Coveney, 2011).

The notion of “blurred boundaries” has emerged as a prominent theme in the extensive social science literature on medicinal and recreational cannabis use, which maintains that people who use cannabis cannot be placed neatly into categories of recreational versus medicinal users (Hakkarainen et al., 2019; Reinarman, 2022; Sznitman & Zolotov, 2015). As Reid reminds us:

“There is a significant overlap between medical and recreational applications of cannabis, and people who use cannabis for medical purposes also situationally use their medicine in a manner similar to recreational users. The opposite is also true where all use can be seen as medical since the individual receives some health-promoting benefit, even if it is just relaxation” (Reid, 2020, pg. 2).

These “blurred boundaries” related to cannabis use practices and their associated meanings may be shaped by the social and structural conditions that surround people’s everyday lives, suggesting that idiosyncratic differences across distinct social positions (e.g., high versus low CSD) may be socially patterned in ways that are important for understanding health inequity. By attending to the unique experiences of low versus high CSD participants, this study raises questions about whether vulnerabilities in the rural health care system not only affect health care access and quality, but also open up space for cannabis to emerge as an alternative palliative for coping that is systematically distributed across stigmatized geographies and populations.

While accumulating research suggests the effectiveness of cannabis use for treating a variety of mental and physical health conditions (Black et al., 2019; Hill et al., 2017; National Academies of Sciences, 2017; Sarris et al., 2020; Whiting et al., 2015), MUC should not be a replacement for care in the absence of other health promoting resources. Moreover, despite some claims that cannabis use is universally normalized, given its legal status including in California where it was legalized for medicinal and recreational use (Proposition 64: The Adult Use of Marijuana Act – Criminal_justice_prop-64, n.d.), it is not immune to the processes of stigmatization. Claims of normalization are based on evidence that cannabis is widely-used and generally deemed socially acceptable by even the non-using public (Pennay & Measham, 2016). However, while cannabis stigma may have waned in recent years, it has certainly not disappeared (Reid, 2020). Cannabis stigma refers to the devalued status attached to people who use cannabis. It derives from multiple levels of influence, including societal structures such as state laws, institutional policies, and social norms that reduce opportunities for or devalue people who use; interpersonal exchanges in which discriminatory behavior is directed towards people who use; and intrapersonal factors whereby an individual who uses cannabis is acutely aware of or internalizes stigmatizing beliefs about cannabis use and cannabis users (Reid, 2020). Drawing on findings of the current study, this raises questions about whether rural, high CSD younger adults who may be systematically more likely to use cannabis medicinally are then also more vulnerable to experiencing cannabis-related stigma which has the potential to further intensify their experiences with social disadvantage, ultimately harming their health and well-being. Future research should investigate the role of cannabis in the lives of rural adults experiencing high CSD in order to better understand potential health and social consequences (e.g., cannabis use disorder, cannabis stigma) as well as possible benefits (e.g., palliative care) associated with relying on cannabis to treat chronic illness.

Several limitations of the current study include self-report and social desirability biases of survey data, though research staff reviewed survey data before the interviews and inquired about conflicting survey and interview reports. Also, the sample is limited to participants in rural California who reported lifetime use of tobacco and/or alcohol use. Though cannabis use was not considered as an eligibility criterion, 78% of study participants reported past month cannabis use. Last, the interview guide did not include questions specific to the role of MUC in participants’ lives and related emerging themes are the result of the high prevalence of cannabis use in this sample. Despite these limitations, results of this mixed-methods study highlight the potential significant role of MUC to manage poor physical and mental health conditions for rural younger adults with high CSD. These findings suggest the need to address CSD inequities in rural communities, such as increasing access to health care, to reduce health inequities and the reliance on cannabis use for managing mental and physical health.

Acknowledgments:

Sincere appreciation is due to the volunteers who gave their time to participate in this study. Without them, our work would not be possible.

Funding:

This research is supported by funds from the Tobacco-Related Disease Research Program (TRDRP), grant number T31IR1513 (Tamar Antin, PI) and the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH), grant number 1R01AA027992-01A1 (Geoffrey Hunt, PI). The content provided here is solely the responsibility of the authors and does not necessarily reflect the opinions of TRDRP nor the NIH.

Footnotes

Conflicts of Interest: The authors have no interests to declare.

Ethics Approval: The study protocol was reviewed and approved by the Institutional Review Board of the Institute for Scientific Analysis.

Consent to Participate: We obtained participants’ consent to participate in the study.

Data Availability:

De-identified data are available upon reasonable request and approval from Drs. Antin and Hunt.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

De-identified data are available upon reasonable request and approval from Drs. Antin and Hunt.