Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design.

INTRODUCTION: The growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics. The Primary Care Diabetes Support Programme (PCDSP) in London, Ontario, is an innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients. In this study, we will employ a quadruple-aim approach to evaluate the health system impacts of the PCDSP. METHODS AND ANALYSIS: We will use multiple methods through a convergent parallel design in this project across five unique studies: a case study, a patient study, a provider study, a complications study and a cost-effectiveness study. The project will be conducted in a dedicated stand-alone clinic specialising in chronic disease management, specifically focusing on diabetes care. Participants will include clinic staff, administrators, family physicians, specialists and patients with type 1 or type 2 diabetes who received care at the clinic between 2011 and 2023. The project design will define the intervention, support replication at other sites or for other chronic diseases and address each of the quadruple aims and equity. Following the execution of the five individual studies, we will build a business case by integrating the results. Data will be analysed using both qualitative (content analysis and thematic analysis) and quantitative techniques (descriptive statistics and multiple logistic regression). ETHICS AND DISSEMINATION: We received approval from the research ethics boards at Western University (reference ID: 2023-1 21 766; 2023-1 22 326) and Lawson Health Research Institute (reference ID: R-23-202). A privacy review was completed by St. Joseph's Healthcare Corporation. The findings will be shared among PCDSP staff and patients, stakeholders, academic researchers and the public through stakeholder sessions, conferences, peer-reviewed publications, infographics, posters, media interviews, social media and online discussions. For the patient and provider study, all participants will be asked to provide consent and are free to withdraw from the study, without penalty, until the data are combined. Participants will not be identified in any report or presentation except in the case study, for which, given the number of PCDSP providers, we will seek explicit consent to identify them.

A survey of educator perspectives toward teaching harm reduction cannabis education.

INTRODUCTION: Substance use is common among youth which can adversely affect youth health. Despite the legalization of cannabis in Canada and much of the United States, there is a lack of harm reduction cannabis education in schools. In addition, educators may not feel prepared to teach students about cannabis. METHODS: A cross-sectional survey explored educator perceptions toward teaching harm reduction substance use education to students in grades 4-12. Data analysis included descriptive statistics to evaluate demographic variables, ANOVAs to identify subgroup differences, and inductive thematic analysis to establish themes from open-ended responses. From the sample of 170 educators, the majority were female (77%) and worked as classroom teachers (59%). RESULTS: Ninety-two percent of educators felt harm reduction was an effective approach to substance use education, and 84% stated that they would feel comfortable teaching cannabis harm reduction education to students. While 68% of educators believed they would be able to recognize if a student was under the influence of cannabis, only 39% felt certain about how to respond to student cannabis use, and just 8% felt that their current teacher training allowed them to intervene and prevent cannabis-related harms. Most educators (89%) expressed interest in harm reduction training, particularly interactive training (70%) and instructor-led lessons (51%). Online curriculum resources were preferred by 57%. Responses differed by gender and age group, with females of any age and educators under 40 reporting greater support of harm reduction approaches and more interest in training. CONCLUSION: Educators expressed considerable support for harm reduction substance use education, but many felt unprepared to address this topic with students. The findings identified a need for educator training on harm reduction substance use education, so that educators can help students make informed choices around substance use, thereby promoting youth health and safety.

A Cross Sectional Survey of Factors Related to Cannabis Use as a Sleep Aid Among Canadian Cancer Survivors.

