Knowledge about the health effects of cannabis before and after ‘recreational’ cannabis legalization in Canada: Findings from the International Cannabis Policy Study, 2018 – 2024

Knowledge about the health effects of cannabis before and after ‘recreational’ cannabis legalization in Canada: Findings from the International Cannabis Policy Study, 2018 – 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge about the health effects of cannabis before and after ‘recreational’ cannabis legalization in Canada: Findings from the International Cannabis Policy Study, 2018 – 2024 Wilson Tong, David Hammond This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7602619/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background To date, few studies have examined the impact of legalization on important psychosocial predictors of cannabis consumption, including risk perceptions. This study addresses this gap by analyzing trends in knowledge of health effects of cannabis consumption following the legalization of recreational cannabis in Canada. Methods Data were collected from repeated cross-sectional national surveys conducted in the year prior to legalization of ‘recreational’ cannabis in Canada (2018), and five years post-legalization (2019–2023) among 93,933 respondents aged 16–65. Regression models examined differences pre vs. post-legalization in health knowledge, assessed as agreement with each of 7 health effects from cannabis and a composite Health Knowledge Index, adjusting for cannabis consumption, mental health history, and sociodemographics. Results Across all years, agreement was highest for the risks of impaired driving (79–81%) and lowest for psychosis and schizophrenia risk (34–38%). Health knowledge was highest among non-consumers, those without mental illness history, and youth aged 16–25 (p < .001, all contrasts). No changes were observed in the Health Knowledge Index pre vs post-legalization; however, modest increases were observed for harms during pregnancy or breastfeeding (p < .001), cannabis addiction (p < .001), risk of psychosis and schizophrenia (p < .001), and teen consumption (p < .001). Conclusions Overall, only modest differences in knowledge of cannabis health effects were observed in the 5 years following cannabis legalization in Canada; however, persistent gaps in health knowledge persisted, particularly among frequent consumers. health knowledge risk perception cannabis Canada legalization Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 BACKGROUND After more than 90 years of prohibition, legalization of recreation cannabis in Canada in 2018 marked a significant shift in federal drug policy, with broad implications for criminal justice and public health ( 1 ). Cannabis legalization also has the potential to impact psychosocial predictors of cannabis consumption, including risk perceptions and health knowledge. Health knowledge encompasses the perceptions and attitudes individuals hold about the health benefits and risks of a substance, which are influenced by personal experiences, societal norms, and public health messaging ( 2 , 3 ). Health knowledge is a central feature of health behaviour models and has important influence on substance use, as illustrated by the vast literature on tobacco use ( 3 – 7 ). Research on tobacco control policies over the past century has demonstrated that increasing strict regulations can increase risk perceptions and decrease tobacco use ( 7 ). Cannabis legalization presents a unique opportunity to examine if the reverse is also true: whether more permissive laws and policies decrease perceptions of risk. Cannabis risk perceptions are inversely associated with consumption and future susceptibility to consume cannabis ( 8 )( 9 ). The association between risk perception and consumption is bi-directional: lower perceptions of risk increase the likelihood of future consumption, whereas frequent consumption can undermine risk perceptions as a result of defensive avoidance and optimism bias ( 10 – 12 ) ( 13 ). To date, few studies have assessed the impact of cannabis legalization on risk perceptions and health knowledge. Nationally representative monitoring surveys observed increased health knowledge between 2018 and 2023 for beliefs about cannabis addictiveness, with decreases observed for beliefs about the risks of cannabis consumption during pregnancy, teenage consumption, harmfulness of cannabis, and association with mental health problems,( 14 ). Surveys conducted among Canadian youth found no immediate changes in risk perceptions among young adults two months after legalization ( 15 ). Several studies have examined risk perceptions following state-level changes in cannabis laws, with mixed findings. National surveys conducted with high school students indicate a decline in risk perceptions for cannabis between 1991 and 2006, which includes the period in which several states legalized medical cannabis consumption and the earliest states to adapt recreational legalization ( 16 ). However, most pre-post studies in states that have legalized cannabis show little or no effect. For example, no differences in risk perceptions were observed among youth and young adults before and after medical cannabis legalization in Massachusetts, similar to null findings before and after recreational cannabis legalization in Colorado, and in difference-in-differences models examining cannabis laws across 22 states ( 17 – 19 ). Mixed findings have also been observed in studies that examined changes in risk perceptions before and after ‘recreational’ legalization in Washington State ( 19 – 22 ). Interpreting state-level differences is complicated by pre-existing differences between states that did and did not implemented cannabis legalization ( 22 , 23 ). As such, the impact of legalization on risk perceptions of cannabis consumption remains unclear ( 24 ). Reductions in perceived risks—and potential increases in cannabis consumption among youth—was among the public health concerns identified in the lead up to legalization in Canada ( 25 ). In addition to speculation that legalization would undermine risk perceptions, there were specific concerns about the impact of commercializing the cannabis market and the impact of industry marketing. Decades of research in tobacco control demonstrated that the positive imagery conveyed in industry marketing was highly effective in increasing social norms and decreasing perceptions of risk, both of which are key mediators in the causal effect of tobacco marketing on youth smoking ( 26 ). Conversely, legalization provides new opportunities for conveying information on the risks of cannabis consumption. Most notably, licensed cannabis products in Canada are mandated to display health warning labels on packages. Packaging must display a series of ‘rotating’ warnings which convey different messages, including the effects of cannabis on mental health, among young people, and impaired driving ( 27 ). Literature reviews of health warnings on tobacco products has demonstrated that comprehensive warnings are effective in increasing knowledge of specific health effects and risk perceptions more generally ( 28 , 29 ). Emerging research on health warnings for cannabis is generally consistent with the literature on tobacco products, but at a relatively early stage, with few population-level studies to date ( 13 , 14 , 29 , 30 ). Recall of cannabis health warnings has increased since legalization, particularly among frequent consumers ( 31 ), however, it is unclear how these effects may translate into population-level indicators of health knowledge. Overall, while there are strong conceptual grounds to suggest that specific regulatory measures may impact perceptions of risk as part of a broader legal framework, this area is largely unexplored. Overall, cannabis legalization has potential to influence a key predictor of cannabis consumption among youth and adults; however, research to date includes few pre-post research designs and is predominantly focussed on risk perceptions among young people, with a lack of studies among the general adult population This represents an important evidence gap given that cannabis consumption in older adults has been increasing and potentially different risk profile compared to younger cohorts ( 32 – 36 ). In addition, most studies have assessed general perception of risk or harm, rather than specific health beliefs. This is notable because many of the risk communications in Canada and other legal markets convey specific health effects as part of mandated warning labels on products and through mass media campaigns targeting impaired driving or use among young people. The current study sought to examine changes in population-level knowledge of the health effects of cannabis before and in the 5-years following legalization in Canada. The study also examined potential differences in the knowledge of health risks of cannabis consumption by frequency of cannabis consumption, mental health status, age, educational attainment, and income adequacy. METHODS Data are from Waves 1–6 of the Canadian component of the International Cannabis Policy Study (ICPS). National online surveys were conducted annually between 2018 and 2023 with respondents aged 16–65. Respondents were sampled through the Nielsen Consumer Insights Global Panel and partner panels. The Nielsen panels are recruited using a variety of probability and non-probability sampling methods. For the ICPS surveys, Nielsen draws stratified random samples from online panels, with quotas based on age and state/province of residence. Upon completion, respondents receive remuneration in accordance with their panel’s usual incentive structure. Monetary incentives have been shown to increase response rates and decrease response bias in subgroups under-represented in surveys, including disadvantaged subgroups. The cooperation rate, which was calculated based on AAPOR Cooperation Rate #2 as the percentage of respondents who completed the survey of eligible respondents those who accessed the survey link, ranged between 53.8% to 64.2% across the six survey waves. Surveys were conducted in English or French, with a median survey time ranging between 20 to 23 minutes across years. Respondents provided consent prior to completing the survey. Respondents received remuneration in accordance with their panel’s usual incentive structure (e.g., points based or monetary rewards, chances to win prizes). A full description of the study methods can be found in the ICPS Technical Reports www.cannnabisproject.ca/methods and methodology paper (37). Measures All survey measures are publicly accessible on the ICPS website https://cannabisproject.ca/publications/ Health knowledge — Knowledge of the health effects of cannabis was assessed using measures of agreement with a list of seven health effects, with the response options “yes”, “no”, “maybe”. Six health effects were selected based on systematic reviews of health effects and those featuring in mandated health warnings under the Cannabis Act (27, 38). In addition, one “false” health belief question that was included for which there is no clear evidence: “Can using marijuana cause diabetes?”. Verbatim wording for the health knowledge questions is included in Supplemental Table 4. An index variable was created by summing the number of correct responses across the seven items included in all years, called the Health Knowledge Index (range 0–14). Responses that were “true” health statements were coded as “Correct” if respondents selected “Yes”, while responses to “false” health statements were coded as “Correct” if respondents selected “No”. Correct responses had a value of 2, while “Maybe /Don’t Know” and incorrect responses had values of 1 and 0, respectively. Sociodemographics — Respondents provided sociodemographic information, including sex at birth, age, ethnicity/race, highest education level, and perceived income adequacy. Age was classified into five categories: 16–25, 26–35, 36–45, 46–55, and 56–65. Ethnicity/race was classified with Canadian-specific measures drawn from the census or benchmark health surveys. Income adequacy was assessed by asking respondents, “Thinking about your family’s income, how difficult or easy is it to make ends meet?”, to which responses ranged on a 5-point Likert scale from very difficult to very easy (39). Cannabis consumption — Respondents were classified into six categories based on the status of cannabis consumption: Never consumed, consumed more than 1 month ago, monthly/weekly consumption, daily/almost daily consumption (≥ 5 days per week). Mental health status — Mental health status was assessed by measuring whether respondents had been diagnosed with any of the mental health conditions in a provided list (see Supplemental Table 5). Responses were classified into 3 categories (No; Yes; Not stated – including Refuse to Answer and Don’t Know responses). Noticing of cannabis product health warnings, advertisements, and education campaigns — Population-level health communication campaigns have the potential to influence health knowledge, three of which were assessed in the current study. First, noticing of cannabis product health warnings was assessed using the question “In the past 12 months, have you seen health warnings on marijuana products or packages?”, with responses classified as (Yes, No, Not applicable – I have not seen any marijuana products or packages, Don’t know, Refuse to answer) (30). Noticing cannabis advertising from any of sixteen channels was assessed using a derived version of the question “In the past 12 months, have you noticed marijuana being advertised or promoted in any of the following places?”, with responses classified as (Yes, No, Don’t know, Refuse to answer) (40). Noticing cannabis education campaigns from any of eighteen channels was assessed using a derived version the question “In the past 12 months, have you noticed education campaigns or public health messages about marijuana in any of the following places?”, with responses classified as (Yes, No, Don’t know, Refuse to answer). All measures are shown in Supplemental Table 6. Analysis A total of 93,933 respondents completed ICPS surveys between 2018 to 2023. The current analysis consisted of a sub-sample of 92,365 after excluding 1,568 respondents who refused to answer any questions on noticing cannabis product health warnings, advertisements, educational campaigns or any health knowledge questions. All analyses present weighted data. Post-stratification sample weights based on sex, age, region, education, race and consumption status were constructed based on the Canadian Census estimates and a raking algorithm applied to the original samples; see the Technical Reports for details ( http://cannabisproject.ca/methods/ ). Weights were rescaled to the unweighted analytic sample size within each wave. Separate logistic regression models were run for each of the seven health belief questions. Models were run in two steps. First, “unadjusted” models included only the indicator variable for survey year to examine trends over time. Second, “adjusted” models were run, which included the following covariates: survey year, cannabis consumption status, mental health diagnosis, age, sex, education, ethnicity, income adequacy. Sensitivity analyses run for each of the seven health beliefs, in which each health belief question was analyzed as a 3-level variable (“Maybe”/”Don’t know” was analyzed as a separate category from “No” responses) showed the same general pattern of significance as the main models. Odds ratios (AORs) and 95% confidence intervals (CIs) are shown. Analyses were conducted using survey procedures in SAS 8.4. A linear regression model was run to examine changes in the Health Knowledge Index (range = 0–14; higher scores indicate more correct responses). Unadjusted and adjusted models were run, as described above. In an additional step, the three policy-related variables were added to the adjusted models: noticing cannabis health warnings (Yes; No; Don’t Know; Not applicable; Refuse to Answer), noticing cannabis advertisements (Noticed no ads; Noticed an ad in at least 1 channel ; Don’t Know), and noticing of public health campaigns (Noticed no education campaigns/public health messages, Noticed an education campaign/public health message in at least 1 channel; Don’t Know). RESULTS Sample characteristics As Table 1 shows, the sample included approximately equal proportions in each age group and females/males. A majority of respondents were White and held a bachelor's degree or higher, and most respondents had consumed cannabis at least once in their lifetime. Table 1 Weighted sample characteristics (n = 92365) Characteristic 2018 (n = 9954) 2019 (n = 15007) 2020 (n = 15531) 2021 (n = 16683) 2022 (n = 15650) 2023 (n = 19540) Total (n = 92365) Age 16–25 years 18.8% (1875) 18.5% (2782) 18.5% (2873) 18.2% (3028) 18.5% (2900) 18% (3516) 18.4% (16974) 26–35 years 20.6% (2052) 20.6% (3093) 20.8% (3232) 21.0% (3501) 21.0% (3289) 21.3% (4156) 20.9% (19323) 36–45 years 19.4% (1934) 19.8% (2978) 20.0% (3099) 20.3% (3382) 20.4% (3199) 20.6% (4024) 20.2% (18615) 46–55 years 21.1% (2176) 20.1% (3010) 19.6% (3043) 19.3% (3224) 19.0% (2968) 19.1% (3735) 19.6% (18069) 56–65 years 20.1% (2090) 21.0% (3145) 21.1% (3285) 21.3% (3548) 21.0% (3293) 21.0% (4109) 21% (19384) Sex at Birth Female 50.0% (4977) 49.9% (7487) 50.1% (7775) 49.9% (8326) 49.9% (7808) 50.0% (9776) 50.0% (46149) Male 50.0% (4977) 50.1% (7520) 49.9% (7756) 50.1% (8357) 50.1% (7842) 50.0% (9764) 50.0% (46216) Ethnicity White only 77.5% (7716) 73.6% (11046) 72% (11109) 68.4% (11415) 67.5% (10567) 66.9% (13064) 70.3% (64916) East/South East Asian only 8.5% (842) 7.7% (1163) 9.1% (1409) 8.5% (1426) 8.8% (1383) 9.1% (1782) 8.7% (8004) Mixed/Other/Unstated 3.8% (382) 6.8% (1018) 6.8% (1052) 7.3% (1212) 7.5% (1177) 7.4% (1451) 6.8% (6291) South Asian only 3.1% (305) 3.2% (479) 3.7% (580) 4.4% (730) 4.6% (719) 5.5% (1070) 4.2% (3882) Black only 1.6% (156) 3.6% (545) 3.5% (543) 4.0% (668) 5.0% (775) 5.0% (979) 4.0% (3665) Indigenous only 3.7% (367) 2.3% (347) 1.8% (285) 2.6% (441) 2.4% (371) 2.4% (468) 