A nuanced view of normalisation: Attitudes of cannabis non-users in a study of undergraduate students at three Canadian universities

Risk-Taking, Social Support, and Belongingness Contribute to the Risk for Cannabis Use Frequency in University Students

Background: Cannabis use and misuse is known to be associated with a variety of negative health, academic, and work-related outcomes; therefore, it is important to study the factors that contribute to or moderate its use. Objectives: The aim of this study was to determine whether risky behavior, belongingness and social support as clustering variables play a role in cannabis use frequency. Method: In a university student sample, participant data on risky behavior, belongingness and social support were used to generate vulnerability profiles through cluster analysis (low vulnerability with low risk, low vulnerability with high belonging, moderate vulnerability, and high vulnerability). Using an analysis of variance, the vulnerability profiles were compared with respect to cannabis use frequency and quantity. Through chi-square tests we assessed whether these profiles are overrepresented in certain demographics. Results: The cluster analysis yielded four groups, which differed in their vulnerability for cannabis use. The most vulnerable cluster group had higher cannabis use frequency relative to the two least vulnerable groups. Low income vs. high income was also associated with high vulnerability group membership. International students were overrepresented in the low vulnerability with high belonging group relative to the low vulnerability with low-risk group. The opposite was observed for domestic students. Conclusions: This research adds to the expanding body of literature on cannabis use and misuse in Canada, which may contribute to public health policy and the prevention and treatment of cannabis addiction by providing new insight on who may be at risk.

Effectiveness of the Minder Mobile Mental Health and Substance Use Intervention for University Students: Randomized Controlled Trial

BACKGROUND

University attendance represents a transition period for students that often coincides with the emergence of mental health and substance use challenges. Digital interventions have been identified as a promising means of supporting students due to their scalability, adaptability, and acceptability. Minder is a mental health and substance use mobile app that was codeveloped with university students.

OBJECTIVE

This study aims to examine the effectiveness of the Minder mobile app in improving mental health and substance use outcomes in a general population of university students.

METHODS

A 2-arm, parallel-assignment, single-blinded, 30-day randomized controlled trial was used to evaluate Minder using intention-to-treat analysis. In total, 1489 participants were recruited and randomly assigned to the intervention (n=743, 49.9%) or waitlist control (n=746, 50.1%) condition. The Minder app delivers evidence-based content through an automated chatbot and connects participants with services and university social groups. Participants are also assigned a trained peer coach to support them. The primary outcomes were measured through in-app self-assessments and included changes in general anxiety symptomology, depressive symptomology, and alcohol consumption risk measured using the 7-item General Anxiety Disorder scale, 9-item Patient Health Questionnaire, and US Alcohol Use Disorders Identification Test-Consumption Scale, respectively, from baseline to 30-day follow-up. Secondary outcomes included measures related to changes in the frequency of substance use (cannabis, alcohol, opioids, and nonmedical stimulants) and mental well-being. Generalized linear mixed-effects models were used to examine each outcome.

RESULTS

In total, 79.3% (589/743) of participants in the intervention group and 83% (619/746) of participants in the control group completed the follow-up survey. The intervention group had significantly greater average reductions in anxiety symptoms measured using the 7-item General Anxiety Disorder scale (adjusted group mean difference=-0.85, 95% CI -1.27 to -0.42; P<.001; Cohen d=-0.17) and depressive symptoms measured using the 9-item Patient Health Questionnaire (adjusted group mean difference=-0.63, 95% CI -1.08 to -0.17; P=.007; Cohen d=-0.11). A reduction in the US Alcohol Use Disorders Identification Test-Consumption Scale score among intervention participants was also observed, but it was not significant (P=.23). Statistically significant differences in favor of the intervention group were found for mental well-being and reductions in the frequency of cannabis use and typical number of drinks consumed. A total of 77.1% (573/743) of participants in the intervention group accessed at least 1 app component during the study period.

CONCLUSIONS

In a general population sample of university students, the Minder app was effective in reducing symptoms of anxiety and depression, with provisional support for increasing mental well-being and reducing the frequency of cannabis and alcohol use. These findings highlight the potential ability of e-tools focused on prevention and early intervention to be integrated into existing university systems to support students' needs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05606601; https://clinicaltrials.gov/ct2/show/NCT05606601.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/49364.

