How has non-medical cannabis legalization served the health and welfare of under-age (adolescent) youth in Canada?

Cannabis is the most commonly used non-legal drug, especially among young people. In 2018, Canada implemented the legalization of non-medical cannabis use and supply for adults.1Fischer B. Jutras-Aswad D. Hall W. Outcomes associated with nonmedical cannabis legalization policy in Canada: taking stock at the 5-year mark.CMAJ. 2023; 195: E1351-E1353Crossref PubMed Scopus (4) Google Scholar This policy reform was framed by multiple primary objectives, which included improved public health, public safety and youth protection, specifically pledging to "keep cannabis out of the hands of youth". Under the formal legalization umbrella ('Cannabis Act'), cannabis may be legally accessed and used by adults ages 19-and-up in most provinces (with Alberta 18 years and Quebec 21 years for exceptions).1Fischer B. Jutras-Aswad D. Hall W. Outcomes associated with nonmedical cannabis legalization policy in Canada: taking stock at the 5-year mark.CMAJ. 2023; 195: E1351-E1353Crossref PubMed Scopus (4) Google Scholar While extensive youth cannabis prevention and education campaigns have been launched, underage youth may be criminally charged for possession of small (>5 g) of dried cannabis or equivalents. Underage (adolescent) youth are a distinctly important and vulnerable group for cannabis-related risks for several reasons. First, Canadian cannabis use rates traditionally have been high (e.g., 25–45% among ages 16–17). Second, adolescents, beyond general substance use-related susceptibilities, are well-documented to be at elevated risk for severe adverse (e.g., cognitive, mental health, psycho-social) health outcomes especially from intensive (e.g., frequent/high-potency) and/or long-term cannabis use.2Lorenzetti V. Hoch E. Hall W. Adolescent cannabis use, cognition, brain health and educational outcomes: a review of the evidence.Eur Neuropsychopharmacol. 2020; 36: 169-180Crossref PubMed Scopus (69) Google Scholar On this basis, it has been questioned how well legalization policy and its implications would serve the health and welfare of underage youth, or how to best design it with these essential good interests in mind. More than 5-years following the implementation of legalization policy in Canada, select—while limited—empirical data document main cannabis-related outcomes for adolescents in health and socio-legal domains. For key examples, in the national Canadian Cannabis Survey (CCS), the prevalence of cannabis use (in the past 12-months) among ages 16–19 years increased from 36% in 2018 to 43% in 2023.3Government of CanadaCanadian Cannabis Survey 2023: summary of results.https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2023-summary.htmlDate: 2024Date accessed: April 7, 2024Google Scholar Somewhat differently, general cannabis use prevalence among secondary students (grades 7–12) remained steady in the national Canadian Student Tobacco, Alcohol and Drugs Survey (18% in both the 2018/19 43: 764-774Crossref PubMed Scopus (0) Google Scholar Among under-age youth in Alberta (<18 years) and Ontario (<19 years), legalization was associated with a 20% increase-equivalent (2015–2019) for emergency department visits involving cannabis-related disorder/poisoning, and there were (moderate) increases in cannabis-related (e.g., for psychosis, poisoning, withdrawal, harmful use) hospitalizations among young individuals (ages 15–24) in Canada's four largest provinces, specifically during legalization's 'commercialization' (2020–2021) compared with the pre-legalization (2015–2018) period.7Callaghan R.C. Sanches M. Vander Heiden J. Kish S.J. Impact of Canada's cannabis legalisation on youth emergency department visits for cannabis-related disorders and poisoning in Ontario and Alberta, 2015–2019.Drug Alcohol Rev. 2023; 42: 1104-1113Crossref PubMed Scopus (3) Google Scholar,8Myran D.T. Gaudreault A. Konikoff L. Talarico R. Liccardo Pacula R. Changes in cannabis-attributable hospitalizations following nonmedical cannabis legalization in Canada.JAMA Netw Open. 2023; 6e2336113https://doi.org/10.1001/jamanetworkopen.2023.36113Crossref Scopus (3) Google Scholar For essential socio-legal outcomes, the CCS found that among adolescent cannabis users, 41% usually obtained their cannabis from "legal purchases" (e.g., legal store/website) and 43% from "social sources" (e.g., family/friends) while with almost none reporting (1%) "illegal" sourcing activities by 2023.3Government of CanadaCanadian Cannabis Survey 2023: summary of results.https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2023-summary.htmlDate: 2024Date accessed: April 7, 2024Google Scholar While the annual prevalence of driving immediately (i.e. within 1 hour) following cannabis use among Ontario adolescents (holding a driver's license) majorly declined from 19.9% in 2001 to 6.8% in 2019, no changes were associated with the implementation of legalization.9Imtiaz S. Nigatu Y.T. Ali F. et al.Cannabis legalization and driving under the influence of cannabis and driving under the influence of alcohol among adult and adolescent drivers in Ontario, Canada (2001–2019).Drug Alcohol Depend. 2024; 255: 111060https://doi.org/10.1016/j.drugalcdep.2023.111060Crossref PubMed Scopus (0) Google Scholar Police-enforced cannabis offenses among adolescents (12–17 years) significantly decreased (from 32,000 to 2,508 among male adolescents and from 8,971 to 558 among female adolescents from pre- (2015–2018) to post-legalization (2018–2021) periods.10Callaghan R.C. Sanches M. Hathaway A. Asbridge M. MacDonald M. Kish S.J. Canada's cannabis legalization and police-reported cannabis-related criminal incidents among youth, 2015–2021.Drug Alcohol Depend. 