Access to legal cannabis market in Canada over the four years following non-medical cannabis legalisation

Changes in Incident Schizophrenia Diagnoses Associated With Cannabis Use Disorder After Cannabis Legalization

Importance

Despite public health concerns that cannabis legalization may increase the number of cases of schizophrenia caused by cannabis, there is limited evidence on this topic.

Objective

To examine changes in the population-attributable risk fraction (PARF) for cannabis use disorder (CUD) associated with schizophrenia after liberalization of medical cannabis and legalization of nonmedical cannabis in Canada.

Design, Setting, and Participants

This population-based cohort study was conducted in Ontario, Canada, from January 1, 2006, to December 31, 2022, among 13 588 681 people aged 14 to 65 years without a history of schizophrenia.

Exposures

Diagnosis of CUD in the emergency department or hospital setting (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada [ICD-10-CA] codes F12x and T40.7).

Main Outcome and Measures

Changes in the PARF for CUD associated with schizophrenia (ICD-10-CA codes F20x and F25x and Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] [DSM-IV] code 295x) over 3 policy periods: prelegalization (January 2006 to November 2015), liberalization of medical and nonmedical cannabis (December 2015 to September 2018), and legalization of nonmedical cannabis (October 2018 to December 2022). A secondary outcome was diagnosis of psychosis not otherwise specified (NOS) (ICD-10-CA code F29x and DSM-IV code 298x). Segmented linear regression was used to examine changes after the liberalization of medical cannabis in 2015 and the legalization of nonmedical cannabis in 2018.

Results

The study included 13 588 681 individuals (mean [SD] age, 39.3 [16.1] years; 6 804 906 males [50.1%]), of whom 118 650 (0.9%) had CUD. A total of 91 106 individuals (0.7%) developed schizophrenia (80 523 of 13 470 031 [0.6%] in the general population without CUD vs 10 583 of 118 650 [8.9%] with CUD). The PARF for CUD associated with schizophrenia almost tripled from 3.7% (95% CI, 2.7%-4.7%) during the prelegalization period to 10.3% (95% CI, 8.9%-11.7%) during the legalization period. The PARF in the postlegalization period ranged from 18.9% (95% CI, 16.8%-21.0%) among males aged 19 to 24 years to 1.8% (95% CI, 1.1%-2.6%) among females aged 45 to 65 years. The annual incidence of schizophrenia was stable over time, while the incidence of psychosis NOS increased from 30.0 to 55.1 per 100 000 individuals (83.7%) in the postlegalization period relative to the prelegalization period. The PARF for CUD associated with schizophrenia increased steadily over the study with no accelerations after cannabis policy changes, while increases in the PARF for CUD associated with psychosis NOS accelerated after medical cannabis liberalization.

Conclusions and Relevance

In this cohort study of individuals aged 14 to 65 years in Ontario, Canada, the proportion of incident cases of schizophrenia associated with CUD almost tripled during a period of substantial liberalization of cannabis policy. Ongoing research is indicated to understand the long-term associations of cannabis policy with the prevalence of psychotic disorders.

Changes in population-level alcohol sales after non-medical cannabis legalisation in Canada

INTRODUCTION

There is considerable interest in whether individuals substitute cannabis for alcohol and in legalisation's potential to reduce or increase alcohol-attributable harms. This study aimed to determine whether non-medical cannabis legalisation in Canada was associated with initial changes in population-level alcohol consumption.

METHODS

This observational population-based study described changes in alcohol sales in Canada between 2004 and 2022. We calculated annual changes in the per capita volume of pure ethanol sold in Canada. We used an interrupted time series approach to examine immediate and gradual changes in per capita price-adjusted alcohol retailer sales value (CAD$) and beer producer sales volume (litres of product) after legalisation.

RESULTS

During 2004-2022, Canadians aged 15+ spent on average CAD $751 per year on alcoholic beverages containing 8.18 L of ethanol. Annual ethanol sales volumes decreased by 0.06 (95% confidence interval [CI] -0.08 to -0.04; p = 0.001) litres per capita annually for beer but increased by 0.05 (95% CI 0.04 to 0.07; p = 0.001) litres per capita annually for other beverages, leaving no significant trend for ethanol sales overall. Following non-medical legalisation in October 2018, there were no immediate (-0.1%, 95% CI -1.3 to 1.1; p = 0.82) or gradual changes (-0.1% monthly, 95% CI -0.3 to 0.0; p = 0.12) in alcohol retailer sales.