2.5% (2278) Latino only 0.9% (88) 1.5% (219) 1.8% (278) 2.8% (468) 2.1% (328) 1.6% (321) 1.8% (1700) Middle Eastern only 1.0% (99) 1.3% (192) 1.8% (276) 1.9% (324) 2.1% (331) 2.1% (406) 1.8% (1627) Income Adequacy Very difficult 8.2% (815) 9.6% (1434) 7.5% (1167) 8.7% (1459) 10.2% (1604) 12.1% (2357) 9.6% (8834) Difficult 20.1% (2001) 22.4% (3354) 18.5% (2869) 19.0% (3175) 22.1% (3459) 23.6% (4614) 21.1% (19473) Neither easy nor difficult 36.0% (3583) 35.1% (5260) 37.5% (5821) 35.1% (5858) 34.1% (5341) 33.8% (6599) 35.1% (32461) Easy 21.2% (2112) 19.8% (2967) 22.1% (3437) 21.5% (3584) 20.1% (3146) 18.8% (3671) 20.5% (18918) Very easy 11.2% (1118) 9.6% (1444) 10.8% (1674) 12.1% (2020) 10.1% (1585) 9.1% (1776) 10.4% (9617) Not stated* 3.3% (325) 3.6% (547) 3.6% (562) 3.5% (588) 3.3% (516) 2.7% (524) 3.3% (3062) Education Less than high school 15.3% (1524) 15.4% (2309) 15.2% (2358) 15.2% (2541) 13.3% (2076) 13.5% (2609) 14.5% (13417) High school diploma or equivalent 26.7% (2656) 26.5% (3976) 26.5% (4112) 26.4% (4405) 26.1% (4079) 25.9% (5062) 26.3% (24290) Bachelor's degree or higher 57.4% (5712) 57.2% (8586) 57.3% (8895) 57.4% (9568) 59.6% (9324) 59.7% (11665) 58.2% (53749) Not stated 0.6% (62) 0.9% (136) 1.1% (166) 1.0% (170) 1.1% (170) 1.0% (205) 1.0% (909) Mental Health Diagnosis No 72.6% (7223) 61.0% (9155) 60.3% (9362) 57.6% (9605) 56.4% (8832) 57.7% (11280) 60.0% (55457) Yes 26.2% (2603) 34.9% (5236) 34.3% (5331) 36.6% (6113) 37.9% (5924) 37.4% (7317) 35.2% (32525) Not stated* 1.3% (128) 4.1% (615) 5.4% (838) 5.8% (965) 5.7% (895) 4.8% (942) 4.7% (4383) Cannabis Consumption Never consumed 43.7% (4345) 38.3% (5741) 39.5% (6133) 38.0% (6343) 38.5% (6027) 38.3% (7476) 39.0% (36066) Consumed more than 1 month ago 37.8% (3758) 38.3% (5748) 37.1% (5757) 35.3% (5885) 36.6% (5732) 36.5% (7128) 36.8% (34008) Monthly/Weekly consumption 9.8% (972) 12.4% (1862) 11.9% (1841) 13.2% (2195) 13.0% (2031) 13.0% (2545) 12.4% (11446) Daily/almost daily consumption 8.8% (879) 11.0% (1657) 11.6% (1800) 13.5% (2259) 11.9% (1859) 12.2% (2391) 11.7% (10845) *Includes “Refuse to answer” & “Don’t Know” responses [INSERT Table 1] Knowledge of individual health effects Figure 1 shows levels of agreement for each of the 7 health effects, by year. Differences in health knowledge observed by cannabis consumption status are shown in Figs. 2.1 –2.7. Across all years, health knowledge was highest for beliefs about driving impairment and consumption during pregnancy and breastfeeding, and lowest for beliefs about risk of psychosis and schizophrenia and diabetes from marijuana use. (See Supplemental Table 2 for responses by survey year and frequency of cannabis consumption.) [INSERT FIGURE 1] [INSERT FIGURE 2.1 –2.7] Supplemental Tables 3.1 to 3.7 show unadjusted and adjusted models testing changes over time for each health belief. Knowledge levels were lower in 2023 compared to 2018 for the effects of marijuana consumption during pregnancy and breastfeeding (2018 = 72.9% vs. 2023 = 70.2%; OR = 0.87, 0.81–0.94; p < .001), driving impairment (2018 = 81.3% vs. 2023 = 79.6%; OR = 0.90, 0.82–0.98; p = .015), risk of psychosis and schizophrenia (2018 = 38.1% vs. 2023 = 35.7%; OR = 0.90, 0.84–0.97; p = .003), and diabetes (2018 = 36.1% vs. 2023 = 33.4%; OR = 1.25, 1.18–1.32; p < .001). no differences were observed for beliefs on the harm of marijuana smoke (2018 = 58.3% vs. 2023 = 57.8%; OR = 0.98, 0.92–1.05; p = .570), addictive potential (2018 = 62.6% vs 2023 = 64.0%; OR = 0.98, 0.99–1.14; p = .080), teenage marijuana consumption (2018 = 60.0% vs 2023 = 58.6%; OR = 0.94, 0.88–1.01; p = .087) in unadjusted models. However, in the adjusted models knowledge levels were lower in 2023 compared to 2018 for only the harm of marijuana smoke (AOR = 0.92, 0.86–0.98; p = .012) and risk of diabetes (AOR = 0.85, 0.79–0.91; p < .001). Moreover, knowledge levels were higher in 2023 compared to 2018 for addictive potential (OR = 1.18, 1.10–1.23; p < .001), while no differences were observed for other beliefs. Health Knowledge Index In the unadjusted linear regression model, compared to Health Knowledge Index sores in 2018, scores were significantly lower in 2020 (β = -0.12, -0.21- -0.03; p = 0.006), 2021 (β = -0.25, -0.33- -0.17; p < .001), and 2022 (β = -0.23, -0.32- -0.15; p < .001), with no significant differences observed compared to other years. Table 2 shows pairwise contrasts for other years. Table 2 Unadjusted linear regression model examining the Health Knowledge Index by year (n = 92365) Reference Comparison Beta (95% CI) P-value 2018 2019 -0.04 (-0.12, 0.05) 0.375 2020 -0.12 (-0.21, -0.03) 0.006 2021 -0.25 (-0.12, 0.04) < .001 2022 -0.23 (-0.13, 0.03) < .001 2023 -0.04 (-0.12, 0.04) 0.329 2019 2020 0.08 (0.01, 0.16) 0.029 2021 0.21 (0.14, 0.28) < .001 2022 0.19 (0.12, 0.26) < .001 2023 0.00 (-0.07, 0.07) 0.950 2020 2021 0.13 (0.06, 0.20) 0.001 2022 0.11 (0.04, 0.18) 0.003 2023 -0.08 (-0.15, -0.01) 0.025 2021 2022 -0.02 (-0.09, 0.05) 0.606 2023 -0.21 (-0.28, -0.14) < .001 2022 2023 -0.19 (-0.26, -0.12) < .001 [INSERT Table 2 ] Findings from the adjusted linear regression models were somewhat different than the unadjusted models. As shown in Table 3 , compared to 2018, scores on the Health Knowledge Index were significantly higher in 2019 (β = 0.09, 0.01–0.17; p = 0.032) and 2023 (β = 0.14 ;0.06–0.22, p < .001). Table 3 shows pairwise contrasts for all other years. Table 3 Adjusted linear regression model examining the Health Knowledge Index (n = 92365) Characteristic Mean (SD) Beta (95% CI) P-value Survey year 2018 10.6 (2.4) ref ref 2019 10.5 (2.5) 0.09 (0.01, 0.17) 0.032 2020 10.5 (2.5) 0.03 (-0.05, 0.11) 0.478 2021 10.3 (2.6) -0.04 (-0.12, 0.04) 0.319 2022 10.4 (2.5) -0.05 (-0.13, 0.03) 0.255 2023 10.5 (2.4) 0.14 (0.06, 0.22) < .001 Cannabis Consumption Never consumed 10.8 (2.4) ref ref Consumed more than 1 month ago 10.7 (2.2) -0.21 (-0.25, -0.16) < .001 Monthly/Weekly consumption 9.7 (2.8) -1.00 (-1.07, -0.92) < .001 Daily/almost daily consumption 9.4 (2.9) -1.30 (-1.38, -1.22) < .001 Mental Health Diagnosis No 10.7 (2.3) ref ref Not stated* 9.1 (3.0) -1.13 (-1.25, -1.02) < .001 Yes 10.3 (2.6) -0.15 (-0.20, -0.11) < .001 Sex Female 10.7 (2.1) ref ref Male 10.2 (3.0) -0.40 (-0.44, -0.36) < .001 Age 16–25 years 10.5 (2.9) ref ref 26–35 years 10.0 (2.9) -0.59 (-0.67, -0.51) < .001 36–45 years 10.3 (2.6) -0.39 (-0.47, -0.32) < .001 46–55 years 10.7 (2.3) -0.12 (-0.19, -0.04) 0.002 56–65 years 10.8 (1.9) -0.16 (-0.23, -0.09) < .001 Ethnicity White only 10.6 (2.4) ref ref East/South East Asian only 10.4 (2.5) -0.39 (-0.46, -0.32) < .001 Mixed/Other/Unstated 10.0 (2.8) -0.35 (-0.44, -0.26) < .001 South Asian only 10.2 (2.8) -0.57 (-0.67, -0.46) < .001 Black only 9.9 (2.9) -0.59 (-0.70, -0.47) < .001 Indigenous only 9.7 (2.9) -0.55 (-0.70, -0.40) < .001 Latino only 10.0 (2.9) -0.53 (-0.70, -0.36) < .001 Middle Eastern only 10.2 (2.9) -0.47 (-0.64, -0.30) < .001 Income Adequacy Very difficult 10.3 (2.6) ref ref Difficult 10.5 (2.5) 0.09 (0.01, 0.17) 0.036 Neither easy nor difficult 10.4 (2.5) -0.05 (-0.13, 0.03) 0.235 Easy 10.7 (2.4) 0.13 (0.05, 0.22) 0.002 Very easy 10.7 (2.5) 0.10 (0.01, 0.20) 0.033 Not stated* 9.5 (2.9) -0.62 (-0.76, -0.48) < .001 Education Less than high school 10.3 (3.5) ref ref High school or equivalent 10.2 (3.3) 0.01 (-0.08, 0.09) 0.890 Bachelor's degree or higher 10.6 (2.1) 0.42 (0.34, 0.49) < .001 Not stated* 8.9 (3.0) -0.57 (-0.81, -0.33) < .001 Compared to respondents who reported having no mental health diagnoses, Health Knowledge Index scores were significantly lower among those who reported 1 or more mental health diagnoses (β = -0.15, -0.20 - -0.11, p < .001) and those who did not respond to this question (β = -1.13, -1.25 - -1.02, p < .001). Compared to respondents who reported 1 or more mental health diagnoses scores were lower among those who did not report (β =-0.98, -1.10 - -0.86, < .001). Younger age was associated with higher Health Knowledge Index scores. Compared to 16–25-year-old respondents, scores were significantly lower among all other age groups, including 26–35-year-old (β = -0.59, -0.67 - -0.51, p < .001), 36–45 year old (β = -0.39, -0.47 - -0.32, p < .001), 46–55 year old (β = -0.12, -0.19 - -0.04, p = 0.002), and 56–65 year old respondents (β = -0.16, -0.23 - -0.09, p < .001). Females also reported greater health knowledge than males (β = 0.40, 0.36–0.44, p < .001). Ethnicity was also significant associated with health knowledge. Compared to respondents who identified as White only, scores were lower for all other identified ethnicities including East/South East Asian only (β = -0.39, -0.46 – -0.32, p < .001), South Asian only (β = -0.57, -0.67 – -0.46, p < .001), Black only (β = -0.59, -0.70 – -0.47, p < .001), Indigenous only (β = -0.55, -0.70 – -0.40, p < .001), Latino only (β = -0.53, -0.70 – -0.36, p < .001), Middle Eastern only (β = -0.47, -0.64 – -0.30, p < .001), and those who identified as mixed, other, or did not state (β = -0.35, -0.44 – -0.26, p < .001). Health knowledge was generally inversely associated with income adequacy and education level. For example, respondents who reported “very difficult” income adequacy reported lower Health Knowledge Index scores than those who reported their income adequacy as difficult (β = 0.09, 0.01–0.17; p = 0.036), easy (β = 0.13, 0.05–0.22; p = 0.002) and very easy (β = 0.10, 0.01–0.20; p = 0.033). Scores were also lower among respondents with less than a high school diploma compared to those with a bachelor's degree or higher (β = 0.42, 0.34–0.49; p < .001). In addition, scores among those who did not state their education were significantly lower compared to all other groups, including those with less than a high school diploma (β = -0.57, -0.81 - -0.33; p < .001), those with a high school diploma or equivalent (β = -0.58, -0.81 - -0.34; p < .001), and those with a bachelor’s degree or higher (β = -0.99, -1.21 - -0.76; p < .001). [INSERT Table 3 ] Figure 3 shows mean Health Knowledge Index scores across all survey years by cannabis consumption. Compared to those who never consumed cannabis, scores were significantly lower among daily/almost daily consumers (β = -1.30, -1.38 - -1.22; p < .001), monthly/weekly consumers (β =-1.00, -1.07 - -0.92; p < .001), and those who consumed more than 1 month ago (β = -0.21, -0.25 - -0.16; p < .001). Those who consumed cannabis more than 1 month ago also scored significantly higher than both monthly/weekly consumers (β = 0.79, 0.72–0.86; p < .001) and daily/almost daily consumers (β = 1.09, 1.01–1.17; p < .001). Furthermore, monthly/weekly consumers scored significantly higher than daily/almost daily consumers (β = 0.30, 0.21–0.40; p < .001). [INSERT Fig. 3 ] Noticing cannabis product health warning labels, cannabis advertising, and education campaigns Table 4 shows the mean Health Knowledge Index score and regression coefficient from the adjusted linear regression models including each of the three policy-relevant variables: noticing health warnings, cannabis advertising, and education campaigns respectively. Table 4 Effects model regressing noticing of cannabis product health warning labels, cannabis advertising, and education campaigns on Health Knowledge Index (n = 92,365) Characteristic Mean (SD) Beta (95% CI) P-value Noticing health warning labels on products No 10.3 (2.7) ref ref Yes 10.5 (2.5) 0.58 (0.51, 0.64) < .001 Not applicable 10.9 (2.1) 0.26 (0.21, 0.31) < .001 Don’t know 9.5 (2.7) -0.47 (-0.56, -0.39) < .001 Refuse to answer 8.4 (3.3) -0.97 (-1.75, -0.18) 0.015 Noticing cannabis advertising Noticed no ads 10.7 (2.3) ref ref Noticed an ad in at least 1 channel 10.4 (2.6) -0.17 (-0.22, -0.13) < .001 Don’t know 9.6 (2.8) -0.75 (-0.83, -0.68) < .001 Noticing education campaigns Noticed no education campaigns 10.6 (2.3) ref ref Noticed an education campaign 10.5 (2.6) 0.01 (-0.03, 0.05) 0.651 Don't know 9.7 (2.7) -0.57 (-0.64, -0.50) < .001 Respondents who reported seeing cannabis health warnings in the past 12 months had higher Health Knowledge Index scores compared to those who reported seeing no cannabis health warnings (β = 0.58, 0.51–0.64; p < .001), those who had not seen any cannabis products or packages (β = 0.32, 0.25–0.38; p < .001), those who reported not knowing whether they saw warnings (β = 1.05, 0.96–1.15; p < .001), and those who refused to answer (β = 1.54, 0.76–2.33; p < .001). Furthermore, respondents who had not seen any cannabis products reported higher scores than those who reported not knowing whether they saw warning labels (β = 0.73, 0.65–0.82; p < .001) and those who refused to answer (β = 1.23, 0.44–2.01; p = 0.002). Respondents who reported seeing cannabis advertisements in the past 12 months reported lower Health Knowledge Index scores compared to those who reported seeing no advertisements (β = -0.17, -0.22 - -0.13; p < .001). In addition, respondents who reported not knowing if they had seen any cannabis advertisements reported lower scores compared to respondents who reported seeing cannabis advertisements (β = -0.58, -0.66 - -0.50; p < .001) and those who reported seeing no advertisements (β = -0.75, -0.83 - -0.68; p < .001). Respondents who reported seeing an educational campaign reported higher Health Knowledge Index scores compared to those who did not know whether they had noticed any (β = 0.58, 0.51–0.66; p < .001), while scoring not significantly different compared to those who reported noticing no education campaigns (β = 0.01, -0.03–0.05; p = 0.651). In addition, those who reported noticing no education campaigns reported higher scores than those who did not know whether they had noticed any (β = 0.57, 0.50–0.64; p < .001). Differences in Health Knowledge Index scores were also observed by cannabis consumption status and noticing of cannabis product health warning labels, cannabis advertising, and education campaigns. As shown in Table 5 , scores increased with decreasing cannabis consumption frequency. Table 5 Mean Health Knowledge Index scores by noticing of cannabis product health warning labels, cannabis advertising, and education campaigns and cannabis consumption status (n = 92365) Characteristic Never consumed Consumed more than 1 month ago Monthly/ Weekly consumption Daily/almost daily consumption Noticing cannabis product health warning labels No 10.7 (2.6) 10.6 (2.3) 9.5 (3.0) 9.0 (3.0) Yes 11.0 (2.6) 10.6 (2.3) 10.4 (2.5) 10.1 (2.7) Not applicable 11.1 (2.1) 10.9 (1.9) 9.2 (2.9) 8.7 (3.0) Don’t know 9.3 (2.9) 10.0 (2.4) 9.4 (2.6) 8.9 (2.8) Refuse to answer 8.8 (3.5) 8.6 (2.7) 7.9 (3.0) 8.4 (4.0) Noticing cannabis advertising Noticed no ads 11.0 (2.2) 10.9 (2.1) 10.2 (2.3) 9.7 (2.8) Noticed an ad in at least 1 channel 10.8 (2.4) 10.6 (2.3) 9.5 (3.0) 9.3 (3.0) Don’t know 9.9 (2.8) 9.9 (2.5) 9.1 (2.8) 8.7 (2.9) Noticing education campaigns Noticed no education campaigns 10.9 (2.2) 10.8 (2.1) 10.0 (2.5) 9.5 (2.8) Noticed an education campaign 11.0 (2.5) 10.7 (2.3) 9.6 (3.1) 9.4 (3.0) Don't know 9.9 (2.7) 10.0 (2.5) 9.1 (2.7) 8.9 (2.9) [INSERT Table 4 ] [INSERT Table 5 ] DISCUSSION The current study is among the first to examine changes in health knowledge of cannabis before and after cannabis legalization. Most notably, no significant changes were observed in overall health knowledge from pre-legalization in 2018 to five years post-legalization in 2023, contrary to our hypothesis. Overall levels of health knowledge dipped in 2020 before returning to pre-legalization levels in 2023. The temporary decrease observed in 2020 may be associated with the emergence of COVID-19 pandemic, which was characterized by increases in substance use among adults, including cannabis ( 46 – 48 ). The current findings are generally consistent with trends observed in the Canadian Cannabis Survey (CCS) over the same period, in which few changes were observed in health knowledge between 2018 and 2023, except for modest increases in the percentage who agreed that cannabis was ‘habit forming’ and smoking cannabis was harmful, and decreases in agreement with the effect of frequent use on mental health ( 14 ). Large differences were observed in the level of agreement with different health effects. Agreement was highest for the risks of impaired driving, which is a common focus for public health education campaigns in Canada. Nevertheless, one third of respondents did not agree that it can be dangerous to drive or operate machinery after using cannabis. Of greatest concern, only one third of respondents agreed that regular cannabis consumption can increase the risk of psychosis and schizophrenia, similar to the percentage who incorrectly reported that cannabis can cause diabetes. Consistent with the current findings, the Canadian Cannabis Survey also found the lowest levels of agreement for mental health effects, despite strong evidence to the contrary ( 14 ). Interestingly, respondents in the current study who reported previous experience of a mental health condition were more likely to agree that regular cannabis consumption can increase the risk of psychosis and schizophrenia, despite reporting lower overall scores on the health knowledge index, similar to previous findings ( 44 ). Overall, the lack of knowledge for mental health effect warrants greater attention, particularly given higher levels of cannabis consumption among people with a history of mental health conditions compared to the general population.( 45 , 46 ). As with previous studies, people that consume cannabis reported lower levels of agreement than non-consumers.