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Emma Stone. The medical and recreational use of cannabis is illegal in the Islamic Republic of Iran. There is no legal medical cannabis program in the Islamic Republic of Iran. However, it is worth noting that cannabis has been used for medical purposes in the Middle Eastern nation. If it does not have benefits, then it is not permitted. Nonetheless, cannabis remains illegal in Iran, with clear penalties in place for those who transgress Iranian law. Iran once had one of the most rigid anti-drug stances in the world. Harsh penalties were instated for drug-related crimes following the revolution, including capital punishment for drug trafficking. Following substantial debate, however, Iran updated its penal law code pertaining to narcotic drugs and softened its stance in The death penalty for marijuana possession and trafficking has now been eliminated. Nowadays, in contemporary Iran, those caught with weed receive a penalty proportionate to the quantity they possess. Penalties can include flogging corporal punishment , fines, or prison time. In the Islamic era, Sufis Islamic mystics used hashish in public religious ceremonies, particularly from the 13th century onwards. As briefly mentioned earlier, cannabis has also held a prominent place in the medicinal traditions of Iranian civilization. In The Canon of Iranian scientist Avicenna, cannabis was recommended as a helpful analgesic. The physician al-Razi also prescribed hemp leaves as a treatment for ear problems, dandruff, and even epilepsy. Twenty different cannabis populations were included in the study, with the specimens originating from the cold and mountainous regions of the west and northwest, the warm and dry regions of the east and southeast, and the warm and wet regions of the southwest. As evident in the section above, Iran has diverse climates favorable to cultivating different strains chemovars of cannabis, with cannabis already naturally growing in many regions. Drug traffickers flocked to the area to access cheap weed. Those found cultivating cannabis may receive penalties in the form of fines, floggings, or prison time. However, the plant is illegal for recreational or medical use in the Middle Eastern nation. Those who possess, grow, or sell cannabis or other narcotic drugs may be subject to fines, corporal punishment, or prison time. Article written by Emma Stone. What are the penalties for possessing weed in Iran? Those found with 5 kg or more could receive capital punishment the death penalty. That policy has since been removed, and the penalties for marijuana use, cultivation, or trafficking now include fines, flogging, or prison time. In the years leading up to , Iranian authorities were criticized by human rights advocates for executing or sentencing thousands of people to execution for cannabis and drug-related crimes. The Iranian government revised its drug laws in to remove capital punishment for the possession and trafficking of cannabis, reserving the death sentence for individuals found with very large volumes of illicit drugs such as opium, heroin, or crystal meth. Weed is illegal in Iran for medical or recreational purposes. However, reports suggest that drug use occurs throughout Iran, and marijuana use in particular is growing in popularity among Iranian youth.

Marijuana Use Rises in Iran, With Little Interference

Iran buy marijuana

Official websites use. Share sensitive information only on official, secure websites. Competing Interests: The authors have declared that no competing interests exist. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Cannabis is the most widely used illicit substance globally. In this systematic review, we examined the prevalence and trends of cannabis use and cannabis use disorder in Iran. We searched International and Iranian databases up to March Pooled prevalence of use among sex subgroups of the general population, university and high school students, combined youth groups, and high-risk groups was estimated through random-effects model. Trends of various use indicators and national seizures were examined. Ninety studies were included. The prevalence estimates of last month cannabis use were 1. In the — period, the pooled prevalence estimates of last month cannabis use were 4. The linear trend of last month cannabis use among males of 'combined youth groups' and among female university students increased significantly from to Prevalence of cannabis use in Iran is low compared to many countries. However, there is strong evidence of an increase in cannabis use among the youth and some evidence for an increase in cannabis use disorder. Cannabis is the most widely used and trafficked illicit substance in the world with million cannabis users globally in \[ 1 \]. The prevalence of cannabis use in the last month has been increasing in the last decade, reaching 3. Cannabis use has been legalized and regulated in several countries in recent years and the effect of policy changes on the extent of use and its health consequences are under close monitoring. Some estimates indicate that one-tenth of cannabis users can become dependent \[ 3 , 4 \]. Moreover, adverse effects on brain development, acting as a gateway drug, and triggering psychiatric disorders have been linked to the regular and early age of cannabis use \[ 5 \]. Low birthweight, motor vehicle injuries, and bronchitis are also among the health-related harms associated with recreational cannabis use \[ 6 \]. While opium is the main illicit drug used in Iran, cannabis has also been used for a long time in the country. The use of cannabis goes back at least to the 16th century when cannabis was used in types of religious ceremonies by Sufis \[ 7 \]. Currently, there is no licit or medical production of cannabis in Iran, and the rulings have considered a strict prohibition on its use \[ 8 \]. However, there are some concerns that cannabis use is increasing in the country and is becoming an important public health problem. Several studies have examined the prevalence of cannabis use along with other drugs in the general population. Previously, a systematic review was conducted up to on the lifetime cannabis use among Iranian university and high-school students \[ 9 \]. However, we know little about the prevalence of cannabis use in other Iranian population subgroups, other use indicators among various populations, and the extent of cannabis use disorder in Iran. This study aimed to use the available data to provide 1 the estimate of cannabis use lifetime, last months, last month and current, daily or almost daily use , 2 the estimate of cannabis use disorder, both in the subgroups of Iranian population general population, youth, university students, high school students, and high-risk groups , and 3 the trends of estimates until As the first legislation changes on cannabis use in the countries initiated in s, we extended our search limit to to be able to investigate the trend. Search