Sharon R. Sznitman

Cannabis for Therapeutic Purposes and public health and safety: A systematic and critical review

BACKGROUND The use of Cannabis for Therapeutic Purposes (CTP) has recently become legal in many places. These policy and legal modifications may be related to changes in cannabis perceptions, availability and use and in the way cannabis is grown and sold. This may in turn have effects on public health and safety. To better understand the potential effects of CTP legalization on public health and safety, the current paper synthesizes and critically discusses the relevant literature. METHODS Twenty-eight studies were identified by a comprehensive search strategy, and their characteristics and main findings were systematically reviewed according to the following content themes: CTP and illegal cannabis use; CTP and other public health issues; CTP, crime and neighbourhood disadvantage. RESULTS The research field is currently limited by a lack of theoretical and methodological rigorous studies. The review shows that the most prevalent theme of investigation so far has been the relation between CTP and illegal cannabis use. In addition, the literature review shows that there is an absence of evidence to support many common concerns related to detrimental public health and safety effects of CTP legalization. CONCLUSION Although lack of evidence provides some reassurance that CTP legalization may not have posed a substantial threat to public health and safety, this conclusion needs to be examined in light of the limitations of studies conducted so far. Furthermore, as CTP policy continues to evolve, including incorporation of greater commercialization, it is possible that the full effects of CTP legalization have yet to take place. Ensuring study quality will allow future research to better investigate the complex role that CTP plays in relation to society at large, and public health and safety in particular.

Exploring substance use normalization among adolescents: A multilevel study in 35 countries

The substance use normalization thesis predicts that adolescent substance users are less likely to report substance use risk factors in high than in low prevalence countries. This study tests whether national population-level alcohol, cigarette and cannabis prevalence rates moderate the strength of the relationship between individual level social and behavioral risk factors and individual level alcohol, cigarette and cannabis use. Data from 2009/2010 Health Behaviour in School-Aged Children Study (N = 68,045, age = 15) from 35 countries was analyzed using logistic Hierarchical Linear Modeling. As expected based on low cannabis prevalence rates in all countries studied, no evidence of normalization was found for recent cannabis use. Also in line with the normalization thesis, results show that for substance use that reaches above 40% in at least some of the countries studied (drunkenness, alcohol and cigarette use), adolescents who reported use are less likely to report social and behavioral risk factors in high prevalence countries than in low prevalence countries. However, support for the normalization thesis was only partial in that results show that in models where evidence for normalization was found, there are risk factors that predict substance use to an equal degree regardless of country level prevalence rates. The current research shows that the normalization thesis is a useful framework for understanding the contextual aspects of adolescent alcohol, tobacco, and cannabis use. The study has implications for drug prevention as it suggests that selective prevention efforts may be particularly useful in low prevalence countries where screening based on risk factors may usefully identify adolescents at most risk for developing drug use problems. This approach may be less useful in high prevalence countries where screening based on risk factors is less likely to satisfactorily identify those at risk for developing drug use problems.

Is cannabis an illicit drug or a medicine? A quantitative framing analysis of Israeli newspaper coverage.

BACKGROUND Various countries and states, including Israel, have recently legalized cannabis for therapeutic purposes (CTP). These changes have received mass media coverage and prompted national and international dialogue about the status of cannabis and whether or not it can be defined as a (legitimate) medicine, illicit and harmful drug, or both. News media framing may influence, and be influenced by, public opinion regarding CTP and support for CTP license provisions for patients. This study examines the framing of CTP in Israeli media coverage and the association between media coverage and trends in the provision of CTP licenses in Israel over time. METHODS All published news articles relevant to CTP and the framing of cannabis (N=214) from the three highest circulation newspapers in Israel were content analyzed. Articles were published between January 2007 and June 2013, a period in which CTP licenses granted by the Ministry of Health increased substantially. RESULTS In the majority of CTP news articles (69%), cannabis was framed as a medicine, although in almost one third of articles (31%) cannabis was framed as an illicit drug. The relative proportion of news items in which cannabis was framed as an illicit drug fluctuated during the study period, but was unrelated to linear or curvilinear trends in CTP licensing. CONCLUSION The relatively large proportion of news items framing cannabis as a medicine is consistent with growing support for the expansion of the Israels CTP program.

Medical Cannabis A Framing Analysis of Israeli Newspaper Coverage

Medical cannabis is a topic of increasing debate. To investigate this issue, we conducted a content analysis of Israeli news coverage of medical cannabis from 2007 to 2013. A deductive framing analysis examined three elite issue frames—medical, policy, and law enforcement. Additionally, inductive analysis revealed a a fourth, nonelite patients’ frame. Each frame was associated with a distinct pattern of textual elements, including portrayal of patients, references to cannabis, opinion about medical cannabis, and salience of scientific research. The most common and most stable frame was the policy frame. Implications for framing theory are discussed.

