Impacts of recreational cannabis legalization on use and harms: A narrative review of sex/gender differences


. 2023 Mar 10;14:1127660.

doi: 10.3389/fpsyt.2023.1127660.

eCollection 2023.


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Justin Matheson et al.

Front Psychiatry.



Legalization of cannabis use for non-medical (recreational) purposes is changing the global cannabis landscape. As attitudes toward cannabis use become more positive and prevalence of use increases in complex ways, concerns emerge about the potential for increased cannabis-attributable harms. Understanding the who, why, and when of this likely increase in cannabis-attributable harms is thus an important public health priority. Both sex and gender contribute to variability in the use, effects, and harms of cannabis and thus sex/gender considerations are important when evaluating the impacts of cannabis legalization. The goal of this narrative review is to broadly discuss sex/gender differences in attitudes toward and prevalence of cannabis use, whether there are sex/gender differences in the impacts of cannabis legalization, and why these sex/gender differences might exist. One of our strongest conclusions is that men have always been more likely to use cannabis than women, yet the sex/gender gap in prevalence of cannabis use has narrowed over time, and this might be partly due to cannabis legalization. The existing evidence suggests that there have also been sex/gender differences in the impacts of legalization on cannabis-attributable harms such as cannabis-involved motor vehicle collisions and hospitalizations, though these results are more variable. The body of literature reviewed has focused almost exclusively on samples of cisgender research participants, and thus future research should encourage inclusion of transgender and gender-diverse participants. More consideration of sex- and gender-based analysis in research evaluating long-term impacts of cannabis legalization is a clear research priority.


attitudes; cannabis; gender; harms; legalization; prevalence; sex.

Conflict of interest statement

BLF has obtained funding from Pfizer (GRAND Awards, including salary support) for investigator-initiated projects. BLF has some in-kind donation of cannabis product from Aurora and medication donation from Pfizer and Bioprojet and was provided a coil for TMS study from Brainsway. BLF has obtained industry funding from Canopy (through research grants handled by CAMH or University of Toronto), Bioprojet, ACS and Alkermes. BLF has received in kind donations of nabiximols from GW Pharma for past studies funded by CIHR and NIH. He has been a consultant for Shionogi. He is supported by CAMH and a clinician-scientist award from the department of Family and Community Medicine of the University of Toronto and an Addiction Psychiatry Chair from the department of Psychiatry of the University of Toronto. BLF also participated in an advisory board meeting for Indivior and got a grant from Indivior for a clinical trial. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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