Experimental and Clinical

Psychopharmacology
Insomnia Symptoms, Cannabis Protective Behavioral
Strategies, and Hazardous Cannabis Use Among U.S.
College Students
Maria M. Wong, Elizabeth A. Craun, Adrian J. Bravo, Matthew R. Pearson, and The Protective
Strategies Study Team
Online First Publication, March 25, 2019. http://dx.doi.org/10.1037/pha0000273

CITATION
Wong, M. M., Craun, E. A., Bravo, A. J., Pearson, M. R., & The Protective Strategies Study Team
(2019, March 25). Insomnia Symptoms, Cannabis Protective Behavioral Strategies, and Hazardous
Cannabis Use Among U.S. College Students. Experimental and Clinical Psychopharmacology.
Advance online publication. http://dx.doi.org/10.1037/pha0000273
 Experimental and Clinical Psychopharmacology
© 2019 American Psychological Association 2019, Vol. 1, No. 999, 000
1064-1297/19/$12.00 http://dx.doi.org/10.1037/pha0000273

Insomnia Symptoms, Cannabis Protective Behavioral Strategies, and

Hazardous Cannabis Use Among U.S. College Students

Maria M. Wong and Elizabeth A. Craun Adrian J. Bravo and Matthew R. Pearson
Idaho State University University of New Mexico

The Protective Strategies Study Team

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Previous research has reported that sleep problems longitudinally predict both onset of cannabis use and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

cannabis-related problems. However, the mediators of this relationship remain unclear. The present study
examined (a) the concurrent relationship between insomnia symptoms and hazardous cannabis use and
(b) examined whether use of protective behavioral strategies (PBS) for cannabis mediated this relation-
ship among college student cannabis users. Participants were 984 (69.9% female) college students who
reported consuming cannabis at least once in the past month and completed measures of insomnia,
cannabis PBS, and cannabis misuse. Data were analyzed by structural equation modeling for binary and
count outcomes. The significance of the mediator was evaluated using bias-corrected bootstrap confi-
dence intervals. Insomnia symptoms were associated with an increase in the odds of hazardous cannabis
use and possible cannabis use disorder. Cannabis PBS significantly mediated the relationship between
insomnia symptoms and hazardous cannabis use, cannabis use disorder symptoms, and cannabis-related
problems. Specifically, higher reports of insomnia symptoms were associated with lower use of cannabis
PBS; which in turn was associated with an increase in the odds of hazardous cannabis use and possible
cannabis use disorder, as well as a higher report of cannabis-related problems. Implications of these
findings on the prevention of cannabis use problems among college students in the United States were
discussed.

Public Health Significance

This study showed that insomnia symptoms were associated with an increase in the odds of
hazardous cannabis use among college students from 10 different U.S. campuses. Use of cannabis
protective behavioral strategies partially explained this relationship. Prevention and intervention
programs could educate college students about the benefits of regular and sufficient sleep, as well as
its relationship with cannabis protective behavioral strategies and cannabis use.

Keywords: sleep, cannabis protective behavioral strategies, hazardous cannabis use, cannabis-related
consequences, college students

According to the World Health Organization, cannabis (i.e., the most widely used illicit substance among college students in
marijuana) is the most cultivated, trafficked, and misused illicit the United States (Schulenberg et al., 2018). Prevalence of use was
drug worldwide (World Health Organization, 2018). Cannabis is estimated to be 38% in the past year and 21% in the past 30 days.

Maria M. Wong and Elizabeth A. Craun, Department of Psychology,
Idaho State University; Adrian J. Bravo and Matthew R. Pearson, Center
on Alcoholism, Substance Abuse, and Addictions, University of New
Mexico; The Protective Strategies Study Team.
This project was completed by the Protective Strategies Study Team
(PSST), which includes the following investigators: Matthew R. Pearson,
University of New Mexico (Coordinating PI); Adrian J. Bravo, University
of New Mexico (Co-PI); Mark A. Prince, Colorado State University (site
PI); Michael B. Madson, University of Southern Mississippi (site PI);
James M. Henson, Old Dominion University (site PI); Alison Looby,
University of Wyoming (site PI); Vivian M. Gonzalez, University of
Alaska-Anchorage (site PI); Amber M. Henslee, Missouri University of
Science & Technology (site PI); Carrie Cuttler, Washington State Univer-
sity (site PI); Maria M. Wong, Idaho State University (site PI); Dennis E.
McChargue, University of Nebraska-Lincoln (site PI).
Maria M. Wong is supported by a research grant from the National
Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National
Institute of General Medical Sciences (R01 AA020365) in the United
States. Adrian J. Bravo is supported by a training grant (T32 AA018108)
from the NIAAA. Matthew R. Pearson is supported by a career develop-
ment grant (K01 AA023233) from the NIAAA.
Correspondence concerning this article should be addressed to Maria M.
Wong, Department of Psychology, Idaho State University, 921 South 8th
Avenue, Pocatello, ID 83209. E-mail: wongmari@isu.edu

