This document discusses marijuana (MJ) use among college students and potential consequences. It notes that MJ use is rising among college students who perceive it as low-risk. However, MJ use can negatively impact students' health, education outcomes, and legal/financial status. College health nurses can use motivational interviewing to help students recognize problems with MJ use and motivate them to reduce harmful behaviors.

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Reducing Marijuana Use and Changing Perceptions about Marijuana Risk Among College
Students Through Motivational Interviewing
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California State University, Sacramento

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Marijuana (MJ) use is on the rise among college students. Students perceive MJ use as
harmless because it is becoming more socially acceptable and available through legalization.
College students are unlikely to recognize problems related to MJ use or ask for help.
Additionally students may be unaware MJ use can have consequences ranging from bronchitis to
psychosis or prison time. College health nurses have daily contact with students who use MJ.
Nurses with knowledge about MJ and motivational interviewing (MI) skills can intervene to
enable a student to make the connection between current difficulties and MJ use. Nurses can use
MI to motivate a student to change harmful MJ behaviors to achieve personal goals.
Background
MJ
MJ is smoked, vaporized, or cooked to extract the cannabinoids. MJ targets cannabinoid
receptors CB1 and CB2 throughout the human body (Mechoulam & Parker, 2013). The effects
are widespread because the endocannabinoid system is involved with metabolism, appetite,
reward system, pain, movement, mood, bone growth, and immune function (Alcohol and Drug
Abuse Institute [ADAI], 2015; National Institutes of Health [NIH], 2015a).
MJ plants are bred for medicinal or recreational properties (Ammerman, Ryan, &
Adelman, 2015). Tetrahydrocannabinol (THC) is the main psychoactive chemical in MJ. The
THC concentration of MJ has tripled since the 90s in some recreational strains (Sevigny, Pacula,
& Heaton, 2014). MJ experiences can vary from relaxation to paranoia (NIH, 2015a).
The Legal Landscape
Over 20 million Americans used MJ in 2013 (Substance Abuse and Mental Health
Services Administration [SAMSA], 2014). The use, sale, and possession of MJ are illegal under
federal law. The Drug Enforcement Agency (DEA) regulates MJ under the Controlled

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Substances Act (CSA) enacted by Congress in 1970 (Thomas, 2010). The DEA categorizes MJ
as a “Schedule I” drug like heroin: highly addictive and without medical purpose. The DEA does
not differentiate between MJ and heroin; all illegal drugs are bad (Dolan, 2012). However, unlike
heroin, no one has died from a MJ overdose (Ammerman et al., 2015).
Americans view MJ law as inconsistent with other federal laws that permit the use of
alcohol and cigarettes (Ammerman et al., 2015). The DEA classification conflicts with personal
MJ experience (Stewart & Moreno, 2013). Forty-three percent of high school seniors in 1975
thought MJ use involved great risk, by 2014 the number had dropped to 36.1%; In comparison
sixty percent of high school seniors believed trying heroin posed great risk in 1975 by 2014 that
number increased to 62.8% (Johnson, O’Malley, Mierch, Bachman, & Schulenberg, 2015). The
government’s stance that all illegal drugs are the same creates distrust among students who are
learning to challenge authority and think for themselves. The DEA position is difficult to
challenge because the schedule I classification restricts MJ research (Hoffmann & Webber,
2010; Joy, Watson and Benson, 1999; Nussbaum, Boyer, & Kondrad, 2011).
Limits of State
Many states disagree with Congress’s MJ law. Recognizing the drug’s medicinal value
California was the first state to legalize MJ in 1996; Medical MJ is now legal in 23 states.
(Neavyn, Blohn, Babu, & Bird, 2014). Other states have gone further, Colorado, Washington,
Oregon, Alaska, and the District of Columbia passed legislation to legalize recreational MJ. In
states where MJ is legal local law enforcement will not arrest, and state prosecutors will not
prosecute, individuals who comply with state law.
The multi-state legalization of MJ State has compelled the Department of Justice (DOJ)
to write several memorandums addressing the issue. The first advised that limited federal

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resources should not be used to prosecute individuals who comply with state MJ law (Hoffmann
& Wells, 2010; Savage, 2012). Other DOJ directives advised state officials that the DOJ would
not interfere with state recreational MJ law (ADAI, 2013; Grim & Reilly, 2013). However the
DOJ’s responsibility to enforce the CSA remains unchanged. Federal prosecutors do prosecute
and will imprison both medicinal and recreational MJ users in states where MJ is legal (Clark,
Capuzzi, & Fick, 2011; Sherer, 2014; Thomas, 2010). Former Deputy Attorney General James M.
Cole wrote that Congress has concluded MJ is dangerous, and its use is a crime therefore the
DOJ and federal law enforcement officers are obligated to enforce the CSA (Cole, 2013).
Federal and State
The discrepancy between state and federal MJ law wastes resources and is confusing to
Americans who could be arrested despite following state law. There is a need for uniformed MJ
law (Clark et al., 2011). Congress passed the Rohrbacher-Farr Amendment in 2015 prohibiting
the use of federal funds for MJ enforcement in states where it is legal. Unfortunately, the DEA
interpreted the law differently; the impact is unclear and will play out in the courts in years to
come. In another attempt, Congress introduced the Compassionate Access, Research Expansion,
and Respect States Act (CARERS) in 2015 to address this need (Senate Bill 683, 2015). The bill
would reschedule MJ to allow research and align federal law with state medical MJ law however
the bill has not progressed. Congress has until December 31, 2016 to pass the bill.
MJ as Medicine
The U.S. Food and Drug Administration (FDA) does not recognize medical MJ, as there
are not enough clinical trials or evidence to support its use (2015). While state laws do not
change the FDA medication approval process, Washington State offers medical guidelines for
MJ use to treat pain related to multiple sclerosis, cancer, fibromyalgia and neuropathy (ADAI,

