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Question What is the association between cannabis use and sinonasal symptoms among US adults? Regular cannabis use was associated with a lower prevalence of sinonasal symptoms, whereas nonregular cannabis use was not associated with sinonasal symptoms. Meaning The results of this study suggest that a higher frequency of cannabis use is associated with a lower likelihood of sinonasal symptoms. Importance Cannabis is the most commonly used illicit substance in the US and worldwide. Understanding the association between cannabis use and sinonasal symptoms may help clinicians and patients better understand the symptomatology associated with cannabis use. Objective To assess the association between frequency of cannabis use and presence of sinonasal symptoms in a nationally representative sample of US adults. Design, Setting, and Participants This population-based, retrospective cross-sectional study included adults aged 20 to 69 years who had completed data on sinonasal symptoms and substance use for the to National Health and Nutrition Examination Survey. The data were analyzed in February Main Outcomes and Measures Presence of sinonasal symptoms, demographic information, and medical history were obtained from National Health and Nutrition Examination Survey questionnaires. Presence of any sinonasal symptoms was defined as responding yes to any of a series of questions assessing rhinologic symptoms. Regular cannabis users were defined as using cannabis 15 or more times within the last 30 days. Nonregular users were defined as using cannabis fewer than 15 times within the last 30 days. Multivariable models were used to examine the association between frequency of cannabis use and presence of sinonasal symptoms while adjusting for demographic characteristics and medical comorbidities. Results The study included adults with a mean SD age of The prevalence of sinonasal symptoms among regular cannabis users Compared with adults who had never used cannabis, regular cannabis users were less likely to have sinonasal symptoms odds ratio, 0. Current tobacco smokers were more likely to have sinonasal symptoms odds ratio, 1. The most common sinonasal symptoms reported were nasal congestion Conclusions and Relevance This cross-sectional study found that the prevalence of sinonasal symptoms was lower among regular cannabis users. Further research is needed to elucidate the mechanisms underlying the association between cannabis use and sinonasal symptoms. More than Sinonasal symptoms are thought to come from several inflammatory disorders that affect mucous membranes and nasal remodelling. The pathophysiology of each sinonasal symptom is unique. Increased mucus production is followed by nasal discharge and runny nose, whereas sinus inflammation and the potential presence of nasal polyps irritate the sinuses and contribute to nasal congestion, nasal obstruction, and a reflexive sneezing response. Cannabis is the most used illicit substance in the US and worldwide, and its use has incrementally risen within the last decade, from 8. In this way, the mechanism of cannabis smoking is very similar to that of tobacco smoking. The person smoking distributes a combination of combustion products that contain either tobacco or cannabis through the upper airway and into the respiratory tract. Previous studies have characterized the negative association of tobacco smoking with sinonasal symptoms. Given the similarities between cannabis smoking and tobacco smoking delivery, there is concern about the adverse association that cannabis might have with upper airway inflammation and sinonasal symptoms. However, to our knowledge, there is limited research investigating the association between cannabis use and sinonasal symptoms. Despite the similarities in the delivery of tobacco and cannabis smoke, the 2 are unrelated compounds. Cannabis is associated with a unique association with gene expression, inflammatory pathway and immune regulation, and oxidative stress. In this study, we extracted data from the to NHANES survey to examine the association between frequency of cannabis use and sinonasal symptoms in US adults aged 20 to 69 years. The prevalence of sinonasal symptoms among surveyed individuals was compared between regular, nonregular, and never cannabis users. The NHANES is a program of studies aimed at assessing the health, function, and nutritional status of the civilian, noninstitutionalized population in the US. As the data are publicly available and deidentified, the study was exempt from institutional review board approval and informed consent was waived. Prevalence of any sinonasal symptoms was defined as responding yes to any of the 9 questions: sneeze frequently; green, yellow, or brown mucus discharge; completely blocked up nose; sinus pain; runny nose; sometimes smell an unpleasant, bad, or burning odor when nothing is there; problem with smell during the past 12 months; change in ability to smell since age 25 years; and frequent nasal congestion. In the final model, sinonasal symptoms were collapsed a priori to a binary variable that detailed the presence or absence of sinonasal symptoms. A loss of consciousness because of a head injury. Cannabis use was measured by self-report. Participants who had never used cannabis were defined as having responded no to the question asking about marijuana or hashish use during their lifetime. Regular and nonregular use was determined using frequency of cannabis use within the last 30 days. Regular users were defined as consuming cannabis 15 or more times within the last 30 days, in accordance with previous studies. Demographic information and medical history were obtained from questionnaires. Sex was characterized as male or female. Education was characterized as less than high school graduate, high school graduate, or some college or more. Cardiovascular disease classification was based on having 1 or more of the following: coronary artery disease, congestive heart failure, angina pectoris, or history of myocardial infarction. Hypertension and stroke history were identified by self-reported history. Asthma history was identified by self-reported history. Tobacco smoking status was defined as never, former, or current. The Patient Health Questionnaire-9, with scores ranging from 0 to 17, was used to assess for depressive disorders. Sample weights were used to account for the complex sampling designs in accordance with the NHANES analytic guidelines. The association between the presence or absence of sinonasal symptoms and cannabis use was analyzed with logistic regression models and reported as odds ratios ORs to demonstrate effect size. Odds ratios greater than 1. Multivariable models were sequentially adjusted for demographic characteristics and medical