Perceptions of Cannabis Use: A Qualitative Descriptive Study of Rheumatology Patients

INTRODUCTION/OBJECTIVES

Some rheumatology patients use or contemplate using cannabis, however, may not be transparent about use with their providers. The objective of this qualitative descriptive study was to describe beliefs, perceptions, and learning needs of adults with rheumatic conditions regarding the use of cannabis products.

METHODS

Purposive sampling was conducted through a rheumatology clinic and sought participants who were using or thinking about using cannabis. Two online focus groups based on cannabis use patterns (non-users and users) were conducted separately. Interviews were audio recorded and transcribed. Three research team members read the transcripts independently to identify initial codes and themes. Data saturation was reached with the interviews.

RESULTS

We recruited 12 participants between 52 and 85 years old. The first theme was pain and desperation. Stigma was the second theme with a perception of physician opposition to cannabis, and the reluctance of many participants to discuss cannabis use with physicians. The final theme was a need for information and a general lack of trustworthy and credible sources. Users were willing to try cannabis even if they still had questions.

CONCLUSION

Rheumatology patients are open to using cannabis due to the burden and suffering associated with pain. They remain silent on the topic, however, because of stigma and lack of engagement from health care professionals, particularly physicians. Patients voiced a strong need for information regarding cannabis and want healthcare providers to initiate discussion. These findings are clinically relevant to the management of rheumatic conditions and the promotion of therapeutic relationships.

Maintaining Normative Functioning Alongside Drug Use: The Recognition of Harms and Adoption of Change Strategies

The current study examined drug users' perspectives on strategies that helped them to maintain normative functioning or resolve impaired functioning. We interviewed 29 drug users who described themselves as functioning normatively while using drugs on a regular basis until they experienced harms or raised concerns of future harms. The content analysis showed that the users maintain their normative functioning through diverse strategies that can be located on a continuum. This continuum was conceptualized as "normative functioning management" based on White et al.'s concept of "recovery management." This study found an ongoing continuum through self-management and social interaction consisting of three regions: the management of normative functioning, the recognition of the harm of drug use to functioning, and the subsequent adoption of change strategies for maintaining normative functioning. This continuum may provide a more nuanced theoretical understanding of the phenomenon of drug users with normative functioning and is therefore relevant for counselors encountering such users in their practice. This study highlights inner resources such as self-awareness and social interaction that help functioning users to maintain their normative functioning and fulfill basic obligations in their normal routines, that is, preserving their professional status, family lives, and relationships.

Qualitative Research on Cannabis Use Among Youth: A Methodological Review

Recreational cannabis legalization has encouraged research regarding cannabis use among youth, especially the use of qualitative approaches. In fact, alcohol and drug use journals have recently encouraged qualitative submissions and provided criteria to ensure “high-quality” research. This study provides an objective account of the qualitative approaches used by researchers in this field and discusses implications for future research. A methodological review was conducted for studies published between January 2010 and November 2019. Targeted keyword searches in four research databases returned 1956 unique records. Pairs of reviewers independently screened records against eligibility criteria and charted data for study philosophical positioning, methodology, study aims, sampling, sample, data collection, and data analysis. 23 studies met the inclusion criteria. Several gaps in study quality criteria are observed: less than half of the studies specified the overarching methodology and just two stated philosophical positioning, with some methods unjustified. Implications for future research are discussed.

Highs and downs: A scoping review of public opinion about cannabis, alcohol and tobacco in Canada

ISSUES

Since the legalisation of cannabis in October 2018, Canada has emerged as a privileged place for research on the properties of this substance, its health effects, but also on its relation with public opinion. However, this scoping review points out the complexity of tracing the evolution of Canadian public opinion on cannabis based on available scientific data.

APPROACH

This review follows the guidelines of the Joanna Briggs Institute and summarises more than 60 years of research on Canadians' public opinion, perception and knowledge of cannabis. The study also includes alcohol and tobacco in order to provide a meaningful comparison between substances.

KEY FINDINGS

One hundred and sixty-one references selected from over 30 000 studies, with the oldest dating back to 1956, show that public opinion on cannabis is under-studied in Canada compared to alcohol and tobacco. Young people and students are among the most studied populations, unlike Aboriginal communities, immigrants and elderly people. The study reveals the absence of experts in public opinion and political communication, and calls for an imperative need for theoretical frameworks rooted in the work of social scientists.

IMPLICATION

These findings do not suggest slowing the rate of publication on alcohol, tobacco, youth or students. Rather, they encourage increasing the rate of publication on other substances used and on other groups also targeted as being particularly at risk of misuse.