DISCUSSION AND CONCLUSION

Canada's non-medical cannabis legalisation was not associated with significant changes in population-level alcohol sales. These findings do not support the idea that cannabis legalisation may result in declining alcohol use and harms through the substitution of cannabis for alcohol.

The adverse public health effects of non-medical cannabis legalisation in Canada and the USA

Cannabis consumption is legally prohibited in most countries in the world. Several countries are legalising cannabis for adult consumption. It is important to monitor the public health effects of these policy changes. In this paper, we summarise the evidence to date on the legalisation of adult non-medical cannabis use in Canada and the USA. We describe regulatory models for cannabis legalisation, changes in cannabis products and pricing, effects on the illicit cannabis market, changes in cannabis use, and changes in cannabis-related physical and mental health harms. We discuss the challenges in assessing the effects of cannabis legalisation on public health outcomes and emphasise the importance of continuous and rigorous monitoring of adverse health effects to inform the design of public health policies and regulations.

Exploring the association between neighborhood disadvantage and cannabis retail density: A multi-measure analysis

INTRODUCTION

There is growing interest in the relationship between neighborhood disadvantage and increased cannabis retail density, driven by evidence suggesting higher density is associated with increased cannabis use. Yet little is known on how this relationship varies across different measures of cannabis retail density. This study explores how measures of neighborhood advantage and disadvantage relate to four cannabis retail density measures in the US.

METHODS

Data on licensed recreational cannabis retailers (n = 5586) were obtained from 18 state agency websites, geocoded, and spatially joined to 3369 census tracts to calculate four retail density measures: count per tract, cannabis retailers per 1000 population, per square mile, and per 10 miles of roadway. Multilevel regression models assessed the association between three Index of Concentration at the Extremes (ICE) measures-capturing tract concentration of racial and economic advantage/disadvantage-and the four cannabis retail density measures.

RESULTS

Census tracts with the highest concentrations of economic and racialized/economic disadvantage exhibited greater odds of increased cannabis retail density across all measures, compared to tracts with the highest concentration of advantage. Tracts with the greatest concentration of racialized populations did not show a higher count or density per population but did exhibit higher density per square mile and per roadway.

CONCLUSION

On average, cannabis retail density is higher in neighborhoods with the greatest structural disadvantage. Researchers, public health agencies, and policymakers should use multiple measures of cannabis retailer density in surveillance and evaluation efforts to identify policy strategies that would most effectively reduce the clustering of cannabis retailers in areas primarily occupied by low-income or racialized populations.

Bridging the gap: Exploring consumer experiences and motivations for transitioning between illicit and regulated cannabis markets

BACKGROUND

Canada pioneered the non-medical legalization of cannabis production and sales, witnessing substantial growth in the regulated market over the last five years, post-legalization. However, persistent barriers hinder many consumers from transitioning to the legal market, necessitating a nuanced understanding of their behaviors for targeted policy interventions. This study aims to improve understanding of cannabis consumers' unregulated purchase decisions in British Columbia (B.C.), and to explore motivational factors for transitioning to the legal market.

METHODS

We conducted semi-structured interviews with cannabis consumers in B.C., who were at least 19 years old and purchased some or all of their cannabis through unregulated sources. Interviews were transcribed and an inductive thematic analysis was conducted using NVivo. Through coding iterations, we moved from descriptive to analytic codes, and finally mapped the codes to themes aligned with the Five Stages of Consumer Decision Making model.

RESULTS

Participants (N = 31) represented a broad range of demographic characteristics (i.e., gender, age, education, income). Four themes were identified: seeking information, evaluation of alternatives, purchase decision, and post purchase evaluation. Despite purchasing all or some of their cannabis from the unregulated market, most participants were supportive of legalization and felt that legal cannabis is safe, accessible, and of reasonable quality. However, several barriers prevent consumers from regularly accessing the regulated market, including: price, lack of sales and promotions, potency, limited product variety, and inadequate product interaction.

CONCLUSION

This study delineates barriers that obstruct consumers' transition to the regulated market. These findings, aligned with considerations for public health and safety, offer valuable insights to inform cannabis policy and promote a more effective and consumer-oriented regulatory framework.

