Trends in youth cannabis use across cannabis legalization: Data from the COMPASS prospective cohort study

Cannabis use among hospitalised adolescents before and after decriminalisation in South Africa

Background

Cannabis is the most widely used substance worldwide, and its use is much higher among adolescents. However, adolescents are at higher risk of negative sequelae secondary to this use, including the possible development of mental disorders. On 31 March 2017, the South African High Court ruled that cannabis use by an adult in a private dwelling should be decriminalised.

Aim

This study aimed to determine the clinical profile of adolescents who use cannabis, who use, who present to a tertiary hospital in Cape Town, South Africa, before and after the high court ruling in 2017.

Setting

Folder review of adolescents admitted at Groote Schuur Hospital (GSH) in the Emergency Psychiatric Unit.

Methods

This study was a retrospective folder review of adolescents admitted from April 2015 to March 2019.

Results

Cannabis was the most commonly used substance in the study, with increased use seen post-ruling. The most common frequency of cannabis use reported was daily. A significantly higher proportion of patients who used cannabis pre-ruling had psychotic disorder (p < 0.001) and cannabis use disorder (p = 0.01). Post-ruling, the results were statistically significant (p < 0.001) for both.

Conclusion

The study showed an increasing prevalence of cannabis use in adolescents admitted with mental illness after the high court ruling in 2017. This study also demonstrates that adolescents remain a vulnerable population to the effects of cannabis and highlights the need for further research.

Contribution

The findings of this study call for more focussed adolescent interventions and services.

Impact of Legalization on Cannabis Use, Attitudes, and Purchasing Preferences: A Repeated Cross-Sectional Survey of Canadian Young Adults

Objective

The Government of Canada legalized recreational cannabis use in October of 2018 with the implementation of the Cannabis Act. The act aimed to reduce the illicit cannabis market, improve consumer health outcomes, and reduce youth access to cannabis. However, little is known about the attitudes and behaviors of young adults, who have been shown to have a high prevalence of cannabis use, towards cannabis after legalization.

Method

In this descriptive study, we examined cannabis use, attitudes, and purchasing preferences among Canadian university-attending young adults both before and after the legalization of cannabis. Participants were recruited from a large Canadian university from 2017 to 2021.

Results

Our findings showed that there was an increase in cannabis use immediately following legalization that subsequently decreased in later years. Additionally, attitudes about the legalization of cannabis became more favorable in later years (following legalization), particularly among those who did not use cannabis. Most young adults were also keen to purchase cannabis from a government-owned store before legalization. However, with the exception of past-month consumers, this preference decreased substantially following legalization.

Conclusions

The current research adds to the knowledge base about changes in cannabis-related attitudes and use after legalization and focuses on a key population - young adults.

Understanding youth and young adult cannabis use in Canada post-legalization: a scoping review on a public health issue

BACKGROUND

Canada legalized recreational cannabis in 2018, and one of the primary objectives of the Cannabis Act was to protect youth by reducing their access to cannabis and providing public education. Canada has the highest prevalence of cannabis use worldwide, particularly among youth and young adults under the age of 25. Cannabis use is linked with many adverse effects for youth and young adults including psychosis, anxiety, depression, respiratory distress, cannabinoid hyperemesis syndrome, and impaired cognitive performance. Despite the high prevalence of cannabis use and the evolution of policies in Canada and globally, significant knowledge and research gaps remain regarding youth and young adult cannabis use. The aim of this scoping review is to map the extent, nature, and range of evidence available on youth and young adult cannabis use in Canada since its legalization, in order to strengthen policies, services, treatments, training, and public education strategies.

METHODS

Using a scoping review framework developed by Arksey and O'Malley, along with the PRISMA-ScR guidelines, we conducted a rigorous search in five academic databases: MEDLINE, Embase, APA PsycINFO, CINAHL and Web of Science Core Collection. We included empirical studies that collected data in Canada after the legalization of recreational cannabis (October 2018) and focused on youth or young adults < 30. Two reviewers independently screened articles in two stages and extracted relevant information from articles meeting the inclusion criteria.

RESULTS

Of the 47 articles meeting our inclusion criteria, 92% used quantitative methods, 6% were qualitative, and 2% used a mixed-methods approach. Over two-thirds (68%) used secondary data. These studies were categorized into six focus areas: (1) prevalence, patterns, and trends, (2) cannabis-related injuries and emergency department (ED) visits, (3) rates and patterns during the pandemic, (4) perceptions of cannabis use, (5) prevention tools, and (6) cannabis-related offenses. Key findings from the studies reviewed include an increase in cannabis use among 18-24-year-olds post-legalization, with mixed results for youth under 18. ED visits for intentional and unintentional cannabis-related injuries have increased in young children and teens. Perception studies show a mix of concern and normalization of cannabis use. Though limited, prevention studies are promising in raising awareness. A decline in cannabis-related offenses was noted by one study. The review highlights several research gaps, including the need for more qualitative data, disaggregation of demographic data, intervention research, and comprehensive studies on the physical and mental health impacts of cannabis use among youth and young adults.

CONCLUSION

Maintaining a public health approach is critical, with a focus on reducing the high prevalence of cannabis use among youth and young adults. This involves implementing prevention strategies to minimize harms, enhancing public education, minimizing commercialization, reducing youth access to cannabis, promoting guidelines for lower-risk cannabis use and harm reduction strategies, and increasing training for healthcare providers.

Recreational Cannabis Legalization, Retail Sales, and Adolescent Substance Use Through 2021

This cross-sectional study using survey datasets evaluates recreational cannabis legalization and retail sales policies and adolescent substance use through 2021.