Normalisation theory: Does it accurately describe temporal changes in adolescent drunkenness and smoking?

INTRODUCTION AND AIMS The multiple risk model postulates that accumulating risk factors increase adolescent drunkenness and smoking. The normalisation theory adds to this by arguing that the relation between accumulative risk and drunkenness and smoking is dependent on the distribution of these behaviours in the larger population. More concretely, normalisation theory predicts that: (i) when population level use increases, low risk adolescents will be more likely to use alcohol and cigarettes; and (ii) adolescents facing multiple risk factors will be equally likely to use alcohol and cigarettes, regardless of trends in population level use. The current study empirically tests these assumptions on five waves of nationally representative samples of Israeli Jewish youth. DESIGN AND METHODS Five cross-sectional waves of data from the Israeli Health Behaviour in School-aged Children survey for Jewish 10th graders were used. Logistic regression models measured the impact of changes in population level use across waves on drunkenness and smoking, and their association with differing levels of risk factors. RESULTS Between zero and two risk factors, the risk of drunkenness and smoking increases for each additional risk factor. When reaching two risk factors, added risk does not significantly increase the likelihood of smoking and drunkenness. Changes in population level drunkenness and smoking did not systematically relate to changes in the individual level relationship between risk factors and smoking and drunkenness. DISCUSSION AND CONCLUSIONS The pattern of results in this study provides strong evidence for the multiple risk factor model and inconsistent evidence for the normalisation theory. [Sznitman SR, Zlotnick C, Harel-Fisch Y. Normalisation theory: Does it accurately describe temporal changes in adolescent drunkenness and smoking? Drug Alcohol Rev 2016;35:424-432].

Examining differences in drinking patterns among Jewish and Arab university students in Israel.

Objectives. Worldwide there is a dearth of studies examining drinking patterns in Arabs and how these compare to other populations. The few studies that exist have suggested distinct drinking patterns in Arabs, with not only high rates of abstinence but also high rates of heavy drinking among current drinkers. No studies have yet examined potential socio-cognitive mechanisms that may contribute to this distinct drinking pattern. Israel represents a unique and valuable resource for studying Arab population drinking patterns because Israeli Arabs are nonimmigrants living in areas where exposure to Western lifestyles, including alcohol consumption, is prevalent. The current study was set out to examine differences in alcohol consumption in a convenience sample of 1310 Jewish and Arab students from Israeli universities and colleges and to explore alcohol expectancies as potential mediators of ethno-religious differences. Design. Logistic regressions were used to produce odds ratios and 95% confidence intervals to test differences between Jewish and Arab students on binary outcomes (lifetime, last month, and heavy drinking). Mediation of ethno-religious differences by alcohol expectancies was tested with bootstrapping procedures. Results. Results show that while Israeli Arab students tend to be more likely to abstain from alcohol than Israeli Jewish students, among current drinkers, Israeli Arab students are at a particular high risk of heavy drinking. Results also show that this is partly mediated by the expectancy that alcohol only influences the drinker at high levels of intake. Conclusion. The current study confirms distinct Arab drinking patterns found in previous studies. The present study is the first demonstration that drinking expectations mediate ethno-religious differences in heavy drinking among Israeli Arabs and Jews. This work contributes to the understanding of ethno-religious group differences in harmful drinking, potentially informing future etiologic research and public health interventions aimed at reducing alcohol-related harm.

The Cannabis Abuse Screening Test (CAST) revisited: examining measurement invariance by age

Defensible use of self‐reported cannabis use problem scales in age comparative frameworks requires that measured constructs have equal psychometric properties across age groups. This study compares the psychometric properties of the Cannabis Abuse Screening Test (CAST) across three age groups (18–24, 25–29, 30–40). Data was collected online from an accessible sample of 1316 cannabis users. Factor analysis compared the optimal factor structure and dimensionality diffraction. Multi‐group Model Invariance tests examined measurement invariance across the three age groups. CAST was two‐dimensional in all age groups with one factor measuring cannabis use problems and the other measuring deviation from a common standard of use. The two‐dimensional structure was more pronounced in older age groups. Weak factorial invariance was supported, suggesting that the meaning of the CAST factors is equivalent across age groups. Partial, but not full, strong factorial invariance was supported, indicating that only the cannabis use problem factor can be defensibly used to measure age group mean differences. Results confirm a well‐defined two‐dimensional CAST structure and factorial invariance across age groups. However, caution is needed when using the two items measuring deviation from a common standard in an age‐comparative framework. Replication studies based on a representative sample are needed.