Reducing the harms of cannabis use in youth post-legalization: insights from Ontario youth, parents, and service providers

BACKGROUND

Canada has one of the highest prevalence of cannabis use globally, particularly among young adults aged 20-24 (50%) and youth aged 16-19 (37%). In 2018, Canada legalized recreational cannabis with the aim of protecting youth by restricting their access and raising public awareness of health risks. However, there has been limited qualitative research on the perceptions of harms associated with youth cannabis use since legalization, which is crucial for developing effective harm reduction strategies. This qualitative study examined perceptions of cannabis use among youth from the perspectives of youth, parents, and service providers. We explored how participants described the perceived risks or harms associated with youth cannabis use, as well as how they described their own and others' approaches to reducing cannabis-related risks and harms.

METHODS

This qualitative study used a community-based participatory research approach in partnership with Families for Addiction Recovery (FAR), a national charity founded by parents of youth and young adults with addiction issues. Virtual semi-structured interviews were conducted, and the data were analyzed using thematic analysis.

RESULTS

The study included 88 participants from three key groups (n = 31 youth, n = 26 parents, n = 31 service providers). Two main themes emerged regarding perceived risks or harms associated with cannabis use: (1) concerns about cannabis-related risks and harms, including addiction, brain development, impact on family, and various adverse effects on areas such as motivation, concentration, finances, employment, education, physical and mental health; and (2) minimization of risks and harms, featuring conflicting messages, normalization, and perceptions of cannabis being less harmful than other substances. Additionally, two themes related to harm reduction approaches were identified: (1) implementation of harm reduction, and (2) challenges in implementing a harm reduction approach. Specific challenges for each participant group were noted, along with structural barriers such as unavailable and inaccessible services, easy access to cannabis, inadequate public education, and insufficient information on lower-risk cannabis use guidelines.

CONCLUSIONS

Youth cannabis use is a significant public health concern that requires a multi-pronged approach. Developing youth-centered harm reduction strategies that recognize the developmental needs and vulnerabilities of youth, as well as the important role of families, is imperative.

Geographic clustering of cannabis stores in Canadian cities: A spatial analysis of the legal cannabis market 4 years post-legalisation

INTRODUCTION

Following the legalisation of non-medical cannabis in 2018, the number of cannabis stores in Canada has rapidly expanded with limited regulation on their geographic placement. This study characterised the clustering of cannabis stores in Canadian cities and evaluated the association of clustering with provincial policy and sociodemographic variables.

METHODS

Cross-sectional spatial analysis of cannabis store density in dissemination areas ('neighbourhoods', n = 39,226) in Canadian cities in September 2022. Cannabis store density was defined as the count of stores within 1000 m of a neighbourhood centre. Clusters of high-density cannabis retail were identified using Local Indicators of Spatial Autocorrelation. Associations between provincial policy (privatised vs. public market), sociodemographic variables and cannabis store density were evaluated using multivariable regression.

RESULTS

Clusters of high-density cannabis retail were identified in 86% of Canadian cities, and neighbourhoods in clusters had a median of 5 stores within 1000 m. Toronto, Canada's most populous city, had the most extreme clustering where neighbourhoods in clusters had a median of 10 stores (and a maximum of 25 stores) within 1000 m. Neighbourhoods in private versus public retail markets had a significantly higher neighbourhood-level density of cannabis stores (adjusted rate ratio [aRR] 63.37, 95% confidence interval [CI] 25.66-156.33). Lower neighbourhood income quintile was also associated with a higher neighbourhood-level density of cannabis stores (Q5 vs. Q1, aRR 1.28, 95% CI 1.17-1.40).

DISCUSSION AND CONCLUSIONS

Since cannabis was legalised, clusters of high-density cannabis retail have emerged in most Canadian cities and were more likely to form lower income neighbourhoods and in private retail markets.

Should cannabis self-cultivation be part of a public health‒oriented legalization policy framework?

