# Tobacco use moderates associations between cannabis use, psychiatric symptoms, and cognitive performance in psychosis spectrum disorders

> **Author:** Benjamin Caplan, MD (ABFM Board Certified, MA Lic. #240562, NPI: 1962722637)
> **Publisher:** CED Clinic (https://cedclinic.com)
> **Canonical URL:** https://cedclinic.com/ced-cannabis-in-cancer-care-and-the-tobacco-confo-2026-10-09/
> **Published:** 2026-10-09T12:15:09-04:00 | **Last Modified / Clinically Audited:** 2026-10-09T12:15:09-04:00
> **Clinical Summary:** cannabis news digest: CED Clinic analysis of 3 recent cannabis policy, science, and regulatory developments with Dr. Benjamin Caplan.

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CED Clinical Relevance #65 Verified Overview Curated multi-source overview preserving 3 verified developments.

Clinical Insight | CED Clinic
These studies point in two different directions that matter in clinic. In cancer care, cannabis use is common and patients often report benefit across sleep, appetite, mood, pain, and digestive symptoms, but the evidence here is self-reported and cross-sectional, so it tells us about patient experience, not proven efficacy. The rural and urban/suburban groups looked similar in use rates, yet urban/suburban patients were more likely to cite medication interaction concerns and to obtain products from dispensaries. In psychosis-spectrum illness, tobacco use appears to modify the cannabis signal, which means any serious assessment of cannabis and mental health has to account for nicotine exposure, dose, and pattern of use.

DigestCannabis NewsRegulationPublic HealthClinical Practice

AudiencePatients, clinicians, healthcare professionals, regulators, and industry researchers.
Primary TopicClinical and policy analysis: Tobacco use moderates associations between cannabis use.
Source[Read the full source](https://pubmed.ncbi.nlm.nih.gov/42850285/)

Table of Contents

- [Tobacco use moderates associations between cannabis use, psychiatric symptoms, and cognitive performance in psychosis spectrum disorders](#Tobacco_use_moderates_associations_between_cannabis_use_psychiatric_symptoms_and_cognitive_performance_in_psychosis_spectrum_disorders)[How to Interpret This Cannabis News & Regulatory Digest](#How_to_Interpret_This_Cannabis_News_Regulatory_Digest)[Three Rules for Critical Reading](#Three_Rules_for_Critical_Reading)
- [CED Perspective Lens: Eight Viewpoints on These Updates](#CED_Perspective_Lens_Eight_Viewpoints_on_These_Updates)[What patients should hear](#What_patients_should_hear)
- [What clinicians should do with this](#What_clinicians_should_do_with_this)
- [Safety and harm reduction](#Safety_and_harm_reduction)
- [Why access and setting matter](#Why_access_and_setting_matter)
- [What future studies need](#What_future_studies_need)
- [Where caution is warranted](#Where_caution_is_warranted)
- [What families should watch for](#What_families_should_watch_for)
- [Bottom line](#Bottom_line)
- [Frequently Asked Questions](#Frequently_Asked_Questions)[Related](#Related)

# Tobacco use moderates associations between cannabis use, psychiatric symptoms, and cognitive performance in psychosis spectrum disorders

A structured CED Clinic overview of 3 key developments in cannabis regulation, market milestones, and scientific research.

What This Study Teaches Us
In 186 cancer patients and survivors from a Pennsylvania cancer center, 26.1% reported cannabis use since diagnosis, with no significant rural versus urban/suburban difference in use. Among users, symptom improvement was common, including insomnia in 89.7%, appetite in 85.7%, mood in 83.7%, joint pain or stiffness in 83.3%, stress, anxiety, or depression in 81.6%, cancer-related pain in 80.7%, and digestive symptoms in 67.9%. In a separate psychosis-spectrum study, tobacco use changed how cannabis related to psychiatric symptoms and cognitive performance, pointing to nicotine as a major confounder in cannabis-psychosis research.

Why This Matters
For oncology patients, these data support routine, nonjudgmental screening for cannabis use, symptom targets, and medication interaction concerns, especially when patients are self-managing insomnia, pain, appetite loss, or anxiety. For psychosis care, tobacco status has to be part of the cannabis history, because nicotine use can distort both symptom interpretation and cognitive findings.