Rewiring the future: drugs abused in adolescence may predispose to mental illness in adult life by altering dopamine axon growth

Adolescence is a period of increased exploration and novelty-seeking, which includes new social behaviors, as well as drug experimentation, often spurred on by peer pressure. This is unfortunate, as the immature state of the adolescent brain makes it particularly susceptible to the negative developmental impact of drug use. During adolescence, dopamine terminals, which have migrated from the ventral tegmental area, pause in the nucleus accumbens, before segregating by either forming local connections or growing towards the prefrontal cortex (PFC). This developmentally late and lengthy process renders adolescent dopamine axon pathfinding vulnerable to disruption by substance use. Indeed, exposure to stimulant drugs in adolescent male mice, but not females, triggers dopamine axons to mistarget the nucleus accumbens and to grow ectopically to the PFC. Some evidence suggests that at this novel site, the functional organization of the ectopic dopamine axons mirrors that of the intended target. The structural rewiring dysregulates local synaptic connectivity, leading to poor impulse control ability, deficits of which are a core symptom of substance-use disorders. In the present commentary, we argue that different substances of abuse induce dopamine mistargeting events with the off-target trajectory prescribed by the type of drug, leading to psychiatric outcomes later in life.

Effects of cannabis legalisation on patterns of cannabis consumption among adolescents in Ontario, Canada (2001-2019)

INTRODUCTION

Cannabis legalisation was enacted on 17 October 2018 in Canada. Accordingly, the effects of cannabis legalisation on patterns of cannabis consumption were examined among adolescents, including on cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence.

METHODS

Data from a biennial population-based, cross-sectional survey of students in Ontario were pooled in a pre-post design (2001-2019; N = 89,238). Participants provided self-reports of cannabis initiation, any cannabis use, daily cannabis use and cannabis dependence. Long-term trends in these patterns of cannabis consumption over two decades of observation were characterised to provide a broader context of usage. The effects of cannabis legalisation on patterns of cannabis consumption were quantified using logistic regression analyses.

RESULTS

Long-term trends over the two decades of observation indicated that cannabis initiation decreased and then increased (p = 0.0220), any cannabis use decreased and daily cannabis use decreased (p < 0.0001 and p = 0.0001, respectively) and cannabis dependence remained unchanged (p = 0.1187). However, in comparisons between the pre-cannabis legalisation period (2001-2017) and the post-cannabis legalisation period (2019), cannabis legalisation was not associated with cannabis initiation (odds ratio; 95% confidence interval 1.00; 0.79-1.27), but it was associated with an increased likelihood of any cannabis use (1.31; 1.12-1.53), daily cannabis use (1.40; 1.09-1.80) and cannabis dependence (1.98; 1.29-3.04).

DISCUSSION AND CONCLUSIONS

Cannabis legalisation was not associated with cannabis initiation, but it was associated with an increased likelihood of any cannabis use, daily cannabis use and cannabis dependence.

Youth perception of difficulty accessing cannabis following cannabis legalization and during the early and ongoing stages of the COVID-19 pandemic: repeat cross-sectional and longitudinal data from the COMPASS study

BACKGROUND

Very little research has examined how perceptions of cannabis access among underage youth in Canada have changed since cannabis was legalized and since the onset of the COVID-19 pandemic. As such, this paper examines the effect of the early and ongoing stages of the COVID-19 pandemic period on youth perceptions of cannabis access over time since the onset of the Cannabis Act in 2018 in a large sample of Canadian youth.

METHODS

Using data from the COMPASS study (T1:2018/19, T2:2019/20, T3:2020/21), we used both repeat cross-sectional data [T1 (n = 38,890), T2 (n = 24,109), and T3 (n = 22,795)] to examine overall trends in perceptions of cannabis access, and sequential cohort longitudinal data [n = 4,677 students linked from T1 to T3] to examine the differential changes in perceptions of cannabis access among students over time.

RESULTS

In the cross-sectional sample, the frequency of students reporting that cannabis was easy to access decreased by 26.7% from T1 (51.0%) to T3 (37.4%), although respondents who have used cannabis were more likely to report access was easy. In the longitudinal sample, perceptions of cannabis access being easy increased over time, especially among cannabis users. Perceived ease of access appears to have been slightly impeded during the initial pandemic period but rebounded during the ongoing pandemic period.

CONCLUSIONS

While the prevalence of youth reporting that cannabis is easy to access has declined since legalization and throughout the early and ongoing pandemic periods, a substantial number of underage youth continue to report that cannabis is easy to access. This suggest that there is an ongoing need for continued cannabis control efforts to address this issue.

Proteome-Wide Profiling Using Sample Multiplexing of a Human Cell Line Treated with Cannabidiol (CBD) and Tetrahydrocannabinol (THC)

Cannabis has been used historically for both medicinal and recreational purposes, with the most notable cannabinoids being cannabidiol (CBD) and tetrahydrocannabinol (THC). Although their therapeutic effects have been well studied and their recreational use is highly debated, the underlying mechanisms of their biological effects remain poorly defined. In this study, we use isobaric tag-based sample multiplexed proteome profiling to investigate protein abundance differences in the human neuroblastoma SH-SY5Y cell line treated with CBD and THC. We identified significantly regulated proteins by each treatment and performed a pathway classification and associated protein-protein interaction analysis. Our findings suggest that these treatments may lead to mitochondrial dysfunction and induce endoplasmic reticulum stress. These data can potentially be interrogated further to investigate the potential role of CBD and THC in various biological and disease contexts, providing a foundation for future studies.