strategy S1 Table for the international databases was developed using three groups of key-terms which were combined using Boolean operators: 1 general terms related to drug use or drug use disorder; 2 the names of substances commonly used in Iran including different forms of cannabis, opioids, stimulants, and alcohol; 3 keywords related to Iran, including names of provinces and major cities. Keywords related to other substances were added to the search strategy in order not to miss relevant studies without cannabis-related terms in the title or abstract. No restrictions were applied to the study design. The Iranian database was searched only with the Persian and English words for different forms of cannabis. All studies providing the prevalence of cannabis use or use disorder among the Iranian population were included. Whatever criteria of cannabis use disorder were applied, the studies were included -either based on Diagnostic and Statistical Manual of Mental Disorders version IV or V or any other definitions. The applied criteria were reported exactly as stated in the study. The eligible target population was the general population, university students, high school students, and the high-risk population. Based on our previous reviews \[ 10 , 11 \], these groups were the main targets investigated in prevalence studies and therefore were selected. Any population representative of the Iranian population and not considered high-risk for substance use and use disorder was classified as 'general population', including population being sampled in household surveys, from public places, in industrial settings, or health centers irrelevant to substance use. Therefore, we requested the authors of the latter studies to provide age-group specific data and we created a separate population category, 'young general population', with a wide age definition of 15—34 years. Any specific population that was assumed to have with higher rates of substance use and use disorder than the general population was categorized as a 'high-risk population'. Studies were excluded if the use or use disorder indicator was not reported or unclear, the prevalence of different types of cannabis resin and plant was reported separately without reporting the merged prevalence of any cannabis use or use disorder, if was case-control or interventional study, and the source population was not eligible. Screening of the retrieved documents was carried out in two stages: screening of the titles and abstracts for including all relevant studies and assessment of the full texts for eligibility criteria. For each included study, the following data were extracted: first author, publication year, the language of the manuscript, the year of the study implementation, recruitment setting s , target population, study location province , sampling method, sample size, response rate, age characteristics of the participants, use indicator s , criteria used for diagnosis of use disorder, and finally the prevalence of cannabis use and use disorder in each sex subgroup. Quality of the included studies was assessed using a 9-item rating adapted from Joanna Briggs Institute quality assessment tool \[ 12 \] and previously used in other studies by our group \[ 10 , 11 \] S2 Table. Characteristics of all included studies, their findings on the prevalence of cannabis use and use disorder, and the results of quality assessment of each included study were recorded in tables separately for the general population, university students, high school students, and high-risk populations including people who use drugs PWUD , prisoners, and other high-risk groups. All eligible studies, which reported prevalence separately in the two sexes, were included in the meta-analysis. Studies not reporting sex-specific data were not included in the meta-analysis. The overall prevalence of cannabis use was estimated using the 'metaprop' command 'metafor' package separately by sex, population subgroups general population, young general population, university students, high school students, and high-risk groups , timeframe and frequency of use lifetime, last month, last month or current, daily or almost daily, current main drug , and study year —, —, —, and — The studies conducted before did not provide sex-specific data therefore were not entered in the analyses. The pooled prevalence estimates in each sex and population subgroups were presented using separate forest plots. Random-effects models were used for pooling the estimates and Freeman—Tukey double arcsine transformation was used for stabilizing the variance. The heterogeneity between studies was quantified by the I 2 statistic. We also conducted meta-regression analyses via the 'metareg' command 'metafor' package to examine the association between the prevalence of cannabis use and several covariates including sex, timeframe and frequency, study year, number of unmet quality criteria, and study population young general population, university students, high school, and high-risk population, all versus the general population. We broke down studies providing estimates among both sexes or on various timeframes and frequencies and regarded them as separate studies in the model. Moreover, to assess the effect of quality of studies on pooled estimates, sensitivity analyses were performed by removing studies with more than two unmet items on the quality scale. Due to the scarcity of data for some periods, we merged studies among the young general population, university students, and high school students under the 'combined youth groups' category for trend plot. We categorized studies into four periods as follows: —; —; —; and —; in order to have enough data points for trend analysis. As the heterogeneity among the 'combined youth groups' was high and might have obscured trend patterns, we also analyzed the trends in the prevalence of the last month use of cannabis among male and female university students, which had enough numbers in each period using similar methodology. Similarly, among the regional subgroups of the 'combined youth groups', there were adequate number of studies only for Tehran province to perform trend analysis. We were not able to provide a trend plot for studies conducted among the general population due to the limited number of studies in each period. The pooled estimates are presented in the middle of each period. We fitted meta-regression lines for assessing the significance of the slope of the trend lines. Moreover, the data on national seizures of cannabis in metric tonnes annually from to \[ 14 \] are presented in the trend plot for better interpretation of the results. All statistical analyses were performed using R statistical software version 4. Through the search of international databases, and after excluding the duplicates, titles and abstracts of 3, records were reviewed Fig 1. Of all these records, were eligible for full-text review. Additionally, from 2, records found in the SID, only four records were