( 14 ). This is consistent with a large number of studies demonstrating optimism bias among those that use substances including cannabis and tobacco ( 8 , 9 ). Other individual-level differences were observed, including greater health knowledge among younger respondents. As hypothesized, the youngest age group of 16–25-year-old respondents had the highest health knowledge compared to all other groups. Other studies also indicate that younger age groups report higher health knowledge and risk perception of cannabis compared to older ages ( 32 , 34 ). Knowledge gaps were also observed by income adequacy and education. As hypothesized, higher socioeconomic status in terms of income adequacy and educational attainment was associated with greater health knowledge. Evidence on socioeconomic status (SES) and risk perception of cannabis consumption is mixed; although one study found that SES indexed by parental education, household income, and cash-on-hand was not related to either risk assimilation or risk denial of cannabis consumption ( 47 ), others have supported an association between increased cannabis consumption and low SES ( 48 – 50 ), which may suggest a potential relationship for risk perceptions and SES. Lower levels of health knowledge among males and ‘non-white’ minority groups are also consistent with previous studies. Markedly lower levels of among respondents self-identifying as ‘black’ and ‘indigenous’—two groups that were disproportionately affected by cannabis prohibition—suggests further efforts are required to reduce cannabis-related disparities, as noted in a recent legislative review ( 1 ). To our knowledge, the current study is the first to examine population-levels of health knowledge for cannabis and associations with risk communication policies. Noticing the mandated health warnings on cannabis products was associated with greater health knowledge. Previous studies examining the effectiveness of cannabis health warnings found that warning labels are associated with increased knowledge of health effects and increased perceived harm of smoking cannabis ( 51 , 52 ). Similarly, in the current study seeing cannabis advertisements was associated with lower health knowledge, consistent with findings from cannabis, tobacco, and alcohol research, which have indicated that positive imagery conveyed in advertising can reduce perceptions of harm ( 53 – 55 ). In contrast, noticing education campaigns was not associated with health knowledge. Few studies have examined the association between noticing public health education campaigns and cannabis risk perceptions; however, findings in Canada’s northern territories found higher risk perceptions of daily cannabis smoking associated with noticing campaigns ( 56 ). The effect of public education campaigns are likely to vary depending upon the prominence and effectiveness of individual media campaigns ( 57 , 58 ). Future research on the impact of specific public education campaigns is warranted. Limitations The current study is subject to several limitations common to survey research. The study design is repeat cross-sectional and did not examine individual-level changes over time. Respondents were recruited using non-probability-based sampling; therefore, the findings do not necessarily provide nationally representative estimates. However, the data were adjusted by age group, sex, education, income adequacy, mental health status, and consumption status. Additionally, the measures of health knowledge used agreement questions and conditional causal wording such as ‘can’ when asking about health effects; which may both lead to higher estimates of health knowledge compared to open-ended, definite causal statements of health effects ( 59 ). Finally, the brief pre-legalization ‘baseline’ period represents a limitation. It is possible that levels of health knowledge may have been changing over a longer period, including in the build up to legalization, during which considerable media attention and public debate about the health effects of cannabis. While a longer baseline period would be an asset, the stability of health knowledge over the course of the 5-year post-legalization period covered by the current study remains notable. CONCLUSIONS The current study suggests that population-level knowledge of the health knowledge of cannabis has generally remain unchanged since the legalization of recreational cannabis in 2018. The lack of change may represent a type of ‘stalemate’ between opposing forces. On the one hand, legalization has the potential to normalize cannabis consumption and undermine perceptions of risk through exposure to cannabis promotions and increased cannabis consumption. On the other hand, legalization provides greater opportunities and responsibility to convey information on the risks of cannabis consumption. This is particularly true in legal markets such as Canada, where all provincial and territorial governments serve as retailers and/or distributors for licensed cannabis products, which also provides resources for education campaigns. The lack of change in health knowledge in the first five years following legalization may allay some concerns about the immediate impact of legalization; however, it also highlights notable knowledge gaps and disparities between population subgroups that will require dedicated efforts to address. Continued monitoring is also essential given the relatively early stage of Canada’s legal market and the potential for longer term changes over time. Declarations Ethics approval and consent to participate The study was reviewed by and received ethics clearance through a University of Waterloo Research Ethics Committee (ORE#31330). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors report there are no competing interests to declare. Funding Funding for this study was provided by a Canadian Institutes of Health Research Project Bridge Grant (PJT-153342) and a Canadian Institutes of Health Research Project Grant (PJT-153342). Authors’ contributions All authors were involved in the overall conceptualization, methodology and review of the manuscript. Acknowledgements The authors would like to thank the ICPS Research team and staff for their assistance. Declaration of interest Hammond has served as a paid expert witness on behalf of public health authorities in response to legal challenges from the cannabis, tobacco, and vaping industries. References Rosenberg M, Ayonrinde O, Conrod PJ, Levesque LL, Selby P. Legislative review of the Cannabis Act, in Final Report of the Expert Panel [Internet]. Health Canada Ottawa; 2024. Available from: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/drugs-medication/legislative-review-cannabis-act-final-report-expert-panel/legislative-review-cannabis-act-final-report-expert-panel.pdf Weinstein ND. What does it mean to understand a risk? Evaluating risk comprehension. J Natl Cancer Inst Monogr. 1999;(25):15–20. Glanz K, Rimer BK, Viswanath K. Health behavior: Theory, research, and practice, 5th ed. 5th ed. John Wiley & Sons; 2015. 512 p. Hyland A, Li Q, Bauer JE, Giovino GA, Steger C, Cummings KM. Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2004 Dec;6 Suppl 3:S363–9. Curry SJ, Grothaus L, McBride C. Reasons for quitting: intrinsic and extrinsic motivation for smoking cessation in a population-based sample of smokers. Addict Behav. 1997;22(6):727–39. Hammond D, McDonald PW, Fong GT, Brown KS, Cameron R. The impact of cigarette warning labels and smoke-free bylaws on smoking cessation: evidence from former smokers. Can J Public Health Rev Can Sante Publique. 2004;95(3):201–4. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General [Internet]. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014 [cited 2024 Dec 13]. (Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK179276/ Salloum NC, Krauss MJ, Agrawal A, Bierut LJ, Grucza RA. A reciprocal effects analysis of cannabis use and perceptions of risk. Addiction. 2018;113(6):1077–85. Pacek LR, Mauro PM, Martins SS. Perceived risk of regular cannabis use in the United States from 2002 to 2012: Differences by sex, age, and race/ethnicity. Drug Alcohol Depend. 2015 Apr 1;149:232–44. Mader J, Smith JM, Smith J, Afzal AR, Arria A, Bugbee BA, et al. Correlates of Perceived Harmfulness of Regular Cannabis Use among Canadian University Students Before and After Legalization. Cannabis. 2022;5(3):23–35. McMahon I, Harris-Lane LM, Donnan J, Bishop L, Harris N. Emerging adult perceptions of higher-risk cannabis consumption behaviours. Harm Reduct J. 2023 Sept 7;20(1):127. Salloum NC, Krauss MJ, Agrawal A, Bierut LJ, Grucza RA. A reciprocal effects analysis of cannabis use and perceptions of risk. Addiction. 2018;113(6):1077–85. Leos-Toro C. Health warnings, cannabis marketing and perceptions among youth and young adults in Canada [Internet] [PhD Thesis]. 2019. Available from: http://hdl.handle.net/10012/14544 Government of Canada. Canadian Cannabis Survey 2023: Summary [Internet]. 2024. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2023-summary.html#s2-1 Robinson J, Copeland C, Pilin M, Meyer A, Krank M. The Impact of Cannabis Legalization in Canada on Adolescents’ Perceptions. J Drug Issues. 2020 Feb 28;50(3):235–41. Sarvet AL, Wall MM, Keyes KM, Cerdá M, Schulenberg JE, O’Malley PM, et al. Recent rapid decrease in adolescents’ perception that marijuana is harmful, but no concurrent increase in use. Drug Alcohol Depend. 2018 May 1;186:68–74. Mennis J, McKeon TP, Stahler GJ. Recreational cannabis legalization alters associations among cannabis use, perception of risk, and cannabis use disorder treatment for adolescents and young adults. Addict Behav. 2023 Mar;138:107552. O’Connell M, Levy S, Shrier LA, Harris SK. Trends in cannabis-related attitudes and behaviors among cannabis-using adolescent and young adult outpatients following medical cannabis legalization in Massachusetts. Subst Abuse. 2022;43(1):328–35. Harpin SB, Brooks-Russell A, Ma M, James KA, Levinson AH. Adolescent Marijuana Use and Perceived Ease of Access Before and After Recreational Marijuana Implementation in Colorado. Subst Use Misuse. 2018 Feb 23;53(3):451–6. Estoup AC, Moise-Campbell C, Varma M, Stewart DG. The Impact of Marijuana Legalization on Adolescent Use, Consequences, and Perceived Risk. Subst Use Misuse. 2016 Dec 5;51(14):1881–7. Bailey JA, Epstein M, Roscoe JN, Oesterle S, Kosterman R, Hill KG. Marijuana Legalization and Youth Marijuana, Alcohol, and Cigarette Use and Norms. Am J Prev Med. 2020 Sept;59(3):309–16. Blevins CE, Marsh E, Banes KE, Stephens RS, Walker DD, Roffman RA. The Implications of Cannabis Policy Changes in Washington on Adolescent Perception of Risk, Norms, Attitudes, and Substance Use. Subst Abuse Res Treat [Internet]. 2018;12. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1177/1178221818815491 Wall MM, Poh E, Cerdá M, Keyes KM, Galea S, Hasin DS. Adolescent marijuana use from 2002 to 2008: higher in states with medical marijuana laws, cause still unclear. Ann Epidemiol. 2011 Sept;21(9):714–6. Goodman S, Hammond D. Perceptions of the health risks of cannabis: estimates from national surveys in Canada and the United States, 2018–2019. Health Educ Res. 2022 Mar 24;37(2):61–78. Task Force on Cannabis Legalization and Regulation. A Framework for the Legalization and Regulation of Cannabis in Canada [Internet]. 2016 Dec. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/laws-regulations/task-force-cannabis-legalization-regulation/framework-legalization-regulation-cannabis-in-canada.html National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012 [cited 2025 July 3]. (Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK99237/ Health Canada. Cannabis health warning messages [Internet]. 2025 [cited 2025 July 3]. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/laws-regulations/regulations-support-cannabis-act/health-warning-messages.html Goodman S, Rynard VL, Iraniparast M, Hammond D. Influence of package colour, branding and health warnings on appeal and perceived harm of cannabis products among respondents in Canada and the US. Prev Med [Internet]. 2021;153. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1016/j.ypmed.2021.106788 Massey ZB, Hammond D, Froeliger B. A systematic review of cannabis health warning research. Prev Med Rep. 2024 Jan;37:102573. Goodman S, Leos-Toro C, Hammond D. Do Mandatory Health Warning Labels on Consumer Products Increase Recall of the Health Risks of Cannabis? Subst Use Amp Misuse. 2022;57(4):569. Goodman S, Hammond D. Noticing of cannabis health warning labels in Canada and the US. Health Promot Chronic Dis Prev Can Res Policy Pract. 2021;41(7–8):201–10. Han BH, Funk-White M, Ko R, Al-Rousan T, Palamar JJ. Decreasing perceived risk associated with regular cannabis use among older adults in the United States from 2015 to 2019. J Am Geriatr Soc. 2021;69(9):2591–7. Health Canada. Cannabis use among older adults in Canada: Exploring perspectives and experiences following cannabis legalization [Internet]. 2023 Dec [cited 2024 Nov 5]. Available from: https://publications.gc.ca/collections/collection_2024/sc-hc/H14-595-2024-eng.pdf Huỳnh C, Roy S, Beaulieu-Thibodeau A, Brière-Charest K, Milot DM. Age differences in cannabis-related perceptions, knowledge, and sources of information among adults in the post-legalization era in Quebec, Canada. Journal of Studies on Alcohol and Drugs. 2024. Hendrickson RG, McKeown NJ, Kusin SG, Lopez AM. Acute cannabis toxicity in older adults. Toxicol Commun. 2020 Jan 1;4(1):67–70. Kuerbis A. Substance Use among Older Adults: An Update on Prevalence, Etiology, Assessment, and Intervention. Gerontology. 2019 Dec 6;66(3):249–58. Hammond D, Goodman S, Wadsworth E, Rynard V, Boudreau C, Hall W. Evaluating the impacts of cannabis legalization: The International Cannabis Policy Study. Int J Drug Policy [Internet]. 2020;77. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1016/j.drugpo.2020.102698 Abrams DI. The therapeutic effects of Cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. Eur J Intern Med. 2018 Mar 1;49:7–11. Acton R, White C, Ryanrd V, Hammond D. Perceived income adequacy versus household income as a measure of socioeconomic status in cross-sectional population-level surveys conducted in six countries: an analysis of the 2022-2023 International Food Policy Study. Public Heatlth Rep. 2025; Winfield-Ward L, Wadsworth E, Driezen P, Rynard V, Hammond D. Exposure to cannabis marketing in the United States and differences by cannabis laws: Findings from the International Cannabis Policy Study. Drug Alcohol Depend. 2025; Imtiaz S, Wells S, Rehm J, Hamilton HA, Nigatu YT, Wickens CM, et al. Cannabis Use During the COVID-19 Pandemic in Canada: A Repeated Cross-sectional Study. J Addict Med. 2021 Dec 1;15(6):484–90. Kar P, Tomfohr-Madsen L, Giesbrecht G, Bagshawe M, Lebel C. Alcohol and substance use in pregnancy during the COVID-19 pandemic. Drug Alcohol Depend. 2021 Aug 1;225:108760. Bartel SJ, Sherry SB, Stewart SH. Self-isolation: A significant contributor to cannabis use during the COVID-19 pandemic. Subst Abuse. 2020;41(4):409–12. Thornton LK, Baker AL, Johnson MP, Lewin T. Perceived risk associated with tobacco, alcohol and cannabis use among people with and without psychotic disorders. Addict Behav. 2013;38(6):2246. Rup J, Freeman TP, Perlman C, Hammond D. Cannabis and Mental Health: Adverse Outcomes and Self-Reported Impact of Cannabis Use by Mental Health Status. Subst Use Misuse. 2022;57(5):719–29. Lee G, Hicks DL, Kedia S, Regmi S, Mou X. Mental health problems, substance use, and perceived risk as pathways to current cannabis use among high school seniors in the United States. Child Youth Serv Rev. 2024 Mar 1;158:107456. Gette JA, Cundiff JM, Gissandaner TD, Littlefield AK. Relations between cannabis use, socioeconomic status, and risk perceptions in a Hispanic/Latinx population. J Ethn Subst Abuse. 2022 Nov 4;21(4):1432–51. Boden JM, Dhakal B, Foulds JA, Horwood LJ. Life-course trajectories of cannabis use: a latent class analysis of a New Zealand birth cohort. Addiction. 2020;115(2):279–90. Cerdá M, Moffitt TE, Meier MH, Harrington H, Houts R, Ramrakha S, et al. Persistent Cannabis Dependence and Alcohol Dependence Represent Risks for Midlife Economic and Social Problems: A Longitudinal Cohort Study. Clin Psychol Sci. 2016 Nov 1;4(6):1028–46. Rafei P, Englund A, Lorenzetti V, Elkholy H, Potenza MN, Baldacchino AM. Transcultural Aspects of Cannabis Use: a Descriptive Overview of Cannabis Use across Cultures. Curr Addict Rep. 2023 Sept 1;10(3):458–71. Mutti-Packer S, Collyer B, Hodgins DC. Perceptions of plain packaging and health warning labels for cannabis among young adults: findings from an experimental study. BMC Public Health. 2018 Dec;18(1):1–10. Pepper JK, Lee YO, Eggers ME, Allen JA, Thompson J, Nonnemaker JM. Perceptions of U.S. and Canadian Cannabis Package Warnings Among U.S. Adults. Drug Alcohol Depend. 2020;217. K K, D H. The impact of cigarette pack shape, size and opening: evidence from tobacco company documents. Addict Abingdon Engl [Internet]. 2013 Sept [cited 2025 Apr 23];108(9). Available from: https://pubmed.ncbi.nlm.nih.gov/23600674/ Moodie C, Ford A. Young adult smokers’ perceptions of cigarette pack innovation, pack colour and plain packaging. Australas Mark J AMJ. 2011 Aug 1;19(3):174–80. Bhat A, Shilpashree KB, Krishnamurthy A, Manjunath C, Shwetha R, Madhusudhan S. Adolescent’s Perception about the Introduction of New Cigarette Packaging and Plain Packaging of Cigarette Packs: A Qualitative Study. Indian J Community Med Off Publ Indian Assoc Prev Soc Med. 2018 Dec;43(Suppl 1):S47–51. Schwartz N, Poon T, Hammond D, Hobin E. Associations between noticing public health education campaigns about cannabis and risk perceptions in the northern Canadian territories: a cross-sectional study. Health Educ Res [Internet]. 2024 June 21; Available from: https://www.ncbi.nlm.nih.gov/pubmed/38905013 Wakefield M, Loken B, Hornik R. Use of mass media campaigns to change health behaviour. Lancet Lond Engl [Internet]. 2010 Oct 9 [cited 2025 Apr 23];376(9748). Available from: https://pubmed.ncbi.nlm.nih.gov/20933263/ Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the National Youth Anti-Drug Media Campaign on youths. Am J Public Health [Internet]. 2008 Dec [cited 2025 Apr 23];98(12). Available from: https://pubmed.ncbi.nlm.nih.gov/18923126/ Weinstein N, Slovic P, Waters E, Gibson G. Public understanding of the illnesses caused by cigarette smoking. Nicotine Tob Res Off J Soc Res Nicotine Tob [Internet]. 2004 Apr [cited 2025 Apr 14];6(2). Available from: https://pubmed.ncbi.nlm.nih.gov/15203808/ Additional Declarations No competing interests reported. 