Factors associated with cannabis use in early adolescence

INTRODUCTION

We examined whether factors identified as associated with cannabis use at age 14 to 16 years are also associated with ever use at age 12.

METHODS

Participants in the AdoQuest study (n = 1852) were recruited in 2005 from among Grade 5 students in 29 French-language elementary schools in Montréal, Canada. Self-report data were collected from participants in Grade 5 (spring 2005) and 6 (fall 2005 and spring 2006) and from parents/guardians in 2006/07. Inclusion in the analytic sample (n = 1076; mean age [SD] = 10.7 [0.5]) required data from participant and parental questionnaires and data on cannabis use in Grade 6 (mean age [SD] = 11.7 [0.4]). We estimated associations between ever use at age 12 with 33 potential correlates, separately in unadjusted and adjusted logistic regression models.

RESULTS

Fifty-three participants (4.9%) reported ever use at age 12. Factors associated with higher odds of ever use included older age, identifying as male, lower household income, more weekly spending money, ever tried cigarettes or other tobacco products, ever drank alcohol or binge drank, ever gambled, friends or siblings smoke cigarettes, greater nicotine dependence, higher depressive symptoms and greater impulsivity. Protective factors included higher levels of parental/guardian monitoring and greater self-esteem and school connectedness.

CONCLUSION

Factors associated with cannabis use at later ages are also associated with ever use at age 12. Our findings suggest that surveillance for and interventions to prevent cannabis use are warranted before age 12.

Canadian cannabis education resources to support youth health literacy: A scoping review and environmental scan

Background

The 2018 legalisation of cannabis in Canada sparked concern and conversation about the potential negative impacts of youth cannabis use. It is clear that young people are already engaging in cannabis use for a variety of reasons; therefore, youth cannabis education is desirable to promote harm reduction and reduce the risk of adverse physical and mental health outcomes.

Objective

To identify and categorise Canadian cannabis education resources using a social-ecological approach informed by the youth health literacy framework, considering multiple factors at the micro-, meso- and macro-levels that influence health literacy and impact behaviour.

Methods

In line with scoping review methodology, database searches and an environmental scan of materials were completed. Specific inclusion criteria were identified to encompass all Canadian cannabis education resources directed towards young people aged 9-18 years and adults in contact with youth.

Results

A total of 60 resources were identified and categorised using the youth health literacy framework in terms of their focus on (1) micro influences (resources for youth); (2) meso influences (resources for teachers, parents, mentors); and (3) macro influences (resources for indigenous communities and medical professionals).

Conclusions

While many resources were identified, issues exist with the accessibility, quality and multicultural considerations of such resources, warranting the development of comprehensive, evidence-based and harm reduction-focused cannabis education for youth.

[Legalization of Recreational Cannabis use in Germany - Implications Based on Experiences in Uruguay, Canada und USA: a Narrative Review]

The current government of Germany has agreed on legalizing the recreational use of cannabis in their coalition agreement. Legalization will be implemented in 2023. This issue has continuously been a subject of controversial discussion including most parts of society, executive authorities and science. This article refers to the experiences of other countries (Uruguay, Canada, USA) yet having legalized Cannabis in the past and tries to discuss implications for Germany.

Youth cannabis use in Canada post-legalization: service providers' perceptions, practices, and recommendations

BACKGROUND

In 2018, Canada legalized recreational cannabis use with the purpose of protecting youth and restricting access. However, concerns have been raised that this objective has not been met as rates of cannabis use among youth aged 16-24 have not declined. Youth cannabis use is associated with various adverse effects including psychosis, anxiety, depression, suicidality, respiratory distress, cannabinoid hyperemesis syndrome, and intoxications. Service providers play a crucial role in addressing youth cannabis use. This study aimed to understand Ontario service providers' perceptions, practices, and recommendations on youth cannabis use.

METHODS

This mixed method study included a survey and two focus groups. The survey was distributed to mental health service providers serving youth aged 16-24 across Ontario who were given the option to participate in a focus group. The survey included closed and open-ended questions regarding perceptions, practices, and recommendations, while the focus groups explored these categories in greater depth. Descriptive statistics were used to analyze close-ended questions and interpretative content analysis was applied for open-ended questions. Focus group data were analyzed using thematic analysis.

RESULTS

The survey was completed by 160 service providers and 12 participated in two focus groups. Regarding perceptions, 60% of survey participants agreed with legalization, 26% had a strong understanding of medical versus recreational cannabis, 84% believed that cannabis has physical and mental health risks, and 49% perceived stigmatization. Less than half of the survey participants reported screening or assessing cannabis use, 16% stated they are highly familiar with treating cannabis use, and 67% reported that they rarely work with families. Subthemes identified in the focus groups under perceptions included normalization and stigmatization, harms for youth, and stigma, racism, and discrimination. Subthemes under practice included cannabis not being the primary focus, challenges with screening, assessment, and intervention, and referral to specialized services. Both the survey and focus group participants recommended increasing public education, enhancing service provider training, improving regulation and policies, reducing stigma and minimization, improving service access, and providing more culturally responsive services.

CONCLUSION

Youth cannabis use in Canada remains a significant public health concern, necessitating a more comprehensive plan to protect Ontario youth and reduce associated harms.

Trends of cannabis use and related harms before and after legalization for recreational purpose in a developing country in Asia

BACKGROUND

Thailand was the first country in Asia to legalize the use and purchase of cannabis leaves in February 2021 and the whole plant in June 2022 after the 2019 allowance for medical purposes. The study explored trends in cannabis use in Thailand before and after the recreational cannabis allowance was imposed.