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2015) in patients who do not respond to other treatments. The quality of evidence supporting
medical MJ is improving and benefits continue to be found through research in other countries
with fewer restrictions (Clark et al., 2011; Pies, 2010; Whitting et al., 2015).
Physicians are the gatekeepers of medical MJ. Medical MJ has safety and dosing
concerns because administering a medicine through inhaled smoke is unhealthy and difficult to
standardize (Volkow et al., 2014). Smoking is the best and fastest route for medical MJ but its
benefits must be weighed against the risks (Clark et al., 2011). Providers recommending medical
MJ to their patients must develop a treatment plan including route, dosing THC/CBD levels, side
effects, follow up, and the potential legal consequences (Nussbaum et al., 2011). Nurses caring
for medical MJ patients must be educated and knowledgeable to discuss MJ dosage, strains, side
effects, and precautions (American Cannabis Nurses Association, 2016).
The Medical Community
The medical community supports MJ reclassification. The Institute of Medicine (IOM)
recommended more clinical trials to further evaluate MJ’s therapeutic value for pain, nausea, and
appetite stimulation (1999). The U.S. Surgeon General and the American Medical Association
(AMA) support the rescheduling of MJ to increase research and recommend drug policy change
(Ferner, 2015; Hoffman & Weber, 2010). The California Medical Association (CMA) endorses
California’s MJ ballot measure (CMA, 2016). Legal MJ will increase research and knowledge to
support MJ policy based on factual evidence valued by young people (Zeese & Lewin, 1999).
The Future
The legal, medical, and political controversy surrounding MJ is complicated and
confusing. Most states do not have policies or public health campaigns in place (like those for
alcohol and tobacco) to protect consumers, and there are no federal regulations (like those for

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schedule II drugs) because the government has surmised that MJ has no medical purpose and
research is unwarranted. State MJ laws have created a need for reliable information and guidance
about MJ use (ACNA, 2016; Hoffman & Webber, 2010). Federal, state, and local agencies have
an obligation to develop clear evidenced-based nonpolitical MJ policies to inform, guide, and
protect the public (McGill, 2014). The CMA recommends in the future, “Medical marijuana
should be strictly regulated like medicine to ensure safe and appropriate use by patients with
legitimate health conditions and adult-use marijuana should be regulated like alcohol” (para. 4)
in the best interest of public health (2016). While Americans continue to discuss and debate MJ,
college students need a reliable resource to be able to make informed decisions about both
recreational and medicinal MJ use. Educated college health nurses can take the lead and be an
expert MJ resource.
Epidemiology
Prevalence of MJ Use
Public opinion polls show 54% of all Americans and 68% of millenninals favor legal MJ
(Pew, 2015). In 2013, 2.4 million persons aged 12 or older tried marijuana for the first time,
approximately 6,600 new users each day (SAMSA, 2014). MJ is part of the mainstream youth
culture (Mostaghim & Hathaway, 2013; Parker, Williams, & Aldridge, 2002; Sanberg, 2012).
The NIH reports that nearly 44% of teens have tried MJ by high school graduation (2015b).
Current MJ use (defines as using MJ once in last 30 days) rates for 18- through 25-year-olds is
19.0% (SAMSA, 2014).
Prevalence of MJ Use in College Students
College students have higher rates of MJ use, abuse, and dependence than the general
population (Elliot, Carey, & Vanable, 2014; Hall, 2009). College students using MJ at least once

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in the last 12 months rose from 30% in 2006 to 34% in 2014; over 5% report near daily use
(Johnson et al., 2015). Daily MJ use exceeds cigarette smoking among college students and is
perceived to be less risky (Johnston et al., 2015).
MJ is no longer considered aberrant college behavior. (Hall, 2009; Pinchevsky et al.
2012). Many students try MJ for the first time in college. The autonomy from parents and contact
with peers who may already use MJ provides opportunity (Fromme, Corbin, & Kruse, 2008).
Seventy-four percent of students reported being offered MJ during college and, of those, 54%
initiated use (Pinchevsky et al., 2012). Hispanic college students are four times more likely to
initiate MJ use at college (Suerken et al, 2014). Beck et al. (2009) reported college students
smoke MJ to make friends and reduce stress. MJ’s perceived ability to ease social situations and
availability make college experimentation appealing (Stewart & Moreno, 2013).
MJ use increases over the course of a student’s education. More college seniors use MJ
than freshmen (Liu, 2007). Non-users are willing to accommodate users (Parker, Lisa, & Judith,
2002), signifying to peers that MJ use is legitimate (Mostaghim & Hathaway, 2013).
Increasingly MJ is used in combination with other college activities like drinking or “hanging out”
(Parker, Lisa & Judith, 2002). The college atmosphere creates an accommodating environment
and a perception that everyone uses MJ (Stewart, 2013).
MJ related consequences in college students
MJ is acceptable, available, and is legal in some states for college students. College
students are a high-risk population for MJ intervention efforts because students are more
vulnerable to MJ’s negative consequences than adults or non-college students (Bava & Tapert,
2010; Hall, 2009). MJ use in college is associated with adverse consequences including some
with lifelong repercussions (Brooks, Lee, Brown, Finch, & Brook, 2011; Buckner, Ecker, &

