Impacts of recreational cannabis legalization on use and harms: A narrative review of sex/gender differences

Exploring cannabis consumption stigma in Canada with consideration of age and gender differences

Background

Despite cannabis legalization in Canada, stigma towards cannabis consumers remains evident, particularly toward younger cannabis consumers. Our study examined how stigma towards a young cannabis consumer differed by age and gender. Additionally, we explored the impacts of the participants' cannabis consumption, age, and gender identity on their perceptions of stigma.

Methods

Canadian citizens, ages 18 years and older completed an online cross-sectional survey using an experimental vignette design (N = 1,114). Participants were randomly assigned to read one of six vignettes depicting a cannabis consumer that varied by age (14, 21, and 28 years) and gender (man, woman). Participants completed the Social Distance Survey as the dependent measure of stigma. Two factorial ANOVAs were conducted to assess the impacts of the vignette character's age and gender, as well as the participant's age and gender identity, on stigma.

Results

Participants (Mage = 48.42, SD = 16.64) displayed more stigmatizing attitudes towards adolescent consumers (14-years-old) compared to 21-years-old or 28-years-old consumers. Additionally, older participants (70 + years) displayed more stigmatizing attitudes than younger participants (18-29 and 30-39 years old). Finally, participants who had not consumed cannabis within the past 6-months displayed more stigmatizing attitudes than those who reported any cannabis use frequency.

Conclusions

Stigma remains a concern, particularly toward younger cannabis consumers. These findings highlight the importance of developing targeted, early interventions, and education strategies aimed at reducing stigma, especially among those who hold more stigmatizing attitudes, such as non-cannabis consumers and older individuals, which could help mitigate negative outcomes like decreased help-seeking behavior and social isolation.

Impact Statement

Stigma toward cannabis consumers was greatest for younger consumers (14-years-old), followed by 21 and 28-year-olds. Specifically, older generations (70 + year old's) endorsed more stigma compared to younger generations. There were no main effects on stigma toward cannabis consumers based on the vignette character's gender or research participants' gender identity.

Patterns of Cannabis Use among Women With HIV in the United States

Cannabis legalization in the United States changed cannabis product potency and consumption modalities. Women with HIV are an aging population with prevalent cannabis use twice that of national estimates. Because cannabis use may confer both health benefits and risks, it is important to understand cannabis use patterns among women with HIV. This analysis characterized prevalence, frequencies, and modes (smoking, vaping, eating) of cannabis use among 1,246 women with HIV in the Women's Interagency HIV Study over 18 months (2018-2019). We compared participant characteristics using chi-square tests and Wilcoxon rank-sum tests. We illustrated flow between cannabis use frequency categories with a Sankey diagram. Median participant age was 52 years (interquartile range: 46, 58). 65% of participants identified as Black/African American; 50% had annual household incomes <$12,000. The period prevalence was 27% for any cannabis use and 15% for daily or more use. 50% reported varying use frequencies. Among women using cannabis, 96% reported smoking, 30% consumed edibles, and 18% vaped. Compared with women not using cannabis, greater proportions of women using cannabis reported alcohol (69% vs. 37%, p < 0.01), cigarette (61% vs. 29%, p < 0.01) and other drug use (16% vs. 4%, p < 0.01). Compared to those with no high potency use, a higher proportion of women using high potency products were in a state legalizing cannabis sales. Cannabis use among women with HIV is common and of variable frequency. Future work should characterize patterns of use, product choice motivations, and associated health impacts in the context of aging and HIV.

Changes in the Sex/Gender Gap in Cannabis Use in Ontario, Canada From 2001 to 2019

INTRODUCTION

Although cannabis use has been historically higher in men than women, some research suggests a narrowing of the sex/gender gap in recent decades. We characterised trends in cannabis use patterns by sex/gender and examined trends in the sex/gender ratios of cannabis use patterns in Ontario, Canada.