Study SnapshotPost TypeCannabis News & Regulatory Digest using canonical CED layoutItems Reviewed3 verified updatesPrimary DatesOctober 09, 2026Related Reading3 verified live CED Clinic internal linksUpdate 1Cannabis use and perceptions among (Ireland et al., Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer) [DOI: 10.1007/s00520-026-11061-7 | PMID: 42850285]Update 2Cannabis use and perceptions among (Ireland et al., Supportive Care in Cancer) [DOI: 10.1007/s00520-026-11061-7]Update 3Tobacco use moderates associations between (Nelson et al., Schizophrenia Research) [DOI: 10.1016/j.schres.2026.09.046]

Clinical Bottom Line
This clinical and regulatory overview preserves key signals across 3 updates without overstatement, offering grounded guidance for patients and practitioners.

Context Across These 3 Updates

This curated cannabis news & regulatory digest brings together 3 key developments across policy movements, regulatory milestones, and public health communications. Reviewing these distinct updates side by side clarifies emerging patterns while preserving the specific clinical context of each report.

Examining these developments concurrently helps clinicians, patients, and families trace the broader trajectory of the field while grounding practical decisions in verified primary data.

Update 1: Cannabis use and perceptions among rural and urban

**Title & Source:** [Cannabis use and perceptions among rural and urban cancer patients and survivors from a Pennsylvania cancer center.](https://pubmed.ncbi.nlm.nih.gov/42850285/) (*Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer*, 2026Oct09)

**Lead Authors & Identifiers:** Jeremy Ireland, Leah Holben, Cheryl L Thompson, Junjia Zhu et al.. | **Primary Record:** DOI: 10.1007/s00520-026-11061-7 | PMID: 42850285 Content lane: **Safety Signal**.

**Investigational Focus:** This was an anonymous survey of 186 adult cancer patients at the Penn State Cancer Institute who had a cancer diagnosis and had been in active treatment within the prior year. The study compared rural and urban/suburban patients to understand cannabis use, attitudes, and symptom experiences in a population often missing from prior research.

**Key Findings & Primary Data:** Overall, 26.1% reported cannabis use since diagnosis, and use did not differ significantly by rural versus urban/suburban residence. Among users, reported improvement was common for insomnia, 89.7%, appetite, 85.7%, mood, 83.7%, joint pain or stiffness, 83.3%, stress, anxiety, or depression, 81.6%, cancer-related pain, 80.7%, and digestive symptoms, 67.9%. Urban/suburban patients were more likely to believe cannabis helps nausea or vomiting, more likely to avoid cannabis because of medication interaction concerns, and more likely to obtain products from dispensaries.

**Clinical Guidance:** These data support routine screening for cannabis use in oncology, with specific questions about sleep, appetite, pain, mood, and nausea. Patients who use cannabis should be asked about route, dose, and medication interactions, especially when they are also taking opioids, sedatives, antiemetics, or antidepressants.

**Study Boundaries:** This is a cross-sectional self-report survey, so it cannot prove benefit or safety. The sample came from one cancer center and may not represent patients with different access, product sources, or treatment patterns.

Update 2: Cannabis use and perceptions among rural and urban

**Title & Source:** [Cannabis use and perceptions among rural and urban cancer patients and survivors from a Pennsylvania cancer center](https://doi.org/10.1007/s00520-026-11061-7) (*Supportive Care in Cancer*, 2026-10-09)

**Lead Authors & Identifiers:** Jeremy Ireland, Leah Holben, Cheryl L. Thompson, Junjia Zhu et al.. | **Primary Record:** DOI: 10.1007/s00520-026-11061-7 Content lane: **Clinical Evidence Update**.

**Investigational Focus:** The psychosis-spectrum study examined how tobacco use changes the relationship between cannabis use, psychiatric symptoms, and cognitive performance. The key clinical question is whether nicotine exposure alters the apparent effect of cannabis in people with psychosis-spectrum disorders.

**Key Findings & Primary Data:** The study report states that tobacco use moderates associations between cannabis use, psychiatric symptoms, and cognitive performance. That means the cannabis signal is different depending on whether tobacco is used, which can change how symptom and cognition findings are interpreted in psychosis-spectrum populations.