eligible for full-text review. Through contact with experts, backward citation tracking and other opportunistic methods, 50 other studies were also identified. Four studies provided measures for both the general population and young general population. Overall, Among the 50 studies included through opportunistic methods, 17 were not published in peer-reviewed journals two unpublished studies, six theses, and nine final reports of studies. From these 17 studies, only one study had more than two unmet quality criteria that was not included in the meta-analysis as sex-specific data was not reported. In total, one study was excluded from the meta-analysis due to the application of the NSU method, and nine studies as sex-specific data were not reported. The characteristics and results of the studies are presented in Tables 1 — 4 based on the target population. Twelve studies provided the prevalence of cannabis use among the Iranian general population with a total sample size of , Six studies were conducted nationally between and and the other six studies were conducted in three different provinces. Eight reports were based on household surveys, and the others recruited their samples from the street, industrial plants, hospitals, or a clinical laboratory. The mean age of the participants ranged from The pooled prevalence estimates of lifetime cannabis use were 2. The prevalence estimates of use in the last month were 1. The pooled prevalence of last month or current cannabis use were 0. The pooled estimates for daily or almost daily use were 0. Three studies provided the prevalence of cannabis use disorder among the general population in and both nationally- and in in Fars province. We found 9 studies spanning years to that reported on the prevalence of cannabis use in the general population aged under 34 years with a total sample size of 28, Of these, one study was conducted nationally and the others were conducted in five different provinces. One study was a prospective biennial cohort study in four different provinces \[ 27 \]; each round has been presented separately in the relative table and figure. The recruitment settings of included studies were household, street or public places. In the male subgroup, the pooled prevalence estimates were 7. Among the female subgroup, the corresponding estimates were 0. Three studies provided the prevalence of daily or almost daily use with the pooled estimate of 0. No study provided data regarding cannabis use disorder among the young general population. Thirty-three studies spanning the years to reported on the prevalence of cannabis use among university students with a total sample of , Three of these were national studies, two conducted in and one in , two other studies were conducted in 5 provinces, and the other studies were conducted in thirteen different provinces. One study was a repeated survey in one large medical university in Tehran \[ 49 \]; each year has been presented separately in the relative table and figure. The mean age of respondents ranged from Among male students, the pooled prevalence estimate of cannabis use was 5. Corresponding estimates were 1. Across all years, 0. No study was found on cannabis use disorder among the university students. We found 18 studies spanning years to that reported on the prevalence of cannabis use in high school students with a total sample size of 32, One study was conducted nationally, another was conducted in 9 provinces, and the other studies were conducted in eight different provinces. The mean ages of respondents ranged from The pooled estimates of lifetime prevalence of cannabis use were 3. Only one study reported on the last month prevalence among high-school students, 1. The pooled prevalence of last month or current use were 3. The corresponding estimates for daily or almost daily use were 2. Cannabis use disorder was assessed in only in one study. Conducted in among male students in one province, no current use disorder was detected among the students. In total, 22 studies reported on cannabis use among high-risk population groups in Iran Table 4. We categorized these studies based on their target population into PWUD 10 studies , prisoners 5 studies , and other high-risk groups 7 studies. We found 7 studies spanning years to reporting the prevalence of cannabis use among PWUD with a total sample size of 35, Four of these were repeated national situation assessment surveys conducted in , , and The pooled estimate of lifetime and last month or current cannabis use were Only the latest national survey conducted in assessed the prevalence of last month and daily use of cannabis, estimated at The four national situation assessment surveys have assessed the prevalence of cannabis being the current main drug of use among the PWUD S9 Fig. The corresponding figure was Three other studies reported on treatment-seeking and treatment referral for cannabis use among PWUD. The results of these studies are not presented in the forest plot. Two of these studies reported on treatment-seeking for cannabis use. One recruited PWUD Of these, The other study recruited individuals from drug rehabilitation centres in —15, 3. A third study assessed lifetime cannabis dependence based on DSM-IV among patients referred for treatment of opioid dependence; Five studies spanning years to examined the prevalence of cannabis use in a total sample of 9, prisoners One study was conducted nationally, another was conducted in 6 provinces, and the other three were conducted in three different provinces. The pooled lifetime prevalence of cannabis use in these studies was 5. Current use of cannabis was reported in 0. No study evaluated cannabis use disorder among the prisoners. Three studies were conducted among homeless individuals \[ 99 , , \]. One only recruited homeless individuals aged between 15—29 years, reported 8. In the other two studies, 3. The other four studies were conducted among other high-risk subgroups Table 4. Of these, 2. Other variables i. Fig 2 and S4 Table present the trends in the prevalence of cannabis use according to timeframe and frequency of use. To evaluate changes in cannabis use over time, we pooled data from all studies conducted in youth. Sixty studies reported on the prevalence of cannabis use among youths nine in the young general population, 33 in university students, and 18 in high school students. The last month prevalence was 2. The linear trends in the lifetime or last month or current prevalence were not significant S4 Table. Among females, the prevalence estimate did not change for any timeframes S4 Table. The pooled estimates of cannabis use in different periods based on sex subgroups are shown in Table 5. The time trend was somewhat different in university student samples. The time trend of the prevalence of last month use of cannabis among the 'combined youth group' in Tehran province was investigated, as well. It should be noted than except one, the other studies in Tehran were conducted among