Cannabis control policies are increasingly being liberalized, including the legalization of non-medical cannabis use and supply in multiple settings, for example in Canada, with main policy objectives focusing on improved public health. An important while contested matter has been the appropriate design of legal cannabis supply structures and sources. These, in most Americas-based legalization settings, have included provisions for (limited) 'home cultivation'. Recent data suggest that about 8% of active consumers engage in cannabis home cultivation for their own supply, while approximately 14% are exposed to it in/around their home. Home cultivation commonly exceeds legal limits and/or occurs where not allowed, and is disproportionately associated with high-frequency and/or other risk patterns of cannabis use. In addition, home cultivation may facilitate exposure or diversion of cannabis to minors, as well as pose possible environmental exposure risks especially when occurring indoors. Given its placement in private spaces, related regulations are largely shielded from enforcement. Home cultivation, therefore, bears substantive potential to circumvent or work counter to public health‒oriented legalization policy objectives. Recent assessments of health outcomes from cannabis legalization show mixed-including multiple adverse-results, implying the need for regulatory revisions towards protecting public health outcomes. Especially in settings where extensive (e.g. commercial) retail systems were established to provide regulated, legal cannabis products to consumers, it is questionable whether home cultivation overall serves primary public health‒oriented objectives; relevant data should be expanded and used to review related provisions.

Cannabis consumers' preferences for legal and illegal cannabis: evidence from a discrete choice experiment

BACKGROUND

In U.S. states that legalized and commercialized recreational cannabis, cannabis sales in illegal markets are still sizable or even larger than those in legal markets. This study aimed to assess cannabis consumers' preferences for purchasing cannabis from legal and illegal markets and estimate the trade-offs under various policy scenarios.

METHODS

963 adults were recruited, who used cannabis in the past year and lived in a state with recreational cannabis legalization. In a discrete choice experiment, participants chose purchasing cannabis from a legal dispensary or an illegal dealer with varying levels in product attributes including quality, safety, accessibility, potency, and price. Mixed logit models were used to analyze preferences.

RESULTS

The likelihood of choosing legal cannabis increased with a higher quality, the presence of lab test, a shorter distance to seller, a higher tetrahydrocannabinol level, and a lower price. The likelihood of choosing illegal cannabis increased with a higher quality, a shorter distance to seller, and a lower price. Among product attributes, quality and accessibility were perceived to be the most important for legal cannabis and price was perceived to be the most important for illegal cannabis. Policy simulations predicted that improving quality, ensuring safety, allowing delivery services, increasing dispensary density, and lowering prices/taxes of legal cannabis may reduce illegal cannabis market share.

CONCLUSIONS

In the U.S., cannabis consumers' preferences for illegal cannabis were associated with both legal and illegal cannabis product attributes. Policies regulating legal cannabis markets should consider potential spillover effects to illegal markets.

Changes in cannabis involvement in emergency department visits for anxiety disorders after cannabis legalization: a repeated cross-sectional study

Background

An increasing number of countries have or are considering legalizing cannabis. One concern is that legalization of cannabis will result in increased cannabis use and in turn a higher prevalence of anxiety disorders. We examined changes in emergency department (ED) visits for anxiety disorders with cannabis involvement in Ontario, over a period that involved medical and non-medical cannabis legalization.

Methods

This repeated cross-sectional population-based study identified all ED visits for anxiety disorders from residents of Ontario, Canada aged 10-105 between 2008 and 2022 (n = 15.7 million individuals). We used interrupted time series analyses to examine immediate and gradual changes in cannabis-involvement and alcohol-involvement (control condition) over four policy periods: medical cannabis legalization (January 2008-November 2015), expanded medical access (December 2015-September 2018), non-medical cannabis legalization with restrictions (October 2018-February 2020), and commercialization which overlapped with the COVID-19 pandemic (March 2020-December 2022). Poisson models were used to generate incidence rate ratios with 95% confidence intervals.

Findings

Over the 14-year study, there were 438,700 individuals with one or more ED visits for anxiety disorders of which 3880 (0.89%) individuals had cannabis involvement and 6329 (1.45%) individuals had alcohol involvement. During the commercialization/COVID-19 period monthly rates of anxiety disorders with cannabis-involvement were 156% higher (0.11 vs 0.29 per 100,000 individuals) relative to the pre-legalization period, compared to a 27% increase for alcohol-involvement (0.27 vs 0.35 per 1100,000 individuals). Rates of anxiety ED visits with cannabis involvement per 100,000 individuals increased gradually over the study period with no immediate or gradual changes after expanded medical access, legalization with restrictions or commercialization/COVID-19. However, during the commercialization/COVID-19 period there were large declines in total anxiety disorder ED visits and anxiety disorder ED visits with alcohol-involvement. Consequently, during this period there was an immediate 31.4% relative increase in the proportion of anxiety visits with cannabis-involvement (incidence rate ratio [IRR], 1.31; 95% CI 1.05-1.65).