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Cohen, 2010;; Caldeira, O’Grady, Vincent, & Arria, 2012)). MJ is associated with an increased
risk for accidents and injuries, a leading cause of death in college students (SAMHSA, 2014). MJ
is the most frequently reported drug in emergency room visits among young adults (SAMSA
report as cited in Berstein et al., 2009). Forty-seven percent of MJ users report driving after
smoking MJ (McCarthy, Lynch, & Pederson, 2007). MJ detection in fatal car crashes continues
to increase while alcohol detection remains stable (Brady & Li, 2014). Individuals testing
positive for THC (1 ng/ml or higher) are at least three times more likely to be responsible for a
car accident (Brady & Li, 2014).
MJ use affects educational and socioeconomic status. MJ is associated with poor college
outcomes including lower grade point average, taking longer to finish, or dropping out (Arria et
al., 2013; Johnson et al., 2015). MJ use on weekends and holidays may affect the ability to learn
during the week. Mental impairment from MJ persists for days after use (Crean, Crane & Crane,
20ll; Meier et al., 2012). Among students smoking MJ five or more times during the past year,
40.1% reported concentration problems, and 13.9% reported missing class due to MJ use
(Caldeira, Arria, O'Grady, Vincent, & Wish, 2008). A longitudinal study found regular MJ
smokers ended up in lower socioeconomic group than their parents; and earned less than peers
who do not regularly smoke MJ (Cerda et al., 2016).
MJ suppresses the immune system. Smoking MJ increased the risk of respiratory
infections like bronchitis, and pneumonia (Owens, Sutter, & Anderson, 2014). MJ has the same
carcinogens as tobacco, but its link to cancer is less clear (Volkow et al., 2014). MJ increases the
likelihood of a cardiovascular event because of the increased workload placed on the heart
through vasoconstriction, tachycardia, and elevated blood pressure. The risk for a heart attack is
almost five times higher in the hour following MJ use (Thomas, Kloner, & Rezkalla, 2014).

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MJ can alter the developing brain leading to mental health problems. Young people are
more vulnerable because the brain and endocannabinoid system continue to develop until age 25
(Mechoulam & Parker, 2013). MJ is linked to increased anxiety, depression, paranoia, and
suicidal ideation in adolescents (Patton et al., 2002; van Ours, Williams, Fergusson, & Horwood,
2013;White & Toughill, 2015). MJ could trigger the onset of schizophrenia if genetically
predisposed (Large, Sharma, Compton, Slade, & Nielson, 2011; Moore et al., 2007).
MJ is addictive. Almost 3 million people over the age of 12 meet criteria for MJ
addiction (SAMSA, 2014). Early MJ use increases the likelihood of dependency suggesting the
younger brain is more vulnerable. Nine percent of individuals, and 17% of teenagers, who
experiment with MJ, will become addicted (Lopez-Quintero et al., 2011). Among college
freshman 9.4% of students met the criteria for cannabis use disorder, and 24.6% among past-year
users (Caldeira et al., 2008). Cessation is challenging because withdrawal effects include
irritability, sleeping difficulty, and anxiety (Budney & Hughes, 2006; Volkow et al., 2014).
Arrest and criminal prosecution for MJ possession has led to serious legal problems for
young people. Almost 400, 000 young people were prosecuted for MJ possession in 2009
(Amerman et al., 2015). Black Americans are three times more likely to be arrested for MJ
possession than whites (SAMSA, 2014). Penalties for MJ possession vary from fines to time in
prison. A drug conviction can disqualify a student for federal financial aid. Even if not
prosecuted arrests can be part of a young person’s record for years. Young adults attending
college are at risk for health, legal, financial, social, and academic consequences when they
smoke MJ (Caldeira et al., 2008; McGill, 2014; NIH, 2015a).
Theoretical Framework
Social Learning Theory

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Social learning theory (SLT) explains how people think and behave (Figure 1). SLT
theorizes that students learn behavior, like MJ use, through ongoing reciprocal interaction
between the environment, cognition, and behavior (Bandura, 1971). MJ intervention programs
target these areas to reduce or deter MJ use.
Figure 1.
Six SLT factors explain how individuals learn, and modify behavior. These include
expectations, observation, behavioral capacity, self-efficacy, reciprocal determination, and
reinforcement (Glanz & Rimer, 1997). Expectations are acquired based on an individual’s ideas
or knowledge about the potential results of an action. Observational learning occurs when beliefs
are obtained by watching others. Behavioral capacity emphasizes an individual’s ability and skill
to change a behavior. Self-efficacy is the student’s self-confidence to take action. Reciprocal
determinism is the constant influence between the individual and environment. Lastly,
reinforcement is the response to a behavior that affects the chances of reoccurrence.
Interventions can target any of these factors to alter behavior. SLT rationalizes that students are
more likely to use MJ if it is available, socially acceptable, peers approve, and use is associated
with rewards (Kristjansson, Agrawal, Lynskey, & Chassin, 2012).