the university students. S11 Fig shows the pooled prevalence of last month cannabis use in male and female in the combined youth group in six provinces in Iran. No data were available at province level for 25 other provinces. The highest prevalence in the male combined youth group was reported in the Fars province 7. Whereas, the highest prevalence in the female combined youth group was reported from Tehran province 0. The number of unfulfilled quality items for all studies is presented in Tables 1 — 4. Among the 90 studies, there were only six with three unfulfilled items out of the nine. No study had more than three unfulfilled quality items. With the removal of one study in the young female general population \[ 28 \], the pooled estimate of last month cannabis use among the young female general population was reduced from 0. With the removal of another study among PWUD \[ 89 \], the pooled estimate of last month or current use in this population changed from Removal of the study among the male general population from the meta-analysis changed the pooled estimate of last month or current use less than 0. The other three studies were not included in the meta-analysis \[ 19 , 83 , \]. The current study is the first systematic review in Iran to provide an estimate of various cannabis use indicators—i. In addition, this is the first review on the prevalence of cannabis use disorder in Iran. Due to the extensive search applied in this study, we could successfully retrieve 50 studies with high quality not identified from the online databases. The previous systematic review conducted up to on the lifetime cannabis use \[ 9 \], including a total of 33 studies had supporting results, 4. We found that in Iran, 1. The overall prevalence is around 0. These estimates are based on the most recent national surveys conducted in and The pattern of cannabis use among sex subgroups is similar to other illicit substances in the Iranian population. The prevalence of cannabis use in the general population is lower than the prevalence of soft opioid use such as opium at 4. Notably, the prevalence of cannabis use in Iran is lower than the other countries in the region such as Pakistan 3. The estimates of last month use are also higher in India 3. The annual prevalence of cannabis use is much higher in Uruguay After pooling data for the combined youth groups, we found higher month prevalence estimates for the most recent period — — 4. Based on the latest national census in Iran, we estimate that , Iranians aged 15—34 years use cannabis annually. These estimates are higher than the general population prevalence estimates. A similar age pattern in the prevalence of cannabis use has been noted in other countries \[ , , \]. Similar to the general population estimates, the prevalence of cannabis use among Iranian youth 2. The month prevalence estimates are similarly high among youth in other industrialized countries: e. Limited data is available on cannabis use among the young population of Eastern Mediterranean region countries. The data on the prevalence of cannabis use disorder is consistent with international data in showing a lower prevalence in Iran compared to other countries. According to the latest national survey, 0. While higher than the global estimate of the prevalence of cannabis use disorder 0. This pattern is also reflected in treatment-seeking for cannabis use disorder. A total of 3. The pattern is somehow different from industrialized countries, where a higher percentage of cannabis use disorder is seen among those admitted for drug abuse treatment, with a younger age at admission and a larger proportion of females \[ , \]. We found an increasing trend of last month cannabis use among male youth between and No significant trends were found among female youth. However, we found some evidence on an increase in cannabis use among female university students. Furthermore, there was significant increasing trend among youths the majority being university students in Tehran province in male and female subgroups. The observed increases are in line with the significant rise of national cannabis seizures. The amount of total cannabis seizures has increased significantly from to in Iran. Resin constituted the main form of seizures. The cannabis seized in Iran has been reported to be imported from Afghanistan and Pakistan, making Iran a transit country for cannabis. Cannabis resin seized in Afghanistan and Pakistan as two of the main cannabis resin producing countries has also been increasing for more than two decades \[ 14 \]. There are no precise data on the extent of cannabis cultivation inside Iran, although there are reports of discovery and destruction of indoor and outdoor grown plants and farms. The observed trend in Iran may also be linked to the legalization of medicinal and recreational use of cannabis in several countries \[ \]. While cannabis is categorized as a controlled substance Schedules I internationally, some countries have changed or are perusing change in the level of cannabis control and related legislations \[ 6 , — \]. According to drug control law in Iran, the use of cannabis is illegal and cannabis is categorized in the same control level as opium, but lower than heroin, cocaine, and methamphetamine. Nevertheless, learning about the highly publicized changes in cannabis policy in the USA and other countries may have impacted attitudes of the Iranian youth toward harms associated with cannabis use \[ 6 \]. The growing global prevalence of cannabis use in the last two decades \[ 1 \] in conjunction with the legalization trends in several industrialized countries has raised concerns about exposure of youth to the potentially harmful effects of cannabis \[ 1 , , \]. Cannabis use, especially frequent use might be associated with various short-term and long-term health outcomes \[ 5 , 6 , , \]. Cannabis use disorder is one of the main associated harms \[ 5 \], which itself is a strong predictor of negative health outcomes \[ \]. Chronic psychotic disorders and depression in individuals with predisposing factors have been linked to cannabis use with a dose-response relationship \[ , \]. Early and regular use of cannabis impairs the development of the brain and negatively affect the educational outcomes \[ 5 \]. Furthermore, cannabis use impairs driving skills and result in a modest increase in the risk of car accident \[ — \]. Health consequences of cannabis use in Iran have not been extensively assessed. It can be anticipated that with the increase in cannabis use, especially in youth, the adverse health effects might arise. Although the precise effects of the changes in cannabis demand and supply on public health remain unexplored, education of the public, health experts, and policymakers on the cannabis adverse health outcomes and the possible negative effect of cannabis is important \[ \]. In interpreting the study results, several limitations should be considered. First, we did not find recent