1
 2 WONG, CRAUN, BRAVO, AND PEARSON
Since 2010, there has been steady increases in cannabis use in
college students and young adults. Publicity on the legalization of
cannabis for medical and recreational use in some states may have
contributed to this trend (Schulenberg et al., 2018).
The therapeutic effects of cannabis on pain and physical func-
tioning (e.g., nausea and vomiting in cancer patients) has been
demonstrated (Aviram & Samuelly-Leichtag, 2017; Nugent et al.,
2017; Sharkey, Darmani, & Parker, 2014; Turgeman & Bar-Sela,
2018). Adverse health and psychosocial consequences of acute
(e.g., anxiety, panic reactions, paranoia, temporary cognitive im-
pairment) and chronic cannabis use (e.g., psychotic symptoms, risk
of cardiovascular disease, cognitive impairment, early school-
leaving) have also been documented (Hall, 2015). Identifying risk
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factors and mediators that may explain the relationship between
This document is copyrighted by the American Psychological Association or one of its allied publishers.
risk factors and problematic cannabis use will lead to a better
understanding of its etiology and inform prevention and interven-
tion efforts. The main purpose of this study was to examine (a) the
relationship between insomnia symptoms (e.g., difficulties falling
and staying asleep) and hazardous cannabis use and (b) whether
use of cannabis protective behavioral strategies mediated this
relationship.
Sleep difficulties1 have been associated with onset of substance
use as well as substance-related problems in both cross-sectional
(Fakier & Wild, 2011; Johnson & Breslau, 2001; McKnight-Eily et
al., 2011; Sivertsen, Skogen, Jakobsen, & Hysing, 2015) and
longitudinal studies (Hasler et al., 2017; Miller, Janssen, & Jack-
son, 2017; Wong, Robertson, & Dyson, 2015). However, most
research has examined alcohol use or substance use in general (i.e.,
includes cannabis use but not restricted to cannabis use). We
briefly review cross-sectional and longitudinal studies that exam-
ine cannabis-related outcomes separately (i.e., not combined with
other substance use).
Cross-sectional data of community samples have shown a pos-
itive relationship between sleep difficulties and cannabis use. A
study of 703 9th and 11th graders in South Africa reported an
association between sleep problems (trouble falling or staying
asleep, morning tiredness and daytime sleepiness) and an increased
likelihood of use of alcohol, tobacco, cannabis, methamphetamine
and other illegal drugs (Fakier & Wild, 2011). Data from the U.S.
National Household Survey on Drug Abuse (N ⫽ 13,381, aged
12–17 years) indicated that adolescents (aged 12–17 years) who
reported having trouble sleeping in the survey were more likely
than those without such problems to use alcohol, cigarettes, and
other illicit drugs, including cannabis (Johnson & Breslau, 2001).
In another nationally representative sample of U.S. high school
students, the Youth and Health Risk Behavior Survey in 2007
(N ⫽ 12,154), insufficient sleep was associated with higher prob-
abilities of alcohol, cigarette, and cannabis use in the last 30 days
(McKnight-Eily et al., 2011). It is useful to note that insufficient
sleep is not necessarily an outcome of sleep difficulties; factors
such as poor sleep hygiene and increasing academic and psycho-
social demands may also lead to insufficient sleep.
Findings from longitudinal research generally support these
cross-sectional findings. Controlling for parental alcoholism,
childhood sleep problems measured by maternal ratings at ages
3–5 predicted onset of any use of alcohol, nicotine, cannabis and
other illicit drugs by ages 12–14 in a sample of boys (N ⫽ 258;
Wong, Brower, Fitzgerald, & Zucker, 2004). In a mixed-sex sam-
ple (N ⫽ 386), sleep problems predicted onset of cannabis use for
boys, but not for girls (Wong, Brower, & Zucker, 2009), suggest-
ing that these effects may be gender-specific.2 However, other
studies that simply control for sex have found the sleep problems
prospectively predict cannabis use among adolescents in general
(LeBourgeois, Giannotti, Cortesi, Wolfson, & Harsh, 2005; Miller
et al., 2017). Conversely, higher levels of weekday and total sleep
among adolescents have been shown to predict a lower likelihood
of cannabis use 2 years later (N ⫽ 704; Pasch, Latimer, Cance,
Moe, & Lytle, 2012).
Taken together, prior research supports that sleep difficulties are
associated with substance use in general and cannabis use in
particular. However, most studies have not examined cannabis use
separately, rather have focused on substance use more generally.
Thus, it is unclear whether insomnia symptoms are uniquely as-
sociated with cannabis use. Moreover, rather than examining any
level of cannabis use, we focus on using cannabis at thresholds
associated with “hazardous” use, possible cannabis use disorder,
and negative cannabis-related problems (Adamson et al., 2010),