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Outcome expectancy. A person is more likely to smoke MJ if there are anticipated
benefits like relaxation and fewer consequences like addiction (Parsons, Siege, & Cousins, 1997).
MJ’s perceived risk continues to fall (Johnston et al., 2015). College students believe MJ has
fewer consequences than alcohol or tobacco (Johnston et al., 2015). The legalization of MJ
further supports the belief MJ is safe (Ghosh et al. 2016).
MJ users associate MJ with positive outcomes (Kilmer, Hunt, Lee, & Neighbors, 2007).
Positive expectancies included hanging out with friends, relaxation, sleep, or getting high
(Simons & Carey, 2006). Positive attitudes and expectancies about MJ correlated with increased
use (Giovazolias & Themelia, 2014).
Conversely students who do not use MJ focus on negative outcomes like addiction, bad
grades, illness and amotivation (Lopez-Quintero & Neumark, 2010). Assigning risk to a behavior
is a judgment about the potential for consequences. It is hard to persuade young adults to
consider unfavorable future consequences, because they focus on the present (Alfonso & Dunn,
2007).
Research suggests adolescents who perceive MJ as risky are less likely to use (Lopez-
Quintero & Neumark, 2010). However interventions, which focus only on, the negative effects
of MJ, are likely to be ignored by young adults (Kristjansson et al., 2012). Focus on MJ’s
disadvantages may create opposition from young people that may have positive personal
experience.
Peers. Research showed attitudes and behaviors of peers influence college substance use
(Neighbors, Lee, Lewis, Fossos, & Larimer, 2007). Students who perceived peer MJ use was
normal, were more likely to use (Perkins, 2002). Peer influence on drug use has been observed in
Asian American (Liu & Iwamoto, 2007) and African American students (Pugh & Bry, 2007).

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Students, who perceive friends use and approve of MJ, used more MJ than students whose
friends did not approve of MJ (Neighbors, Geisner, & Lee, 2008). A public health campaign in
Colorado reinforced the fact most students do not smoke pot (Colorado Department of Public
Health, 2015).
Self-efficacy. Young adults are unique developmentally because their brain is still
maturing and they have a need to be independent and assert autonomy. Additionally, college
students are surrounded by peers and are away from parental authority (Caldeira et al., 2008).
College students may have not have developed the skills or strategies to prevent MJ use. Belief
in one’s ability to implement a behavior, and a sense of self-efficacy to refuse MJ, are protective
factors against MJ use (Giovazolias & Themelia, 2014). Interventions, which focus on a
student’s prior experience, values, expectations, goals, and strengths, can reinforce self-efficacy.
(Bandura, 1977; Rimal & Real, 2003).
College MJ use is related to environmental and cognitive elements, which are open to
influence during the transition from high school to adulthood (Depue, 2010). College students
integrate perceived peer use, and outcome expectancies into personal MJ behavior (Kristjansson
et al., 2012). SLT theorizes effective interventions will focus on expectancies, peer norms, and
self-efficacy.
Literature Review Strategy
A literature search conducted on February 5, 2016 included the following databases:
PubMed, the Cumulative Index to Nursing and the Allied Health Literature (CINAHL), and the
Cochrane Library. Publication dates were limited to 2005-2016. The search terms “marijuana”,
“cannabis”, “adverse consequences”, “college students”, “perceived risk”, “registered nurses”,
“nursing”, and “motivational interviewing” were used. There were no additional filters.

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Publications were required to be in English with full text available. Search of the Cochrane
Library: two articles. Search of PubMed 117 articles. Search of CINAHL 86 articles.
Publications were considered for inclusion if any of the following were discussed: motivational
interviewing to change MJ use belief or behavior, college student beliefs, behavior, or attitudes
about marijuana, college student substance abuse, adverse affects of marijuana, or nurses
utilizing motivational interviewing. The reference lists of found articles were searched to identify
additional articles. Of the thirty-three articles that were reviewed: twenty-one articles were
scientific studies (including two pilot studies), ten were review articles, and the remaining
articles were expert opinion. The overall quality of the research was fair.
Key Concepts
Information alone is not effective at reducing college substance use (Larimer, Kilmer, &
Lee, 2005). There is little research targeting interventions to reduce college MJ use. (Dennhardt
& Murphy, 2013). Alcohol use among college students has been widely studied, and could be
adapted to target MJ (Dennhardt & Murphy, 2013). Colleges could also consider applying
adolescent, or adult substance use interventions to the college population to reduce MJ use
(Larimer et al., 2005). Developing and publishing evidence-based interventions to reduce college
MJ use is important (Larimer et al., 2005).
Interventions to change college MJ behavior should include: education (MJ’s positive
and negative effects), goal clarification, social norming, and screening with brief interventions
like MI (Ghosh et al., 2016). There is a need for secondary MJ prevention in college health
because many college students start using MJ in high school (McCambridge, Slym, & Strang,
2008). Colleges have intervention programs for alcohol, but few have done so for MJ (Dennhardt
& Murphy, 2013). Student health centers provide an opportunity to intervene with non-treatment