METHODS

Data were drawn from the Centre for Addiction and Mental Health Monitor Survey, a repeated, population-based, cross-sectional telephone survey of adults in Ontario, Canada (2001-2019). Participants provided self-reports of cannabis use during lifetime and cannabis use during the past 12 months. Male-to-female ratios of both outcomes in each year were calculated. Trends in these outcomes were analysed using join point regression.

RESULTS

All outcomes increased among males and females between 2001 and 2019: cannabis use in lifetime (average annual percentage change [AAPC; 95% confidence interval]: 2.0 [0.6-3.3] and 2.9 [1.8-4.0], respectively) and cannabis use during past 12 months (3.5 [2.2-4.9] and 4.7 [2.8-6.6], respectively). The male-to-female ratio of cannabis use during lifetime decreased between 2001 and 2019 (AAPC [95% confidence interval]: -0.7, [-1.0 to -0.4]), unlike cannabis use during past 12 months (-0.5 [-1.8-0.7]).

DISCUSSION AND CONCLUSIONS

Our findings suggest a narrowing of the sex/gender gap in cannabis use. Continued monitoring of the sex/gender gap is important to inform health promotion efforts and guide cannabis policy.

Exploring perceived gender norms about cannabis among treatment-seeking adults in the era of cannabis legalization in Canada: A qualitative analysis

INTRODUCTION

Prevalence of cannabis use has historically been higher among men than among women, yet the past few decades have seen a significant narrowing of this gender gap. The narrowing gender gap is likely attributable to multiple factors, including global and regional shifts in gender norms related to cannabis, which may be influenced by legalization of recreational cannabis use in many countries, including in Canada where the present study took place. The goal of this study was to explore perceived gender norms about cannabis use and how these norms might influence behavior.

METHODS

We conducted in-depth, one-to-one interviews with a sample of 23 adults in Toronto, Ontario, Canada who had been in treatment for cannabis-related harms. We used the Braun & Clarke method of reflexive thematic analysis and a theoretical framework grounded in Connell's masculinities science and more recent critical femininities scholarship to explore perceived gender norms about cannabis. In particular, we were interested in how perceived norms might influence behavior and how an understanding of changing norms can contribute to developing gender-responsive or gender-transformative interventions for cannabis use disorder (CUD).

RESULTS

Our analysis generated three main themes. Masculine Dominance of Cannabis Use demonstrates the social construction of recreational cannabis use (especially smoking cannabis) as a dominant masculine behavior. Cannabis Use as Deviation from Femininity demonstrates how increased stigma and social harms experienced by women and gender-diverse people is accomplished by framing their cannabis use as inauthentic and deviant. Finally, Rejecting and Reconfiguring Gender Norms about Cannabis suggests challenges to masculine dominance of cannabis use and how cannabis legalization may have catalyzed this process (possibly by increasing visibility of women using cannabis).

CONCLUSIONS

Our results suggest that gender continues to play a meaningful role in determining social cannabis norms, though relationships between gender and cannabis norms are clearly changing, possibly in connection to legalization of non-medical cannabis use. We end by discussing implications for treatment (e.g., norm-based interventions to encourage treatment-seeking among men) and public health (e.g., normalizing women's and gender-diverse people's cannabis use may reduce sociocultural harms associated with cannabis use).

Relationship Between Cannabis Dispensary Density, Proximity, and Attitudes Toward Medical Cannabis: A Cross-Sectional Study

Background and Aims

Public attitudes toward medicinal cannabis (MC) remain mixed, particularly in areas with legal access to recreational cannabis (RC). This study aimed to explore the relationship between proximity to cannabis dispensaries, dispensary density, and attitudes toward MC. Specifically, we hypothesized that individuals living closer to cannabis dispensaries or in areas with higher dispensary density would have more negative attitudes toward MC.

Methods

Data were collected through an online survey administered from February to July 2021 and March to May 2022. Respondents' attitudes toward MC were measured using the Medical Cannabis Attitudes Scale (MCAS), and their zip code was used to calculate dispensary density and proximity. Statistical analyses included Spearman's rank-order correlation, ANOVA to assess relationships between attitudes, distance, and density, and a Generalized Least Squares regression analysis to evaluate the relationship between demographic, social, and geographic predictors and MCAS scores.

