Weeding out the information: an ethnographic approach to exploring how young people make sense of the evidence on cannabis

Approaches to addressing cannabis use are fragmented in Canada, which contributes to a climate of confusion regarding its potential harms. On the one hand, advocates of the substance promote its beneficial properties, while those in opposition focus on the harms associated with the drug. Indeed cannabis is a complex substance with blurred boundaries between its medicinal properties and recreational appeal [1]. Although recreational cannabis use is illegal in Canada, it remains the most widely used illicit drug particularly among young people. Health Canada data indicate that young people are experimenting with cannabis at a younger age than in the past, with the average age of first use currently at 13.7 years [2].

In Canada, there is growing support among law makers and health professionals [3], as well as the general public [4] for changes that will permit the regulation of cannabis in a climate where current approaches to criminalizing the substance are considered counterproductive to overall public health. The support to regulate cannabis in neighboring American States of Washington and Colorado in the 2012 United States election has added fuel to this issue in Canada. Within this environment of polarized views on the substance, little attention has focused on how young people come to understand the potential harms and benefits related to cannabis use.

Navigating the abundant research on cannabis is a continuous exercise in weighing the best evidence. Although the adverse health effects of cannabis use have been studied extensively [5–7], some evidence remains inconclusive which adds to the challenge of addressing the harms related to this drug [8]. Cannabis is a complex substance with differing ratios and effects of its psychoactive components, tetrahydrocannabinol (THC) and cannabidiol (CBD) [9]; to date, however, the psychopharmacology of this substance has been largely under researched. Furthermore, scientific literature supports contradictory evidence. For example, the anxiolytic properties of CBD are well documented [10] and recently have been noted to benefit individuals with schizophrenia [11, 12]. In contrast, other findings link cannabis use and psychosis [5, 13–15]. Translating similar conflicting evidence to make it accessible is no easy task [16]. In the popular media, cannabis is often depicted in a way which distills and distorts scientific evidence to highlight findings that promote its salutary aspects. As a result, some young people have come to view cannabis as therapeutic [17, 18]. An in-depth understanding of how young people make sense of the contrary scientific evidence on cannabis is lacking in an era and social context where they are exposed to diverse sources of information.

An absence of consistent messages and harm reduction strategies related to cannabis has particular implications for young people as they encounter opposing information and make choices regarding its use. Within the Canadian context, young people receive adult-driven public health messages emphasizing the harms of cannabis, yet frequently hear about permissible medicinal use and are exposed to an environment where recreational use among peers and adults is common. Adolescence represents a critical developmental period for targeting substance use prevention and harm reduction strategies given that experimentation with substance use coincides with this stage of development. If our intention is that young people minimize the harms related to cannabis use, an understanding of how they engage in weighing the evidence and making decisions regarding use is indicated.

Approaches to addressing the topic of cannabis are inconsistent in school settings in Canada. A dominant abstinence discourse prevails in some high school communities with well-intended anti-drug messages to refrain from cannabis use altogether. Relying solely on such messages, however, may be ineffective as many young people have started to routinely use cannabis by their early teenage years. Other high school communities convey messages emphasizing that cannabis use will not be tolerated during the school day, which some youth interpret as an attempt to avoid addressing the topic directly [19]. In short, open dialogue and balanced discussion about cannabis with young people is lacking, resulting in minimal engagement to explore their understandings of the risks associated with cannabis.

Reducing the potential harms related to cannabis use requires a planned process of disseminating information and engaging in dialogue regarding the reasons for use and the associated risks based on the best evidence available. The growing field of knowledge translation (KT), which is aimed at promoting the utilization of best evidence to improve health outcomes, provides a useful lens for informing efforts to reduce the risks associated with cannabis use among young people. While KT is a broad field encompassing a range of approaches, there is heightened interest placed on the importance of utilizing collaborative methods, engaging end-users of knowledge throughout the KT process [20, 21]. Referred to as interactive or integrated KT, this type of approach is seen to enhance the relevance and meaning of research evidence among knowledge users [22]. Although the decision to use an integrated KT strategy should be based on the purpose of the research and desired outcomes, it may provide a particularly useful approach for enhancing the utilization of evidence among young people given that “children do indeed interpret their worlds differently from adults; they have distinctly different perspectives, values and understandings about all sorts of things…” [23] p. 318. However, while KT provides a mechanism for enhancing youth awareness of best evidence on the harms associated with cannabis use, to date, there has been a reticence to share such evidence with young people within the school context. As a result, there is a lack of understanding regarding young people’s ability to actively engage in the KT process — to critically weigh or appraise scientific evidence, or to be involved in the development of public health messages targeting youth; a gap we seek to address in our research.

