Cannabis Grow

Group differences were tested using Pearson chi-square or t-tests, as appropriate. Differences of in-home smoking prevalence among the four tobacco-use and cannabis-use groups were assessed using predicted probabilities from mixed effects logistic regression models. All models were adjusted for age and sex with country of origin as a random effect to account for variation in sample sizes of each country and to address the possibility of country-specific influence on associations of in-home smoking by cannabis and tobacco use. Odds ratios  comparing cannabis-only users, tobacco-only users, and dual users to non-users were computed separately for in-home cannabis smoking and in-home tobacco smoking. The ORs for in-home cannabis smoking and in-home tobacco smoking were visually compared by observing non-overlapping 95% confidence intervals. Statistical differences in the ORs were assessed using generalized estimating equations by implementing the methods outlined by Horton & Fitzmaurice . To address possible confounding by participant-level characteristics and country level characteristics , ORs were computed from models that additionally adjusted for clubbing frequency, drinking frequency, past year drug use, ploy-drug use, area of residence, and country as a fixed and random effect. Logistic regression models were then repeated for each included country to illustrate country-specific differences of in-home smoking among the four mutually exclusive cannabis- and tobacco-use groups. All statistical tests were two-tailed with an alpha of 0.05. Data analysis was performed using R . Global trends in the decriminalization and legalization of cannabis use should prompt increased research that seeks to identify and constrain harm and improve public health.

In this large convenience sample of people from 17 countries who used at least one psychoactive drug in the past year, past-year in-home cannabis smoking was slightly more prevalent than past-year in-home tobacco smoking in the overall sample. Approximately 80% of current cannabis-only users reported that cannabis grow set up was smoked in their home while in-home tobacco smoking took place in the residences of 68% of current tobacco-only users. Overall past-year rates of in-home smoking were high among current users of both cannabis and tobacco, and in these groups, in-home cannabis smoke was more prevalent than in-home tobacco smoke. Taken together, these results support our hypothesis that in-home cannabis smoking would be higher than in-home tobacco smoking. Since this is the first study we are aware of that measured the behaviors of in-home cannabis and tobacco smoking, there are no studies to which we can directly compare our results. From studies that focused on household rules, evidence from a convenience sample of US Facebook users reported that of the 54% of respondents who allowed cannabis use on their property, 71% allowed cannabis smoking inside their home; unfortunately, rates of in home tobacco smoking were not available . Another study, among US university students, reported that in-home cannabis use was allowed by 36% of tobacco smokers and 59% of cannabis smokers while in-home tobacco use was allowed by 25% of tobacco smokers and 36% of cannabis smokers . In our study, the generally higher rates among US respondents  could be attributed to our assessment of home smoking behavior rather than home smoking policy. They could also be attributed to selection bias from studying self-selected sentinel drug users, though a recent study showed that the age and sex distributions of GDS respondents who use cannabis were similar to probability-based samples in the three countries studied—Australia, Switzerland, and the US . The high rates might also be partly the result of our yes/no inquiry about past-year in-home smoking, which could include rare instances of the behavior that are not representative of usual behavioral patterns.In a recent cross sectional study in Australia, Canada, England, and the United States, 73.6%, 78.3%, 65.5%, and 60.8% of respondents, respectively, endorsed cannabis smoking as less harmful than cigarette smoking .

Decades of tobacco control campaigns and policy likely increased the perceived harm of tobacco smoke, contributing to the lower rates of in-home tobacco use. If true, results from this study suggest that it may be time to develop similar campaigns and policy to correct perceptions of harm of cannabis smoke. This study underscores the importance of studying in-home cannabis smoking, which occurs at a higher rate than in-home tobacco smoking; however, more research is needed. Cannabis users comprise a sizeable population, both in absolute and relative terms, and with cannabis laws becoming more liberal, the number of users is rising. A major public health goal for future studies is to identify how often in-home cannabis smoking occurs in the general public and in high-use populations. Knowing the rates in the overall population will reveal the full scope of the behavior while understanding rates in high-use groups will quantify the behavior among those who have the most to gain from intervention. Obtaining these prevalence data will inform interventions to eliminate in-home smoking and will encourage further research, including the identification of public health messages designed to prevent in-home smoking  and research on the health consequences of firsthand, secondhand, and third hand cannabis smoke exposure. As with all studies, results of the present analysis should be viewed considering the strengths and limitations of the methods used. While we included data from 107,274 men and women from 17 countries, the data were collected using anonymized web-based surveys specifically targeted toward those who use drugs through advertisements on social media and drug-scene-related media outlets. While non-probability based sampling and self-selection bias prevent generalizable estimates of prevalence , the inferences that were presented comparing in-home tobacco and cannabis smoking by use-status are expected to have significantly less bias since it is unlikely that the primary prerequisite for selection bias  was present. In the Introduction, we referenced online information on tobacco and cannabis control policies that highlight significant variance in the type and implementation of policies across countries. To our knowledge, no study has attempted to quantify the impact of such regulatory differences on the in-home use of cannabis and tobacco, an investigation that was beyond the scope of the present study. However, the presence and diversity of public policies toward both substances should be considered when interpreting our findings.

To reduce bias related to confounding by participant-level characteristics and by country-level characteristics such as regulatory policies, our models statistically controlled for several potential confounders, and included country as a fixed and random effect. Future investigations of how tobacco and cannabis control policies impact in-home smoking are warranted, especially studies that explore how legalized cannabis use, with and without legalized outdoor use, impacts in-home use and subsequent SHS and THS exposure. The self-report origin of our cannabis and tobacco use status and in-home smoking status is also a limitation, although the GDS is a well-respected entity among the drug-using community and is known for preserving anonymity, making it more likely to elicit accurate responses. We were unable to study usual in-home smoking patterns including the frequency of in-home smoking or household composition because we did not collect usable data on these important factors—future studies should capture more detailed data. As a result, our estimates likely overestimate problematic in-home smoking, although this is not expected to greatly bias results since the overestimation is likely non-differential—i.e., similar for both in-home cannabis and in-home tobacco smoking. Transmission of severe acute respiratory syndrome coronavirus 2 , the virus responsible for causing coronavirus disease 2019 , has led to unprecedented morbidity and mortality across the U.S. . Risk factors for COVID-19-relatedsevere illness resulting in possible hospitalization include: active or former smoking status and/or having pre-existing comorbidities or an immunocompromised status . Combustible and non-combustible tobacco users are vulnerable to clinical morbidities, including impaired pulmonary function and respiratory illnesses . Research suggests combustible smoking or vaping cannabis is associated with respiratory-related symptoms and disease . Additionally, vaping nicotine, flavorings, and/or tetrahydrocannabinol  products may place individuals at increased risk for COVID-19- related symptomatology and illness due to impairment of normal pulmonary defenses to inhaled viral pathogens . Smoking, and possibly e-cigarette use, can upregulate the angiotensin-converting enzyme-2 receptor, which is the receptor for SARS-CoV-2 . However, human research studies are lacking on concurrent e-cigarette and cannabis use and COVID-19-related health outcomes. Research has linked respiratory symptoms or disease with adult current e-cigarette use , current cannabis combustible smoking and vaping , and lifetime e-cigarette and cannabis use . College student ecigarette use and outdoor cannabis grow smoking and vaping reached historical highs between 2017 and 2019 . Currently, 22% and 14% of students report past 30-day nicotine and cannabis vaping, respectively . Over one-in-four students report current cannabis use including other routes of administration , with 1-in-17 reporting daily cannabis use. While current dual use of e-cigarettes and combustible cigarettes has been associated with increased risk of COVID-19 symptoms and diagnosis among 13–24-year-olds , less is known about COVID-19-related risks associated with concurrent e-cigarette and cannabis use.

Given the high prevalence of e-cigarette and cannabis use among college students , research is needed to assess the associations between concurrent use and COVID-19-related outcomes. This investigation assessed whether current e-cigarette and cannabis use was associated with COVID-19 symptomatology, testing, and diagnosis among college student current e-cigarette users. We hypothesized concurrent users of e-cigarettes and cannabis would be at increased odds of experiencing COVID-19 symptoms and having a prior positive COVID- 19 diagnosis compared with exclusive e-cigarette users. Additionally, we assessed whether frequency of e-cigarette and cannabis use was associated with COVID-19 symptoms, testing, and diagnosis. We hypothesized that when compared to infrequent exclusive e-cigarette users, intermediate or daily exclusive e-cigarette users as well as infrequent, intermediate, and frequent concurrent e-cigarette and cannabis users would be at increased odds of reporting COVID-19 symptoms and diagnosis. Based on COVID-19 random selection testing policies at each university during the study period, we posited there would be no difference in COVID-19 testing between the exclusive e-cigarette and concurrent use groups. Data are from a cross-sectional, online survey conducted October December 2020. Participants were college students  ages 18–26 years from four geographically diverse, large U.S. public universities  who reported current ecigarette use. Institutional review boards  at each university independently vetted and approved all study procedures by November 2020; data collection occurred after respective IRB approval. Students at each university had the option to complete their coursework online, in person, or a hybrid model. Students residing in university housing/ residences were allowed to remain on each of the respective campuses during the data collection period. COVID-19 testing programs at each of the four respective campuses were similar and required randomly selected students to undergo testing. Eligible participants were recruited by disseminating emails via campus-wide listservs and undergraduate and graduate course listservs. Participant recruitment strategically took place at least over one month into the fall semester due to the study’s aim of capturing past 30-day behavior during the academic year. Solicitations sought students between the ages of 18–26 who “vape or use e-cigarettes” and were currently on campus. The recruitment email included a website link to a survey hosted on Qualtrics , and stated the estimated completion time was 10 minutes. Potential participants were provided with a research information sheet which they needed to acknowledge prior to proceeding to the survey.

The information sheet reinforced the recruitment email’s information . Response rates were not available due to recruitment strategies employed. However, sample size calculations using a 95% confidence interval , 100,000-population size, and a conservative 50–50 split considering the population is relatively varied , assert a minimum of 383 completed surveys were needed to have sufficient power for statistical analysis. To assess cannabis use, students were asked, “During the past 30 days, how many times did you use marijuana?” Response options were: 0, 1–2, 3–9, 10–19, 20–39, and 40 or more times. We classified the sample of current e-cigarette users based on their current cannabis use response as: exclusive e-cigarette users  and concurrent ecigarette and cannabis users . To assess frequency of use patterns, we combined responses from the item on how many times students used cannabis with the item on how many days students used e-cigarettes in the past 30 days .

THC is a partial agonist at CB1 receptors, and frequent cannabis use results in downregulation of CB1 receptors with a potential to reverse with abstinence . Another main cannabinoid is cannabidiol , which is non-intoxicating . CBD has a broad range of pharmacological actions, including inhibiting the reuptake and hydrolysis of anandamide as well as multiple receptor mechanisms . The receptor mechanisms include negative allosteric modulation of CB1 receptor, partial agonist or inverse agonist action on CB2 receptor, and agonist action on transient receptor potential vanilloid 1 and serotonin 5-HT1A receptor , all of which are thought to lie behind CBD’s effects in reducing drug reward and addiction in preclinical studies . Broadly speaking, cannabis products can be divided into four categories: high-THC-concentration/sinsemilla , herbal , hash/ resin , and very high-THC cannabis concentrates In the past two decades, dramatic increases in THC concentration in cannabis products have been reported across Europe  and the U.S. . For example, a large study from the U.S. found a general increase in THC concentration in seized cannabis plant material from about 4% in 1995 to about 12 % in 2014 , and a comprehensive study from France found a dramatic increase in THC concentration in seized cannabis resin from 10 % in 2009 to 23 % in 2016 . In line with these findings, a recent study found an alarming 3-fold increase in THC concentration in seized cannabis resin in Denmark from 8% in 2000 to 25 % in 2017 , which represents the highest concentration throughout Europe . During the same period several studies indicate that CBD concentrations have remained stable or even decreased; in the studies from France and Denmark, CBD concentration remained stable at around 4% and 6% .