OBJECTIVES: Poor sleep is a common side effect of cancer. Cannabis is increasingly used to manage cancer treatment-related symptoms, including sleep. This study investigated factors related to cannabis use for sleep among Canadian cancer survivors. METHOD: Adult Canadian cancer survivors (N = 940) were recruited via the Angus Reid Institute and completed an online, cross-sectional survey. Univariate and multiple binomial logistic regression models identified factors associated with cannabis use for sleep. RESULTS: Of the participants (Mage = 64.5 yrs; Women = 51.1%; White = 92.9%), 25.1% (n = 236) currently use cannabis for sleep. Participants were at greater odds of using cannabis for sleep if they identified as a gender other than man or woman (AOR = 11.132), were diagnosed with multiple medical conditions (2:AOR = 1.988; 3+:AOR = 1.902), two psychological conditions (AOR = 2.171), multiple sleep disorders (AOR = 2.338), insomnia (AOR = 1.942), bone (AOR = 6.535), gastrointestinal (AOR = 4.307), genitourinary (AOR = 2.586), hematological (AOR = 4.739), or an unlisted cancer (AOR = 3.470), received hormone therapy only (AOR = 3.054), drink heavily (AOR = 2.748), or had mild insomnia (AOR = 1.828). Older participants (AOR=.972) and those with sleep apnea were less likely to use cannabis for sleep (AOR=.560). CONCLUSION: Given its prevalence, research is needed to understand how factors associated with cannabis use as a sleep aid among Canadian cancer survivors may influence its use and effectiveness and whether these factors are barriers to accessing evidence-based treatments.

Exploring consumer preferences for cannabis edible products to support public health policy: A discrete choice experiment.

BACKGROUND: In October 2019, cannabis edibles were legalized for sale in Canada for non-medical use. This move was intended to improve public safety by regulating contents (including a maximum 10 mg tetrahydrocannabinol (THC) per package) and packaging to prevent accidental ingestion or over consumption. This study aimed to explore consumer preferences for cannabis edibles to inform cannabis policy. METHODS: We explored the relative importance and trade-offs consumers make for attributes of cannabis edibles using a discrete choice experiment. Attributes included type of edible, price, THC content, cannabis taste, package information, product consistency, product recommendations, and Health Canada regulation. Participants lived in Canada, were 19 years of age or older, and purchased a cannabis edible in the last 12 months. A multinomial logit (MNL) model was used for the base model, and latent class analysis to assess preference sub-groups. This study was approved by the institutional ethics committee. RESULTS: Among 684 participants, the MNL model showed that potency was the most relevant attribute, followed by edible type. A two-group latent class model revealed two very distinct preference patterns. Preferences for group 1 (~65% of sample) were driven primarily by edible type, while for group 2 (~35% of sample) were driven almost entirely by THC potency. CONCLUSION: This study found that consumer preferences for ~65% of consumers of cannabis edibles are being met through regulated channels. The remaining ~35% are driven by THC potency at levels that are not currently available on the licensed market. Attracting this market segment will require reviewing the risks and benefits of restricting THC package content.

Planting the seeds for success: A qualitative study exploring primary healthcare providers' perceptions about medical cannabis.

BACKGROUND: In Canada, cannabis legalization altered the way that the public can access cannabis for medical purposes. However, Canadians still struggle with finding healthcare professionals (HCPs) who are involved in medical cannabis counselling and authorization. This raises questions about the barriers that are causing this breakdown in care. Our study explored the perceptions of primary care providers regarding cannabis in their practice. METHODS: Semi-structured interviews were conducted by Zoom with HCPs in Newfoundland and Labrador (NL) to discuss their experiences with medical and non-medical cannabis in practice. Family physicians and nurse practitioners who were practicing in primary care in NL were included. The interview guide and coding template were developed using the Theoretical Domains Framework (TDF). A thematic analysis across the TDF was then conducted. RESULTS: Twelve participants with diverse demographic backgrounds and experience levels were interviewed. Five main themes emerged including, knowledge acquisition, internal influences, patient influences, external HCP influences, and systemic influences. The TDF domain resulting in the greatest representation of codes was environmental context and resources. INTERPRETATION: The findings suggested that HCPs have significant knowledge gaps in authorizing medical cannabis, which limited their practice competence and confidence in this area. Referring patients to cannabis clinics, while enforcing harm-reduction strategies, was an interim option for patients to access cannabis for medical purposes. However, developing practice guidelines and educational resources were suggested as prominent facilitators to promote medical cannabis authorization within the healthcare system.

Examining attributes of retailers that influence where cannabis is purchased: a discrete choice experiment.

