Do Mandatory Health Warning Labels on Consumer Products Increase Recall of the Health Risks of Cannabis?

INTRODUCTION: Warning labels are an important source of health information. This study examined awareness of health warnings on cannabis packages over time in Canada-where large rotating messages are mandated-versus US states with legal adult-use cannabis, which have less comprehensive regulations. METHODS: Repeat cross-sectional data were collected from the International Cannabis Policy Study online surveys among past 12-month cannabis consumers in Canada and the US (n = 38,448). Free recall of warning messages was assessed in 2018-2020, followed by a prompted recognition task (2020 only). Adjusted logistic regression models tested differences in free recall and recognition of warnings between Canada and US states with and without legal adult-use cannabis ("legal" and "illegal" states, respectively). RESULTS: Free recall of ≥1 warning increased to a greater extent in Canada from 2018 (5%; pre-legalization) to 2019 (13%; post-legalization) compared to US "legal" (AOR = 1.93, p < 0.001) and "illegal" states (AOR = 1.80, p = 0.007), and from 2018 to 2020 (5% vs. 15%) compared to US "legal" states (AOR = 2.23, p = 0.027). In all jurisdictions, free recall of warnings was higher among more frequent consumers (p < 0.001) and those who purchased products from legal retail stores/websites (p < 0.001). With few exceptions, when a specific message was mandated (e.g., impaired driving), consumers were more likely to both freely recall and recognize that message (all p < 0.05). CONCLUSIONS: Cannabis legalization is associated with greater recall of health warning messages. Awareness of specific warning messages was higher in jurisdictions where the associated warning was mandated on packages, suggesting that warning labels may improve knowledge of cannabis-related health risks.Supplemental data for this article is available online at.

The efficacy of health warnings and package branding on perceptions of cannabis products among youth and young adults.

INTRODUCTION: Little empirical evidence exists about the efficacy of labelling and marketing restrictions in a regulated cannabis market. This study examined perceptions of cannabis product packaging designs, health warning labels (HWL) and perceptions of packs displaying brand imagery and leading descriptors on measures of appeal, and perceived consumer attributes. METHODS: An online experimental survey of Canadian cannabis users and non-users (n = 870) aged 16-30 years containing eight between-group experiments was conducted in October 2017. Primary outcomes were appeal and perceived consumer attributes of cannabis product packaging, including the likelihood of being younger, female, fashionable, health conscious and likely to go out and party. RESULTS: When cannabis product branding was present, respondents were more likely (P = 0.027) to report greater appeal than when branding was absent. When an HWL was present, respondents were less likely (P = 0.010) to report greater appeal than when absent. The presence of a celebrity sponsor (P < 0.001), music references (P < 0.001) or party references (P < 0.001) increased the likelihood that respondents perceived the product as targeted at someone younger, and a party lifestyle. Differences by cannabis use status were observed across experiments; those who had used were more likely to find branding elements appealing. DISCUSSION AND CONCLUSIONS: The findings demonstrate that brand imagery on cannabis packaging can promote lifestyle associations and increase the appeal of cannabis products among young people. Plain/standardised packs displaying HWLs were perceived as less appealing than packs with branding or without HWLs. Lifestyle associations can be communicated through brand imagery on cannabis packaging.

Prevalence and forms of cannabis use in legal vs. illegal recreational cannabis markets.

BACKGROUND: Recreational or 'non-medical cannabis' has been legalized in several US states, and was legalized federally in Canada in October 2018. There is little comparative data on product use across jurisdictions, particularly with respect to the types of cannabis products used, which differentially impact health. METHODS: Data are from Wave 1 of the International Cannabis Policy Study, collected from Aug 27-Oct 7, 2018. Respondents (n = 27,024) aged 16-65 completed an online survey measuring patterns of cannabis use, quantities and routes of administration. Respondents were recruited from Canada (n = 9976) and US states that had (n = 7362) and had not (n = 9686) legalized non-medical cannabis ('legal' and 'illegal' states, respectively). RESULTS: Prevalence of at least daily, weekly, and monthly cannabis use were significantly higher in US 'legal' states (11.3%, 18.2%, 25.0%, respectively) than US 'illegal' states (7.4%, 11.6%, 16.8%, respectively; p<0.001) and Canada (8.9%, 14.1%, 19.0%, respectively; p ≤ 0.01). Dried herb was the dominant form of cannabis reported by past 12-month users across all jurisdictions (77.7%-80.8%). Although the amount of dried herb used per year did not differ by jurisdiction (range: 210.3-229.4 g), those in US 'legal' states were significantly more likely to use dried herb daily or weekly than were those in 'illegal' states and Canada (p<0.001). Use of cannabis concentrates, vaped oils, edibles, and drinks was more prevalent among US 'legal' states than 'illegal' states and Canada (p ≤ 0.001). Vaping dried herb was more common in both legal and illegal US jurisdictions than in Canada (p<0.05), whereas Canadians were more likely to smoke dried herb with tobacco (p<0.001). CONCLUSION: The prevalence of cannabis use-and use of products such as cannabis concentrates, edibles and drinks-was higher in US states that had legalized cannabis. Additional longitudinal research is required to determine whether these differences reflect causal effects of legalization or pre-existing secular trends.