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12:29:31","extension":"xml","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":336053,"visible":true,"origin":"","legend":"","description":"","filename":"da9bcced67ac4ddaad869d779ebd1ecb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/f9e46a252d536001377b8f6f.xml"},{"id":92173306,"identity":"a2e1a30c-4b5d-497b-ae16-1d3a6f85b9b2","added_by":"auto","created_at":"2025-09-25 12:21:31","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":337488,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/f16f55b204774137169f03d5.html"},{"id":92174192,"identity":"51cba6b6-1221-43ff-85b5-8bf3d4bed8e0","added_by":"auto","created_at":"2025-09-25 12:29:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41466,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFrequency of correct responses to cannabis health knowledge questions over time\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/6866f745f13ac184242e4fda.png"},{"id":92173274,"identity":"16bdf979-67c9-44ba-aaea-0fe644a7f0f6","added_by":"auto","created_at":"2025-09-25 12:21:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20353,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.1: Belief that marijuana smoke can be harmful, by cannabis consumption status \u003c/strong\u003e(n = 92365)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/e811333ce34ae05f53110495.png"},{"id":92174397,"identity":"16a35a49-b3c8-4cbd-a3cf-10b378379edb","added_by":"auto","created_at":"2025-09-25 12:37:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21582,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.2: Belief that marijuana consumption can be harmful while pregnant or breastfeeding, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/ec86f05c993a0baa68a447bc.png"},{"id":92173278,"identity":"f4802ddf-d2c3-4e7b-bcf0-7b023e23a109","added_by":"auto","created_at":"2025-09-25 12:21:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20340,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.3: Belief that it can be dangerous to drive or operate machinery after using marijuana, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/20151f2f64b9e32c886e1d43.png"},{"id":92174398,"identity":"f7ba9e77-cb8d-4b20-a62f-3a84aacd00ea","added_by":"auto","created_at":"2025-09-25 12:37:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":20317,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.4: Belief that marijuana can be addictive, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/374f86c487ef1ec57b5e1dbf.png"},{"id":92174198,"identity":"8eca9c38-117f-4d2c-9ac9-01f108d0f006","added_by":"auto","created_at":"2025-09-25 12:29:31","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":19561,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.5: Belief that marijuana use can increase the risk of psychosis and schizophrenia, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/0ca66d6ff05fb3f1945b9742.png"},{"id":92173286,"identity":"aa25c5e7-3f18-48cf-b4d9-3ccf7b072666","added_by":"auto","created_at":"2025-09-25 12:21:31","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":20897,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.6: Belief that teenagers are at greater risk of harm from marijuana use than adults, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/0d4aa8ead99dd37b5cff5cec.png"},{"id":92174201,"identity":"13a97b96-3946-47be-8f0f-43874bb0cc82","added_by":"auto","created_at":"2025-09-25 12:29:31","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":19750,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2.7: Belief that marijuana use can cause diabetes, by cannabis consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/90baef16cfc15398f49c8467.png"},{"id":92173288,"identity":"50ecfa26-a9e4-4efa-bd1b-fdb1ab0fc0f3","added_by":"auto","created_at":"2025-09-25 12:21:31","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":343401,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3: Mean Health Knowledge Index scores by year and consumption status\u003c/strong\u003e (n = 92365)\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/ba702191c2e5fe6a6e3e36fd.png"},{"id":92175424,"identity":"e57b9686-9e9c-4e80-bf0f-cf4003dd458d","added_by":"auto","created_at":"2025-09-25 12:45:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2580406,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/66d90fce-9bb5-482e-88e6-4e5f2ebdf513.pdf"},{"id":92173280,"identity":"836b16a7-e638-4ccb-b3cd-723298a8499a","added_by":"auto","created_at":"2025-09-25 12:21:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":70899,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTALFILES.docx","url":"https://assets-eu.researchsquare.com/files/rs-7602619/v1/bf418bf9815eb804848bf1c6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge about the health effects of cannabis before and after ‘recreational’ cannabis legalization in Canada: Findings from the International Cannabis Policy Study, 2018 – 2024","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eAfter more than 90 years of prohibition, legalization of recreation cannabis in Canada in 2018 marked a significant shift in federal drug policy, with broad implications for criminal justice and public health (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Cannabis legalization also has the potential to impact psychosocial predictors of cannabis consumption, including risk perceptions and health knowledge. Health knowledge encompasses the perceptions and attitudes individuals hold about the health benefits and risks of a substance, which are influenced by personal experiences, societal norms, and public health messaging (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Health knowledge is a central feature of health behaviour models and has important influence on substance use, as illustrated by the vast literature on tobacco use (\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Research on tobacco control policies over the past century has demonstrated that increasing strict regulations can increase risk perceptions and decrease tobacco use (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Cannabis legalization presents a unique opportunity to examine if the reverse is also true: whether more permissive laws and policies decrease perceptions of risk.\u003c/p\u003e\u003cp\u003eCannabis risk perceptions are inversely associated with consumption and future susceptibility to consume cannabis (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The association between risk perception and consumption is bi-directional: lower perceptions of risk increase the likelihood of future consumption, whereas frequent consumption can undermine risk perceptions as a result of defensive avoidance and optimism bias (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). To date, few studies have assessed the impact of cannabis legalization on risk perceptions and health knowledge. Nationally representative monitoring surveys observed increased health knowledge between 2018 and 2023 for beliefs about cannabis addictiveness, with decreases observed for beliefs about the risks of cannabis consumption during pregnancy, teenage consumption, harmfulness of cannabis, and association with mental health problems,(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Surveys conducted among Canadian youth found no immediate changes in risk perceptions among young adults two months after legalization (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSeveral studies have examined risk perceptions following state-level changes in cannabis laws, with mixed findings. National surveys conducted with high school students indicate a decline in risk perceptions for cannabis between 1991 and 2006, which includes the period in which several states legalized medical cannabis consumption and the earliest states to adapt recreational legalization (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, most pre-post studies in states that have legalized cannabis show little or no effect. For example, no differences in risk perceptions were observed among youth and young adults before and after medical cannabis legalization in Massachusetts, similar to null findings before and after recreational cannabis legalization in Colorado, and in difference-in-differences models examining cannabis laws across 22 states (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Mixed findings have also been observed in studies that examined changes in risk perceptions before and after \u0026lsquo;recreational\u0026rsquo; legalization in Washington State (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Interpreting state-level differences is complicated by pre-existing differences between states that did and did not implemented cannabis legalization (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). As such, the impact of legalization on risk perceptions of cannabis consumption remains unclear (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eReductions in perceived risks\u0026mdash;and potential increases in cannabis consumption among youth\u0026mdash;was among the public health concerns identified in the lead up to legalization in Canada (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In addition to speculation that legalization would undermine risk perceptions, there were specific concerns about the impact of commercializing the cannabis market and the impact of industry marketing. Decades of research in tobacco control demonstrated that the positive imagery conveyed in industry marketing was highly effective in increasing social norms and decreasing perceptions of risk, both of which are key mediators in the causal effect of tobacco marketing on youth smoking (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Conversely, legalization provides new opportunities for conveying information on the risks of cannabis consumption. Most notably, licensed cannabis products in Canada are mandated to display health warning labels on packages. Packaging must display a series of \u0026lsquo;rotating\u0026rsquo; warnings which convey different messages, including the effects of cannabis on mental health, among young people, and impaired driving (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Literature reviews of health warnings on tobacco products has demonstrated that comprehensive warnings are effective in increasing knowledge of specific health effects and risk perceptions more generally (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Emerging research on health warnings for cannabis is generally consistent with the literature on tobacco products, but at a relatively early stage, with few population-level studies to date (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Recall of cannabis health warnings has increased since legalization, particularly among frequent consumers (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), however, it is unclear how these effects may translate into population-level indicators of health knowledge. Overall, while there are strong conceptual grounds to suggest that specific regulatory measures may impact perceptions of risk as part of a broader legal framework, this area is largely unexplored.\u003c/p\u003e\u003cp\u003eOverall, cannabis legalization has potential to influence a key predictor of cannabis consumption among youth and adults; however, research to date includes few pre-post research designs and is predominantly focussed on risk perceptions among young people, with a lack of studies among the general adult population This represents an important evidence gap given that cannabis consumption in older adults has been increasing and potentially different risk profile compared to younger cohorts (\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In addition, most studies have assessed general perception of risk or harm, rather than specific health beliefs. This is notable because many of the risk communications in Canada and other legal markets convey specific health effects as part of mandated warning labels on products and through mass media campaigns targeting impaired driving or use among young people.\u003c/p\u003e\u003cp\u003eThe current study sought to examine changes in population-level knowledge of the health effects of cannabis before and in the 5-years following legalization in Canada. The study also examined potential differences in the knowledge of health risks of cannabis consumption by frequency of cannabis consumption, mental health status, age, educational attainment, and income adequacy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eData are from Waves 1–6 of the Canadian component of the International Cannabis Policy Study (ICPS). National online surveys were conducted annually between 2018 and 2023 with respondents aged 16–65. Respondents were sampled through the Nielsen Consumer Insights Global Panel and partner panels. The Nielsen panels are recruited using a variety of probability and non-probability sampling methods. For the ICPS surveys, Nielsen draws stratified random samples from online panels, with quotas based on age and state/province of residence. Upon completion, respondents receive remuneration in accordance with their panel’s usual incentive structure. Monetary incentives have been shown to increase response rates and decrease response bias in subgroups under-represented in surveys, including disadvantaged subgroups. The cooperation rate, which was calculated based on AAPOR Cooperation Rate #2 as the percentage of respondents who completed the survey of eligible respondents those who accessed the survey link, ranged between 53.8% to 64.2% across the six survey waves. Surveys were conducted in English or French, with a median survey time ranging between 20 to 23 minutes across years.\u003c/p\u003e\n\u003cp\u003eRespondents provided consent prior to completing the survey. Respondents received remuneration in accordance with their panel’s usual incentive structure (e.g., points based or monetary rewards, chances to win prizes). A full description of the study methods can be found in the ICPS Technical Reports www.cannnabisproject.ca/methods and methodology paper (37).\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eMeasures\u003c/h2\u003e\n \u003cp\u003eAll survey measures are publicly accessible on the ICPS website https://cannabisproject.ca/publications/\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eHealth knowledge\u003c/em\u003e — Knowledge of the health effects of cannabis was assessed using measures of agreement with a list of seven health effects, with the response options “yes”, “no”, “maybe”. Six health effects were selected based on systematic reviews of health effects and those featuring in mandated health warnings under the Cannabis Act (27, 38). In addition, one “false” health belief question that was included for which there is no clear evidence: “Can using marijuana cause diabetes?”. Verbatim wording for the health knowledge questions is included in Supplemental Table\u0026nbsp;4.\u003c/p\u003e\n \u003cp\u003eAn index variable was created by summing the number of correct responses across the seven items included in all years, called the Health Knowledge Index (range 0–14). Responses that were “true” health statements were coded as “Correct” if respondents selected “Yes”, while responses to “false” health statements were coded as “Correct” if respondents selected “No”. Correct responses had a value of 2, while “Maybe /Don’t Know” and incorrect responses had values of 1 and 0, respectively.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSociodemographics\u003c/em\u003e — Respondents provided sociodemographic information, including sex at birth, age, ethnicity/race, highest education level, and perceived income adequacy. Age was classified into five categories: 16–25, 26–35, 36–45, 46–55, and 56–65. Ethnicity/race was classified with Canadian-specific measures drawn from the census or benchmark health surveys. Income adequacy was assessed by asking respondents, “Thinking about your family’s income, how difficult or easy is it to make ends meet?”, to which responses ranged on a 5-point Likert scale from very difficult to very easy (39).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCannabis consumption\u003c/em\u003e — Respondents were classified into six categories based on the status of cannabis consumption: Never consumed, consumed more than 1 month ago, monthly/weekly consumption, daily/almost daily consumption (≥ 5 days per week).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMental health status\u003c/em\u003e — Mental health status was assessed by measuring whether respondents had been diagnosed with any of the mental health conditions in a provided list (see Supplemental Table\u0026nbsp;5). Responses were classified into 3 categories (No; Yes; Not stated – including Refuse to Answer and Don’t Know responses).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eNoticing of cannabis product health warnings, advertisements, and education campaigns\u003c/em\u003e — Population-level health communication campaigns have the potential to influence health knowledge, three of which were assessed in the current study. First, noticing of cannabis product health warnings was assessed using the question “In the past 12 months, have you seen health warnings on marijuana products or packages?”, with responses classified as (Yes, No, Not applicable – I have not seen any marijuana products or packages, Don’t know, Refuse to answer) (30). Noticing cannabis advertising from any of sixteen channels was assessed using a derived version of the question “In the past 12 months, have you noticed marijuana being advertised or promoted in any of the following places?”, with responses classified as (Yes, No, Don’t know, Refuse to answer) (40). Noticing cannabis education campaigns from any of eighteen channels was assessed using a derived version the question “In the past 12 months, have you noticed education campaigns or public health messages about marijuana in any of the following places?”, with responses classified as (Yes, No, Don’t know, Refuse to answer). All measures are shown in Supplemental Table\u0026nbsp;6.