Cannabis Legislation Research Articles

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Cannabinoids and Genetic Epilepsy Models: A Review with Focus on CDKL5 Deficiency Disorder

Pediatric genetic epilepsies, such as CDKL5 Deficiency Disorder (CDD), are severely debilitating, with early-onset seizures occurring more than ten times daily in extreme cases. Existing antiseizure drugs frequently prove ineffective, which significantly impacts child development and diminishes the quality of life for patients and caregivers. The relaxation of cannabis legislation has increased research into potential therapeutic properties of phytocannabinoids such as cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC). CBD’s antiseizure properties have shown promise, particularly in treating drug-resistant genetic epilepsies associated with Lennox–Gastaut syndrome (LGS), Dravet syndrome (DS), and Tuberous Sclerosis Complex (TSC). However, specific research on CDD remains limited. Much of the current evidence relies on anecdotal reports of artisanal products lacking accurate data on cannabinoid composition. Utilizing model systems like patient-derived iPSC neurons and brain organoids allows precise dosing and comprehensive exploration of cannabinoids’ pharmacodynamics. This review explores the potential of CBD, THC, and other trace cannabinoids in treating CDD and focusing on clinical trials and preclinical models to elucidate the cannabinoid’s potential mechanisms of action in disrupted CDD pathways and strengthen the case for further research into their potential as anti-epileptic drugs for CDD. This review offers an updated perspective on cannabinoid’s therapeutic potential for CDD.

T2 - Recreational Cannabis Legislation and Binge Drinking in U.S. Adolescents and Adults Between 2008-2019

T2 - Recreational Cannabis Legislation and Binge Drinking in U.S. Adolescents and Adults Between 2008-2019

Road hazard: a systematic review of traffic injuries following recreational cannabis legalization.

Acute cannabis use is associated with impaired driving performance and increased risk of motor vehicle crashes. Following the Canadian Cannabis Act's implementation, it is essential to understand how recreational cannabis legalization impacts traffic injuries, with a particular emphasis on Canadian emergency departments. This study aims to assess the impact of recreational cannabis legalization on traffic-related emergency department visits and hospitalizations in the broader context of North America. A systematic review was conducted according to best practices and reported using PRISMA 2020 guidelines. The protocol was registered on July 5, 2022 (PROSPERO CRD42022342126). MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), and Scopus were searched without language or date restrictions up to October 12, 2023. Studies were included if they examined cannabis-related traffic-injury emergency department visits and hospitalizations before and after recreational cannabis legalization. The risk of bias was assessed. Meta-analysis was not possible due to heterogeneity. Seven studies were eligible for the analysis. All studies were conducted between 2019 and 2023 in Canada and the United States. We found mixed results regarding the impact of recreational cannabis legalization on emergency department visits for traffic injuries. Four of the studies included reported increases in traffic injuries after legalization, while the remaining three studies found no significant change. There was a moderate overall risk of bias among the studies included. This systematic review highlights the complexity of assessing the impact of recreational cannabis legalization on traffic injuries. Our findings show a varied impact on emergency department visits and hospitalizations across North America. This underlines the importance of Canadian emergency physicians staying informed about regional cannabis policies. Training on identifying and treating cannabis-related impairments should be incorporated into standard protocols to enhance response effectiveness and patient safety in light of evolving cannabis legislation.

Recreational cannabis dispensary access effects on prescription opioid use and mortality

While opioid prescribing rates have fallen since 2012, opioid mortality in the United States (US) climbed to record highs in 2022, per CDC reports. In the last decade, evidence emerged that recreational cannabis legislation (RCL) may help mitigate adverse opioid-related outcomes. Yet, the empirical evidence on the relationship between RCL and opioid misuse as a whole is inconsistent and possibly spurious, given common estimation methods. Studies reporting beneficial associations between RCL and opioid mortality tend to avoid the mechanism of change, often assuming mortality benefits stem from substituting cannabis for opioids. We test this relationship using prescription opioid quantities and access to recreational cannabis in the US state of Oregon. Our approach uses within-state variation in distance to recreational dispensary access generated by RCL and prior volumes of legal opioid use to assess the impact of dispensary access on prescription opioids. Results suggest that communities located closer to recreational dispensaries are associated with lower rates of prescription opioids per capita. We also show that reasonable bounds to our primary specification suggest communities located within a mile from a recreational dispensary have prescription opioid rates per capita that are 1.0–3.9 percent lower than surrounding communities. Despite the reduction, we find no evidence that reducing barriers to cannabis access and subsequent declines in prescription opioids are associated with meaningful changes in opioid mortality.