METHODS

Cannabis and other variables of substance use, cannabis use disorder, and attitude towards cannabis of the Thai population aged 18 to 65 years in 2019 (n = 5,002), 2020 (n = 5,389) and 2021 (n = 5,669) were obtained from annual surveys conducted in the last two months of each year by the Centre for Addiction Studies. The surveys were repeat cross-sectional surveys of the general population of Thailand. Repeated variables from at least two annual surveys were included for analysis using the Chi-square test and the t-test.

RESULTS

The prevalence of cannabis use in the past year had increased from 2.2% in 2019 to 2.5% and 4.2% in 2020 and 2021 respectively, while those of methamphetamine, alcohol, and tobacco use had decreased. Trends in past-year drinking/eating cannabis products had increased, especially among the middle age group (40-49 years) from 2.1% (95% confidence interval (CI): 1.3, 3.1) in 2019 and 1.1% (95% CI: 0.6, 1.9) in 2020 to 3.8% (95% CI: 2.8, 5.0) in 2021. The younger population aged 18-19 had an increase in cannabis smoking from 0.9% (95% CI: 0.1, 3.3) in 2019 to 2.0% (95% CI: 0.5, 5.1) and 2.2% (95% CI: 0.7, 5.1) in 2020 and 2021 respectively. Symptoms of cannabis use disorder among cannabis users increased from 2019 to 2020 and then reversed afterwards in 2021. Thais had greater health knowledge about the benefits and harms of cannabis and had attitudes toward more harm of cannabis in 2021; however, 35.6% or a third of the sample in 2021 truly believed that cannabis was a cure for cancer, and 23.2% or one-fourth were uncertain or did not believe that cannabis was addictive.

CONCLUSIONS

Although most of the substances had a lower prevalence of use during the COVID-19 pandemic in Thailand, cannabis had a higher use after legalization. Thai youth had a growing trend to smoke cannabis.

The Impact of Recreational Cannabis Legalization on Cannabis Use and Associated Outcomes: A Systematic Review

Background

Recreational cannabis legalization has become more prevalent over the past decade, increasing the need to understand its impact on downstream health-related outcomes. Although prior reviews have broadly summarized research on cannabis liberalization policies (including decriminalization and medical legalization), directed efforts are needed to synthesize the more recent research that focuses on recreational cannabis legalization specifically. Thus, the current review summarizes existing studies using longitudinal designs to evaluate impacts of recreational cannabis legalization on cannabis use and related outcomes.

Method

A comprehensive bibliographic search strategy revealed 61 studies published from 2016 to 2022 that met criteria for inclusion. The studies were predominantly from the United States (66.2%) and primarily utilized self-report data (for cannabis use and attitudes) or administrative data (for health-related, driving, and crime outcomes).

Results

Five main categories of outcomes were identified through the review: cannabis and other substance use, attitudes toward cannabis, health-care utilization, driving-related outcomes, and crime-related outcomes. The extant literature revealed mixed findings, including some evidence of negative consequences of legalization (such as increased young adult use, cannabis-related healthcare visits, and impaired driving) and some evidence for minimal impacts (such as little change in adolescent cannabis use rates, substance use rates, and mixed evidence for changes in cannabis-related attitudes).

Conclusions

Overall, the existing literature reveals a number of negative consequences of legalization, although the findings are mixed and generally do not suggest large magnitude short-term impacts. The review highlights the need for more systematic investigation, particularly across a greater diversity of geographic regions.

Impact of Canada's cannabis legalisation on youth emergency department visits for cannabis-related disorders and poisoning in Ontario and Alberta, 2015-2019

INTRODUCTION

Although there is momentum towards legalising adult recreational cannabis use worldwide, the extent of youth cannabis-related harm associated with legalisation is still uncertain. The current study aimed to assess whether the initial implementation of Canada's cannabis legalisation (via the Cannabis Act) on 17 October 2018 might be associated with youth harm, as assessed by emergency department visits for cannabis-related disorders/poisoning.

METHODS

We used Ontario and Alberta, Canada emergency department data from 1 April 2015 to 31 December 2019. We identified all cannabis-related disorders/poisoning (ICD-10 CA: F12.X, T40.7) emergency department visits of youth (n = 13,615), defined as patients younger than the minimum legal cannabis sales age (18 years, Alberta; 19 years, Ontario). Seasonal Autoregressive Integrated Moving Average (SARIMA) models were employed to assess the impact of legalisation on weekly counts of cannabis-related harms.

RESULTS

The final SARIMA intervention (step) parameter indicated a post-legalisation increase of 14.7 (95% confidence interval [CI] 5.0; 24.3, p < 0.01) weekly youth cannabis-related disorder/poisoning presentations to Ontario/Alberta emergency department settings, equivalent to an increase of 20.0% (95% CI 6.2%; 33.9%). There was no evidence of associations between cannabis legalisation and comparison series of youth alcohol, opioid or appendicitis emergency department episodes.

DISCUSSION/CONCLUSION

Our findings require replication and extension but are consistent with the possibility that the implementation of the Cannabis Act was associated with an increase in youth cannabis-related presentations to Ontario/Alberta emergency departments.

Influence of Mild Traumatic Brain Injury History and Mental Health Status on Alcohol and Cannabis Use in University Athletes

OBJECTIVE

This study examined the relationship between mild traumatic brain injury (mTBI) history, mental health, and sex with single and polysubstance use in university athletes.

DESIGN

Observational study.

SETTING

University in Ontario, Canada.