Results

A total of 935 respondents participated, with 743 residing in zip codes with no dispensaries, 160 in moderate-density zip codes, and 32 in high-density zip codes. A weak positive correlation was found between greater distance from a dispensary and more favorable attitudes toward MC MCAS, r s(933) = 0.090, p < 0.05. However, there was no statistically significant difference in MCAS scores between different density groups (F(2932) = 0.683, p = 0.505). The overall model was significant, F(9918) = 2.62, p = 0.005, with an R 2 of 0.025; gender (p = 0.004), age (p = 0.048) and state legal status (p < 0.001) contributed significantly to the model.

Conclusion

The study provides evidence of a weak positive correlation between distance from cannabis dispensaries and favorable attitudes toward MC, with gender and state legal status contributing to attitudes, while dispensary density did not significantly impact attitudes. However, neither density nor distance from dispensaries contributed to the regression model. These findings suggest that while proximity may influence MC attitudes, the factors impacting attitudes toward MC require further investigation.

Do Medical and Recreational Marijuana State Laws Impact Trends in Postoperative Opioid Prescriptions Among Patients Who Have Undergone TJA?

BACKGROUND

Total joint arthroplasty (TJA) is a painful procedure frequently managed with opioid medication, which puts patients at risk for chronic opioid use. Marijuana is a pain modifier and may be an effector of opioid-use reduction. Recently, many states have legalized the use of medical and recreational marijuana, and these legalization events have correlated with reductions in opioid prescriptions. This trend has not yet been demonstrated in the context of orthopaedic surgery, and there is limited evidence overall investigating the effect of marijuana on perioperative opioid use in TJA.

QUESTION/PURPOSES

(1) Is legalization of medical marijuana associated with changes in perioperative opioid use in patients who have undergone TJA? (2) Is legalization of recreational marijuana associated with changes in perioperative opioid use in patients who have undergone TJA? (3) Are these changes observed in any specific subpopulations of patients who have undergone TJA?

METHODS

The MarketScan Commercial and Medicare Supplemental Claims and Encounters Database was queried to assess the relative effect of marijuana legalization on perioperative opioid use in THA and TKA between May 1, 2017, and September 30, 2021, which was around and after the time that the opioid crisis was declared a public health emergency. We identified 129,132 inpatient TJA procedures (THA = 49,718, TKA = 79,414). The perioperative period was defined as 30 days before surgery and 90 days after surgery. We used the recreational and medical marijuana legalization effective dates in all 50 states and Washington, DC to conduct a difference-in-difference analysis to compare trends of outpatient opioid prescriptions among patients who underwent TJA in states with legalizations of medical or recreational marijuana with those among patients who underwent TJA in states without a change in marijuana legalization status.

RESULTS

We observed no impact of medical marijuana legalization on morphine milligram equivalent (MME)/day (difference-in-difference change 4.38 [95% confidence interval (CI) -4.49 to 13.22]). However, recreational marijuana legalization implementation was associated with an increase in MME/day (difference-in-difference change 8.83 [95% CI 0.22 to 17.43]). When we looked at specific patient groups, the implementations of medical and recreational marijuana laws were both associated with increases in perioperative opioid prescriptions in women, while recreational marijuana legalization was associated with increased opioid use in patients undergoing TKA and patients without prior use of opioids.

CONCLUSION

We did not identify differences with respect to medical marijuana legalization implementation. However, we found that recreational marijuana legalization was associated with an increase in perioperative MME/day for TJA. This is important because surgeons in states with the implementation of recreational marijuana law should be aware of the potential for increased marijuana availability for their patients and how this may impact their postoperative course, particularly with respect to pain and opioid utilization.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The roles of cannabis potency and gender in cannabis dependence and anxiety in recent cannabis users with trauma exposure histories