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seeking MJ users (D’Amico, Miles, Stern, & Meridith 2008; Magill, Barnett, Apodaca,
Rohsenow, & Monti, 2009).
Substance Use Interventions
Informational programs. Informational programs attempt to prevent MJ use or change
student expectancies to reduce use (Kristjansson et.al., 2012). De Gee, Verdurmen, Bransen, de
Jonge, & Schippers (2014) found increased knowledge of MJ’s negative consequences was not
effective at reducing MJ use in non-treatment seeking adolescents. Prior research also concluded
“information” only programs were not effective in reducing substance use (Larimer & Cronce,
2002; Licciardone, 2003). Programs combining MJ information and the benefits of reduced MJ
use might be more successful (Giovazolias & Themelia, 2014).
Normative re-education programs. Normative re-education programs ensure students
have accurate information about peer substance use. Personal drug use was linked to an
overestimation of peer use (Dennhardt & Murphy, 2013). Evidences about peer MJ use, and
individualized feedback about personal use may create a stimulus to change (White et al., 2006).
Perceived peer use, and perceived peer approval of use were associated with increased personal
MJ use (Neighbors, Geisner, & Lee, 2008). Normative re-education programs were more
effective when personalized substance use was compared to peer norms (Larimer & Cronce,
2007).
Web-based interventions. Web-based interventions targeting alcohol have been used to
increase outreach, reduce cost, and decrease staff impact with favorable results (Hustad, Barnett,
Borsari, & Jackson, 2010). Lee, Neighbors, Kilmer, & Larimer (2010) found computerized
feedback targeting MJ use did not change use. MJ “e-TOKE” is a web-based intervention
directed at college students. E-TOKE corrected perceived norms about MJ, but did not reduce

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use (Elliot et al., 2014). Palfai et al. piloted a student health study that offered e-TOKE to
students who reported monthly MJ use (2014). The on-line intervention changed perceived
norms about peer MJ use, but did not decrease student MJ use.
Screening and brief intervention. Brief interventions in primary care were found to be
cost effective and reduced resistance to behavior change (Humeniuk et al., 2012). Several studies
evaluated the implementation of screening and brief intervention (SBI) in the college health
setting to reduce substance use. Schaus and colleagues (2009) conducted a randomized control
trial, and found SBI reduced alcohol consumption among college students. Werch et al. found
SBI reduced both alcohol and MJ consumption when compared to standard care (2008). In
another control study, students received either a clinician-delivered intervention or written
instructions; both groups reduced high-risk MJ behavior (Fischer, Jones, Shuper, & Rehm, 2012).
This study suggested SBI was effective, but it was unclear which method was best.
Motivational interviewing. Motivational interviewing (MI) is a counseling technique to
help people change behavior (Miller & Rose, 2009). MI is persuasive and supportive, not
coercive and argumentative. The goal is to increase the motivation for change from within and to
solidify an individual’s self-efficacy and commitment to change.
Three systemic reviews found MI had varied success depending on substance and
population (Lindson-Hawley, Thompson, & Begh, 2015; Rubak, Sandbaek, Lauritzen, &
Christensen, 2005; Smedslund et al., 2011). MI was found to reduce substance use compared to
no intervention (Rubak et al., 2005). MI was conducted in one to six sessions with each session
ranging from ten minutes to one hour, but optimal delivery of MI requires further research.
(Lindson-Hawley et al., 2015).
MI was better at changing behavior than information alone in a healthcare setting

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(Larimer & Cronce, 2007; Rubak et al., 2005). MI reduced alcohol use among high-risk college
freshman (Kazemi, Levine, Dmochowski, Nies, & Sun, 2013). Amaro et al. (2010) found MI
directed at alcohol use also reduced college student drug use.
Larimer et al. (2005) found MI reduced substance use among adolescents and adults, and
recommended it be used in the college population. A randomized control study of non-treatment
seeking adults found MI reduced negative MJ consequences when compared to education alone
(Stephens, Roffman, Fearer, Williams, & Burke, 2007). MI reduced MJ use in non-treatment
seeking young adult women (Stein, Hagerty, Herman, Phipps, & Anderson, 2011).
McCambridge et al. (2008) found talking as effective as MI in reducing MJ use in non-treatment
seeking adolescents. A review study of MI to reduce substance use found MI was significantly
better than no treatment, however other treatments were equally effective (Smedslund et al.,
2011).
Three randomized control studies utilized MI to reduce college MJ use. McCambridge
and Strang (2004) found MI be more effective at reducing MJ use than the control and
recommended counselor delivered MI may show promise for MJ use reduction among college
students. White et al. (2006) compared MI to a written feedback intervention in college students.
The MI was presented as a counseling session. Both interventions were equally effective in
reducing MJ use. Lee et al. (2013) found in-person personalized feedback reduced the amount of
MJ used in comparison to no intervention.
Integration of Findings
The current research does not support one intervention over the others to reduce college
MJ use. It suggests educational approaches are unlikely to work alone. Normative re education
can be helpful. Web-based interventions require more research but are important because they