PARTICIPANTS

Participants were identified from a dataset of 416 university athletes ages 18 to 21. Participants were classified based on their substance use habits and, 153 met criteria for the nonsubstance group, 195 for the alcohol use (AU) only group, and 64 polysubstance use group [ie, a combined substance use (AU+) group].

INDEPENDENT VARIABLES

Athletes received baseline assessments and completed self-reported questions regarding alcohol, cannabis, or other recreational substance use, the Patient Health Questionnaire-9, self-reported mTBI history, and self-reported anxiety, and/or panic disorder endorsement information.

MAIN OUTCOME MEASURES

Comparison of mTBI history and mental health status between individuals in the alcohol only or polysubstance use group.

RESULTS

Mild traumatic brain injury history was a significant predictor of AU ( P < 0.001) and AU+ ( P < 0.001). Anxiety endorsement was also a significant predictor of polysubstance use ( P < 0.001) and there was a small but nonsignificant association of polysubstance use in men ( P = 0.057).

CONCLUSIONS

University athletes who experience mTBI are more likely to engage in single or polysubstance use and athletes who experience anxiety are more likely to engage in polysubstance use. Consideration of mTBI history and mental health may inform clinical concussion management for identifying potential high-risk behavior such as polysubstance use in university athletes and tailoring intervention strategies (eg, incorporating education about substance use).

Digital interventions for substance use disorders in young people: rapid review

BACKGROUND

Young people are disproportionately more likely than other age groups to use substances. The rise in substance use and related harms, including overdose, during the Covid-19 pandemic has created a critical need for more innovative and accessible substance use interventions. Digital interventions have shown effectiveness and can provide more engaging, less stigmatizing, and accessible interventions that meet the needs of young people. This review provides an overview of recent literature on the nature of recently published digital interventions for young people in terms of technologies used, substances targeted, intended outcomes and theoretical or therapeutic models employed.

METHODS

Rapid review methodology was used to identify and assess the literature on digital interventions for young people. An initial keyword search was conducted using MEDLINE the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA) and PROSPERO for the years 2015-2020, and later updated to December 2021. Following a title/abstract and full-text screening of articles, and consensus decision on study inclusion, the data extraction process proceeded using an extraction grid developed for the study. Data synthesis relied on an adapted conceptual framework by Stockings, et al. that involved a three-level treatment spectrum for youth substance use (prevention, early intervention, and treatment) for any type of substance.

RESULTS

In total, the review identified 43 articles describing 39 different digital interventions. Most were early interventions (n = 28), followed by prevention interventions (n = 6) and treatment interventions (n = 5). The identified digital technologies included web-based (n = 14), game-based (n = 10), mobile-based (n = 7), and computer-based (n = 5) technologies, and virtual reality (n = 3). Most interventions targeted alcohol use (n = 20) followed by tobacco/nicotine (n = 5), cannabis (n = 2), opioids (n = 2), ketamine (1) and multiple, or any substances (n = 9). Most interventions used a personalized or normative feedback approach and aimed to effect behaviour change as the intended outcome. Interestingly, a harm reduction approach guided only one of the 39 interventions.

CONCLUSIONS

While web-based interventions represented the most common type of technology, more recently developed immersive and interactive technologies such as virtual reality and game-based interventions call for further exploration. Digital interventions focused mainly on alcohol use, reflecting less concern for tobacco, cannabis, co-occurring substance use, and illicit drug use. Specifically, the recent exacerbation in the opioid crisis throughout North American underlines the urgent need for more prevention-oriented digital interventions for opioid use. The uptake of digital interventions among youth also depends on the incorporation of harm reduction approaches.

Mental health and cannabis use among Canadian youth: Integrated findings from cross-sectional and longitudinal analyses

BACKGROUND AND PURPOSE

Using data from two methodologically independent youth research studies in Canada, the Health Behaviour in School-aged Children (HBSC) study and the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) study, the objective of this study was to compare associations between youth's mental health and cannabis use across samples. Using similar indicators in both studies, our goal was to affirm the potential for nationally representative cross-sectional analyses (HBSC) to replicate findings found in a longitudinal non-representative data source (COMPASS), enhancing opportunity for causal inferences.

METHODS

Data were collected from grade 9 and 10 Canadian students participating in the 2017/18 HBSC (n=8462) and 2017/18 to 2018/19 waves of COMPASS (n=32,023). Using multivariable Poisson regression models, the strength and statistical significance of the effects of mental health indicators on cannabis use outcomes were estimated within both studies and compared for consistency. Using a 2-year linked sample of students participating in COMPASS, models examining the impact of mental health indicators on cannabis use initiation and maintenance over time were similarly fit using Poisson regression to estimate relative risk.

RESULTS

Similar associations between mental health problems and cannabis use were observed in both data sources. The direction, magnitude, and precision of the estimates for restless sleep, loneliness, poor wellbeing, and cannabis use were highly comparable across both studies. Worse mental health was consistently associated with current and lifetime cannabis use among youth.

DISCUSSION

Cross-sectional and longitudinal findings from two large methodologically diverse studies in Canada demonstrate a replicable association between indicators of mental health and youth cannabis use. Similarities were identified and two generalizations may be concluded: 1) potentially causal etiological relationships inferred from HBSC data were supported in longitudinal findings based on COMPASS, and 2) longitudinal COMPASS data aligns with nationally representative data from HBSC.

