Addictive Behaviors 81 (2018) 50–54

Contents lists available at ScienceDirect

Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh

Short Communication

Risky sexual behavior among cannabis users: The role of protective T

behavioral strategies
⁎
Julia D. Buckner , Elizabeth M. Lewis, Sonia M. Shah, Katherine A. Walukevich
Department of Psychology, Louisiana State University, 236 Audubon Hall, Baton Rouge, LA, 70803, USA

H I G H L I G H T S

• Cannabis users utilized condoms less often than cannabis abstainers.

• Cannabis users utilized less condom-related protective behavioral strategies (PBS).
• Cannabis use status was unrelated to normative beliefs regarding peer condom use.
• PBS mediated the relation between cannabis use status and condom use.

A R T I C L E I N F O A B S T R A C T

Keywords: Cannabis users tend to use condoms less often than cannabis abstainers, placing them at risk for sexually
Cannabis transmitted disease and unplanned pregnancies. This is especially problematic among college students, who
Marijuana experience such problems at especially high rates. Despite accumulating data indicating that cannabis users are
Condom use less likely to use condoms, little research has identified potentially malleable cognitive vulnerability factors that
Risky sexual behavior
may be related to condom use in this vulnerable population. Thus, the current study tested whether cannabis
Protective behavior strategies
users believed others use condoms less often and/or whether they engaged in less condom-related protective
behavior strategies (PBS) than cannabis abstainers and whether cannabis use status was indirectly related to
condom use via these vulnerability factors. Among 214 college students (64 past-month cannabis users), can-
nabis users engaged in less PBS (although cannabis use was unrelated to normative beliefs). Cannabis use status
was indirectly related to condom use via PBS and cannabis use status was unrelated to condom use after con-
trolling for PBS. Results highlight the importance of PBS use among cannabis users, a group at particular risk for
risky sexual behaviors.

1. Introduction
Rates of past-year college cannabis use rates rose from 31% in 2013
to 51% in 2015 (Miech, Patrick, O'Malley, & Johnston, 2017). Further,
90.8% of past-month cannabis users experience at least one cannabis-
related problem (Pearson, Liese, & Dvorak, 2017) and one-fourth of
past-month users meet DSM-IV criteria for cannabis use disorder
(Caldeira, Arria, O'Grady, Vincent, & Wish, 2008). One understudied
cannabis-related problem is engaging in risky sexual behavior (RSB),
including not using condoms (Braithwaite & Stephens, 2005; Brodbeck,
Matter, & Moggi, 2006; Kingree, Braithwaite, & Woodring, 2000).
Less condom use among cannabis-using undergraduates is con-
cerning because although overall rates of sexually transmitted diseases
(STDs), including human immunodeficiency virus (HIV), have de-
creased, rates in the young adult population are growing (Center for
Disease Control and Prevention, 2014). Individuals aged 20–24 are at a
higher risk for contracting STDs than other age groups and this group
accounts for the largest proportion of new STD cases each year, with
rates continuing to increase (Center for Disease Control and Prevention,
2014). In fact, nearly half of all new infections occur among individuals
aged 15 to 24 (American Sexual Health Association, 2013; Center for
Disease Control and Prevention, 2014), with the greatest rates of STDs
contracted among individuals aged 19–24 (Crosby, DiClemente,
Wingood, Lang, & Harrington, 2003). RSB among college students puts
them at risk for negative outcomes (e.g., transmitting or receiving an
STD, poor academic performance, physical health consequences
(Cooper, 2002).