Mental Health and Medical Cannabis Use among Youth and Young Adults in Canada.

Background: In October 2018, Canada became the second country to legalize non-medical cannabis. However, medical cannabis has been legally available in Canada since 2001 and, in 2015, approximately 800,000 Canadians reported using cannabis for medical purposes. Mental health is a common reason reported for using medical cannabis. Objectives: The current study examined perceived mental health among four groups: (1) Non/ex-users; (2) Recent non-medical users; (3) Recent unauthorized medical users; and (4) Recent authorized medical users. Methods: A total of 867 Canadian cannabis users and nonusers aged 16 to 30 were recruited through an online consumer panel in 2017, one year before non-medical cannabis legalization. Logistic and multinomial regression models were fitted to examine differences among cannabis use status and mental health measures. All estimates represent weighted data. Results: Self-reported emotional and mental health problems were higher among unauthorized (83.9%) and authorized medical cannabis users (83.2%) compared to non-medical users and non/ex-users (44.5% and 39.5%, respectively). Medical users were more likely to report using cannabis to manage or improve mental health problems than non-medical users (p < .001). There were few differences between unauthorized and authorized medical users, and between non/ex-users and non-medical users. Conclusions: The findings highlight a discrepancy between the recommendation that individuals with some mental health problems should avoid cannabis and the widespread practice of using cannabis to manage mental health. Education and reduced stigma around using cannabis after legalization in Canada may help address users coming forwards regarding use of cannabis for mental health problems.

The impact of plain packaging and health warnings on consumer appeal of cannabis products.

BACKGROUND: Canada implemented 'plain packaging' regulations and rotating health warnings for cannabis products upon legalizing non-medical cannabis in October 2018. Plain packaging and health warnings are effective policy measures for reducing appeal of tobacco products; however, there is little evidence in the cannabis domain. METHODS: An experimental task was conducted as part of the online International Cannabis Policy Study. Participants aged 16-65 from Canada (n = 9987) and US states with 'legal' (n = 7376) and 'illegal' (n = 9682) recreational cannabis were randomly assigned to see one of 18 cannabis product images. Outcomes were product appeal (0 = Not at all appealing, 10 = Very appealing) and perceived youth orientation (4 age groups). A 3 (branding: full branding, brand logo only, or plain black packaging) x 2 (health warning labels: present or absent) x 3 (product type: edible gummies, cannabis oil, or pre-rolled joints) factorial design was used. RESULTS: Compared to plain packaging or a brand logo, packages with full branding were considered more appealing and more likely to be youth-oriented (p < 0.001). Products with health warnings were considered less appealing than packages without warnings (p < 0.001). Edible gummies were perceived as more appealing and more likely to be youth-oriented than pre-rolled joints and cannabis oil (p < 0.001). Additionally, edible gummies were rated as significantly more appealing by 16-18 and 19-35-year-olds than by older adults (p < 0.02 for all). CONCLUSIONS: Comprehensive health warnings and 'plain packaging' regulations may reduce the appeal of cannabis products in a legal market. The results also provide empirical evidence that edible gummies are perceived to appeal to youth.

Perceptions of effectiveness and believability of pictorial and text-only health warning labels for cannabis products among Canadian youth.