BACKGROUND: With the legalization of cannabis in Canada, consumers are presented with numerous purchase options. Licensed retailers are limited by the Cannabis Act and provincial regulations with respect to offering sales, advertising, location, maximum quantities, and information sharing in an effort to protect public health and safety. The degree these policies influence consumer purchase behavior will help inform regulatory refinement. METHODS: A discrete choice experiment within a cross-sectional online survey was used to explore trade-offs consumers make when deciding where to purchase cannabis. Attributes included availability of sales/discounts, proximity, product information, customer service, product variety, and provincial regulation. Participants ≥ 19 years old who lived in Canada and purchased cannabis in the previous 12 months were recruited through an online market research survey panel. A multinomial logit (MNL) model was used for the base model, and latent class analysis was used to assess preference sub-groups. Key limitations included ordering effect, hypothetical bias, and framing effect. RESULTS: The survey was completed by 1626 people, and the base model showed that customer service carried the most weight in purchase decisions, followed by proximity and availability of sales and discounts. There was considerable heterogeneity in preference patterns, with a five-group latent class model demonstrating best fit. Only one group (15% of sample) placed a high value on the store being provincially regulated, while three groups were willing to make a trade-off with regulation to access better customer service, product information, or closer proximity. One group preferred non-regulated sources (24% of sample); this group was also primarily driven by the availability of sales and discounts. Three groups (60.5% of sample) preferred online stores. CONCLUSION: This study highlighted that there exists significant diversity with respect to the influence of consumer experiences on cannabis purchase behaviors. Modifications to cannabis retail regulations that focus on improving access to product information as well as reviewing limitations on sales and discounts could have the most impact for shifting customers to licensed retailers.

Canadian cannabis education resources to support youth health literacy: A scoping review and environmental scan.

Background: The 2018 legalisation of cannabis in Canada sparked concern and conversation about the potential negative impacts of youth cannabis use. It is clear that young people are already engaging in cannabis use for a variety of reasons; therefore, youth cannabis education is desirable to promote harm reduction and reduce the risk of adverse physical and mental health outcomes. Objective: To identify and categorise Canadian cannabis education resources using a social-ecological approach informed by the youth health literacy framework, considering multiple factors at the micro-, meso- and macro-levels that influence health literacy and impact behaviour. Methods: In line with scoping review methodology, database searches and an environmental scan of materials were completed. Specific inclusion criteria were identified to encompass all Canadian cannabis education resources directed towards young people aged 9-18 years and adults in contact with youth. Results: A total of 60 resources were identified and categorised using the youth health literacy framework in terms of their focus on (1) micro influences (resources for youth); (2) meso influences (resources for teachers, parents, mentors); and (3) macro influences (resources for indigenous communities and medical professionals). Conclusions: While many resources were identified, issues exist with the accessibility, quality and multicultural considerations of such resources, warranting the development of comprehensive, evidence-based and harm reduction-focused cannabis education for youth.

A cross-sectional survey of the prevalence and patterns of using cannabis as a sleep aid in Canadian cancer survivors.

PURPOSE: Poor sleep is one of the most common side effects of cancer. It can persist for years beyond treatment and negatively impact quality of life and health. Cannabis is increasingly used to manage cancer treatment-related symptoms, including sleep. This study investigated the use and perceived effects of cannabis as a sleep aid in Canadian cancer survivors. METHODS: Adult Canadian cancer survivors (N = 1464) were recruited via the Angus Reid Institute and completed an online, cross-sectional survey including the Insomnia Severity Index and questions about cannabis use for sleep. Standard descriptive statistics, such as means, standard deviations, and ranges were produced for measured variables to assess the ways cancer survivors use cannabis for sleep. Frequencies were tabulated for categorical and ordinal variables. RESULTS: On average, participants (Mage = 61.1 years; Women = 50%: Men = 48%) received their cancer diagnosis 12.5 years prior. Of participants, 23.5% (n = 344) currently use cannabis as a sleep aid, with reported benefits including relaxation, reduced time to fall asleep, fewer nocturnal awakenings and improved sleep quality. Two thirds (68.3%, n = 235) only began using cannabis for sleep after their cancer diagnosis. Over a third of participants (36.3%, n = 125) use cannabis as a sleep aid every day. Among the 344, the most common other reasons for using cannabis were pain (31.4%, n = 108), recreational use (24.4%, n = 84), and anxiety (12.5%, n = 43). CONCLUSIONS: Given the prevalence and potential impact, research is needed to examine the actual efficacy of cannabis as a sleep aid. IMPLICATIONS FOR CANCER SURVIVORS: It is important that cancer survivors have information on methods to help their sleep to avoid impairments to quality of life and health.