⁎
Corresponding author.
E-mail address: jbuckner@lsu.edu (J.D. Buckner).

https://doi.org/10.1016/j.addbeh.2018.01.039
Received 6 December 2017; Received in revised form 29 January 2018; Accepted 30 January 2018
Available online 01 February 2018
0306-4603/ © 2018 Elsevier Ltd. All rights reserved.
J.D. Buckner et al.
1.1. Normative beliefs and RSB among college students
College students underestimate their peers' engagement in protec-
tive sexual behaviors (e.g., use of condoms) and overestimate their
peers' RSB (e.g., frequency of “casual sex,” number of alcoholic drinks
prior to intercourse (Bon, Hittner, & Lawandales, 2001; Hines, Saris, &
Throckmorton-Belzer, 2002; Scholly, Katz, Gascoigne, & Holck, 2005;
Seal & Agostinelli, 1996). Misperceptions of peer RSB are problematic
because perceived norms are positively associated with one's own
sexual behavior (Lewis, Lee, Patrick, & Fossos, 2007). Normative beliefs
regarding RSB (including condom use) are theorized to be associated
with safer sex behaviors including condom use (Catania, Kegeles, &
Coates, 1990). Yet, no known work has investigated the relation be-
tween cannabis use and normative beliefs.
1.2. Protective behavior strategies
Condom-related protective behavior strategies (PBS) are behaviors
geared toward increasing condom-use during sex (Bryan, Fisher, &
Fisher, 2002). These strategies include keeping condoms handy, telling
partners you want to use a condom, and having a mental plan to use
condoms (Bryan et al., 2002; Lewis, Kaysen, Rees, & Woods, 2010). PBS
use is associated with condom use in high school and college samples
(Abraham, Sheeran, Norman, Conner, & Vries Nd, 1999; Bryan et al.,
2002; Lewis, Kaysen, et al., 2010; Zimmerman, Noar, Feist-Price, et al.,
2007), including heavy-drinking undergraduates (Gilmore, Granato, &
Lewis, 2013), a population that has less condom use (Kiene, Barta,
Tennen, & Armeli, 2009; LaBrie, Earleywine, Schiffman, Pedersen, &
Marriot, 2005; Lewis, Rees, Logan, Kaysen, & Kilmer, 2010). However,
no known work has investigated the relation between cannabis and PBS
use.
1.3. The current study
This study sought to further understanding of cannabis's relation to
condom use among undergraduates, given that cannabis-using under-
graduates are especially vulnerable to RSB. First, we sought to replicate
prior work (Braithwaite & Stephens, 2005; Brodbeck et al., 2006;
Kingree et al., 2000) that current cannabis users would report using
condoms less often than cannabis abstainers. Second, we sought to
extend this work by identifying mechanisms underlying the cannabis-
condom relation. Specifically, we tested whether cannabis users would
endorse lower normative beliefs regarding peer condom use and use
fewer PBS. We then tested whether norms and PBS would account for
the relation between cannabis use status and condom use.
2. Method
2.1. Participants and procedures
Participants were recruited through the university's psychology
department participant pool January–October 2017 and received re-
search credit for study completion. Recruitment materials indicated
that eligibility included being sexually active in the past month.
Inclusion criteria included being: 18 years and older, sexually active
within the last 30 days, not pregnant, and free of current STD (given
that pregnancy and STD status could impact condom use). Sexually
active was defined per the Timeline Followback for Sexual Behavior
and Substance use (TLFB-SS) (Weinhardt et al., 1998) as engaging in
anal (“when a man puts his penis inside another person's rectum or
buttocks”) or vaginal (“when a man puts his penis inside a woman's
vagina”) intercourse. Of the 270 students who completed the survey, 48
students did not meet inclusion criteria: younger than 18 (n = 2), de-
nied past-month intercourse (n = 30), and current STD (n = 16). Item
