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.
Group dynamics at play
Participants came to the project with different perspectives and experiences. This clearly influenced the dynamics within the group and shaped the process of collaboratively engaging with the evidence. Some of the young people revealed that they knew very little about the substance, while others possessed strong opinions and claimed knowledge based on their personal cannabis use. This made for animated discussions, inspired curiosity for learning, and accommodated diverse perspectives and dialogue focused on the evidence.
Comfort levels and participation during discussion were distinct between both groups. Personal experience with marijuana was a powerful force that was particularly palpable in Group 1. Those who were regular cannabis users were vocal, revealing their use to others early in the process; they also spoke with authority. Those without personal cannabis experience listened intently to the confident and persuasive voice of “knowledge” based largely on personal experience. Subtle silencing transpired suggesting that some participants were unprepared to challenge this self-assured voice. In contrast, the participants in Group 2 were immediately relaxed with one another. This group included several youth who had used cannabis occasionally, but no regular cannabis users.
In both groups, certain participants (including those without personal cannabis experience) spoke with considerable ease. During discussion, these youth made frequent contributions about their understandings of the evidence and were influential players as demonstrated when select content was later picked up and repeated by others. One participant, who had smoked marijuana once, was described by his peers as having “a way of capturing the audience” when sharing his understanding of the evidence. On occasion, articulate and effusive youth shared misinformation unknowingly whereby it was necessary for the research team to provide clarification. Other participants’ contributions regarding the evidence were measured, suggesting a preference for reflection while quietly making sense of the evidence. These youth surprised the team with their sophisticated understanding of cannabis at project end. Despite the serious focus of the sessions, the dynamics also included laughter and playful elements that were most often initiated by the male participants. Humor appeared to be a way to puncture potential awkwardness within this context of different perspectives and experiences.
Expecting simple answers
Many participants entered into an examination of the scientific literature with the notion that there would be clear, straight forward answers in the research on cannabis. This was based on the assumption that this body of science was firmly established. As a result, many looked for single causes in research findings and pursued consistent and concrete results. Within little time, however, they encountered unanticipated and contradictory evidence. Many expressed their frustration with these perceived shortcomings in the evidence that was particularly apparent when researchers acknowledged that findings remained “inconclusive.” Proposed “theories” of benefit and harm undermined any sense of certainty and, for some youth, they were difficult to grasp. In response, many participants became guarded when making sense of the evidence; some reacted with skepticism. For example, with regard to the association between cannabis and schizophrenia, one participant remarked, “it could be this [or] it could be this… and it might not be marijuana that’s causing this, [pause] or it could be.” Another young person was particularly dissatisfied when researchers concluded with the phrase “we don’t know” which was interpreted as “an easy out”.
It’s a classic answer for a complicated question in science …it’s better than saying an answer that could be false or that you don’t really have sufficient evidence to back up. So it’s not necessarily like not a bad answer, well, I want more. (Female, 17, occ. MJ use).
It was also somewhat unsettling for some participants to realize that the evidence was neither as solid nor straight forward as had been suggested when exposed to abstinence styled public health messaging. At the same time, it was as if a light switch had been turned on; most were beginning to appreciate the complexity surrounding the substance and were intent on unraveling the puzzle so as to gain more certainty. After reading one academic article, one young woman noted in her log, “the claim that I found interesting was the negative effect on memory may depend solely on the strain [of cannabis].” These youth embarked on the challenge of unpacking the evidence on cannabis to gain more clarity.
Wrestling with uncertainty
Participants engaged with and “puzzled” over contradictory and inconclusive findings. In addition, unexpected evidence challenged what young people had previously held to be true, which was an obvious source of confusion. Certain findings were simply labeled “bizarre,” pointing to the level of surprise for some participants. For one young man, firm beliefs about the health harms of cannabis were exposed and needed to be re-examined when confronted with evidence suggesting that smoking tobacco was more harmful than cannabis. A female participant commented on the evidence related to cannabis use and driving noting how it was “kind of hard to wrap your head around” some of the evidence adding, “Marijuana impairs your psychomotor performance, so why would some drivers actually improve their performance?” Findings could not be taken at face value. Participants’ efforts and abilities to absorb new information required inquisitiveness and diligence.