which tend to have more serious consequences. Furthermore,
research on mediators and moderators of sleep-cannabis use rela-
tionship is still lacking.
Stemming from a harm reduction perspective, protective behav-
ioral strategies (PBS) are behaviors that are used immediately prior
to, during, after, and/or instead of substance use that reduce con-
sumption, intoxication, and/or substance-related harm (Pearson,
2013). Specific to cannabis, cannabis PBS (assessed via the Pro-
tective Behavioral Strategies for Marijuana Scale, Pedersen, Hum-
mer, Rinker, Traylor, & Neighbors, 2016; Pedersen, Huang,
Dvorak, Prince, & Hummer, 2017) include strategies that are
related to limiting cannabis intake by setting consumption limits
(e.g., “Having a set amount of times you take a hit of a marijuana
joint”), avoiding behaviors that lead to more intoxication than one
would like (e.g., “Avoiding mixing marijuana with other drugs”),
and avoiding serious harm from impaired driving (e.g., “Using a
designated driver after using marijuana”). Increasing evidence
suggests that cannabis PBS use is a robust protective factor asso-
ciated with lower cannabis use and consequences (Bravo, Anthe-
nien, Prince, Pearson & Marijuana Outcomes Study Team, 2017;
Pedersen, Huang, Dvorak, Prince, & Hummer, 2017; Pedersen et
al., 2016). Cannabis PBS has been shown to mediate the effects of
known risk factors on cannabis outcomes including effects of
gender, impulsivity-like traits, and specific cannabis use motives
(Bravo, Prince, Pearson, & Marijuana Outcomes Study Team,
2017).
Previous research indicate that sleep difficulties and deficits
have deleterious effects on inhibitory processes as well as cogni-
tive control (Durmer & Dinges, 2005; Pilcher & Huffcutt, 1996;
Wong, Brower, Nigg, & Zucker, 2010). The use of cannabis PBS
plausibly requires inhibition of the impulses to consume cannabis
as well as the ability to focus on safe use while dealing with
distracting information (e.g., withstand friends’ encouragement to
1
Sleep problems or difficulties refer to problems such as insomnia or
insomnia symptoms, nightmares and overtiredness. As we did not include
any studies on sleep apnea, the terms did not include sleep apnea.
2
We used the term gender to refer to the social categories of female and
male (e.g., certain behaviors may be influenced by social and cultural
factors; Tobach, 2004; Unger, 2007). We used the term sex to refer to the
biological status of being female or male.
 INSOMNIA, PROTECTIVE BEHAVIORS, CANNABIS USE
use more cannabis than planned). Taken together, sleep difficulties
may be associated with problematic cannabis use via a reduction in
the use of cannabis PBS.
Purpose of Present Study
The purpose of the present study is to examine the concurrent
associations between insomnia symptoms, cannabis PBS, and
problematic cannabis use among college students. Specifically, the
present study used cross-sectional data to examine the hypotheses
that insomnia symptoms lowered one’s tendency to engage in
cannabis PBS and lower PBS use was associated with an increase
in the likelihood of hazardous cannabis use, possible cannabis use
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disorder, and more cannabis-related problems. Given mixed find-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ings regarding whether the sleep– cannabis associations are con-
sistent across the two sexes, exploratory analyses examined sex as
a moderator in our models.
Method
Participants and Procedure
Participants were college students (n ⫽ 7,307) recruited to
complete an online cross-sectional survey via Psychology Depart-
ment Participant Pools at 10 universities across 10 U.S. states (for
more information, see (Bravo, Villarosa-Hurlocker, Pearson, &
Protective Strategies Study Team, 2018). To minimize burden on
participants, we used a planned missingness design, or matrix
sampling (Graham, Taylor, Olchowski, & Cumsille, 2006; Scha-
fer, 1997). To test our study aims, we limited the analytic sample
for the present study to 984 students who reported consuming
cannabis at least once in the last 30 days, completed measures of
insomnia symptoms and cannabis PBS. Among our analytic sam-
ple, the majority of participants identified as being either White,
non-Hispanic (n ⫽ 740; 75.2%) or of Hispanic/Latino ethnicity
(n ⫽ 186; 16.8%), female (n ⫽ 688; 69.9%), and reported a mean
age of 20.21 (median ⫽ 19.00; SD ⫽ 3.14) years. Participants
received research participation credit for completing the study.
This protocol was approved by institutional review boards at each
participating university. Specifically, at the primary author’s insti-
tution, the protocol was approved by the Idaho State University
Human Subjects Committee (Protocol: IRB-FY2017-206 and Ti-
tle: Protective Strategies Study Team).
Measures
Insomnia symptoms. Past 2-week insomnia symptoms were
assessed using the seven-item Insomnia Severity Index (ISI;