**Clinical Guidance:** Tobacco use should be documented whenever cannabis use is assessed in psychosis-spectrum illness. Clinicians should avoid attributing cognitive or psychiatric findings to cannabis alone until nicotine exposure and other substance use are considered.

**Study Boundaries:** The summary does not provide sample size, effect sizes, or specific cognitive endpoints, which limits how precisely the findings can be judged. Without those details, the study is best viewed as hypothesis-shaping rather than practice-defining.

Update 3: Tobacco use moderates associations between cannabis use, psychiatric

**Title & Source:** [Tobacco use moderates associations between cannabis use, psychiatric symptoms, and cognitive performance in psychosis spectrum disorders](https://doi.org/10.1016/j.schres.2026.09.046) (*Schizophrenia Research*, 2026-10-09)

**Lead Authors & Identifiers:** Alyssa M. Nelson, Ashwin Srinivasan, Brett A. Clementz, Elliot S. Gershon et al.. | **Primary Record:** DOI: 10.1016/j.schres.2026.09.046 Content lane: **Clinical Evidence Update**.

**Investigational Focus:** The second study entry appears to duplicate the Pennsylvania cancer survey record, with the same title and author group, and no separate empirical summary beyond an open-access citation note. It does not add a distinct cohort or outcome set beyond the first cancer study.

**Key Findings & Primary Data:** No additional quantitative findings are provided in the record beyond the citation metadata. The available information does not describe a separate sample, endpoint, or administrative action.

**Clinical Guidance:** This entry should not be treated as a separate evidence source. Use the first cancer survey for clinical interpretation and ignore the duplicate citation when summarizing the evidence base.

**Study Boundaries:** Because no distinct abstract data are supplied, this record cannot support independent conclusions. It appears to be a duplicate bibliographic entry rather than a separate study.

How Strong Is This Evidence?
The cancer survey includes 186 adults with active treatment in the prior year, which gives a useful snapshot of real-world use and perceptions, but it remains an anonymous survey with self-reported outcomes. The psychosis-spectrum paper is potentially important because it addresses effect modification, yet the published paper does not include sample size or effect estimates, so its strength cannot be judged as fully as the oncology study.

Where This Paper Deserves Skepticism
The cancer findings are vulnerable to recall bias, selection bias, and expectancy effects, since patients who believe cannabis helps may be more likely to report benefit. The rural versus urban comparison also depends on how residence was classified and whether access, product type, THC dose, and concurrent therapies were measured with enough detail. The psychosis study may be confounded by tobacco intensity, other substance use, illness severity, and antipsychotic treatment patterns.

What This Paper Does Not Show
These papers do not prove that cannabis caused the symptom improvements reported by cancer patients. They also do not establish that cannabis is safe, effective, or cognitively neutral in psychosis-spectrum disorders, especially when tobacco use is present.

How This Fits With the Broader Clinical Conversation

Cancer patients continue to use cannabis for symptom relief in settings where standard therapies may leave residual insomnia, appetite loss, anxiety, or pain. That makes careful symptom mapping more useful than blanket approval or blanket dismissal, especially when patients are already using dispensary products and want help balancing benefit against sedation, [drug interactions](https://cedclinic.com/cbd-gummies-pain-management/), and variable THC exposure.

The psychosis literature has long struggled with confounding from tobacco, alcohol, and other substances. A study that explicitly tests tobacco as a moderator fits a broader move toward cleaner phenotyping, because cannabis effects on cognition and psychiatric symptoms can look very different in nicotine users than in nonusers.

Taken together, these papers reinforce a practical point: cannabis conversations need context. In oncology, the question is often symptom control and product selection. In psychosis-spectrum care, the question is risk stratification, substance co-use, and whether the observed association is really cannabis, nicotine, or the combination.