CONCLUSION

New studies need to measure and contribute to the understanding of Canadian public opinion on cannabis in comparison with public policies currently in place.

Understanding Lower-Risk Cannabis Consumption from the Consumers' Perspective: A Rapid Evidence Assessment

Background: In the current rapid evidence assessment, we summarize the existing research on lower-risk cannabis consumption as understood by those who consume cannabis. Methods: We identified 7111 unique articles published between 1900 and 2021 using search terms related to a) cannabis consumption, b) beliefs and behaviors, and c) positive outcomes. Results: Twelve articles met our inclusion criteria. Three themes emerged that reflect lower-risk cannabis beliefs and behaviors (informed self-regulation, protective behavioral strategies, and the normalization of cannabis consumption) and one theme reflected motivations that undermine lower-risk cannabis consumption (e.g., using cannabis to cope). Conclusions: Results suggest a need for targeted lower-risk cannabis consumption research-research focused on how those who consume cannabis do so in a positive, non-problematic manner. Such research would help to inform policy and practice and, ultimately, help promote lower-risk cannabis consumption strategies.

The effect of attitudes, subjective norms and stigma on health-care providers' intention to recommend medicinal cannabis to patients

AIM

The aim of this study was to explore the effect of health-care providers' attitudes towards the medical use of cannabis, subjective norms and perceived stigma towards medicinal cannabis users on health-care providers' intention to recommend medicinal cannabis for patients with qualifying conditions.

METHODS

A cross-sectional correlational study included 221 health-care providers (mean age, 42.2 ± 11.2; 74.2% women and 76.5% nurses) who completed a questionnaire examining theory-based variables and stigma towards medicinal cannabis users.

RESULTS

More positive attitudes towards the medical use of cannabis were associated with lower stigma towards medicinal cannabis users, which, in turn, was associated with a higher intention of recommending medicinal cannabis for patients with qualifying conditions. The relationship between attitudes towards the medical use of cannabis and the intention to recommend medicinal cannabis varies according to subjective norms.

CONCLUSIONS

Among nurses and physicians, stigma towards medicinal cannabis users mediated the relationship between attitudes towards the medical use of cannabis and the intention to recommend medicinal cannabis for patients with qualifying conditions, whereas subjective norms moderated this relationship. Effective treatment with medicinal cannabis might be compromised by health-care providers' negative attitudes, stigma and subjective norms.

Toward a Typology of Normative Drug Users Based on Levels of Functioning, Justifications and Types of Use

The study explores 29 individuals who described themselves as functioning normatively while using drugs on a regular basis. They defined their use as intensive, constant, and playing a significant part in their normative lives. The content analysis revealed a typology consisting of four different types of normative users: the socially connected users, the better coping users, the ambivalent users, and the recovering users. This typology was created on the basis of three axes: level of functioning, justification of use, style of use. Our typology highlights the differences between normative users with varying patterns of drug usage and levels of functioning, ranging from users who claim that drug use causes them no harm to those who acknowledge that drug use has significantly damaged their functioning. This typology places particular emphasis on normative users who are experiencing a range of difficulties and need specific forms of therapy to preserve their normative lives.

Self-Reported Reasons for Abstinence from Illicit Drugs

OBJECTIVE

To provide a more balanced understanding of the initiation and restraint of substance use, educators, clinicians, and researchers would benefit from a review of research assessing the reasons nonusers report for having abstained from drugs.

METHOD

Based on searches of computerized databases and the reference sections of relevant articles, we identified 15 relevant studies that assessed and quantified participants' expressed reasons for having abstained from (a) one or more named substances or (b) drugs (or alcohol and drugs) with little or no further specification. We defined as more salient those 25% of reasons in each study that were endorsed most frequently, ranked highest, or rated most influential.

RESULTS

Five reasons - concerns about physical health, lack of interest, harmful psychological consequences, personal beliefs/morals, and peer/family disapproval - were most frequently identified as salient across studies and substances.

CONCLUSION

These salient reasons are consistent with outcome expectancy and social learning models that have been proposed to explain drug initiation. To enhance the value of future research, we recommend testing whether importance ratings differ across contexts; repeatedly assessing within-subject variability of reasons across time; evaluating the association of psychological characteristics with reasons for abstaining; and continuing to evaluate which reasons for abstaining vary by type of drug, gender, ethnicity, and religiosity. We also recommend additional research comparing which reasons predict continued abstinence and which predict initiation of use during follow-up.