Bastien, Vallières, & Morin, 2001) measured on a 5-point response
scale ranging from 0 (not at all) to 4 (extremely). The seven items
assess severity of difficulties falling asleep, staying asleep, sleep
quality, and its impact on daily functioning. We summed items to
create a total score of insomnia (M ⫽ 8.17; SD ⫽ 5.80; ␣ ⫽ .87).
Cannabis PBS. Past month cannabis PBS use was assessed
using the 17-item version (Pedersen et al., 2017) of the Protective
Behavioral Strategies-Marijuana Scale (Pedersen et al., 2016). The
items were measured on a 6-point response scale ranging from 1
(never) to 6 (always). Example items include, “Avoid mixing
marijuana with other drugs” and “Only use one time during a
3
day/night”. We averaged items to create a total score of cannabis
PBS use (M ⫽ 4.35; SD ⫽ 1.12; ␣ ⫽ .91).
Problematic cannabis use. Problematic cannabis use was
assessed using the 8-item Cannabis Use Disorders Identification
Test—Revised (CUDIT-R; Adamson et al., 2010). The CUDIT-R
assesses the domains of consumption, cannabis problems (abuse),
dependence, and psychological features. Cut-off scores of 8
(CUDIT-R scores ⱖ8) and 12 (CUDIT-R scores ⱖ13) were used
to indicate hazardous cannabis use and possible cannabis use
disorder, respectively (Adamson et al., 2010).
Cannabis-related problems. Cannabis-related consequences
were measured by a 21-item Brief Marijuana Consequences Ques-
tionnaire (B-MACQ; Simons, Dvorak, Merrill, & Read, 2012).
The B-MACQ measures eight domains of cannabis consequences
in the past month (0 ⫽ no, 1 ⫽ yes), including interpersonal
consequences, negative self-perception, impaired control, risk be-
haviors, self-care, academic/occupational consequences, physical
dependence and blackout use. A composite score of cannabis-
related problems was calculated by summing up responses on the
items (␣ ⫽ .88). One item assessing difficulty with sleeping after
cutting down cannabis use was omitted so that cannabis-related
consequences do not overlap with insomnia symptoms measured
by the ISI. The test–retest reliability, as well as the convergent and
discriminant validity of MACQ has been demonstrated in previous
research (Simons et al., 2012).
Analytic Strategy
We used structural equation modeling (SEM) to examine whether
insomnia symptoms and cannabis PBS predicted cannabis-related
outcomes. Three outcome variables of cannabis use were exam-
ined, hazardous cannabis use, possible cannabis use disorder, and
cannabis-related consequences. Hazardous cannabis use and pos-
sible cannabis use disorder were modeled as binary variables.
Model fit was evaluated by the ␹2 goodness-of-fit test and three fit
indices— comparative fit index (CFI; Bentler, 1990), Tucker
Lewis Index (TLI; Tucker & Lewis, 1973), and root mean square
of approximation (RMSEA; Steiger & Lind, 1980). The ␹2 statistic
evaluates the difference between the data and the fitted covariance
matrices, that is, the hypothetical model (Bentler & Bonett, 1980).
An insignificant value indicates a good fit. However, the ␹2 test
becomes overly sensitive to small differences between the data and
the hypothetical model when sample size increases (Bentler, 1990;
West, Taylor, & Wu, 2012). Therefore, other indices are also used
to evaluate model fit. A value of 0.9 or above on fit indices such
as the CFI and TLI indicates a good fit, whereas a value of 0.95
above indicates an excellent fit (Hu & Bentler, 1999). Values of
0.06 or below on the RMSEA indicate a satisfactory fit (Hu &
Bentler, 1999).
Cannabis-related consequences were modeled as a count outcome,
as the responses were positive integers. We fitted models with a
Poisson distribution, a negative binomial distribution, and zero-
inflated versions of these models. The Pearson ␹2, a goodness-of-fit
index for count outcomes, was used to evaluate overall model fit
(Cameron & Trivedi, 2013; Long, 1997). It measures the discrepancy
between the observed counts and the model predicted counts. A
nonsignificant ␹2 indicates a good fit.
We used bias-corrected bootstrapped estimates (Efron & Tib-
shirani, 1993) to examine whether cannabis PBS mediated the
 4 WONG, CRAUN, BRAVO, AND PEARSON
relationship between insomnia symptoms and cannabis-related
outcomes. These estimates are robust to deviations from normality
of the indirect effects (Erceg-Hurn & Mirosevich, 2008; Hayes &
Scharkow, 2013). A bias-corrected bootstrapped confidence inter-
val based on 10,000 bootstrap samples was created for each
cannabis use outcome. We chose 10,000 bootstrap samples as
recommended in recent resampling literature to improve Monte
Carlo accuracy (Chihara & Hesterberg, 2019). The mediator was
significant if the 95% bootstrapped confidence interval does not
include zero.
The three outcomes investigated in this article were either
binary or count data. To interpret the estimated coefficients for
binary or count outcomes, it is standard practice to exponentiate