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eA total of 93,933 respondents completed ICPS surveys between 2018 to 2023. The current analysis consisted of a sub-sample of 92,365 after excluding 1,568 respondents who refused to answer any questions on noticing cannabis product health warnings, advertisements, educational campaigns or any health knowledge questions.\u003c/p\u003e\u003cp\u003eAll analyses present weighted data. Post-stratification sample weights based on sex, age, region, education, race and consumption status were constructed based on the Canadian Census estimates and a raking algorithm applied to the original samples; see the Technical Reports for details (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://cannabisproject.ca/methods/\u003c/span\u003e\u003cspan address=\"http://cannabisproject.ca/methods/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Weights were rescaled to the unweighted analytic sample size within each wave.\u003c/p\u003e\u003cp\u003eSeparate logistic regression models were run for each of the seven health belief questions. Models were run in two steps. First, \u0026ldquo;unadjusted\u0026rdquo; models included only the indicator variable for survey year to examine trends over time. Second, \u0026ldquo;adjusted\u0026rdquo; models were run, which included the following covariates: survey year, cannabis consumption status, mental health diagnosis, age, sex, education, ethnicity, income adequacy. Sensitivity analyses run for each of the seven health beliefs, in which each health belief question was analyzed as a 3-level variable (\u0026ldquo;Maybe\u0026rdquo;/\u0026rdquo;Don\u0026rsquo;t know\u0026rdquo; was analyzed as a separate category from \u0026ldquo;No\u0026rdquo; responses) showed the same general pattern of significance as the main models. Odds ratios (AORs) and 95% confidence intervals (CIs) are shown. Analyses were conducted using survey procedures in SAS 8.4.\u003c/p\u003e\u003cp\u003eA linear regression model was run to examine changes in the Health Knowledge Index (range\u0026thinsp;=\u0026thinsp;0\u0026ndash;14; higher scores indicate more correct responses). Unadjusted and adjusted models were run, as described above. In an additional step, the three policy-related variables were added to the adjusted models: noticing cannabis health warnings (Yes; No; Don\u0026rsquo;t Know; Not applicable; Refuse to Answer), noticing cannabis advertisements (Noticed no ads; Noticed an ad in at least 1 channel ; Don\u0026rsquo;t Know), and noticing of public health campaigns (Noticed no education campaigns/public health messages, Noticed an education campaign/public health message in at least 1 channel; Don\u0026rsquo;t Know).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eSample characteristics\u003c/h2\u003e\u003cp\u003eAs Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows, the sample included approximately equal proportions in each age group and females/males. A majority of respondents were White and held a bachelor's degree or higher, and most respondents had consumed cannabis at least once in their lifetime.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eWeighted sample characteristics\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;92365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9954)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15007)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15531)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16683)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15650)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19540)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;92365)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.8% (1875)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.5% (2782)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.5% (2873)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.2% (3028)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.5% (2900)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18% (3516)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e18.4% (16974)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.6% (2052)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.6% (3093)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.8% (3232)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.0% (3501)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.0% (3289)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.3% (4156)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20.9% (19323)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36\u0026ndash;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.4% (1934)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.8% (2978)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.0% (3099)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.3% (3382)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.4% (3199)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.6% (4024)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20.2% (18615)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e46\u0026ndash;55 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.1% (2176)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.1% (3010)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.6% (3043)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.3% (3224)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.0% (2968)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.1% (3735)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e19.6% (18069)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e56\u0026ndash;65 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.1% (2090)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.0% (3145)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.1% (3285)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.3% (3548)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.0% (3293)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.0% (4109)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21% (19384)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex at Birth\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.0% (4977)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.9% (7487)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.1% (7775)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.9% (8326)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.9% (7808)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e50.0% (9776)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e50.0% (46149)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.0% (4977)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.1% (7520)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49.9% (7756)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50.1% (8357)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50.1% (7842)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e50.0% (9764)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e50.0% (46216)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77.5% (7716)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.6% (11046)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72% (11109)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68.4% (11415)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e67.5% (10567)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e66.9% (13064)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e70.3% (64916)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEast/South East Asian only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.5% (842)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7% (1163)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.1% (1409)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.5% (1426)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.8% (1383)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9.1% (1782)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e8.7% (8004)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed/Other/Unstated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.8% (382)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.8% (1018)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8% (1052)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.3% (1212)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.5% (1177)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7.4% (1451)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.8% (6291)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouth Asian only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1% (305)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.2% (479)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.7% (580)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.4% (730)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.6% (719)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.5% (1070)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4.2% (3882)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.6% (156)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.6% (545)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.5% (543)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.0% (668)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.0% (775)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.0% (979)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4.0% (3665)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndigenous only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.7% (367)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3% (347)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8% (285)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.6% (441)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.4% (371)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.4% (468)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.5% (2278)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLatino only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.9% (88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5% (219)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8% (278)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.8% (468)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.1% (328)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.6% (321)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.8% (1700)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Eastern only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.0% (99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3% (192)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8% (276)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9% (324)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.1% (331)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.1% (406)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.8% (1627)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome Adequacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.2% (815)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.6% (1434)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.5% (1167)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.7% (1459)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.2% (1604)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12.1% (2357)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e9.6% (8834)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.1% (2001)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.4% (3354)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.5% (2869)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.0% (3175)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22.1% (3459)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e23.6% (4614)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21.1% (19473)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeither easy nor difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.0% (3583)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.1% (5260)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.5% (5821)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.1% (5858)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34.1% (5341)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e33.8% (6599)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e35.1% (32461)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEasy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.2% (2112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.8% (2967)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.1% (3437)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.5% (3584)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.1% (3146)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.8% (3671)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20.5% (18918)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery easy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.2% (1118)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.6% (1444)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.8% (1674)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.1% (2020)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.1% (1585)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9.1% (1776)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e10.4% (9617)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.3% (325)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.6% (547)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.6% (562)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.5% (588)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.3% (516)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.7% (524)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3.3% (3062)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.3% (1524)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.4% (2309)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.2% (2358)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.2% (2541)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.3% (2076)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13.5% (2609)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e14.5% (13417)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school diploma or equivalent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.7% (2656)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.5% (3976)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.5% (4112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.4% (4405)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26.1% (4079)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25.9% (5062)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e26.3% (24290)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor's degree or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.4% (5712)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.2% (8586)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.3% (8895)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e57.4% (9568)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59.6% (9324)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e59.7% (11665)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e58.2% (53749)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6% (62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.9% (136)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1% (166)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0% (170)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.1% (170)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.0% (205)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.0% (909)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental Health Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.6% (7223)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.0% (9155)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.3% (9362)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e57.6% (9605)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e56.4% (8832)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e57.7% (11280)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e60.0% (55457)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.2% (2603)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.9% (5236)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.3% (5331)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.6% (6113)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37.9% (5924)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e37.4% (7317)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e35.2% (32525)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.3% (128)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.1% (615)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.4% (838)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.8% (965)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.7% (895)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.8% (942)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4.7% (4383)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCannabis Consumption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever consumed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.7% (4345)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.3% (5741)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.5% (6133)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.0% (6343)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38.5% (6027)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e38.3% (7476)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e39.0% (36066)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConsumed more than 1 month ago\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.8% (3758)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.3% (5748)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.1% (5757)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.3% (5885)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36.6% (5732)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36.5% (7128)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e36.8% (34008)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly/Weekly consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.8% (972)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4% (1862)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.9% (1841)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.2% (2195)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.0% (2031)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13.0% (2545)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e12.4% (11446)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaily/almost daily consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8% (879)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.0% (1657)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.6% (1800)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.5% (2259)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.9% (1859)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12.2% (2391)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e11.7% (10845)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Includes \u0026ldquo;Refuse to answer\u0026rdquo; \u0026amp; \u0026ldquo;Don\u0026rsquo;t Know\u0026rdquo; responses\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e[INSERT Table 1]\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge of individual health effects\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows levels of agreement for each of the 7 health effects, by year. Differences in health knowledge observed by cannabis consumption status are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e\u0026ndash;2.7. Across all years, health knowledge was highest for beliefs about driving impairment and consumption during pregnancy and breastfeeding, and lowest for beliefs about risk of psychosis and schizophrenia and diabetes from marijuana use. (See Supplemental Table\u0026nbsp;2 for responses by survey year and frequency of cannabis consumption.)