Developments and Changes in Primary Public Health Outcome Indicators Associated with the Legalization of Non-Medical Cannabis Use and Supply in Canada (2018): A Comprehensive Overview

Canada legalized non-medical cannabis use and supply for adults in 2018. We examined developments and changes associated with the legalization policy reform on key indicators for public health, namely cannabis (including frequent/problematic) use prevalence, cannabis-related hospitalizations, cannabis-impaired driving, and cannabis sourcing. We identified peer-reviewed and "grey" study data that featured population-level or other quasi-representative samples and comparable outcome data for pre- and post-legalization periods, including possible trends of changes over time. Cannabis use has increased in select population groups, with use modes shifting away from smoking. Evidence on cannabis-related hospitalizations (e.g., for mental health) is mixed. The prevalence of cannabis-impaired driving appears to be generally steady but THC exposure among crash-involved drivers may have increased. Increasing proportions of users obtain cannabis products from legal sources but some-especially regular-users continue to use illicit sources. Overall, data suggest a mixed and inconclusive picture on cannabis legalization's impacts on essential public health indicators, including select extensions in trends from pre-legalization.

Youth substance use service provider’s perspectives on use and service access in ontario: time to reframe the discourse

Background

Age is a critical factor in substance use and related outcomes, with adolescence being a particularly sensitive period. Early initiation of substance use has been linked with higher risk for developing substance use disorders. In Ontario, Canada, substance use is common among youth, yet treatment is underutilized, suggesting the potential for an unmet need in terms of substance use care. Despite these challenges, there is limited research examining factors that contribute to youth substance use and youth-specific barriers to substance use care. To fill this knowledge gap, this study sought to include the unique perspectives of service providers who work directly with youth to examine these issues.

Methods

We used a cross-sectional mixed-methods design to examine factors that contribute to substance use among youth and identify youth-specific barriers to substance use among a sample of 54 Ontario-based youth service providers. Data collection included an online survey completed by all study participants followed by qualitative interviews of a subsample of 16 participants. Data analysis included basic frequency tabulations for survey results and thematic qualitative analyses to identify common themes.

Results

Licit substances were identified as the most commonly used among youth, where 94% of respondents identified cannabis use and 81% identified alcohol use. Thematic analyses identified the role of dominant substance use discourses in normalizing certain substances (i.e., cannabis and alcohol) while also endorsing stigmatizing beliefs and sentiments. According to youth service providers, the intersection of these two discourses simultaneously lead to an increase in substance use while deterring youth from seeking substance use care.

Conclusions

Normalization and stigmatization are two dominant discourses around youth substance use, with important implications for public health interventions. Key public health strategies, as identified by participants, to reduce the overall negative effect of these factors include the need to reframe substance use discourse, from a moral failing to a public health issue and to educate youth about the impacts of use. To accomplish this goal educational campaigns to raise awareness around the health effects of use and address stigmatization are needed. Educational reforms are also needed to ensure that these programs are integrated into the school system.

Shifting school health priorities pre-post cannabis legalization in Canada: Ontario secondary school rankings of student substance use as a health-related issue

This study examined how schools prioritize ten key health concerns among their student populations over time and whether schools' prioritization of alcohol and other drug use (AODU) corresponds to students' substance use behaviours and cannabis legalization as a major policy change. Data were collected from a sample of secondary schools in Ontario, Canada across four years (2015/16-2018/19 [N2015/16 = 65, N2016/17 = 68, N2017/18 = 61 and N2018/19 = 60]) as a part of the COMPASS study. School-level prevalence of cannabis and alcohol use between schools that did and did not prioritize student AODU as a health concern was examined. Ordinal mixed models examined whether student cannabis and alcohol use were associated with school prioritization of AODU. Chi-square tests examined changing health priorities among schools pre-post cannabis legalization. School priority ranking for AODU was mostly stable over time. While AODU was identified as an important health concern, most schools identified mental health as their first priority across the four years of the study. No significant changes to school AODU priorities were observed pre-post cannabis legalization nor was school prioritization of AODU associated with student cannabis and alcohol use behaviours. This study suggests that schools may benefit from guidance in identifying and addressing priority health concerns among their student population.

Does recreational cannabis legalization change cannabis use patterns? Evidence from secondary school students in Uruguay

BACKGROUND AND AIMS

In 2013, Uruguay became the first country to legalize and regulate the production and distribution of cannabis for recreational use. We measured whether Uruguay's non-commercial model of recreational cannabis legalization was associated with changes in the prevalence of risky and frequent cannabis use among secondary school students.

DESIGN

We used data from repeated cross-sectional surveys of secondary students in Uruguay and Chile (2007-2018). Using a difference-in-difference approach, we evaluated changes in the prevalence of past-year, past-month, any risky and frequent cannabis use following enactment (2014) and implementation (2016) of cannabis legalization among the full sample of secondary students and among students who reported past-year/month use. We examined changes separately for students ages 12 to 17, and students for whom cannabis became legally accessible, ages 18 to 21.

SETTING

Uruguay and Chile (2007-2018).

PARTICIPANTS

Secondary school students in 8th, 10th and 12th grade (n = 204 730).

MEASUREMENTS

Past-year and past-month cannabis use; any risky cannabis use measured with the Cannabis Abuse Screening Test (CAST); and frequent cannabis use (10+ days in the past-month).

FINDINGS

We found a decrease in past-year and past-month use following enactment or implementation. Among students ages 18 to 21, post-enactment, we observed a transitory increase in 2014 that decreased thereafter for: any risky use among those who reported past-year use (prevalence difference [PD] = 13.5%; 95% CI: 2.0, 24.9), frequent use in the full sample (PD = 4.5%; 95% CI: 1.0, 8.1), and frequent use among those who reported past-month use (PD = 16.8%; 95% CI: 1.9, 31.8).