comorbidities. All analyses were conducted using Stata version Table 1 describes the unweighted sample characteristics by cannabis use. Regular cannabis users were more likely to be male, Black, have less education and lower income, currently smoke, have depression, have history of stroke, and report smoking and other drug use. Table 2 describes unweighted sample characteristics by sinonasal symptom prevalence. Among the subgroup reporting sinonasal symptoms, adults were more likely to be female, Black, have a higher education level, have hypertension, diabetes, and depression, report other drug use, and have a history of head injury and nasal fracture. The prevalence of sinonasal symptoms and cannabis use was estimated while accounting for sampling weights. The prevalence of sinonasal symptoms among adults reporting regular cannabis use was There was a negative association of cannabis use regular cannabis use compared with never use with sinonasal symptoms in a multivariable model accounting for demographic characteristics, medical comorbidities, asthma, depression, and history of nasal fracture and head injury Table 3. Regular cannabis use was associated with a decreased prevalence of sinonasal symptoms OR, 0. Depression was positively associated with sinonasal symptoms in univariate OR, 2. Current tobacco smoking was associated with an increased likelihood of having sinonasal symptoms OR, 1. Nonregular cannabis use was not associated with increased presence of sinonasal symptoms OR, 0. Asthma was also associated with an increased likelihood of having sinonasal symptoms OR, 2. Black participants were more likely to report sinonasal symptoms compared with individuals of other racial and ethnic groups OR, 2. Using the sampling weights according to the NHANES analytic guidelines, we estimated that among those with sinonasal symptoms, the most common symptoms were nasal congestion, which was reported at This cross-sectional study aimed to examine the association between cannabis use and sinonasal symptoms in a nationally representative sample of US adults. We found a clinical difference in the prevalence of sinonasal symptoms between regular cannabis users and never cannabis users. In the multivariable logistic regression analyses, regular cannabis use was associated with a decreased likelihood of having sinonasal symptoms after adjustment for sociodemographic characteristics and medical comorbidities, including asthma. In the multivariable analysis, race, specifically Black race, was also shown to be associated with greater sinonasal symptom prevalence. Understanding the association between cannabis use and sinonasal symptoms may enable health care clinicians to better counsel patients on the possible effects of cannabis use. Previous studies have explored the association between smoking and sinonasal diseases, such as CRS and AR. The present study had similar findings, with current tobacco smokers reporting increased sinonasal symptoms. In vitro studies suggested several possible mechanisms in which smoking may affect sinonasal mucosa. Different pathophysiological mechanisms include alterations in chloride ion transport, 34 , 35 reduced ciliary clearance, 35 and inflammatory gene activation. However, because of the cross-sectional nature of the study, we cannot draw causal interpretations between cannabis use and sinonasal symptoms. Of the sinonasal symptoms reported, the most frequent symptom was nasal congestion. Nasal congestion has a complex pathophysiology that involves vascular, neural, and inflammatory components. Sympathetic activation is followed by smooth muscle contraction of capacitance vessels within the nasal cavity, which is followed by decreased venous drainage and increased swelling of the mucosa. Cannabidiol, a constituent of cannabis, has been associated with time-dependent vasodilatory effects in human and animal models, 41 - 43 which increase venous drainage, thereby decreasing mucosal swelling. Additionally, Mazzari et al 24 demonstrated that oral treatment of mice with a CB2 receptor agonist reduced the number of mast cells that underwent degranulation. Similarly, CB1 activation was associated with a reduction of the proinflammatory mediator histamine. Although a couple studies have suggested a positive association between cannabis use and sinonasal symptoms, the present study specifically assesses the association between the frequency of cannabis use and sinonasal symptoms. Previous studies simplified cannabis use into a binary category yes or no without accounting for duration of use or frequency. Black participants were more likely to report a higher prevalence of sinonasal symptoms compared with other individuals of other racial and ethnic groups. Previous studies have suggested that the prevalence of sinonasal symptoms is lower among Black patients. Historically, Black patients have presented with a higher severity of various other diseases, such as vascular disease and obstructive sleep apnea, compared with patients of other racial and ethnic groups at the time of initial clinical presentation. Further epidemiological studies are needed to investigate the prevalence of sinonasal symptoms in diverse populations outside of the clinical setting. Depression was another factor that largely attenuated the association between cannabis use and sinonasal symptoms. Depression, which is a risk factor for sinonasal symptoms and higher cannabis use, may be of one the major confounders of this association. Further longitudinal clinical studies are needed to explore the direct role of cannabis use regarding depression and sinonasal symptoms. A strength of this study is the analysis of data from a nationally representative sample of the US adult population. Most of the literature regarding sinonasal symptoms only includes data collected from patients seeking care in a clinical setting. Using a nationally representative cohort of adults allows for comparisons between subsets of patients that are historically difficult to access. A similar previous study analyzed the to National Surveys on Drug Use and Health for the association between the duration of cannabis use and sinusitis. The narrow age inclusion criteria of cannabis use excludes most cannabis users, as the present study found the median age of regular and nonregular cannabis users to be younger than 35 years. Therefore, this epidemiologic analysis may present a more generalizable estimate of sinonasal symptom presentation among cannabis-using adults, which to our knowledge has not been reported in previous epidemiologic studies. There are several limitations to this study. First, the study was cross-sectional in nature, thereby limiting the ability to provide causative conclusions on the associations between cannabis and sinonasal symptoms. Second, cannabis