2023; : 109892https://doi.org/10.1016/j.drugalcdep.2023.109892Crossref PubMed Scopus (3) Google Scholar Yet, despite similar declines, cannabis possession (i.e., use-related) incidents (adolescent males: 29,015/1603; adolescent females: 8377/367) remained as the respective relative majorities of enforced cannabis offenses in the post-legalization period.10Callaghan R.C. Sanches M. Hathaway A. Asbridge M. MacDonald M. Kish S.J. Canada's cannabis legalization and police-reported cannabis-related criminal incidents among youth, 2015–2021.Drug Alcohol Depend. 2023; : 109892https://doi.org/10.1016/j.drugalcdep.2023.109892Crossref PubMed Scopus (3) Google Scholar Despite a supposed general 'ban' on cannabis-related advertisement especially for youth protection, almost two-thirds (63%) of Canadian adolescents reported exposure to cannabis-related advertisements or promotions in 2023.3Government of CanadaCanadian Cannabis Survey 2023: summary of results.https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2023-summary.htmlDate: 2024Date accessed: April 7, 2024Google Scholar Half-a-decade into legalization and its consequential 'normalization' environment for cannabis, we observe a mixed picture of developments for main outcome indicators among underage/adolescent youth in Canada. While cannabis use rates have remained steady at best at comparably high levels, selected adverse cannabis-related health outcomes (e.g., hospitalizations), and some risk-behaviors have increased. With exposure to cannabis commercialization common, adolescents' cannabis sourcing practices have shifted from predominantly 'illegal' to 'legal' (albeit so only for adults) and 'grey' (e.g., 'social') sources. Cannabis-related enforcement has been markedly reduced; however, cannabis (possession) offenses remain disproportionately enforced against underage individuals, for whom related adverse consequences (e.g., punishment, record-entries, stigma) may be particularly severe. The—widely promoted—objective of effective cannabis access and use reduction for this particular age group has not been achieved through legalization. The mixed results for Canada are generally similar to those observed in US-based legalization settings.11Hammond C.J. Chaney A. Hendrickson B. Sharma P. Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates.Int Rev Psychiatry. 2020; 32: 221-234Crossref PubMed Scopus (90) Google Scholar We infer that the overall evaluation of Canadian cannabis legalization's impact for underage/adolescent youth as arguably the most vulnerable and important group of concern crucially depends on how developments for variably increasing health-related problems are weighted against substantive socio-legal benefit outcomes.11Hammond C.J. Chaney A. Hendrickson B. Sharma P. Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates.Int Rev Psychiatry. 2020; 32: 221-234Crossref PubMed Scopus (90) Google Scholar Also following the observations of a recent review of the 'Cannabis Act', there is tangible need and opportunity for adjustments to Canada's legalization policy parameters towards better serving adolescents' health and welfare.1Fischer B. Jutras-Aswad D. Hall W. Outcomes associated with nonmedical cannabis legalization policy in Canada: taking stock at the 5-year mark.CMAJ. 2023; 195: E1351-E1353Crossref PubMed Scopus (4) Google Scholar,12Government of CanadaLegislative review of the Cannabis Act. Final report of the expert panel.https://www.canada.ca/en/health-canada/services/publications/drugs-medication/legislative-review-cannabis-act-final-report-expert-panel.html#a1Date accessed: April 25, 2024Google Scholar Related efforts should include comprehensive evidence-based (e.g., prevention) measures to lower the continuously high (and high-risk) cannabis use rates among adolescents, while better shielding them from—direct or indirect—access to cannabis products legal for adults and specifically the adverse fallouts (e.g., promotion/advertisement) from cannabis commercialization. At the same time, we categorically recommend against the criminalization of adolescent cannabis use due to excessive adverse consequences especially in the present 'normalization' contexts. These insights should be helpful also to other jurisdictions contemplating cannabis legalization policy development with adolescents' interests in mind. BF developed the concept for the article; all authors collected and interpreted related data for the study. BF led the manuscript writing; DJA and TR edited and revised the manuscript for substantive intellectual content. Dr. Fischer and Dr. Jutras-Aswad have held research grants and contracts in the areas of substance use, health, policy from public funding and government organizations (i.e., public-only sources) in the last five years; Dr. Fischer was temporarily employed as a Research Scientist by Health Canada (2021–2022). Dr. Jutras-Aswad had received study materials (oral cannabidiol and inhaled cannabidiol and THC) for publicly funded clinical trials examining the behavioral, cognitive and biological effects of cannabinoids. He has not been employed, has not owned any stocks nor has received honoraria or other payments from Cardiol Therapeutics and/or Exka. Mrs. Robinson has no competing interests to declare. Funding: Dr. Fischer acknowledges a research fellowship from the Max-Planck-Society, Germany. Jutras-Aswad acknowledges a clinical scientist career award from Fonds de Recherche du Québec (FRQS). This present study was not supported by any specific sponsor or funder.