Changing cannabis legislation in Canada and a longitudinal look at “regular” cannabis use in patients with eating disorders

Regular cannabis use (CU), defined as “weekly or more often”, is associated with a number of negative mental health outcomes. In the last decade, Canada legalized first medical and then recreational CU. Despite higher prevalence in mental health populations, little research has documented changes in frequency of CU with progressive legalization of cannabis. This study examined rates of CU in a sample of 843 treatment-seeking patients with eating disorders (ED) in an outpatient setting between 2004 and 2020. Across ED diagnoses, segmented regression indicated a significant break-point in regular CU in 2014, commensurate with the relaxation of medical cannabis laws. Regular CU increased from 4.9 % to 23.7 % from 2014 to 2020; well above the stable 6 % found in the general population. No significant break-point was observed in either alcohol or illicit substance use over the same time period. Significant increases in regular CU were found in patients with anorexia nervosa and binge eating disorder, while regular use remained stable in patients with bulimia nervosa. Comorbid psychiatric diagnoses did not increase odds of regular CU. Findings suggest certain patient groups with mental illness may be at risk of engaging in high frequency use in the context of legislation implying medical benefits of cannabis.

State cannabis laws and cannabis positivity among fatally injured drivers

BackgroundAs of November 8, 2023, 24 states and the District of Columbia have legalized cannabis for both recreational and medical use (RMCL-states), 14 states have legalized cannabis for medical use only (MCL-states) and 12 states have no comprehensive cannabis legislation (NoCL-states). As more states legalize cannabis for recreational use, it is critical to understand the impact of such policies on driving safety.MethodsUsing the 2019 and 2020 Fatality Analysis Reporting System data, we performed multivariable logistic regression modeling to explore the association between state level legalization status and cannabis positivity using toxicological testing data for 14,079 fatally injured drivers. We performed a sensitivity analysis by including multiply imputed toxicological testing data for the 14,876 eligible drivers with missing toxicological testing data.ResultsOverall, 4702 (33.4%) of the 14,079 fatally injured drivers tested positive for cannabis use. The prevalence of cannabis positivity was 30.7% in NoCL-states, 32.8% in MCL-states, and 38.2% in RMCL-states (p < 0.001). Compared to drivers fatally injured in NoCL-states, the adjusted odds ratios of testing positive for cannabis were 1.09 (95% confidence interval: 0.99, 1.19) for those fatally injured in MCL-states and 1.54 (95% confidence interval: 1.34, 1.77) for those fatally injured in RMCL-states. Sensitivity analysis yielded similar results.ConclusionsOver one-third of fatally injured drivers tested positive for cannabis use. Drivers fatally injured in states with laws permitting recreational use of cannabis were significantly more likely to test positive for cannabis use than those in states without such laws. State medical cannabis laws had little impact on the odds of cannabis positivity among fatally injured drivers.

Cannabis Use Is Associated with Pain Severity and Interference Among Cancer Survivors.