use may have been underreported in certain states depending on the legal status or stigma within individual states. In this study cohort, the rate of cannabis use was comparable with the national average in Cannabis is not a standardized product, can contain upwards of different chemicals, and can be consumed in numerous ways, including inhalation, oral ingestion, and sublingual administration. Additionally, we collapsed cannabis use and sinonasal symptom variables a priori for simpler statistical comparisons. Therefore, the results may vary by adaptation of different definitions of regular and nonregular cannabis use or classifications of sinonasal symptoms. Finally, despite adjusting for multiple confounders in this study, including sociodemographic factors, comorbidity factors such as asthma history, history of head injury, and depression, and history of nasal fracture, we were unable to account for sinonasal disease history, such as CRS or AR, which may result in residual confounding effects. The results of this cross-sectional study suggest that the prevalence of sinonasal symptoms was lower among regular cannabis users compared with nonusers after adjustment for demographic characteristics, medical comorbidities, and history of facial trauma. There was an association between the frequency of cannabis use and presence of sinonasal symptoms. Further research is needed to investigate the mechanisms underlying the association between cannabis use and sinonasal symptoms. Published Online: July 28, Author Contributions : Ms Orozco and Dr Hur had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported. Download PDF Comment. Table 1. View Large Download. Table 2. Table 3. Prevalence of potential adult chronic rhinosinusitis symptoms in the United States. Upper and lower airway remodelling mechanisms in asthma, allergic rhinitis and chronic rhinosinusitis: The one airway concept revisited. Clinical practice guideline update : adult sinusitis. PubMed Google Scholar. Springer; Allergic rhinitis. Nasonasal reflexes, the nasal cycle, and sneeze. Lack of significant correlation between rhinosinusitis symptoms and specific regions of sinus computer tomography scans. Facial pain: sinus or not? Chronic rhinosinusitis-related smell loss: medical and surgical treatment efficacy. Marijuana legalization and historical trends in marijuana use among US residents aged results from the National Survey on drug use and health. Data and statistics. Accessed June 8, United Nations Office on Drugs and Crime. World drug report Accessed March 5, A mixed methods analysis of cannabis use routines for chronic pain management. Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature. A systematic review of the association between cigarette smoke exposure and chronic rhinosinusitis. The association of active and passive tobacco smoke exposure with chronic rhinosinusitis symptom severity: a cross-sectional study. Impact of habitual marijuana and tobacco smoke on severity of chronic rhinosinusitis. Nasal and sinus symptoms and chronic rhinosinusitis in a population-based sample. The role of histamine in allergic disease: re-appraisal of its inflammatory potential. N- 2-hydroxyethyl hexadecanamide is orally active in reducing edema formation and inflammatory hyperalgesia by down-modulating mast cell activation. Selective cannabinoid receptor-1 agonists regulate mast cell activation in an oxazolone-induced atopic dermatitis model. Comprehensive characterization of mainstream marijuana and tobacco smoke. Association of marijuana use with psychosocial and quality of life outcomes among patients with head and neck cancer. Therapeutic cannabis and endocannabinoid signaling system modulator use in otolaryngology patients. National Health and Nutrition Examination Survey data. Accessed January 10, Accessed January 17, Cannabis use, sedentary behavior, and physical activity in a nationally representative sample of US adults. Frequency of cannabis use and alcohol-associated adverse effects in a representative sample of U. The PHQ validity of a brief depression severity measure. Exposure to cigarette smoke condensate reduces calcium activated chloride channel transport in primary sinonasal epithelial cultures. Cigarette smoke condensate inhibits transepithelial chloride transport and ciliary beat frequency. Tumor necrosis factor-alpha is central to acute cigarette smoke-induced inflammation and connective tissue breakdown. Endogenous cannabinoids may regulate chronic inflammation in aspirin-exacerbated respiratory disease. Adrenoceptors in the control of human nasal mucosal blood flow. Cysteinyl leukotrienes: multi-functional mediators in allergic rhinitis. Time-dependent vascular actions of cannabidiol in the rat aorta. Cannabidiol causes endothelium-dependent vasorelaxation of human mesenteric arteries via CB1 activation. Vasodilatory effects of cannabidiol in human pulmonary and rat small mesenteric arteries: modification by hypertension and the potential pharmacological opportunities. Medical manifestations associated with hashish. Cannabis hemp positive skin tests and respiratory symptoms. Associations between duration of illicit drug use and health conditions: results from the national surveys on drug use and health. Demographic variation in chronic rhinosinusitis by subtype and region: a systematic review. PubMed Google Scholar Crossref. Presentation to emergency departments for acute rhinosinusitis: disparities in symptoms by race and insurance status. Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention. Differential outcomes among survivors of head and neck cancer belonging to racial and ethnic minority groups. Differences in symptoms and severity of obstructive sleep apnea between Black and White patients. Demographic correlates of anxiety and depression symptoms in chronic sinonasal diseases. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis. Cannabis use behaviors and prevalence of anxiety and depressive symptoms in a cohort of Canadian medicinal cannabis users. Perceived efficacy of medical cannabis in the treatment of co-occurring health-related quality of life symptoms. Save Preferences. Privacy Policy Terms of Use. This Issue. Views 35, Citations 0. View Metrics. X Facebook More LinkedIn. Original Investigation. Key Points Question What is the association between cannabis use and sinonasal symptoms among US adults? Study Population. Sinonasal Symptom and History Measures. Cannabis Use Measures. Other Study Measures. Statistical Analysis. Strengths and Limitations. Back to top Article Information. Access your subscriptions. Access through your institution. Add or change institution. Free access to newly published articles. Purchase access. Rent article Rent this article from DeepDyve. Sign in to access free PDF. Save your search. Customize your interests. Create a personal account or sign in to:. Privacy Policy. Make a comment.
