Abstract The legalization of non-medical cannabis use and supply is impending in Canada. This constitutes a major policy change with the declared objective of improving public health outcomes, which requires rigorous monitoring and evaluation. While numerous different aspects associated with legalization will be examined, a focused perspective is required for effective policy evaluation purposes. To these ends, we have identified a set of 10 core indicators associated with cannabis-related risk/harm outcomes—based on current best evidence—that are expected to measure the primary impacts of legalization on public health outcomes. We briefly review these indicators, and their respective data availability in Canada. As ideally an integrated outcome assessment of cannabis legalization’s impact on public health will be available, we further propose options to merge the individual indicators into an integrated, weighted ‘index’, considering their expected relative impact for public health. One possible approach to undertake this is ‘multi-criteria decision analysis’ as a method to weight the relative indicator impact on public health; alternative approaches are proposed. The integrated ‘public health index’ for cannabis legalization will allow for scientifically comprehensive, while focused, monitoring and evaluation of the effects of legalization in Canada for the benefits of science and evidence-based policy alike. Canada, cannabis, harm, indicators, legalization, policy, public health Introduction In 2018, Canada will move to legalize, and regulate, the non-medical use and supply of cannabis.1 This will constitute a fundamental policy change—or ‘social experiment’2—for Canada, following a century of control of cannabis by means of criminal law.3 It will also be a landmark reform internationally, as Canada will be the only G-20 nation to legalize cannabis (and the second nation to do so, following Uruguay).1,4,5 Major objectives of cannabis legalization in Canada include the protection of ‘public health and safety’.1 While, by standard (e.g. burden of disease) measurements, the public health burden of cannabis is smaller than that for licit drugs (e.g. alcohol or tobacco), and other illicit substances, it is substantial by international and Canadian assessments.6–8 Given the stated objectives, it is essential to systematically monitor and evaluate the impact of legalization on public health outcomes. In general, major substance—or health—policy reforms should be rigorously evaluated for evidence-based policy principles.2,9,10 This is even more important here, as the likely impacts of cannabis legalization are uncertain, at best; experiences in other jurisdictions are mixed.11 For example, increases in select acute harm outcomes—e.g. cannabis-impaired driving, hospitalizations, poisoning calls—have been found in the US legalization states (since 2014) of Colorado and Washington.12,13 But how to meaningfully evaluate the impact of cannabis policy reform on public health, especially in a focused fashion? Since announcing the prospects of legalization in Canada, an almost uncountable array of question and data inquiries and efforts into different aspects of cannabis use and harms have been discussed and initiated, e.g. by governments, funding agencies and researchers.14 Assessments from other legalization jurisdictions, to date, also mainly present individual data or outcome pieces.12,15 However, it is unclear whether these will generate both concise while comprehensive summary information, or allow for overall conclusions on the public health impact of legalization. On this basis, we outline a core set, and subsequent ‘index’ framework, of 10 essential indicators for monitoring health impacts of cannabis legalization within the specific case study of Canada. The indicators presented are derived from currently best conceptual and empirical evidence, and documented to be—directly or indirectly—linked to population-level health harms,16–18 thus comprising essential outcomes for public health and a focused ‘gauge’ on legalization impact.9,16 We believe that if this core set of indicators—combined with the weighted ‘index’ laid out—is monitored over a sufficient examination period, the empirical impact of cannabis legalization on public health in Canada can be meaningfully ascertained for both science and policy-making purposes. Cannabis use prevalence A common question concerning the consequences of legalization is whether cannabis use in the population will increase. While ‘use’ is not a tangible harm in itself,16 it constitutes the necessary exposure to any possible cannabis-related harm, and should be measured on this basis alone. In the USA, cannabis use rates (including among young people), have been found higher among jurisdictions with liberalized (legal) cannabis regimes (e.g. through ‘medical marijuana’) compared to non-legalization states; however, these appear to be mainly ecological rather than representing causal effects.19,20 Importantly—and specifically in Canada—current (e.g. past-year) cannabis use prevalence has fluctuated in the Canadian adult population (e.g. from 7.4% (1994) to 14.1% (2004))21,22 despite consistent policy parameters. Distinctly relevant for cannabis use levels in the population is use initiation among young people. Specifically, ‘age of initiation’ is a strong predictor of subsequent cannabis-related problems, as inversely related to risk for future acute and chronic (e.g. brain functioning, mental health, educational) problem outcomes.23–27 Hence, in addition to cannabis use prevalence in the population, age of use initiation should be a focus of monitoring. In Canada—national and provincial—general (e.g. adult, youth/student) population surveys can provide relevant data.22,28,29 Patterns of use Just like for other psychoactive substance use (e.g. alcohol), harm outcomes are unequally distributed across cannabis users; rather, specific patterns of use are recognized as a major predictor of acute and chronic adverse outcomes.30,31 Specifically, intensive or frequent (e.g. daily or near-daily) patterns of cannabis use are associated with increased risk for brain functioning and mental health problems, dependence, and other outcomes.30,32–36 Various survey data (e.g. among North American adults/adolescents) show that the proportion of frequent (i.e. daily/near-daily) cannabis users has almost doubled since the early 2000’s.21,22,37 Thus, while legalization may not influence the overall prevalence of use, it—for example, through changing cannabis availability and/or social norms—may lead to increases in use patterns, and subsequent population-level harm outcomes.9,38,39 Frequency patterns of cannabis use can be measured with relevant items in general population surveys; these items, however, have been defined inconsistently in surveys in the past. Modes of use Modes of cannabis use have greatly diversified in recent years.40 While, for long, the predominant mode of cannabis use occurred by smoking burnt cannabis products (e.g. a ‘joint’), various alternative use modes have become popular,41,42 including inhalation-based (e.g. vaporizer/e-cigarette utilizing electronic processes) as well as non-inhalational (e.g. edible/drinkable) modes.40 Smoking ‘burnt’ cannabis remains the most