It is clear that youth require evidence-based, culturally appropriate strategies that can effectively convey the risks associated with cannabis use. In this KT study, we engaged with young people in a supportive academic environment to foster the development of basic research and critical thinking skills with the goal of enhancing youth capacity to navigate the scientific and lay literature pertaining to cannabis. The purpose of this project was twofold: 1) to understand the processes by which young people work collaboratively to make sense of evidence on cannabis and, 2) to understand how youth engage with the literature for the purpose of contributing to the public health dialogue on cannabis.

An ethnographic approach was used in this study to observe how young people worked with cannabis-related materials, synthesized information, and interacted with peers during group activities. An ethnographic approach focuses on complex and multilayered practices and the meanings attached to processes and practices utilized [24]. Ethnographic methods are well suited for providing a holistic approach to explore a phenomenon, in our case, how participants made sense of scientific evidence on cannabis and created public health messages, and presenting this information from participants’ perspectives [25].

Ethical approval was obtained from the Research Ethics Board at the University of British Columbia. Information about participating in this study was circulated widely within high school communities. Our sample consisted of two groups and included a total of 18 young people (10 females and 8 males), aged 15 to 18, who were hired to participate in weekly study sessions. Most participants had never tried cannabis (n = 12), a few had tried on several occasions (n = 3) while others used it regularly (n = 3). The first group took place over a six-week period (n = 10), and the second group met over the course of eight weeks (n = 8). Group 1 was facilitated by two adult researchers, whereas Group 2 was facilitated by one adult researcher and one youth who had been a participant in Group 1. The sessions were held after school at the University of British Columbia in a conference room transformed into an informal learning environment. The group sessions began with an introduction to the basic topics of research, such as confidentiality and informed consent, and participants signed a consent form which outlined the expectations of the research project (e.g., completing homework, attending all sessions). Weekly activities included reviewing select literature and other sources of cannabis-related messaging as well as preparing an individual evidence-informed public health message.

To facilitate the participants’ skills in evidence appraisal, we engaged them in group learning activities that involved a discussion of materials (i.e., research articles, reviews, lay commentaries) selected by the team on topics such as distinguishing evidence from opinion and balanced from biased content. Participants also attended a library orientation that focused on conducting literature searches. In addition, the research team provided ongoing support for accessing and interpreting articles related to their personal projects.

Data were collected from a number of sources. Participants maintained reflective logs and presented their evidence-informed public health message at the end of the project. Sessions were audio-recorded and relevant segments were transcribed. Throughout the project, participant observation occurred and extensive field notes were made; the youth facilitator in Group 2 also maintained field notes. A member check was integrated into the analysis that involved sharing excerpts from group discussion, and emerging findings to ensure that the research team was on track with early analysis and to maximize participants’ understanding of the research process. Individual follow-up interviews were conducted with all participants to further explore their reflections on making sense of the evidence on cannabis. Although we draw on different sources of data in this paper, we focus on the observational component of this ethnographic study, thereby supporting the research teams’ interpretations of how participants worked collaboratively to make sense of the evidence and how they engaged with the scientific literature.

Analysis involved a team of three researchers who focused on reviewing and interpreting sections of the data that focused on how youth made sense of the evidence on cannabis. The software program, NVIVO, was used for the purpose of storing and organizing the data. One member of the research team (BMM) was responsible for managing and coding relevant data. Emergent themes and relevant excerpts from the data were discussed with the research team to ensure accuracy of interpretations.

Reviewing the evidence on cannabis was an uncharted and challenging task for the participants. From the outset, they were enthusiastic vis-à-vis the prospect of learning more about cannabis and the opportunity to participate in ongoing discussion focused specifically on the substance. We begin by turning our gaze to the overarching group dynamics that unfolded within the confines of this research project. Next, we describe the processes by which participants made sense of the current evidence on cannabis, and finally we depict the manner in which they engaged with the literature for the purpose of creating a public health message to share with the group. At project end, youth in Group 2 created collaborative public health recommendations based on their understanding of the evidence. One participant from Group 2 assisted with the development of a brochure showcasing these messages.

There are clear benefits to understanding how young people make sense of the literature on cannabis. Most youth in this project were capable of reading scientific literature, making sense of content and weighing potential risks related to cannabis use. Given the status of the current evidence on cannabis as well as the abundance and accessibility of information, can we expect youth to reach an unwavering understanding of the associated risks? While it is not possible to monitor how youth access information on cannabis, it is possible to support them in the review of credible sources, and in so doing, foster capacity for the critical examination of evidence. Importantly, our study findings point to untapped opportunities to challenge beliefs on cannabis and encourage reflection upon possible misunderstandings.