Emerging adult perceptions of higher-risk cannabis consumption behaviours.

BACKGROUND: Emerging adults have the highest cannabis consumption rates in Canada and are among the most vulnerable to cannabis-related harms. Since certain cannabis consumption behaviours carry greater risks of harm, the Lower-Risk Cannabis Use Guidelines (LRCUG) provide harm reduction strategies. To address a critical gap in the literature, the current study examined emerging adults' awareness of the guidelines and perceptions of higher-risk cannabis consumption behaviours identified within the LRCUG. METHODS: Emerging adults (N = 653) between the ages of 18-25 years were recruited from across Canada. Participants were presented with five vignettes depicting a character's cannabis consumption behaviours. Each vignette focused on a unique aspect of the character's consumption (frequency, polysubstance use, family history of mental illness, method of consumption, and potency). Participants were randomly assigned to one of three conditions within each of the five vignettes that were altered to capture varying levels of risk (e.g. weekly, almost daily, or daily consumption). Following each vignette, participants were asked to respond to four items relating to overall risk of harm, cognitive health, physical health, and mental health. RESULTS: Participants perceived: (1) frequent consumption to be associated with greater risks than less frequent consumption; (2) simultaneous consumption of cannabis and tobacco as being associated with higher risk of harm, yet no difference between simultaneous consumption of cannabis and alcohol or cannabis consumption alone; (3) consuming cannabis with a family history of psychosis or substance use disorder as being associated with greater overall risk than consumption with no family history; (4) smoking and vaping cannabis as associated with more risk than ingesting edibles; and (5) higher-potency THC-dominant strains as being associated with more risk than lower-potency CBD-dominant strains, yet no difference between the two higher-potency THC-dominant strains. CONCLUSIONS: While emerging adults seemed to appreciate the risks associated with some cannabis consumption behaviours, they had difficulty identifying appropriate levels of harm of other higher-risk behaviours. Through an improved understanding of emerging adult perceptions, effective education campaigns should be designed to improve the awareness of cannabis risks and encourage the uptake of harm reduction awareness and strategies.

Emerging adult perceptions of cannabis consumption: Examining changes in perceptions from pre-legalization to post-legalization.

BACKGROUND: Emerging adults (EAs) have the highest rates of cannabis consumption in Canada and are vulnerable to the potential impacts of frequent cannabis consumption. This study assessed EAs' perceived risk of cannabis consumption across multiple domains of potential harm based on the age (14-year-old, 21-year-old, or 28-year-old) and sex (male or female) of the vignette character, time-point (pre- or post-legalization), and participant's gender. METHODS: Secondary analyses were conducted on data from a pre-legalization study and post-legalization replication. Participants included EAs between 18 and 25 years of age and living in Newfoundland and Labrador. Participants from the pre- and post-legalization studies were matched based on demographic variables and the assigned vignette character. Participants responded to seven items of perceived risk based on their assigned vignette character's (varied by age or sex) almost daily cannabis consumption. RESULTS: Participants (N = 689) viewed cannabis consumption to have greater risks for a 14-year-old compared to a 21- or 28-year-old in all domains except for social life. Prior to legalization, participants who identified as a woman felt that cannabis had more detrimental impacts on social life than participants who identified as a man. Findings also suggested that pre-legalization cannabis consumption by a female was perceived as more detrimental to their social life than pre-legalization consumption by a male and post-legalization consumption by a female. CONCLUSION: EAs do not fully appreciate the risks of cannabis consumption, suggesting that it is imperative for public health strategies to promote increased awareness of the risks of frequent cannabis consumption, and improve cannabis health literacy in this population.