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the coefficient. If an explanatory variable has coefficient ␤, then e␤
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is the odds ratio (OR) for a binary outcome (Hosmer, Lemeshow,
& Sturdivant, 2013) or the count ratio, also called incidence rate
ratio (IRR), for a count outcome (Hilbe, 2011). Therefore, when
the explanatory variable is increased by 1 SD, the odds (for binary
outcome) or counts (for count outcome) is expected to change by
(e␤⫻SD ⫺ 1) ⫻ 100%. In particular, if the path from insomnia
symptoms to PBS is a and the path from PBS to cannabis use
outcome controlling for insomnia symptoms is b, the indirect
effect of insomnia on cannabis use outcome in terms of percentage
change is (eab⫻SD ⫺ 1) ⫻ 100% when insomnia symptoms in-
crease by one SD (MacKinnon, 2008). Given the planned miss-
ingness design, missing data were handled by full information
maximum likelihood estimates, which used all available data and
produces unbiased estimates of coefficient parameters if data are
missing completely at random (Enders, 2010; Graham, 2009). All
analyses controlled for three demographic variables that have been
shown to associate with substance use, that is, sex (0 ⫽ male, 1 ⫽
female), age, and race (White: 0 ⫽ no; 1 ⫽ yes). We also
conducted exploratory analyses examining sex as a moderator in
our models. SEM models were estimated using Mplus 7.4 (Muthén
& Muthén, 1998 –2018).
Results
Descriptive statistics and bivariate correlations of major vari-
ables are presented in Table 1. Among participants who consumed
cannabis in the past 30 days, completed measures of insomnia
symptoms and cannabis PBS, 43% reported hazardous cannabis
use (score ⱖ8 on CUDIT-R) and 21% exceeded the cut-off for
possible cannabis use disorder (score ⱖ13 on CUDIT-R). On the
average, these participants reported slightly more than 3 (M ⫽
Table 1
Zero-Order Correlations and Descriptive Statistics Among All Study Variables
Variable 1 2
1. Insomnia — 8.17
2. Protective behavioral strategies ⫺.07ⴱ — 4.35
3. Hazardous cannabis use .02 ⫺.36ⴱⴱ
4. Cannabis use disorder symptoms .07 ⫺.34ⴱⴱ
5. Marijuana consequences questionnaire .14ⴱⴱ ⫺.28ⴱⴱ
6. Gender (0 ⫽ men, 1 ⫽ women) .09ⴱⴱ .14ⴱⴱ
7. Race (0 ⫽ non-White, 1 ⫽ White) .03 ⫺.06
8. Age .09ⴱⴱ ⫺.06
ⴱ ⴱⴱ
p ⬍ .05. p ⬍ .01.
3.35, SD ⫽ 4.00) cannabis-related consequences/problems in the
previous month.
Controlling for sex, age, and race, insomnia symptoms was
associated with an increase in the odds of hazardous cannabis use
(odds ratio [OR] ⫽ 1.02, p ⫽ .05) and cannabis use disorder
symptoms (OR ⫽ 1.04, p ⬍ .01). As insomnia symptoms increased
by one standard deviation, the odds of hazardous cannabis use
increased by 12% (e.02⫻5.80 ⫺ 1) and the odds of cannabis use
disorder symptoms increased by 20% (e.04⫻5.80 ⫺ 1).
Hazardous Cannabis Use Model
Insomnia symptoms had a negative relationship with cannabis
PBS (b ⫽ ⫺.02 [.01], ␤ ⫽ ⫺.08, t ⫽ ⫺2.13, p ⬍ .05), such that
higher insomnia symptoms were associated with lower use of
cannabis PBS. Women were more likely to use cannabis PBS then
men (b ⫽ .36 [.08], ␤ ⫽ .14, t ⫽ 4.63, p ⬍ .001). Controlling for
demographics variables and insomnia symptoms, cannabis PBS
was negatively associated with the odds of hazardous cannabis use
(b ⫽ ⫺.38 [.03]; OR ⫽ .68, p ⬍ .001). Cannabis PBS significantly
mediated the relationship between insomnia symptoms and haz-
ardous cannabis use (95% bias-corrected bootstrap CI for ab [.001,
.01]). Sex did not moderate this indirect relationship (sex effect on
insomnia ¡ cannabis PBS [“a” path]: b ⫽ .01[.01], ␤ ⫽ .03, t ⫽
.39, p ⫽ .70; cannabis PBS ¡ hazardous cannabis use controlling
for insomnia [“b” path]: b ⫽ ⫺.01[.03], ␤ ⫽ ⫺.05, t ⫽ ⫺.62, p ⫽
.54). As insomnia symptoms increased by one SD, the odds of
hazardous cannabis use increased by about 5% (e⫺.02⫻5.80⫻⫺.38) ⫺ 1
via cannabis PBS use. The model fit the data well, ␹2(2) ⫽ 5.13, p ⫽
.08, CFI ⫽ .98, TLI ⫽ .93, RMSEA ⫽ .04 (Figure 1).
Possible Cannabis Use Disorder Model
Similar to the above findings, controlling for insomnia symp-
toms and demographic variables, cannabis PBS was negatively
associated with the odds of a possible cannabis use disorder
(b ⫽ ⫺.38 [.03], OR ⫽ .68, p ⬍ .001). Cannabis PBS significantly
mediated the relationship between insomnia symptoms and a pos-
sible cannabis use disorder (95% bias-corrected bootstrap CI [.001,
.01]). Sex did not moderate this relationship (sex effect on insom-
nia ¡ cannabis PBS [“a” path]: b ⫽ .01 [.01], ␤ ⫽ .04, t ⫽ .52,
p ⫽ .61; cannabis PBS ¡ possible cannabis use disorder con-
trolling for insomnia [“b” path]: b ⫽ .15 [.17], ␤ ⫽ .16, t ⫽ .87,
p ⫽ .39). As insomnia symptoms increase by 1 SD, the odds of
a possible cannabis use disorder increased by about 5%
3 4 5 6 7 8 M SD
5.80
1.11
— .43 .50
.66ⴱⴱ — .21 .41
.53ⴱⴱ .57ⴱⴱ — 3.35 4.00
⫺.17ⴱⴱ ⫺.15ⴱⴱ ⫺.19ⴱⴱ — .70 .46
.01 .01 ⫺.001 ⫺.08ⴱⴱ — .75 .43
.04 ⫺.007 ⫺.02 ⫺.007 ⫺.02 — 20.21 3.14
 INSOMNIA, PROTECTIVE BEHAVIORS, CANNABIS USE 5