Cannabis Use and Sinonasal Symptoms in US Adults
Guimaraes buying ganja
Official websites use. Share sensitive information only on official, secure websites. Reviewed by: Ulrich W. This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. 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 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. 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. Keywords: youth, adolescents, legalization, cannabis policy, Canada, cannabis marijuana. Cannabis is one of the most globally prevalent psychoactive substances 1 , with the onset of use usually in mid-adolescence 2 , 3. Cannabis use has been linked to many short- and long-term adverse effects 4 including motor vehicle accidents 5 , respiratory diseases 6 , higher risk for acute myocardial infarction among people aged 15—22 7 , and cannabis use disorder 4 , 8. In addition, youth who use cannabis are at increased risk for adverse mental health and cognitive outcomes, including development and exacerbation of early-onset psychosis 9 , depression and anxiety 10 , suicidal ideations and suicide attempts 11 , alteration of brain development and structure 12 , 13 lower educational attainment 14 , 15 , lower cognitive function, and decreased motivation Also, individuals using cannabis during youth are at increased risk for addictive behaviors later in life 4. The production, distribution, and consumption of non-medical cannabis were legalized in Canada at the federal national level in October The federal government determines the types of cannabis products that can be legally sold. At the time of legalization, dried or fresh cannabis, cannabis oil, and cannabis seeds were the legal products. Edibles, extracts and topicals became legal 1 year later, and drinks 2 years after that The Canadian Medical Association Journal published an editorial in stating that the proposed legislation would fail to protect Canadian youth 19 , to which others responded that prohibition was also harmful to youth and that legalization would provide the opportunity for strict regulation that would reduce cannabis-related harms 20 , In general, Canada's public health and substance use sectors were in favor of cannabis legalization for non-medical purposes 22 , 23 while its medical community tended to be against it As part of its approach to cannabis legalization, the federal government endorsed Canada's lower-risk cannabis use guidelines 25 , which were designed as an evidence-based means of educating the public and health care professionals to reduce cannabis-related harms 25 , This narrative review will focus on the impact of cannabis legalization on youth in Canada. This review aims to provide a broad description of the Canadian experience that may be of interest for jurisdictions considering the legalization of cannabis for non-medical purposes. We will describe the regulation of cannabis legalization for non-medical purposes and changes related to cannabis use and cannabis-related behaviors. Specifically, we will look at the prevalence of cannabis use, alternative modes of consumption, the potency of cannabis, age of first use, negative consequences related to use, and education regarding cannabis. This paper will use the World Health Organization's youth definition of ages 15—24 Information used to write this narrative review was collected from the sources listed in Table 1. Cannabis legalization in Canada took place with the passage of the Cannabis Act While the Cannabis Act applies to the entire country, due to the nature of Canada's political system, some aspects of cannabis regulation have been set by the federal government and others by the governments of Canada's 10 provinces and three territories. Here we will discuss the elements of Canada's cannabis regulations most relevant to youth. The Cannabis Act set the minimum age for legal cannabis purchases at 18, with the provision that provinces and territories could raise but not lower it if desired The Act also states that underage individuals cannot legally possess more than 5 g of cannabis—in other words, youth under 18 cannot legally acquire cannabis but technically can possess under 5 g without legal consequences. Minors possessing over that amount may be charged under the Youth Criminal Justice Act , which prioritizes extra-judicial measures in order to avoid criminalizing youth Provinces have also implemented their own penalties for underage possession of cannabis; generally, it is treated like underage possession of alcohol, punishable by a fine This is further discussed below. The Cannabis Act set upper limits on personal possession of cannabis by adults, with provinces and territories able to lower those limits if desired. They can also grow up to four cannabis plants at home. Regulation of public cannabis use is left to provinces and territories All limit the public smoking or vaping of cannabis in some way. Seven provinces and territories ban public cannabis smoking and vaping altogether. The other six allow cannabis smoking and vaping only in locations where tobacco smoking and vaping are allowed Regulations in this area are determined by provinces and territories. Two have adopted private retail systems, in which sales are left to the private sector. The availability of legal cannabis varies accordingly: jurisdictions with private retail systems tend to have far higher numbers of stores per capita than those with public retail 34 , Provinces and territories also differ with respect to limitations on retail locations 32 :. Five jurisdictions have a requirement that cannabis stores maintain a certain distance from schools—generally m. Three allow communities to determine such requirements for themselves. Eight jurisdictions allowed municipalities to opt out of hosting cannabis stores. We are not aware of any reviews of municipal cannabis store bans across Canada. Significantly from a public health perspective, no province or territory has a formal limit or cap on the overall number of cannabis retail locations. The packaging and labeling requirements described below apply to all cannabis products; the Cannabis Act also prohibits products that are appealing to youth Further, cannabis edibles, extracts, and topicals are subject to THC limits: edibles, for instance, may contain no more than 10 mg of THC per package For comparison, the state of Colorado sets a maximum potency for cannabis edibles of 10 mg of THC per serving, but allows up to mg of THC per package In Canada, illegal edibles seem to contain more THC than legal ones, with one study finding illegal products with over mg of THC Legal sources of cannabis are slowly replacing illicit ones. The Cannabis Act determines regulations in this area and they