Cannabis use for symptom management among individuals with cancer is increasingly common. We sought to describe the (1) prevalence and characteristics of cannabis use, (2) perceived therapeutic benefits of cannabis use, and (3) examine how use of cannabis was associated with self-reported pain, mood, and general health outcomes in a representative sample of patients treated at a National Cancer Institute (NCI)-designated Oregon Health and Science University Knight Cancer Institute. We conducted a population-based, cross-sectional survey developed in conjunction with 11 other NCI-designated cancer centers and distributed to eligible individuals. The survey inquired about characteristics of cannabis use, perception of therapeutic benefits, pain, mood, and general health. Responses were population weighted. We examined the association of cannabis use with self-reported pain, mood, and general health using logistic regression controlling for relevant sociodemographic and clinical characteristics. A total of 523 individuals were included in our analytic sample. A total of 54% endorsed using cannabis at any time since their cancer diagnosis and 42% endorsed using cannabis during active treatment. The most commonly endorsed reasons for use included the following: sleep disturbance (54.7%), pain (47.1%), and mood (42.6%). We found that moderate pain was associated with more than a twofold (odds ratio = 2.4 [95% confidence interval = 1.3-4.6], p = 0.002) greater likelihood of self-reported cannabis use. Depressed mood and general health were not associated with cannabis use. In a state that had early adoption of medical and recreational cannabis legislation, a high number of cancer survivors report cannabis use. Moderate or more severe pain was associated with an increased likelihood to use cannabis, while mood and general health were not associated. Oncologists should be aware of these trends and assess use of cannabis when managing long-term symptoms of cancer and its treatments.

Patterns of cannabis use, perception of harm, and perceived impact of legislative change in an online sample of young adults from Lebanon: insight on recreational users versus dual motive users

BackgroundLebanon remains as one of the major sources of cannabis worldwide. In 2020, its government passed a legislation enabling the cultivation of local medicinal cannabis. This first study following the legislative change examines the overlapping use of cannabis for recreational/medicinal purposes and characteristics of the distinct cannabis user types.MethodsA total of 1230 young adults (18–24 years) filled an anonymous online survey in early 2020.ResultsYoung adults in the sample were distributed as follows: 33% 18–20 years; 60% males; 94% Lebanese; 75% students; and 89% living with family. The older young adults (21–24), males, those employed, living with non-family members, and who perceived themselves as being a little/lot richer than most were statistically significantly more present in the cannabis user subtypes (recreational only or recreational/medicinal) than non-cannabis users. When dual recreational/medicinal users are compared to recreational users only, the latter seemed to have a more conservative profile of behaviours, attitudes, and perceptions and acts of harm. The prevalence ratio comparing the prevalence of users supporting consuming cannabis “once or twice” in dual motive users vs. recreational users only was 1.13 for “once or twice”, 1.25 for “occasionally”, 1.64 for “regularly”, and 2.4 for “daily”. Any other illicit drug use was reported by 1% of the non-cannabis users, 36% of the recreational users only, and 58% of the recreational/medicinal users (p-value < 0.01). Similarly, any prescription drug use was reported by 3% of the non-cannabis users, 16% of the recreational users only, and 28% of both recreational/medicinal users (p-value < 0.01).ConclusionThe interface between recreational and medicinal cannabis use is complex. Dual motive users may warrant special attention as a subpopulation of cannabis users. This is relevant to contexts experiencing medicinal cannabis legislation changes, such as Lebanon, as policymakers and implementers should be sensitized to the emerging evidence for more data-informed policy changes.

International Effect: The Ongoing Tension with Medical Marijuana Legalization

Purpose: In the landscape of the United States, an escalating number of states are ushering in a new era by enacting legislation that affords individuals the right to employ cannabis for medical purposes. However, this commendable stride toward medical autonomy is accompanied by an escalating tension, a discordant symphony of conflict between state and federal jurisdictions. This study embarks on a journey through the labyrinth of legislative intricacies, seeking to unravel the roots of this tension and proffering insights into potential resolutions. At the heart of the matter lies the dichotomy between state and federal legislation. While states pave the way for medical cannabis use, the federal stance casts a looming shadow of ambiguity and discord. The conflict, multifaceted and dynamic, beckons for a nuanced exploration.&#x0D; Methodology: The study adopted desktop literature research design.&#x0D; Findings: By delving into the intricacies of the legislative measures themselves, this research identifies mitigating factors that can potentially alleviate the tension between conflicting jurisdictions. Mitigation, however, requires more than a superficial understanding of legislative nuances. It demands a comprehensive acknowledgment of the extensive legal and medical data interwoven with the fabric of cannabis use for medical purposes.&#x0D; Unique Contribution to Theory, Practice and Policy: The study advocates for a holistic approach, urging policymakers to draw upon a repository of knowledge that transcends mere legal frameworks. In doing so, it seeks to bridge the gap between state and federal perspectives, fostering a more informed and cooperative discourse. Navigating the path toward resolution involves a delicate balance. The sculpting of legislative measures should be informed by a deep appreciation of the medical intricacies associated with cannabis use. The study underscores the significance of considering medical data as an essential compass in the journey toward harmonizing state and federal regulations. By acknowledging the complex interplay between legality and medical efficacy, this research contributes to the ongoing dialogue surrounding cannabis legislation. In conclusion, this study illuminates the intricate dance between state and federal jurisdictions in the realm of medical cannabis use. Through a meticulous examination of legislative intricacies and a robust consideration of legal and medical data, it endeavors to pave the way for a more harmonious coexistence between state and federal perspectives.