Figure 1. Protective behavioral strategies mediated the relationship between sleep difficulties and hazardous
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cannabis use. Model fit: ␹2(2) ⫽ 5.13, p ⫽ 0.08, comparison fit index ⫽ 0.98, Tucker-Lewis index ⫽ 0.93, root
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mean square error of approximation ⫽ 0.04; OR ⫽ odds ratio.

(e⫺.02⫻5.80⫻⫺.38 ⫺ 1) via cannabis PBS use. The direct effect
of insomnia symptoms remained significant. Controlling for
cannabis PBS, a one SD increase in insomnia symptoms was
associated with 12% (e.02⫻5.80 ⫺ 1) increase in the odds of a
possible cannabis use disorder. Overall model fit was good,
␹2(2) ⫽ 4.98, p ⫽ .08, CFI ⫽ .98, TLI ⫽ .92, RMSEA ⫽ .04
(Figure 2).
Cannabis-Related Consequences Model
We fitted the cannabis-related consequences count outcome
using Poisson, negative binomial and zero-inflated versions of
these count models. The Poisson count model was rejected, Pear-
son ␹2(978) ⫽ 3685.38, p ⫽ .00. Zero-inflated Poisson model was
also rejected, Pearson ␹2(972) ⫽ 1756.27, p ⫽ .00. The negative
binomial model fitted the data well, Pearson ␹2(977) ⫽ 861.45,
p ⫽ .99. The zero-inflated negative binomial model showed sim-
ilar fit, Pearson ␹2(971) ⫽ 845.63, p ⫽ .99. The parameter esti-
mates, their significance, and the indirect effect are very similar in
the two models. For ease of presentation, we chose the negative
binomial model and reported the results below.
More severe insomnia symptoms were associated with lower
cannabis PBS (b ⫽ ⫺.02[.01], ␤ ⫽ ⫺.08, t ⫽ ⫺2.37, p ⬍ .05),
which significantly predicted cannabis-related consequences
(b ⫽ ⫺.24[.03], IRR ⫽ .78, t ⫽ ⫺8.10, p ⬍ .001). Lower cannabis
PBS significantly mediated the relationship between insomnia
symptoms and cannabis-related consequences (95% bias-corrected
bootstrap CI [.001, .01]). One SD increase in insomnia symptoms
was associated with approximately 3% increase in the cannabis-
related consequences via PBS.(e⫺.02⫻5.80⫻⫺.24 ⫺ 1) Sex did not
significantly moderate the indirect effect (sex effect on insomnia ¡
cannabis PBS [“a” path]: b ⫽ .01[.01], ␤ ⫽ .04, t ⫽ .47, p ⫽ .64;
cannabis PBS ¡ possible cannabis use disorder controlling for
insomnia [“b” path]: b ⫽ .04 [.03], ␤ ⫽ .24, t ⫽ 1.34, p ⫽ .18).
More severe insomnia symptoms also directly predicted cannabis-
related consequences (b ⫽ .03 [.01], IRR ⫽ 1.03, t ⫽ 4.67, p ⬍
.001). Controlling for cannabis PBS, a one SD increase of insom-
nia symptoms predicted approximately 19% (e.03⫻5.80 ⫺ 1) in-
crease in the number of cannabis-related consequences (Figure 3).
Discussion
Previous studies examining the relationship between sleep dif-
ficulties and substance use reported an association between insom-
nia symptoms and cannabis-related outcomes. However, most of
these studies focused on the association between sleep difficulties
and substance use in general; only a few studies specifically
analyzed the relationship between sleep parameters and cannabis
use. Moreover, none of these studies examined hazardous cannabis
use, possible cannabis use disorder, or a broad-spectrum assess-
ment of cannabis-related problems. This study examined whether
insomnia symptoms were associated with problematic cannabis