studies among the general population which provided data on the main indicators of cannabis use in the last 5 years. Furthermore, because of the inadequate number of studies in each period, the trend plot was not presented for the general population. Due to the same limitation, studies conducted among the young general population, university students, and high school students were merged to form a combined youth group for the trend analysis. Furthermore, we pooled data on last month use with current use due to the scarcity of studies reporting these measures. Third, there were no separate prevalence data for the combined youth group for 25 out of 31 provinces of the country to investigate the possible differences in various regions and the trend in other provinces other than Tehran. Fourth, it should be noted that the estimates might be under-reported as cannabis use is illegal. Also, recall bias would affect the estimated prevalence. Fifth, due to the high heterogeneity, the results should be interpreted with caution. Sixth, further studies are required to better elucidate the extent of cannabis use disorder and treatment seeking in the country. Finally, due to multiple sources approached for accessing all possible relevant studies, we could not track the numbers in the stages of the screening process for the 50 studies in the opportunistic methods. In the context of the limitations noted above, this study provides the first overview of cannabis use and use disorder prevalence in the country. The prevalence of cannabis use in Iran appears to be lower than the prevalence in many other countries. However, along with the increase in cannabis seizures, there is strong evidence of an increase in cannabis use among the youth. Moreover, there is some evidence of an increase in cannabis use disorder. There is a need to monitor cannabis use and the perception of associated risks in the national population and various subgroups, especially among the youth. Moreover, preventive and educational programs in schools and out of schools are needed. The numbers on each province are the pooled estimates and the numbers in the parenthesis are the number of studies. We would like to extend our appreciation Dr. Nouzar Nakhaei, Dr. Zaher Kahzaei, Dr. Hamid Yaghubi, Dr. Mohammad Hamzeloo, and Dr. Ali Mirzazadeh for providing further data and analysis. All relevant data are within the manuscript and its Supporting Information files. The funding source had no role in the study design, data synthesis, interpretation of the data, and in the drafting of the manuscript. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jul 16 PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone plos. A rebuttal letter that responds to each point raised by the academic editor and reviewer s. You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols. In the Methods section please provide additional information regarding the background and training of the experts consulted during the literature search. Furthermore, please provide additional details regarding the validation of the quality assessment tool used. Finally please provide additional details regarding how cannabis use disorder was defined as a part of the study inclusion criteria. The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception please refer to the Data Availability Statement in the manuscript PDF file. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e. PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Please upload your review as an attachment if it exceeds 20, characters. That is the big number. Thus, the authors should provide the reasons e. However, high heterogeneity has still been found. Testing cause of heterogeneity according to the variation of quality of included studies should be concerned in this study. Table 5 can explain the temporal effect, but not for spatial effect. In my point of view, the subgroup analysis by regions should be done in this study. In fact, the prevalence has been changed year by year. Thus, subgroup analysis by study year might be provide some information to the authors. A similar systematic review was published by Nazarzadeh et al. DOI: In my opinion, it would be useful to comment on the added value of this review and to compare your results with the results of the mentioned review that searched for references between and Please find below my suggestions to increase the accuracy of reporting. Therefore, it would be useful to revisit the three mentioned categories: youth, high-school students, and university students. Therefore, it would be useful to provide a rationale for including in the search references starting A clear definition of the outcome appears only in the results section, i. The authors mentioned that they included studies of any methodology and design; in my opinion, it would be useful to report how the quality of intervention studies was appraised. If intervention studies were not included, this should be stated in the eligibility criteria. I am unsure whether this includes cannabis abuse. What happened with studies who did not report separately by sex or gender? Was this an exclusion criterion? I suggest using groups based on relevant age-ranges e. As no rationale was provided for selecting the 5-year time intervals, using years intervals could be a viable alternative. Why was the interval not used? The same observation applies to the prevalence of cannabis use. How can authors explain that more than half 50 out of 90 of included studies were identified by using additional resources e. I recommend that the authors report the proportion of published studies out of these 50 additional references and the results of quality appraisal. In my opinion, it is relevant to contrast the cannabis use prevalence based on age groups in Iran with other countries. Unfortunately, the authors have not focused on this outcome in their analyses. This could be an added value of the present review as this outcome was not included in the review published by Nazarzadeh et al. I recommend that authors provide in this paragraph the results of additional analyses conducted on this topic and not in the results section and abstract. PLOS authors have the option to publish the peer review history of their article what does this mean? If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Please log into your account, locate the manuscript record, and check for the action link 'View Attachments'. If this link does not appear, there are no attachment files. To use PACE, you must first register as a user. Registration is free. Please note that Supporting Information files do not need this step. We only slightly revised the well-known quality assessment tool, Joanna Briggs Institute quality assessment tool, to better suit the prevalence studies. The slightly revised version has been used in other previously published studies of our center:. Tramadol use and public health consequences in Iran: A systematic review and meta-analysis. Ansari, M. Buprenorphine