The Relationship Between Rates of Cannabis Use and Covid-19 Infection Rates During the Pandemic: An Analysis of Canada's National Cannabis Survey.

Background: The well-documented relationship between mental health and substance use is corroborated by recent research on the impacts of the Covid-19 pandemic on cannabis use behavior. Social isolation, anxiety, depression, stress, and boredom are all linked to the greater prevalence of cannabis and other substance use. Objectives: To better understand the relationship between infection rates in Canada and cannabis use behavior, this research examines the prevalence and frequency of cannabis use across health regions in all 10 provinces at the height of the pandemic. Methods: Our analyses linked data from the National Cannabis Survey with Covid-19 case rates and cannabis availability through legal retail outlets at the end of 2020, 2 years after cannabis legalization came into effect. Hierarchical generalized linear models were employed, controlling for age, gender, SES, mental health, the number of cannabis stores per square kilometer, and prevalence of cannabis use in each health region prior to the pandemic. Results: Even after controlling for other predictors, our models show that those residing where infection rates are higher are more likely to use cannabis and use it more often. Conclusions: The findings of this study support investing in better-targeted harm reduction measures in areas hit hardest by the pandemic to address contributing societal conditions. The implications are noteworthy for drug policy observers in North America and other global jurisdictions pursuing evidence-based public health approaches to regulating cannabis and other substance use.

Legal sourcing of ten cannabis products in the Canadian cannabis market, 2019-2021: a repeat cross-sectional study.

BACKGROUND: One of the objectives of cannabis legalization in Canada is to transition consumers from the illegal to the legal market. Little is known about how legal sourcing varies across different cannabis product types, provinces, and frequency of cannabis use. METHODS: Data were analyzed from Canadian respondents in the International Cannabis Policy Study, a repeat cross-sectional survey conducted annually from 2019 to 2021. Respondents were 15,311 past 12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models estimated the association between legal sourcing ("all"/ "some"/ "none") of ten cannabis product types, province, and frequency of cannabis use over time. RESULTS: The percentage of consumers who sourced "all" their cannabis products from legal sources in the past 12 months varied by product type, ranging from 49% of solid concentrate consumers to 82% of cannabis drink consumers in 2021. The percentage of consumers sourcing "all" their respective products legally was greater in 2021 than 2020 across all products. Legal sourcing varied by frequency of use: weekly or more frequent consumers were more likely to source "some" (versus "none") of their products legally versus less frequent consumers. Legal sourcing also varied by province, with a lower likelihood of legal sourcing in Québec of products whose legal sale was restricted (e.g., edibles). CONCLUSION: Legal sourcing increased over time, demonstrating progress in the transition to the legal market for all products in the first three years of legalization in Canada. Legal sourcing was highest for drinks and oils and lowest for solid concentrates and hash.

Increasing Cannabis Use Is Associated With Poorer Cigarette Smoking Cessation Outcomes: Findings From the ITC Four Country Smoking and Vaping Surveys, 2016-2018.

INTRODUCTION: Concurrent use of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation. AIMS AND METHODS: Nationally representative samples of adult cigarette smokers from Canada (n = 1455), the United States (n = 892), England (n = 1416), and Australia (n = 717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes. RESULTS: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than noncannabis-using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI = 0.31% to 0.86%); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI = 0.15% to 0.62%). CONCLUSIONS: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to noncannabis-using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates. IMPLICATIONS: Cigarette smokers who start using cannabis may be less likely to quit cigarettes compared with smokers who do not use cannabis at all. If smokers who also use cannabis are more likely to continue smoking, it is important to monitor these trends and understand the impact, if any, on smoking cessation in jurisdictions that have legalized cannabis for nonmedical use.

Consumer perceptions of legal cannabis products in Canada, 2019-2021: a repeat cross-sectional study.