Figure 2. Protective behavioral strategies mediated the relationship between sleep difficulties and possible
cannabis use disorder. Model fit: ␹2(2) ⫽ 4.98, p ⫽ 0.08, comparison fit index ⫽ 0.98, Tucker-Lewis index ⫽
0.92, root mean square error of approximation ⫽ 0.04; OR ⫽ odds ratio.
 6 WONG, CRAUN, BRAVO, AND PEARSON
Figure 3. Protective behavioral strategies mediated the relationship between sleep difficulties and cannabis-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
related consequences. Model fit: Pearson ␹2(977) ⫽ 861.45, p ⫽ .99, IRR ⫽ incidence rate ratio.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
use. In addition, we tested whether cannabis PBS mediated these
relationships. Overall, the results supported our hypotheses that
insomnia symptoms were associated with lower use of cannabis
PBS, which at least partially accounted for the associations be-
tween insomnia symptoms and cannabis-related outcomes.
The present study supports the plausibility that individuals with
insomnia symptoms underutilize cannabis PBS, and thus are at
higher risk of problematic cannabis use. To our knowledge, this is
the first study showing insomnia symptoms had a negative rela-
tionship with cannabis PBS. Those who had insomnia symptoms
were less likely to use cannabis PBS, which predicted a lower
likelihood of hazardous cannabis use. There are at least two
reasonable explanations for these findings.
A deficit-based model may suggest that individuals with sleep
problems experience cognitive deficits and thus are less effective
at planning or following through with plans to use PBS. Indeed,
insomnia symptoms (e.g., difficulties falling and staying asleep)
and inadequate sleep has been linked to memory deficits (Walker,
2008, 2009), emotional reactivity (Gujar, Yoo, Hu, & Walker,
2011; Walker & van der Helm, 2009), as well as poor executive
functioning (Warren, Riggs, & Pentz, 2017; Wong et al., 2010).
The use of cannabis PBS (e.g., limit use to weekends, avoid using
marijuana to cope with emotions such as sadness or depression)
requires planning and thinking in advance before cannabis use.
Problems falling or staying asleep likely make it difficult for
individuals to have the mental energy and self-control to engage in
these strategies.
A motivation-based model may suggest that individuals with
sleep problems are less motivated to use PBS, perhaps related to
their motivations for using cannabis as a sleep aid (Bonn-Miller,
Babson, & Vandrey, 2014; Goodhines, Gellis, Kim, Fucito, &
Park, 2017; Walsh et al., 2013). In the alcohol research field, one
of the primary reasons that drinkers reported not wanting to use
alcohol PBS was their motivation to drink (Bravo et al., 2018;
Pearson, 2013). Related to the present findings, it is plausible that
individuals who use cannabis to help with sleep-related problems
may see using cannabis PBS as inconsistent with their goals.
Determining the extent to which these distinct explanations
account for these associations has important implication for inter-
ventions. The deficit-based model would imply that self-
regulation-based interventions that make PBS less cognitively
demanding or more automatic would be ideal. The motivation-
based model would imply that motivation-based interventions that
highlight how use of PBS does not necessarily interfere with their
goals for cannabis use would be ideal. Clearly, additional studies
are needed to replicate and extend these findings to garner support
for one or both of these explanations. Finally, we examined
whether sex moderated the associations between insomnia symp-
toms and cannabis-related outcomes. The mediated effects of
insomnia symptoms on hazardous cannabis use, possible cannabis
use disorder, and cannabis-related problems were consistent across
men and women, suggesting that the mediated effects of cannabis
PBS are not gender-specific. A previous study found that the
protective effect of cannabis PBS on cannabis use was slightly
stronger among males than females but found no gender differ-
ences in the association between cannabis PBS and cannabis-
related consequences (Bravo, Anthenien, et al., 2017). Given that
the Bravo et al. study used a different measure of cannabis use
(Marijuana Use Grid; Pearson & Marijuana Outcomes Study