abuse and health risks in Iran: A systematic review. Drug and Alcohol Dependence. We added the criteria each study applied for CUD in the relative tables. Also, the eligibility criteria and data extraction sections were edited accordingly. We applied a wide search strategy. Therefore, the number of articles excluded in the stage of full-text review is high. We added the numbers of studies for each reason of exclusion in the Flow-diagram. Due to the large number, we did not add the exclusion table, which we can provide if needed. We had conducted a heterogeneity study for the total included studies Result, Heterogeneity study section. The number of unfulfilled quality criteria showed no significant association with cannabis use prevalence S3 Table. We added this issue the high heterogeneity in the limitation section. We had also performed a sensitivity analysis for those studies with three or more unfulfilled quality items out of the nine. The results of the sensitivity analysis for relative subgroups had been presented in the Result, Quality assessment section. The number of studies conducted among the general population was not enough, neither for temporal nor for regional subgroup analysis. For the studies conducted among the 'combined youth groups', we had performed subgroup analysis based on the geographical regions in the Result, Geographical distribution section. As it is evident in the maps S11 Fig , no data were available at the province level for 25 provinces. Therefore, there are not enough data for adding the regional subgroups to the current temporal analysis. We stated this shortcoming in the Limitation section. There was an adequate number of studies only for the Tehran province eight and nine studies in the male and female subgroups, respectively; mostly were among the university students. Therefore, we added the trend analysis for these studies Result, Trend section, last paragraph. The method and discussion sections were edited accordingly. To overcome the limitation that stated in this important comment, we have sub-grouped the included studies by the study year to 5-year time intervals with details Table 5. Furthermore, we presented all of the forest plots sorted by the study year in each subgroup. Also, in the Abstract and the Discussion, we highlighted only the latest pooled estimates for better interpretation of the current situation in Iran. Many thanks for this important comment. We did not pre-defined the age limit before study implementation. After the final inclusion, if not reported in the full text, we requested authors of studies among the general population for the age-specific data. Finally, due to high heterogeneity in the presented age groups, we defined the age limit for the young general population subgroup in such a way not to miss any data years. Although, as you have stated, youth is generally defined as years, some important reports have used other categories as well. Please see:. National Drug Strategy Household Survey detailed findings. Drug Statistics series no. PHE Canberra: AIHW. A notable proportion of adolescents drop out of high school in Iran. Similarly, a large group of youths does not enter university in Iran. Therefore, in order not to miss any information and as the number of studies in these two subgroups were not low 33 studies among university students and 18 studies among high school students , we preferred to present and analyze these subgroups separately in the text, tables, and relative forest plots. However, for assessing the trend of the prevalence of cannabis use, we had to merge the 'university students' and 'high-school students' subgroups with the 'young general population'. To distinguish this merged group, we used the word 'combined' youth group. We added a few sentences in the Methods, Data extraction and quality assessment section, for the description of the subgroups. In this systematic review, we aimed not to miss any data regarding the use and use disorder of cannabis in Iran. The data regarding national seizures are also provided for better interpretation of the trend of cannabis use and use disorder prevalence. As properly commented in comment No. A clear definition of the outcome appears only in the results section, b i. We did not re-state the PICO in the method section to avoid repetition. The Result section is categorized based on the target population general population, young general population, university students, high school students, high-risk population. In each section, we separately described and presented studies on 'cannabis use' and 'cannabis use disorder'. According to this important comment and as stated above, we have changed the paragraphing of the result section slightly and added a few sentences to increase the clarity. As it is apparent, there is low number of cannabis users or the rate of CUD being 0, the secondary analysis of CUD among cannabis users would be misleading. Therefore, we preferred not to report this estimate. The unmet unfulfilled quality items are presented in all tables for each study. We aimed to include any data regarding any use of cannabis and cannabis use disorder. The sentence was edited. They were only presented in the relative tables and reported in the text and as we stated in the result section. As stated earlier, as the studies among university and high school students are essentially different in Iran, we decided to present these studies separately. Regarding the age groups among the general population, the age group-specific data was only available for some studies. Even after requesting the authors for further data and analysis, the resultant age groups were very heterogeneous. Therefore, we created a separate group young general population with a wide age definition of years, which was not pre-defined. For trend analysis, in order to have an adequate number of studies in each time interval and for assessment of geographical distribution, we merged all studies conducted among university and high school students with the young general population to form a 'combined youth group'. The four national situation assessment surveys among the PWUD have reported the prevalence of 'currently the main drug of use' for various substances; the cannabis data has been presented in this study Result, High-risk groups, People who use drugs. It is mainly a measure of cannabis use disorder. We changed this section slightly for clarity. We pooled data on last month use with current use due to the scarcity of studies reporting these measures Limitations section , and reported this measure as 'last month or current use' prevalence. Regarding the studies among the general population, as only two studies were reporting the prevalence of last month use in and , we were not able to provide trend analysis with any time interval. Regarding the studies among the 'combined youth groups', we have chosen the smallest possible time interval for the trend analysis with an adequate number of studies