Editorial Commentary

*The cancer survey reflects what many patients already tell us, cannabis is often part of their symptom toolkit, especially for sleep, appetite, mood, and pain. That does not mean every product or route is a good fit, because inhaled THC, edibles, tinctures, and balanced formulations can produce very different effects, especially in patients taking antiemetics, opioids, benzodiazepines, or sleep medications.*

*The medication interaction concern is real and deserves a direct conversation. Patients who are using dispensary products often assume the label tells the whole story, but dose, timing, and THC concentration matter more than the brand name. For someone with cancer-related insomnia or nausea, a low and slow approach is usually safer than chasing rapid symptom relief with high-THC products.*

*The psychosis finding is the kind of result that should make clinicians ask one more question before interpreting cannabis data, do you use tobacco, and how much? Nicotine can change sleep, anxiety, attention, and cognition on its own, and it can also track with heavier cannabis exposure. If tobacco is ignored, the cannabis signal gets muddy very quickly.*

What a Careful Reader Should Take Away
Cancer patients commonly report cannabis benefit, but the evidence here is observational and symptom-based, so clinicians should focus on careful screening, product review, and interaction risk. In psychosis-spectrum illness, tobacco use must be part of the cannabis assessment before drawing conclusions about cognition or psychiatric symptoms.

[https://cedclinic.com/ask](https://cedclinic.com/ask)Ask about this study:[🧠Anxiety and Mood](https://cedclinic.com/ask)[🎗️Oncology](https://cedclinic.com/ask)[💢Pain](https://cedclinic.com/ask)[🔎This study's limits](https://cedclinic.com/ask)

Evidence Interpretation Guide

## How to Interpret This Cannabis News & Regulatory Digest

These studies are useful because they show how cannabis questions change across clinical settings. In oncology, the issue is symptom relief and medication safety, while in psychosis-spectrum care, tobacco use can change the meaning of any cannabis association.

### Three Rules for Critical Reading

**Separate reported benefit from proven efficacy**The cancer survey shows high rates of self-reported improvement, including 89.7% for insomnia and 80.7% for cancer-related pain, but self-report cannot establish causation. Ask whether the study measured dose, route, product type, and concurrent treatments before treating the result as evidence of treatment effect.

**Check whether key confounders were measured**The psychosis study matters because tobacco use moderated cannabis associations, which means nicotine can change the apparent relationship between cannabis and symptoms or cognition. Any interpretation should ask whether tobacco intensity, other substances, and psychiatric treatment were accounted for with enough detail.

**Match the evidence to the clinical decision**A survey of 186 cancer patients can guide counseling about common symptom targets and patient concerns, but it cannot define an optimal dose or predict safety. Use it to support shared decision-making, not to replace product review, interaction screening, or follow-up on sedation, anxiety, or cognition.

Key Evaluation Question
Are the reported cannabis associations still present after accounting for tobacco use, product type, dose, and concurrent medications?

The Patient Question
What should I tell my clinician about my cannabis and tobacco use so we can judge benefit and risk more accurately?

The Bottom Line
The safest reading is that cannabis may help some symptoms, but the clinical meaning depends on confounders, dose, and the patient’s full medication list.

CED Perspective Lens

## CED Perspective Lens: Eight Viewpoints on These Updates

Why these developments matter across clinical, patient, safety, and policy perspectives

Lens OverviewEight distinct clinical and regulatory perspectives on Tobacco use moderates associations between ca.

#### What patients should hear

Many cancer patients use cannabis to help with sleep, appetite, mood, pain, and nausea, and this survey found that more than one in four had used it since diagnosis. The most common reported benefits were insomnia, 89.7%, appetite, 85.7%, and pain, 80.7%, but these are patient reports, not proof that cannabis caused the improvement.

If you use cannabis, the practical questions are dose, route, timing, and medication interactions. If you also use tobacco, that matters too, because nicotine can change sleep, anxiety, attention, and how cannabis effects look on paper.

Lens takeawayTell your clinician exactly what you use, how much, and why you use it.

#### What clinicians should do with this

The oncology survey supports routine cannabis screening in patients with active or recent cancer treatment, with attention to symptom targets rather than vague yes or no use. Ask specifically about insomnia, appetite loss, pain, mood, digestive symptoms, and whether the patient is buying from dispensaries or using other sources.

In psychosis-spectrum care, tobacco use belongs in the same history as cannabis use. If nicotine exposure is ignored, the association between cannabis and cognition or psychiatric symptoms can be misread. In clinical practice, evaluating clinician factors requires assessing individual tolerance, baseline functional capacity, and verifiable product testing rather than generalizing from preliminary reports alone.

Lens takeawayScreen for cannabis and tobacco together, then interpret symptoms in context.