Cannabis reduction among adolescents as spillover from successful tobacco control

BackgroundNational programs that reduce adolescent cannabis use warrant renewed attention in light of current discussions to reform cannabis legislation, including the possibility of legalization for recreational use. This study measures the size of a decrease in a country's prevalence of adolescent cannabis use that accompanies a decrease in its prevalence of adolescents who had ever smoked a cigarette. MethodsData are from the European School Survey Project on Alcohol and Other Drugs (ESPAD), which is a collaborative effort of more than 40 European countries to surveil adolescent substance use. This study uses data from the seven survey administrations in 1995, 1999, 2003, 2007, 2011, 2015, and 2019. The main analysis is a fixed-effect regression analysis of country-level, four-year changes in adolescent lifetime cannabis use prevalence on country-level, four-year changes in adolescent lifetime cigarette use prevalence. ResultsDecreases in the national prevalence of adolescents who had ever smoked a cigarette were accompanied by decreases half as large in national prevalence of adolescent lifetime cannabis use. ConclusionFor European countries considering the legalization of adult recreational cannabis use, tobacco control can offer a tool to help counter potential increases in cannabis use among adolescents.

The effect of cannabis legislation on opioid and benzodiazepine use among aging Americans

&lt;sec&gt;&lt;title&gt;Background&lt;/title&gt;&lt;p&gt;This study sought to evaluate whether medicinal cannabis (marijuana) laws (MMLs) influence opioid and benzodiazepine use through displacement from opioids and companion drugs toward cannabis for arguably better or comparable pain management among aging Americans (i.e., those aged 50 years and older) as opposed to concentrating on &lt;italic&gt;older&lt;/italic&gt; people aged 65 years and above. This aging demographic is an understudied but vulnerable population to unknown or paradoxical policy effects amid the current medical and legal landscape. Should this displacement occur, the implementation of such legislation may ultimately aid in mitigating the adverse repercussions that ensue from an excessive dependence on these more traditional medications. However, it is also critical to assess whether these laws worsen outcomes among this population.&lt;/p&gt;&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Methods&lt;/title&gt;&lt;p&gt;To investigate these possibilities, 2022 data from the National Survey on Drug Use and Health (NSDUH) are used along with multiple logistic regression procedures to evaluate the use of opioids and benzodiazepines in MMLs for those aged 50 years and older compared to those younger.&lt;/p&gt;&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Results&lt;/title&gt;&lt;p&gt;Findings reveal that less opioid reliance is reported among the aging residing in MML states compared to non-MML states. However, no effect from the laws is observed for benzodiazepines or co-prescribed opioids and benzodiazepines among this population.&lt;/p&gt;&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Conclusions&lt;/title&gt;&lt;p&gt;MMLs may serve to attenuate the consequences of opioid reliance among the aging but not use of opiates in combination with benzodiazepines or the use of benzodiazepines alone.&lt;/p&gt;&lt;/sec&gt;

The impact of cannabis legislation on benzodiazepine and opioid use and misuse

The impact of cannabis legislation on benzodiazepine and opioid use and misuse

Investigating Small-scale Farmers and Barriers to Entry in Cannabis Cultivation in South Africa