The COVID-19 pandemic and cannabis use in Canada-a scoping review.

BACKGROUND: Since the start of the COVID-19 pandemic in Canada, the cannabis industry has adapted to public health emergency orders which had direct and indirect consequences on cannabis consumption. The objective of this scoping review was to describe the patterns of consumption and cannabis-related health and safety considerations during the COVID-19 pandemic in Canada. METHODS: For this scoping review, we searched four electronic databases supplemented with grey literature. Peer-reviewed or pre-print studies using any study design and grey literature reporting real-world data were included if published in English between March 2020 and September 2021 and focused on cannabis and COVID-19 in Canada. A content analysis was performed. RESULTS: Twenty-one studies met the inclusion/exclusion criteria. Study designs included cross-sectional surveys (n = 17), ecological study (n = 1), conceptual paper (n = 1), longitudinal study (n = 1), and prospective cohort study (n = 1). Most were conducted solely in Canada (n = 18), and the remaining included global data. Our content analysis suggested that cannabis consumption during the pandemic varied by reasons for use, consumers' age, gender, and method of consumption. Health and safety impacts due to the COVID-19 pandemics included increased mental illness, increased emergency visits, and psychosocial impacts. DISCUSSION: This scoping review suggested that the impact of the pandemic on cannabis consumption in Canada is more complex than simplistic assumptions of an increase or decrease in consumption and continues to be difficult to measure. This study has explored some of those complexities in relation to reasons for use, age, gender, method of consumption, and health impacts. This scoping review is limited by focusing on the breadth compared to depth. CONCLUSIONS: Legalizing nonmedical use of cannabis in Canada in 2018 has had its challenges of implementation, one of which has been the changing context of the society. The findings of this study can help inform cannabis policy updates in Canada as the country is reaching its fifth year of legalizing nonmedical use of cannabis.

Drivers of Purchase Decisions Among Consumers of Dried Flower Cannabis Products: A Discrete Choice Experiment.

OBJECTIVE: Cannabis was legalized for nonmedical use in Canada in 2018. However, with a long-established illegal market, it is important to understand cannabis consumers' preferences in order to create a market that encourages purchasing cannabis through legalized channels. METHOD: A survey including a discrete choice experiment was conducted to estimate preference weights for seven attributes of dried flower cannabis purchases (price, packaging, moisture level, potency, product recommendations, package information, and regulation by Health Canada). Participants were at least 19 years of age, lived in Canada, and purchased cannabis in the last 12 months. A multinomial logit (MNL) model was used for the base model, and latent class analyses to identify subgroups preference profiles. RESULTS: A total of 891 participants completed the survey. The MNL model showed that all attributes significantly influenced choice, except product recommendations. Potency and package information were most important. A three-group latent class model showed that about 30% of the sample were most concerned with potency, whereas two groups--jointly making up the remaining 70%--were most concerned with package type (about 40% preferred bulk packaging, and about 30% preferred pre-rolled joints). CONCLUSIONS: Consumer purchase preferences for dried flower cannabis were influenced by different attributes. Preference patterns can be grouped into three categories. About 30% of the population appeared to have their preferences met by the legalized market, whereas another 30% appeared to be more loyal to the unlicensed market. The remaining 40% represented a group that may be influenced through regulatory changes to simplify packaging and increase availability of product information.

Exploring Consumer Preferences for Cannabis Vaping Products to Support Public Health Policy: A Discrete Choice Experiment.

BACKGROUND: Phase two of cannabis legalisation in Canada brought cannabis vaping products to the market. This decision was controversial due to an outbreak of vaping cannabis use-associated lung injury. This resulted in three provinces banning the sale of cannabis vaping products causing inequitable access. This study sought to explore consumer preferences for cannabis vaping products to inform cannabis policy. METHODS: We used a discrete choice experiment to explore consumer preferences for attributes of cannabis vaping products. Attributes included type of device, price, tetrahydrocannabinol (THC) potency, vape liquid content, product recommendations and Health Canada regulation. Participants lived in Canada, were aged ≥ 19 years, and had purchased a cannabis vape in the last 12 months. A multinomial logit (MNL) model was used for the base model, and latent class analysis to assess preference sub-groups. RESULTS: In total, 384 participants completed the survey; the MNL model showed that price and potency were the most important attributes. A three-group latent class model showed that ~ 40% of the sample was driven primarily by Health Canada Regulation and were willing to pay $56 more for a product that was regulated compared to one that was not. About 33% of the sample was driven by price, and 26% was driven by type of device. CONCLUSION: While regulated status by Health Canada was most important to some consumers (~ 40%), nearly 60% of the sample were willing to make trade-offs in regulated status for products with a lower price. Therefore, policymakers need to consider the broader public health implications of banning cannabis vapes in some regions.