common use mode according to (US- and Canada-based) survey data, with however, up to one in three users reporting alternative (non-smoking) use modes.29,41,43 Cannabis use modes influence key public health-relevant outcomes. Specifically, cannabis ‘smoking’ is associated with a variety of acute and chronic bronchial/pulmonary problems, and may independently be associated with lung cancer.44–46 While available non-smoking use modes come with some of their own distinct risks (e.g. specific toxins, psychoactive delay and over-use effects), and more rigorous studies are needed to compare inter-mode outcomes, some of these alternatives (e.g. vaporized or edible cannabis use) can overall be assumed to be safer at least for pulmonary-bronchial health outcomes.40 Based on its mandate for direct education and regulation, legalization may influence and promote (safer) use modes among users.16,40 Monitoring of cannabis use modes can occur both based on user surveys, as well as retail distribution/sales data for different (e.g., mode-specific) cannabis products. Cannabis potency Potency of cannabis products—i.e. primarily its tetrahydrocannabinol (THC) content concentration—is positively associated with the risk for severe (acute and chronic) adverse outcomes.31,47,48 Concretely, high-potency cannabis is associated with a 3-fold risk for a psychotic disorder.49–53 Despite contexts of varying cannabis control regimes, cannabis potency levels have substantially increased in different jurisdictions (including North America but also Europe) in recent decades.54–58 For example, average THC values for cannabis flower products have increased from ~4 to ~12% or higher in the US 1994–2014; similar trends have been reported from Europe;55,57 newer THC extract (concentrate) products (e.g. ‘shatter’) reach THC concentrations of up to 80–90%.59,60 Similarly, in Canada, limited evidence indicates current average THC concentrations ranging between 15 and 20%.61–63 At the same time, the psychoactive potency of cannabis products may be moderated by other cannabinoid components (e.g. CBD).64–66 Furthermore, the possibility of users ‘titrating’ higher-potency cannabis, and thus reducing their dose-intake, exists, yet evidence is limited.67 Overall, the potency of cannabis products consumed is an important indicator to measure for public health outcomes; basic information can be monitored both from (legal) product sales information and/or population survey data (i.e., legal and illegal products used). Cannabis product sourcing A large extent of legalization’s expected public health benefits rests on the assumption that users will switch from illegal (e.g. ‘black market’) to legal (e.g. retail) sources to obtain regulated and quality-controlled cannabis products.1,16 For long before legalization, illegal cannabis markets have been well-established and active in Canada, and were recently (2015) estimated to be more than $6 billion in value;68–70 even for minors, accessing cannabis products is as easy as obtaining alcohol or tobacco.28,37 Moreover, illicit cannabis markets are not bound by regulatory restrictions, and are highly adaptable.10,71 Thus, it cannot be safely assumed to which extent users will switch from illegal to legal cannabis sources under legalization, for various factors that may include product availability, pricing, access and other restrictions or regulations (as well as potentially other subjective or ‘cultural’ factors).72 Recent survey data indicate that among a convenience sample of self-identified users from US legalization states, 45% were still purchasing cannabis from the black market.73 A failure to bring at least a substantial majority of cannabis users into legal cannabis distribution may crucially undermine the potential to realize the desired benefits of legalization.10,74 This, hence, is a key indicator for monitoring for which relevant data can be generated from both (user) surveys, as well as licit distribution (sales) and illicit market (e.g. enforcement) data. Cannabis-impaired driving and injuries Seminal studies indicate that acute cannabis-impairment—i.e. as occurring shortly following use—is associated with moderately elevated risk (factor 2–4) for motor-vehicle accident involvement, and related injuries and/or fatalities;75–77 these risks are further elevated in combination with alcohol.78,79 This makes cannabis-impaired driving a - while rare - direct cannabis-related cause of mortality.8,80,81 In Canada, approximately 3% of general population adults, but as many as 9% among young drivers (or about one in three cannabis users in the respective age groups), report (past-year) cannabis-impaired driving.29,82–85 Roadside driver and emergency room admission samples indicate somewhat higher rates of cannabis-exposure, respectively,86,87 and recent estimates found cannabis-impaired driving to be a lead contributor of cannabis-attributable disease burden for Canada (both morbidity/mortality counts as well as DALYs).8,80,81 With this major impact potential, it is uncertain how cannabis-impaired driving will evolve under legalization. While greater cannabis availability may lead to increases, intensified targeted interventions (e.g. prevention or enforcement) may lead to reductions in cannabis-impaired driving and subsequent harm.88,89 In US legalization states, increases in cannabis-impaired driving injuries have been observed.12 To monitor these key harm indicators, general population and driver (roadside) surveys, as well as emergency room and accident fatality data (e.g. from coroner’s reports) can be utilized. Hospitalizations (including poisonings) Cannabis use can lead to severe acute and/or chronic morbidity requiring hospitalization (including emergency departments), for example, psychotic symptoms, poisonings and accident-related injuries.17,18 These, due to severity and consequences, are important contributors to, and indicators of, the cannabis-related public health burden. A California-based study documented that all-cause hospitalization rates among cannabis users were ~50% elevated compared to non-users;90 European data indicate similarly elevated rates in cannabis-related hospitalizations, primarily for mental health outcomes.91,92 In Colorado, substantial (i.e. >doubling) increases in cannabis-related hospitalizations have occurred through different steps (i.e., medical and recreational) of cannabis legalization (2001–13).12,93 In addition, cannabis-related poison center calls have increased in states with legalized cannabis.93–95 In Canada, rates of cannabis-related hospital separations have increased pre-legalization, from 4.64 to 6.49/100 000 population (2011/12–2015/16);96 select provincial data also indicate increases in cannabis-related poison center calls.97 In Canada’s single-payer/public healthcare system, data on cannabis-related hospitalizations are available from respective (provincial) administrative healthcare utilization databases, based on respective ICD-codes and established data collection mechanisms (e.g. the National Ambulatory Care Reporting System [NACRS]); poison call data can be available from provincially mandated poison centers. Cannabis use disorders A serious adverse (chronic) cannabis use outcome is cannabis use disorder (CUD, including dependence), measured by