apply to the whole country. Advertising rules are quite strict: advertising is essentially banned outside of the point of purchase i. In addition, cannabis products must be sold in plain packaging with standardized fonts see Figures 1 , 2 below ; minimal brand elements are allowed. The anterior side of cannabis packaging in Canada. Packaging and Labelling Requirements. Health Canada, modified Adapted and reproduced with permission from the Minister of Health, The posterior side of cannabis packaging in Canada. Since the federal government introduced the Cannabis Act in , it has continually emphasized the protection of youth as its main reason for cannabis legalization Its stated rationale is that prohibition failed to curtail youth cannabis consumption, and legalization would provide the opportunity for cannabis to be strictly regulated As discussed below, so far there is limited data about the impact of cannabis legalization on Canadian youth. For now, we can simply point out that Canada's regulatory model looks very different from that of other jurisdictions with legal cannabis, especially those in the United States. There is emerging evidence that Canada's plain packaging makes cannabis less appealing to youth Since there is strong evidence that youth are particularly susceptible to tobacco and alcohol advertising 44 , 45 , the ban on cannabis advertising is also noteworthy. Both of these regulations are among the measures recommended to the federal government by experts in the public health and substance use sectors 22 , However, violations of advertising rules by licensed cannabis firms seem widespread on the Internet, especially on social media 47 ; in addition, the cannabis industry has been lobbying for the ability to advertise and for plain packaging to be eliminated This section will discuss trends in youth cannabis use since Canadian cannabis legalization. In Canada, a number of periodic surveys track the prevalence of cannabis use. We will present the available results from the surveys including individuals below 18 years old. The CCS is an online cross-sectional survey that has been conducted annually since with participants 16 and above The NCS is another cross-sectional survey that has been conducted quarterly since Other surveys that will be discussed do not focus primarily on cannabis. Table 2 presents the prevalence of cannabis use in the Canadian youth population before and after legalization by the different surveys; when applicable, the rate of daily or almost daily use is presented. We included only studies that presented pre- and post-legalization — data. A, Not available. Canada has one of the highest youth cannabis use rates in the world 61 , 62 , and the prevalence of use among Canadian youth is about double the prevalence of use among people 25 years and older use Nonetheless, data from pre-legalization years show a decreasing trend in adolescents' cannabis use 63 — A Canadian survey found that a substantial proportion of Canadian youth intended to try cannabis for the first time or increase their use following cannabis legalization Accordingly, data collected in the CCHS throughout 67 show that use prevalence has increased to CCS data also report an increase in the prevalence of past-year use between and Results from waves 1—3 of the Youth Tobacco and Vaping Survey also found that cannabis use prevalence increased significantly between and However, other data collected after legalization show no marked change in youth cannabis use. Results from the NCS report an increase in past-3 months use and daily use among to year-old Canadians compared to pre-legalization and ; however, the change is not statistically significant Longitudinal data from this study suggest that the differences between pre and post-legalization cohorts are minor Unfortunately, so far, there are no other available survey results representing cannabis use in or In summary, there are mixed results related to youth pre- and post-legalization cannabis use. There is contradictory evidence regarding regular and daily or almost daily use, with some results suggesting no pronounced change and others suggesting an increase in youth daily use. Importantly, pre-legalization, Canada witnessed a trend of a decrease in adolescents' cannabis use. The initial evidence from the 2 years post-legalization suggests a possible reversal of that trend; however, the most recent study representing shows a decrease in cannabis use among both adolescents and emerging adults. Overall, results should be taken with caution as they are mixed and represent only up to 3 years post-legalization. This is important as a previous cross-national study suggests that the link between youth cannabis use and cannabis liberalization may only be statistically significant 5 years post- liberalization Additionally, the surveys which target high school students might represent an underestimate since young who dropped out of school have higher rates of cannabis use In March , following the onset of the COVID pandemic, Canadian provinces enacted new public health measures, including social distancing and closures of in-person schools including high schools, colleges and universities Given the interference of those changes in daily routines, it was speculated that a shift in cannabis-related behaviors would be seen. So far, studies conducted in this context only evaluated the early and mid-stages of the COVID pandemic. Their results are presented below. One study found that fewer Canadians aged 16—18 reported cannabis use after social distancing practices started, but those who used reported increased frequency of use Another study found that cannabis use among high school students increased between and after the start of social distancing practices. However, this increase was smaller compared to the — period. In this study, the youth already using cannabis did not increase their use Cross-sectional repeated data from the CCS and show that in many people who use cannabis have either increased or decreased in However, in more people who use cannabis have increased their cannabis use in both age groups: 16—19 and 20—24 years old Using cannabis to cope with depression predicted an increased quantity and frequency of cannabis use during the pandemic In summary, both increases and decreases in cannabis use were observed in the early stages of the COVID pandemic. However, more recent data suggest an overall increase in cannabis use among Canadian youth. Self-isolation and using cannabis to cope with depression were associated with increased cannabis use. Also, the majority of the available data represent the early period of the pandemic, and there is a need for evidence representing later and post-pandemic periods and also evidence about vulnerable populations, such as people that deal