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e[INSERT FIGURE 1]\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e[INSERT FIGURE \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e\u0026ndash;2.7]\u003c/h2\u003e\u003cp\u003eSupplemental Tables\u0026nbsp;3.1 to 3.7 show unadjusted and adjusted models testing changes over time for each health belief. Knowledge levels were lower in 2023 compared to 2018 for the effects of marijuana consumption during pregnancy and breastfeeding (2018\u0026thinsp;=\u0026thinsp;72.9% vs. 2023\u0026thinsp;=\u0026thinsp;70.2%; OR\u0026thinsp;=\u0026thinsp;0.87, 0.81\u0026ndash;0.94; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), driving impairment (2018\u0026thinsp;=\u0026thinsp;81.3% vs. 2023\u0026thinsp;=\u0026thinsp;79.6%; OR\u0026thinsp;=\u0026thinsp;0.90, 0.82\u0026ndash;0.98; p\u0026thinsp;=\u0026thinsp;.015), risk of psychosis and schizophrenia (2018\u0026thinsp;=\u0026thinsp;38.1% vs. 2023\u0026thinsp;=\u0026thinsp;35.7%; OR\u0026thinsp;=\u0026thinsp;0.90, 0.84\u0026ndash;0.97; p\u0026thinsp;=\u0026thinsp;.003), and diabetes (2018\u0026thinsp;=\u0026thinsp;36.1% vs. 2023\u0026thinsp;=\u0026thinsp;33.4%; OR\u0026thinsp;=\u0026thinsp;1.25, 1.18\u0026ndash;1.32; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). no differences were observed for beliefs on the harm of marijuana smoke (2018\u0026thinsp;=\u0026thinsp;58.3% vs. 2023\u0026thinsp;=\u0026thinsp;57.8%; OR\u0026thinsp;=\u0026thinsp;0.98, 0.92\u0026ndash;1.05; p\u0026thinsp;=\u0026thinsp;.570), addictive potential (2018\u0026thinsp;=\u0026thinsp;62.6% vs 2023\u0026thinsp;=\u0026thinsp;64.0%; OR\u0026thinsp;=\u0026thinsp;0.98, 0.99\u0026ndash;1.14; p\u0026thinsp;=\u0026thinsp;.080), teenage marijuana consumption (2018\u0026thinsp;=\u0026thinsp;60.0% vs 2023\u0026thinsp;=\u0026thinsp;58.6%; OR\u0026thinsp;=\u0026thinsp;0.94, 0.88\u0026ndash;1.01; p\u0026thinsp;=\u0026thinsp;.087) in unadjusted models. However, in the adjusted models knowledge levels were lower in 2023 compared to 2018 for only the harm of marijuana smoke (AOR\u0026thinsp;=\u0026thinsp;0.92, 0.86\u0026ndash;0.98; p\u0026thinsp;=\u0026thinsp;.012) and risk of diabetes (AOR\u0026thinsp;=\u0026thinsp;0.85, 0.79\u0026ndash;0.91; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Moreover, knowledge levels were higher in 2023 compared to 2018 for addictive potential (OR\u0026thinsp;=\u0026thinsp;1.18, 1.10\u0026ndash;1.23; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), while no differences were observed for other beliefs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eHealth Knowledge Index\u003c/h2\u003e\u003cp\u003eIn the unadjusted linear regression model, compared to Health Knowledge Index sores in 2018, scores were significantly lower in 2020 (β = -0.12, -0.21- -0.03; p\u0026thinsp;=\u0026thinsp;0.006), 2021 (β = -0.25, -0.33- -0.17; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and 2022 (β = -0.23, -0.32- -0.15; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), with no significant differences observed compared to other years. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows pairwise contrasts for other years.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eUnadjusted linear regression model examining the Health Knowledge Index by year\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;92365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeta (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e2018\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.04 (-0.12, 0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.375\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.12 (-0.21, -0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25 (-0.12, 0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.23 (-0.13, 0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.04 (-0.12, 0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.329\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e2019\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08 (0.01, 0.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.21 (0.14, 0.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.19 (0.12, 0.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.00 (-0.07, 0.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.950\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e2020\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.13 (0.06, 0.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.11 (0.04, 0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.08 (-0.15, -0.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e2021\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.02 (-0.09, 0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.606\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.21 (-0.28, -0.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2022\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.19 (-0.26, -0.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/h2\u003e\u003cp\u003eFindings from the adjusted linear regression models were somewhat different than the unadjusted models. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, compared to 2018, scores on the Health Knowledge Index were significantly higher in 2019 (β\u0026thinsp;=\u0026thinsp;0.09, 0.01\u0026ndash;0.17; p\u0026thinsp;=\u0026thinsp;0.032) and 2023 (β\u0026thinsp;=\u0026thinsp;0.14 ;0.06\u0026ndash;0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows pairwise contrasts for all other years.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eAdjusted linear regression model examining the Health Knowledge Index\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;92365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeta (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurvey year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.6 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09 (0.01, 0.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.03 (-0.05, 0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.04 (-0.12, 0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.4 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.05 (-0.13, 0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.255\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.14 (0.06, 0.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCannabis Consumption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever consumed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.8 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsumed more than 1 month ago\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.21 (-0.25, -0.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly/Weekly consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.7 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.00 (-1.07, -0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaily/almost daily consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.4 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.30 (-1.38, -1.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental Health Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.1 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.13 (-1.25, -1.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.15 (-0.20, -0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.40 (-0.44, -0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.0 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.59 (-0.67, -0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36\u0026ndash;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.39 (-0.47, -0.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e46\u0026ndash;55 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.12 (-0.19, -0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e56\u0026ndash;65 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.8 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.16 (-0.23, -0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.6 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEast/South East Asian only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.4 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.39 (-0.46, -0.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed/Other/Unstated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.0 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.35 (-0.44, -0.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouth Asian only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.57 (-0.67, -0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.9 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.59 (-0.70, -0.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndigenous only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.7 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.55 (-0.70, -0.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLatino only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.0 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.53 (-0.70, -0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Eastern only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.47 (-0.64, -0.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome Adequacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09 (0.01, 0.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeither easy nor difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.4 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.05 (-0.13, 0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEasy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.13 (0.05, 0.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery easy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10 (0.01, 0.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.5 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.62 (-0.76, -0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school or equivalent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.01 (-0.08, 0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.890\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor's degree or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.6 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.42 (0.34, 0.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot stated*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.9 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.57 (-0.81, -0.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCompared to respondents who reported having no mental health diagnoses, Health Knowledge Index scores were significantly lower among those who reported 1 or more mental health diagnoses (β = -0.15, -0.20 - -0.11, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and those who did not respond to this question (β = -1.13, -1.25 - -1.02, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Compared to respondents who reported 1 or more mental health diagnoses scores were lower among those who did not report (β =-0.98, -1.10 - -0.86, \u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003eYounger age was associated with higher Health Knowledge Index scores. Compared to 16\u0026ndash;25-year-old respondents, scores were significantly lower among all other age groups, including 26\u0026ndash;35-year-old (β = -0.59, -0.67 - -0.51, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), 36\u0026ndash;45 year old (β = -0.39, -0.47 - -0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), 46\u0026ndash;55 year old (β = -0.12, -0.19 - -0.04, p\u0026thinsp;=\u0026thinsp;0.002), and 56\u0026ndash;65 year old respondents (β = -0.16, -0.23 - -0.09, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Females also reported greater health knowledge than males (β\u0026thinsp;=\u0026thinsp;0.40, 0.36\u0026ndash;0.44, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Ethnicity was also significant associated with health knowledge. Compared to respondents who identified as White only, scores were lower for all other identified ethnicities including East/South East Asian only (β = -0.39, -0.46 \u0026ndash; -0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), South Asian only (β = -0.57, -0.67 \u0026ndash; -0.46, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Black only (β = -0.59, -0.70 \u0026ndash; -0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Indigenous only (β = -0.55, -0.70 \u0026ndash; -0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Latino only (β = -0.53, -0.70 \u0026ndash; -0.36, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Middle Eastern only (β = -0.47, -0.64 \u0026ndash; -0.30, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and those who identified as mixed, other, or did not state (β = -0.35, -0.44 \u0026ndash; -0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003eHealth knowledge was generally inversely associated with income adequacy and education level. For example, respondents who reported \u0026ldquo;very difficult\u0026rdquo; income adequacy reported lower Health Knowledge Index scores than those who reported their income adequacy as difficult (β\u0026thinsp;=\u0026thinsp;0.09, 0.01\u0026ndash;0.17; p\u0026thinsp;=\u0026thinsp;0.036), easy (β\u0026thinsp;=\u0026thinsp;0.13, 0.05\u0026ndash;0.22; p\u0026thinsp;=\u0026thinsp;0.002) and very easy (β\u0026thinsp;=\u0026thinsp;0.10, 0.01\u0026ndash;0.20; p\u0026thinsp;=\u0026thinsp;0.033). Scores were also lower among respondents with less than a high school diploma compared to those with a bachelor's degree or higher (β\u0026thinsp;=\u0026thinsp;0.42, 0.34\u0026ndash;0.49; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). In addition, scores among those who did not state their education were significantly lower compared to all other groups, including those with less than a high school diploma (β = -0.57, -0.81 - -0.33; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), those with a high school diploma or equivalent (β = -0.58, -0.81 - -0.34; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and those with a bachelor\u0026rsquo;s degree or higher (β = -0.99, -1.21 - -0.76; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows mean Health Knowledge Index scores across all survey years by cannabis consumption. Compared to those who never consumed cannabis, scores were significantly lower among daily/almost daily consumers (β = -1.30, -1.38 - -1.22; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), monthly/weekly consumers (β =-1.00, -1.07 - -0.92; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and those who consumed more than 1 month ago (β = -0.21, -0.25 - -0.16; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Those who consumed cannabis more than 1 month ago also scored significantly higher than both monthly/weekly consumers (β\u0026thinsp;=\u0026thinsp;0.79, 0.72\u0026ndash;0.86; p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and daily/almost daily consumers (β\u0026thinsp;=\u0026thinsp;1.09, 1.01\u0026ndash;1.17; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Furthermore, monthly/weekly consumers scored significantly higher than daily/almost daily consumers (β\u0026thinsp;=\u0026thinsp;0.30, 0.21\u0026ndash;0.40; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003e[INSERT Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eNoticing cannabis product health warning labels, cannabis advertising, and education campaigns\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the mean Health Knowledge Index score and regression coefficient from the adjusted linear regression models including each of the three policy-relevant variables: noticing health warnings, cannabis advertising, and education campaigns respectively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eEffects model regressing noticing of cannabis product health warning labels, cannabis advertising, and education campaigns on Health Knowledge Index\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;92,365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeta (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticing health warning labels on products\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.58 (0.51, 0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.9 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.26 (0.21, 0.