BACKGROUND: Health warnings have been shown to increase knowledge and awareness of health risks, influence social norms, and reduce consumption of tobacco products. With the legalization of non-medical cannabis in Canada and other subnational jurisdictions, there is a need for empirical studies to examine the impact of cannabis health warnings on consumer perceptions and behaviour relevant to cannabis. METHODS: In October 2017, a between-group experiment was conducted as part of an online survey of Canadians aged 16 to 30 years (N = 870) recruited from a national consumer panel. Participants rated the perceived effectiveness and believability of either text-only or pictorial cannabis health warnings and then completed a message recall task. Participants also reported their level of support for cannabis warnings, and support for including cessation information and a quitline on the warnings. RESULTS: Pictorial health warnings for cannabis products were perceived as more effective and believable than text-only warnings (p < 0.001), and the superiority of pictorial warnings was found across different warnings: dose (p = 0.039), co-morbid drug use (p = 0.006), and pregnancy (p < 0.001). Pictorial warnings were also rated as more believable (p = 0.048). Overall, 87.7% respondents supported having health warnings on cannabis products, and 84.0% supported the inclusion of a quitline number on cannabis health warnings. CONCLUSION: The current study provides the first empirical test of cannabis health warnings, consistent with the considerable body of evidence on the effectiveness of pictorial warnings on tobacco products. There was strong support for the inclusion of picture warnings and the inclusion of resources and quitlines on cannabis packaging.

Trends in cannabis use over time among Canadian youth: 2004-2014.

Cannabis is the most commonly used illicit substance among Canadian youth. The current study examined national trends in cannabis use among Canadian youth from 2004/05 to 2014/15 using nationally representative data from the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS). Data were collected from students in Grades 7 to 12 as part of the Canadian Student Tobacco, Alcohol and Drugs Survey (formerly the Youth Smoking Survey) using a repeat-cross sectional survey across 6 biennial survey waves between 2004 and 2014 (N = 243,057). Regression models examined factors associated with cannabis use in the past 12 months, perceived ease of access, and a multilinear regression examined age of initiation across survey cycles. The findings indicate that use of cannabis in the past 12-months significantly decreased among Canadian youth. Past-year use peaked in 2008/09 at 27.3%; compared to 16.5%, in 2014/15. Mean age of initiation did not vary over time, while youth in recent cycles reported that cannabis was more difficult to access: in 2006/07, 77.1% reported that it would be easy to access cannabis compared to 49.0% in 2014/15. Overall, cannabis use among Canadian youth appears to have peaked around 2008/09, with substantial declines over the past decade. It will be critically important to examine any changes in patterns of use following legalization of non-medical cannabis in Canada.

Perceived support for medical cannabis use among approved medical cannabis users in Canada.

INTRODUCTION AND AIMS: Very little is known about the social experience of medical cannabis use, including the experience of stigma among approved users. The current study examined perceptions of support from physicians, family and friends as well as the prevalence of 'hiding' medicinal cannabis use. DESIGN AND METHODS: An online cross-sectional survey (N = 276) was conducted from 29 April to 8 June 2015. No public sampling frame was available from which to sample approved medical cannabis users (MCU). Eligible respondents were approved MCUs, aged 18 years or older, and reported cannabis use in the past 30 days for health reasons. Logistic regression analyses were used to assess aspects of stigma, including perceived support from their immediate social environment as well as behaviours reflecting a perceived social disapproval. RESULTS: Approximately one-third of respondents (32.6%) reported that their physician had refused to provide a medical document, and the vast majority of respondents (79.3%) reported hiding their medical cannabis use, most commonly to avoid judgement. Fewer than half of approved users perceived that their doctor was 'supportive' (38%), whereas two-thirds perceived support from family (66.3%) and friends (66.3%). Perceptions of support were similar across most socio-demographic sub-groups. DISCUSSION AND CONCLUSIONS: Substantial proportions of approved MCUs in Canada report a lack of support and most have made some effort to conceal their medical cannabis use. Overall, the findings suggest that social norms around medical cannabis use remain unfavourable for many users, despite that fact that medical cannabis has been legal in Canada for more than a decade.

Prevalence of problematic cannabis use in Canada: Cross-sectional findings from the 2013 Canadian Tobacco, Alcohol and Drugs Survey.