Emerging Adult Perceptions of Cannabis Consumption Post-Legalization: Considering Age and Sex Differences.

PURPOSE: Increased access to legalized non-medical cannabis has led to growing concern over the potential adverse health impacts of cannabis consumption among youth and emerging adults. This study explored emerging adult perceptions of cannabis consumption and if perceptions changed based on the age and sex of the cannabis consumer. METHODS: Canadian emerging adults between the ages of 18 and 25 years (N = 1,424, Mean = 21.23) were randomly assigned to one of six vignettes that varied by age (14 years, 21 years, and 28 years) or sex (male, female) of the cannabis consumer. Participants were asked to rate seven single-item measures on perceived dangerousness, problematic consumption, negative impacts, and level of disapproval related to the vignette character's almost daily cannabis consumption. RESULTS: The results of seven 2 × 3 factorial analyses of variance revealed a main effect of age on six of seven items, no main effects of sex, and no interactions. Except for social life, participants noted significant differences in harms of cannabis consumption by 14-year-olds, compared to 21-year-olds and 28-year-olds. There were no significant differences in overall perceived dangerousness, problematic consumption, or impact on mental or cognitive health between 21-year-olds and 28-year-olds. Participants perceived cannabis consumption by a 21-year-old to be more harmful to brain development and reported greater disapproval than consumption by a 28-year-old. DISCUSSION: Emerging adults may appreciate the impacts of cannabis consumption within their age cohort on brain development and perceive greater risks for youth. Further education should focus on the potential cognitive and mental health impacts of cannabis in emerging adults.

Driving under the influence of cannabis: perceptions from Canadian youth.

BACKGROUND: Cannabis legalization is intended to protect the public from potential harm by restricting access and promoting greater awareness of cannabis-related risks. Youth are at a greater risk for experiencing road-related harms due to their own or others' use of cannabis. This qualitative research explored youths' perceptions about cannabis and road safety. METHODS: A qualitative study using focus groups (FG) was conducted with youth (age 13-18) and young adults (age 19-25) who resided in Newfoundland and Labrador. Using semi-structured interview questions, the facilitator asked participants to share their opinions about cannabis and road safety. All sessions were hosted virtually using Zoom with recruitment until saturation was met. All sessions were audio recorded, de-identified, and transcribed. Analysis utilized an inductive thematic approach informed by Braun and Clarke's (2006) method and inductive coding was facilitated using NVivo. RESULTS: Six youth (n = 38) and five young adult (n = 53) FG were conducted. Five prominent themes emerged throughout discussions across both age groups including: a) normalization of driving under the influence of cannabis, b) knowledge and awareness, c) perceptions of risk, d) modes of transportation, and e) detection. Variation in perceptions appeared to be influenced by lack of awareness of the impact of cannabis on driving ability, residence in urban versus rural locations, type of vehicle driven (e.g., car vs. off-road vehicles), and gender. CONCLUSION: The themes uncovered from this research will help inform future enhancement of cannabis policy to ensure the safety of all citizens. These findings will also support the inclusion of youth-focused education that will equip youth with informed decision-making strategies regarding road safety. Furthermore, these findings can be utilized to inform the refinement of cannabis driving policies to ensure the safety of all citizens on or off the road.

Analyzing sentiments and themes on cannabis in Canada using 2018 to 2020 Twitter data.