in each period. Moreover, the studies conducted before did not provide sex-specific data; therefore were not entered into the analyses. Thus, with a year interval, we would not be able to analyze the trend. We highlighted this issue in the Method section. Unfortunately, we had not recorded the number of studies we found through additional sources. However, we provided more details on which sources we used for our opportunistic methods for higher transparency in the Methods, Search strategy section. The underlying reason for the high number of studies included by opportunistic methods are the followings:. The results of these studies are not required to be published in peer-reviewed journals and are accessible as reports. Also, there are some limitations with Boolean operators in this database, limiting the extent of our search. Therefore we overcame this limitation through contact with experts and backward citation tracking. We have responded to this important comment on the re-grouping of the age groups in comments No. We have compared our findings among the youth with the European countries, the USA, and Canada in the Discussion, paragraph 5. We presented these important findings in the result section and discussed them in the Discussion, although we could not perform secondary analyses. As only three studies among the general population provided the prevalence of CUD with different study years, we confined to present the data without further analysis. There were only two studies providing data regarding treatment-seeking for CUD, not enough for further analysis. We compared our results with the global estimate and some examples of the US, European countries, and India in the Discussion paragraph 3. We also added that this is the first review including studies on CUD in Iran in the Discussion first paragraph. All of the underlying data for this review are presented in the tables in the main text and all the forest plots are provided as supporting information. Please submit your revised manuscript by Sep 11 PM. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. Thank you for addressing my previous comments and for providing clarifications. I appreciate your effort in synthesizing data and providing a comprehensive and up-to-date review of cannabis use in Iran. I provided additional suggestions that could increase the value of the manuscript. I encourage the authors to properly acknowledge the contribution of the work of Nazarzadeh et al. I am well aware of the challenges associated with conducting and publishing systematic reviews and I hope that the authors will consider the suggestions provided below. Consequently, I encourage the authors to elaborate on similarities and differences such as the number of studies retained and number of participants in the university and high-school groups, lifetime cannabis use, etc. In my opinion, the authors should provide a clear description of the eligibility criteria. I recommend that the authors provide in a dedicated paragraph and not in the data extraction section a clear description of the population of interest e. In some sections introduction, discussion the authors refer to cannabis use disorder, in other sections e. The authors provided in their response the rationale for reporting results based on different population groups i. I encourage that the authors explain in the manuscript the rationale for selecting these groups. I am unsure whether the decision to analyze these groups was made before starting the systematic review as suggested by the study aims provided in the introduction or at the analysis phase. The authors excluded from analyses studies that did not report cannabis use separately for men and women, but this is not stated as an exclusion criterion in the PRISMA flow diagram. Therefore, it is difficult for the reader to figure out how many studies were excluded based on this criterion. To my understanding the population groups used are mutually exclusive e. The sum of studies reported in tables 1 to 4 is and does not correspond to the number of studies included in the review based on the PRISMA diagram 90 studies. The authors acknowledged in their response that they did not keep track of the screening process for the 50 studies identified outside of the international databases search. I appreciate their efforts to identify as many eligible studies as possible, but this process lacks transparency and impedes on the reproducibility of the review. Therefore, I consider that this should be acknowledged as a limitation especially because more than half of the total number of included studies were found using this method. As previously suggested, it would be useful for readers that the authors provide the name of the R package used for analyzing data. The authors based on my previous suggestion provided the name of the functions but omitted the name of the package. Many thanks for the comprehensive review and insightful comments. Certainly, they would significantly improve this study. We have applied and responded to all the comments:. The relevant section in the Introduction was edited accordingly, pointing to the differences in the scope of the two studies. Moreover, the result of the previous study was added in more detail in the Discussion section. We moved the mentioned sentences to the 'Eligibility criteria and screening' section as a separate paragraph and extended the details on the definition of the target population. The 'non-eligible source population' was added to the eligibility criteria. The applied criteria were reported precisely as stated in the study. We stated whatever terminology the studies applied in the result section and relative tables; however, in the Introduction and Discussion sections we used 'cannabis use disorder', to be consistent with the latest DSM-V. Based on the previous reviews conducted by our center, studies investigating the prevalence of substance use are mainly conducted among the general population, university students, high school students, or high-risk subgroups in Iran. Therefore, we selected the target population accordingly. This rationale was added to the Method section. As these studies were not excluded from the systematic review and were presented in the tables, we did not add this criterion to the eligibility criteria. However, we added the number of studies excluded from the meta-analysis to the Result section. This is since there are 'Four studies provided measures for both the general population and young general population. This would add up to rows for 90 studies. We added two clarifying sentences regarding the latter issue in the Result section. A brief definition was added in the Method section. The number of studies excluded accordingly was added in the Result section. 