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.5 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.47 (-0.56, -0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRefuse to answer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.4 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.97 (-1.75, -0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNoticing cannabis advertising\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed no ads\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed an ad in at least 1 channel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.4 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.17 (-0.22, -0.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.6 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.75 (-0.83, -0.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNoticing education campaigns\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed no education campaigns\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.6 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed an education campaign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.5 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.01 (-0.03, 0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.651\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon't know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.7 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.57 (-0.64, -0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRespondents who reported seeing cannabis health warnings in the past 12 months had higher Health Knowledge Index scores compared to those who reported seeing no cannabis health warnings (β\u0026thinsp;=\u0026thinsp;0.58, 0.51\u0026ndash;0.64; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), those who had not seen any cannabis products or packages (β\u0026thinsp;=\u0026thinsp;0.32, 0.25\u0026ndash;0.38; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), those who reported not knowing whether they saw warnings (β\u0026thinsp;=\u0026thinsp;1.05, 0.96\u0026ndash;1.15; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and those who refused to answer (β\u0026thinsp;=\u0026thinsp;1.54, 0.76\u0026ndash;2.33; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Furthermore, respondents who had not seen any cannabis products reported higher scores than those who reported not knowing whether they saw warning labels (β\u0026thinsp;=\u0026thinsp;0.73, 0.65\u0026ndash;0.82; p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and those who refused to answer (β\u0026thinsp;=\u0026thinsp;1.23, 0.44\u0026ndash;2.01; p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\u003cp\u003eRespondents who reported seeing cannabis advertisements in the past 12 months reported lower Health Knowledge Index scores compared to those who reported seeing no advertisements (β = -0.17, -0.22 - -0.13; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). In addition, respondents who reported not knowing if they had seen any cannabis advertisements reported lower scores compared to respondents who reported seeing cannabis advertisements (β = -0.58, -0.66 - -0.50; p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and those who reported seeing no advertisements (β = -0.75, -0.83 - -0.68; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003eRespondents who reported seeing an educational campaign reported higher Health Knowledge Index scores compared to those who did not know whether they had noticed any (β\u0026thinsp;=\u0026thinsp;0.58, 0.51\u0026ndash;0.66; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), while scoring not significantly different compared to those who reported noticing no education campaigns (β\u0026thinsp;=\u0026thinsp;0.01, -0.03\u0026ndash;0.05; p\u0026thinsp;=\u0026thinsp;0.651). In addition, those who reported noticing no education campaigns reported higher scores than those who did not know whether they had noticed any (β\u0026thinsp;=\u0026thinsp;0.57, 0.50\u0026ndash;0.64; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003eDifferences in Health Knowledge Index scores were also observed by cannabis consumption status and noticing of cannabis product health warning labels, cannabis advertising, and education campaigns. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, scores increased with decreasing cannabis consumption frequency.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eMean Health Knowledge Index scores by noticing of cannabis product health warning labels, cannabis advertising, and education campaigns and cannabis consumption status\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;92365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNever consumed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConsumed more than 1 month ago\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMonthly/ Weekly consumption\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDaily/almost daily consumption\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eNoticing cannabis product health warning labels\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.5 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.0 (3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.0 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.4 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.1 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.9 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.2 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.7 (3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.3 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.4 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.9 (2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRefuse to answer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.8 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.6 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.9 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.4 (4.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNoticing cannabis advertising\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed no ads\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.0 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.9 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.2 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.7 (2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed an ad in at least 1 channel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.8 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.5 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.3 (3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.9 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.9 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.1 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.7 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNoticing education campaigns\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed no education campaigns\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.9 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.8 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.0 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.5 (2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed an education campaign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.0 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.7 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.6 (3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.4 (3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon't know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.9 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.9 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e]\u003c/h2\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe current study is among the first to examine changes in health knowledge of cannabis before and after cannabis legalization. Most notably, no significant changes were observed in overall health knowledge from pre-legalization in 2018 to five years post-legalization in 2023, contrary to our hypothesis. Overall levels of health knowledge dipped in 2020 before returning to pre-legalization levels in 2023. The temporary decrease observed in 2020 may be associated with the emergence of COVID-19 pandemic, which was characterized by increases in substance use among adults, including cannabis (\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The current findings are generally consistent with trends observed in the Canadian Cannabis Survey (CCS) over the same period, in which few changes were observed in health knowledge between 2018 and 2023, except for modest increases in the percentage who agreed that cannabis was \u0026lsquo;habit forming\u0026rsquo; and smoking cannabis was harmful, and decreases in agreement with the effect of frequent use on mental health (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLarge differences were observed in the level of agreement with different health effects. Agreement was highest for the risks of impaired driving, which is a common focus for public health education campaigns in Canada. Nevertheless, one third of respondents did not agree that it can be dangerous to drive or operate machinery after using cannabis. Of greatest concern, only one third of respondents agreed that regular cannabis consumption can increase the risk of psychosis and schizophrenia, similar to the percentage who incorrectly reported that cannabis can cause diabetes. Consistent with the current findings, the Canadian Cannabis Survey also found the lowest levels of agreement for mental health effects, despite strong evidence to the contrary (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Interestingly, respondents in the current study who reported previous experience of a mental health condition were more likely to agree that regular cannabis consumption can increase the risk of psychosis and schizophrenia, despite reporting lower overall scores on the health knowledge index, similar to previous findings (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Overall, the lack of knowledge for mental health effect warrants greater attention, particularly given higher levels of cannabis consumption among people with a history of mental health conditions compared to the general population.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs with previous studies, people that consume cannabis reported lower levels of agreement than non-consumers.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This is consistent with a large number of studies demonstrating optimism bias among those that use substances including cannabis and tobacco (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Other individual-level differences were observed, including greater health knowledge among younger respondents. As hypothesized, the youngest age group of 16\u0026ndash;25-year-old respondents had the highest health knowledge compared to all other groups. Other studies also indicate that younger age groups report higher health knowledge and risk perception of cannabis compared to older ages (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Knowledge gaps were also observed by income adequacy and education. As hypothesized, higher socioeconomic status in terms of income adequacy and educational attainment was associated with greater health knowledge. Evidence on socioeconomic status (SES) and risk perception of cannabis consumption is mixed; although one study found that SES indexed by parental education, household income, and cash-on-hand was not related to either risk assimilation or risk denial of cannabis consumption (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), others have supported an association between increased cannabis consumption and low SES (\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), which may suggest a potential relationship for risk perceptions and SES. Lower levels of health knowledge among males and \u0026lsquo;non-white\u0026rsquo; minority groups are also consistent with previous studies. Markedly lower levels of among respondents self-identifying as \u0026lsquo;black\u0026rsquo; and \u0026lsquo;indigenous\u0026rsquo;\u0026mdash;two groups that were disproportionately affected by cannabis prohibition\u0026mdash;suggests further efforts are required to reduce cannabis-related disparities, as noted in a recent legislative review (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo our knowledge, the current study is the first to examine population-levels of health knowledge for cannabis and associations with risk communication policies. Noticing the mandated health warnings on cannabis products was associated with greater health knowledge. Previous studies examining the effectiveness of cannabis health warnings found that warning labels are associated with increased knowledge of health effects and increased perceived harm of smoking cannabis (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Similarly, in the current study seeing cannabis advertisements was associated with lower health knowledge, consistent with findings from cannabis, tobacco, and alcohol research, which have indicated that positive imagery conveyed in advertising can reduce perceptions of harm (\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). In contrast, noticing education campaigns was not associated with health knowledge. Few studies have examined the association between noticing public health education campaigns and cannabis risk perceptions; however, findings in Canada\u0026rsquo;s northern territories found higher risk perceptions of daily cannabis smoking associated with noticing campaigns (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). The effect of public education campaigns are likely to vary depending upon the prominence and effectiveness of individual media campaigns (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Future research on the impact of specific public education campaigns is warranted.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe current study is subject to several limitations common to survey research. The study design is repeat cross-sectional and did not examine individual-level changes over time. Respondents were recruited using non-probability-based sampling; therefore, the findings do not necessarily provide nationally representative estimates. However, the data were adjusted by age group, sex, education, income adequacy, mental health status, and consumption status. Additionally, the measures of health knowledge used agreement questions and conditional causal wording such as \u0026lsquo;can\u0026rsquo; when asking about health effects; which may both lead to higher estimates of health knowledge compared to open-ended, definite causal statements of health effects (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Finally, the brief pre-legalization \u0026lsquo;baseline\u0026rsquo; period represents a limitation. It is possible that levels of health knowledge may have been changing over a longer period, including in the build up to legalization, during which considerable media attention and public debate about the health effects of cannabis. While a longer baseline period would be an asset, the stability of health knowledge over the course of the 5-year post-legalization period covered by the current study remains notable.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe current study suggests that population-level knowledge of the health knowledge of cannabis has generally remain unchanged since the legalization of recreational cannabis in 2018. The lack of change may represent a type of \u0026lsquo;stalemate\u0026rsquo; between opposing forces. On the one hand, legalization has the potential to normalize cannabis consumption and undermine perceptions of risk through exposure to cannabis promotions and increased cannabis consumption. On the other hand, legalization provides greater opportunities and responsibility to convey information on the risks of cannabis consumption. This is particularly true in legal markets such as Canada, where all provincial and territorial governments serve as retailers and/or distributors for licensed cannabis products, which also provides resources for education campaigns. The lack of change in health knowledge in the first five years following legalization may allay some concerns about the immediate impact of legalization; however, it also highlights notable knowledge gaps and disparities between population subgroups that will require dedicated efforts to address. Continued monitoring is also essential given the relatively early stage of Canada\u0026rsquo;s legal market and the potential for longer term changes over time.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was reviewed by and received ethics clearance through a University of Waterloo Research Ethics Committee (ORE#31330).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by a Canadian Institutes of Health Research Project Bridge Grant (PJT-153342) and a Canadian Institutes of Health Research Project Grant (PJT-153342).\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eAll authors were involved in the overall conceptualization, methodology and review of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the ICPS Research team and staff for their assistance.\u003c/p\u003e\n\u003cp\u003eDeclaration of interest\u003c/p\u003e\n\u003cp\u003eHammond has served as a paid expert witness on behalf of public health authorities in response to legal challenges from the cannabis, tobacco, and vaping industries.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRosenberg M, Ayonrinde O, Conrod PJ, Levesque LL, Selby P. Legislative review of the Cannabis Act, in Final Report of the Expert Panel [Internet]. Health Canada Ottawa; 2024. Available from: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/drugs-medication/legislative-review-cannabis-act-final-report-expert-panel/legislative-review-cannabis-act-final-report-expert-panel.pdf\u003c/li\u003e\n\u003cli\u003eWeinstein ND. What does it mean to understand a risk? Evaluating risk comprehension. J Natl Cancer Inst Monogr. 