INTRODUCTION: The Canadian Cannabis Act came into effect on October 17, 2018, which allowed Canadian adults to consume cannabis for non-medical purposes (Government of Canada, Cannabis regulations (SOR/2018-144). Cannabis Act, (2018a); Parliament of Canada, C-45: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, 2018). With this major policy change, it is unknown how the attitude of the public changed and how information on cannabis changed. Social media platforms, including Twitter, are significant venues for studying emerging patterns in social issues such as cannabis legalization. This study aimed to examine sentiments, themes and contents of cannabis-related tweets by suppliers (both licensed and unlicensed) and general tweets in Canada. To our knowledge, this is the first analysis that mixes sentiment analysis and thematic analysis of Canadians' cannabis-related Twitter data. METHOD: A sample of Canadian cannabis-related tweets was collected from January 2018 to August 2020 through the Twitter Application Programming Interface (API). Using a standard access token and the Twitter Standard Search API, tweets were extracted based on Twitter handles to capture the content of both licensed and unlicensed cannabis retailers in Canada, as well as relevant cannabis-related keywords to capture public content. We conducted sentiment and positive polarity analyses, and content analysis to identify attitudes and themes around cannabis use in Canada. RESULTS: This study gathered and analyzed a total of 44,970 tweets in the sentiment analysis and a total of 1035 tweets in the thematic analysis. Descriptive analysis showed that monthly tweets peaked prior to legalization in October 2018 and again during the initial wave of the COVID-19 pandemic in February and March 2020. The data showed an overall positive sentiment polarity with a high of + 0.24 in April 2019 and a low of + 0.14 in March 2020. Thematic analysis revealed the themes: (i) education/information, (ii) uses of cannabis, (iii) cannabis products including packing, quality, price, types, and sources, (iv) cannabis policies including regulations and public safety, (v) access, (vi) social issues include gender and stigma, and (vii) COVID-19 impact. CONCLUSION: This study combined the power of big data collection and analysis with manual coding and analysis methods to extract rich content from large data using social media communications on issues related to cannabis in Canada. The findings of this study may inform policies on advertising cannabis products and highlighted some patterns related to education, access, and safety that deserve further investigation.

Patient Preferences for Attributes of Health Canada Approved Weight Loss Medications Among Adults Living with Obesity in Canada: A Qualitative Study.

Purpose: Obesity is a complex disease with negative impacts on physical and mental health. The treatment of obesity is an area where shared decision making and patient preferences play an important role. Recommendations surrounding weight loss medications are evolving and only recently, with the publication of the 2020 Canadian Obesity Management Clinical Guidelines, pharmacotherapy has become a recommended alternative for obesity management. Guidelines recommend three medications: orlistat, liraglutide, and naltrexone/bupropion. This study sought to identify medication attributes relevant to patients starting pharmacotherapy for weight management. Patients and Methods: Semi-structured focus groups and interviews were conducted with Canadian residents who were ≥18 years of age and were living with obesity (body mass index [BMI] ≥30kg/m2 or ≥27kg/m2 with adiposity-related complications). Sessions were conducted virtually, audio recorded, and transcribed. Two team members used a combination of inductive and deductive coding to independently code the data. A final coding template was agreed upon through discussion. Results: A total of 21 individuals participated (85.7% female, 76.2% ≥40 years of age) with the average BMI being 44.3 kg/m2. Participants touched upon many attributes which were categorized into five categories: 1) cost, 2) regimen, 3) side effects, 4) benefits, and 5) non-medication attributes. Cost of medications, lack of coverage by insurance companies, and stigma were identified as major barriers to accessing medications. There was consensus in the desire for a simple regimen, however there was heterogeneity among opinions on tolerability of side effects, desired benefits, and route of administration. Conclusion: This study identified attributes that influenced patient's decisions when considering a new anti-obesity medication. Understanding these attributes can assist clinicians in shared decision-making. This study highlighted the stigma that is prevalent among providers and the need for education. Further research should be conducted to understand the tradeoffs patients in our study make between the identified attributes.

Drivers of purchase decisions for cannabis products among consumers in a legalized market: a qualitative study.