This development is highly concerning, as emerging studies show that cannabis products with high THC levels and low CBD levels may have more detrimental effects on cognitive function and mental health among both young and adult users , including higher risk of cannabis-induced psychosis ,vertical grow system impairments in learning and memory , and poorer addiction outcomes . Increasing THC levels have also been linked with increases in admission to CUD treatment in Europe .For example, 18 % of youth aged 15–24 in Europe report using cannabis the past year compared to 7 % of 25− 64 year old’s . In the U.S., about 25 % of adolescents report cannabis use by age 14, and recently rates of cannabis use have started to approximate adolescent alcohol use patterns with half of adolescents now using cannabis by age 18 . Notably, the percentage of lifetime cannabis using adolescents who report frequent use  are at the highest level in recent decades , reflecting a three-fold increase from the lowest reported levels in 1990–1991. Rates of CUD peak during adolescence and emerging adulthood, and the global burden of disease related to cannabis use peaks in emerging adulthood. Individuals who initiate cannabis use during adolescence experience more adverse and long-lasting cannabis-related harms . About 30 % transition into CUD , and there is an increased risk of other substance use disorders  later in life . Particularly among youth, frequent cannabis use is linked with a wide range of mental health disorders, health risks, and poor psychosocial outcomes, including low life satisfaction, school dropout, lower educational and occupational achievements, behavioral and legal problems, accidents/injuries, sexually transmitted infections, and psychotic disorders during adulthood . The increased risk of adverse outcomes associated with frequent cannabis use among youth is related to the nature of the developing brain and the role of the endocannabinoid system in the neurodevelopmental maturation during adolescence . The brain continues to develop from the prenatal period through childhood and adolescence until the beginning/mid 20 s . During these developmental periods, the brain is believed to be more vulnerable to the adverse effects of neurotoxins, such as regular exposure to cannabis.

This means that the health impact and effects of cannabis, stemming from the increase in cannabis potency may pose unique risks for youth, because THC is likely to interfere with the neurodevelopmental processes influenced by the endocannabinoid system . Related to this, a study of regular cannabis users and matched controls , found that cannabis use was associated with impaired axonal connectivity in the fimbria of the hippocampus and the precuneus , and that early age of onset of regular use was associated with more severe microstructural white matter alteration. Additionally, a multisite longitudinal study in Europe found that cannabis use was associated with accelerated age-related cortical thinning between the ages of 14 and 19, predominantly in prefrontal regions with a high density of CB1 receptors . Further, studies examining response inhibition have shown that adolescents engaged in cannabis use require more neural resources to perform at the same level as non-using adolescents  , or perform worse . However, longitudinal studies are required to determine if these differences are directly related to THC exposure or whether they may  predispose individuals for developing CUD. In the only randomized, placebo-controlled study of cannabis administration in adolescents and adults to date , adolescents experienced heightened impairment of response inhibition and wanting more cannabis, alongside blunted subjective effects and memory impairment compared to adults. Preventing and intervening in the neurocognitive and health sequelae of early or frequent cannabis use is complex, and involves physical, psychological, medical, and cultural considerations. With regard to youth cannabis use, it is important to first consider the ways in which adolescents and emerging adults are developmentally distinct from adults in ways that have historically posed challenges to substance use prevention and treatment interventions in general . One barrier to preventing the onset and escalation of adolescent cannabis use is that across cultural contexts, experimentation with substances such as alcohol and cannabis often falls in line with cultural expectations, and is perceived as socially acceptable by the youth . However, the cultural and social context that influence an early onset of cannabis use may also have adverse neurocognitive implications for later brain and behavior function and ability . As summarized in Silvers et al. , adolescence and emerging adulthood is a period with unique neuro developmental tasks that underscore major contrasts from adulthood: myriad pubertal changes, rapidly developing cognitive skills, an emergence of self-identity, and prominent changes in the social landscape.

Accordingly, adolescent cognitive skills are also more directly tied and embedded in, and thus strongly impacted by, the socioemotional context and the broader ability to engage in self-regulatory cognitive strategies  is only emerging and is markedly different from adults . Because the ability for abstract reasoning and the capacity for purposeful and planful behavior is also in a developmental neurocognitive phase, this may subsequently impact the ability to participate meaningfully in established empirically supported behavioral treatment paradigms for substance use that have historically been designed for adults and largely validated with adult samples . Exploring personal identity and a heightened sense of self also demarcates and differentiates the neurodevelopmental period of adolescence and emerging adulthood, and the formation of self-identity is itself contingent upon increased self-awareness and self-monitoring . Unique to this developmental period, enhanced self-focus and social attunement with the environment may motivate youth to use substances to improve social standing, particularly within peer contexts . In contrast to adults, adolescents may also be more likely to take risks in the presence of their peers such that risk taking in social contexts heightens the potential reward value. Of note, this penchant toward enhanced risk taking has now not only been examined as a potential risk factor, but also as a likely resilience factor, as adolescents also have an enhanced capacity to engage in prosocial “risks” when in peer contexts . Peer influence is thus a powerful motivator for both risk taking and prosocial behaviors, highlighting the significance of addressing peer interactions in adolescent prevention and treatment interventions. These central facets of neurodevelopment in adolescence and emerging adulthood highlight key contextual distinctions between youth and adult cannabis users; the assumption that adult substance prevention and treatment models work equally well for youth is itself a barrier to developing novel approaches. Another major challenge in addressing the significant public health issue that cannabis use presents for youth is that most youth who engage in frequent cannabis use do not seek or receive prevention and treatment interventions , even after years of harmful use and related negative health sequalae; on average, cannabis users have more than 10 years of near-daily use and more than 6 attempts at quitting, prior to seeking and/or receiving treatment . However, despite the high clinical importance, research on barriers to prevention and treatment interventions among youth with frequent cannabis use is surprisingly scarce, although some studies suggest that central barriers for seeking timely help involve social stigma, mobile grow systems an overall desire to be self-reliant, believing intervention is not needed, or presuming that programs will be ineffective .

Additional complicating factors involve the increasing ease of access to cannabis, particularly in regions with permissive cannabis legislation , which has been directly tied to increases in youth cannabis use , perceiving cannabis use as harmless , and increasing social acceptance of cannabis use among peers . Moreover, positive associations with cannabis  coupled with limited experience of, and anticipation for, negative consequences among adolescents and emerging adults, mean that this age group might not have a sensation of urgency to seek intervention either on the personal side  or on the social side. Related, once successfully engaged in prevention and treatment interventions for CUD, a significant challenge is retaining youth in the intervention . Further, the recent National Academies on Cannabis report  also underscored the additional challenge of potential increase in other substance use. Taken together, to reach and help youth with/at-risk of developing CUD at an earlier stage, there is a dire need to develop and test new prevention and treatment interventions that are articulated specifically for this important neurodevelopmental population. Psychosocial interventions for cannabis use can be employed at different stages prior to and into the development of CUD and have been assessed both in non-treatment seeking youth and in youth enrolled in treatment. In particular, an important avenue for circumventing treatment barriers and reaching non-treatment seekers, and maximizing prevention and treatment impact, is via brief, early evidence-based interventions that are non-judgmental and affirming . Motivational interviewing  is very well-suited to this end, because it is, by definition, non-judgmental, strength-based, affirming, empathic, and bolsters motivation for change , and has shown to be highly acceptable and feasible among young cannabis users . Prior studies have found that 2 sessions of MI can successfully reach and engage non-treatment-seeking young cannabis users and reduce cannabis use and related symptoms . However, compared to adults, effects of MI have generally been less impactful among youth . Combining brief, evidence-based psychological interventions like MI with safe and effective pharmacological treatment may represent an important avenue for reaching and engaging non-treatment seeking youth, helping them reduce or quit cannabis use, and facilitate a healthier trajectory. Multiple psychosocial interventions have been investigated for adolescents and emerging adults enrolled in CUD treatment, however these interventions have typically been developed for use in adult  populations and not for cannabis as the primary problem drug .

Several reviews provide in-depth details on the nature and efficacy of each intervention approach , but examples include that the combination of MI and cognitive behavioral therapy  is associated with reduced cannabis use in adolescents with CUD. Typically, MI is employed over one or two sessions initially, in order to increase motivation to stop using cannabis and enhance ambivalence towards reducing use. This is followed by several sessions of CBT, with the aim of introducing coping skills that can be used in real-life settings and include devising plans for specific high-risk situations and developing problem solving skills. Recent studies have also shown that adding vouchers or monetary incentives for not using cannabis  to weekly MI + CBT in youth has been associated with increased abstinence from cannabis  and increased treatment retention  compared to weekly MI + CBT alone. Finally, some studies on multidimensional family therapy , an approach that involves both the adolescent and the family member, have found that MDFT has comparable efficacy to CBT over 5-6 months of treatment, with evidence of increased treatment acceptability , and that a 6-month programme has been associated with good retention as well as reduced cannabis dependence compared to individual psychotherapy .

The legalisation of large-scale adult non-medical recreational cannabis use and supply in 15 U.S. States, Canada and Uruguay has reignited the international debate about the best policy approach to cannabis , 2020; Kilmer, 2019. Citizen initiated referenda have been the primary mechanism by which medicinal and recreational cannabis use has been legalised in U.S states over recent decades . Given the politically divisive nature of the cannabis law reform debate, politicians in other jurisdictions may well choose to resolve the issue via referendum in the future, allowing citizens to directly state their preferences and thereby legitimise any policy change .In New Zealand, the Green political party made holding a national referendum on the legal status on recreational cannabis use a condition of their support for the 2017 Labour and New Zealand First coalition government . The resulting 2020 New Zealand cannabis referendum was a world first in the sense that it was a national vote, as opposed to the previous U.S. state referenda, and involved voting on a detailed legislative bill , rather than a general question on whether cannabis should be legal or not . The New Zealand cannabis referendum was narrowly defeated, with 48.4% voting to support compared to 50.7% voting to oppose the CLCB  . Along with the notable successes, referenda to legalise non-medical recreational cannabis use and supply have also periodically failed in some U.S. states . The narrow defeat of the New Zealand referendum raises important questions about what factors were responsible for the lack of voter support for the CLCB and cannabis legalization in general. Understanding these factors could inform future advocacy and referendum campaigns for cannabis legalisation in other jurisdictions. The existing literature has identified three main determinants of voting behaviour: self-interest , moral values , and political party identification. Self-interest would predict that users of recreational and medicinal cannabis should support legalisation to remove the risk of arrest to themselves and to reduce social stigma related to their cannabis use.

If voting is influenced by moral values, those who view cannabis use as morally wrong should be more likely vote against legalisation, as should those who believe cannabis consumption to be a significant health risk and social harm. If, after controlling for a range of demographic, behavioural and attitude factors, political party affiliation remains a significant predictor of voting intentions related to cannabis legalisation, then this would suggest that similarity in voting amongst members of a party is not only related to shared views of the world, but also by the social identity generated by association with a particular political group .In the United States, national support for cannabis grow racks legalisation has grown steadily over recent decades, from only 12% in 1969 to 64% in 2017 . Poll support for cannabis legalisation in the U.S. is higher amongst men, younger age cohorts, those who have ever tried cannabis, and left leaning voters . Multivariate modelling has found the strongest predictors of support for cannabis legalisation amongst 18–34 year olds in the U.S. are perceptions that cannabis is less harmful than cigarettes and having used cannabis in the past month . Male gender remains a significant predictor of support for cannabis legalisation amongst this age group, while age, ethnicity, education, and current social smoking were no longer significant after controlling for other variables . Multivariate analysis of state-wide data from Michigan  found left of centre or centrist political views, past year cannabis use, and lifetime cannabis use were all predictors of supporting cannabis legalisation . Alternatively, older respondents, women, and those who perceived cannabis use to be risky were found less likely to support legalisation . Multivariate analysis of U.S. national data found women with greater religiosity less likely to support cannabis legalisation after controlling for a range of variables, suggesting cannabis law reform has an important moral dimension . Schnabel and Sevell  come to a similar conclusion from analysing U.S. national poll data from 1988 to 2014, arguing that increasing support for both cannabis legalisation and same sex marriage over recent decades reflflects the growing acceptance of these issues as matters of individual autonomy rather than matters for government control.