The legalisation of the prodigal green crop has left the most vulnerable small-scale cannabis farmers high and dry. In 2018 the South African constitutional court legalised the use of cannabis for personal and medical use. The 2018 regulations on cannabis were welcomed and a new lifeline in the eradication of poverty. However, in the haste to join the global urgency in cultivating cannabis, small-scale farmers were left behind and prevented in the bid of the green-gold rush. The cannabis legislation and laws that were created to enable South Africans to participate in the lucrative cannabis market has done the opposite and has crafted barriers of entry. Using a desktop study, this article explores how the 2018 regulations on cannabis cultivation prevent small-scale farmers in participating in the l market in South Africa. The aim of this paper is to highlight the challenges that small-scale cannabis farmers face in South Africa and how their participation in the newly opened market would benefit the communities they live and operate in. The main findings of the research indicate the challenges for small-scale farmers of no support system and transformational issues persist even after the 24 years of democracy in South Africa.

What Parents Are Missing: Parental Knowledge of Adult-Use Cannabis Legislation and Health Effects, and Communication with Adolescents

Background: The cannabis regulation landscape is ever evolving, and it may be difficult for parents to stay up to date. This study aimed to assess parental knowledge of recent cannabis legislation and cannabis health effects, as well as communication around cannabis use. Materials and Methods: Data were collected through the 2020 Voices of Child Health in Chicago Parent Panel Survey. Parents were asked about the veracity of statements on cannabis legislation and health effects, and about communication with their children. Descriptive statistics were calculated to characterize response frequencies. Rao-Scott chi-square test explored differences in the proportion of parents who answered all questions correctly or got at least one question wrong. Results: 75% and 74% of parents answered at least one legislation or health items incorrectly, respectively. Most parents reported talking to their children about legislation (56%), not using cannabis (75%) and rules around drug use (90%). Conclusions: While parents reported communicating with their children about cannabis, the majority had gaps in their knowledge. The results of this study indicate a need for effective cannabis education interventions.

Parental openness and communication regarding cannabis and alcohol use with their children.

Given increases in youth cannabis and alcohol use and changes in the cannabis market, we examined parental openness and communication about cannabis and alcohol. Among 197 participants who had children ≤18 years old and lived in six US metropolitan areas (Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, Seattle), we examined sociodemographic and use correlates of parental openness (i.e., acceptability of child use, rules regarding use in the home or around children, communication) about cannabis and alcohol, as well as being more open about cannabis versus alcohol. In this sample (Mage = 32.30, 70.1% female, 30.5% sexual minority, 33.0% racial/ethnic minority, 41.6% in recreational cannabis state), 33.5% reported past-month cannabis use, and 59.9% alcohol (22.8% used both, 29.4% used neither). Multivariable regression indicated that cannabis users (vs. nonusers) and sexual minority (vs. heterosexual) individuals were more open about cannabis use; alcohol users (vs. nonusers) were more open about alcohol use. Additionally, older parental and child age correlated with greater cannabis- and alcohol-related communication, and females (vs. males) reported greater cannabis-related communication. Those married/cohabitating and reporting past-month alcohol use were less likely to allow cannabis versus alcohol in the home or near children. Parents in legalized recreational (vs. nonlegalized) states, females, and heterosexual individuals reported greater cannabis- versus alcohol-related communication. Interventions are needed to support parental communication regarding substance use, particularly cannabis. This study addressed parenting and youth substance use during evolving cannabis legislation and can inform youth substance use prevention interventions targeting parent-child communication.

Recreational cannabis legislation and binge drinking in U.S. adolescents and adults.

Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.). We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies. Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30. Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

The impact of cannabis legalization and decriminalization on acute poisoning: A systematic review.

