Title:
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Investigating associations of cannabis and cigarette use with mental health outcomes
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There is a substantial body of evidence showing that substance use is associated with
mental health problems, but establishing whether associations are causal and whether
specific substances have independent effects is more challenging.
The studies in this thesis aimed to investigate whether cannabis and cigarette use are
associated with psychotic experiences, depression and anxiety, and examine the extent
to which associations might be due to confounding, bias and reverse causation.
Data used were from ALSPAC, a large longitudinal birth cohort. For most analyses
exposure measures were assessed when participants were aged 16 years, and outcome
measures at 18 years. Regression models were used to assess associations before and
after adjustment for a large variety of potential confounders. Multiple imputation was
used to try and account for potential attrition bias. A Mendelian randomisation
approach was used to assess whether associations between smoking and psychotic
experiences are likely to be causal, using SNP rsl051730 as an instrumental variable.
Cannabis and cigarette use were associated with all mental health outcomes in
unadjusted analyses. Adjustment for pre-birth and childhood confounding made little
difference to most analyses. Adjustment for other substance use led to substantial
attenuation in many of the analyses investigated. Although there appeared to be some
divergence between the effects of different substances on specific outcomes, and
differences in the specific effects of substances between outcomes, this was not
supported by statistical evidence. There was no evidence to support reverse causation.
The Mendelian randomisation analysis did not provide evidence of a causal association
between smoking and psychotic experiences, but was underpowered.
The findings are consistent with previous literature from longitudinal studies that show
associations between both cannabis and cigarette use with incident mental health
outcomes, but also indicate that unmeasured confounding likely affects most studies to
date. At present there is not enough evidence to be confident that associations between
substance use and mental health are causal. Future research should utilise novel
methods to approach these questions from multiple angles in order to progress the
field.
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