Use of conditional language added to existing uncertainty. Specifically, the terms “could” and “may” that frequently appeared in scientific materials were deemed unsatisfactory and vague. In addition, the concept of “risk” was elusive and hard to comprehend. Weighing balanced evidence that explored risk was particularly challenging for those who had previously aligned themselves with strong beliefs that cannabis was either safe or harmful. As such, one young person, a fervent advocate for the use of vaporizers, initially had difficulty accepting that there were risks associated with “vaporizing” cannabis. In contrast, those who had always seen it as a harmful substance struggled to acknowledge the value of purported medicinal benefits.
Some participants came to understand that there were degrees of evidence when sorting through “information.” One young person noted the importance of being able to distinguish between “facts, kind of facts, and somewhat factual.” Communicating their confusion, emerging understandings and insights of the evidence with one another appeared to be a helpful outlet as participants recognized a shared uneasiness with the uncertainty in the literature.
Relaxing with ambiguity
Over time, we observed that most participants developed the ability to consider opposing findings when making sense of the evidence by applying varying degrees of critical thinking. Most were gaining skills in recognizing bias and valued balanced reporting in the literature that they were encountering.
Participants settled into a position where they proposed that cannabis “affects everybody differently”, making it a substance that was “not black and white”. This indisputable stance appeared to bring some relief. Having reviewed select evidence, they had gained a level of confidence and reflected on how they understood the status of the evidence. The limitations were underscored with claims that “everyone said there needs to be more research”. One youth concluded that “confounding factors can contribute to the results”. They readily acknowledged that the topic of cannabis was “so controversial”. Having explored the literature and weighed the evidence, they felt justified with their position in this middle zone where cannabis was perceived as neither good nor bad.
I thought doing the research would kind of help us find the ‘yes’ and the ‘no’s, but it actually didn’t, it made us more confused. But we did learn more of the why it could be ‘yes’ or it could be a ‘no’. So, I think those are really valuable towards finding the conclusions. (Female, 16, non-user).
Despite this lack of certainty in the midst of inconclusive and conflicting evidence, the exercise of inquiry was deemed to be worthwhile.
Most youth who came into the project thinking that cannabis was “all bad”, no longer believed that was the case at project end, an unanticipated finding for the research team. Furthermore, those who initially held extreme beliefs about cannabis as either a good or bad substance appeared at ease with their uncertainty. Participants had gained an appreciation for the complexity surrounding the evidence on cannabis. Most had developed basic critical thinking skills and were better able to identify bias and unreliable sources of information. As a result, participants were able to relax within the scope of uncertainty that was present in the literature.
Approaches to reading the literature
Reading the scientific literature involved encountering new terminology and interpreting a “different” style of writing initially described as “hard to read/understand due to the vocabulary and complex sentence structures”. Participants soon developed strategies for “weeding out the information”. The degree to which participants remained engaged in the activity of careful reading varied over the course of the project. Two distinct styles became apparent within several weeks: effortful engagement and intermittent engagement. Although some participants drew on both approaches depending on the material at hand, most relied primarily on one style. Of note, there was no association between personal cannabis use and style of engaging with the literature.
With the first approach, participants became immersed in a methodical sorting through the evidence on cannabis because they were curious about the topic and wanted to learn. They demonstrated perseverance when grappling with challenging and unfamiliar materials, highlighting articles, making notes, and developing systems for organizing the new information. One youth routinely read articles twice and was purposeful in her approach.
The first time was sort of to get a feel of it and the second time was to pick out key ideas, to pick out words that I didn’t know, to pick out any questions I might have about the article … to focus more on bias. (Female, 17, non-user).
This approach was characterized by enthusiasm for focused learning about the evidence on cannabis, and curiosity about the topic selected for their final research project.
At times, this type of engagement was ephemeral. For one young man, it occurred in spurts based entirely on his interest in specific materials. One research article addressed the debate on measurement issues and cannabis which had sparked his curiosity. After reading it thoroughly, he was articulate in sharing his understanding of the different points of view represented in the article and accompanying commentaries. However, his level of engagement was not sustained when it came to his final presentation, reflective of the second style, intermittent engagement, highlighting the ebb and flow of effort observed with some participants when tasked with engaging with the literature.