standardized diagnostic tools.98–100 Typically, CUD is a consequence of intensive (e.g. chronic/frequent and/or high-potency) cannabis use and requires professional treatment.98 Older estimates suggest that about 1-in-10 cannabis users develop dependence; recent (e.g. US-based) estimates indicate that as many as one-in-three current users meet CUD criteria.101,102 Several (e.g. European) jurisdictions indicated recent increases in CUD treatment demand, especially among young people.18,103,104 While CUD has been estimated to be a main cannabis-related burden of disease contributor,8,80 cannabis-related treatment demand data in Canada are sporadic and inconsistent. Among (publicly funded) treatment agencies in Ontario, the number of cannabis-related treatment admissions has been stable at ~30 000 annual cases (2007/08–2015/16).105,106 In Nova Scotia, this rate however has increased by about 50% (2009/10–2011/12).107,108 Given the severity of CUD as both a health outcome and considering its intervention needs, it is a key public health indicator to monitor post-legalization, where population-level use may become more intensive and thus problematic. In Canada, only select provincial, but no national, databases limited to publicly funded treatment services exist,106,109,110 implying limitations on data scope and quality for monitoring. Other psychoactive substance use Beyond direct cannabis use-related health outcomes, there is good reason to assess possible indirect consequences on population-level health outcomes under legalization. A key issue, specifically, concerns how availability of legal cannabis may impact the risky use of, or morbidity/mortality harm associated with, other commonly used psychoactive substances (e.g. [prescription] opioids, alcohol or tobacco) through so-called ‘substitution’ effects; conversely (undesirable) ‘complementarity’ effects may occur.111,112 Concretely, US-based studies documented that increased (legal) cannabis availability through medical (13 states, 1999–2010) or recreational (Colorado, 2000–15) legalization has been associated with reductions in opioid-related mortality,113–115 although these studies are largely ecological .116 Furthermore, associations with reductions in opioid-related hospitalizations and driving fatalities have been observed.117,118 For alcohol, increased cannabis use may be associated with reductions in risky drinking as well as injuries (e.g. driving-fatalities), however, existing evidence is mixed and inconsistent, and rigorous studies are lacking.112,119–122 Furthermore, there is some—yet also inconsistent—evidence that increases in legal cannabis supply and use may be associated with increasing tobacco (mainly co-) use.123–125 In Canada, no systematic population-level data on either outcome exist. As the aforementioned substance groups (e.g. opioids, alcohol and tobacco) are exerting extensive public health tolls, respective substitution effects might be beneficial for public health; these may however be outweighed by adverse complementarity effects (e.g. from tobacco use) or by increases in cannabis-related disease burden.120,122,126 Over-time analyses in respective general population survey, or injury/fatality datasets, would allow for ecological assessments of possible inter-substance use and harm outcomes; more rigorous analyses could be conducted with longitudinal cohort/population samples. Cannabis-related ‘harm-to-others’ While the focus of most cannabis-related harms is on outcomes with users, an important complementary perspective is ‘harm-to-others’, i.e. ‘non-users’ or the social environment. The ‘harm-to-others’-concept has become well-established for other substance (e.g. alcohol and tobacco) use realms, and can include health harms, e.g. injuries or disease (e.g. from violence or smoke), or quality-of-life hazards, occurring with others.127–129 The concept’s relevance for cannabis use is underscored by the fact that greater than four-in-five Canadians are current non-users,22 yet potentially vulnerable to related harms. While cannabis’ main effects, based on its distinct pharmaco-behavioral properties (unlike other psychoactive substances) do not involve extensive aggression or violence, its impairment or other use consequences (e.g. cannabis smoking) may result in substantial inconvenience or harm-to-others.130–132 A specific ‘harm-to-others’ consequence may include development issues among un-/new-born infants of cannabis-using mothers, although evidence is limited.133,134 Potential ‘harm-to-others’ dynamics are illustrated in emerging Canadian (provincial) regulations for permitted cannabis use locations, with some restricted to ‘private homes’ only.74,135 Particularly with legalization policy aiming for ‘public’ health and safety, ‘harm-to-others’ constitutes an essential element for outcome monitoring.1,71 Its assessment can occur through relevant items in general population surveys (including both users and non-users), similar to what has been used for alcohol, yet also comprise other ‘social cost’ perspectives.136 Specific types of cannabis-related harm-to-others (e.g. injuries, harm to infants) would require data which is not easily or readily available with respective diagnostics. Discussion Main finding The legalization of non-medical cannabis use is imminent in Canada, following similar reforms elsewhere. While it continues to be controversially discussed, primary objectives of cannabis legalization as a major policy reform include the protection of public health and safety in Canada. Also in the context of (mixed) experiences with similar reforms elsewhere to date,137 and given the various—acute and chronic—well-documented health risks associated with cannabis use,17 the outcomes of the legalization policy ‘experiment’ on public health need to be rigorously monitored and evaluated. To that end, we have presented 10 groups of principal indicators which, based on current information, will express and allow the assessment of the main impacts of cannabis legalization on public health relevant risks and outcomes in the population. This, ideally, will occur based on data including baseline (i.e. pre-legalization) data and trends, yet still be valuable if mainly including longitudinal observations post-legalization. On this basis, implementing these indicators will allow for both a comprehensive but focused monitoring and evaluation effort for the impacts of cannabis legalization on public health. What is already known on this topic The risks for acute and chronic health harms associated with cannabis use are well documented.17 While, on population levels, many of these have substantially evolved under relatively consistent control conditions (e.g. prohibition), there is good reason to assume that they may further change with legal cannabis availability and use. To that extent, ongoing cannabis legalization experiments—e.g. in US states or Uruguay—have shown rather mixed outcomes, i.e. with certain health outcome indicators such as cannabis-related treatment admissions remaining stable, but others, such as cannabis-related accidents and hospitalizations increasing.12,137 In Canada, many such indicators will be examined individually and/or within select sub-groups. Neither the ongoing international legalization experiments, nor