1999;(25):15\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eGlanz K, Rimer BK, Viswanath K. Health behavior: Theory, research, and practice, 5th ed. 5th ed. John Wiley \u0026amp; Sons; 2015. 512 p. \u003c/li\u003e\n\u003cli\u003eHyland A, Li Q, Bauer JE, Giovino GA, Steger C, Cummings KM. Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2004 Dec;6 Suppl 3:S363\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCurry SJ, Grothaus L, McBride C. Reasons for quitting: intrinsic and extrinsic motivation for smoking cessation in a population-based sample of smokers. Addict Behav. 1997;22(6):727\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eHammond D, McDonald PW, Fong GT, Brown KS, Cameron R. The impact of cigarette warning labels and smoke-free bylaws on smoking cessation: evidence from former smokers. Can J Public Health Rev Can Sante Publique. 2004;95(3):201\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eUS Department of Health and Human Services. The Health Consequences of Smoking\u0026mdash;50 Years of Progress: A Report of the Surgeon General [Internet]. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014 [cited 2024 Dec 13]. (Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK179276/\u003c/li\u003e\n\u003cli\u003eSalloum NC, Krauss MJ, Agrawal A, Bierut LJ, Grucza RA. A reciprocal effects analysis of cannabis use and perceptions of risk. Addiction. 2018;113(6):1077\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003ePacek LR, Mauro PM, Martins SS. Perceived risk of regular cannabis use in the United States from 2002 to 2012: Differences by sex, age, and race/ethnicity. Drug Alcohol Depend. 2015 Apr 1;149:232\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eMader J, Smith JM, Smith J, Afzal AR, Arria A, Bugbee BA, et al. Correlates of Perceived Harmfulness of Regular Cannabis Use among Canadian University Students Before and After Legalization. Cannabis. 2022;5(3):23\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eMcMahon I, Harris-Lane LM, Donnan J, Bishop L, Harris N. Emerging adult perceptions of higher-risk cannabis consumption behaviours. Harm Reduct J. 2023 Sept 7;20(1):127. \u003c/li\u003e\n\u003cli\u003eSalloum NC, Krauss MJ, Agrawal A, Bierut LJ, Grucza RA. A reciprocal effects analysis of cannabis use and perceptions of risk. Addiction. 2018;113(6):1077\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eLeos-Toro C. Health warnings, cannabis marketing and perceptions among youth and young adults in Canada [Internet] [PhD Thesis]. 2019. Available from: http://hdl.handle.net/10012/14544\u003c/li\u003e\n\u003cli\u003eGovernment of Canada. Canadian Cannabis Survey 2023: Summary [Internet]. 2024. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/research-data/canadian-cannabis-survey-2023-summary.html#s2-1\u003c/li\u003e\n\u003cli\u003eRobinson J, Copeland C, Pilin M, Meyer A, Krank M. The Impact of Cannabis Legalization in Canada on Adolescents\u0026rsquo; Perceptions. J Drug Issues. 2020 Feb 28;50(3):235\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eSarvet AL, Wall MM, Keyes KM, Cerd\u0026aacute; M, Schulenberg JE, O\u0026rsquo;Malley PM, et al. Recent rapid decrease in adolescents\u0026rsquo; perception that marijuana is harmful, but no concurrent increase in use. Drug Alcohol Depend. 2018 May 1;186:68\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eMennis J, McKeon TP, Stahler GJ. Recreational cannabis legalization alters associations among cannabis use, perception of risk, and cannabis use disorder treatment for adolescents and young adults. Addict Behav. 2023 Mar;138:107552. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connell M, Levy S, Shrier LA, Harris SK. Trends in cannabis-related attitudes and behaviors among cannabis-using adolescent and young adult outpatients following medical cannabis legalization in Massachusetts. Subst Abuse. 2022;43(1):328\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eHarpin SB, Brooks-Russell A, Ma M, James KA, Levinson AH. Adolescent Marijuana Use and Perceived Ease of Access Before and After Recreational Marijuana Implementation in Colorado. Subst Use Misuse. 2018 Feb 23;53(3):451\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eEstoup AC, Moise-Campbell C, Varma M, Stewart DG. The Impact of Marijuana Legalization on Adolescent Use, Consequences, and Perceived Risk. Subst Use Misuse. 2016 Dec 5;51(14):1881\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eBailey JA, Epstein M, Roscoe JN, Oesterle S, Kosterman R, Hill KG. Marijuana Legalization and Youth Marijuana, Alcohol, and Cigarette Use and Norms. Am J Prev Med. 2020 Sept;59(3):309\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eBlevins CE, Marsh E, Banes KE, Stephens RS, Walker DD, Roffman RA. The Implications of Cannabis Policy Changes in Washington on Adolescent Perception of Risk, Norms, Attitudes, and Substance Use. Subst Abuse Res Treat [Internet]. 2018;12. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1177/1178221818815491\u003c/li\u003e\n\u003cli\u003eWall MM, Poh E, Cerd\u0026aacute; M, Keyes KM, Galea S, Hasin DS. Adolescent marijuana use from 2002 to 2008: higher in states with medical marijuana laws, cause still unclear. Ann Epidemiol. 2011 Sept;21(9):714\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eGoodman S, Hammond D. Perceptions of the health risks of cannabis: estimates from national surveys in Canada and the United States, 2018\u0026ndash;2019. Health Educ Res. 2022 Mar 24;37(2):61\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eTask Force on Cannabis Legalization and Regulation. A Framework for the Legalization and Regulation of Cannabis in Canada [Internet]. 2016 Dec. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/laws-regulations/task-force-cannabis-legalization-regulation/framework-legalization-regulation-cannabis-in-canada.html\u003c/li\u003e\n\u003cli\u003eNational Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012 [cited 2025 July 3]. (Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK99237/\u003c/li\u003e\n\u003cli\u003eHealth Canada. Cannabis health warning messages [Internet]. 2025 [cited 2025 July 3]. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/laws-regulations/regulations-support-cannabis-act/health-warning-messages.html\u003c/li\u003e\n\u003cli\u003eGoodman S, Rynard VL, Iraniparast M, Hammond D. Influence of package colour, branding and health warnings on appeal and perceived harm of cannabis products among respondents in Canada and the US. Prev Med [Internet]. 2021;153. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1016/j.ypmed.2021.106788\u003c/li\u003e\n\u003cli\u003eMassey ZB, Hammond D, Froeliger B. A systematic review of cannabis health warning research. Prev Med Rep. 2024 Jan;37:102573. \u003c/li\u003e\n\u003cli\u003eGoodman S, Leos-Toro C, Hammond D. Do Mandatory Health Warning Labels on Consumer Products Increase Recall of the Health Risks of Cannabis? Subst Use Amp Misuse. 2022;57(4):569. \u003c/li\u003e\n\u003cli\u003eGoodman S, Hammond D. Noticing of cannabis health warning labels in Canada and the US. Health Promot Chronic Dis Prev Can Res Policy Pract. 2021;41(7\u0026ndash;8):201\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eHan BH, Funk-White M, Ko R, Al-Rousan T, Palamar JJ. Decreasing perceived risk associated with regular cannabis use among older adults in the United States from 2015 to 2019. J Am Geriatr Soc. 2021;69(9):2591\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHealth Canada. Cannabis use among older adults in Canada: Exploring perspectives and experiences following cannabis legalization [Internet]. 2023 Dec [cited 2024 Nov 5]. Available from: https://publications.gc.ca/collections/collection_2024/sc-hc/H14-595-2024-eng.pdf\u003c/li\u003e\n\u003cli\u003eHuỳnh C, Roy S, Beaulieu-Thibodeau A, Bri\u0026egrave;re-Charest K, Milot DM. Age differences in cannabis-related perceptions, knowledge, and sources of information among adults in the post-legalization era in Quebec, Canada. Journal of Studies on Alcohol and Drugs. 2024. \u003c/li\u003e\n\u003cli\u003eHendrickson RG, McKeown NJ, Kusin SG, Lopez AM. Acute cannabis toxicity in older adults. Toxicol Commun. 2020 Jan 1;4(1):67\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eKuerbis A. Substance Use among Older Adults: An Update on Prevalence, Etiology, Assessment, and Intervention. Gerontology. 2019 Dec 6;66(3):249\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eHammond D, Goodman S, Wadsworth E, Rynard V, Boudreau C, Hall W. Evaluating the impacts of cannabis legalization: The International Cannabis Policy Study. Int J Drug Policy [Internet]. 2020;77. Available from: https://doi-org.proxy.lib.uwaterloo.ca/10.1016/j.drugpo.2020.102698\u003c/li\u003e\n\u003cli\u003eAbrams DI. The therapeutic effects of Cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. Eur J Intern Med. 2018 Mar 1;49:7\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eActon R, White C, Ryanrd V, Hammond D. Perceived income adequacy versus household income as a measure of socioeconomic status in cross-sectional population-level surveys conducted in six countries: an analysis of the 2022-2023 International Food Policy Study. Public Heatlth Rep. 2025; \u003c/li\u003e\n\u003cli\u003eWinfield-Ward L, Wadsworth E, Driezen P, Rynard V, Hammond D. Exposure to cannabis marketing in the United States and differences by cannabis laws: Findings from the International Cannabis Policy Study. Drug Alcohol Depend. 2025; \u003c/li\u003e\n\u003cli\u003eImtiaz S, Wells S, Rehm J, Hamilton HA, Nigatu YT, Wickens CM, et al. Cannabis Use During the COVID-19 Pandemic in Canada: A Repeated Cross-sectional Study. J Addict Med. 2021 Dec 1;15(6):484\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eKar P, Tomfohr-Madsen L, Giesbrecht G, Bagshawe M, Lebel C. Alcohol and substance use in pregnancy during the COVID-19 pandemic. Drug Alcohol Depend. 2021 Aug 1;225:108760. \u003c/li\u003e\n\u003cli\u003eBartel SJ, Sherry SB, Stewart SH. Self-isolation: A significant contributor to cannabis use during the COVID-19 pandemic. Subst Abuse. 2020;41(4):409\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eThornton LK, Baker AL, Johnson MP, Lewin T. Perceived risk associated with tobacco, alcohol and cannabis use among people with and without psychotic disorders. Addict Behav. 2013;38(6):2246. \u003c/li\u003e\n\u003cli\u003eRup J, Freeman TP, Perlman C, Hammond D. Cannabis and Mental Health: Adverse Outcomes and Self-Reported Impact of Cannabis Use by Mental Health Status. Subst Use Misuse. 2022;57(5):719\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eLee G, Hicks DL, Kedia S, Regmi S, Mou X. Mental health problems, substance use, and perceived risk as pathways to current cannabis use among high school seniors in the United States. Child Youth Serv Rev. 2024 Mar 1;158:107456. \u003c/li\u003e\n\u003cli\u003eGette JA, Cundiff JM, Gissandaner TD, Littlefield AK. Relations between cannabis use, socioeconomic status, and risk perceptions in a Hispanic/Latinx population. J Ethn Subst Abuse. 2022 Nov 4;21(4):1432\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eBoden JM, Dhakal B, Foulds JA, Horwood LJ. Life-course trajectories of cannabis use: a latent class analysis of a New Zealand birth cohort. Addiction. 2020;115(2):279\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eCerd\u0026aacute; M, Moffitt TE, Meier MH, Harrington H, Houts R, Ramrakha S, et al. Persistent Cannabis Dependence and Alcohol Dependence Represent Risks for Midlife Economic and Social Problems: A Longitudinal Cohort Study. Clin Psychol Sci. 2016 Nov 1;4(6):1028\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eRafei P, Englund A, Lorenzetti V, Elkholy H, Potenza MN, Baldacchino AM. Transcultural Aspects of Cannabis Use: a Descriptive Overview of Cannabis Use across Cultures. Curr Addict Rep. 2023 Sept 1;10(3):458\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eMutti-Packer S, Collyer B, Hodgins DC. Perceptions of plain packaging and health warning labels for cannabis among young adults: findings from an experimental study. BMC Public Health. 2018 Dec;18(1):1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003ePepper JK, Lee YO, Eggers ME, Allen JA, Thompson J, Nonnemaker JM. Perceptions of U.S. and Canadian Cannabis Package Warnings Among U.S. Adults. Drug Alcohol Depend. 2020;217. \u003c/li\u003e\n\u003cli\u003eK K, D H. The impact of cigarette pack shape, size and opening: evidence from tobacco company documents. Addict Abingdon Engl [Internet]. 2013 Sept [cited 2025 Apr 23];108(9). Available from: https://pubmed.ncbi.nlm.nih.gov/23600674/\u003c/li\u003e\n\u003cli\u003eMoodie C, Ford A. Young adult smokers\u0026rsquo; perceptions of cigarette pack innovation, pack colour and plain packaging. Australas Mark J AMJ. 2011 Aug 1;19(3):174\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eBhat A, Shilpashree KB, Krishnamurthy A, Manjunath C, Shwetha R, Madhusudhan S. Adolescent\u0026rsquo;s Perception about the Introduction of New Cigarette Packaging and Plain Packaging of Cigarette Packs: A Qualitative Study. Indian J Community Med Off Publ Indian Assoc Prev Soc Med. 2018 Dec;43(Suppl 1):S47\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eSchwartz N, Poon T, Hammond D, Hobin E. Associations between noticing public health education campaigns about cannabis and risk perceptions in the northern Canadian territories: a cross-sectional study. Health Educ Res [Internet]. 2024 June 21; Available from: https://www.ncbi.nlm.nih.gov/pubmed/38905013\u003c/li\u003e\n\u003cli\u003eWakefield M, Loken B, Hornik R. Use of mass media campaigns to change health behaviour. Lancet Lond Engl [Internet]. 2010 Oct 9 [cited 2025 Apr 23];376(9748). Available from: https://pubmed.ncbi.nlm.nih.gov/20933263/\u003c/li\u003e\n\u003cli\u003eHornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the National Youth Anti-Drug Media Campaign on youths. Am J Public Health [Internet]. 2008 Dec [cited 2025 Apr 23];98(12). Available from: https://pubmed.ncbi.nlm.nih.gov/18923126/\u003c/li\u003e\n\u003cli\u003eWeinstein N, Slovic P, Waters E, Gibson G. Public understanding of the illnesses caused by cigarette smoking. Nicotine Tob Res Off J Soc Res Nicotine Tob [Internet]. 2004 Apr [cited 2025 Apr 14];6(2). Available from: https://pubmed.ncbi.nlm.nih.gov/15203808/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"health knowledge, risk perception, cannabis, Canada, legalization","lastPublishedDoi":"10.21203/rs.3.rs-7602619/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7602619/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTo date, few studies have examined the impact of legalization on important psychosocial predictors of cannabis consumption, including risk perceptions. This study addresses this gap by analyzing trends in knowledge of health effects of cannabis consumption following the legalization of recreational cannabis in Canada.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData were collected from repeated cross-sectional national surveys conducted in the year prior to legalization of \u0026lsquo;recreational\u0026rsquo; cannabis in Canada (2018), and five years post-legalization (2019\u0026ndash;2023) among 93,933 respondents aged 16\u0026ndash;65. Regression models examined differences pre vs. post-legalization in health knowledge, assessed as agreement with each of 7 health effects from cannabis and a composite Health Knowledge Index, adjusting for cannabis consumption, mental health history, and sociodemographics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAcross all years, agreement was highest for the risks of impaired driving (79\u0026ndash;81%) and lowest for psychosis and schizophrenia risk (34\u0026ndash;38%). Health knowledge was highest among non-consumers, those without mental illness history, and youth aged 16\u0026ndash;25 (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, all contrasts). No changes were observed in the Health Knowledge Index pre vs post-legalization; however, modest increases were observed for harms during pregnancy or breastfeeding (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), cannabis addiction (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), risk of psychosis and schizophrenia (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and teen consumption (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOverall, only modest differences in knowledge of cannabis health effects were observed in the 5 years following cannabis legalization in Canada; however, persistent gaps in health knowledge persisted, particularly among frequent consumers.\u003c/p\u003e","manuscriptTitle":"Knowledge about the health effects of cannabis before and after ‘recreational’ cannabis legalization in Canada: Findings from the International Cannabis Policy Study, 2018 – 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 12:21:26","doi":"10.21203/rs.3.rs-7602619/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-07T01:41:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T15:40:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-17T18:53:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97312789424257709147167893906915520843","date":"2025-11-05T14:09:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52264599539662052850967905948119294941","date":"2025-11-04T13:51:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137269855071307946919905594038099717494","date":"2025-10-21T13:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-17T00:58:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T04:18:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T04:18:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cannabis Research","date":"2025-09-12T17:21:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7492ad6e-7ffd-4cf9-8c5f-d7162103b44f","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T06:53:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-25 12:21:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7602619","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7602619","identity":"rs-7602619","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}