BACKGROUND: Cannabis was legalized in Canada for non-medical use in 2018. The goal of legalization was to improve health and safety by creating access to regulated products, with accurate product labels and warnings and no risk of contamination. However, more than 2 years post-legalization, a large proportion of purchases are still suspected to be through unlicensed retailers. This study sought to identify the factors that influenced the purchase decisions of cannabis consumers in Newfoundland and Labrador (NL). METHODS: Semi-structured focus groups and interviews were conducted in NL with individuals who were > 19 and had purchased cannabis within the last 12 months. All sessions were conducted virtually, audio-recorded, and transcribed. A thematic analysis was conducted, and two members of the research team coded the data using NVivo. A combination of deductive and inductive coding was carried out, themes from the literature were identified, and new themes from the transcripts were discovered. A final coding template of the data was agreed upon by the team through discussion and consensus. RESULTS: A total of 23 individuals (30% women) participated, with 83% coming from urban areas. While all cannabis product types were discussed, the conversation naturally focused on dried flower products. Participants discussed a variety of considerations when making purchase decisions categorized around five broad themes: 1) price, 2) quality, 3) packaging and warnings, 4) the source of the cannabis, and 5) social influences. The price difference between licensed and un-licensed sources was commonly discussed as a factor that influenced purchase decisions. Product quality characteristics (e.g. size, color, moisture content) and social influences were also considered in purchase decisions. Participants were generally indifferent to packaging and warning labels but expressed concern about the excessive packaging required for regulated products. CONCLUSION: This study explores the many attributes that influence purchase decisions for dried leaf cannabis. Understanding the drivers of purchase decisions can help inform policy reforms to make regulated cannabis products more appealing to consumers. Further research is needed to measure the effect of each attribute on cannabis purchase decisions.

Characteristics that influence purchase choice for cannabis products: a systematic review.

INTRODUCTION: When non-medical cannabis use became legal, government regulators implemented policies to encourage safer consumption through access to a regulated market. While this market is growing, sales still occur through unregulated channels. This systematic review identifies factors influencing cannabis purchasing to help policymakers understand why consumers still purchase illicit market cannabis (registered with PROSPERO CRD42020176079). METHODS: A comprehensive search strategy included databases in health, business, and social science fields (inception to June 2020). Studies were eligible for inclusion if they were conducted with persons who purchase cannabis and examine at least one attribute that would influence purchase choice and were published in the English language. Studies could be of any methodological design. Two independent reviewers completed two levels of screening, and all extraction was verified by a second reviewer. A qualitative synthesis of the findings was completed. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. RESULTS: Of the 4839 citations screened, 96 were eligible for full-text review and 35 were included in the final synthesis. Aspects of price were the most common factors (27 studies). Twenty studies measured price elasticity; most studies found that demand was price inelastic. Many other attributes were identified (e.g., product quality, route of administration, product recommendations, packaging), but none were explored in depth. Eleven studies addressed aspects of product quality including demand elasticity based on quality, potency, and aroma. Studies also explored consumer-perceived "quality" but provided no definition; differences in quality appeared to impact consumer choice. Smoking cannabis appeared to be the preferred route of administration but was only examined in three studies. There was insufficient data to understand in the impact of other attributes on choice. There appeared to be preference heterogeneity for different attributes based on the consumer's experience, reason for use, and gender. CONCLUSION: While price influences choices, demand is relatively inelastic. This suggests that consumers may be seeking lowest-cost, unregulated cannabis to avoid reducing consumption. Beyond price, there is a significant gap in our understanding of consumer choices. Perceived quality does appear to impact choice; however, more research is needed due to the lack of a recognized definition for cannabis quality.

An Update on Perinatal Cannabis Use.

Since the legalization of non-medical cannabis, many questions have arisen regarding cannabis use during pregnancy. Obstetrical care providers can minimize the harms of prenatal cannabis use using evidence-based information. This commentary describes populations at highest risk for use, the predictors of use, the reasons birthing people continue or stop using cannabis during pregnancy, and short- and long-term outcomes for infants and children exposed to cannabis prenatally. Our goal is to equip providers with knowledge from the literature to inform practical decision-making.