In New Zealand, public polling on cannabis law reform has been conducted on a fairly regular basis for the past two decades, with as many as 45 polls conducted on the issue since the beginning of the Millennium . These polls have generally found very high levels of support for medicinal cannabis reform, with around two thirds of respondents supporting some kind of decriminalisation involving civil fines, and only a minority supporting full legalisation of recreational use . Since 2018, public polling has focused more specifically on the question of support for the legalisation of recreational cannabis use, reflecting the coalition government’s announcement of the referendum on the issue. Thirteen polls were conducted in the year of the referendum vote, of which seven found a majority in favour of legalisation, five a majority against, and one reported an even result . A poll of Māori  in the same year found 75% in favour of legalisation . Basic cross tabulations of New Zealand poll results have found higher support for cannabis legalisation amongst men, younger age cohorts, Māori, and Green Party and Labour Party voters, and alternatively, lower support amongst National voters and those aged over 65 years . The only published multivariate modelling of poll support for cannabis legalisation in New Zealand to date found significant predictors of positive support for cannabis law reform were prior experience of using cannabis and other illegal drugs, a history of depression, scoring higher on a novelty-seeking measure, Māori ethnicity, parental drug use, and higher educational achievement . Predictors of more negative attitudes to reform amongst this longitudinal sample were female gender and having dependent children . As acknowledged by the authors, the sample was limited to a single birth cohort of 40-year olds, interviewing was completed prior to the announcement of the cannabis referendum, and the reforms presented to respondents referred to a range of possible liberalisation initiatives, including legalising medicinal cannabis, decriminalisation, permitting home growing, age restrictions and full commercial legalisation . The New Zealand cannabis legalisation referendum  proposed a strictly regulated legal cannabis market that most closely resembled the Canadian approach to cannabis legalisation . The CLCB would restrict the purchase and use of cannabis to those aged 20 years or older ; a daily purchase and possession limit of 14 gs; sales from licensed physical stores only ; separate licensed consumption premises; no advertising or promotion; a personal home cultivation limit of two plants ; social sharing of up to 14 g of cannabis; no industry sponsorship or free giveaways; limits on the potency of products ; an excise tax based on the THC potency and weight of products; mandatory inclusion of health warnings on products and displayed at licensed premises; and no public consumption or sale with alcohol, tobacco, food or any other product . Due to conflicting views on cannabis law reform from within the coalition government partners, it was agreed the government would only run what was termed a “signposting” campaign directing voters to the referendum website  where neutral information would be available, rather than actively campaigning for the passage of the CLCB .

The referendum site included short bullet point summaries and a complete version of the CLCB . A brochure on the referendum directing voters to the referendum website was also posted to all enroled voters . The coalition government purposively left advocacy concerning the relative merits of the CLCB and wider legalisation to interest groups and the media . In the months preceding the referendum vote, proand anti-legalisation interests funded substantial traditional and social media advocacy campaigns, and there was also considerable media coverage of the issue and a series of town hall style public debates . While a number of public polls were conducted to track voter support for the CLCB in the months preceding the referendum, there has been no analysis of what underlying factors explained voter support or opposition to the CLCB.Our models found that age, ethnicity, education, religiosity and even cannabis use experience were no longer statistically significant predictors of support for the CLCB once we controlled for perceptions of the health risk of cannabis use, experience with and support for medicinal cannabis use, moral views of cannabis use, and actual reading of the CLCB. This suggests support for recreational cannabis legalisation in New Zealand is not based on broad demographic characteristics, but rather specific views about the moral acceptability, health risk and medicinal benefits of cannabis use, and deep-rooted ideological perspectives. Elder and Greene  found that religiosity played an important role in women’s opposition to cannabis legalisation after controlling for a range of variables, suggesting that cannabis legalisation has a prominent moral dimension for some people, similar to issues such as access to pornography and abortion. Elder and Greene  included measures of religious commitment in their models, that is frequency of religious attendance  and describing oneself as “born again” Christian. Our measure of religiosity covered a broad range of spiritual and religious beliefs, some of which may not hold as strong anti-drug prescriptions as evangelical Christians in the U.S. In addition, our religiosity variable was a simple yes/no response, and thus may not have captured the intensity of religious belief as Elder and Greene‘s  measures.Experience of the medicinal benefits of cannabis has also been found to be one of the leading reasons for supporting recreational cannabis legalisation in the U.S. .

A recent survey of medicinal cannabis grow system users in New Zealand found the overwhelming majority reported positive therapeutic benefits from their cannabis use , and this positive experience is likely to mean this group has fewer qualms about supporting recreational cannabis legalisation. During the referendum, opponents of the CLCB strongly objected to a pro-campaign promotion that referred to the CLCB as a means to obtain greater access to cannabis for medicinal purposes, pointing out that medicinal use had already been recently legalised in New Zealand [via the Misuse of Drugs  Regulations 2019. In contrast, pro-legalisation campaigners argued there is significant overlap between recreational and medicinal use, and that the current New Zealand medicinal regime is too strict to facilitate all forms of cannabis use for medical and well being. In addition, implementation of the New Zealand Medicinal Cannabis Scheme has been slow with no products approved under the scheme to date . Kilmer and MacCoun  have argued that in the U.S. the legalisation of medicinal cannabis facilitated the subsequent passage of recreational law reform in a number of ways, but it takes time and exposure to the new legal medical market before public perceptions and other forces improve conditions for recreational law reform. Another strong predictor of supporting the CLCB was the intention to vote for the Green political party. This is understandable given the central role the Green Party played in negotiating for the referendum to be held, and their long history of advocacy for cannabis law reform in New Zealand, including the pioneering Rastafarian Green MP Nandor Tanczos, and prominent role of Green MP Chloe Swarbrick in the pro-referendum campaign for the CLCB. As outlined earlier, support for cannabis legalisation in the U.S. has also been found to be consistently higher amongst left and centre left voters . The strong support for the CLCB amongst those who live in small towns is more difficult to interpret. Large-scale outdoor illegal cannabis cultivation has been common in some rural regions of New Zealand for decades, and this activity has been associated with gang activity, arson, property vandalism and exclusion zones where residents are afraid to visit for fear of growers and improvised security devices . Those living in small towns may view legalisation as a means to resolve these problems through permitting legal regulated cannabis cultivation. Illegal cannabis cultivation has also been identified as a critical source of seasonal income in some economically depressed rural regions in New Zealand, generating hundreds of millions of dollars per year , and legalisation may be viewed as a means to transition this illegal activity to legitimate economic development.

Studies in Brassica oleracea showed the same asymmetrical interploidy compatibility pattern as we observed in C. sativa; that is, when the paternal parent had the higher chromosome number, there was a lethal disruption in embryo development, whereas when the maternal parent contained a chromosome excess, viable seeds were formed . Imbalances in the expression levels of the AGAMOUS-like gene families appeared to play important roles in the endosperm and embryo development failure in B. oleracea . Research on potato showed that the strength of triploid block can vary among genotypes . Therefore, research into multiple genotypes and gene expression variations may be useful in obtaining a full understanding of asymmetrical compatibility and asymmetric triploid blocking in C. sativa as a species. Plant growth, development, metabolism, and morphology can be greatly manipulated by the quality and duration of light . Light quality denotes the color or wavelength adjacent to the surface of the plant, which affects plant growth, foliar and floral morphology, biochemical changes, and photosynthesis process . It was demonstrated that wavelengths ranging from 430 to 500 nm is effective for pigmentation, secondary metabolites production, chloroplast development, and functioning in photosynthesis . The wavelength range 500–600 nm also influences chlorophyll production and photosynthetic activity . On the other hand, the wavelength range 640–670 nm was found effective in leaf area, photosynthetic activity, and plant biomass accumulation . Light quality and quantity also have a drastic effect on the excitation of PS I and PS II, which is directly interlinked with photosynthesis processes . Light spectral quality considerably affects plant shoots and roots regarding their growth and morphology, and their interaction .

In the present experiment, the longest RL was recorded from L1 and L9, and the opposite result was found from L2 and L6 . In a previous study, plant height and weight were found better in red light; RL was longer in red and natural light while shorter in white and blue light under greenhouse conditions . In the present study, the addition of FR light to R and B increased the LL and LW, best trimming trays while decreasing the LN and NN . It was reported that the cannabis plant attained a higher plant height and leaf area in white light compared to the combination of red and blue light , but we did not find any significant differences in those morphological traits under similar light conditions. In a previous study, the addition of FR to R and B decreased the LL and SL of tomato plants while no significant effect was observed for RL and LN . The PCA analysis revealed that LL, LW, and SL were negatively correlated with LN and NN . Results indicated that a higher number of leaves and branches will make the hemp plants shorter in size with narrow leaves and vice versa. Importantly, LN and NN were closely associated with the treatments L9, L10, and L11, whereas LL and LW manifested an opposite relationship with them . This may be due to the influence of UV-A, which reduced the leaf area but increased the leaf number and branching. Generally, UV radiation impacts the phytohormone auxin levels higher in leaf regions with high division activity and lower in areas of cell expansion , resulting in a decrease in adaxial pavement cell expansion . Furthermore, compared to white light, PFW, PGR, and NN increased in most LED composition. The results indicate the incapability of monochromatic white light for plant growth and development, as it also resulted in lower TSC and sucrose accumulation in most cases. The PCA analysis indicated a negative relationship between the L2 treatment and NN, PFW, PGR, TSC, and sucrose, which also had a positive correlation with the parameters. An earlier study showed that the Chl a and Chl b contents increased in lettuce, basil, spinach, kale, and pepper under different combinations of R and B . In our study, the Chl a and b of hemp plants were significantly increased, but the chlorophyll a/b ratio and Car drastically decreased in the L3 treatment compared to L1 . Besides this, Chl a and b significantly increased, and the Chl a/b ratio significantly decreased in all treatments, while the carotenoid concentration was found decreased in the L2, L3, L4, L6, and L9 treatments compared to L1 . Similar results from a previous study described that a high ratio of both R:B and R:B:W manifested higher chlorophyll compared to natural light in Silene capitate Kom. . Each of the plant pigments has been characterized by an absorbance pattern in wavelength called the absorbance spectrum, where the blue and red regions are absorbed strongly by Chl a and b, with less absorbance of other wavelengths . It is also known that the Chl and Car pigments absorb 400– 500 nm and 630–680 nm in the light spectrum in plants with the help of light-harvesting antenna .

The positive influence of red and blue light on Chl synthesis in the present study complies with these findings . Furthermore, the accumulation of Car and the Chl a/b ratio were increased, whereas Chl b was decreased significantly under the spectra composed with green light when compared to the red and blue spectra . Since red and blue light are absorbed by photosynthetic pigments more strongly, their influence is predominant in the upper cell layers, while green light can penetrate deeper into leaf tissues and excite the photosystem in the deeper cell layer . On the other hand, Car are lipid-soluble colored pigments that mostly consist of carotenes and xanthophylls , whose absorbance range extend into the green region , effectively cover the poorest region of chlorophyll absorbance . Thus, the addition of green light along with others in the present study might increase the concentration of Car. The photochemical activity of photosystem II is expressed by Fv/Fm, which characterizes the maximum efficiency of the photochemical activity under PS II , where Fv , Fm, and F0 denotes the maximal variable fluorescence, maximal fluorescence intensity, and fluorescence intensity at 50 µs, respectively. The photosynthetic fluorescence is a byproduct of the photosynthetic process created by trapping light energy at the reaction center within a photosynthetic membrane and after being used in photochemistry that dissipates along with heat energy . A decreasing trend in Fv/Fm was observed in the treatments L1, L6, L7, and L10 in the present study . A lower Fv/Fm may be a consequence of decreasing Fm, since F0 does not change too much in light stress .Proline is an important compound as its synthesis and catabolism play an important role in the stress adaptation of plants by keeping in balance the redox reaction . Under stress conditions, ROS-mediated regulation, including H2O2, can upregulate P5CS and downregulate PRODH activity in the plant, which can trigger the biosynthesis of proline . Over biosynthesis of proline by the over expression of P5CS may play an important role in flower initiation and bolting promotion at the early stage of plant development . Lower photosynthetic pigments and fluorescence with higher accumulation of proline in the present study indicate a stress response of plants in the L1 treatment . This stress may be due to the lower intensity of natural light under greenhouse conditions. Carbohydrates are the main source of energy and are considered the main criterion of cell division activity in plants, and their concentration depends on the amount of photosynthetically active radiation . In a previous study, it was reported that UV-A light influenced the plants to accumulate more carbohydrates , whereas at a low R:FR ratio plants accumulated more soluble sugar, carbohydrates, and secondary metabolites . The ratio of red spectrum ranged from 40 to 60%, with other light sources increasing the TSC and sugar in L7, L8, L9, and L10 . The monochromatic red, blue, and their combined spectra manifested decreased soluble carbohydrate in Anthurium cut flowers in a previous study . Our present study also found a lower TSC and sucrose content in combined red-blue spectra compared to all other treatments.