CONCLUSION

The legalization of recreational cannabis in Uruguay was not associated with overall increases in either past-year/past-month cannabis use or with multi-year changes in any risky and frequent cannabis use among young people.

A Systematic Review and Narrative Synthesis of the Evolution of Adolescent and Young Adult Cannabis Consumption Before and After Legalization

PURPOSE

To systematically review evidence assessing the evolution of cannabis consumption before and after the implementation of non-medical cannabis legislation.

METHODS

MEDLINE, PubMED, PsycINFO, Scopus, and Web of Science were systematically searched for studies that examined change in cannabis consumption before and after nonmedical cannabis legislation. Data were tabulated by study design, levels of consumption, and individual subgroups. Data were analyzed using a narrative synthesis approach, considering study quality.

RESULTS

32 studies were included (11 higher quality and 21 lower quality). 40% of higher quality evidence supported an increase in postlegalization consumption (55% did not report a change and 5% reported a decrease). The increase was most evident for young adults (42% of higher quality evidence) and in the consumption in the past month (37% of higher quality evidence). There was limited supporting evidence for new users having grown in response to legalization. Based on subgroup analysis, the increase in postlegalization consumption was higher among women and those who engage in binge-drinking.

CONCLUSIONS

Higher quality evidence suggests an increase in adolescent past-month consumption of cannabis following legalization in several geographical jurisdictions. Consumption evolution prelegalization and postlegalization differed by age group and for young women and for binge drinkers. Consumption evolution differences suggest a variety of strategies might be required in efforts to lower public health impacts of cannabis consumption following legalization.

Incidence of inpatient cases with mental disorders due to use of cannabinoids in Germany: a nationwide evaluation

Background

Quantitative (e.g. increasing recreational cannabinoid use) and qualitative (e.g. increasing availability and use of synthetic cannabinoids and cannabis preparations with increased tetrahydrocannabinol content) changes in cannabinoid use may be associated with changes in the prevalence of cannabinoid-related mental and behavioural disorders and, accordingly, changes in the need for medical care. We aimed to investigate if there are changes in the number of inpatient cases (ICs) due to cannabinoid-related disorders in Germany.

Methods

Data were obtained from the Federal Statistical Office of Germany (Destatis) and comprised type and number of hospital main diagnoses (according to ICD-10) of all ICs in Germany in the period 2000–18. Linear trend analysis of absolute and relative annual frequencies (AFs) of ICs with diagnoses related to the use of cannabinoids (DRUCs), and, as controls, alcohol-related psychiatric disorders and schizophrenia-spectrum disorders was performed.

Results

Absolute AFs of ICs with DRUCs increased statistically significantly (P<0.0001, trend analysis) in Germany between 2000 and 2018 and corresponding relative AFs increased considerably (4.8-fold increase when comparing 2000 and 2018). Specifically, absolute AFs of ICs with cannabinoid intoxications (P<0.0001), harmful use (P=0.0005), dependence syndrome (P< 0.0001), withdrawal state (P<0.0001), psychotic disorders (P< 0.0001) and residual and late-onset psychotic disorder (P<0.0001) statistically significantly increased. Absolute AFs of schizophrenia-spectrum disorders slightly, but statistically significantly decreased (P=0.008), and alcohol dependence did not statistically significantly change (P=0.844).

Conclusions

Our evaluation demonstrates increasing numbers of ICs with mental and behavioural disorders due to use of cannabinoids in Germany and emphasizes the need for adequate prevention of such disorders.

The Relations between Youth Cannabis Use, School Cannabis Use-Related Disciplinary Approaches and Student Perceptions of School Support

Background: In the school year immediately following cannabis legalization in Canada, this paper investigated youth perceptions of school support for the prevention and cessation of substance use. Scant research has examined student perceptions in relation to school disciplinary approaches. This study was the first to classify school discipline approach styles using school-level measures.Objective: The objective of this study was to examine whether different school cannabis use-related disciplinary approaches are associated with student cannabis use and perceptions of school supportiveness for the prevention and cessation of substance use.Results: School- and student-level survey data from Year 7 (the 2018/2019 school year) of the COMPASS study were used, including 68,037 grade 9-12 (Secondary I-V in Quebec) students attending 131 Canadian secondary schools. Schools were classified as using different cannabis use-related disciplinary styles based on school-administrator reported approaches to student first-offense violations of school cannabis policies. We identified that although none of the cannabis use-related disciplinary approach styles examined were associated with cannabis use, they were associated with student perceptions. Students attending schools classified as using a Permissive/Supportive approach had a higher likelihood of perceiving their school as supportive for substance use prevention/cessation than their peers at Authoritarian schools. Students who perceived their school as supportive for substance use prevention/cessation were less likely to report current cannabis use than their peers who perceived their school as unsupportive.Conclusions: Unlike previous studies using school classification styles that are based on student perceptions, results do not support direct associations between school cannabis use-related disciplinary styles and student cannabis use. Future prospective research should examine whether supportive disciplinary approaches (e.g., counseling referrals, educational programs) promote student perceptions of school supportiveness, and in turn, deter student substance use.