BACKGROUND: Consumer perceptions of legal cannabis products may drive willingness to purchase from the illegal or legal market; however, little is known on this topic. The current study examined perceptions of legal products among Canadian cannabis consumers over a 3-year period following federal legalization of non-medical cannabis in 2018. METHODS: Data were analyzed from Canadian respondents in the International Cannabis Policy Study, a repeat cross-sectional survey conducted in 2019-2021. Respondents were 15,311 past 12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined the association between perceptions of legal cannabis and province of residence, and frequency of cannabis use over time. RESULTS: In 2021, cannabis consumers perceived legal cannabis to be safer to buy (54.0%), more convenient to buy (47.8%), more expensive (47.2%), safer to use (46.8%) and higher quality (29.3%) than illegal cannabis. Except for safety of purchasing, consumers had more favourable perceptions of legal cannabis in 2021 than 2019 across all outcomes. For example, consumers had higher odds of perceiving legal cannabis as more convenient to buy in 2021 than 2019 (AOR = 3.09, 95%CI: 2.65,3.60). More frequent consumers had less favourable perceptions of legal cannabis than less frequent consumers. CONCLUSIONS: Three years since legalization, Canadian cannabis consumers generally had increasingly favourable perceptions of legal vs. illegal products - except for price - with variation across the provinces and frequency of cannabis use. To achieve public health objectives of legalization, federal and provincial governments must ensure that legal cannabis products are preferred to illegal, without appealing to non-consumers.

Home cannabis cultivation in the United States and differences by state-level policy, 2019-2020.

Background: As of 2022, all but two U.S. states with adult-use cannabis laws also allow home cultivation. Home cultivation has the potential to support or oppose public health measures, and research in U.S. states is nascent.Objectives: 1) estimate the percentage of respondents who reported growing cannabis plants; 2) estimate the average number of plants grown; 3) examine the association between home cultivation, jurisdiction, and individual-level factors; and 4) examine the association between home cultivation and state-level policies in adult-use states.Methods: Repeat cross-sectional survey data come from U.S. respondents aged 21-65 in 2019 and 2020. Respondents were recruited through online commercial panels. Home cultivation rates were estimated among all U.S. respondents (n = 51,503; 46-52% male). Additional analyses were conducted on a sub-sample of respondents in states that allowed adult-use home cultivation (n = 29,100; 50% male).Results: A total of 6.8% and 7.3% of U.S. respondents reported home cultivation in 2019 and 2020, respectively. Respondents in states that allowed adult-use home cultivation had higher odds of reporting home cultivation than respondents in states without medical or adult-use cannabis laws (AOR = 1.48, 95% 1.26, 1.75). Among respondents in states that allowed adult-use home cultivation, the median number of plants that respondents reported growing was below state cultivation limits.Conclusion: Home cultivation rates in the U.S. were higher in states that allowed adult-use home cultivation; however, other evidence suggests these same states had higher rates predating adult-use legalization. Further work is needed to examine how home cultivation relates to public health measures in adult-use states.

Perceived access to cannabis and ease of purchasing cannabis in retail stores in Canada immediately before and one year after legalization.

Background: Canada legalized non-medical cannabis in October 2018. Little research has examined the change in perceived access to cannabis after legalization in Canada, including the perceived ease of purchasing cannabis in a legal market.Objectives: To: 1) describe changes in perceived ease of access to cannabis before and one year after legalization; 2) examine associations between perceived ease of cannabis access and cannabis use; and 3) examine associations between perceived ease of purchasing from cannabis stores and cannabis use.Methods: Repeat cross-sectional data come from Canadian respondents aged 16-65 (50% male) in August-October 2018 (n = 10,057) and September-October 2019 (n = 15,256). Respondents were recruited through commercial online panels. Multivariable logistic regression models examined correlates of perceived proximity to retail stores, ease of access, and ease of purchasing from retail stores.Results: Canadians who do not consume cannabis were more likely to report "easy" access to cannabis in 2019 than in 2018 (55% vs. 42%; AOR = 1.80:1.66,1.96). All cannabis consumer groups were more likely to report living 15 minutes or less from a retail store in 2019 than 2018, but the association was strongest among non-consumers in 2019 vs 2018 (AOR = 2.01:183,2.21 vs. AOR = 1.33:1.03,1.73 for daily consumers). Non-daily and daily cannabis consumers were more likely to report it was easy to purchase from an illegal (AOR ranged 1.58-2.22) or legal (AOR ranged 1.31-1.39) store than non-consumers in 2019.Conclusion: Most cannabis consumers and non-consumers perceived access to cannabis as 'easy' before legalization and the percentage increased one year after legalization.

An analysis of cannabis home cultivation and associated risks in Canada, before and after legalization.