Interpretation

We found large relative increases in anxiety disorder ED visits with cannabis involvement over a 14-year period involving medical and non-medical cannabis legalization. These findings may reflect increasing anxiety disorder problems from cannabis use, increasing self-medication of anxiety disorders with cannabis use, or both. The proportion of anxiety ED visits with cannabis involvement increased during the final period of the study but could have been the results of the market commercialization, COVID-19 or both and ongoing monitoring is indicated.

Funding

Canadian Institutes of Health Research (grant #452360).

Changes in medical cannabis use in Ontario, Canada (2014 to 2019): Trajectory of trends, medical authorization patterns and association with recreational cannabis legalization

Objectives

We characterized trends in medical cannabis use; examined characteristics associated with medical cannabis use without medical authorization; and examined the association between recreational cannabis legalization and medical cannabis use in Ontario, Canada.

Methods

Data were from a repeated, population-based, cross-sectional survey of adults (N = 19,543; 2014-2019). Cannabis use was categorized as either medical cannabis use, recreational cannabis use or no cannabis use. The analytical strategy included jointpoint regression, logistic regression and multinomial logistic regression.

Results

Medical cannabis use increased from 4 % to 11 % (Annual Percentage Change [APC]: 25 %, 95 % Confidence Interval [CI]: 17 %-33 %) and recreational cannabis use increased from 9 % to 15 % (APC: 9 %, 95 % CI: 3 %-15 %) between 2014 and 2019. Being 18 to 29 years old compared with being 65+ years old was associated with an increased likelihood of medical cannabis use without medical authorization (Odds Ratio [OR]: 4.05, 95 % CI: 2.12-7.72), while being of fair or poor self-perceived health compared with excellent, very good or good self-perceived health (OR: 0.61, 95 % CI: 0.40-0.95) was associated with a decreased likelihood of medical cannabis use without medical authorization. Recreational cannabis legalization was associated with an increased likelihood of medical cannabis use compared with no cannabis use (OR: 1.48, 95 % CI: 1.19-1.85) and of recreational cannabis use compared with no cannabis use (OR: 1.35, 95 % CI: 1.11-1.65).

Conclusions

Although medical cannabis use increased, it was largely used without medical authorization. Guidance and education that encourages medical usage under clinical supervision is recommended, and mitigation of known barriers to medical cannabis authorization.

Germany's cannabis act: a catalyst for European drug policy reform?

With the enforcement of the Cannabis Act on 1 April 2024, Germany has adopted one of the most liberal legal approaches to cannabis on the continent. The German model prioritises a non-profit approach and precludes legal market mechanisms. We believe these are the main drivers for increasing cannabis use and related health problems, based on observations following cannabis legalisation in Canada and many states in the U.S. Although legalising cannabis possession and cultivation may not immediately eliminate the illegal market, it is expected to serve public health goals. Despite the overall positive evaluation of the Cannabis Act in Germany, there are three potential areas of concern: the potential for misuse of the medical system, the normalization of cannabis use, and the influence of the cannabis industry. The German model may herald the beginning of a new generation of European cannabis policies, but concerted efforts will be required to ensure that these policy reforms serve rather than undermine public health goals.

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.

Cannabis-involvement in emergency department visits for self-harm following medical and non-medical cannabis legalization

AIMS

Cannabis use may increase the risk of self-harm, but whether legalization of cannabis is associated with changes in self-harm is unknown. We examined changes in cannabis-involvement in emergency department (ED) visits for self-harm after the liberalization of medical and legalization of non-medical cannabis in Canada.

METHODS

This repeated cross-sectional study used health administrative data to identify all ED visits for self-harm in individuals aged ten and older between January 2010 and December 2021. We identified self-harm ED visits with a co-diagnosis of cannabis (main exposure) or alcohol (control condition) and examined changes in rates of visits over four distinct policy periods (pre-legalization, medical liberalization, non-medical legalization with restrictions, and non-medical commercialization/COVID-19) using Poisson models.