the—many—planned Canadian outcome evaluation efforts, however, have presented or developed monitoring approaches to assess or gauge the impact of legalization on public health overall. What this study adds On their own, the here proposed outcome indicators still consist of individual measures which may see differential evolvement—partly independent—of one another, and in themselves will not yet provide an integrated assessment of public health impacts of legalization (as policy-makers ideally utilize for evidence-based policy assessments).138–140 Furthermore, each of the indicators features (quantitatively) differential potential impact on the public health burden. Thus, towards further meaningful development and utilization of the public health indicators presented, we propose for these to be integrated into a weighted ‘index’ to measure the impact of cannabis legalization on public health. This should involve scaling (for inter-indicator comparability) and relative weighting of the individual indicators, considering the expected relative individual impact of each on overall public health burden.141,142 On this basis, monitoring data can then be combined into ongoing weighted index values (e.g. for regular, annual, measurements).141,143 For example, it can be expected that ‘cannabis use disorder’ or ‘cannabis-impaired driving’ outcomes will be associated with substantially higher public health burden than cannabis-related ‘harm-to-others’ or ‘use modes’; this relative ‘weighting’ ought to be defined for each measure towards, and reflected in, an integrated index. Various scientifically established methods for such weighted indexing exist. If the final outcome is unidimensional—such as burden of disease, which is usually measured as disability-adjusted life years (a summary indicator composed of years of life lost due to premature mortality and disability)144—an index can be construed via epidemiologic modeling. This index can subsequently be re-assessed and compared, if the associations between indicators and outcome, and the assumptions behind them, remain stable. If more than one dimension is involved, human judgment and valuations about relative impact explicitly come into play. Another option is to assemble an index with the help of ‘multi-criteria decision analysis’ (MCDA).145–147 MCDA involves (at times subjective) expert judgment and valuations, and is usually applied to consider and integrate different factors towards policy-relevant decisions or outcomes, e.g. in health or other policy settings.148,149 MCDA has also been applied in the ‘drug policy’ field, to compare and rank the harm potential of different psychoactive substances based on multiple criteria.142,150 Independent of the chosen approach to combine and integrate the above indicator dimensions into a composite index, actual values, and over-time changes for each of the indicators could be weight-scored over regular monitoring points, and so allow for longitudinal integrated assessments of public health outcomes following cannabis legalization. Limitations The present study presents a conceptual framework for empirical measurement. The proposed indicators are data-driven but selective, and may not capture the full public health impact associated with cannabis legalization. Indicator changes to be observed may include ecological effects. Proposed indicator integration and indexing may involve subjective judgments for weighting towards approximated composite outcome assessments. Conclusions Cannabis legalization towards public health ends—like other major policy reforms—requires rigorous monitoring and evaluation, as to whether the main policy objectives are met and/or adjustments are needed.10,71,151 Numerous individual—and likely inconsistent—outcomes associated with legalization will be observed, however, a scientifically solid ‘big picture’ assessment of legalization’s impact on public health will be required in Canada for evidence-based policy evaluation.138,139 The proposed 10 key outcome indicators, and options for integration into a cannabis public health ‘indicator index’, offer such a—timely—tool that is relatively easy and feasible to develop and implement towards these ends. Funding This work was supported by the Canadian Institutes of Health Research (CIHR) for the Canadian Research Initiative in Substance Misuse (CRISM) Ontario Node Team [Grant #SMN-139150], and by the Chair in Addiction, Department of Psychiatry, University of Toronto. Conflict of interest The authors have no conflicts of interest to declare. References 1 Task Force on Cannabis Legalization and Regulation . A Framework for the Legalization and Regulation of Cannabis in Canada: The Final Report of the Task Force on Cannabis Legalization and Regulation . Ottawa, ON : Government of Canada , 2016 . Google Preview WorldCat COPAC 2 Campbell DT . Reforms as experiments . Am Psychol 1969 ; 24 : 409 – 29 . Google Scholar Crossref Search ADS WorldCat 3 Room R , Fischer B , Hall W et al. Cannabis Policy: Moving Beyond Stalemate . New York, NY : Oxford University Press , 2010 . Google Preview WorldCat COPAC 4 Pardo B . Cannabis policy reforms in the Americas: a comparative analysis of Colorado, Washington, and Uruguay . Int J Drug Policy 2014 ; 25 : 727 – 35 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Cerdá M , Kilmer B . Uruguay’s middle-ground approach to cannabis legalization . Int J Drug Policy 2017 ; 42 : 118 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Degenhardt L , Ferrari AJ , Calabria B et al. The global epidemiology and contribution of cannabis use and dependence to the global burden of disease: results from the GBD 2010 study . PLoS One 2013 ; 8 : e76635 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Degenhardt L , Whiteford HA , Ferrari AJ et al. Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010 . Lancet (London, England) 2013 ; 382 : 1564 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Imtiaz S , Shield KD , Roerecke M et al. The burden of disease attributable to cannabis use in Canada in 2012 . Addiction 2016 ; 111 : 653 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Hall W , Lynskey M . Evaluating the public health impacts of legalizing recreational cannabis use in the United States . Addiction 2016 ; 111 : 1764 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Fischer B , Rehm J , Crepault JF . Realistically furthering the goals of public health by cannabis legalization with strict regulation: response to Kalant . Int J Drug Policy 2016 ; 34 : 11 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Dills AK , Goffard S , Miron J . The Effects of Marijuana Liberalizations: Evidence From Monitoring the Future . Cambridge, MA : National Bureau of Economic Research , 2017 . Google Preview WorldCat COPAC 12 Rocky Mountain High Intensity Drug Trafficking Area . The Legalization of Marijuana in Colorado: The Impact Volume 5 . Denver, Colorado : Rocky Mountain High Intensity Drug Trafficking Area , 2017 . Google Preview WorldCat COPAC 13 Forecasting and Research Division . Monitoring Impacts of Recreational Marijuana Legalization: 2016 Update Report . Olympia, Washington : Forecasting and Research Division, Washington State Office of Financial Management , 2017 . Google Preview WorldCat COPAC 14 The Canadian Press . 