Over the past 20 years, levels of Δ9-tetrahydrocannabinol (THC) in cannabis have significantly increased, while levels of cannabidiol (CBD) have increased much less in comparison. Cannabis with higher THC potency (commonly assessed via THC:CBD ratio) may increase the risk for cannabis dependence and trigger/exacerbate anxiety. However, few studies of cannabis potency effects on cannabis dependence and anxiety have examined gender moderation. Additionally, there are issues with how cannabis potency is calculated via the THC:CBD ratio that may contribute to inconsistencies in the literature. N = 202 (55.8 % women) recent cannabis users (>1 g in the past month) with trauma histories - a group at high risk for anxiety and cannabis dependence - completed an online survey including a self-report measure of THC and CBD levels in participants' typically-used cannabis product. Cannabis potency was calculated as THC:CBD ratio (THC%/CBD%) and as relative THC proportion (THC%/[THC%+CBD%]). Cannabis dependence and anxiety levels were self-reported on the Cannabis Use Disorder Identification Test-Revised (CUDIT-R) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Consistent with prior findings in the general population, cannabis potency was significantly positively correlated with cannabis dependence, p = .002, and anxiety levels, p = .020, but only when assessed via THC proportion and not THC:CBD ratio. Consistent with prior research, women reported significantly higher anxiety levels but also unexpectedly, higher THC:CBD ratios, than men. No significant gender differences were found in the associations of either potency measure with either outcome variable. Results are consistent with recent reports of gender convergence in cannabis use prevalence. Additionally, these results identify relative THC proportion as a superior predictor of adverse cannabis and anxiety outcomes than the THC:CBD ratio in both men and women.

Sex and gender differences in the Italian forensic psychiatric population: a residences for the execution of security measures study

Although sex and gender differences are well-known in psychiatry, their research in the forensic psychiatric population is still limited. This study is aimed at bridging this gap by examining gender-specific factors and treatment needs among forensic psychiatric patients who are highly dangerous. By retrospectively analyzing data from a 1-year observational study on the Italian Residences for the Execution of Security Measures (REMS) patients (n = 730), we compared the main sociodemographic, clinical, and criminological variables between n = 80 female and n = 650 male patients. Female offenders exhibited a higher prevalence of personality (p < 0.001) and depressive disorders (p < 0.001), as well as more severe crimes leading to REMS admission, notably homicide or attempted homicide (p < 0.05). Furthermore, female offenders had a less frequent history of substance abuse (p < 0.001) than male offenders. Despite these differences, there was no evidence of gender-based differences in different sociodemographic and clinical parameters. This study highlights gender differences in forensic psychiatric patients and underscores the importance of nuanced assessment for implementing tailored interventions in forensic psychiatric care.

Changes in the incidence of cannabis-related disorders after the Cannabis Act and the COVID-19 pandemic in Québec, Canada

BACKGROUND

The Canadian Cannabis Act (CCA, implemented in October 2018) and the COVID-19 pandemic (April 2020) might have contributed to cannabis-related harms in Québec, known for its stringent cannabis legal framework. We explored changes in incidence rates of cannabis-related disorders (CRD) diagnoses associated with these events in Québec.

METHODS

We utilized linked administrative health data to identify individuals aged 15 year+ newly diagnosed with CRD during hospitalizations, emergency, and outpatients clinics across Québec, from January 2010 and March 2022 (147 months). Interrupted time-series analyses (ITSA) assessed differences (as percentage changes) in sex- and age-standardized, and sex-stratified, monthly incidence rates (per 100,000 population) attributed to the CCA and the COVID-19 pandemic, compared to counterfactual scenarios where pre-events trends would continue unchanged.

RESULTS

The overall monthly mean rates of incident diagnoses nearly doubled from the pre-CCA period (1.56 per 100,000 population) to the COVID-19 pandemic period (3.02 per 100,000 population). ITSA revealed no statistically significant level or slope changes between adjacent study periods, except for a decrease in the slope of incidence rates among males by 1.84 % (95 % CI -3.41 to -0.24) during the COVID-19 pandemic compared to the post-CCA period. During the post-CCA period, the trends of incidence rates in the general and male populations grew significantly by 1.22 % (95 % CI 0.08 to 2.35) and 1.44 % (0.04 to 2.84) per month, respectively. Similarly significant increases were observed for the general and female populations during the COVID-19 pandemic, with monthly rates rising by 1.43 % (95 % CI 0.75 to 2.12) and 1.75 % (95 % CI 0.13 to 3.37), respectively. These increases more than doubled pre-CCA rates.