responses > 3.29 standard deviations above respective means
(Tabachnick & Fidell, 2007) were considered outliers and excluded
51
Addictive Behaviors 81 (2018) 50–54
from analyses (n = 8).
The final sample (N = 214; 81.3% female) reported a mean age of
19.96 (SD = 1.62) years and class standings were as follows: first year
(24.8%), second year (22.9%), junior (24.3%), senior (26.6%), and
other (1.4%). The racial/ethnic composition was 19.2% non-Hispanic
African American/Black, 1.4% Hispanic African American/Black,
65.4% non-Hispanic Caucasian/White, 4.7% Hispanic Caucasian/
White, 5.1% Asian/Asian American, 0.5% American Indian, and 3.7%
“other.” Nearly 30% (n = 64) endorsed past-month cannabis use.
The university's Institutional Review Board approved the study and
participants provided informed consent prior to data collection. The
consent form explained that participants' names would not be linked to
their responses and that a certificate of confidentiality was obtained
from the National Institute of Mental Health to further protect con-
fidentiality. Participants completed computerized self-report measures
remotely using a secure, on-line data collection website (qualtrics.com).
2.2. Measures
2.2.1. Screening questions
Participants were asked whether they were pregnant (i.e., Yes/No)
and whether they ever been diagnosed with the STD (e.g., genital
herpes, chlamydia, gonorrhea) in the past and if they currently have the
STD via questions were adapted from the Known STI Exposure ques-
tionnaire used at the university's student health center (B. Prudhomme,
personal communication, May 26, 2016).
2.2.2. Condom use
Participants completed a modified version of the TLFB (Sobell,
Brown, Leo, & Sobell, 1996) to assess condom use. Participants were
shown a calendar for the past 30 days. For each day, participants en-
tered: the number of times they had vaginal/anal intercourse and how
many times they used a condom. Modified versions of the TLFB have
been shown to be feasible, reliable, and valid when used to assess for
sexual behaviors among psychiatric outpatients (Carey, Carey, Maisto,
Gordon, & Weinhardt, 2001). The TLFB has been administered online to
assess condom use (Starosta, Cranston, & Earleywine, 2016). Use of
count data is more indicative of risk behaviors and is more precise than
measures of relative frequencies (e.g., rating behaviors on a scale of
“always” to “never” (Schroder, Carey, & Vanable, 2003). Percent of
times condoms were used was calculated ([# times used condom/#
times engaged in sex] × 100) and number of times participants en-
gaged in sex without a condom (i.e., unprotected sex) was calculated by
subtracting the number of times participants used a condom from the
number of times they had sex.
2.2.3. Normative perceptions
Participants were asked to estimate how often the typical LSU stu-
dent had intercourse in the past 30 days and how many times the ty-
pical LSU student used condoms within the past 30 days (adapted from
Lewis et al. (2007)).
2.2.4. Protective behavioral strategies
Participants completed the Condom-Related Protective Behavioral
Strategies Scale (Lewis, Logan, & Neighbors, 2009), a six-item measure
of PBS (e.g., “how much did you engage in talking about condom use
with a partner prior to sex”, “how much did you engage in carrying a
condom and keeping it handy”). Response options ranged from 0
(never) to 6 (always). This measure has demonstrated good internal
consistency in prior work (Lewis, Kaysen, et al., 2010) and in the cur-
rent sample (α = 0.90).
2.2.5. Infrequency scale
Four questions from the Infrequency Scale IS (Chapman & Chapman,
1983); were used to identify random/invalid responders. As in prior
online studies (Cohen, Iglesias, & Minor, 2009), those who endorsed
J.D. Buckner et al. Addictive Behaviors 81 (2018) 50–54