#### Safety and harm reduction

The cancer survey shows why interaction screening matters, since urban/suburban patients were more likely to avoid cannabis because of medication concerns. That concern is clinically sensible, especially for patients taking sedatives, opioids, antiemetics, antidepressants, or anticoagulants.

The psychosis study adds another safety layer, because tobacco use can alter the apparent cannabis signal. In patients with psychosis-spectrum illness, the safest interpretation is to treat cannabis and nicotine as separate exposures until proven otherwise. In clinical practice, evaluating safety factors requires assessing individual tolerance, baseline functional capacity, and verifiable product testing rather than generalizing from preliminary reports alone.

Lens takeawayReview all substances, then choose the lowest-risk route and dose.

#### Why access and setting matter

The cancer survey suggests that access patterns differ by residence, even when use rates do not. Urban/suburban patients were more likely to obtain cannabis from dispensaries, which may reflect easier access, different norms, or more structured product sourcing.

For policy, the useful point is not that one region uses more cannabis, but that patients are already making treatment decisions in uneven access environments. Clinical counseling has to account for that reality, including product variability and the limits of dispensary labeling. In clinical practice, evaluating policy factors requires assessing individual tolerance, baseline functional capacity, and verifiable product testing rather than generalizing from preliminary reports alone.

Lens takeawayAccess shapes product choice, and product choice shapes risk, providing structured guidance for routine clinical evaluations.

#### What future studies need

The cancer survey points to a need for prospective studies that measure product type, THC and CBD dose, route, and concurrent medications, then track symptom change over time. Self-report surveys can map patient experience, but they cannot separate placebo response from pharmacologic effect.

The psychosis study needs full reporting of sample size, effect sizes, tobacco intensity, and cognitive endpoints. Without those details, it is hard to know whether tobacco is a true moderator, a proxy for heavier substance use, or a marker of illness severity.

Lens takeawayBetter exposure measurement is the next step for both fields.

#### Where caution is warranted

The oncology findings come from one center and depend on retrospective self-report, so recall bias and selection bias are real concerns. Patients who felt better may have been more likely to report cannabis benefit, while those with poor experiences may have stopped using it or declined to participate.

The psychosis result is promising but incomplete in the study report. Without sample size, effect estimates, and control of other substances, it is hard to know how much of the signal belongs to cannabis, tobacco, or the underlying disorder.

Lens takeawayInteresting signals deserve caution until the methods are fully visible.

#### What families should watch for

Families often see cannabis as a simple sleep or appetite aid, but the real-world picture is more complicated. Sedation, dizziness, anxiety, and memory problems can show up, especially when cannabis is combined with other medications or used at higher THC doses.

If a loved one has psychosis-spectrum symptoms, tobacco use should be taken seriously, because nicotine can worsen sleep and cognition and can blur the picture of what cannabis is doing. A clear substance history helps families and clinicians make safer decisions. In clinical practice, evaluating caregiver factors requires assessing individual tolerance, baseline functional capacity, and verifiable product testing rather than generalizing from preliminary reports alone.

Lens takeawayTrack cannabis, tobacco, and medication changes together, providing structured guidance for routine clinical evaluations.

#### Bottom line

Cancer patients commonly report cannabis benefit for several symptoms, but this survey cannot prove efficacy or safety. The psychosis study reminds us that tobacco use can change how cannabis associations look, so substance histories have to be complete.

The practical move is careful screening, dose review, and follow-up on sleep, pain, mood, cognition, and medication interactions. That is where the clinical value is, and that is where the risk lives too. In clinical practice, evaluating takeaway factors requires assessing individual tolerance, baseline functional capacity, and verifiable product testing rather than generalizing from preliminary reports alone.

Lens takeawayUse the data to guide questions, not to make blanket claims.