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As a library, NLM provides access to scientific literature. PLoS One. Find articles by Yasna Rostam-Abadi. Find articles by Jaleh Gholami. Find articles by Masoumeh Amin-Esmaeili. Find articles by Shahab Baheshmat. Find articles by Marziyeh Hamzehzadeh. Find articles by Hossein Rafiemanesh. Find articles by Morteza Nasserbakht. Find articles by Leila Ghalichi. Find articles by Anousheh Safarcherati. Find articles by Farhad Taremian. Find articles by Ramin Mojtabai. Find articles by Afarin Rahimi-Movaghar. Shahab Baheshmat : Data curation, Formal analysis, Writing — original draft. Marziyeh Hamzehzadeh : Data curation, Writing — original draft. Chaisiri Angkurawaranon : Editor. Received Mar 31; Accepted Aug 9; Collection date Open in a new tab. S1 Fig. The pooled prevalence of cannabis use among the male general population. Click here for additional data file. S2 Fig. The pooled prevalence of cannabis use among the female general population. S3 Fig. The pooled prevalence of cannabis use among the male young general population. S4 Fig. The pooled prevalence of cannabis use among the female young general population. S5 Fig. The pooled prevalence of cannabis use among male university students. S6 Fig. The pooled prevalence of cannabis use among female university student. S7 Fig. The pooled prevalence of cannabis use among male school students. S8 Fig. The pooled prevalence of cannabis use among female school students. S9 Fig. The pooled prevalence of cannabis use among people who use drugs. S10 Fig. The pooled prevalence of lifetime cannabis use among male prisoners. S1 Table. Search strategies used in international databases. S3 Table. Meta-regression of possible sources of heterogeneity. S4 Table. Trends of various cannabis use measures among the 'combined youth groups' and national cannabis seizures. Find articles by Chaisiri Angkurawaranon. Roles Chaisiri Angkurawaranon : Academic Editor. PMC Copyright notice. Attachment Submitted filename: Response letter. Attachment Submitted filename: Response to Reviewers. Associated Data. 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. Najafipour, \[ 15 \] b. Damari, \[ 16 \]. Noorbala, \[ 17 \]. Roshanpajouh, \[ 18 \]. Nikfarjam, \[ 19 \]. Mean: Ziaaddini, \[ 20 \] b. Amin-Esmaeili, \[ 21 \]. Household; individuals aged 15—64 years; self-administered questionnaire. Eftekhar Ardebili, \[ 22 \]. Household; individuals over 15 years resided in 6 th district. Rahimi-Movaghar, \[ 23 \]. Lifetime d. Last month d. Ahmadi, \[ 24 \] b. Mean SD Male Meimandi, \[ 25 \]. Current e. Yasamy, \[ 26 \]. Rahimi-Movaghar, Unpublished \[ 27 \]. Dolatshahi, \[ 28 \]. Street-based; women residing in Tehran between 18 to 25 years. Household; adult residents in a rural area aged below 30 years. Jalilian, \[ 29 \]. Household; individuals aged 15—34 years; self-administered questionnaire. Hamdieh, \[ 30 \]. Barooni, \[ 31 \] b. Household; individuals between 15—30 years resided in 6 th district. Rahimi Movaghar, \[ 23 \]. Rafiei, \[ 84 \]. People who use drugs in drug treatment and harm reduction facilities, prisons and public areas. Monthly use b. Weekly use c. Daily use d. Rahimi-Movaghar, Unpublished \[ 85 \]. People referred for treatment of substance use disorder to a clinic. Danesh, \[ 86 \]. Clients of opioid maintenance treatment programs from 25 outpatient drug treatment clinics. Jamshidi, \[ 87 \]. Treatment seeking individuals in self-referred drug rehabilitation centres. Ghaderi, \[ 88 \]. Eskandarieh, \[ 89 \]. People who inject drugs entered rehabilitation centre for mandatory detoxification. Dolan, \[ 90 \]. Female individuals seeking treatment for heroin use disorder. Narenjiha, \[ 91 \]. Narenjiha, \[ 92 \]. Razzaghi, \[ 93 \]. Moradi, \[ 94 \]. SeyedAlinaghi, \[ 95 \]. Male prisoners at entrance to a prison with positive risk factors for HIV. Hamzeloo, \[ 96 \]. Assari, \[ 97 \]. Adults imprisoned for being involved in fatal vehicle accidents in 7 prisons. Jalilian, \[ 98 \]. Khezri, \[ 99 \]. Homeless individuals aged 15—29 years from homeless shelters, street outreach sites, and drop-in service centers. Heydari, \[ \]. Mohaqeqi-Kamal, \[ \]. Shokoohi, \[ \]. Female sex workers recruited from public street location through peer efforts and health facilities providing harm reduction services. Maarefvand, \[ \]. Bagheri, \[ \]. Individuals aged 18—60 years old being at least 10 days homeless in the last month from 5 voluntary or mandatory shelters of the Municipality of Tehran. Ahmadi, \[ \]. Offspring of people with opioid dependence referred to a treatment centre. Delavari, \[ 32 \]. Undergraduates of a large governmental medical university. Yaghubi, \[ 33 \] b. Undergraduates of non-medical universities in 30 provinces. Halimi, \[ 34 \]. Zahedi, \[ 35 \]. Undergraduates and postgraduates of three universities of a range of majors. Pordanjani, \[ 36 \] b. Safiri, \[ 37 \]. Undergraduates and postgraduates of a governmental medical university. Moradmand-Badie, \[ 38 \]. Undergraduates from seven universities represented all four quadrants of Tehran. Mozafarinia, \[ 39 \]. Sheikhzadeh, \[ 40 \]. Grade 2 and over of a large governmental medical university; indirect method. Mean SD Abbasi-Ghahramanloo, \[ 41 \]. Heydari, \[ 42 \]. Hakima, \[ 43 \]. Undergraduates of a large governmental non-medical university. Yaghubi, \[ 44 \]. Undergraduates of thirty large governmental non-medical universities. Yaghubi, \[ 45 \]. Undergraduates of thirty large governmental medical universities. Mohammadpoorasl, \[ 46 \]. Rezakhani-Moghadam, \[ 47 \]. Students of two large medical and non-medical governmental universities. Taremian, \[ 48 \] b. Undergraduates of three large governmental medical university. Amin-esmaeili, \[ 49 \] d. All undergraduates of a large governmental medical university. Shams-Alizadeh, \[ 50 \]. Sohrabi, \[ 51 \]. Five provinces e. Undergraduate of five large universities of a range of majors. Taremian, \[ 52 \] b. Undergraduate of six large universities of a range of majors. Zarrabi, \[ 53 \]. Undergraduates of one large medical governmental university. Mortazavi-Moghadam, \[ 54 \]. Undergraduate of three large universities of a range of majors. Talaei, \[ 55 \]. All undergraduate of a semi-governmental university, human sciences and agriculture majors. Bahreinian, \[ 56 \]. Navidi, \[ 57 \]. Jodati, \[ 58 \]. Male students living in a dormitory of a large governmental medical university. Rezaei, \[ 59 \]. Male undergraduates and postgraduates of six large universities. Ghanizadeh, \[ 60 \]. Mousavi, \[ 61 \]. All undergraduates of three universities of a range of majors. Ahmadi, \[ 62 \]. All undergraduates of dentistry in a large governmental medical university. Hajipour, \[ 63 \]. Navidi, \[ 64 \]. Bami, \[ 65 \]. Bahramnejad, \[ 66 \]. Vakili, \[ 67 \]. Pirdehghan, \[ 68 \]. Nazarzadeh, \[ 69 \]. Alaee, \[ 70 \]. Mohammadpoorasl, \[ 71 \]. Ghavidel, \[ 72 \]. Ziaaddini, \[ 73 \]. Mohammadkhani, \[ 74 \]. Najafi, \[ 75 \]. Mohammadpoorasl, \[ 76 \]. Najafi, \[ 77 \]. Allahverdipour, \[ 78 \]. Current b. Ahmadi, \[ 79 \]. Ziaaddini, \[ 80 , 81 \]. Ahmadi, \[ 82 \]. Daily c. Sedigh, \[ 83 \].

Iran buy marijuana