The impact of cannabis legalization for recreational purposes on youth: A narrative review of the Canadian experience

Cannabis legalization for non-medical purposes (subsequently referred to as "cannabis legalization" or "legalization") took place in Canada in October 2018. One of the federal government's stated goals with cannabis legalization was to protect Canadian youth from cannabis-related harms. The main objective of this narrative review is to describe the impact of cannabis legalization on Canadian youth. To that end, we discuss the regulation of the Canadian cannabis market, outline changes in the epidemiology and parameters of cannabis use (modes of use, potency of cannabis) among youth, and discuss prevention and education initiatives related to cannabis. The Canadian model differs from other jurisdictions that legalized recreational cannabis use, especially with regard to a higher degree of government regulation of the cannabis market. Another difference is the development and endorsement of lower-risk cannabis use guidelines to educate the public and health professionals. The results available for this review cover only 3 years post-legalization. Cannabis legalization in Canada brought an apparent increase in use among Canadian older than 25. However, results for youth are mixed, with the majority of studies showing no pronounced increase. Notably, the trend of a decrease in adolescents' cannabis use seen pre-legalization may have reversed. Emerging evidence also suggests that cannabis-related hospitalizations and emergency department visits among Canadian youth may have increased due to cannabis legalization. Data about changes in the age of initiation, the influence of legalization on sex and gender, and race/ethnicity are limited, with evidence suggesting that the age of initiation slightly increased. So far, there is limited data about the impact of cannabis legalization on Canadian youth. Further long-term monitoring and research to assess the effects of cannabis legalization on Canadian youth.

Changes in alcohol use by cannabis use status among adolescents and young adults in the United States: Emerging evidence for both substitution and complementarity

BACKGROUND

The majority of adolescents and young adults (AYA) who use cannabis also use alcohol. Although cannabis use is increasing in the United States (US), it is not known whether the increase contributes to either increased co-use of alcohol and cannabis (e.g., complementarity) or replacement of alcohol with cannabis (e.g., substitution). The current study estimated the prevalence of alcohol use by cannabis use status among US AYA ages 12 to 25 in 2018 and trends in alcohol use by cannabis use status from 2002 to 2018.

METHODS

Data were drawn from the 2002 to 2018 National Survey on Drug Use and Health public use data files. The analytic sample included AYA ages 12 to 25 (2018 sample, n = 26,924; total combined sample 2002 to 2018, n = 576,053). Linear and logistic regression models were used to estimate past-month alcohol use, daily alcohol use, and average quantity of alcohol consumed among AYA with and without past-month cannabis use from 2002 to 2018.

RESULTS

In 2018, any alcohol use and daily alcohol use were significantly more common among AYA who used cannabis use than those who did not use cannabis. Overall, any alcohol use, daily alcohol use, and average drinks per day declined from 2002 to 2018 among AYA irrespective of recent cannabis use. However, the decline in any alcohol use, daily alcohol use, and average alcohol drinks per day was more rapid among AYA who used cannabis (daily and nondaily) than those who did not use cannabis. The rate of decline in average alcohol drinks per day was also higher among AYA with daily compared to nondaily cannabis use.

CONCLUSIONS

Even with declines in alcohol use over time, drinking is much more common among AYA who report cannabis than those without recent cannabis use, which is consistent with complementarity. Yet, because the decline in alcohol use has been more rapid among AYA who use cannabis, there is also evidence of substitution. Thus, the current data on alcohol and cannabis use are consistent with both complementarity and substitution. However, these relationships may change as cannabis legalization expands over time.

Youth Cannabis use and Legalization in Canada - Reconsidering the Fears, Myths and Facts Three Years In

Canada legalized and regulated non-medical cannabis in October 2018, and in the lead up to this policy change much debate was generated around the Federal Government's stated objective of "keeping cannabis out of the hands of children and youth". As Canada moved through the process of passing Bill C-45 (the Cannabis Act), a contentious issue was whether the 'public health approach' to legalization with strict regulation guiding Federal policy would protect young people from accessing cannabis and from the potential harms of use. Now that we are several years post-legalization of cannabis, in this brief commentary we reconsider the arguments made about the potential consequences of legalization for youth, centered on three key concerns: that prevalence would significantly increase, that there would be greater incidence of harms to youth brain development, and that there would be increased presentations of severe mental illnesses associated with cannabis use. We also consider how focusing narrowly on clinical outcomes has neglected the association between criminalization and social inequities, where the burdens are disproportionate for marginalized and racialized youth.

Examining the impact of the early stages of the COVID-19 pandemic period on youth cannabis use: adjusted annual changes between the pre-COVID and initial COVID-lockdown waves of the COMPASS study

Background

Given the high rates of cannabis use among Canadian youth and that adolescence is a critical period for cannabis use trajectories, the purpose of this paper was to examine the effect of the early stages of the COVID-19 pandemic period on youth cannabis use in the context of a natural experiment.

We used 3-year linked data from the COMPASS study, including 7653 Canadian (Quebec, Ontario) adolescents from which 1937 completed all 3 survey waves (pre-COVID-19 [2018, 2019] and online [2020] during the early pandemic period [May–July 2020]). Structural equation modeling (SEM) and double difference (DD) models were used to estimate pre-COVID-19 to initial COVID-19 pandemic period change (2019–2020) in cannabis use (monthly, weekly, daily) compared to 2018 to 2019 change to adjust for age-related effects. Models were adjusted for age of entry into the cohort and sociodemographic characteristics.

Results

In the SEM and DD models, monthly, weekly, and daily cannabis use increased across all waves; however, the expected increases from the pre-COVID-19 wave (2019) to the initial COVID-19 period wave (2020) were lesser relative to the changes seen across the 2018 to 2019 waves. The cross-sectional data from May to July 2020 identified that the majority of youth who use cannabis did not report increased cannabis use due to COVID-19 or using cannabis to cope with COVID-19.

Conclusion

During the early stages of the COVID-19 pandemic period, there does not appear to be a detrimental effect on youth cannabis use, when adjusted for age-related changes. Further prospective research is needed to explore the impact of the ongoing pandemic response on youth cannabis use onset and progression.