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affordably screen a large numbers of students, provide individualized feedback, and can identify
high-risk students. Research suggests college students who received MI reduce MJ use, however
other active and less costly interventions might be as effective as MI at reducing student MJ use.
Limitations of Research
There are few control studies targeting college students’ MJ use (Larimer et al., 2005).
The dearth of research required examining other populations (adolescence and adults), and
substances (alcohol and other drugs), which may or may not be applicable. The current evidence
is mostly low quality due to low completion rates, small sample size, and no control group or
active control.
Researchers frequently delivered the intervention. Researchers may not have the same
time constraints, comfort level, or ethical concerns as healthcare staff which limits applicability.
Characteristics of the college populations, and student selection criteria varied: high-risk,
mandated treatment, current drug or alcohol users, and opportunistic screening making
comparisons difficult. Outcomes were measured by self-report and reliability questionable
(Caldeira et al., 2008). Study comparisons were also problematic because interventions were not
well described. Replicating research requires the intervention be well described. Simpson (2002)
recommended that researchers should outline the intervention to allow replication and
comparison.
Implications for Nursing
MJ continues to be legalized. College health nurses interact with students who use MJ on
a daily basis. College students are unaware of MJ’s harmful effects (Hoffman & Webber, 2010).
Norberg et al. (2012) found 77% of nurses believe they do not have the skills to provide
interventions related to MJ use in primary care (PC). Nurses are the main providers health

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education in PC (White & Toughill, 2015). There is limited guidance for MJ education (Hall,
2009). MJ may not have been taught in school, like other medications or controlled substances
(Nussbaum et al., 2011). Nurses must take the initiative to educate themselves about the potential
risks and benefits of MJ to be able to provide guidance for students (Neavyn et al., 2014).
SLT provides a foundation for MI to change beliefs and behavior about MJ. This is
important because few interventions target non-treatment seeking students (Elliot, Carey, &
Vanable, 2014; Stephens et al., 2007). Nurses stated “MI was very helpful and made us feel more
confident and thus able to do a better job” (Brobeck, Bergh, Odencrants, & Hildingh, 2011).
Nurses can use MI to engage MJ users to contemplate change. Opportunistic interventions are
essential because students are unlikely to ask for help (Wu, Pilowsky, Schlenger, & Hasin, 2007).
College health nurses trained in MI can encourage students to consider lifestyle changes to meet
personal ambitions (Kazemi et al., 2013; Ostlund, Wadensten, Haggstrom, & Kristofferzon,
2013).
Nurses and patients are affected by the scientific, medical, political and legal debates
surrounding MJ. MJ challenges personal and ethical beliefs (American Nurses Association,
2008; Lee et al., 2013; Nayna Philipsen, Butler, Simon-Waterman, & Artis, 2014). MJ use is a
public health concern (Stewart, 2013). Nurses must develop the knowledge, and skills to
intervene with students who use MJ in order to minimize adverse consequences. Research
suggests MI has the potential to be effective at reducing MJ use in the college health setting.
Clinical Question
Among college students 18- 26 years of age, who report MJ use during a routine student
health center visit, does a MI intervention by a nurse reduce MJ use or change perceptions about
MJ related risks 30 days post intervention?

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Nursing. SLT concepts can be applied to students changing MJ behavior, as well as, to
nurses learning and utilizing a new skill. MI by nurses involves change in the current clinic
system and nurse behavior. Maintaining the change requires motivation, skill, and self-efficacy.
Information, and education are not enough. Motivation for staff to implement, and maintain a
new behavior like MI can be come from sharing success stories, competition, mentoring
monitoring, and recognition. Nurses viewed MI as a satisfying way to help patients make
changes (Brobeck et al., 2011).
Students. SLT can guide nurses using MI to discern which factors to target to motivate
behavior change including self-efficacy and expectancies. Empathetic understanding and focus
on the student’s verbalized motivation for change can provide clarity about where to place MI
efforts (Miller & Rose, 2009). The change must be consistent with the student’s values, beliefs,
goals and expectations.
Implementation
Overview