Background: In 2018, Canada legalized the use and sale of non-medical cannabis, with most provinces also permitting home cultivation. To advance the knowledge of home cultivation patterns in Canada within the context of legalization, this study examines (1) the demographics and use patterns of cannabis home growers before and after legalization and (2) the relationship between home cultivation and cannabis-related risks, including workplace use and driving after cannabis use(DACU). Data and methods: The study is based on seven waves of the National Cannabis Survey, dating from 2018 to 2019. Descriptive statistics were used to analyze home cultivation across several individual and sociodemographic characteristics pre- and post-legalization. Logistic regression was used to examine whether home cultivation is correlated to selected cannabis-related risks. Results: The rate and demographics of home cultivation remained relatively unchanged post-legalization. Those most likely to cultivate cannabis post-legalization were male; 35 years and older; not single; married, common law, divorced, separated or widowed; lived in the Atlantic provinces; consumed cannabis medically or medically and non-medically on a daily or almost daily basis; had more than a high school diploma; and reported "smoking" as their primary consumption method. Home cultivation was correlated to workplace use but not to DACU. Interpretation: The research provides early insights into home cultivation within a legalized framework. It also shows a relationship between home cultivation and certain cannabis-related risks (e.g., workplace use), suggesting a need for future research to determine whether tailored education and policy interventions are needed to target cannabis home growers.

Legal status of recreational cannabis and self-reported substitution of cannabis for opioids or prescription pain medication in Canada and the United States.

Aims: With increased liberalization of cannabis policies in North America, there is growing interest in the use of cannabis to manage pain instead of opioids. The objectives of the study were to (1) examine the use of cannabis for pain relief in Canada and the United States (US) in 2018 and 2019; (2) examine the association between recreational cannabis laws and changes in the use of cannabis for pain relief, instead of opioids or prescription pain medication. Methods: Repeat cross-sectional survey data were used from Wave 1 and Wave 2 of the International Cannabis Policy Study conducted in 2018 and 2019 in Canada and the US. Respondents were recruited through commercial panels, aged 16-65, and had ever tried cannabis (N = 44,119). Weighted binary logistic regression models examined the association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication (n = 15,092). Results: Between 14-33% of cannabis consumers in Canada and the US reported using cannabis to manage headaches or pain. Of these consumers, 79% and 78% respondents in Canada; 80% and 83% in US illegal states; and 83% and 84% in US legal states, in 2018 and 2019, respectively, reported cannabis use for pain relief instead of opioids or prescription pain medication. There was little evidence of an association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication, among Canadian (AOR = 0.98, 95% CI: 0.78, 1.22) and US respondents (AOR = 1.11, 95% CI: 0.96, 1.28). Conclusions: Although substitution of cannabis for opioids or prescription pain medication is common among those who use cannabis for pain, there does not seem to be a significant difference according to cannabis legality. Future research should examine cannabis and opioid substitution using different research designs and time frames.

Modes of delivery in concurrent nicotine and cannabis use ("co-use") among youth: Findings from the International Tobacco Control (ITC) Survey.

BACKGROUND: Cannabis use is more common among nicotine users than non-users. This study characterized concurrent use of nicotine and cannabis ("co-use") among 12,064 youth aged 16-19 years residing in Canada, the United States, and England in 2017. Methods: Data were from the ITC Youth Tobacco & Vaping Survey (Wave 1). Seven modes of cannabis delivery (MOD) were characterized by country of residence and past 30-day use of combusted tobacco and electronic cigarettes. Weighted multivariable regression models were fitted to assess the correlates of co-use and each cannabis MOD. Results: Seventy percent of cannabis users reported nicotine use. Co-users exhibited behavioral and demographic differences compared to exclusive users of either substance. "Smoking cannabis without tobacco" was the most popular form of use (78%). Use of nicotine-containing e-cigarettes was associated with "using an e-cigarette to vape cannabis oil/liquid" (aOR: 4.96, 95%CI: 2.23-11.06). Combustible tobacco use was associated with "smoking cannabis with tobacco in a joint/blunt" (aOR: 2.93, 95%CI: 1.89-4.56). Country-level differences were detected. Conclusions: Nicotine use is substantial among cannabis users, and associations exist between modes of delivery for both drugs. Results underscore the importance of studying cannabis and nicotine use concurrently, and the need to address the use of both substances in developing interventions for youth users.

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.

A market on both "sides" of the law: The use of the hidden web for the sale of new psychoactive substances.