CONCLUSIONS

The incidence rates of CRD diagnoses across Québec appears to have increased following the implementation of the CCA and during the COVID-19 pandemic. Our findings echo public health concerns regarding potential cannabis-related harms and are consistent with previous Canadian studies.

Effects of sexual assault vs. other traumatic experiences on emotional and cannabis use outcomes in regular cannabis users with trauma histories: moderation by gender?

Introduction

While sexual assault may have particularly adverse emotional effects compared with other forms of trauma, it remains unclear which emotional outcome dimensions are impacted, whether cannabis outcomes are similarly impacted, and whether gender differences exist in sexual assault's links with these outcomes.

Methods

N = 100 cannabis users with trauma histories (M age = 33.1) completed standardized measures of demographics, trauma exposure, posttraumatic stress (PTS) and depressive symptoms, hopelessness, and cannabis outcomes (frequency, medicinal prescription, motives, and craving).

Results

Sexual assault was experienced more often by women (83.9%) than men (31.8%). A series of 2 × 2 analyses of variance [gender: women (n = 56) vs. men (n = 44) × trauma type: sexual assault (n = 61) vs. other (n = 39)] and logistic regression revealed that sexual assault survivors scored higher than other trauma survivors on re-experiencing and hyperarousal PTS symptoms (DSM-5 Clusters B and E), cognitive depressive symptoms, hopelessness, cannabis use frequency, medicinal cannabis prescription, cannabis use to cope with psychological symptoms, and compulsivity craving; and lower on social and enhancement cannabis use motives. In terms of gender main effects, women scored higher than men on cannabis use to cope with negative emotions. In terms of interactions for PTS Cluster D symptoms (negative alterations in mood/cognitions), among men only, sexual assault survivors scored higher than other trauma survivors; and for cannabis enhancement motives and purposefulness cannabis craving, among sexual assault survivors only, women scored higher than men.

Discussion

Across many different trauma, women survivors' use of cannabis to cope with negative affect should be a specific therapeutic focus. Moreover, we identified specific emotional and cannabis use outcomes that should be of specific clinical concern among sexual assault survivors regardless of gender. Finally, in terms of gender differences of clinical interest among sexual assault survivors, while PTS Cluster D symptoms should be specific treatment targets in men, cannabis enhancement motives and purposefulness craving should be treatment targets in women.

Predicting Maternal and Infant Tetrahydrocannabinol Exposure in Lactating Cannabis Users: A Physiologically Based Pharmacokinetic Modeling Approach

A knowledge gap exists in infant tetrahydrocannabinol (THC) data to guide breastfeeding recommendations for mothers who use cannabis. In the present study, a paired lactation and infant physiologically based pharmacokinetic (PBPK) model was developed and verified. The verified model was used to simulate one hundred virtual lactating mothers (mean age: 28 years, body weight: 78 kg) who smoked 0.32 g of cannabis containing 14.14% THC, either once or multiple times. The simulated breastfeeding conditions included one-hour post smoking and subsequently every three hours. The mean peak concentration (Cmax) and area under the concentration-time curve (AUC(0-24 h)) for breastmilk were higher than in plasma (Cmax: 155 vs. 69.9 ng/mL; AUC(0-24 h): 924.9 vs. 273.4 ng·hr/mL) with a milk-to-plasma AUC ratio of 3.3. The predicted relative infant dose ranged from 0.34% to 0.88% for infants consuming THC-containing breastmilk between birth and 12 months. However, the mother-to-infant plasma AUC(0-24 h) ratio increased up to three-fold (3.4-3.6) with increased maternal cannabis smoking up to six times. Our study demonstrated the successful development and application of a lactation and infant PBPK model for exploring THC exposure in infants, and the results can potentially inform breastfeeding recommendations.