Normative
a1 beliefs b1
Cannabis Condom
use status use
Protective
a2 b2
behavior
strategies
Fig. 1. Conceptual path model for the effect of cannabis use status on condom use via
normative beliefs and protective behavior strategies.
three or more items were excluded from analyses (n = 0).
2.3. Data analytic strategy
Condom use was examined in two ways: percentage of times con-
doms were used (to control for frequency of sexual activity) and
number of times engaging in sex without a condom (to assess frequency
of this RSB). First, relations between predictor (cannabis use status) and
proposed mediators (norms, PBS) and criterion variable (% condom
use, number of times engaged in unprotected sex) were examined.
Second, two models (separate model for each condom use criterion
variable) tested the impact of norms and PBS as mediators of the re-
lation between predictor and criterions (conceptual path model pre-
sented in Fig. 1). Although mediational models are ideally tested using
prospective data, cross-sectional tests of putative indirect effects is an
important first step (Hayes, 2013). These analyses were conducted
using PROCESS, a conditional process modeling program that utilizes
an ordinary least squares-based path analytical framework to test for
both direct and indirect effects.(Hayes, 2013) All specific and condi-
tional indirect effects were subjected to follow-up bootstrap analyses
with 10,000 resamples from which a 95% confidence interval (CI) was
estimated.(Hayes, 2009; Preacher & Hayes, 2004, 2008)
3. Results
The two groups did not differ on demographic variables, heavy
drinking, or norms (Table 1). Cannabis users reported less condom use,
more sex without a condom, and fewer PBS. Heavy drinking was un-
related to condom use, r = −0.10, p = 0.171, and PBS, r = 0.05,
p = 0.516.
3.1. Mediational analyses
The total effects model accounted for significant variance in %
condom use (R2 = 0.023, df = 1, 209, F = 4.88, p = 0.0283). The full
model with norms and PBS predicted significant variance in % condom
use (R2 = 0.444, df = 3, 207, F = 55.17, p < 0.0001), and there was
no longer a significant direct effect of cannabis use on % condom use
after controlling for norms and PBS (b = −3.47, SE = 5.13,
p = 0.4986). Cannabis use was indirectly related to condom use
through PBS, b = −11.25, SE = 4.40, 95% CI [−20.12, −2.87], but
not norms, b = 0.02, SE = 0.61, 95% CI [−1.17, 1.48]. The difference
between these two indirect effects was significant, b = −11.27,
SE = 4.38, 95% CI [−20.11, −3.08].
The total effects model accounted for significant variance in number
of times participants engaged in unprotected sex (R2 = 0.020, df = 1,
209, F = 4.31, p = 0.0392). The full model with norms and PBS pre-
dicted significant variance in unprotected sex (R2 = 0.247, df = 3, 207,
F = 22.68, p < 0.0001), and there was no longer a significant direct
effect of cannabis use on unprotected sex after controlling for norms
and PBS (b = 0.87, SE = 90, p = 0.3341). Cannabis use was indirectly
related to unprotected sex through PBS, b = 1.22, SE = 0.50, 95% CI
[0.34, 2.29], but not norms, b = −0.00, SE = 0.12, 95% CI [−0.30,
0.22]. The difference between these two indirect effects was significant,
b = 1.23, SE = 0.50, 95% CI [0.33, 2.30].
4. Discussion
With college students engaging in increased risky behaviors, such as
cannabis use and unprotected sex, it is critical to identify factors as-
sociated with these behaviors. Consistent with prior research
(Braithwaite & Stephens, 2005; Brodbeck et al., 2006; Kingree et al.,
2000), results from the current study support that cannabis users re-
ported less condom use during sexual intercourse than cannabis ab-
stainers. The present study extended this work by serving as one of the
first known tests of mechanisms underlying the cannabis-condom re-
lationship. Our findings indicated that cannabis users did not have
lower normative beliefs regarding peer condom use. Cannabis users
engaged in less condom-related PBS, which is consistent with prior
work finding college student drinkers use fewer condom-related PBS
(Gilmore et al., 2013).
Furthermore, cannabis use was related to condom use indirectly via
PBS and the relationship between cannabis and condom use was no
longer significant after controlling for PBS. These data serve as an in-
itial test of mediation, suggesting that PBS may play an important role
in condom use among cannabis users. Although future, prospective
work will be an important next step in testing this potential causal
pathway, our data suggest that PBS might be useful to target in inter-
ventions to increasing condom use among cannabis users.
The finding that cannabis users did not underestimate other's
condom use is surprising given that cannabis users tend to misperceive
peers' engagement in other risky health behaviors (e.g., cannabis use
(Buckner, 2013; Buckner, Walukevich, & Henslee, in press)). This
finding suggests that cannabis users do not simply assume others