OBJECTIVE: The hidden Web is used for the anonymous sale of drugs, and with the UK Psychoactive Substances Act, 2016, implemented on May 26th 2016; it could increase as a platform for obtaining new psychoactive substances (NPS). This study aims to describe the NPS market on the visible and hidden Web preban, and assess whether the hidden Web is a likely place for the sale of NPS postban. METHODS: Data collection of 113 online shops took place in October 2015. Data collection of 22 cryptomarkets took place every 2 months from October 2015 to 2016 as part of the CASSANDRA project. RESULTS: All online shops with a UK domain location sold NPS that were uncontrolled by the UK Misuse of Drugs Act, 1971, and closed after the ban. Of the cryptomarkets analysed, the total number of vendors selling NPS, number of substances, and listings advertised, all increased over the year. The majority of the NPS advertised on the hidden Web were phenethylamines and cathinones, yet the majority of uncontrolled NPS were synthetic cannabinoids. CONCLUSIONS: Vendors selling and availability of NPS increased over the 12 months of data collection. Potential displacement from the visible Web to hidden Web should be taken into consideration.

The challenge of complex drug use: Associated use of codeine-containing medicines and new psychoactive substances in a European cross-sectional online population.

OBJECTIVE: Misuse of codeine-containing medicines in combination with new psychoactive substances (NPS) is inadequately described. This study characterises codeine consumption amongst NPS users and non-NPS users to provide warning of health issues. METHODS: Online survey conducted between July 2015 and March 2016. RESULTS: Out of 340 respondents, residing in a country in Europe and using codeine recently, 63.8% were female. Mean age: 34.9 years (SD = 12.4). Substance use included NPS (18.5%) and illicit controlled drugs (55.9%). Factors relating to codeine use found to significantly predict NPS use were consuming codeine extracted from combination tablets (OR = 16.79, 95% CI [8.67, 32.51]), obtaining codeine from friends, family, and acquaintances (OR = 3.98, 95% CI [1.82, 8.7]), use of illicit controlled drugs (OR = 34.99, 95% CI [8.39, 145.94]) and use of codeine to experience euphoria (OR = 6.41, 95% CI [3.42, 12.04]). CONCLUSIONS: Amongst NPS users, codeine is less likely to be used daily but more likely to be used for recreational purposes. Smaller populations engaging in high-risk use exist who take multiple drugs in high doses. Combinations of misused codeine and NPS highlight the need for policy to respond to a more complex drug situation.

Self-reported THC content and associations with perceptions of feeling high among cannabis consumers.

INTRODUCTION: Few studies have examined consumer knowledge and communication of tetrahydrocannabinol (THC) content among cannabis consumers, including potential differences by cannabis legislation. The study sought to: (i) examine self-reported knowledge of THC content across 10 cannabis products; (ii) examine self-reported intoxication levels; and (iii) examine association between self-reported THC levels and intoxication levels. METHODS: Repeat cross-sectional surveys were conducted in Canada and the United States in September-November 2020 as part of the International Cannabis Policy Study. Respondents were past 12-month cannabis consumers, aged 16-65 (n = 13,689). A weighted logistic regression model examined the association between expected intoxication of dried flower, jurisdiction and frequency of cannabis use. RESULTS: Across all 10 cannabis products, approximately two-thirds of consumers did not know the quantitative THC level of the cannabis product they last used. Qualitative levels of THC (e.g., 'low' or 'high' THC) showed moderate correspondence with quantitative self-reported THC levels for most products. Approximately half of consumers across all products reported achieving their desired intoxication level at last use, with higher levels among more frequent consumers and Canadian consumers of dried flower (F = 2.54, p = 0.019). DISCUSSION AND CONCLUSIONS: Overall, comprehension of THC levels in cannabis products is low among consumers in both illegal and legal markets.

Self-reported Impact of the COVID-19 Pandemic on Cannabis Use in Canada and the United States.

The current study examined the self-reported impact of the COVID-19 pandemic on cannabis consumption and behaviors among past 12-month cannabis consumers in Canada and the U.S. across different cannabis laws. Cross-sectional survey data were collected in 2020 from respondents recruited through online commercial panels, aged 16-65, who consumed cannabis in the past 12 months (n = 13,689). Weighted multinomial logistic regression models examined differences between jurisdictions for five outcomes: 1) cannabis consumption; 2) use of product types; 3) use of sources to obtain cannabis; 4) legality of source used; and 5) access to cannabis. Approximately one third of cannabis consumers reported changes to their consumption during the pandemic. Edibles (23% - 31%) and dried flower (21% - 30%) were the two most common products that respondents reported they were "more likely" to use during the pandemic. Most consumers reported "no difference" to changes in sourcing cannabis. Compared to consumers in U.S. recreational states, consumers in U.S. medical (AOR = 1.27, 95% CI: 1.07, 1.50) and illegal states (AOR = 1.22, CI: 1.00,1.48) had higher odds of reporting it was "harder" to access cannabis, and consumers in Canada had lower odds (AOR = 0.73, CI: 0.63,0.84). Future research should examine whether these changes remain after public health restrictions due to the pandemic are removed.