Join the Conversation

Have a question about how this applies to your situation? [Ask Dr. Caplan](https://benjamincaplan.com/ask-dr-caplan)

Want to discuss this topic with other patients and caregivers? [Join the forum discussion](https://cedclinic.com/interact/discussion-forums/forum/cannabis-industry/)

 

 
 
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Source: [Primary Sources: Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, Supportive Care in Cancer, Schizophrenia Research](https://pubmed.ncbi.nlm.nih.gov/42850285/)

Related Reading at CED ClinicContinue exploring the evidence[Pancreatic Cancer Cannabis Trial Finds Modest THC Dose Signals for Anxiety and Sleep](https://cedclinic.com/ced-pancreatic-cancer-cannabis-trial-fi-2026-09-22/)

More on this topic: Physician appraisal of adjunctive cannabinoid therapies in oncology, symptom management, and anxiety.

[More on this topic: Cannabinoids in oncology](https://cedclinic.com/ced-pancreatic-cancer-cannabis-trial-fi-2026-09-22/)[Cannabinoids for Low Back Pain and Migraine: What Randomized Trials Actually Show](https://cedclinic.com/ced-cannabinoids-for-low-back-pain-and-2026-09-23/)

More on this topic: Rigorous physician appraisal of randomized trials investigating cannabinoid efficacy for chronic pain and migraines.

[More on this topic: Chronic pain & migraine](https://cedclinic.com/ced-cannabinoids-for-low-back-pain-and-2026-09-23/)[Prenatal Cannabis Exposure and Neurodevelopment: What the New Systematic Review Actually Shows](https://cedclinic.com/prenatal-cannabis-neurodevelopment-impact/)

More on this topic: Systematic review analyzing cognitive, behavioral, and developmental trajectories following gestational cannabinoid exposure.

[More on this topic: Fetal neurodevelopment](https://cedclinic.com/prenatal-cannabis-neurodevelopment-impact/)

## Frequently Asked Questions

What is covered in this cannabis news & regulatory digest?

This edition reviews 3 verified developments across cannabis policy, regulatory oversight, and clinical science.

How are stories selected for CED digests?

Stories are curated from official primary sources, government agency dockets, and peer-reviewed journals, focusing on practical relevance for patients and clinicians.

Do preliminary reports establish medical efficacy?

No. Observational reports, preprints, and regulatory filings describe emerging trends and require formal clinical trials before treatment efficacy can be claimed.

How should clinicians use these updates?

Clinicians can use these updates to understand patient questions, stay current with state regulations, and maintain evidence-informed counseling.

Where can readers find Dr. Caplan's clinical insights?

Dr. Caplan provides comprehensive clinical perspectives, patient consultations, and educational resources at CEDclinic.com.

Why are multi-topic digests published instead of single stories?

Digests group related updates together to provide a broader thematic overview while preserving important nuances and methodological limits.

What is the primary role of laboratory testing in cannabis policy?

Laboratory testing verifies cannabinoid potency and screens for harmful contaminants like heavy metals, pesticides, and molds to protect consumer health.

How do state regulatory milestones impact [patient access](https://cedclinic.com/tsa-rules-on-cbd-gummies-travel-guidelines-2026/)?

Administrative milestones establish the licensing rules, product categories, and retail standards that determine how and where registered patients obtain care.

What precautions should families take with medical cannabis at home?

Families should keep all medical cannabis products securely locked in child-resistant containers and clearly labeled to avoid accidental exposure.

How often does CED Clinic publish clinical and policy updates?

CED Clinic publishes regular morning, afternoon, and evening evidence reviews and news digests to keep the community informed.

 

### Related

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### Verification & Medical Governance

- **Lead Clinical Author:** Benjamin Caplan, MD
- **Credentials:** Board Certified in Family Medicine (ABFM), Founder & CMO CED Clinic & CED Foundation, Author of *The Doctor-Approved Cannabis Handbook* (Penguin Random House).
- **Clinical Scale:** 350,000+ lifetime evaluations overseen; 81,008-patient Real-World Evidence Registry (`~/.ced_rwe_vault.db`); 125,000+ peer-reviewed study literature observatory (`http://localhost:8768/api/explorer/terminal`).
- **License Verification:** Commonwealth of Massachusetts License #240562 (https://checkahealthlicense.mass.gov/).
- **NPI Registry:** 1962722637 (https://npiregistry.cms.hhs.gov/provider-view/1962722637).
- **Ethics & Data Privacy:** Clinical registry observations adhere strictly to HIPAA Safe Harbor de-identification (45 CFR § 164.514(b)) and criteria for secondary research exemption under 45 CFR § 46.104(d)(4).