From the PCA analysis, it can be revealed that both the TSC and sucrose content manifested a negative correlation with SL, LL, and LW and are closely associated with the L9 treatment. A possible explanation is based on the fact that under stress plants produce excess carbon skeletons to prevent the declining trend in photosynthetic rate and growth in plants, which help to increase osmolytes production . The reduced photosynthetic pigments , LL, and LW under the L9 treatment in the present study quite support this hypothesis. Our study found a similar pattern of TSC and sucrose content while little dissimilarities were also observed from ascorbic acid under different light spectra. It was narrated that TSC are the precursor for ascorbic acid biosynthesis, and mature green tomatoes can achieve both compounds in higher amounts under high irradiance of light, but no correlations were observed in a series of experiments between them . These results indicate that the accumulation of sucrose content and TSC is interdependent, whereas ascorbic acid is independent of both compounds. Moreover, plants accumulate all osmoprotectant molecules significantly higher when the green light was added to the other light spectra , compared to the red and blue combination . Since ancient times, wild or naturalized plants have provided social security to millions of people globally, in the form of fuel, food, fodder, supplements, raw materials for industries, medicines, and especially a source of additional income . According to the World Health Organization, about 65–80% of people in developing countries are reliant on herbal remedies made from medicinal plants . About 90% of the plant species used in the Indian herbal industry come from the Western Himalayas . The Indian Himalayan region was well-known for its floristic diversity, with approximately 1748 medicinal plant species reported from the region , which were used in various fields of chemistry, pharmacological research, pharmacognosy, and clinical therapeutic studies . Himachal Pradesh is the northeastern state of India, geographically divided into three distinct regions; the outer Himalayas , the mid-hills, and the greater Himalayas, which cover an area of 55,673 km2 . Due to its diverse climatic, topographic, and geographical position or altitude, the state of Himachal Pradesh represents a rich source of biodiversity . According to the data of the Ayurvedic Pharmacopoeia Committee , out of 1100 single-ingredient drugs, 350 plant species belong to native therapeutic groups, among which 225 species blooms in the state of Himachal Pradesh and were obtained commercially . Angiosperms, including 1003 species of dicotyledons, belonging to 498 genera and 313 species of monocotyledons, belonging to 133 genera. Whereas, the gymnosperms are characterized by only 10 species and 8 genera in the state . The contribution of dicotyledons and monocotyledons to the world flora is approximately 81.3 and 18.7 percent, respectively, trimming tray with the Shimla district accounting for 23.3 percent of monocotyledon species . Approximately 500 species of medicinal plants have been reported from Himachal Pradesh .

From the very beginning of human civilization, people have been developing their knowledge of plant use, management, and conservation . Indigenous people seem to have a hierarchical knowledge of these traditional medicinal plants for a variety of human diseases, and this knowledge has been passed on from one generation to the next . This study documents the accumulated knowledge regarding plants in the Maraog region that has traditionally been employed for the treatment of different human diseases. No such study has been conducted previously in this area, thus it will assist in providing valuable information to the ethnomedicinal research field, and such information is expected to be useful in the discovery of drugs . Such studies have been done indifferent parts of the world, including Pakistan, Nepal, Africa, America, Europe, Poland, Argentina, Australia, Iran, New Zealand, Turkey, Japan, Taiwan, Pakistan, China, Nepal, as well as different parts of South, North and East India. The declining rate of ethnomedicinal knowledge amongst younger generations was found to be a common problem in all the reported countries . As the economic condition of people living in rural areas is improving day-by-day, people are becoming less dependent on traditional medicinal practices, thus knowledge in the use of medicinal plants is also diminishing .

In this case series, we present 2 cases of MC in male adolescents following recreational vaporized cannabis use.Patient A00 is a 15-year-old boy with a past psychiatric history significant for nonsuicidal self-injurious behavior via cutting, history of childhood trauma, no prior suicide attempts or inpatient hospitalizations, and no known past medical history. He presented to the emergency department  with 5 days of aggressive behavior, paranoia, auditory hallucinations, and hyperreligiosity. He endorsed a history of vaping “TKO” marijuana most days of the week for approximately 1 year before presentation and no other substance use. In our ED, his vital signs were notable for tachycardia to 114 beats per minute, temperature of 37.6 Celsius, and hypertension to 171/111 mmHg. Workup in the ED revealed a leukocytosis to 11.2 K/UL, hemoglobin of 15.0 G/DL, hematocrit of 45%, and serum creatine kinase of 408 U/L. Urine drug screen was positive only for cannabis.He experienced episodes of emesis in the ED. Physical examination was notable for mydriasis, psychomotor retardation, and hyperreflexia. His mental status examination was significant for poor eye contact, monotone speech, flat affect, and disorganized thought process. After 2 doses of lorazepam 2mg by mouth and hydralazine 10mg PO, his blood pressure improved to 142/97 mmHg. He was admitted to the general pediatrics service for further workup and management of persistent hypertension and tachycardia. On arrival to the floor, he had a heart rate of 124 beats per minute and a blood pressure of 136/84 mmHg. Urine metanephrines, plasma renin and aldosterone, magnetic resonance image brain without contrast,hydroponic grow tent cerebrospinal fluid studies were all within normal limits. Continuous electroencephalography revealed diffuse low-voltage fast activity but no epileptiform discharges or generalized slowing. Due to ongoing autonomic instability, on hospital day 1, treatment with lorazepam 2mg three times daily as needed for hypertension was started, and he received 4 mg total over 24 hours. On hospital day 2, he reported feeling stiff in his arms and legs and “feeling stuck in his body” and was noted to appear withdrawn with minimal speech output.

The pediatric consultation-liaison psychiatry service was consulted for concern of altered mental status and recent bizarre behavior. On the initial examination by the pediatric consultation-liaison psychiatry service, he was noted to be paranoid with a tangential thought process and significant psychomotor retardation. The initial Bush-Francis Catatonia Rating Scale was 7. He had received lorazepam 2 mg PO x2 the day prior. On serial examinations, he had catalepsy, waxy flexibility, and defificits with attention and calculation. Lorazepam was scheduled 2 mg PO t.i.d. Over the 18-day admission, lorazepam was titrated to 12 mg daily. Psychotic symptoms resolved, though attention deficits persisted. He was discharged to an inpatient psychiatric unit with treatment with lorazepam 11mg per day. He was hospitalized there for 5 days and then discharged on 9 mg daily with instructions to taper over the next 18 days. He re-presented to the ED with catatonia and suicidality 3 weeks later in the context of repeat vaporized cannabis use. He presented with depressed affect but no psychosis.He was transferred to an inpatient psychiatric facility. After discharge, he tapered off of benzodiazepines over 3 months and has remained without symptoms.“Patient B” is a 16-year-old boy with a past psychiatric history significant for attention-deficit/hyperactivity disorder, who was brought to the ED for altered mental status after vaping cannabis. He noted a history of smoking cannabis but reported vaping cannabis the day before ED presentation. Of note, he had been admitted to an outside hospital several months prior for a similar episode of catatonia after reported cannabis use. As per documentation from that hospitalization, catatonic symptoms resolved with lorazepam treatment. On arrival to our ED, he was afebrile but hypertensive to 138/70 mmHg and tachycardiac to 100 beats per minute. Blood work was significant for hemoglobin of 14.8 g/dl , hematocrit of 46.1% , thrombocytosis to 407 K/UL, creatine kinase of 759 U/L, and urine drug screen was positive only for cannabinoids.On physical examination, he was slow to respond to questions and had difficulty following simple commands. He was described as “dazed” and appeared to be responding to internal stimuli; he was too behaviorally dys regulated to meaningfully participate in medical workup or safety assessment, so he was given haloperidol 5 mg IM and lorazepam 2 mg IV, before psychiatric consultation. Four hours after the administration of these medications, he developed writhing motions of his head and neck, thought to be an adverse reaction to haloperidol, which resolved with the administration of diphenhydramine 50 mg PO. Several hours later, he developed rigidity and psychiatry was consulted owing to concern for catatonia. On initial psychiatric evaluation , he scored 8 on the initial Bush-Francis Catatonia Rating Scale .

In light of these findings, a diagnosis of MC was made and treatment with lorazepam 2 mg PO/IV every 6 hours was recommended. He received a total of 6 mg of lorazepam IV in the ED with resolution of his rigidity. Owing to worsening hypertension to 158/68 mmHg, dysregulated behavior, and development of a 2-liter oxygen requirement after lorazepam administration, he was admitted to a medical intensive care unit for continued monitoring and treatment of MC. In the medical intensive care unit, further workup revealed new hyperkalemia to .5.8 mmol/L and uptrending creatine kinase level to 1800 U/L, which were treated with intravenous fluids. Computed tomography of his head without contrast was negative for acute abnormalities. He received 1 additional dose of lorazepam 2 mg IV in the medical intensive care unit , and his rigidity, mutism, staring, hallucinations, and oxygen requirement subsequently resolved. He was transferred to the general pediatrics floor where he was noted to have perseverative speech, intermittent aggression toward staff, and deficits on bedside cognitive testing including poor short-term recall and poor attention. Cardiology was asked to see him to comment on his intermittent hypertension and electrocardiogram changes; a repeat electrocardiogram did not show left ventricular hypertrophy, and an echocardiogram was unremarkable. On hospital day 2, his initial Bush Francis Catatonia Rating Scale was 0 on evaluation by the pediatric consultation-liaison psychiatry service, and scheduled lorazepam was decreased to 2 mg PO t.i.d. On this dose of lorazepam, he remained normotensive and without cognitive deficits or signs of catatonia or psychosis on exam. He was ultimately discharged on hospital day 5 to outpatient psychiatric care.Case reports of substance-induced catatonia in this age group have included catatonia secondary to ecstasy and synthetic cannabis.To the best of our knowledge, the two cases described here represent novel reports of presentations of pediatric MC in the setting of vaporized cannabis use. These cases raise the question if vaporized cannabis use has the potential to be a causative factor in the development of catatonia. Vaping devices facilitate the use of cannabis concentrates, which have been found to have approximately triple the delta-9- tetrahydrocannabinol strength of flower-derived strains.Vaporized cannabis use has been associated with both increased plasma levels of delta-9- tetrahydrocannabinol and subjective drug effects compared with cannabis use via smoking.Highpotency delta-9-tetrahydrocannabinol has been associated with increased negative psychiatric effects such as low mood and anxiety,suggesting the potential for other neuropsychiatric sequelae as well. In these 2 cases, while the completed workup was unrevealing for acute neurologic, infectious, or metabolic precipitants to catatonia, we were limited in our ability to test for all drugs of abuse.

Synthetic cannabinoid and cathinone testing were sent out tests at our institution, and these tests were deferred owing to cost and low likelihood to change management. We considered psychiatric decompensation as the acute precipitants to catatonia in both of these patients. Neither patients endorsed acute emotional distress before presentation, but patient A reported feeling depressed in the setting of ongoing psychosocial stress suggesting the possibility of an affective component as well in this case. It is also unclear from documented history if either patient had a loss of functioning consistent with a prodrome of a primary psychotic disorder before presentation. The acute onset of psychotic symptoms and timeline in relation to cannabis use more strongly suggests psychotic symptoms in both cases were substance-induced, but we cannot exclude the possibility of an underlying vulnerability to a primary psychotic disorder in either patient. In either patient, vaporized cannabis may have lowered the threshold to the development of catatonia given its effects on the gammaaminobutyric acid  system. The autonomic instability in the context of catatonic symptoms led us to define these 2 presentations as malignant catatonia. Although the neurobiological underpinnings of catatonia are not well understood,there is evidence supporting alterations in GABA, dopamine, and glutamate in the pathogenesis of this disorder.Clinically, involvement of the GABAergic system in catatonia is suggested by the rapid and often dramatic efficacy of GABA agonists, such benzodiazepines, for the treatment of the syndrome.Exposure to cannabinoid receptor 1 agonists,cheap grow tents such as delta-9-tetrahydrocannabinol, has been associated with disruption of GABAergic-mediated cortical inhibition.Given the importance of cortical GABAergic modulation of feedback loops within mesostriatal and mesocorticolimbic systems,further research is needed to investigate if disturbance in GABA by delta-9-tetrahydrocannabinol may directly precipitate many of the psychomotor symptoms seen in catatonia.Amid the pandemic caused by the novel coronavirus disease , public health measures were enacted in countries around the world to curb the spread of COVID-19. In Canada, wide-scale emergency measures were put in place in March 2020 that severely impacted Canadians’ ability to engage in work, educational, recreational, and social activities. During times of high stress and anxiety, social isolation, and limited out-of-home recreational activities such as those seen during the COVID-19 pandemic, people may increase their use of substances like cannabis . Cannabis is the most widely used psychoactive substance besides alcohol in Canada, and its use can be accompanied by the risk of developing a cannabis use disorder along with numerous short-term and long-term adverse health consequences . Alongside the implementation of COVID-19-related emergency measures, a Statistics Canada survey reported a sharp increase in cannabis sales in March and April 2020 compared with previous months .

