Overview of Statistics Canada social statistics data with

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Overview of Statistics Canada social statistics data with cannabis content -Final Michelle Rotermann Health

Overview of Statistics Canada social statistics data with cannabis content -Final Michelle Rotermann Health Analysis Division November 29, 2018

Cannabis for non-medical purposes became legal October 17, 2018 The Cannabis Act has 3

Cannabis for non-medical purposes became legal October 17, 2018 The Cannabis Act has 3 goals: keep cannabis out of reach of youth keep profits out of the hands of criminals protect public health and safety by allowing adults access to safe, legal cannabis (Health Canada) 2

What is legal as of October 17, 2018 Subject to P/T restrictions, adults aged

What is legal as of October 17, 2018 Subject to P/T restrictions, adults aged 18/19 + can legally: -Purchase limited amounts of fresh or dried cannabis, cannabis oil, seeds, or plants from P/T authorized retailers; -Possess up to 30 grams of dried legal cannabis or equivalent in public; -Consume cannabis in locations authorized by local jurisdictions; -Grow up to 4 plants/household (not person/personal use only), from licensed suppliers; -Share up to 30 grams of dried cannabis or equivalent with other adults; -Make legal cannabis-containing products at home (e. g. food and drinks), provided that dangerous organic solvents are not used in process 3 -Pre-made edibles & concentrates legal by Oct. 2019

Key milestones in path to legalization: Process not an event 1923 1969 Cannabis deemed

Key milestones in path to legalization: Process not an event 1923 1969 Cannabis deemed illegal in Canada Royal (Le. Dain) Commission of Inquiry in the non-medical use of drugs 1972 Le. Dain Commission recommends the removal of criminal penalties for use & possession Fed. gov't begins issuing ministerial exemptions-- allowing individuals to possess/ cultivate marijuana for medical purposes. 1999 2000 2001 20032005, 2011 ON Court of Appeal decides in R. v. Parker that legislation prohibiting marijuana possession infringes the rights of persons who need it medically; ministerial exemption scheme is also unconstitutional Fed. gov't responds by implementing Marihuana for Medical Access Regulations (MMAR). Authorizes persons meeting medical criteria to possess/have produced the marijuana necessary to alleviate condition. ON Superior Court decides in R. v. Hitzig that the MMAR falls short of constitutional requirements b/c they don't provide a legal (marijuana) supply to persons entitled to possess it for medical purposes. Ongoing Charter challenges & rulings against Fed. gov't. MMAR continually modified in response Fed. gov't introduces Marihuana for Medical Purposes Regulations (MMPR), incl. commercially licensed industry for production & distribution 2013 2015 MMPR changed to allow authorized medical patients access to cannabis oil not just dried marijuana, based on Supreme Court R. v. Smith and another challenge resulting in restatement of provision to allow personal cultivation 4 2016 Access to Cannabis for Medical Purposes Regulations (ACMPR) replaces MMPR 2018 C-45 Cannabis Act

Legalization with aim to find balance between social/health harms and commercialization Rolles S &

Legalization with aim to find balance between social/health harms and commercialization Rolles S & Murkin G. How to regulate cannabis: A practical guide, 2 nd ed. Transform Drug Policy Foundation 2016 www. tdpf. org. uk/resources/publications/how-regulate-cannabis-practical-guide 2

Innovation: one-stop shop for cannabis data announcements, links to articles, etc. 6

Innovation: one-stop shop for cannabis data announcements, links to articles, etc. 6

Framework documents: key overview 1) A cannabis economic account – The framework (Nov. 21,

Framework documents: key overview 1) A cannabis economic account – The framework (Nov. 21, 2017) https: //www 150. statcan. gc. ca/n 1/pub/13 -605 x/2017001/article/54881 -eng. htm -vision of the cannabis economic account -introduce new industry, product, and expenditure classifications -compiling the cannabis account 2) Preparing the social statistics system for the legalization of nonmedical cannabis (Oct. 12, 2018) https: //www 150. statcan. gc. ca/n 1/pub/75 -006 x/2018001/article/54979 -eng. pdf -describes recent adjustments and initiatives undertaken to enhance the capability to assess C-45 impacts on health and social institutions -identified 4 key domains; each domain linked to key indicators and identified data sources Particularly relevant 7