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Winter Quarter 2016
1. Research problem and policy. See background section of this paper.
2. Consider potential solutions. See literature review section of this paper.
Spring Quarter 2016
1. Gain campus stakeholder support. The college chancellor, student affairs vice
chancellor, student judicial affairs, student health executive director, student housing, campus
police, associated student body president, and campus health and education promotion all have
an interest in a healthy student body. Campus support is necessary to implement, and sustain
change. Reducing student MJ use benefits the student, and the campus community (Caldeira et
al., 2008). Campus health and safety is placed at risk when students are under the influence.
Engaging campus support at the beginning allows stakeholder input to be incorporated through
out the project.
2. Foster a campus climate that supports MJ prevention and intervention efforts.
Collaborate with campus judicial and disciplinary officers, law enforcement, student affairs staff,
and health care staff to develop a comprehensive MJ policy that is congruent with campus goals
(Larimer & Cronce, 2002). Confirm enforcement and consequences are equitable, fair, and have
desired effect (Ammerman et al., 2015).
3. Build a PC multidisciplinary team. The team should consist of clinic manager, risk
manager, nursing supervisor, physician supervisor, medical assistant (MA) supervisor, campus
substance abuse counselor, staff nurse champion, staff physician champion, staff MA champion,
information technology advisor, student focus group (include international students and high-risk
students), health education supervisor, substance abuse health educator, pharmacist, and

21. 13 21
marketing and outreach. A multidisciplinary team can coordinate care that is efficient and
meaningful to the student (Larimer, Cronce, Lee, & Kilmer, 2004).
4. Identify project manager, and leadership team.
5. Set goals and objectives, and develop timeline.
6. Establish budget.
Summer 2016
1. Design a clinic process for intervening with a student who identifies MJ use during a
routine clinic visit. Palfai et al. found students wanted to talk about substance use in PC (2014).
Pilot Project Budget: MI and MJ Reduction
Budget PERCENTAGE OF INCOME SPENT
Item Amount
Budget $100,000.00
SUMMARY
Total Annual Income Total Annual Expenses
Project Expenses $100,000 $100,000
Item Amount
Indirects Costs $10,000.00
Supervisor RN .25 FTE $5,000.00
Health Educator $2,500.00
Administrative Asst. $1,500.00
Benefits $3,500.00
Evaluation $10,000.00
Supplies/Materials $1,000.00
Staff Education/Training $5,000.00
Educational Flyer $1,500.00
Informational Technolgy $2,000.00
Focus Group $1,500.00
Incentives $2,000.00
Miscellaneous $2,000.00
Graphic Artist .25 FTE $18,000.00
It/Web design .25 FTE $28,000.00
General Staff Training $2,000.00
100%
Balance
$0
$100,000 $100,000
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
Income Expenses

22. 13 22
Opportunistic MI is important because few students identify their MJ use as problematic
(Stephens et al., 2007). MI can create a desire to change behavior (Caldeira, 2009).
2. Obtain institutional review board approval.
3. Conduct nursing needs assessment to implement the intervention (Larimer et al., 2005).
4. Develop MJ education based on needs assessment. Provide staff with evidenced based
information that includes legality, refusal skills (Finn, 2014; Kazemi et al., 2013), side effects,
and risks and benefits of use (Nussbaum et al., 2011).
5. Develop risk reduction guidelines. Risk reduction guidelines might include: delay use
as long as possible to reduce risk of schizophrenia or addiction, avoid daily use to reduce
memory problems and learning impairment, consider a vaporizer to reduce respiratory harm,
understanding the different strains of MJ, and wait at least four hours after smoking before
driving (Fischer et al., 2012; McCambridge et al., 2008; Vancouver Costal Health, 2014).
Utilize student focus group and multidisciplinary team to provide input.
6. Develop MI training based on nursing needs assessment. MI may not have been taught
in nursing school (Brobeck et al., 2011; Ostlund et al., 2013). MI is increasingly used in
healthcare and works best with self-efficacy (Bandura, 2001). Self-efficacy is the belief that one
is capable of changing behavior to meet goals. MI engages the student to be an active participant
in behavior change. SLT theorizes the decision to use a substance is partially based on the
anticipated outcomes (Kristjansson et al., 2012). MI allows the patient to determine goals and
alter behavior to reach them. Reduction might be a reasonable goal (Turner, Spithoff, & Kahan,
2014). Thompson found MI to be more successful when carried out by nurses or counselors
(2015).

23. 13 23
7. Evaluate MI fidelity. MI is learned best through ongoing training supervision, and
feedback (Kazemi et al., 2013). Provide feedback to nurses on MI technique through post
training supervision, including recorded/transcribed practice (McCambridge et al., 2008;
Smedslund et al., 2011). Implement on-going MI evaluation.
8. Describe the MI intervention. Standardization of the intervention (including who is
performing it, for how long, how many times and when and where it happens) allows for
replication. Improved outcomes incorporate sharing of information, a positive relationship, and
promoting self-efficacy (Turner et al., 2014).
9. Create a student MJ information handout. Use a student focus group and
multidisciplinary team to evaluate handout and provide feedback (Larimer & Cronce, 2002). The
Colorado Health Department found young people want truthful information to make health
decisions (2015).
10. Develop a pre and post intervention survey to evaluate MJ behavior and perception
changes. Use student group to evaluate and provide feedback on survey. Administer an on-line
survey in clinic (pre) and through secure messaging (post). Use questions from Washington’s
Alcohol and Drug Abuse Institute Young Adult Youth Health Survey (2015) and the American
College Health Association National College Health Assessment (2013) to assess MJ attitudes
and behavior. Comparison of pre and post survey results to determine if change occurred.
11. Select implementation team and unit; appoint leader, and schedule weekly meetings
throughout fall quarter 2016. The implementation team will complete project evaluations
throughout the study, to be part of the quality improvement process.