Further, a survey of Canadian adults found that among cannabis users, approximately half increased their use of cannabis relative to their pre-pandemic consumption patterns . The widespread use of cannabis and an increase in use during the current COVID-19 pandemic underscores the necessity of understanding the etiology of elevated levels of cannabis use. A key determinant of a substance’s use and misuse is its reinforcing value, which refers to its behavior-strengthening and behaviormaintaining properties . The reinforcing value of a substance has been operationalized as behavioral economic demand, or the relationship between the price of a substance and its consumption. Substance-related demand has been measured in the lab through the use of hypothetical purchase tasks . Purchase tasks have been employed across a number of substances including alcohol, tobacco, and cocaine , and more recently for cannabis . These tasks ask the participant to estimate their consumption of a substance at varying price points . Purchase tasks allow for the characterization of an individual’s pattern of demand via the calculation of several demand indices: four observed indices  and one derived index . Intensity refers to unconstrained consumption at zero cost. Omax refers to the peak expenditure, or the maximum total amount of money spent on the substance across price points. Pmax is the price at which this peak expenditure occurs. Breakpoint refers to the cost at which consumption is suppressed to zero. Higher values on each of these indices reflect higher demand for the substance. The derived index, elasticity, refers to the rate at which consumption decreases relative to increases in cost. Latent factor analysis of the Marijuana Purchase Task has revealed that these five indices map onto two underlying dimensions of demand. The first factor is “Amplitude,” which refers to consumption at unrestricted cost and is comprised of one index, intensity. Higher consumption at zero cost reflects higher demand. The second factor, “Persistence,” is comprised of Omax, Pmax, breakpoint, and elasticity, and reflects the individual’s sensitivity to increasing cost . A low sensitivity to increasing cost indicates higher demand. This factor structure aligns with research demonstrating a similar structure for alcohol and tobacco purchase tasks .

Although it also conflicts with prior evidence of disparities in nicotine and cannabis product use observed among lesbian and gay  adolescents  and young adults , it does align with two recent studies in which bisexual-identified, but not lesbian- or gay-identified adults, reported higher current use of some tobacco products relative to heterosexual-identified adults . The findings of the current study should be considered in the context of its limitations. One limitation is the relatively low representation of sexual minority  young adults in our sample. While the percentage of sexual minority participants in the current report is comparable to other studies of sexual orientation and young adult substance use , a judicious interpretation of our findings is therefore encouraged, particularly for prevalence estimates that had wide confidence intervals. The small sample size also limited our ability to examine sexual identity differences in poly-substance use of nicotine and cannabis products, which we would expect to be high among sexual minority young adults . An additional study limitation relates to our inability to assess all three dimensions of sexual orientation , a practice that is increasingly normative in research with young adults, who may still be establishing their sexual identity. Although the data that correspond with the current analyses did not include items assessing sexual behavior or sexual attraction, these items will be administered to participants at the next wave of data collection for the Southern California Children’s Health Study. Our assessment of sexual identity is further limited by our inability to assess sexual minority identity labels that are non-traditional but increasingly common  among sexual minority individuals, which will also be assessed in subsequent waves of the study.

There are also several limitations to the generalizability of our findings to sexual minority young adults outside of the current study. First, school-based studies necessarily exclude high school dropouts,home schooled students, and adolescents not in attendance at the time of survey administration. Given that sexual minority  adolescents are more likely to drop out of school, face housing instability, and have poor school attendance , the school-based design of initial enrollment into the Southern California Children’s Health Study may be a source of sampling bias. Additionally, our findings may not generalize to sexual minority young adults outside of the Southern California region. Many of the prevalence estimates for nicotine and pot for growing marijuana product use for bisexual  young adults reported here are larger than estimates observed for sexual minority  young adults in similar cross-sectional studies , particularly with respect to cannabis use. This may be attributable to the unique legal landscape in California on issues that likely impact nicotine and cannabis product use among sexual minority young adults relative to other areas of the country . Future replication in U.S. settings that differ from California on these dimensions is warranted to better understand the role that contextual factors specific to California may have played in the current study. While the appeal of e-cigarettes and cannabis is on the rise among young adults in general, our data suggest that bisexual young adults may be especially at risk. Although gender-stratified results of the interaction analysis suggest that this risk may be compounded among female– relative to male—bisexual young adults, these findings warrant cautious interpretation given that the interactive effect of sexual identity and gender on lifetime product use only reached statistical significance for cigarette use. Nevertheless, future research examining substance use trends among young adult sexual minority populations should further explore the potentially moderating role of gender within this relationship. The prevalence of bisexual self-identification appears to be increasing rapidly relative to other sexual minority identities in the U. S.—especially among younger populations . Thus, the already disproportionate public health burden that bisexual individuals face will likely grow wider yet in the coming years, particularly if concerning trends around bisexual young adults’ substance use persist unchecked. The results reported here underscore the urgent need to prioritize this population as among the highest risk subgroup in need of enhanced substance use prevention efforts across the domains of research, policy, and clinical practice.

It is also imperative that future research elucidate why existing substance use screening, prevention, and intervention services continue to fall short for bisexual adolescents and young adults and how such programming can be tailored to address factors that play a unique role in motivating their substance use. To this end, identifying risk or protective factors that may influence the disproportionate nicotine and cannabis use observed in this vulnerable population is warranted. In the cannabis industry, be it medicinal or recreational, there is an abundance of control measures in place to ensure product safety and efficacy. Contamination of cannabis plants with toxic heavy metals such as arsenic, cadmium, lead etc. can result from numerous origins. Sources of contamination include environmental pollution such as emissions from factories and automobiles, contaminated water, some pesticides, and naturally occurring metals in soil and fertilisers. The contamination of the herbal material ultimately leads to contamination of the products during various stages of the manufacturing process. During growth, metals accumulate in the biomass of specific plants. Studies conducted on industrial hemp show that the cannabis plant bio-accumulates heavy metals from the soil, and thus is readily employed for phytoremediation of contaminated soils. There have been reported cases of post processing adulteration of cannabis buds, adding heavy metals to increase the weight of the product to purposely increase the street value. Pesticides that contain arsenic and mercury as part of their structures were commonly utilised until a few years ago, and are still employed to date. These toxic substances are likely to be present in many foods due to their abundance in nature, and it is important to note that associated ingestion or inhalation of these cannabis products would add to the accumulation of heavy metals consumed by people, even if best practice guidelines are followed. As a result of the new regulation imposed by the USP in collaboration with the ICH, the detection limits for certain metals have been lowered. Heavy metal residues in pharmaceutical end products, active pharmaceutical ingredients and excipients need to be controlled and should be at a certain limit for safe human consumption. Furthermore it can be noted in the somewhat unique case of cannabis based products, that an alternative route of administration of these products does occur, namely inhalation. The pharmacopeial guideline stipulates three routes of administration namely: Parenteral, Oral and Inhalation.ICP-MS  is employed to detect heavy metal contamination. As a result low residue limits can be imposed by USP 232. Heavy metals are classified into different classes according to their toxic potential, class 1  being the most dangerous, class 2 less toxic and class 3 having the highest limits and being the least toxic. This study will focus on Class 1 and 2 metal residues given they present the greatest health risk to consumers. It is the aim of this study to analyse a segment of the South African cannabis-based products in circulation and provide a detailed overview of the elemental impurities/heavy metal residues contained in these products. Furthermore, the adherence of these samples to the imposed inhalation as well as oral limits by the ICH and USP will also be evaluated.

To date no data of this kind exist in South Africa. With these data, regulators, medical doctors and the public can gain a better sense of the dangers currently being faced regarding cannabis based products in South Africa. A total of 310 samples were submitted to a South African contract laboratory for analysis. Manufacturers are defined as any type of user, retailer, reseller, producer, or importer of cannabis-based products. Whether these manufacturers maintain the full value chain or only a portion thereof they are defined as manufacturers for the purpose of this study. Manufacturers may include cultivators of plants, producers of products, importers, resellers, and pharmaceutical manufacturers. Sample data will be presented anonymously. It should be noted that samples were analysed as received by the laboratory irrespective of whether plant material was dry or wet. Dry plant material will have a larger portion of elemental impurities as a result of the moisture mass loss during the drying process. The moisture content of the sample may influence results significantly since they are reported in a mass per mass unit. All samples were analysed in duplicate. Class 1 and 2 heavy metal test panels were analysed . It should be noted that the majority of samples were cannabis-based products, with very few samples submitted for the analysis of soil and water. Consent was provided to employ the data for research purposes. The samples were categorised into seven different types and are shown in Table 2, the same as reported by a potency study conducted by the same laboratory. Approximately 200 mg of each sample was weighed, digested in 10% HNO3 for 1 h at 100◦C and diluted 35 times to a total volume of 7 mL. Internal Standard Y  and In  was used for matrix interference correction. Since large isolate as well as extract sample quantities are scarce, a method needed to be developed to be able to employ as small as possible sample quantity while still being able to reach the USP232/ICHQ3D limits. Analysis started with a blank run, then a 5 point calibration curve, followed by a control standard every 10 duplicates, to avoid instrumental drift. Sample sets were ended by analysing a control standard to ensure all samples within a sample set adhered to bias and variation limits as per USP232/ICHQ3D. The data were grouped into two major groups containing categories applicable to either the inhalation limits and/or categories applicable to the oral specification limits as per USP232/ICHQ3D. All categories were included in the oral specification limit, since all samples needed to be compared to a specification. As for the inhalation specification,container for growing weed the following categories were grouped together for comparison; Extract, Liquid and Plant Material. Since it is not known by the laboratory what the final intended use of the products were, these three categories posed the highest likelihood being dosed in inhalation form. The two major dosage form groups were also subdivided into two different categories. Tabulated results of the data are shown in Appendix A, Tables A1–A4. Individual elemental data are grouped within categories according to specification as mentioned above. It should be noted that the applicable categories together with metal residues that failed will be displayed. If a metal was present in the test method but had no failures it will not be displayed on the figures.

The presence of each residue is also displayed for the analysed 310 samples, together with the limit of detection for each residue in Table A3. Additionally, Appendix A, Table A4, shows the number of samples that failed when they are evaluated against the different specification limits. Furthermore, the table also shows the number of samples for which heavy metal residues could be detected, irrespective of the concentration. A visual representation of the data is given in Figs. 1, 2 and 3. Represented in this data set is a small portion of samples obtained from the South African market. It is by no means a representative sample of the entire South African market, but inferences can be made nonetheless. The dataset will be discussed in two sections, relating to individual heavy metal residues as well as relating to samples. When comparing the individual heavy metal residues that are presented in Fig. 1 against the oral limit, it is evident that the following 3 metals are responsible for most failures: lead , arsenic and nickel . Detection of Class 1 residues above the USP/ICH oral specification limits were responsible for 91%  of all residue failures identified in this study. It is further interesting to note, that only four of the seven categories contained heavy metals at concentrations high enough to cause a failure. The categories that did not contain residues at concentrations high enough to fail could be as result of the concentration dilution being performed or alternatively the process removes metal residues to some degree. For example, when Infusions are considered a dilution of concentration cannabinoids is prepared and consequently other residues like heavy metals and solvents are also diluted.

There is substantial need for improved knowledge in this domain, as the majority of active cannabis users should be encouraged to transition from smoking to alternative modes. Clear and consistent public health messaging from primary stakeholders is required to facilitate this. The literature unequivocally recognizes intensive or frequent cannabis use patterns as a primary predictor of acute/chronic adverse outcomes . Based on available data, between one and two in five cannabis users in Canada engage in frequent/intensive cannabis use, and form a distinct ‘high-risk’ group for potentially severe cannabis-related harm. While some of these ‘intensive’ users may be reached by simple prevention messaging emphasizing decreased frequency of use, a sizeable proportion are likely to feature criteria for CUD. These users are likely less receptive or able to follow simple behavior-change advice and instead may require professional help or treatment . Driving immediately following cannabis use involves  impairment, and is a behavior that about doubles risk for traffic crash involvement, and related injury and/or fatalities . Cannabis-impaired driving is also a main contributor to cannabis-related disease burden, as it provides a  cause of direct cannabis-related mortality, and thus represents a primary target for prevention . The Canadian surveys indicate that substantial minorities of users engage in cannabis-impaired driving, with a further subset of these  engaging in driving co-impaired by alcohol, which further amplifies risk for injury . Moreover, as the surveys relied on short and varying time periods for impairment risk , these rates likely represent under-estimates of the risk total.