OBJECTIVES: Cannabis is the most widely used illicit substance in Canada. There exist a variety of tools to measure problematic characteristics of cannabis use; however, there is no consensus on the operational definition of "problematic use". The current study sought to estimate the prevalence of problematic cannabis use in Canada, in terms of the kinds of problems Canadians report due to their cannabis use, the levels of harm associated with cannabis consumption, and potential differences among socio-demographic groups. METHODS: Cross-sectional, nationally representative data for Canadians were obtained from the publicly available Statistics Canada's 2013 Canadian Tobacco, Alcohol and Drugs Survey (CTADS) (n = 13 635). Binary logistic regression analyses were conducted to examine subgroup differences in patterns of cannabis use and problematic outcomes defined by the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool embedded in CTADS. RESULTS: The findings indicate that, while 1 in 10 Canadians reported using cannabis in the past 3 months, only 2% of the sample of Canadians who reported using cannabis in the past 3 months were characterized as having a "high risk" of severe health or other problems. Canadian male respondents were more likely to report social problems than females and to be categorized as high risk. Youth and young adults between the ages of 15 and 29 consistently reported a greater prevalence of problems associated with their cannabis consumption than their older counterparts. CONCLUSION: A very small proportion of Canadians report using cannabis to a degree that is problematic. Approximately one in two young people reported using cannabis at some point in their lives, of concern given the negative health outcomes of early cannabis use. This study highlights the need for the development of more sensitive instruments to detect problematic cannabis use.

Under the influence: examination of prevalence and correlates of alcohol and marijuana consumption in relation to youth driving and passenger behaviours in Canada. A cross-sectional study.

BACKGROUND: Consequences of alcohol- and drug-impaired driving affect youth disproportionately. We describe individual- and area-level characteristics associated with risky driving and passenger behaviours among grade 9-12 students in Canada. METHODS: The 2014-2015 Canadian Student Tobacco, Alcohol and Drug Survey was administered to 24 650 students in provincially generalizable samples. Dichotomous outcomes included ever and last-30-day driving after drinking alcohol, ever and last-30-day driving after using marijuana, and ever and last-30-day reporting of being a passenger with a driver who had been drinking or using marijuana. RESULTS: A total of 9.1% (99% confidence interval 7.9-10.3) of grade 11-12 students reported ever driving after drinking, and 9.4% (99% confidence interval 8.3-10.4) reported ever driving after using marijuana. Almost half (48%) of grade 11-12 students reported ever participating in any risky driving or passenger behaviour. Over one-third (35%) of grade 9-12 students reported ever riding with a driver who had been drinking, and 20% reported ever riding with a driver who had been using marijuana. Logistic regression models showed that boys had higher odds of risky driving behaviours relative to girls, whereas girls had higher odds of risky passenger behaviours relative to boys. Students from rural schools had higher odds of drinking and driving and of riding with a driver who had drunk relative to students from urban schools. There were significant differences in risky driving and passenger behaviours by province. INTERPRETATION: A substantial number of Canadian youth reported risky driving and passenger behaviours, which varied by individual and area-level characteristics. Federal marijuana policy should aim to reduce the prevalence of drug-impaired driving. Additional provincial policies to prevent impaired driving are needed.

A cross-sectional examination of medicinal substance abuse and use of nonmedicinal substances among Canadian youth: findings from the 2012-2013 Youth Smoking Survey.

BACKGROUND: Medicinal substance abuse is prevalent in Canada; however, little is known about patterns of abuse among young people. In this study, we sought to characterize the abuse of medicinal substances, such as prescription medications and selected over-the-counter substances, as well as that of licit and illicit nonmedicinal substances, using a nationally representative sample of young people. METHODS: Cross-sectional, nationally representative data for children in grades 7-12 were obtained from Health Canada's 2012-2013 Youth Smoking Survey (n = 38 667). Multinomial regression analyses were conducted to examine subgroup differences in medicinal substance abuse and comorbid abuse of both medicinal and nonmedicinal substances. RESULTS: About 5% of youth reported abusing medicinal substances in the previous year. Dextromethorphan, a substance found in many cough and cold syrups, was the most widely abused (2.9%), followed by pain medications (2.6%), sleeping medications (1.8%), stimulants (1.7%) and sedatives (1.0%). Abuse of nonmedicinal substances aside from tobacco and alcohol was reported by 21.3% of the population, and abuse of any substances was detected in 23.0% of the surveyed population. Girls at each grade level reported higher rates of abuse of medicinal substances than boys. Regional differences were seen with regard to the types of substances abused across Canada. INTERPRETATION: A substantial minority of Canadian youth report abusing medicinal substances, including over-the-counter medications (e.g., cough syrup) and prescriptions medications (e.g., pain medication). In contrast to nonmedicinal substances, girls were more likely than boys to report abuse of medicinal substances.