4 key social domains established in the social framework –today’s focus = 1 &

4 key social domains established in the social framework –today’s focus = 1 & 2 1. Basic surveillance measures, which include frequency of use, quantity used, purpose and method of use, along with basic sociodemographic characteristics such as gender and age. 2. Public health and health care, to assess the impact on the health of the Canadian population and on the Canadian health care system. Variables of concern include cannabis use disorders, couse with other substances and health care attributable to cannabis use. 3. Public safety and justice, to monitor and assess the implications of the legislation on law enforcement, the administration of justice, and community safety and well-being. 4. Other social statistics, to assess the potential impact on various outcomes, including school dropout rates, truancy, workplace safety and work performance. 8

Basic Surveillance Measures Importance/rationale Frequency of use -fundamental to determining associated risks; can be

Basic Surveillance Measures Importance/rationale Frequency of use -fundamental to determining associated risks; can be an indicator of dependence Main data source NCS, CTADS (CADS), CHSCY Quantity used NCS Purpose of use Method of cannabis exposure SES, sociodemographic covariates -frequency alone can be insufficient as a measure of risk -know that daily users can use more per day than non-daily users -medical, non-medical, or both -can be consumed in various ways: -smoked, vaporized (vaped), dabbed, consumed in edible products/drinks, absorbed topically and sublingually, mixed with tobacco, etc. -Method used affects uptake of psychoactive constituents Age, gender, sex, household income, ethnicity, labour force participation, education, aboriginal identity CTADS (2015 & 2017), CADS, NCS 2018 Q 4 CTADS (CADS), NCS, CHSCY 9

National Cannabis Survey https: //www. statcan. gc. ca/eng/survey/household/5262 • Rapid. Stats program is a

National Cannabis Survey https: //www. statcan. gc. ca/eng/survey/household/5262 • Rapid. Stats program is a new survey model aimed at improving timeliness and being responsive to emerging issues. • Surveys under this model would be completed from start to finish in about 4 months. • The National Cannabis Survey is the second survey conducted within the new Rapid. Stats infrastructure and has been collected 3 times in 2018 (and continuing into 2019) • Desire to have survey quarters collected both pre- and –post legalization • Objective: To better understand cannabis usage and to monitor changes in behaviour pre- and –post implementation of C-45 10

National Cannabis Survey Target Population: General hhld. population aged 15 + Geography: Provinces most

National Cannabis Survey Target Population: General hhld. population aged 15 + Geography: Provinces most quarters; 3 territorial capitals included Quarter 2 (Q 2) 2018 and Q 2 2019 Collection mode: Electronic Questionnaire (EQ) with telephone follow-up Content (originally): 15 questions, with 5 additional demographic questions (household size, age, gender, postal code, education, marital status, health status) Response rate: targeted sample size 12 K, RR ~50%; ~6, 000 Collection: 2018 Q 1 mid-February to mid-March ==Apr 18 Q 2 mid-May to mid-June ==Aug 9 Q 3 mid-August to mid-September ==Oct 11 Q 4 mid-November to mid-December ==Jan 2019 Q 1 mid-February to mid-March ==TBD 11

National Cannabis Survey –Q 1, Q 2 & Q 3 References cannabis use and

National Cannabis Survey –Q 1, Q 2 & Q 3 References cannabis use and related behaviours in previous 3 months Use of cannabis, quantity used by type, frequency of use Themes Source of cannabis Purchasing habits (spending by product and quantity) Attitudes about consumption; anticipate behaviour change with legalization Impaired driving or being a passenger (Q 2 & Q 3 only) Demographic information 12

NCS–Q 4 Reason for use (medical/non-medical) New content Method of consumption e. g. smoked,

NCS–Q 4 Reason for use (medical/non-medical) New content Method of consumption e. g. smoked, vaped Factors considered when selecting source to buy from Frequency of use before school or work Problematic use/harm measured with ASSIST Driving or being passenger within 2 hours of using alcohol & cannabis 13

Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2017 http: //www 23. statcan. gc. ca/imdb/p

Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2017 http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&SDDS=4440 Objective: Monitor changes regarding the usage of tobacco, alcohol and drugs (prescription and non-prescription) Target Population: General household population aged 15 +; voluntary Geography: Provinces only Collection mode: CATI Content: tobacco, alcohol, prescription and non-prescription drug use, e-cigarettes, exposure to second-hand smoke (ETS) + SES/socio-demographic Cannabis content: modes of use, age of initiation, lifetime use, past year and 3 -month use, purpose of use (medical/non-medical), frequency, harms Response rate: , RR ~40%; ~16, 000 Collection: February to December 2017 14

General Social Survey (Victimization 28) http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl?