RESULTS

The study included 158,912 individuals with one or more self-harm ED visits, of which 7810 (4.9 %) individuals had a co-diagnosis of cannabis use and 24,761 (15.6 %) had a co-diagnosis of alcohol use. Between 2010 and 2021, the annual rate of ED visits for self-harm injuries involving cannabis per 100,000 individuals increased by 90.1 % (3.6 in 2010 to 6.9 in 2021 per 100,000 individuals), while the annual rate of self-harm injuries involving alcohol decreased by 17.3 % (168.1 in 2010 to 153.1 in 2021 per 100,000 individuals). The entire increase in visits relative to pre-legalization occurred after medical liberalization (seasonally adjusted Risk Ratio [asRR] 1.71 95 % CI 1.09-1.15) with no further increases during the legalization with restrictions (asRR 1.77 95%CI 1.62-1.93) or commercialization/COVID-19 periods (asRR 1.63 95%CI 1.50-176).

CONCLUSIONS

Cannabis-involvement in self-harm ED visits almost doubled over 12 years and may have accelerated after medical cannabis liberalization. While the results cannot determine whether cannabis is increasingly causing self-harm ED visits or whether cannabis is increasingly being used by individuals at high risk of self-harm, greater detection for cannabis use in this population and intervention may be indicated.

Individual differences in legal and illicit cannabis purchasing behaviour in British Columbia, Canada: Findings from a 2021 cross-sectional survey

BACKGROUND

Despite thousands of licensed cannabis retail stores operating across Canada, there remains a significant illicit cannabis market. Some cannabis users continue to buy cannabis from dealers, illicit stores, and/or illicit online retailers.

METHODS

Data are from the 2021 British Columbia Cannabis Use Survey. Respondents (n = 8473) were 19 years or older, lived in British Columbia at the time of the survey, and reported using cannabis in the past 12 months.

RESULTS

Buying cannabis from all types of illicit sources was more common among younger cannabis users, those who use cannabis more frequently and started using cannabis before the age of 17 (vs. 19 or older), and among those who co-use cannabis with other drugs. Specifically, buying cannabis from a dealer was more common among men, those with lower educational attainment, and those who seek the lowest prices when buying cannabis. In contrast, those using cannabis for medical (vs. non-medical) purposes were more likely to report getting cannabis from illicit retail stores, while buying cannabis from illicit websites was more common among people who use edible cannabis products.

CONCLUSION

Consistent with other studies, younger and more frequent cannabis users were more likely to report buying cannabis from illicit sources. However, these findings suggest there is significant heterogeneity among those who buy cannabis from different types of illicit sources, which should be carefully considered when developing policies and strategies aimed at encouraging consumers to transition to legal sources.

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.

The impact of legal cannabis availability on cannabis use and health outcomes: A systematic review

BACKGROUND

For alcohol, regulating availability is an effective way to reduce consumption and harm. Similarly, the higher availability of medical cannabis dispensaries has been linked to increased cannabis consumption and harm. For recreational cannabis markets, such a link is suspected but still poorly understood.

METHODS

A systematic literature review (PROSPERO registration number 342357) was conducted on 1 July 2022 in common libraries (Medline, Web of Science, PsycInfo, Psyndex, CINAHL, Embase, SCOPUS, Cochrane) for publications since 2012. Studies linking variations in the availability of legal cannabis products to behavioral outcomes (cannabis use or related health indicators) were included, while studies focusing solely on the legalization of medical cannabis were excluded. The risk of bias was assessed using an adapted version of the Newcastle-Ottawa-Scale.

RESULTS

After screening n = 6,253 studies, n = 136 were selected for full-text review, out of which n = 13 met the inclusion criteria, reporting on n = 333,550 study participants and n = 855,630 presentations to emergency departments. All studies were conducted in North America, with the majority from Western US states. Using longitudinal (n = 1), cross-sectional (n = 4), or repeated cross-sectional (n = 8) study designs, an increased availability of legal cannabis was linked to increased current cannabis use and health-related outcomes (vomiting, psychosis, or cannabis-involved pregnancies), regardless of the indicator employed to measure availability (proximity or density) among both adults and adolescents. The positive correlation between cannabis availability and consumption is most pronounced among those groups who have been less exposed to cannabis before legalization. The association between the availability of legal cannabis and risky use indicators was less consistent.

CONCLUSIONS

Groups who have been least exposed to cannabis before legalization may be most susceptible to increased availability. In jurisdictions with legal cannabis markets, restrictions on the number of legal cannabis retailers, especially in densely populated areas, appear warranted.