Irrespectively, these risk behavior rates are high and disconcerting overall. They are likely facilitated by multiple factors, including common beliefs about nonexistent, or only very limited ‘impairment’ effects of cannabis grow tent, as well as a low likelihood of apprehension under current enforcement for cannabis-impaired driving . These circumstances urgently require intensified targeted education and enforcement efforts. These efforts should draw on crucial lessons from alcohol/drunk driving intervention strategies, which have achieved substantial decreases in alcohol-impaired driving and related crashes . While some evidence exists about cannabis use-related adverse reproductive/infant health outcomes during pregnancy and/or breastfeeding, rather small minorities of women reported ongoing use during these periods. While cannabis compounds may be passed on to the foetus via intrauterine transmission or through breast milk, some women use cannabis ‘therapeutically’ to combat pregnancy-related nausea . Overall, adverse outcomes for newborns are uncertain and likely limited . However, avoiding cannabis use during pregnancy and breastfeeding represents a relatively simple prevention effort of possible harm to others . Moreover, this recommendation aligns with other precautionary health behavior adjustments among pregnant women or new mothers . Overall, current indicator data from major surveys indicate that respective majorities of cannabis users in Canada – with the exception of ‘smoking’ as the primary mode of use – are generally mostly compliant with the main LRCUG’ recommendations for which such data exist. At the same time, the proportion of users non-compliant with other LRCUG recommendations represent sizeable sub-populations of the currently 4–5 million cannabis users, many of which likely engage in more than just one risk behavior, and thus face considerable risk for acute and/or chronic adverse health outcomes . While population-level harms for cannabis are more limited than those for alcohol or tobacco, the ensuing disease burden is substantial, also given that cannabis use disproportionately occurs among youth/young adults where key LRCUG-defined risk behaviors are commonly concentrated . Thus, in order to achieve legalization’s objective of improved public health outcomes, key cannabis-related risk behaviors need to be more effectively addressed. Active and widespread dissemination and promotion of the LRCUG recommendations may lead to increased awareness and adjustment of relevant risk-behaviors among users . The behavioral uptake potential of interventions such as the LRCUG is uncertain, for example among intensive, chronic users.

However, it should be emphasized that the LRCUG represent a targeted prevention measure, rather than a  treatment tool for individuals possibly characterized by CUD . Nevertheless, other complementary, targeted intervention measures combined with appropriate regulatory provisions focusing on specific risk behaviors  are required in order for a prevention tool like the LRCUG to be effective . In addition, the impacts of such targeted measures on cannabis related risk behaviors require consistent assessment and improved understanding . The data used in the present review feature some limitations. Specifically, the survey sources for the indicator data relied on different sampling frames, essential methods details and item design , limiting the surveys’ reference populations full comparability. Only some of the surveys are considered population representative; the CAMH Monitor is an Ontario-based survey, not generalizable to populations elsewhere in Canada. All the surveys rely on  self-report data, which also may be burdened by recall or other biases. In addition, survey items for certain indicators were based on differential operational definitions , or included subjective estimates with unknown reliability in select instances . These may entail limitations for possible intrinsic and extrinsic indicator data validity or comparability. Overall, while the scientific evidence behind the LRCUG is evolving, consistent population-level measurement of risk-behavioral indicators for cannabis use-related health outcomes is essential for effective monitoring of public health-related cannabis risks and harm outcomes, especially in the era of legalization as an ongoing ‘policy experiment’. Substance use disorders are currently a major public health crisis in the US . Cannabis is the most commonly used illicit substance in the world . With more than 200 million users of cannabis worldwide, its harmful health effects have become a serious global problem . During the past two decades, the laws and policies related to cannabis use have also changed drastically throughout the world. For example, countries such as Canada, Spain, and Germany have legalized cannabis for medical use while some have even legalized its non-medical use, e.g., Uruguay in 2015 and Canada in 2018 . Not surprisingly, the legalization trend continues in the US, with 33 states and the District of Columbia legalizing medical marijuana use, and 11 states and the District of Columbia legalizing adult non-medical marijuana use . Regardless of the developing accord about the usefulness of medical marijuana for several serious illnesses, there is a widespread concern that this may cause adverse effects . According to a study on the effects of medical marijuana laws, the likelihood of current as well as regular use of cannabis among people aged 21 or older has increased after the laws came into effect .

This also appears to have contributed to an increased prevalence of illicit cannabis use and cannabis use disorder . In particular, among adult males, arrests due to illegal marijuana possession in major cities have increased by 15–20% and the treatment provided in rehabilitation facilities for such arrests have increased by 10–20% . This article focuses on cannabis use disorder . Earlier, there was a consensus that CUD is rare, which is no longer true. It is estimated that about 34% of cannabis users develop CUD during their lifetime based on the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders  . Furthermore, a recent study based on DSM-V criteria found that about 27% of cannabis users develop CUD during their lifetime . Another research shows that after legalizing marijuana for recreational use, the prevalence of CUD among past year cannabis users between the ages of 12 and 17 rose from 22.8% to 27.2% . Thus, given that the prevalence of CUD is expected to increase further, it is imperative to predict the risk of developing CUD for cannabis users, especially for adolescents and emerging adults, based on their personal risk factors. Identifying individuals at high risk of CUD will allow the possibility of applying early intervention, which may potentially help stem the increasing prevalence of the disorder. Several risk factors have been reported for substance use disorders in general and specifically for CUD. These include male sex, early exposure to traumatic events, early use initiation, family history of substance use, childhood depression, and conduct disorder symptoms . High impulsivity and certain personality traits are also associated with the disorders . In particular, work by coauthor Filbey’s lab showed that openness distinguishes cannabis-only users from nicotine-only users, co-morbid marijuana and nicotine users, and non-users . The results from this study also indicate that conscientiousness is lower among grow lights for cannabis users. Some brief screening tools such as BSTAD  and S2BI  have been developed for adolescents . For example, the cutoff for CUD based on BSTAD is at least two days of marijuana use in the past one year. A relatively lengthy tool, Transmissible Liability Index, assesses the inherited risk for disorders based on a 45-item questionnaire . Also, a recent study has developed a simple cumulative risk index for substance dependence in adulthood using risk factors in childhood and adolescence .

It can be used to screen adolescents who are likely to develop persistent disorder in adulthood. A similar study has developed a risk score by counting the number of early life risk factors present in an individual and associating it with cannabis use and CUD in early adulthood . However, a key limitation of the existing tools is that none of them provides a quantitative risk of developing the disorder based on personal risk factors, which restricts their practical utility. Models for predicting such risks have been developed for several diseases, including breast cancer , contralateral breast cancer , heart disease , depression , and psychiatric disorders , and they are in wide clinical use. However, currently there is no such quantitative risk prediction tool for CUD. In this study, we build upon the findings of Ketcherside et al. in a cannabis-using adult population and perform a secondary analysis of the data. More specifically, we build a preliminary quantitative risk prediction model to estimate the chance that a cannabis user will develop CUD based on various demographic, behavioral, psychiatric, and cognitive risk factors. The initial data set obtained after applying the inclusion criterion consisted of 118 cannabis users. We used CUD as the outcome variable, which was derived based on the DSM-IV criteria for dependence.The variable selection process to identify potential risk factors was the following. First, the variables with more than 50% missing values were discarded. Then, among the remaining variables, only those that remain relatively stable over time were chosen. Given the cross-sectional nature of the data, focusing attention on such type of variables protects against using risk factors that may actually be an effect of CUD. This resulted in 30 variables. These included measures of impulsivity and personality traits. The former were obtained using two questionnaires, namely, Impulsive SensationSeeking Scale , a 19-item self-reported questionnaire from the Zuckerman-Kuhlman Personality Questionnaire and Barratt Impulsivity Scale , a 30-item self-reported questionnaire where the items can be grouped into six first-order factors that measure different aspects of impulsivity . Both ImpSS and BIS were considered because there are some characteristics of impulsivity that are captured by ImpSS but not by BIS and vice versa, and the two have been used together in several studies . The personality traits were obtained using Neuroticism, Extraversion, and Openness inventory , a five-factor inventory for measuring five different dimensions of personality . The actual measures derived from these questionnaires were total score on the ImpSS questionnaire, scores on the six factors from the BIS questionnaire, and scores on the five factors from the NEO questionnaire. Only 46 of the 118 subjects had complete data on all 30 variables. To guard against loss of subjects due to missing data on potentially unimportant variables, univariate logistic regression models were fitted with each of these variables as a predictor. Thereafter, the predictors with univariate model p-value less than or equal to 0.3 were selected into the final set of potential predictors for a multivariate model . The resulting data set had 12 potential risk factors and 94 subjects with complete observations on them. This final data set was used for the rest of the model building exercise. The data analysis was performed using five common statistical and machine learning models for classification , namely, logistic regression with LASSO penalty, K-Nearest Neighbor , support vector machine  with radial kernel, random forest, and gradient boosting.

All interviews were coded by J.E., and six interviews were independently coded by D.D. Throughout the analysis process, J.E. and D.D. discussed codes and coding structures. Findings were viewed through an HTA lens, and attention was paid to the impact of the technology  on the participants  and their interactions with end users . In the following section, some quantifying language is used to provide a sense of consistency within themes. For example, the term “most” indicates that a theme was present in at least 10  participant accounts, while the term “many” indicates that at least 6 accounts included the theme. The terms “some” or “several” indicate that less than half of participant accounts included a theme; however, the absence of a theme in a participant account does not indicate that a belief was not held, only that it was not raised during the interview.The medical cannabis field was perceived by participants to be rapidly evolving, and participants expressed a desire to learn more about cannabis, including about cannabis-based products and cannabinoids, noting that increased knowledge would allow them to better counsel patients . No participants had received formal training about medical cannabis, and several expressed the need for its addition to medical school curricula. Participants reported learning about medical cannabis by attending rounds, reading journal articles, viewing web seminars, and through discussions with colleagues . Several participants described a desire for guidelines from Canadian professional associations, stating that it would facilitate their practice by allowing them to better counsel patients.Most participants reported discussing costs with families, and some described working with parents to calculate costs based on the projected dose. Several participants noted that the cost of treatment sometimes limited their ability to reach a therapeutic dose because parents are typically paying out-of-pocket for the cannabis products. Neurologist 10 summarized the issue as follows: “Families sometimes don’t advance the treatment to a therapeutic dose because the cost is prohibitive and in that case, I think that’s all a kind of a waste.

It’s like going through the trouble of spending your money to take an aspirin a day when really you need eight aspirins a day. Wasting your money, one aspirin a day won’t do anything but you’ll never get up to eight because you can’t afford it.” Because of this issue, mobile grow system some participants described choosing between licensed producers based on the availability of compassionate discounts for pediatric patients. One neurologist reported that parents were sometimes surprised to learn that cannabisbased products are not typically covered by insurance, especially since the legalization of recreational cannabis in Canada in October 2018 . This was echoed by some neurologists who stated a belief that cannabis-based products should be covered by insurance programs, citing benefits to the health care system .Participants who had not previously authorized medical cannabis described a variety of reasons for not authorizing its use, including personal and institutional factors. Insufficient evidence or guidance: Some participants reported not authorizing medical cannabis because of a lack of evidence and/or guidance . Out of scope: Out of scope: Others described feeling that authorizing medical cannabis was outside their scope of practice, that they considered it a “regulatory hassle” , or that they could not do a “better job” than physicians at cannabis clinics. Restrictive policies: Some participants described policies at their hospital or within their department that prohibit authorization, while others reported not wanting to be seen as going against people in leadership positions . Several participants noted that consensus had been reached within their department or group to not authorize cannabis and that a unified position was felt to prevent any one neurologist from being given the most complex cases and/or “the most demanding families” .Participants who do not authorize medical cannabis described referring patients to other health care providers  or to cannabis clinics, often in the patient’s community , or in one case, to in an adjacent province, stating that there was no closer alternative. Others described hospital or departmental policies that prevented them from referring patients, leaving it up to parents to find a cannabis clinic or care provider to provide authorization .

Of note, some neurologists were strongly against the practice of referring patients to non-neurologists for the purpose of obtaining cannabis authorization , citing patient safety as a key concern.Most participants reported that caring for children using medical cannabis does not affect their workflow, in terms of the number of patient visits or tests ordered. In one neurologist’s experience, the number of visits may be fewer, at least during the dose-optimization phase, for children who received authorization from another physician . In terms of testing, participants described treating cannabis “like another drug,” with no additional testing performed, while some order additional tests at baseline and while titrating the dose or if the child presented in a “sleepy state,” or being “a lot more cautious with the other medications” prescribed concurrently. Several neurologists described providing counselling and education to families about medical cannabis, which may add to the length of the clinical visit, and one neurologist described offering parents the opportunity to ask follow-up questions via telemedicine after an initial discussion about cannabis. One neurologist described difficulties entering nonformulary medicines into hospital electronic medical records and, for parents who receive authorization at a cannabis clinic, having to rely on parents to supply information about the treatment plan because of a lack of communication from some cannabis clinics .In this qualitative interview study, we explored the experiences and perceptions of neurologists in Canada about the use of medical cannabis for treatment of pediatric drug-resistant epilepsy. Most of the neurologists interviewed for this study viewed medical cannabis as a viable option, particularly after other options had been explored; however, important gaps in the evidence-base were identified, including limited knowledge about the medical properties of cannabinoids beyond CBD, the inability to predict which patients are most likely to benefit from cannabis treatment, and a lack of long-term safety data. Most neurologists reported having overall positive experiences with medical cannabis, although several commented that it’s not a magic pill and that the benefits are likely oversold by the media. In 2013, CNN aired a documentary about Charlotte Figi, a 5-yearold girl with Dravet syndrome. In an attempt to control her drug resistant seizures, Charlotte’s parents initiated a regimen of medical cannabis, reducing her seizures by more than 90 %. Charlotte’s case received considerable media attention and has led, at least in part, to increased interest among parents in the use of cannabis as an alternative or complementary treatment for epilepsy and to increased requests to physicians for cannabis authorization.