Prices and Purchase Sources for Dried Cannabis Flower in the United States, 2019-2020.

Introduction: The price of cannabis has major implications for public health, public safety, social equity, and government revenues. This article examines prices and sources of purchased dried cannabis flower among consumers facing different state laws in the United States. Methods: Repeat cross-sectional survey data were collected from the International Cannabis Policy Study in 2019 and 2020. U.S. respondents were recruited through online commercial panels, ages 16-65, and purchased dried flower in the past year (n=9766). Weighted binary logistic regression models examined legal purchasing in states that had legalized recreational cannabis. Results: Compared with respondents in states with recreational stores, respondents living in "illegal," "medical," and "recreational" states without stores were associated with paying a higher unit price of dried flower (+20.5%, +23.6%, +27.4%, respectively; all p<0.05). The majority of respondents in states with recreational stores last purchased from stores/dispensaries (2019: 66.6%; 2020: 62.0%) and the odds of purchasing legally was greater with each additional year after stores opened (adjusted odds ratio=1.48, 95% confidence interval: 1.37, 1.60). Conclusions: Cannabis prices and purchase behaviors are strongly influenced by its legal status and presence of stores. After states legalize for recreational purposes, it takes multiple years for the legal market to become established as the number of retail stores increase and prices decrease. The findings demonstrate that consumers use sources that they are legally allowed to access, suggesting an increased number of physical retail stores and online delivery services could expand uptake of legal sources in states with recreational cannabis laws.

Co-use of cannabis and alcohol before and after Canada legalized nonmedical cannabis: A repeat cross-sectional study.

BACKGROUND: This study examined changes in population-level co-use of cannabis and alcohol before and 12 months after nonmedical cannabis legalization in Canada, relative to the United States that had previously legalized and not legalized (US legal and illegal states, respectively). METHODS: Data are from waves 1 and 2 of the International Cannabis Policy Study, collected in 2018 (before) and 2019 (12 months after legalization in Canada). Respondents aged 16-65 years from Canada (n = 25,313) and US legal (n = 25,189) and US illegal (n = 19,626) states completed an online survey. Changes in co-use between 2018 and 2019 in US legal and illegal states compared to those in Canada were assessed using multinomial logistic regression. RESULTS: Descriptive analyses show increases in cannabis use and monthly or more frequent (MMF) co-use between 2018 and 2019 in all jurisdictions. Compared to no MMF use of cannabis or alcohol, there was no evidence suggesting differences in changes in MMF co-use in US legal or illegal states relative to Canada. However, respondents in US legal states had 33% higher odds of MMF alcohol-only use (OR = 1.33, 99% CI: 1.12, 1.57) compared to no MMF use relative to Canada. CONCLUSIONS: Increases in co-use were observed between 2018 and 2019 in all jurisdictions regardless of the legal status of cannabis. These shifts were largely due to increases in cannabis use across the population, including those that use alcohol, and may indicate changing societal norms toward cannabis generally. As the cannabis legalization transition in Canada matures, evaluation over the longer term will improve understanding of the influence of cannabis liberalization on co-use.

Proximity to Legal Cannabis Stores in Canada and Use of Cannabis Sources in the First Three Years of Legalization, 2019-2021.