Table 1
Descriptive data by cannabis use status.

Variable Cannabis abstainer (n = 147) Cannabis user (n = 64)

M or % SD M or % SD F or χ2 p d or Cramer's V

Race (% Caucasian) 36.73 29.68 0.979 0.323 0.068

Gender (% Female) 81.63 81.25 0.004 0.948 0.005
Age 20.31 2.92 20.19 1.56 0.105 0.747 0.047
Class standing 1.55 1.17 1.66 1.26 0.345 0.557 0.092
Heavy drinking 5.63 3.73 6.48 4.48 1.888 0.171 0.214
# times engaged in sex 8.03 6.50 9.83 7.53 3.10 0.080 0.018
# time engaged in sex without a condom 4.47 6.47 6.56 7.32 4.31 0.039 0.311
% past month condom use 55.12 44.85 40.42 43.47 4.878 0.028 0.331
Normative beliefs 58.37 26.28 58.55 25.51 0.002 0.964 0.007
Protective behavior strategies 14.29 11.05 10.02 10.47 6.872 0.009 0.393

52
J.D. Buckner et al.
behave as they themselves do in all domains but rather that mis-
perception of others' risky behaviors may be specific to cannabis use.
Alternatively, it may be that our measure of normative beliefs regarding
typical same-university students' condom use did not assess salient
normative beliefs. Normative beliefs concerning more salient groups
(e.g., family, friends) tend to be more strongly related to cannabis use
than beliefs concerning more distal groups (e.g., students in general
(Buckner, 2013)) and testing the impact of such beliefs will be an im-
portant next step.
The present study has several limitations. First, the study was lim-
ited to a cross sectional design. Given that factors such as impulsivity
(Caspi, Begg, Dickson, et al., 1995; Kahn, Kaplowitz, Goodman, &
Emans, 2002; Vangsness, Bry, & LaBouvie, 2005) and sensation-seeking
(Deckman & DeWall, 2011; Kalichman, Heckman, & Kelly, 1996;
Martin, Kelly, Rayens, et al., 2002; Zuckerman, 1994) are related to
both cannabis and condom use, prospective work that delineates tem-
poral sequencing of the relations between cannabis and condom use
that includes tests of the impact of these potentially important “third
variables” will be an important step in testing causal relationships
(Garber & Hollon, 1991). Second, future work could benefit from multi-
method (e.g., biological verification of cannabis use, ecological mo-
mentary assessment of condom use), multi-informant (e.g., collateral
reports of condom use) approaches. Third, participants were primarily
female and replication with more men will be important. Fourth, data
were collected in a state in which recreational cannabis use remains
illegal and future work is necessary to test whether results generalize to
cannabis users in states in which cannabis has been legalized at the
state level. Fifth, although participants were assured of confidentiality
in the consent form, future work could benefit from inclusion of a
measure of impression management.
Despite these, the current study provides novel data on the re-
lationship between cannabis and condom use. Findings indicate that
cannabis users are vulnerable to using fewer PBS, which may play an
important role in their RSB. Given the high rates of STD combined with
high rates of cannabis use among college students, identification of a
potentially malleable cognitive vulnerability factor (in this case, PBS)
can inform prevention and intervention efforts.
Role of funding source
This study received no funding.
Contributors
Dr. Buckner and Ms. Shah designed the study and wrote the pro-
tocol. Dr. Buckner conducted the statistical analyses. All authors con-
tributed to writing the manuscript and approved the final manuscript.
Conflict of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this paper.
Acknowledgements
Data were collected as a component of a Doctoral Dissertation by
Sonia M. Shah.
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