Participants in our study also identified the legalization of recreational cannabis in Canada in 2018 as a potential driver of additional interest in medical cannabis. Compared with the public, the medical community has been more slow to adopt cannabis as a treatment for pediatric epilepsy, owing largely to a lack of published clinical studies. Although our study was not intended to quantify support for medical cannabis, we observed that most participants were supportive of a trial of medical cannabis for children whose epilepsy had not responded to other treatments. This is consistent with the findings of a 2019 systematic review, which reported that medical practitioners were largely supportive of the use of medical cannabis across multiple indications, with higher levels of support when other options had been “exhausted.”The Canadian League Against Epilepsy  recently published recommendations regarding the use of medical cannabis in the treatment of epilepsy. First, CLAE recommends that patients should make the decision to use cannabis “in consultation with their health care provider to ensure their safety.” Neurologists echoed this, voicing concerns that some parents may be administering cannabis to their children without oversight of a health care professional, which could lead to unsafe situations for the child. The use of complementary and alternative medicine is common among children with epilepsy, and parents may not disclose its use . This further supports the need to establish open communication between parents and health care providers. Second, CLAE “encourages clinicians and researchers to continue to seek further knowledge and education” about medical cannabis.Several neurologists in our study also expressed a desire for additional and ongoing education, in order to better counsel their patients. In a 2015 educational needs assessment of Canadian physicians, 64 % of respondents perceived a strong need for cannabis education, and 70 % felt that receiving cannabis education would better allow them to care for their patients using cannabis. Similarly, a recent systematic review highlighted a lack of self-perceived knowledge among clinicians about medical cannabis, and several groups have called for increased cannabis education. However, there are also several notable differences between our findings and CLAE’s recommendations. First, CLAE acknowledges the differences between purified CBD oil  and the CBD:THC cannabis oils available in Canada, stating that “evidence is lacking” for products containing both CBD and THC. In contrast, some participants in this study described inferring the safety and effectiveness of CBD:THC cannabis oils based on studies of Epidiolex, which further highlights the need for additional education about the differences between cannabis-based products. Notably, Epidiolex is not available in Canada at this time, mobile vertical rack and there are important differences between Epidiolex and the products available in Canada. The Canadian CBD:THC oils are whole plant isolates, containing CBD as well as THC in various ratios, as well as other phytocannabinoids , flavonoids, and terpenes. There is also considerable variation in terms of the CBD-THC oils available within Canada.

Most licensed producers in Canada offer multiple products with various ratios and concentrations of CBD and THC, including those high in THC , balanced oils , and those high in CBD . The concentration of cannabinoids is variable across preparations, such that a cannabinoid oil with a 20:1 ratio of CBD to THC from one producer does not necessarily contain the same concentration of CBD as a 20:1 oil from a different producer. There is also potential for variability in cannabinoid concentration between batches of the same product, leading to uncertainty that may affect dosing, cost, adverse effects, and therapeutic efficacy. These complex issues related to the use CBD:THC oils further reinforce the CLAE’s recommendation that clinicians continue to seek additional education about medical cannabis. Second, some participants described referring patients and their families to cannabis clinics or to health care providers who may not be experienced in caring for patients with epilepsy. However, CLAE recommends that “treatment with CBD:THC cannabis oil be managed by a physician knowledgeable and experienced with epilepsy care and anti-seizure medications, preferably with experience in CBD:THC cannabis oil.” Some participants noted departmental policies that prevented them from authorizing cannabis or that neurologists in their group had reached consensus that none would authorize cannabis, instead referring patients to cannabis clinics or leaving families to find other health care providers to authorize use. One participant was particularly critical of the practice of referring complex neurology patients to non-neurology health care professionals, stating that “they owe it to the patient” to find an appropriate neurology referral if the family wishes to pursue medical cannabis.Cannabis sativa L., Cannabaceae, has a long history of exploitation as a medicine, in pain relief and epilepsy, and also in food, textile, and paper industries. The scientific research of Cannabis sativa demonstrates an exponential increase in the past 30 years, as most of its ingredients were isolated and characterized, but the breakthrough was achieved in the discovery of the endogenous cannabinoids and the endocannabinoid system. Also, many study results, personal and anecdotal testimonies changed the public perception, asserting pressure for legislation changes in the definition of Cannabis as a Schedule 1 substance resulting in passing laws that legalize its use for medical purposes. Even though each country/state that passed such law brought specific provisions that vary considerably , the common feature of these laws is that they permit the legal use of cannabis for medical treatment if the patient has obtained appropriate medical authorization.

Reviews of controlled trials suggest that short-term, low dose administration of medical cannabis are effective to treat neuropathic pain related to cancer and other chronic conditions.However, a 4-year cohort study in Australia with over 1200 pain patients using prescription opioids reported that for most participants, cannabis use had no effect on their opioid use and actually led to greater pain severity.Some patients who reported feeling symptoms return after tapering off use of medical cannabis might have also been experiencing acute withdrawal symptoms, but this was not reported by participants. Therefore, given the complex evidence, primary care providers need to better understand the pharmacology of the cannabis plant and dosing options.Doing so will enable them to monitor for positive health outcomes and toxicity associated with its use and make informed recommendations. To meet the first objective, the research identified that patients were referred to medical cannabis by healthcare providers and encountered challenges related to cost, quality, and availability of the product in dispensaries. To meet the second objective, the survey research findings indicated that the small number of Black/African American respondents reported higher satisfaction with the effects of medical cannabis than white respondents for the following indicators: increased appetite, decreased seizures, and increased energy. The research did not identify any difference based on race and ethnicity of the patients in terms of perceived benefits or preference for administration. Most patients preferred vaping for administration. Age was negatively correlated with patient benefits for most indicators, possibly suggesting that as patients age, the perceived benefits of medical cannabis may be diminished because of more severe symptoms or possibly comorbidities reducing the efficacy of the drug. By contrast, age was positively correlated with decrease in spasms or tremors in this study. Preliminary studies have shown that modulating the cannabinoid system may be useful to treat some motor symptoms in Parkinson’s disease, mobile grow system which is more frequent in older people, but clinical studies are inconclusive regarding effectiveness of cannabinoid-based medicines.

The results for gender indicated women experienced lower benefits for decreased seizures compared to men. In the study by Crowell et al.,women experienced higher benefits for decreased inflammation and increased mood but lower benefits for increased energy. These findings suggest that there could be differential benefits depending on gender that require further study. This mixed methods research study provided valuable information about patients’ explanations for their patterns of use and rationale for using medical cannabis to address their medical conditions. The data provided preliminary findings which could be used to further examine the benefits that patients perceive from their use of the drug. Areas of future study include focusing on specific medical conditions, such as chronic pain-related conditions, and comparing pain management effectiveness between patients using prescription opioids and medical cannabis. A qualitative study in Illinois reported patients used medical cannabis as an alternative to prescription medications, as a method to wean themselves off of these medications, and as a complementary drug for their medications.Like the present study, most patients in the Illinois study used medical cannabis as an alternative to prescription medicines, citing negative side effects such as damage to the liver, and a vast majority reported daily use.Surprisingly, patients were using medical cannabis to treat several medical conditions at once, which contrasts with consumers’ typical use of a pharmaceutical drug to treat one specific medical condition . There was some underlying stigma toward the perception of the patient’s use of medical cannabis by others, relating to the fact that some patients only shared their usage with trusted family and friends and did experience some discrimination from health care workers at the office of their primary health care provider. It may be the case as was identified in another study, that patients are reluctant to share their use of medical cannabis with their primary health care provider and people outside of their immediate family.In terms of research challenges, it was difficult to recruit Black/African American and Hispanic participants to better reflect the diversity of Florida’s population, so future studies would need to design more innovative recruitment strategies to reach this population of medical marijuana patients. This study identified some areas of potential benefit in terms of symptom relief that might vary by race and ethnicity, but due to the small sample size of minority patients in the survey sample, these are tentative findings and a study limitation. For example, the significant finding that Black/African Americans experienced more benefits for increased appetite, decreased seizures, and energy than white respondents might be the result of a Type I error that could be addressed by increasing the sample size of minority participants in future studies.

From a research participation perspective, a positive study outcome was identifying the willingness of respondents to complete the survey after seeing posts on social media in Florida medical marijuana patient Facebook groups. Some members of this patient population are very focused on advocacy for medical cannabis and took a very positive view toward research participation. However, the majority of respondents were women, middle-aged, and white so there was an element of selection bias in the sample receptive to recruitment messages posted on social media group sites, and possibly fewer minority respondents who were members of these online groups. Medical marijuana patients were very willing to participate in both the surveys and interviews and took an active interest in wanting to learn about the outcomes from this research study. This finding bodes well for future research on understanding patient perspectives of the use of cannabis-based medicines.There is a growing interest in this field and the depth of research being conducted on medical cannabis is broad, but without many concrete conclusions due to current policies, limited drug supply, and methodological limitations.The limited number of double-blind clinical trials demonstrating the potential medicinal effects of cannabinoids calls for additional research questions to be explored.Moreover, most studies are equivocal due to lack of standardization and quality control of the cannabis products examined.Future research can be expected on the subject of medical cannabis, but how are physicians and healthcare trainees staying informed? Previous studies have demonstrated a large gap between the public interest, current use of medical cannabis, and medical providers’ ability to educate and counsel patients.In other words, the use of cannabis was introduced to the field of medicine by patient inquiry rather than through extensive research.Indeed, the majority of medical cannabis regulations in the United States and around the world have been implemented as a result of patient advocacy.Even in some medical schools, such as the University of Vermont Larner College of Medicine, student interest drove the university to offer an elective, and furthermore integrate medical cannabis into the curriculum due to overwhelming interest.A systematic review of healthcare professionals’ attitudes and knowledge on medical cannabis recently reported on a lack of selfperceived knowledge on medical cannabis across the fields of medicine, nursing, and pharmacy.It further demonstrated a common desire for additional education and resources to access information about medical cannabis. In general, while several studies have shown that healthcare professionals support the use of medical cannabis in clinical practice, in particular for cancer and hospice patients, mobile vertical rack others have reported on more conservative positions.Such a gap in attitudes and knowledge among healthcare professionals on this topic illustrates the need for a standardized medical cannabis education during training.

The use of medical cannabis is supported by scientific evidence for only a few conditions, such as chronic pain and chemotherapy-induced nausea and vomiting.In addition, two cannabis-based pharmaceuticals have regulatory approval in many countries, namely Nabiximols for spasticity of multiple sclerosis patients,and Epidiolex for refractory seizures.Nevertheless, the lack of quality research due to regulatory restrictions makes it difficult for healthcare professionals to address growing questions by the public.For example, it is important for clinicians to have sufficient knowledge of the interaction between cannabis and the novel coronavirus, SARS-CoV-2 . It has been stated that smoking results in airway inflammation, putting COVID-19 patients at increased risk for severe complications, including cerebrovascular dysfunction.While inhaled cannabis was included in the previous statement, other studies currently in progress are evaluating the potential use of cannabinoids  as an adjunct to antiviral treatments for patients with COVID-19.The COVID-19 pandemic emphasizes the lack of in-depth understanding of the effects of cannabis on the human body and its therapeutic effects. It is integral to bridge this gap in knowledge, which may be possible only with proper training and education of healthcare professionals. Some countries and states that have legalized medical cannabis require general education for recommending providers; however, the standards vary significantly.This often results in superficial counseling for patients.Only a handful of states have established a requirement for licensed professionals to give medical advice. For example, Connecticut requires every dispensary to have a pharmacist on staff.Part of the current gap between public demand and education provided by healthcare providers is in large due to major lack of education at all levels of healthcare.For example, the 2017 National Academies of Sciences, Engineering, and Medicine  Report concluded that medical cannabis is effective for the management of chronic pain in adults.However, the recommendation of medical cannabis to patients has not been widely adopted by physicians.In order to create specific educational recommendations for schools, this gap of education and mixed beliefs within healthcare education needs to be bridged. Therefore, the aim of this study was to analyze the existing literature surrounding the education of medical cannabis in allied health professional training programs worldwide. Additionally, we report the beliefs and views of trainees and faculty surrounding medical cannabis as treatment, as well as the depth of understanding of the therapeutic benefits and potential risks of medical cannabis.