Differentiating the Drug Normalization Framework: A Quantitative Assessment of Cannabis Use Patterns, Accessibility, and Acceptability Attitudes among University Undergraduates

BACKGROUND/OBJECTIVES

The drug normalization framework investigates the social integration of substance use. This article contributes a quantitative assessment of cannabis normalization as differentiated by social location predictors.

METHODS

Logistic and zero-inflated negative binomial regression models assess three areas of cannabis normalization: accessibility, acceptability, and recent use. Peer network cannabis use prevalence, gender, nativity, campus locale and living arrangement are explored as focal predictors of variation in normalization among 1,713 cannabis using and nonusing undergraduate students in Canada.

RESULTS

Women report lower odds of positive cannabis acceptability attitudes. While women report lower rates of recent cannabis use, gender is not a significant predictor for lifetime prevalence. Being a recent immigrant significantly predicts lower recent use, lower odds of favorable attitudes to cannabis, and reduced accessibility in comparison to students born in Canada. Longer-term immigrants do not show significant differences from students born in Canada on accessibility and acceptability, suggesting a substance use acculturation effect. Lower peer cannabis use prevalence exhibits a protective effect against use. In comparison to students who report that "some" of their peer network uses cannabis, those with "all" users in their network exhibit lower acceptability attitudes. This suggests a threshold relationship between peer use prevalence and acceptability. Conclusions/Importance: This article provides a data point for assessing future shifts in cannabis normalization prior to impending changes in Canadian drug policy that will legalize recreational cannabis use. Results show that normalization components of recent use, acceptability, and accessibility are differentiated by gender, nativity, and peer network cannabis use prevalence.

Developing harm reduction in the context of youth substance use: insights from a multi-site qualitative analysis of young people's harm minimization strategies

BACKGROUND

Youth substance use programming and educational strategies are frequently informed by prevention approaches that emphasize abstinence goals, which often do not resonate with youth in their lack of acknowledgment of young people's social context and how young people perceive positive effects of substance use. Further, approaches to drug prevention have been critiqued as adopting a one-size-fits-all approach and therefore inadequate in addressing substance use in the context of population variation and inequities. In response to the limitations of current approaches to prevention, programming informed by harm reduction principles that aims to minimize harms without requiring abstinence is emergent in school settings. However, youth perspectives informing harm reduction are limited in both research and program development.

METHODS

This paper draws on data from the Researching Adolescent Distress and Resilience (RADAR) study, which utilized an ethnographic approach to bring youth voice to the literature on mental health and substance use. Qualitative data collection included individual interviews (n = 86) with young people aged 13-18 across three communities-representing urban, suburban, and rural geographies-in British Columbia, Canada. A multi-site qualitative analysis of interview data was conducted to identify themes across and within each research site.

RESULTS

Across all three sites, young people's individual experiences of substance use were shaped by geographic, socio-cultural, and political contexts, with youth describing their use in relation to the nature of substance use in peer groups and in the broader community. To manage their own substance use and reduce related harms, youth employed a variety of ad hoc harm minimization strategies that were reflective of their respective contexts.

CONCLUSIONS

The findings from this study suggest the importance of harm reduction approaches that are contextually relevant and responsive to the lived experiences of youth. Youth perspectives in the development of harm reduction programming are needed to ensure that approaches are relatable and meaningful to young people, and effective for promoting the minimization of substance-related harms.

Perspectives on Cannabis Legalization Among Canadian Recreational Users

This article examines the perspectives of a select group of 41 adult Canadian cannabis users on the decriminalization and legalization of cannabis. The research departs from previous research on cannabis use by focusing on employed adults working in a variety of occupations, including white-collar professionals and graduate students, who use cannabis for nonmedical, recreational purposes. Drawing on in-depth interview data, we explore their perspectives on Canadian law and legal policy and on the possible impact of cannabis reform policies on their own cannabis consumption. Overall, the vast majority of interview participants strongly favored the legalization of cannabis use for the following reasons: (a) prohibition is unjust, (b) economic benefits, (c) reducing violent crime associated with the drug trade, (d) reducing the cost of the criminal justice system, (e) increased safety, and (f) reducing the stigma associated with cannabis use. We conclude by discussing the implications of our research for the literature on cannabis normalization and drug policy reform.