Many countries have recently legalized medicinal and recreational cannabis. With increasing use and access come the potential for harms. We aimed to examine the effect of cannabis legalization/decriminalization on acute poisoning. A systematic review and meta-analysis registered with PROSPERO (CRD42022323437). We searched Embase, Medline, Scopus and Cochrane Central Register of Controlled Trials from inception to March 2022. No restrictions on language, age or geography were applied. Abstracts from three main clinical toxicology conferences were hand-searched. Included studies had to report on poisonings before and after changes in cannabis legislation, including legalization and decriminalization of medicinal and recreational cannabis. Where possible, relative risk (RR) of poisoning after legalization (versus before) was calculated and pooled. Risk of bias was assessed with ROBINS-I. Of the 1065 articles retrieved, 30 met inclusion criteria (including 10 conference abstracts). Studies used data from the United States, Canada and Thailand. Studies examined legalization of medicinal cannabis (n = 14) and decriminalization or legalization of recreational cannabis (n = 21). Common data sources included poisons centre records (n = 18) and hospital presentations/admissions (n = 15, individual studies could report multiple intervention types and multiple data sources). Most studies (n = 19) investigated paediatric poisoning. Most (n = 24) reported an increase in poisonings; however, the magnitude varied greatly. Twenty studies were included in quantitative analysis, with RRs ranging from 0.81 to 29.00. Our pooled estimate indicated an increase in poisoning after legalization [RR = 3.56, 95% confidence interval (CI) = 2.43-5.20], which was greater in studies that focused on paediatric patients (RR = 4.31, 95% CI = 2.30-8.07). Most studies on the effect of medicinal or recreational cannabis legalization/decriminalization on acute poisoning reported a rise in cannabis poisoning after legalization/decriminalization. Most evidence is from US legalization, despite legalization and decriminalization in many countries.

Working memory-related brain activity in cannabis use disorder: The role of cross-cultural differences in cannabis attitudes.

Cannabis legislation and attitudes towards use are changing. Given that evidence from cultural neuroscience research suggests that culture influences the neurobiological mechanisms underlying behaviour, it is of great importance to understand how cannabis legislation and attitudes might affect the brain processes underlying cannabis use disorder. Brain activity of 100 dependent cannabis users and 84 controls was recorded during an N-back working memory (WM) task in participants from the Netherlands (NL; users = 60, controls = 52) and Texas, USA (TX; users = 40, controls = 32). Participants completed a cannabis culture questionnaire as a measure of perceived benefits (positive) and perceived harms (negative) of cannabis from their personal, friends-family's and country-state's perspectives. Amount of cannabis use (grams/week), DSM-5 CUD symptoms and cannabis use-related problems were assessed. Cannabis users self-reported more positive and less negative (personal and friends-family) cannabis attitudes than controls, with this effect being significantly larger in the TX cannabis users. No site difference in country-state attitudes was observed. TX cannabis users, compared with NL cannabis users, and those cannabis users perceiving more positive country-state attitudes showed a more positive association between grams/week and WM-related activity in the superior parietal lobe. NL cannabis users, compared with TX cannabis users, and those cannabis users with less positive personal attitudes showed a more positive association between grams/week and WM-load-related activity in the temporal pole. Both site and cultural attitudes moderated the association of quantity of cannabis use with WM- and WM-load-related activity. Importantly, differences in legislation did not align with perceived cannabis attitudes and appear to be differentially associated with cannabis use-related brain activity.

Self-reported THC content and associations with perceptions of feeling high among cannabis consumers.

Few studies have examined consumer knowledge and communication of tetrahydrocannabinol (THC) content among cannabis consumers, including potential differences by cannabis legislation. The study sought to: (i) examine self-reported knowledge of THC content across 10 cannabis products; (ii) examine self-reported intoxication levels; and (iii) examine association between self-reported THC levels and intoxication levels. Repeat cross-sectional surveys were conducted in Canada and the United States in September-November 2020 as part of the International Cannabis Policy Study. Respondents were past 12-month cannabis consumers, aged 16-65 (n = 13,689). A weighted logistic regression model examined the association between expected intoxication of dried flower, jurisdiction and frequency of cannabis use. Across all 10 cannabis products, approximately two-thirds of consumers did not know the quantitative THC level of the cannabis product they last used. Qualitative levels of THC (e.g., 'low' or 'high' THC) showed moderate correspondence with quantitative self-reported THC levels for most products. Approximately half of consumers across all products reported achieving their desired intoxication level at last use, with higher levels among more frequent consumers and Canadian consumers of dried flower (F = 2.54, p = 0.019). Overall, comprehension of THC levels in cannabis products is low among consumers in both illegal and legal markets.