General Social Survey (Victimization 28) http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&SDDS=4504 Objective: to provide information on specific social policy issues of current or emerging interest. Target Population: General household population aged 15 +; voluntary Geography: Provinces + territories Collection mode: CATI only provinces; CATI/CAPI territories Collected: January 2014 - January 2015 Response rate: 53%; Sample size: 33 K Cannabis content: Past month use and frequency by respondents and their partners/spouses Note: cannabis content collected as covariate rather than for prevalence estimation 15

Canadian Health Survey on Children and Youth (CHSCY) - 2019 http: //www 23. statcan.

Canadian Health Survey on Children and Youth (CHSCY) - 2019 http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&Id=282165 Objective: to paint a portrait of the health and well-being of Canadian children and youth Target Population: General household population aged 1 to 17; voluntary Geography: Provinces + territories Collection mode: EQ Collected: Feb to June 2019 Sample size: ~25, 000 Cannabis content: frequency of cannabis use, age at first use, perceived harm resulting from use, access and usual source 16

Aboriginal Peoples Survey (APS) (2018) http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl?

Aboriginal Peoples Survey (APS) (2018) http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&SDDS=3250 Description: is a national survey on the social and economic conditions of First Nations people living off reserve, Métis and Inuit aged 6 years and over. The 2018 APS represents the 6 th cycle of the survey and focuses on issues of education, employment and health Target Population: General population aged 6 + Geography: Provinces + territories Collection mode: CATI/CAPI Cannabis content: Past month use and frequency Response Rates= ~70 -80% depending on prov/territory Sample size: ~35, 000 Data available: Fall 2018 17

Limitations, gaps and opportunities (Basic surveillance measures) Quantity of cannabis used -quantity used only

Limitations, gaps and opportunities (Basic surveillance measures) Quantity of cannabis used -quantity used only asked by NCS -important for estimating exposure to active psychoactive ingredients (THC) -difficult for users to provide -ongoing issues with equivalences and units -anticipated that legalization will lead to an ↑ in people using cannabis with labels and known quantities and potencies Territorial -CTADS and NCS pertain to residents of provinces residents -2018 Q 2 & 2019 Q 2 conducted in territorial capitals -CTADS and NCS excludes residents of reserves Statistical -% reporting cannabis use = minority power - #s depend on reference period of use (lifetime vs 30 days), -combination of “use” + qualifier (daily) + covariates of interest =can limit ability to disaggregate 18

Public health and health care Age at first daily/ regular use Importance/rationale -↑ risk

Public health and health care Age at first daily/ regular use Importance/rationale -↑ risk of dependence/harms Main data source CADS/CTADS (age of initiation) ; CCHS 2019/20 Pattern of use -can be used to develop measure upon which dose NCS (quantity); CCHS, CTADS(CADS), -response analysis could be based NCS (freq) Anxiety or depression -cannabis use associated with different mental disorders CCHS 2019/20 Cannabis related harms -what % of population experiencing harms due to cannabis (ASSIST or SDS) -frequency of use or quantity not always sufficient ASSIST: CTADS (CADS), NCS Q 4 Co-use with other substances Driving/ being a passenger Use during pregnancy -use with other substances an important public health concern -impairs judgement, reaction time CTADS (CADS) -use during pregnancy could affect infant’s health CADS Medical consultations attributable to cannabis -trends in usage of ER, poison control, rehab, mental health care Discharge Abstract Database (DAD) -excludes QC 19 -excludes adult psychiatric beds Severity of Dependence Scale (SDS): CCHS 2019/20 NCS, CCHS 2019/20, CTADS (CADS)

Canadian Community Health Survey (CCHS) –Annual 2019/20 http: //www 23. statcan. gc. ca/imdb/p 2

