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Evidence for an increase in cannabis use in Iran – A systematic review and trend analysis

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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. 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. Data Availability: 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. Competing interests: The authors have declared that no competing interests exist. 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. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Background and aims Cannabis is the most widely used illicit substance globally. Methods We searched International and Iranian databases up to March Results Ninety studies were included. Conclusions Prevalence of cannabis use in Iran is low compared to many countries. Introduction Cannabis is the most widely used and trafficked illicit substance in the world with million cannabis users globally in \[ 1 \]. Eligibility criteria and screening All studies providing the prevalence of cannabis use or use disorder among the Iranian population were included. Data extraction and quality assessment 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. Statistical analysis 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. Results Through the search of international databases, and after excluding the duplicates, titles and abstracts of 3, records were reviewed Fig 1. Download: PPT. Table 1. Characteristics and results of studies on the prevalence of cannabis use and use disorder among the general population. Table 2. Characteristics and results of studies on the prevalence of cannabis use among the university students. Table 3. Characteristics and results of studies on the prevalence of cannabis use and use disorder among the school students. Table 4. Characteristics and results of studies on the prevalence of cannabis use and use disorder among the high-risk populations. General population Twelve studies provided the prevalence of cannabis use among the Iranian general population with a total sample size of , Table 5. Pooled prevalence of cannabis use through time among general population, young general population, university students, high school students, and 'combined youth groups'. Young general population 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, University students Thirty-three studies spanning the years to reported on the prevalence of cannabis use among university students with a total sample of , High school 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, High-risk groups In total, 22 studies reported on cannabis use among high-risk population groups in Iran Table 4. People who use drugs. Other high-risk groups. Trend Fig 2 and S4 Table present the trends in the prevalence of cannabis use according to timeframe and frequency of use. Fig 2. Geographical distribution 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. Quality assessment The number of unfulfilled quality items for all studies is presented in Tables 1 — 4. Discussion The current study is the first systematic review in Iran to provide an estimate of various cannabis use indicators—i. Limitations In interpreting the study results, several limitations should be considered. Conclusion In the context of the limitations noted above, this study provides the first overview of cannabis use and use disorder prevalence in the country. Supporting information. S1 Fig. The pooled prevalence of cannabis use among the male general population. 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. S11 Fig. S1 Table. Search strategies used in international databases. S2 Table. Quality assessment tools. 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. S1 Checklist. Acknowledgments We would like to extend our appreciation Dr. References 1. United Nations. World Drug Report United Nations publication, Sales No. World Health Organization. Geneva: World Health Organization; Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet London, England. 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