with mental health disorders. Cannabis potency is typically defined as the percentage of deltaTetrahydrocannabinol THC the main psychoactive component in the cannabis product In the past decades, there has been a strong increase in cannabis potency 4 , 75 — For example, in the United States, the mean potency of cannabis plant material increased from 8. This trend is concerning, as higher-potency cannabis is associated with more short and long-term health risks 74 , Evidence suggests that CBD is well-tolerated and has relatively very few serious adverse events, such as drug-to-drug interactions, pneumonia, hepatic abnormalities, diarrhea, fatigue, vomiting and somnolence 79 , CBD is correlated with several positive effects, such as neuroprotective 81 , anxiolytic 82 , and antipsychotic 83 effects. CCS cross-sectional data show that in , Another study that tracked the potency of legal and illegal cannabis products for 2 months following legalization in Canada found a mean THC concentration of These studies both took place after legalization; to the best of our knowledge, no published study has assessed changes in cannabis potency in Canada before and after legalization. In summary, data suggest that in the last few years, higher-potency cannabis has gained popularity; however, there is no available data about changes in potency before and after legalization. Research is needed to monitor future changes in this area. Data from the US suggest that modes of cannabis use other than smoking e. This finding is important, as edible cannabis products tend to have higher potency and delayed effects compared to smokable products, and thus may lead to over-intoxication 88 , Also, when removed from their packaging, they may look like food, thus increasing the risk for unintentional consumption, especially by children Vaping cannabis is also a concern. Although it exposes the individual to fewer toxins compared to smokable cannabis, it has been associated with cases of acute lung injury and often involves high-potency cannabis products, which increases long and short-term risks Potent cannabis extracts also increase the risk of over-intoxication, and limited evidence suggests that frequent extract use is linked with problematic cannabis use, cannabis use disorder and mental health problems The long-term health impact of these alternative modes of cannabis use is unknown One study suggests that smoking was still the most prevalent mode of use among Canadians aged 16—19, with no significant changes between and However, in those years, e-cigarettes and extracts have gained popularity AOR for e-cigarette use was 2. High school students who consumed cannabis in multiple modes were significantly more likely to binge drink alcohol, vape, use cannabis regularly, and endorse experiencing more depressive symptoms In summary, data suggest that after cannabis legalization, the Canadian youth extended modes of cannabis use, including more potent forms of cannabis. However, there is no data regarding whether youth using cannabis are obtaining it from a legal or illegal source. This distinction is important, as legal edibles, extracts, and topical products are subject to THC limits. In this section, we will discuss special considerations such as the age of initiation, the influence of sex and gender, as well as race and ethnicity. Delaying the age of initiation of cannabis use is an important priority for public health, as early initiation of cannabis use e. Among youth aged 16—19 in the CCS, the mean age of initiation increased slightly from These estimates are slightly higher than data from previous youth surveys have suggested. In summary, the limited data available suggest that the age of initiation of cannabis use might have increased slightly from pre- to post-legalization but has likely not decreased. Both sex and gender impact cannabis use and effects. Animal models have shown that females are more sensitive to the effects of THC and other cannabinoids and that gonadal hormones e. Cannabis use and cannabis use disorder have a more significant effect on self-reported mental health quality of life among women than men Human laboratory research has suggested that females experience the same subjective effects as males after smoking less cannabis, which recapitulates some of the sex differences in acute cannabinoid effects observed in animal models 97 , Using data from the pre-legalization and post-legalization cycles of NCS found an increase in pastmonth cannabis use from Unfortunately, these data rarely provide a breakdown of gender differences by age group, so it is not clear how the legalization of cannabis might have impacted boys and girls differently. In addition, no data were located that included gender-diverse or non-binary youth. There was no other significant gender-related change between pre and post-legalization While not specifically focused on youth arrests, Owusu-Bempah and Luscombe recently showed that Black and Indigenous people in five major Canadian cities were significantly more likely to be arrested for cannabis possession than white people How cannabis legalization has impacted youth of color in Canada and whether the disproportionate targeting and surveillance of Black and Indigenous youth in Canada have lessened with cannabis legalization is an important topic of further research. Starting in , the CCS began to report pastmonth cannabis use by ethnicity, sex, and age group, though the data on youth were often suppressed due to high sampling variability or small sample size. Data broken down by Indigenous status showed a high prevalence of cannabis use among Indigenous youth aged 16—24 years—where Comparable data from the CCS were not available due to high sampling variability or low sample size. When data were broken down by ethnicity, only data on white youth in the 16—19 year age group were available In this age group, In the CCS, In summary, more data are needed to clarify how cannabis legalization might have impacted youth of color in Canada. While there has been substantial focus on the impact of cannabis legalization on cannabis use prevalence and frequency among youth, considerably less attention has been paid to cannabis-related harms among youth. Emerging evidence suggests that cannabis-related hospitalizations and emergency department ED visits among Canadian youth may have increased due to cannabis legalization. Using data that was collected during the initial 5—6 months following cannabis legalization, two studies evaluated the impact of legalization of cannabis in Canada on youth cannabis-related hospitalizations, defined in both studies as admissions for poisonings or for mental or behavioral effects of cannabis using the 10th revision of the International Classification of Diseases ICD The first study conducted in