Do recreational cannabis users, unlicensed and licensed medical cannabis users form distinct groups?

BACKGROUND This study aims to gain a more nuanced perspective on the differences between recreationally and medically motivated cannabis use by distinguishing between people who use cannabis for recreational purposes, unlicensed and licensed medical users. METHODS Data collection was conducted online from a convenience sample of 1479 Israeli cannabis users. Multinomial regression analysis compared unlicensed medical users (38%) with recreational (42%) and licensed medical (5.6%) users in terms of sociodemographics, mode, frequency and problematic cannabis use. RESULTS There were more variables distinguishing unlicensed from licensed users than there were distinguishing features between unlicensed and recreational users. Recreational users were more likely to be male, less likely to eat cannabis, to use cannabis frequently and to use alone and before midday than unlicensed users. Licensed users were older than unlicensed users, they reported less hours feeling stoned, less cannabis use problems and they were more likely to report cannabis use patterns analogous of medication administration for chronic problems (frequent use, vaping, use alone and use before midday). CONCLUSION This study suggests that a sizable proportion of cannabis users in Israel self-prescribe cannabis and that licensed medical cannabis users differ from unlicensed users. This is, in turn, suggestive of a rigorous medicalized cannabis program that does not function as a backdoor for legal access to recreational use. However, due to methodological limitations this conclusion is only suggestive. The most meaningful differences across recreational, unlicensed and licensed users were mode and patterns of use rather than cannabis use problems. Current screening tools for cannabis use problems may, however, not be well suited to assess such problems in medically motivated users. Indeed, when screening for problematic cannabis use there is a need for a more careful consideration of whether or not cannabis use is medically motivated.

Peer social network and adolescent alcohol use

Introduction This review examines the limited, albeit growing research literature related to peer social networks and adolescent alcohol use. Specifically, the literature review examines what types of alcohol use have been examined in relation to social network structures, how social network structures are related to adolescent alcohol use and the implications for public health. Materials and methods A search on PubMed and Sociological Abstracts was conducted to identify relevant keywords contained in the title, abstract and subject descriptors. Searches included combinations of the following terms: alcohol, binge drinking, substance use, social network, friendship network, peer influences, youth and adolescents. Results This review shows that while studies have generally examined moderate alcohol use, initiation and heavy use have been less studied. In terms of social network structures, researchers have mainly focused on influence/selection, network relation type and sociometric positions. While the literature is often ambiguous in terms of the association between network structures and adolescent alcohol use, there are some instances where the literature paints a coherent picture. The literature tends to agree that both selection and influence is important when explaining peer similarity in alcohol use and popular adolescents tend to be at risk for alcohol use. Discussion Based on the literature reviewed, this paper offers four recommendations for future social network research that may help fill current gaps in the literature: (1) focus more on harmful use of alcohol and alcohol initiation, (2) determine whether resistance skills work differently based on network relation type, (3) focus more on how adolescent social networks are formed and how these formation processes influence adolescent alcohol use and (4) examine whether use of network data can support peer-led alcohol use interventions and identification of peer leaders. Conclusion The limited available literature suggests that there are significant structural and alcohol use aspects of peer relations that are important to adolescent alcohol use. Future research should continue to apply social network analysis to the study of adolescent alcohol use to improve the knowledge which can be used to develop better prevention and intervention programs to reduce alcoholrelated harm.

Examining the blurred boundaries between medical and recreational cannabis – results from an international study of small-scale cannabis cultivators

Abstract Aim: To compare characteristics of recreational vs. medical growers in a sample of small-scale cannabis cultivators from 12 countries. Methods: Six thousand eight hundred ninety six respondents who took part in an online survey were divided into three groups as: those who reported growing for recreational use, those cultivating for medical purposes who also reported use of other illegal drugs, and those who reported cultivation for medical use and didn’t use other illegal substances. The groups were compared using multinomial logistic regression. Findings: In comparison to recreational growers, the two groups of medical growers included more females, consumed cannabis more frequently, and were more likely to cite health-related motivations for growing. The medical growers without other illicit drug use shared some of the same features with the medical growers with illicit drug use, but in comparison to both other groups, they were older, used less alcohol and tobacco, and were less likely to be involved in illicit activities other than drug crimes. Conclusions: Findings suggest that claims of medical use are not simply an attempt to justify personal cannabis consumption, but do at least partly reflect a genuine belief in medical benefit. However, those growing cannabis for medical reasons form a heterogeneous group of people.