24. 13 24
12. Create a written implementation plan and procedure. Use a flow diagram. Outline the
process from initial student disclosure of MJ use to final survey return by student. Include
obtaining informed consent, and referral resources in the process.
13. Evaluate additional staff needs assessment and incorporate into staff training.
14. Practice implementation plan using pan student focus group. Incorporate input.
15. Identify any additional required resources or expertise after reviewing flow diagram.
16. Outline monitoring and evaluation process for implementation, create feedback loops
to resolve barriers and identify support needs quickly. Learning and improving is a continuous
part of implementation.
17. Create communication links with campus stakeholders, and multidisciplinary team to
keep apprised of pilot program’s progress, maintain support, and solicit input.
Fall Quarter 2016
1. Implement pilot program. All students who self-report MJ use during a routine clinic
visit will be asked to participate in the pilot study (Caldeira, 2008; de Gee et al., 2014). After
obtaining informed consent, students will complete a pre-intervention on-line survey to establish
current MJ use perceptions and behavior. After the survey is completed students will be
randomly assigned to the experimental intervention group (MI by RN) or the control intervention
(MJ information handout given to the patient by RN). A post-intervention on-line survey will be
sent to the student by the RN 30 days after the intervention.
End of Fall Quarter 2016
1. The pre and post survey results will be compared to determine if student MJ behavior,
and risk perceptions have changed.

25. 13 25
2. Implementation team will evaluate pilot program, expected outcomes, summarize
problems with implementation, make recommendations for program continuation and
improvement, communicate progress of study, and make stakeholders aware of efforts.
Potential Barriers
1. Old habits. Nurses must make a conscious effort to use MI (Brobeck et al., 2011). MI
is challenging for nurses who give expert advice (Resnicow et al, 2002). Nurses often use closed
questions, and to tell patients what to do (Efraimsson, Fossum, Ehrenberg, Larsson, & Klang
2011).
2. Time constraints. MI requires time consuming training (Brobeck et al., 2011; Kazemi
et al., 2013;White et al., 2006).
3. Staff may resist implementation. New interventions require time and effort; staff may
be uncomfortable providing interventions or discussing MJ (Norberg et al., 2012). It will be
more successful if staff is motivated (Brobeck et al., 2011). Staff resistance is often related to
lack of skills and knowledge (Cohen, 2006).
4. Students may be unwilling to discuss MJ in the face of other health problems.
5. Students may need incentives to participate or complete study (Lee et al., 2013).
Evaluation
Evaluation of this pilot project is ongoing and incorporated into the implementation plan
(Appendix A). The project management team will meet throughout the project to ensure project
goals are being met, barriers removed, and the project moves forward. This project has many
components, which must be evaluated individually; examples include education and training
needs, MI intervention fidelity, handout appropriateness, survey reliability, and clinic flow. The
project is located in a PC clinic with many other competing needs. Ongoing evaluation during

26. 13 26
the pilot study is important to address effectiveness of the intervention in this environment. The
project will fail if staff is unable to connect students who report using MJ with the MI
intervention nurse.
The data for the expected outcomes will be collected from the on-line pre and post
interventions surveys taken by students who reported MJ use during a clinic visit. An invitation
will be sent to the student to complete the survey just prior to the intervention, and 30 days post
intervention. The data from the surveys will be collected and analyzed. The pre and post survey
results will be compared. The results will be discussed to determine if expected outcomes were
met. The findings will be reported to the implementation team, multidisciplinary team, and
stakeholders.
Expected Outcomes
College students who participate in the MI nursing intervention will report:
1. An increase in the perceived risk of MJ use by 10% from fall quarter 2016 baseline.
2. An increase in use of risks reduction strategies by 10% from fall quarter 2016 baseline.
3. A reduction in 30-day prior MJ use by 10% from fall quarter 2016 baseline.
Self-Evaluation
Members of the implementation team will complete a series of weekly self- evaluations
during implementation, which will be reviewed and discussed by the team. The feedback will be
used to make adjustments to the pilot program. On-going evaluation is important to ensure the
project is operating as planned. Questions include:
1. Is the project achieving its objective?
2. Does the staff have the skills and knowledge?
3. How efficient is process?

27. 13 27
4. What is going well?
5. What are the barriers and limitations?
6. Recommendations?
Conclusion
Experimentation with MJ increases in college. MJ is the most widely used illegal drug in
college. The controversy surrounding medical and recreational MJ makes it a confusing student
issue. Legalization of MJ supports the belief that MJ is a safe drug. Students who use MJ are at
risk for adverse consequences, and should be targeted for intervention. PC visits represent an
opportunity to intervene with students who use MJ before problems escalate. MI is a
nonjudgmental intervention that appeals to students (de Gee et al., 2014). Nurses with the MI
skills and MJ knowledge can intervene with students to promote MJ behavior change and
encourage a healthy successful transition from college to adulthood.

28. 13 28
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