Canadian Community Health Survey (CCHS) –Annual 2019/20 http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&SDDS=3226 Objective: to gather health-related data at the sub-provincial levels of geography (health region or combined health regions). Target Population: General household population aged 12 +; Geography: Provinces + territories Collection mode: CATI; voluntary Content: diseases/health conditions, health services, lifestyle/social conditions, mental health + SES/socio-demographic Cannabis content: various reference periods, modes of use, age of initiation, lifetime use, purpose of use (medical/non-medical), frequency, harms, driving after consuming Response rate: TBD; ~60, 000 per year Collection: January to December 20

Other annual CCHS cycles cannot be used for national cannabis-related analysis because drug use

Other annual CCHS cycles cannot be used for national cannabis-related analysis because drug use content previously optional Canadian Community Health Surveys(CCHS) collecting drug use module by prov/terr year 2001 2003 2005 2007 2008 2009 2010 2011 2013 2014 2012 2015 2016 2017 2018 2019 NL PE NS NB PQ ON MN SK AB BC YT NWT NV NS NS O O NS NS NS C NS NS NS NS C NS NS NS O O NS NS NS C NS NS O O NS NS O O C NS NS NS NS C NS NS NS O O O C NS NS NS NS O O C NS NS NS O O O NS NS C NS NS NS O O NS NS C NS NS NS O O NS NS NS C NS NS NS NS NS NS O O C NS NS NS O O O O NS NS C 2020 C O NS C C C C drug use module selected by P/T drug use module not selected by P/T drug use module core

However CCHS-MH 2002 & 2012 also an important source of prevalence/correlates of drug use

However CCHS-MH 2002 & 2012 also an important source of prevalence/correlates of drug use http: //www 23. statcan. gc. ca/imdb/p 2 SV. pl? Function=get. Survey&SDDS=5015 22

Discharge Abstract Database (DAD) linked to CCHS https: //www. statcan. gc. ca/eng/rdc/cencchs-dad • Purpose

Discharge Abstract Database (DAD) linked to CCHS https: //www. statcan. gc. ca/eng/rdc/cencchs-dad • Purpose of this record linkage project is to better understand & quantify the association between risk factors (behavioural, socioeconomic, and environmental), hospital utilization and health outcomes at the individual & population level among householddwelling Canadians. • Linkage brings together CCHS annual component for 2000 to 2011, the Canadian Community Health Survey Focus Content for Mental Health and Wellbeing (2002), Nutrition (2004) and Healthy Aging (2008), and the Discharge Abstract Database 1999/2000 through 2012/2013. • Stat. Can does not have Quebec hospitalization data and thus Quebec data are not included in this linkage 23

Limitations, gaps and opportunities (Public Health and Health care) Pattern of use (quantity) Similar

Limitations, gaps and opportunities (Public Health and Health care) Pattern of use (quantity) Similar to those listed for Basic Surveillance Anxiety/ depression Cross-sectional survey design prevents establishment of temporal relationship i. e. which came first depression or cannabis use? Cannabis harms Different tools; lack of consensus e. g. SDS vs. ASSIST Medical consultations attributable to No nationwide data on outpatient services, Dr. visits, etc. Bias Social desirability bias can affect response accuracy Coverage Surveys exclude residents of reserves, homeless, frequently Northern communities 24

With these data we have started to answer some important questions… 25

With these data we have started to answer some important questions… 25

Is cannabis use more common now than previously? 26 https: //www 150. statcan. gc.

Is cannabis use more common now than previously? 26 https: //www 150. statcan. gc. ca/n 1/pub/82 -003 -x/2018002/article/54908 -eng. pdf

Is use among all age groups increasing? Source: Canadian Tobacco Use Monitoring Survey (CTUMS)

Is use among all age groups increasing? Source: Canadian Tobacco Use Monitoring Survey (CTUMS) & CTADS https: //www 150. statcan. gc. ca/n 1/pub/82 -003 -x/2018002/article/54908 -eng. pdf 27

Will Canadians change their behaviours once legalized? • About 8 in 10 Canadians 15

Will Canadians change their behaviours once legalized? • About 8 in 10 Canadians 15 years and over said they would be unlikely to try cannabis or increase their consumption with legalization • However, intention to use cannabis in the future and once legal largely depended on whether the person reported current use. • 28% of current users said they would likely increase use, more than 4 X the percentage of those not currently using (6%) Source: National Cannabis Survey 2 nd Quarter , 2018 28

How many Canadians currently consume cannabis? Does it differ regionally? https: //www 150. statcan.