The group setting provided an important context that facilitated some participants’ understandings of the evidence of cannabis, albeit with prominent group dynamics at play. There was clearly much value from the discussion component of the project, a time to reflect on and share understandings of the evidence within the group setting. Creating and supporting this environment where youth were able to participate in facilitated cannabis-related discussion with peers and not be judged for held views or personal cannabis practices was well received. Participants were eager to discuss opposing research findings, highlighting the pros and cons of cannabis use, an opportunity that did not exist within the school setting. Building similar opportunities for in-depth discussion on cannabis to encourage young people to think critically about the evidence would foster meaningful dialogue.

The different approaches applied to making sense of the evidence are hardly a surprise given the range in personal learning styles and abilities to take in new information. In our study, we intentionally focused on youth aged 15 and older, recognizing that younger people (i.e. those in Grades 8 and 9) need structure and would likely have encountered additional challenges with the demands of the project. Participants were motivated to make sense of the evidence when they were passionate about a specific topic. However, Gasser [27] notes the double edge sword of knowledge and expertise readily available on the internet, specifically “how the absence of traditional gatekeepers engenders a complicated information landscape, capable of facilitating honest exchange and empowerment as well as danger and harm” (p. 40), hence the urgency of taking into consideration what information young people are now able to uncover. Indeed, this highlights the need to encourage access to and support the uptake of credible information on cannabis.

Admittedly language use remains a challenge in public health [28]; conveying precise and accurate “risk” information to youth and adult populations regarding cannabis is no easy task when much remains unclear [29]. Our study findings point to the importance of using clear and precise terminology. Ambiguity can be off putting for young people with the use of terms such as “could” and “may”, perceived to be indicative of a failure to take a stand by some youth in our study. Not surprisingly, participants carefully selected simple and direct language for their collaborative public health recommendations. How the evidence on cannabis translates into public health messages, including potential risk deserves ongoing attention. Given that proposed “theories” regarding risk were perceived to undermine certainty, they may be beyond the comprehension of some youth. Nonetheless, engaging in meaningful discussion about and reflecting upon possible risks and theories appears to contribute to more sophisticated understandings as was the case for some participants in this study.

With regard to researchers engaged in KT activities, our findings reveal that young people are indeed capable and appreciative of the opportunity to engage in KT activities. Furthermore, given that involving knowledge users in the KT process is seen as an important step towards enhancing the outcomes of this work, youth must be acknowledged and engaged as a central stakeholder group, particularly when it concerns evidence for use by youth populations; young people respond differently to information than do adults [23].

Finally, project findings revealed how young people can contribute to the public health dialogue on cannabis. Creating accurate and credible public health recommendations is undeniably a challenge, yet the youth in our study were able to do so. Currently in Canada, there is little consensus on appropriate public health messages for this illicit yet widely used substance. Recommendations or “Lower risk guidelines” for cannabis use were created for adult populations [30] and implicitly for youth and young adult populations in a “Taking Care with Cannabis”, brochure [31]; both were written by adults without input from young people. Including youth voices and perspectives on culturally relevant public health recommendations has the potential for reaching the youth population in a credible fashion. For most youth who are recreational cannabis users, cannabis is harmless, a rite of passage that ends as young people settle into adults lives and careers [6]. Balanced public health dialogue regarding potential risks of cannabis based on the best evidence must be part of health education for it to be deemed believable.

This study is not without limitations. Most participants were clearly motivated as demonstrated by their willingness to participate in an after school activity that required additional reading and project work; most were high achievers academically. Given this small sample, our findings are not representative of all youth. In many ways, participants reflected the demographics of Vancouver; for some, English was not their first language which may have added a layer of difficulty with comprehension of some materials. One participant from Group 1, who encountered challenges finalizing his research project, did not attend the final session and was lost to follow-up. Gordon [32] notes that in ethnography, data is generated by researchers rather than collected. Obviously, the team could only make observations when youth were physically present. Although some research logs contained rich data that shed light on making meaning of the evidence on cannabis, it was not possible to observe what transpired when youth were engaged in making sense at home.

As adults, it is a challenge to understand the perspectives of young people. The aim of this study was to attempt to understand how young people make sense of the evidence on cannabis. Our study findings reveal the abilities of some young people to critically review the evidence and to contribute to public health and harm reduction messaging. As Reist proposes, health literacy in the domain of drug education is a resource or asset, and a precursor for healthy action [33]. Adults involved in the field of public health must not underestimate the capabilities of young people.