the province of Quebec found no significant evidence of an increase in cannabis-related hospitalizations among youth, comparing a pre-legalization period October 17, —March 31, to a post-legalization period October 17, —March 31, However, in boys aged 10—14 years, there was a significant increase in the proportion of substance-related hospitalizations involving cannabis, from A recent repeated cross-sectional study conducted in Ontario evaluated ED visits and related hospitalizations involving cannabis exposure covering a long period pre- and post-legalization between January and March This study identified a total of ED visits due to cannabis exposure over the study period; 81 visits occurred during the pre-legalization period January —September , visits occurred during the period immediately after the legalization of cannabis flower products October —January , and visits occurred during the period after commercial sale of cannabis edibles was legalized February —March , which represented a significant pre-post increase for both post-legalization time periods. Importantly, even after adjusting for the increasing time trend of cannabis-related hospitalizations over the study period, the period following the legalization of commercial sale of cannabis edibles remained significantly associated with an increase in ED visits Another study conducted in the province of Alberta found that while there was not an overall increase in the volume of pediatric cannabis-related ED visits in a post-legalization period October 1, —March 1, compared to a pre-legalization period October 1, —September 30, , there was a significant increase in unintentional ingestions of cannabis among both children and older adolescents Finally, a retrospective chart review of ED visits at a pediatric hospital in Ottawa, Ontario found an increase in pediatric ED visits related to unintentional exposures to cannabis, though the absolute number was still relatively low 5 visits in the 5-year period prior to legalization, 32 visits in the 2-year period following legalization Data on cannabis-involved driving among youth are limited and mixed. Preliminary results from the NCS suggested that the percentage of young adults aged 18—24 years reporting driving within 2 h of using cannabis in the past 3 months actually decreased following legalization, from Being a passenger in a vehicle operated by a driver who had consumed cannabis within 2 h of driving in the past 3 months similarly decreased from CCS data are somewhat harder to compare, as cannabis-involved driving questions changed slightly with each new year of data. In , In support of these findings, a recent study found no significant association between cannabis legalization and traffic injury ED visits among youth drivers aged 14—17 years in the province of Alberta, 16—18 years in the province of Ontario Cannabis legalization has the potential to impact youth seeking mental health support. A recent study analyzed data from one pre-legalization cohort and one post-legalization cohort of youth accessing treatment through an outpatient addictions and concurrent disorders treatment program for youth offered by the Centre for Addiction and Mental Health in Toronto, Ontario. They found no significant differences in a range of cannabis-related outcomes associated with legalization, including no changes in youth polysubstance use and no changes in mental health or substance dependence symptoms Using a similar retrospective observational design, another study examined data from patients at least 12 years old who had visited a psychiatrist in the emergency unit of the Centre hospitalier universitaire de Sherbrooke CHUS , comparing a period of 5 months post-legalization to a period of 2 years prior to legalization. They observed a significant increase in diagnoses of a cannabis use disorder, which was especially prominent among patients aged 18—24 years from This study also reported a significant increase in active use of cannabis among young adults presenting for psychiatric services, from These data suggest that extra care should be taken to screen for cannabis use and potential cannabis use disorder among youth presenting for psychiatric services In contrast to potential harms associated with legalization, recent evidence about legal encounters suggests a possible net benefit to youth. Using data from the Canadian Uniform Crime Reporting Survey UCR-2 , a recent study found that implementation of the Cannabis Act was associated with a significant decrease in police-reported cannabis-related criminal offences among youth aged 12—17 years, an effect that was significant among both boys and girls. Importantly, no association was observed between the implementation of the Cannabis Act and property crimes or violent crimes among youth, providing preliminary evidence that cannabis legalization was not associated with overall increases in youth crimes Finally, a recent report using data from Statistics Canada found a dramatic reduction in the number of cannabis possession charge counts among youth aged 12—17 years in Canada, from 9, cases in to just cases in In summary, data on changes in cannabis-attributable harms associated with cannabis legalization among youth are limited and mixed. Though very preliminary, the current data do suggest an increase in cannabis-related hospitalizations among Canadian youth, which is possibly related specifically to the legalization of commercial sale of edible cannabis products. Unlike in the United States Colorado, Washington State , the limited data do not suggest any major changes in driving under the influence of cannabis among youth, though an increase in THC-positive drivers under age 30 that were involved in car accidents was noted in British Columbia. Data from one university health center in the province of Quebec found an increase in cannabis use disorder diagnoses among young adults immediately following legalization, but it is unclear whether this generalizes to the rest of the country. Encouragingly, cannabis legalization appears to have led to a significant decrease in cannabis-related criminal offences among youth, with no significant changes in property or violent crimes. Within the provinces and territories, the approach to prevent cannabis-related harms varies. So far, little data exists to determine if these approaches have been effective in reducing cannabis-related harms among youth or not. However, starting in , the CCS began collecting data on exposure to and attitudes toward cannabis educational campaigns. In , among youth aged 16—19 years, only The most common locations for exposure to cannabis education campaigns or messages included social media Also, in , respondents were asked if their knowledge of cannabis-related harms increased since the new cannabis law came into