A second style involved a ‘cherry picking’ approach to reading materials on cannabis. Some young people claimed to already have the answer, whereas others appeared generally capable but uninterested in investing the necessary time. This expedient approach was characterized by “skimming” the literature, all the while expressing confidence in “knowing what to look for” in order to “skip through to the important parts”. One participant elaborated on selecting what to read.
I pick out the parts that I find interesting. And I read those and then I also look through the graphs first because they’re well organized and interesting and I find the relevant sections of text that actually elaborate on those graphs…. I can form my own thought process because I’m reading through it in my own way. (Male, 17, occ. MJ use).
Based on a superficial and partial read, conclusions were drawn quickly. Some entered into the literature, determined to find evidence to support what they already believed and not pursue that which challenged it. On occasion, errors were made as a result of relying on this approach.
Despite the challenges that all participants experienced when making sense of the scientific evidence on cannabis, collaborative public health messages were created by participants in Group 2, reflecting language that was concrete and direct. There was a palpable sense of accomplishment that the group had made sense of some evidence on cannabis.
It is better to stay abstinent than to suffer the potential consequences.
It’s best not to resort to marijuana when life isn’t going well. There is always help available.
Initiating cannabis use before adulthood is a lot more dangerous than beginning at a later age.
Marijuana affects everyone differently, both physically and mentally. Know what you’re gambling with when using marijuana.
If you do choose to use it, make sure it only impacts your life and not the lives of others.
Know your source. There may be more in the dose than just marijuana.
The higher the dosage, the more severe the impairment.
Know the risks, make informed decisions, use responsibly.
As one young person acknowledged, “Public health messaging is focused more and more around knowledge and making your own decision from this knowledge, and less around scare tactics”. Accordingly, these participants had created balanced public health messages based on their shared knowledge on the topic of cannabis following a review of the evidence. It is worth noting that the above public health messages were produced by a group of young people with a low rate of cannabis use. No doubt comparable messages by youth counterparts who use cannabis regularly would encompass a more permissive tone.
How participation in this study would inform decision-making about whether or not to use cannabis in the future was not the goal of this study. That said, at the end of the project, most participants who had not used cannabis conveyed a resolve to “avoid marijuana at all costs”. Participating in this project also influenced self-reflection for several participants who did use cannabis regularly. As one young man noted, “I now feel more cautious in my approach to pot”.
In keeping with a KT approach, the collaborative, youth-driven public health messages were assembled into an information brochure, a process which involved substantial input from a Group 2 participant; these resources were later made available to youth prevention workers based in Vancouver high schools. Responses to these brochures have been positive and, consistent with other KT research projects, demonstrate the enhanced applicability of findings that result from involving the end-users of evidence throughout the entire KT process . One youth worker shared, “I really like the messaging” adding “the layout would work really well for the type of work we do. It gives 8 solid points - great youth voice quotes, and reminds us what is most important to youth.... how the message is communicated”. Another youth worker identified how the brochure supports initiating critical dialogue on cannabis use, which to date, has been largely absent in schools , adding “it helps that it's through youth voice and not the usual adult or health authority”. Requests for additional brochures from several local high schools have resulted in needing to print additional copies. It also points to the dearth of culturally relevant materials available on cannabis to support balanced dialogue on the topic within school settings. Although no formal evaluation of brochure has yet occurred, it is clear that the brochure has been a welcome resource.
By project end, participants conveyed continuing enthusiasm to learn more about cannabis, demonstrating that their interest in the evidence was alive and well. One young man suggested, “Besides making our own messages for teens, I feel that we can use our research to try and reach out to programs such as D.A.R.E. to help them improve their courses”. They expressed appreciation for the opportunity to have engaged in research focused on cannabis that had “broadened knowledge” and “opened their eyes” to the challenges in drawing “definite conclusions”. Attitudinal shifts towards the substance were expressed from a position of “strictly opposed and ignorant” to “more educated” and able to “consider both sides”. And one young man who used cannabis on a regular basis noted, from here on, he would be “more careful checking the credibility of facts”. Most were visibly eager to deliver their personal health message and to participate in discussion about a topic that was perceived as “controversial, misunderstood, demonized” and rarely talked about in a non-judgmental forum. One young woman proposed, “Just keep the conversation open… teens love to express themselves given the chance”.