OBJECTIVE: The accessibility of legal cannabis in Canada may influence how consumers source their cannabis. The aims of this study were to examine (a) the distance between respondents' homes and legal retail stores, (b) the cannabis sources used in the past 12 months, and (c) the association between cannabis sources used and distance to legal retail stores. METHOD: Data were analyzed from Canadian respondents participating in the International Cannabis Policy Study from 2019 to 2021. Respondents were 15,311 past-12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined cannabis sources used and their association with the Euclidean distance to the nearest legal store, province of residence, and year (n = 12,928). RESULTS: Respondents lived closer to a legal retail store in 2021 (1.5 km) versus 2019 (6.8 km) as the number of retail stores increased. Respondents in 2020 and 2021 had higher odds of obtaining cannabis from legal sources (e.g., legal stores: 47.9% and 60.0% vs. 38.6%, respectively, adjusted odds ratio [AOR] range: 1.41-2.42) and lower odds of obtaining cannabis from illegal sources versus 2019 (e.g., dealers: 22.6% and 19.9% vs. 29.1%, respectively, AOR range: 0.65-0.54). Respondents who lived closest to legal stores had higher odds of sourcing from legal stores and lower odds of sourcing from legal websites or growing their own cannabis. CONCLUSIONS: Legal cannabis stores are increasingly accessible to people living in Canada 3 years after legalization. Household proximity to a legal cannabis store was associated with sourcing cannabis from legal retail stores, but only among those who live very close (<3 km). Findings suggest that proximity to legal cannabis stores may aid uptake of the legal market, yet there may be diminishing returns after a certain point.

Perceptions of cannabis use risk to mental health among youth in Canada, England and the United States from 2017 to 2021.

BACKGROUND: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states). METHODS: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization. RESULTS: Perceptions that cannabis use posed "no risk" to mental health decreased between July 2017 and August 2021 in Canada (6.1-4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0-11.3%; AOR=0.74, 0.65-0.84) but not England (3.7-4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of "no risk" were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74). CONCLUSION: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Reasons for Purchasing Cannabis From Illegal Sources in Legal Markets: Findings Among Cannabis Consumers in Canada and U.S. States, 2019-2020.

OBJECTIVE: Nonmedical cannabis is legal in Canada and several U.S. states. Displacing the illegal market is a primary goal of legalization; however, there are little data on factors that predict consumers' transition from the illegal to the legal market. The current study aimed to examine reasons for purchasing illegal cannabis and, thus, potential barriers to purchasing legal cannabis among consumers in Canada and U.S. states. METHOD: Data are from the 2019 and 2020 International Cannabis Policy Study, a repeat cross-sectional survey conducted among 16- to 65-year-olds. Reasons for purchasing illegally in the past 12 months were asked of male and female cannabis consumers in Canada and U.S. legal states (n = 11,659). Changes over time in reasons for illegal purchasing were tested. Analyses among Canadians also examined associations between reasons for illegal purchasing and objective data on cannabis prices and retail density. RESULTS: In both years, the most commonly reported barriers to legal purchasing were price (Canada: 35%-36%; United States: 27%) and inconvenience (Canada: 17%-20%; U.S.: 16%-18%). In 2020 versus 2019, several factors were less commonly reported as barriers in Canada, including inconvenience (17% vs. 20%, p = .011) and location of legal sources (11% vs. 18%, p < .001). Certain barriers increased in the United States, including slow delivery (5% vs. 8%, p = .002) and requiring a credit card (4% vs. 6%, p = .008). In Canada, consumers in provinces with more expensive legal cannabis were more likely to report price as a barrier, and those in provinces with fewer legal retail stores were more likely to report inconvenience as a barrier (p < .001). CONCLUSIONS: Higher prices and inconvenience of legal sources were common barriers to purchasing legal cannabis. Future research should examine how perceived barriers to legal purchasing change as legal markets mature.

Use and Perceptions of Cannabidiol Products in Canada and in the United States.

Objectives: This study aimed to characterize use and perceptions of cannabidiol (CBD) products. Materials and Methods: Participants aged 16-65 years in Canada (n=15,042) and the United States (n=30,288) completed measures on prevalence and patterns of CBD product use and perceptions of CBD oil as part of the 2019 International Cannabis Policy Study online survey. Results: Past 12-month CBD product use was significantly more prevalent among respondents in the United States (26.1%) than in Canada (16.2%). Consumers in the United States and Canada reported using a range of CBD products, including drops (46.3% vs. 47.3%, respectively), topicals (26.0% vs. 16.7%), edibles/foods (23.8% vs. 17.6%), vape oils (18.9% vs. 13.3%), capsules (13.3% vs. 16.7%), and dried flower (10.1% vs. 16.1%). CBD was most commonly reported for management of pain, anxiety, and depression. Over half of CBD consumers in both countries reported that CBD oil was beneficial for health. Conclusions: Use of CBD products is common in both the United States and Canada, primarily to manage self-reported health conditions for which there is little or no evidence of efficacy. Clearer public health messaging regarding the therapeutic effects of CBD is warranted.