14 Marijuana research projects across Canada to receive federal funding . Global News . 2018 . https://globalnews.ca/news/3984777/marijuana-research-projects-federal-funding/ (29 January 2018, date last accessed). WorldCat 15 Northwest High Intensity Drug Trafficking A . Washington State Marijuana Impact Report . Seattle, Washington : Northwest High Intensity Drug Trafficking Area , 2016 . Google Preview WorldCat COPAC 16 Fischer B , Russell C , Sabioni P et al. Lower-Risk Cannabis Use Guidelines (LRCUG): a comprehensive update of evidence and recommendations . Am J Public Health 2017 ; 107 ( 8 ): e1 – e12 . Google Scholar Crossref Search ADS PubMed WorldCat 17 National Academies of Sciences Engineering and Medicine . The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research . Washington, DC : The National Academies Press , 2017 . Google Preview WorldCat COPAC 18 World Health Organization (WHO) . The Health and Social Effects of Nonmedical Cannabis Use . Geneva, Switzerland : World Health Organization (WHO) , 2016 . Google Preview WorldCat COPAC 19 Hasin DS , Wall M , Keyes KM et al. Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys . Lancet Psychiatry 2015 ; 2 : 601 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Stolzenberg L , D’Alessio SJ , Dariano D . The effect of medical cannabis laws on juvenile cannabis use . Int J Drug Policy 2016 ; 27 : 82 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Canadian Centre on Substance Abuse (CCSA) and Health Canada . Canadian Addiction Survey (CAS): A National Survey of Canadians’ Use of Alcohol and Other Drugs—Prevalence of Use and Related Harm . Ottawa, ON : Canadian Centre on Substance Abuse (CCSA) , 2004 . Google Preview WorldCat COPAC 22 Health Canada . Canadian Tobacco, Alcohol and Drugs Survey (CTADS): Summary of Results for 2015 . Ottawa, ON : Health Canada , 2016 . Google Preview WorldCat COPAC 23 Jacobus J , Tapert SF . Effects of cannabis on the adolescent brain . Curr Pharm Des 2014 ; 20 : 2186 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Lisdahl KM , Gilbart ER , Wright NE et al. Dare to delay? The impacts of adolescent alcohol and marijuana use onset on cognition, brain structure, and function . Front Psychiatry 2013 ; 4 : 53 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Camchong J , Lim KO , Kumra S . Adverse effects of cannabis on adolescent brain development: a longitudinal study . Cereb Cortex 2017 ; 27 : 1922 – 30 . Google Scholar PubMed WorldCat 26 Volkow ND , Swanson JM , Evins AE et al. Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review . JAMA Psychiatry 2016 ; 73 : 292 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Stefanis NC , Dragovic M , Power BD et al. Age at initiation of cannabis use predicts age at onset of psychosis: the 7-to 8-year trend . Schizophr Bull 2013 ; 39 : 251 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Health Canada . Summary of Results: Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS) 2014-15 . Ottawa, ON : Health Canada , 2016 . Google Preview WorldCat COPAC 29 Health Canada . Canadian Cannabis Survey: 2017 Summary . Ottawa, ON : Health Canada , 2017 . Google Preview WorldCat COPAC 30 Marconi A , Di Forti M , Lewis CM et al. Meta-analysis of the association between the level of cannabis use and risk of psychosis . Schizophr Bull 2016 ; 42 : 1262 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Hall W , Degenhardt L . Adverse health effects of non-medical cannabis use . Lancet 2009 ; 374 : 1383 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Batalla A , Bhattacharyya S , Yucel M et al. Structural and functional imaging studies in chronic cannabis users: a systematic review of adolescent and adult findings . PLoS One 2013 ; 8 : e55821 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Lorenzetti V , Solowij N , Whittle S et al. Gross morphological brain changes with chronic, heavy cannabis use . Br J Psychiatry 2015 ; 206 : 77 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Lev-Ran S , Roerecke M , Le Foll B et al. The association between cannabis use and depression: a systematic review and meta-analysis of longitudinal studies . Psychol Med 2014 ; 44 : 797 – 810 . Google Scholar Crossref Search ADS PubMed WorldCat 35 van der Pol P , Liebregts N , de Graaf R et al. Predicting the transition from frequent cannabis use to cannabis dependence: a three-year prospective study . Drug Alcohol Depend 2013 ; 133 : 352 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Degenhardt L , Coffey C , Romaniuk H et al. The persistence of the association between adolescent cannabis use and common mental disorders into young adulthood . Addiction 2013 ; 108 : 124 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Azofeifa A , Mattson ME , Schauer G et al. National estimates of marijuana use and related indicators—National Survey on Drug Use and Health, United States, 2002-2014 . MMWR Morb Mortal Wkly Rep 2016 ; 65 : 1 – 28 . Google Scholar PubMed WorldCat 38 Hall W , Weier M . Assessing the public health impacts of legalizing recreational cannabis use in the USA . Clin Pharmacol Ther 2015 ; 97 : 607 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 39 Asbridge M , Valleriani J , Kwok J et al. Normalization and denormalization in different legal contexts: comparing cannabis and tobacco . Drugs Educ Prev Policy 2016 ; 23 : 212 – 23 . Google Scholar Crossref Search ADS WorldCat 40 Russell C , Rueda S , Room R et al. Routes of administration for cannabis use—basic prevalence and related health outcomes: a scoping review and synthesis . Int J Drug Policy 2018 ; 52 : 87 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 41 Schauer GL , King BA , Bunnell RE et al. Vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014 . Am J Prev Med 2016 ; 50 : 1 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 42 Borodovsky JT , Crosier BS , Lee DC et al. Smoking, vaping, eating: is legalization impacting the way people use cannabis? Int J Drug Policy 2016 ; 36 : 141 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 43 Singh T , Kennedy SM , Sharapova SS et al. Modes of ever marijuana use among adult tobacco users and non-tobacco users—Styles 2014 . J Subst Use 2016 ; 21 : 631 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 44 Martinasek MP , McGrogan JB , Maysonet A . A systematic review of the respiratory effects of inhalational marijuana . Respir Care 2016 ; 61 : 1543 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat 45 Bouti K , Rajae B , Hicham F et al. Cannabis smoking and risk of lung cancer: a systematic review and meta-analysis . Int J Med Surg 2014 ; 1 : 31 – 7 . Google Scholar Crossref Search ADS WorldCat 46 Hashibe M , Morgenstern H , Cui Y et al. Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study . Cancer Epidemiol Biomarkers Prev 2006 ; 15 : 1829 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 47 Hall W , Degenhardt L . High potency cannabis: a risk factor for dependence, poor psychosocial outcomes, and psychosis . Br Med J (Clinical research ed). 2015 ; 350 : h1205 . Google Scholar Crossref Search ADS WorldCat 48 Volkow ND , Baler RD , Compton WM et al. Adverse health effects of marijuana use . N Engl J Med 2014 ; 370 : 2219 – 27 . Google Scholar Crossref Search ADS PubMed WorldCat 49 Di Forti M , Marconi A , Carra E et al. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study . Lancet Psychiatry 2015 ; 2 : 233 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 50 Pierre JM , Gandal M , Son M . Cannabis-induced psychosis associated with high potency ‘wax dabs’ . Schizophr Res 2016 ; 172 : 211 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat 51 Ramaekers JG , Kauert G , van Ruitenbeek P et al. High-potency marijuana impairs executive function and inhibitory motor control . Neuropsychopharmacology 2006 ; 31 : 2296 – 303 . Google Scholar Crossref Search ADS PubMed WorldCat 52 Di Forti M , Sallis H , Allegri F et al. Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users . Schizophr Bull 2014 ; 40 : 1509 – 17 . Google Scholar Crossref Search ADS PubMed WorldCat 53 Freeman TP , Winstock AR . Examining the profile of high-potency cannabis and its association with severity of cannabis dependence . Psychol Med 2015 ; 45 : 3181 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 54 Cascini F , Aiello C , Di Tanna G . Increasing delta-9-tetrahydrocannabinol (Delta-9-THC) content in herbal cannabis over time: systematic review and meta-analysis . Curr Drug Abuse Rev 2012 ; 5 : 32 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat 55 Niesink RJ , Rigter S , Koeter MW et al. Potency trends of Delta9-tetrahydrocannabinol, cannabidiol and cannabinol in cannabis in the Netherlands: 2005-15 . Addiction 2015 ; 110 : 1941 – 50 . Google Scholar Crossref Search ADS PubMed WorldCat 56 Englund A , Freeman TP , Murray RM et al. Can we make cannabis safer? Lancet Psychiatry 2017 ; 4 : 643 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 57 ElSohly MA , Mehmedic Z , Foster S et al. Changes in cannabis potency over the last 2 decades (1995–2014): analysis of current data in the United States . Biol Psychiatry 2016 ; 79 : 613 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 58 Mehmedic Z , Chandra S , Slade D et al. Potency trends of Delta9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008 . J Forensic Sci 2010 ; 55 : 1209 – 17 . Google Scholar Crossref Search ADS PubMed WorldCat 59 Raber JC , Elzinga S , Kaplan C . Understanding dabs: contamination concerns of cannabis concentrates and cannabinoid transfer during the act of dabbing . J Toxicol Sci 2015 ; 40 : 797 – 803 . Google Scholar Crossref Search ADS PubMed WorldCat 60 Stogner JM , Miller BL . Assessing the dangers of ‘dabbing’: mere marijuana or harmful new trend? Pediatrics 2015 ; 136 : 1 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 61 Grundig T , Common D. What’s in your pot? Marketplace tests today’s weed. CBC News. 2016 . http://www.cbc.ca/news/canada/marketplace-marijuana-thc-cbd-legalization-1.3861144 (20 March 2018, date last accessed). 62 Government of Canada . About Cannabis . Ottawa, ON : Government of Canada , 2018 . Google Preview WorldCat COPAC 63 Martin B . ACMPR Market Scan: Dried Cannabis per Gram Pricing vs Cannabinoid Content. https://news.lift.co/acmpr-market-scan-dried-cannabis-per-gram-pricing-vs-cannabinoid-content/ (12 December 2017, date last accessed). 64 Batalla A , Crippa JA , Busatto GF et al. Neuroimaging studies of acute effects of THC and CBD in humans and animals: a systematic review . Curr Pharm Des 2014 ; 20 : 2168 – 85 . Google Scholar Crossref Search ADS PubMed WorldCat 65 Bhattacharyya S , Morrison PD , Fusar-Poli P et al. Opposite effects of delta-9-tetrahydrocannabinol and cannabidiol on human brain function and psychopathology . Neuropsychopharmacology 2010 ; 35 : 764 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 66 Iseger TA , Bossong MG . A systematic review of the antipsychotic properties of cannabidiol in humans . Schizophr Res 2015 ; 162 : 153 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 67 van der Pol P , Liebregts N , Brunt T et al. Cross-sectional and prospective relation of cannabis potency, dosing and smoking behaviour with cannabis dependence: an ecological study . Addiction 2014 ; 109 : 1101 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 68 Macdonald R , Rotermann M . Experimental Estimates of Cannabis Consumption in Canada, 1960 to 2015 . Ottawa, ON : Economic Analysis Division and Health Analysis Division, Statistics Canada , 2017 . Google Preview WorldCat COPAC 69 Tang B , de Ruijter A . Canadian Cannabis Industry Overview . Vancouver, BC : Fundamental Research Corp , 2017 . Google Preview WorldCat COPAC 70 Press C . Canadian Cannabis Market Worth $6.2B in 2015: Statistics Canada. Huffington Post. 2017 . http://www.huffingtonpost.ca/2017/12/18/canadian-cannabis-market-worth-6-2b-in-2015-statistics-canada_a_23310828/ (09 January 2018, date last accessed). 71 Rehm J , Fischer B . Cannabis legalization with strict regulation, the overall superior policy option for public health . Clin Pharmacol Ther 2015 ; 97 : 541 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 72 Henchman J , Scarboro M . Marijuana Legalilzation and Taxes: Lessons for Other States from Colorado and Washington . Washington, DC : The Tax Foundation , 2016 . Google Preview WorldCat COPAC 73 Bolivar LA , Coalition CC . Cannabis Consumers Coalition: Report on Cannabis Consumer Demographics and Consumption Habits. Denver, Colorado: Cannabis Consumers Coalition, 2017 . 74 Fischer B . Legalisation of non-medical cannabis in Canada: will supply regulations effectively serve public health? Lancet Public Health 2017 ; 2 : e536 – e7 . Google Scholar Crossref Search ADS PubMed WorldCat 75 Hartman RL , Huestis MA . Cannabis effects on driving skills . Clin Chem 2013 ; 59(3) : 478 – 92 . Google Scholar Crossref Search ADS WorldCat 76 Rogeberg O , Elvik R . The effects of cannabis intoxication on motor vehicle collision revisited and revised . Addiction 2016 ; 111 : 1348 – 59 . Google Scholar Crossref Search ADS PubMed WorldCat 77 Li M-C , Brady JE , DiMaggio CJ et al. Marijuana use and motor vehicle crashes . Epidemiol Rev 2012 ; 34 : 65 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 78 Asbridge M , Hayden JA , Cartwright JL . Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis . Br Med J 2012 ; 344 : e536 . Google Scholar Crossref Search ADS WorldCat 79 Dubois S , Mullen N , Weaver B et al. The combined effects of alcohol and cannabis on driving: impact on crash risk . Forensic Sci Int 2015 ; 248 : 94 – 100 . Google Scholar Crossref Search ADS PubMed WorldCat 80 Fischer B , Imtiaz S , Rudzinski K et al. Crude estimates of cannabis-attributable mortality and morbidity in Canada-implications for public health focused intervention priorities . J Public Health 2016 ; 38 : 183 – 8 . Google Scholar Crossref Search ADS WorldCat 81 Wettlaufer A , Florica RO , Asbridge M et al. Estimating the harms and costs of cannabis-attributable collisions in the Canadian provinces . Drug Alcohol Depend 2017 ; 173 : 185 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 82 Canadian Centre on Substance Abuse . Impaired Driving in Canada . Ottawa, ON : Canadian Centre on Substance Abuse (CCSA) , 2017 . Google Preview WorldCat COPAC 83 Health Canada . Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): Summary Results for 2012 . Ottawa, ON : Government of Canada , 2013 . Google Preview WorldCat COPAC 84 Ialomiteanu AR , Hamilton H , Adlaf E et al. CAMH Monitor eReport 2015: Substance Use, Mental Health and Well-Being Among Ontario Adults . Toronto, Ontario : Centre for Addiction and Mental Health , 2016 . Google Preview WorldCat COPAC 85 Boak A , Hamilton HA , Adlaf EM et al. Drug Use Among Ontario Students, 1977-2017: Detailed Findings From the Ontario Student Drug Use and Health Survey (OSDUHS) . Toronto, ON : Centre for Addiction and Mental Health (CAMH) , 2017 . Google Preview WorldCat COPAC 86 Beirness DJ , Beasley EE , McClafferty K . Alcohol and Drug Use among Drivers in Ontario: Findings From the 2014 Roadside Survey . Ottawa, ON : Ministry of Transportation , 2015 . Google Preview WorldCat COPAC 87 Traffic Injury Research Foundation (TIRF) . Marijuana Use Among Drivers in Canada, 2000-2014 . Ottawa, ON : Traffic Injury Research Foundation (TIRF) , 2017 . Google Preview WorldCat COPAC 88 Anderson P , Chisholm D , Fuhr DC . Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol . Lancet 2009 ; 373 : 2234 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat 89 Fischer B , Fidalgo T , Varatharajan T . Reflections on Pollini et al. (2017)—implications for interventions for driving while using psychotropic medications with impairment risk . J Stud Alcohol Drugs 2017 ; 78 : 814 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 90 Gerberich SG , Sidney S , Braun BL et al. Marijuana use and injury events resulting in hospitalization . Ann Epidemiol 2003 ; 13 : 230 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 91 Jouanjus E , Leymarie F , Tubery M et al. Cannabis-related hospitalizations: unexpected serious events identified through hospital databases . Br J Clin Pharmacol 2011 ; 71 : 758 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 92 Schubart C , Boks M , Breetvelt E et al. Association between cannabis and psychiatric hospitalization . Acta Psychiatr Scand 2011 ; 123 : 368 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 93 Kim HS , Monte AA . Colorado cannabis legalization and its effect on emergency care . Ann Emerg Med 2016 ; 68 : 71 . Google Scholar Crossref Search ADS PubMed WorldCat 94 Ghosh TS , Van Dyke M , Maffey A et al. Medical marijuana’s public health lessons—implications for retail marijuana in Colorado . N Engl J Med 2015 ; 372 : 991 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 95 Cao D , Srisuma S , Bronstein AC et al. Characterization of edible marijuana product exposures reported to United States poison centers . Clin Toxicol (Phila) 2016 ; 54 : 840 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 96 Canadian Institute for Health Information (CIHI) . Crude Separation Rates for Selected Substance-Related Disorders as a Primary Diagnosis, Canada, 2011-2012 to 2015-2016 . Toronto, ON : Hospital Mental Health Database, Canadian Institute for Health Information (CIHI) , 2017 . Google Preview WorldCat COPAC 97 Cumming E , Kosatsky T . Calls to BC poison control on 4/20: a case-only analysis . BC Medical Journal 2018 ; 60 : 62 – 3 . WorldCat 98 Copeland J , Swift W . Cannabis use disorder: epidemiology and management . Int Rev Psychiatry 2009 ; 21 : 96 – 103 . Google Scholar Crossref Search ADS PubMed WorldCat 99 Stinson FS , Ruan WJ , Pickering R et al. Cannabis use disorders in the USA: prevalence, correlates and co-morbidity . Psychol Med 2006 ; 36 : 1447 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 100 Budney AJ , Roffman R , Stephens RS et al. Marijuana dependence and its treatment . Addict Sci Clin Pract 2007 ; 4 : 4 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 101 Hasin DS , Saha TD , Kerridge BT et al. Prevalence of marijuana use disorders in the United States between 2001-2002 and 2012-2013 . JAMA Psychiatry 2015 ; 72 : 1235 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 102 Wagner FA , Anthony JC . From first drug use to drug dependence: developmental periods of risk for dependence upon marijuana, cocaine, and alcohol . Neuropsychopharmacology 2002 ; 26 : 479 – 88 . Google Scholar Crossref Search ADS PubMed WorldCat 103 McCulloch L . Why did cannabis treatment presentations rise in England from 2004-2005 to 2013-2014? Drugs and Alcohol Today 2017 ; 17 : 218 – 31 . Google Scholar Crossref Search ADS WorldCat 104 United Nations Office on Drugs and Crime (UNODC) . World Drug Report 2016 . New York, NY : United Nations , 2016 . Google Preview WorldCat COPAC 105 Drug Alcohol Treatment Information System (DATIS) . Substance Abuse Statistical Tables: Fiscal Year 2007/2008 to Fiscal Year 2012/2013 . Toronto, ON : Centre for Addiction and Mental Health , 2013 . Google Preview WorldCat COPAC 106 Drug and Alcohol Treatment Information System (DATIS) . Substance Abuse Statistical Tables: Fiscal Year 2010/11–2015/16 . Toronto, ON : Centre for Addiction and Mental Health , 2016 . Google Preview WorldCat COPAC 107 Government of Nova Scotia . Nova Scotia Addiction Services Annual Report: 2009–2010 . Halifax, NS : Government of Nova Scotia , 2011 . Google Preview WorldCat COPAC 108 Government of Nova Scotia . Nova Scotia Addiction Services Annual Report: 2011–2012 . Halifax, NS : Government of Nova Scotia , 2013 . Google Preview WorldCat COPAC 109 Rotondi NK , Rush B . Monitoring utilization of a large scale addiction treatment system: The Drug and Alcohol Treatment Information System (DATIS) . Substance Abuse Res Treat 2012 ; 6 : 73 – 84 . WorldCat 110 Pirie T , Wallingford SC , Di Gioacchino LA et al. National Treatment Indicators Report: 2013-2014 . Ottawa, ON : Canadian Centre on Substance Abuse (CCSA) , 2016 . Google Preview WorldCat COPAC 111 Fischer B , Murphy Y , Kurdyak P et al. Medical marijuana programs—why might they matter for public health and why should we better understand their impacts? Prev Med Rep 2015 ; 2 : 53 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 112 Lucas P , Walsh Z , Crosby K et al. Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: the impact of contextual factors . Drug Alcohol Rev 2015 ; 35 : 326 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 113 Bachhuber MA , Saloner B , Cunningham CO et al. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999–2010 . JAMA Intern Med 2014 ; 174 : 1668 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 114 Livingston MD , Barnett TE , Delcher C et al. Recreational cannabis legalization and opioid-related deaths in Colorado, 2000–2015 . Am J Public Health 2017 ; 107(11) : 1827 – 9 . Google Scholar Crossref Search ADS WorldCat 115 Powell D , Pacula RL , Jacobson M . Do medical marijuana laws reduce addictions and deaths related to pain killers? J Health Econ 2018 ; 58 : 29 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 116 Hall W , West R , Marsden J et al. It is premature to expand access to medicinal cannabis in hopes of solving the US opioid crisis . Addiction 2018 ; 113(6) : 987 – 8 . Google Scholar Crossref Search ADS WorldCat 117 Kim JH , Santaella-Tenorio J , Mauro C et al. State medical marijuana laws and the prevalence of opioids detected among fatally injured drivers . Am J Public Health 2016 ; 106 : 2032 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 118 Shi Y . Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever . Drug Alcohol Depend 2017 ; 173 : 144 – 50 . Google Scholar Crossref Search ADS PubMed WorldCat 119 Anderson DM , Hansen B , Rees DI . Medical marijuana laws, traffic fatalities and alcohol consumption . J Law Econ 2013 ; 56 : 33 – 339 . WorldCat 120 Pacula RL , Powell D , Heaton P et al. Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details . J Policy Anal Manage 2015 ; 34 : 7 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 121 Wen H , Hockenberry JM , Cummings JR . The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances . J Health Econ 2015 ; 42 : 64 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat 122 Reiman A . Cannabis as a substitute for alcohol and other drugs . Harm Reduct J 2009 ; 6 : 35 – 7517-6-35 . Google Scholar Crossref Search ADS PubMed WorldCat 123 Wang JB , Ramo DE , Lisha NE et al. Medical marijuana legalization and cigarette and marijuana co-use in adolescents and adults . Drug Alcohol Depend 2016 ; 166 : 32 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 124 Cerdá M , Sarvet AL , Wall M et al. Medical marijuana laws and adolescent use of marijuana and other substances: alcohol, cigarettes, prescription drugs, and other illicit drugs . Drug Alcohol Depend 2018 ; 183 : 62 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 125 Schauer GL , Berg CJ , Kegler MC et al. Assessing the overlap between tobacco and marijuana: trends in patterns of co-use of tobacco and marijuana in adults from 2003–2012 . Addict Behav 2015 ; 49 : 26 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 126 Fischer B , Rehm J . Revisiting the ‘paradigm shift’ in opioid use: developments and implications 10 years later . Drug Alcohol Rev 2018 ; 37(S1) : 5199 – 202 WorldCat 127 Stratton K , Shetty P , Wallace R et al. Clearing the smoke: the science base for tobacco harm reduction—executive summary . Tob Control 2001 ; 10 : 189 – 95 . Google Scholar Crossref Search ADS PubMed WorldCat 128 Blackburn C , Spencer N , Bonas S et al. Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey . Br Med J 2003 ; 327 : 257 . Google Scholar Crossref Search ADS WorldCat 129 Room R , Ferris J , Laslett A-M et al. The drinker’s effect on the social environment: a conceptual framework for studying alcohol’s harm to others . Int J Environ Res Public Health 2010 ; 7 : 1855 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 130 Boles SM , Miotto K . Substance abuse and violence . Aggress Violent Behav 2003 ; 8 : 155 – 74 . Google Scholar Crossref Search ADS WorldCat 131 Hoaken PNS , Stewart SH . Drugs of abuse and the elicitation of human aggressive behavior . Addict Behav 2003 ; 28 : 1533 – 54 . Google Scholar Crossref Search ADS PubMed WorldCat 132 Moore TM , Stuart GL . A review of the literature on marijuana and interpersonal violence . Aggress Violent Behav 2005 ; 10 : 171 – 92 . Google Scholar Crossref Search ADS WorldCat 133 Gunn JK , Rosales CB , Center KE et al. Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis . BMJ Open 2016 ; 6(4) : e009986 . Google Scholar Crossref Search ADS WorldCat 134 Conner SN , Bedell V , Lipsey K et al. Maternal marijuana use and adverse neonatal outcomes: a systematic review and meta-analysis . Obstet Gynecol 2016 ; 128 : 713 – 23 . Google Scholar Crossref Search ADS PubMed WorldCat 135 The Canadian Press . A Look at Provincial Marijuana Plans. CTV News. 2017 . https://www.ctvnews.ca/canada/a-look-at-provincial-marijuana-plans-1.3682177 (5 January 2018, date last accessed). 136 Navarro HJ , Doran CM , Shakeshaft AP . Measuring costs of alcohol harm to others: a review of the literature . Drug Alcohol Depend 2011 ; 114 : 87 – 99 . Google Scholar PubMed WorldCat 137 Maxwell JC , Mendelson B . What do we know about the impact of the laws related to marijuana? J Addict Med 2016 ; 10 : 3 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 138 Brownson RC , Chriqui JF , Stamatakis KA . Understanding evidence-based public health policy . Am J Public Health 2009 ; 99 : 1576 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 139 Sanderson I . Evaluation, policy learning and evidence‐based policy making . Public Adm 2002 ; 80 : 1 – 22 . Google Scholar Crossref Search ADS WorldCat 140 Bowen S , Zwi AB . Pathways to ‘evidence-informed’ policy and practice: a framework for action . PLoS Med 2005 ; 2 : e166 . Google Scholar Crossref Search ADS PubMed WorldCat 141 Babbie E . The practice of social research. Toronto, ON : Nelson Education, 2015 . 142 Nutt DJ , King LA , Phillips LD . Drug harms in the UK: a multicriteria decision analysis . The Lancet 2010 ; 376 : 1558 – 65 . Google Scholar Crossref Search ADS WorldCat 143 Groth-Marnat G . Handbook of Psychological Assessment . Hoboken, NJ : John Wiley & Sons , 2009 . Google Preview WorldCat COPAC 144 World Health Organization (WHO) . Metrics: Disability-Adjusted Life Years (DALY): Quantifying the Burden of Disease from Mortality and Morbidity . Geneva, Switzerland : World Health Organizaton (WHO) , 2018 . Google Preview WorldCat COPAC 145 Dodgson J , Spackman M , Pearman A et al. Multi Criteria Analysis: a Manual. London, UK: Department of the Environment, Transport and the Regions, 2000 . 146 Adunlin G , Diaby V , Xiao H . Application of multicriteria decision analysis in health care: a systematic review and bibliometric analysis . Health Expect 2015 ; 18 : 1894 – 905 . Google Scholar Crossref Search ADS PubMed WorldCat 147 Marsh K , Lanitis T , Neasham D et al. Assessing the value of healthcare interventions using multi-criteria decision analysis: a review of the literature . Pharmacoeconomics 2014 ; 32 : 345 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 148 Nobre FF , Trotta LTF , Gomes LFAM . Multi–criteria decision making -an approach to setting priorities in health care . Stat Med 1999 ; 18 : 3345 – 54 . Google Scholar Crossref Search ADS PubMed WorldCat 149 Baltussen R , Niessen L . Priority setting of health interventions: the need for multi-criteria decision analysis . Cost Eff Resour Alloc 2006 ; 4 : 14 . Google Scholar Crossref Search ADS PubMed WorldCat 150 van Amsterdam J , Nutt D , Phillips L et al. European rating of drug harms . J Psychopharmacol 2015 ; 29 : 655 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 151 Pacula RL , Kilmer B , Wagenaar AC et al. Developing public health regulations for marijuana: lessons from alcohol and tobacco . Am J Public Health 2014 ; 104 : 1021 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Journal of Public Health – Oxford University Press
Published: Jun 1, 2019
It’s your single place to instantly
discover and read the research
that matters to you.
Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.
All for just $49/month
Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly
Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.
Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.
Read from thousands of the leading scholarly journals from SpringerNature, Wiley-Blackwell, Oxford University Press and more.
All the latest content is available, no embargo periods.
“Hi guys, I cannot tell you how much I love this resource. Incredible. I really believe you've hit the nail on the head with this site in regards to solving the research-purchase issue.”Daniel C.
“Whoa! It’s like Spotify but for academic articles.”@Phil_Robichaud
“I must say, @deepdyve is a fabulous solution to the independent researcher's problem of #access to #information.”@deepthiw
“My last article couldn't be possible without the platform @deepdyve that makes journal papers cheaper.”@JoseServera