effect; Overall, Thus, it appears that youth in Canada are being exposed to cannabis-related public health messaging, and the messages are being perceived as credible and trustworthy, but further data are needed to evaluate if these messages are having a positive impact on the cannabis use behaviors of youth, especially in regards to cannabis-attributable harms. At the level of the school, data from the COMPASS study have described disciplinary approaches to cannabis use policy violations in Canadian secondary schools , While punitive options e. Clearly, more resources are needed for schools and school boards to facilitate implementation of supportive approaches to cannabis use policy violations in Canadian high schools. A few educational interventions targeting youth were identified that have been evaluated since cannabis legalization or are currently under evaluation. For example, the Check Your Cannabis brief intervention is an anonymous digital health brief intervention based on normative feedback, harm reduction, and motivational interviewing, which has been evaluated as a potential tool for cannabis-involved driving concerns among youth, but can be tailored to focus on other cannabis-related concerns The use of low-cost digital health interventions may be particularly useful to target youth who experience more cannabis-related problems. In summary, data suggest that Canadian youth are being exposed to cannabis-related health messaging, which is encouraging. However, it is unclear how effective these messages are. More data are needed to evaluate the impact of cannabis legalization in Canada on education and prevention. Cannabis legalization for non-medical purposes took place in Canada in October One of the federal government's stated goals in legalizing cannabis was to protect Canadian youth from cannabis-related harms In this narrative review, exploring the impact of cannabis legalization on Canadian youth, we described the Canadian experience in detail. We discussed the regulation of the Canadian cannabis market, outlined changes in the epidemiology and parameters of cannabis use among youth, and discussed cannabis related prevention and education initiatives. The purpose of this review is to provide a broad description of the Canadian experience that may be of value to jurisdictions considering the legalization of cannabis. The Canadian model differs from other jurisdictions which legalized recreational cannabis use in a number of aspects. First and foremost, the level of cannabis market regulation is much more extensive, with strict limits on packaging and labeling as well as advertising, marketing and promotion. Another difference is the government's endorsement of Canada's lower-risk cannabis use guidelines 25 as a way to educate the public and public health professionals Although it is too early to ascertain, there are indications that Canadian provinces and territories with looser cannabis retail sales regulations have seen a higher increase in use compared to those with stricter regulations This would be consistent with the alcohol and tobacco literature, which suggests that relative increases in availability are associated with increased consumption 33 , From a public health and youth protection perspective, provinces and territories should develop and enforce limits on retail density The Cannabis Act includes a requirement that the federal government review the legislation 3 years after it comes into effect. This review is expected to be conducted in The cannabis industry has been pushing for a repeal on many of the Act's regulations, notably the requirement for plain packaging and the restrictions on advertising, marketing and promotion 48 , It is critical that these regulations be maintained, from a public health perspective, as it is less appealing for youth compared to non-plain packaging While cannabis legalization brought an apparent increase in use among Canadians older than 25 years of age 40 , 56 , results for youth are mixed. Most studies show no pronounced increase, a few studies suggest an increase and the most recent national survey suggest a decline in youth cannabis use. Overall, however, the results suggest that the trend of a decrease in adolescents' cannabis use seen pre-legalization 64 may have reversed. Also, data collected after legalization suggests that the prevalence of cannabis use among Canadian Indigenous youth is higher, compared to other ethnical groups Notably, data on changes in cannabis-attributable harms among youth associated with legalization are limited and mixed, with emerging evidence suggesting an increase in youth hospitalization and ED visits as a result of cannabis legalization. Canadian youth are being exposed to cannabis-related health messaging, which is encouraging. The results presented in this review might support effective policies and educational initiatives. In particular, the finding that the trend of a decrease in adolescents' cannabis use has either reversed or stopped can further support educational endeavors. This finding can also be used by the public health sector advocating for continuing the strict packaging restrictions. In addition, the finding of increased cannabis use among indigenous youth, compared to other ethnical groups 94 stresses the need for prevention and treatment programs targeting specific groups. Thus far, there is limited evidence linking specific policies to public health consequences. Future research about it can be a useful resource for both Canada and other jurisdictions considering the legalization of cannabis for recreational purposes. The results available for this review cover only 3 years post-legalization; thus, it is not surprising that the data is limited and mixed. Further monitoring and research are needed to assess the impact of cannabis legalization on Canadian youth and the current results should be taken with caution. All authors contributed to the review and editing, read, and approved the final manuscript. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. As a library, NLM provides access to scientific literature. Front Psychiatry. Find articles by Dafna Sara Rubin-Kahana. Find articles by Justin Matheson. Find articles by Bernard Le Foll. Received Jul 2; Accepted Aug 30; Collection date Open in a new tab. The prevalence of Cannabis use in the Canadian youth population before and after legalization. A 44 N. A 44 21 N. A 37 20 N. A 20—24 45 N. A 51 N. A 52 26 N. A 49 29 N. A Q4 A 18—24 Q1 A Q1 A Drugs Survey 60 Grade 7—12 students —17 17 N. A —19 October and June 18 N. A Cannabis use, Obesity, Mental health, Grade 9—12 students —17 A c A 27 Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. National Cannabis Survey Drugs Survey Tobacco and Vaping Survey
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