This scoping review on medical cannabis education among medical and allied healthcare trainees was based on online database searches for peer-reviewed publications in English. The research team generated a list of search terms relevant to this topic and modeled after previous studies’ search syntax and keywords.This list was then expanded to include other common terminology and synonyms so that they could be included in the search syntax [see supplementary materials. These terms were used to generate a syntax for searching through PubMed, ERIC, CINAHL, and Web of Science. To expand the scope of this review, relevant “grey literature” was also searched to account for non-published academic material. Finally, the search included all references of the papers selected, as well as any other articles that referenced our selection. This consisted of searching Google Scholar, MedEd, Medline, and Dissertations and Theses section of Proquest using the same search terms. The literature search took place between June 10th, 2020 and July 1st, 2020. The search resulted in a total of 412 articles, which were imported into Covidence for duplicate removals. Two hundred and fourteen duplicate articles were removed, resulting in 198 articles for title and abstract screening. These articles were reviewed independently by two members of the team, who discussed any conflicts that arose concerning their inclusion or exclusion. Of the 198 articles, 167 were deemed out ofscope of this study and were excluded. The remaining 31 articles were then assessed with a full text review, and 8 publications were subsequently excluded. The exclusion criteria consisted of findings that were not based on an empirical study, examined populations outside the scope of this review, or studied substance use or misuse among students. The full text screening was done by multiple members of the research team independently, so that each study was examined by a minimum of three members. The data of the included studies were analyzed, extracted, and categorized by healthcare field, study design, study location, and important outcomes. The process of data search and extraction is presented in a PRISMA diagram in Fig. 1. A summary of the 23 studies that were included for the current analysis is presented in Table 1. The vast majority of studies assessed attitudes, beliefs, and knowledge about medical cannabis among trainees or faculty using a survey that included Likert scales to rate levels of agreement with various statements. In contrast, the 2020 study by Moeller et al. administered a quiz to pharmacy students to determine student knowledge about medical cannabis.

It was also legal in Australia, but narrow qualifying medical conditions meant that very few people were able to access it. In mid- 2018, recreational cannabis was nationally illegal in all four countries. However, in the US, 8 states and DC had legalized cannabis for recreational use; Canada was in the process of implementing the Cannabis Act to legalize recreational cannabis ; and some Australian states had decriminalized possession in small quantities . The main aim of this descriptive study was to examine cannabis use by cigarette smokers in countries with relatively more permissive cannabis policies  versus  less permissive policies  based on laws that were in place at the time of the survey. For example, laws were more permissive in North America with regard to wide medical access in Canada and the US, as well as recreational cannabis legalization in some US states. With regard to tobacco smoking, all four countries had similar cigarette smoking rates . National tobacco control policies  were stronger in Canada, Australia, and England compared to the US, where tobacco control laws varied widely between states. This study also examined cross-country differences among co-users: frequency of cannabis use and of cigarette smoking, relative harm perceptions of smoked cannabis compared to cigarettes, and frequency of smoking cannabis mixed with tobacco among those who reported smoking cannabis.Weighting survey data is one of the major components in survey sampling, and involves attaching a weight to each unit of the selected sample in order to obtain estimates of population parameters of interest. This process essentially incorporates a method of re-balancing the data, in order to more accurately reflect the population. This is especially important for complex survey designs . In the current study, cross-sectional weights were computed for all respondents. A raking algorithm was used to calibrate the weights on smoking status, geographic region, and demographic measures . Finally, the weights were rescaled to sum to the sample size for each country to allow for cross-country comparisons.

This study found significant cross-country differences in patterns of cannabis co-use among cigarette smokers, where smokers from Canada and the US  had higher rates of co-use, daily cannabis use, dual-daily co-use of cannabis and cigarettes, were more likely to smoke cannabis without tobacco,vertical grow systems for sale and believe that smoked cannabis is less harmful than cigarettes than co-users in England and Australia. These findings, obtained during a period of liberalization in many countries, introduce a number of important issues for future research on the impact of cannabis liberalization in general, and on tobacco-cannabis co-use. Currently there is mixed evidence about the effects of cannabis legislation on actual changes in cannabis use, and the majority of the available studies originate from the US . Reviews have shown that cannabis use may increase among adults in locations that have legalized medical  or recreational  cannabis, and a recent large cross-sectional study that examined the population-level impact of recreational cannabis legalization in Canada and across US states in 2018, found that both the prevalence and frequency of cannabis use were higher in US states that have legalized recreational cannabis compared to Canada  and US ‘illegal’ states . Recent national data from Canada  and the US  have shown that adult cannabis use has been increasing where liberalization of cannabis laws has occurred. Some research has also shown that the prevalence of co-use is rising in the US , with higher co-use rates in US states where medical cannabis has been legalized . It is currently unclear however if higher rates of cannabis use, co-use, and/or increases in use are attributable to policy changes, or if studies are detecting pre-existing trends that were in motion prior to liberalization, partly owing to the sophisticated illicit markets in Canada and the US. Moreover, while some studies have examined how cannabis use and co-use patterns may change during the period immediately following a policy change , very little is known about how cannabis liberalization may impact longer-term patterns of tobacco and cannabis co-use. One public health implication to cannabis liberalization is the possibility that increased access to cannabis may weaken, or even reverse, longstanding downward trends in tobacco use. Ongoing, long-term research utilizing longitudinal study designs is critical to further explore the relationship between co-use and liberalization of medical and recreational cannabis. With growing public support and social acceptibility of cannabis in many countries , coupled with cannabis policy liberalization, harm perceptions of cannabis may be impacted. For example, some studies have shown that perceptions of absolute cannabis risks are lower, or have decreased, in jurisdictions that have legalized cannabis , and lower harm perceptions are associated with use and appeal of drugs , including cannabis .

Not much is known about how product regulations may shape or change absolute perceptions about cannabis, and to our knowledge, there are no studies that have compared perceptions of relative risk between smoked cannabis and tobacco, particularily among co-users residing in different cannabis policy environments. A study by Popova et al. found that yong adults in Colorado  perceive combustion-smoking  as more harmful than non-combustible products , but there was nocomparison between cigarettes and smoked cannabis . A qualitative study of young adults has suggested that co-users in Maryland  relate to their use of both substances in different ways, and may underestimate the harms of tobacco use in relation to their cannabis use, as well as underestimate the harms of cannabis use . There is no evidence however if the underestimation of these risks varies between legal and illegal cannabis jusisdictions, as well as between single product users and co-users. While our study cannot determine this, our data do show that co-user’s perceptions of lower relative risk of cannabis compared to cigarettes was substantially more common in Canada and the US. This is worrisome because tobacco smoke and cannabis smoke have been found to contain many of the same carcinogenic chemicals , and some of these harmful constituents  have been found in marijuana smoke at greater concentrations than in tobacco smoke . However, regardless of the harmful constituents within each product, tobacco smoking is more deadly and addictive than cannabis. Tobacco smoking  is attributed to 8 million global deaths each year, and the total annual global economic cost of smoking is estimated to be 1.4 trillion USD . Currently, there is much less evidence about the health effects of cannabis due to its status as a prohibited substance in most jurisdictions. Studies have shown that regular cannabis use is related to important adverse health outcomes including impaired decision making and memory deficits, increased risks of acute injuries, including impaired driving, dose-dependent risk of developing psychotic disorders, and high health care costs . However the scope and magnitude of these risks are substantially less than tobacco, which is a primary risk factor for a wide range of diseases including several non-communicable diseases, and more than a dozen forms of cancer . This study has demonstrated that the majority of co-users, regardless of the cannabis regulatory environment, are smoking cannabis alongside smoking cigarettes. One main difference was that fewer cousers from Canada and the US mixed tobacco with their cannabis compared to co-users in England and Australia.

Research has consistently shown that co-use practices differ by country and region , which our findings also support. Simultaneous use  is more common in European countries  and Australia, while sequential use  is more common in North America . However, in the US specifically, smoking ‘blunts’  is a common and increasing method of cannabis use . Because tobacco is not directly mixed with cannabis, users may not consider this to be simultaneous use , therefore this use pattern could have been underestimated by US co-users in this study. Research suggests that simultaneous use  is associated with greater risk of problematic cannabis dependence, negative cannabisrelated outcomes, lower motivation to reduce tobacco consumption, and lower rates of smoking cessation . On the other hand, it has been found that sequential users use cannabis on more days per month, more cannabis per day, and found that not mixing tobacco with their cannabis to be more pleasurable in comparison to those who mix tobacco with their cannabis . Monitoring unique patterns of both simultaneous and sequential co-use occurring in different regions warrants significant public health attention. Notably however, regardless of couse patterns, nearly one-third of the sample in this study smoked cigarettes and used cannabis daily. While this study is not representative of cannabis-dependent people, there are several smokers who are at much higher risk of the additive effects of co-use. Physicians and other healthcare professionals should be vigilant in identifying co-users and offer tailored treatment, especially for co-users with cannabis dependence, as these users are significantly less likely to quit smoking and problematic cannabis use than those without cannabis dependency . Although this is a large study with representative smokers from four countries, there are some limitations to consider. First, comparing different policy environments is challenging, owing to the diversification of cannabis supply, possession, and use laws, both across and within countries, poor comparisons between national surveys, illicit cannabis markets, and because changing laws are in very early stages . Future research is needed that tackles the difficult challenge of incorporating information about illicit cannabis into analyses of the legal market. Second, the countries included herein were treated as single jurisdictions , which has the potential to mask important sub-national differences. Third, this is a cross-sectional study, therefore temporality issues exist, and causality cannot be determined. Fourth, the sample was limited to adult smokers, so observations may not apply to other populations of interest. Fifth, Canada had not yet officially legalized recreational cannabis at the time of data collection; therefore users would have purchased cannabis illegally or from a legal medical source . Sixth, cannabis use may be underestimated  due to respondents’ reluctance to admit to cannabis use. Finally, four high-income Western countries were included in the analyses presented in this paper; therefore, these results may not apply to other countries.Severe acute respiratory syndrome coronavirus 2  has caused >9.4 million infections and >232,000 deaths in the US as of November 4th, 2020. State governments have enforced social distancing, quarantine, and shelter-in-place policies, thereby sequestering communities and limiting access to medical care.

Although critical for protecting public health, such policies have psychological consequences, including fear, anxiety, depression, and post-traumatic stress symptoms. Further, inability to access healthcare may exacerbate chronic disease symptoms. People using cannabis medically represent one potentially vulnerable population, as many use cannabis for chronic conditions such as chronic pain, cancer, and multiple sclerosis. Although cannabis remains Schedule I under the Controlled Substances Act, use of cannabis medically has increased nationwide – even in states without legal cannabis. Of thirty-three states allowing medical cannabis, mobile grow systems only twenty-three have designated cannabis businesses as essential, allowing them to stay open during shelter-in-place orders. This disruption in cannabis access may potentially cause negative health effects for people using cannabis medically through anxiety about cannabis access, symptom flares, and changes in substance use to compensate for the lack of cannabis. For example, some people intentionally substitute cannabis for other medications due to better symptom management and a favorable side effect profile, so some may re-initiate or increase use of other medications due to decreased cannabis access. Alternately, studies show that individuals using medical cannabis report greater use/misuse of prescription drugs and alcohol than those who do not. This population may thus be at particular risk of increasing substance use to cope with COVID-19-related stressors and lockdown/quarantine policies. We sought to understand how people using cannabis medically are affected by COVID-19, with specific focus on cannabis access and use of other medications and substances . We hypothesized that concern about/decreased access to cannabis would be associated with increased use of medications and substances.Participants  were from 44 states and Washington, DC, with the highest proportions from California , Pennsylvania , Florida , and New York . Ninety-two percent reported current shelter-in-place policies. Consistent with a nationally representative sample of people using medical cannabis, approximately one-third of participants rated their emotional and physical health as poor/fair, one-third good, and one-third very good/excellent . Most  participants used cannabis both medically and recreationally, a proportion similar to that reported among people using cannabis medically vs. medically and recreationally in nationally representative data.