How many Canadians currently consume cannabis? Does it differ regionally? https: //www 150. statcan. gc. ca/n 1/daily-quotidien/181011/dq 181011 b-eng. htm 29 Source: NCS Q 3 + Whitehorse (23%), Yellowknife (27%) and Iqaluit (33%) NCS Q 2

How many consume daily/almost? 6% Canadians (1. 8 million) report using daily/almost daily. Daily/almost

How many consume daily/almost? 6% Canadians (1. 8 million) report using daily/almost daily. Daily/almost daily use more common among 15 to 24 year olds (8%) vs. among 45+ (3%) Source: National Cannabis Survey Quarter 3, 2018 30 https: //www 150. statcan. gc. ca/n 1/daily-quotidien/181011/dq 181011 b-eng. htm

How many Canadians drive or were passengers in vehicles operated by a driver who

How many Canadians drive or were passengers in vehicles operated by a driver who had consumed cannabis within two hours? Source: NCS Q 2 & Q 3 31 https: //www 150. statcan. gc. ca/n 1/daily-quotidien/181011/dq 181011 b-eng. htm

Which products are used by which people? https: //www 150. statcan. gc. ca/n 1/daily-quotidien/180809/dq

Which products are used by which people? https: //www 150. statcan. gc. ca/n 1/daily-quotidien/180809/dq 180809 a-eng. pdf % of cannabis users 32

At what age do Canadians start trying different substances, including cannabis? Source: CTADS 2017

At what age do Canadians start trying different substances, including cannabis? Source: CTADS 2017 https: //www 150. statcan. gc. ca/n 1/daily-quotidien/181030/dq 181030 b-eng. htm 33

How many Canadians use cannabis for medical purposes? What are the main reasons? Source:

How many Canadians use cannabis for medical purposes? What are the main reasons? Source: CTADS 2017 https: //www 150. statcan. gc. ca/n 1/daily-quotidien/181030/dq 181030 b-eng. htm 34

Ongoing challenges/data gaps: - Unlike cigarettes/alcoholic beverages cannabis does not come in standardized units

Ongoing challenges/data gaps: - Unlike cigarettes/alcoholic beverages cannabis does not come in standardized units - Unknown potency - Changing willingness to report use; might exaggerate gap between past and present statistics - Technically no universal def’n of a medical user vs non-medical user - Legalization a process not an event –makes the assessment of C-45 (change in access) on behavior difficult - Provincial retail models differs regionally & unknown mix of legal and illegal sources (with limited data) 35

Complex retail landscape *All provinces and territories sell online + private-licensed stores + gov’t

Complex retail landscape *All provinces and territories sell online + private-licensed stores + gov’t operated stores https: //www. canada. ca/en/health-canada/services/drugsmedication/cannabis/laws-regulations/provinces-territories. html 36

Much more to do: the way forward for cannabis information… • National Cannabis Survey:

Much more to do: the way forward for cannabis information… • National Cannabis Survey: Rapid Stats Program • Pre and post legalization collection • Economic accounts production, margins, trade, consumption and inventories) • Canadian Health Survey on Children and Youth • Canadian Community Health Survey • Canadian Health Measures Survey • Canadian Alcohol and Drug Survey • Uniform Crime Reporting Administrative data – new offences • Police Administration Survey (training, expenditures) • Courts Administrative data (offences, court processing) • Victimization survey • Crowdsourcing prices • Wastewater pilot project Quarterly, rapid monitoring Innovative, alternative approaches New content, adapting administrative and survey data sources Integrated data, administrative and survey • Data linkages: Health surveys to hospital records • Justice data to other social domains 37

Thanks for listening! Questions/Comments? Michelle Rotermann Health Analysis Division Statistics Canada Michelle. Rotermann@Canada. ca

Thanks for listening! Questions/Comments? Michelle Rotermann Health Analysis Division Statistics Canada Michelle. Rotermann@Canada. ca