Co-Use of Alcohol and Cannabis During COVID-19: Associations Between Sociodemographic Factors and Self-Reported Mental Health Symptoms and Heavy Episodic Drinking in Canadian Adults

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors of the manuscript “Co-use of alcohol and cannabis during COVID-19: Associations between Sociodemographic Factors and Self-reported Mental Health Symptoms and Heavy Episodic Drinking in Canadian Adults” (psychoactives-3663166) presented a comprehensive and well-structured work with findings that can be translated to developing public health and clinical interventions for preventing and treating excessive alcohol or cannabis use must consider both alcohol and cannabis use patterns and should be tailored to the highest-risk TGD and young adults.

 

A few comments, beneficial for the paper,  are listed below:

1. Abstract – including aOR or CI in the abstract to present effect sizes.
2. Methods - specify that the study used repeated cross-sectional data over time.
3. Discussion - expand on why TGD individuals showed higher odds of co-use, link to minority stress theory or access barriers, and how anxiety and depression drive co-use patterns.
4. Conclusion – expand on practical implications and include future recommendations.

Author Response

The authors of the manuscript “Co-use of alcohol and cannabis during COVID-19: Associations between Sociodemographic Factors and Self-reported Mental Health Symptoms and Heavy Episodic Drinking in Canadian Adults” (psychoactives-3663166) presented a comprehensive and well-structured work with findings that can be translated to developing public health and clinical interventions for preventing and treating excessive alcohol or cannabis use must consider both alcohol and cannabis use patterns and should be tailored to the highest-risk TGD and young adults.

A few comments, beneficial for the paper,  are listed below:

Thank you for reviewing this manuscript and providing helpful suggestions to enhance its quality.

Comments 1: 1. Abstract – including aOR or CI in the abstract to present effect sizes.

Response 1: Thank you for suggesting this. We added the aOR (95%CI) in the abstract.

Comments 2: 2. Methods - specify that the study used repeated cross-sectional data over time.

Response 2: Following your comments, we added in the material and methods section that the data were obtained from nine repeated web-based cross-sectional surveys (Page 3, third paragraph, lines 111-112) and we described the timeline of the surveys in page 3, third paragraph, lines 118-123.

Comments 3: 3. Discussion - expand on why TGD individuals showed higher odds of co-use, link to minority stress theory or access barriers, and how anxiety and depression drive co-use patterns.

Response 3: Thank you for bringing this point to our attention. We added in the revised version to the discussion on pages 9- 10, lines 264-270:

“The increase in psychological distress among TGD individuals may be due to the interruption of gender-affirming treatments in Canada during the pandemic. These treatments are known to help alleviate gender dysphoria, which is the distress some TGD individuals feel when their gender identity does not match the sex assigned at birth. However, during the pandemic, these treatments were delayed or put on hold to prioritize medical resources for the increasing number of COVID-19 patients.”

We chose to expand on barriers to access to care, as this was a significant issue during the pandemic.

Regarding the discussion on “how anxiety and depression drive co-use patterns” we added a paragraph on page 10, lines 302-310, as follows:

“Our findings indicate that co-use of alcohol and cannabis is associated with higher self-reported anxiety and depression. This conclusion aligns with findings in the literature, where many individuals turned to these substances to cope with the overwhelming stress caused by social distancing measures during the COVID-19 pandemic [58]. These measures enacted by governments, which included interdiction of large gatherings, stay-at-home measures, school closures, and restrictions on restaurants and bars, have contributed to increasing people's mental health problems. It is important to recognize the risks of co-using alcohol and cannabis during a crisis, as well as the urgent need for practical support strategies during difficult times.”

Comments 4: 4. Conclusion – expand on practical implications and include future recommendations.

Response 4: We have expanded the conclusions to add some implications and recommendations for future public health policies and research in Page 11, lines 336-345, as follows:

“An equitable and inclusive approach is essential to design and implement measures to reduce disease propagation during major public health crises, such as limiting access to non-essential health services (e.g., gender-affirming treatments). While these measures are necessary, the needs of minority and more vulnerable groups must be considered through an approach that can help anticipate and mitigate potential negative impacts that may drive vulnerable individuals towards unhealthy behaviours, exacerbating their already precarious situations. A continuous evaluation of the effects of lockdown rules and social distancing (related to the pandemic) on unhealthy behaviours among at-risk populations may help inform targeted health promotion strategies for future public health crises.”

Reviewer 2 Report

Comments and Suggestions for Authors

In the work entitled “Co-use of alcohol and cannabis during COVID-19: Associations between Sociodemographic Factors and Self-reported Mental Health Symptoms and Heavy Episodic Drinking in Canadian Adults” the authors assessed the prevalence of alcohol and cannabis co-use during COVID-19 across sociodemographic groups and identified risk factors for co-use in Canadian adults, while also examining the associations between co-use of these substances and mental health symptoms and HED.

The study is generally well-structured, and its conclusions are supported by the collected/presented data. The limitations are clearly outlined, and the included citations are appropriate and up-to-date. However, certain aspects should be addressed before the manuscript can be considered for publication.

 

Minor Revisions:

Typographical errors should be corrected (see lines 161, 173, 180, ...).

 

Major Revisions:

The authors did not account for participants’ clinical histories (e.g., prior trauma or neurological conditions) among the 9,011 individuals studied. Additionally, it should be clarified whether any participants had undergone pharmacological treatments that could significantly influence the investigated parameters (e.g., anxiety and depression). If so, these individuals should be excluded from the analysis.

Author Response

In the work entitled “Co-use of alcohol and cannabis during COVID-19: Associations between Sociodemographic Factors and Self-reported Mental Health Symptoms and Heavy Episodic Drinking in Canadian Adults” the authors assessed the prevalence of alcohol and cannabis co-use during COVID-19 across sociodemographic groups and identified risk factors for co-use in Canadian adults, while also examining the associations between co-use of these substances and mental health symptoms and HED.

The study is generally well-structured, and its conclusions are supported by the collected/presented data. The limitations are clearly outlined, and the included citations are appropriate and up-to-date. However, certain aspects should be addressed before the manuscript can be considered for publication.

Thank you for your kind comments and suggestions.

Minor Revisions:

Comments 1: Typographical errors should be corrected (see lines 161, 173, 180, ...).

Response 1: Thank you! We corrected the error in lines 173 and 180 by suppressing the second closing bracket. But the two closing brackets in line 161 are correct.

Line 160-161: ethno-racial background (White and Non-white (i.e., Asian/Black/Indigenous/Arab/Latinx and other ethnicities))

Major Revisions:

Comments 2: The authors did not account for participants’ clinical histories (e.g., prior trauma or neurological conditions) among the 9,011 individuals studied. Additionally, it should be clarified whether any participants had undergone pharmacological treatments that could significantly influence the investigated parameters (e.g., anxiety and depression). If so, these individuals should be excluded from the analysis.

Response 2: Thank you for your comments. We used survey data that did not include information on participants’ clinical histories or whether they had undergone pharmacological treatments. Then it was not possible to account for these factors in the analysis.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript is well-written, the objectives were defined and the results are relevant. This is an improved version of an original submission and it seems suitable for publication.

Author Response

Attached

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors did not account for participants’ clinical histories (e.g., prior trauma or neurological conditions) among the 9,011 individuals studied. It is also critically important to clarify whether any participants had undergone pharmacological treatments that could significantly influence the investigated parameters (e.g., anxiety and depression). These factors could substantially affect the study outcomes, potentially leading to a speculative interpretation of the results.

Author Response

Attached

Author Response File: Author Response.pdf