Team, 2018), further research is needed to clarify the associations
between cannabis PBS use and cannabis outcomes across genders.
Limitations and Future Research
The present study had a number of important limitations that
must be considered when interpreting our findings. The cross-
sectional study design does not allow us to establish temporal
precedence among variables. Although our focus on the role of
insomnia symptoms in problematic cannabis use is based on pre-
vious studies (Hasler et al., 2017; Wong et al., 2015), the relation-
ship between insomnia and cannabis use is likely bidirectional and
we are unable to determine whether insomnia symptoms lead to a
higher likelihood of problematic cannabis use, or if problematic
cannabis use leads to greater insomnia symptoms using data from
a single time point. The effects of delta-9-tetrahydrocannabinol
(THC) in cannabis vary across individuals, depending on factors
such as the amount consumed, chronicity (whether someone is a
naïve, occasional or chronic user), methods of consumption
(smoked in a joint or ingested as an edible), specific cannabinoid
profile (the presence of cannabidiol [CBD] and other cannabinoids
modulate the effects of THC), and interactions with other sub-
stance use (Iversen, 2007). Using cannabis as a sleep aid has been
reported among college students (Goodhines et al., 2017), patients
with posttraumatic disorder symptoms (Bonn-Miller et al., 2014),
and patients with different medical conditions and symptoms
(Walsh et al., 2013). However, cannabis may also increase onset
 INSOMNIA, PROTECTIVE BEHAVIORS, CANNABIS USE
latency, increase slow wave sleep, and decrease REM sleep in
others (Schierenbeck, Riemann, Berger, & Hornyak, 2008). Sleep
disturbances are especially common during periods of withdrawal
(Gates, Albertella, & Copeland, 2016). It is also possible that
lower marijuana PBS caused increase in cannabis use and insom-
nia symptoms. Taken together, we cannot rule out alternative
explanations such as problematic cannabis use leading to sleep
difficulties or lower marijuana PBS causing increases in both
cannabis use and insomnia symptoms. Future studies, especially
those with longitudinal data, could investigate the temporal and the
bidirectional relationships among sleep parameters, cannabis PBS,
and cannabis use.
In this study, we examined one possible mediator of the sleep–
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cannabis association. However, we realize that there are probably
This document is copyrighted by the American Psychological Association or one of its allied publishers.
additional mediators that account for insomnia symptoms leading
to cannabis use, and likely different mediators that account for
cannabis use leading to insomnia symptoms. Longitudinal studies
that explore these bidirectional pathways are needed. Although we
obtained a large sample of college students, our convenience
sampling methods did not ensure that our sample is representative
of the college student population, thus there are concerns for
generalizing our findings to the college student population as a
whole. These concerns are mitigated by the fact that our sample
appears rather similar to other national studies of college students
in terms of cannabis use prevalence (Bravo, Prince, et al., 2017).
For instance, the rate of possible CUD is this study (21%) is
similar to the rate reported among college students who used
cannabis in a previous study (24.6%; Caldeira, Arria, O’Grady,
Vincent, & Wish, 2008).
Conclusions
In conclusion, the present study identified cannabis PBS use as
a possible mediator of the relationship between insomnia symp-
toms and hazardous cannabis use in a sample of college students.
Intervention programs that emphasize on the importance of sleep
hygiene, adequate sleep, as well as the relationship between in-
somnia and PBS may be beneficial to college students who use
cannabis. The findings of this article need to be replicated and
extended in future studies. Longitudinal studies that reveal the
reciprocal relations between sleep problems and cannabis use will
be particularly useful.
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Received October 15, 2018
Revision received January 9, 2019
Accepted January 29, 2019 䡲