Additional file 1 of Attitudes toward driving after cannabis use: a systematic review

Additional file 3. Thematic synthesis codes. 

Additional file 3 of Attitudes toward driving after cannabis use: a systematic review

Importance
The impact of nonmedical cannabis legalization on traffic injuries and cannabis involvement in traffic injuries is unclear.


Objective
To examine changes in the number and characteristics of cannabis-involved traffic injury emergency department (ED) visits from before to after legalization and subsequent commercialization (ie, increased retail store and product availability) of cannabis in Ontario, Canada.


Design, Setting, and Participants
This repeated cross-sectional study examined changes in cannabis- and alcohol-involved traffic injury ED visits in Ontario, Canada, during 3 time periods: prelegalization (January 2010-September 2018), legalization with product and retail store restrictions (October 2018-February 2020), and commercialization with new products and expanded number of stores, which coincided with the COVID-19 pandemic (March 2020-December 2021). All individuals aged 16 years and older eligible for Ontario's Universal Health Coverage were included. Season- and time-adjusted quasi-Poisson models were used to generate rate ratios with 95% CIs. Data were analyzed from March to April 2023.


Main Outcomes and Measures
Quarterly counts of cannabis-involved ED visits for traffic injury.


Results
There were 947 604 traffic injury ED visits, of which 426 (0.04%) had documented cannabis involvement and 7564 (0.8%) had documented alcohol involvement. Of the 418 individuals with documented cannabis involvement, 330 (78.9%) were male, 109 (25.6%) were aged 16 to 21 years (mean [SD] age at visit, 30.6 [12.0] years), and 113 (27.0%) had an ED visit or hospitalization for substance use in the 2 years before their traffic injury ED visit. Annual rates of cannabis-involved traffic injury ED visits increased 475.3% over the study period (0.18 visits per 1000 total motor vehicle collisions in 2010 to 1.01 in 2021). Over the same period, alcohol-involved traffic injury ED visits increased by 9.4% (8.03 in 2010 to 8.79 per 1000 traffic injury ED visits in 2021). Legalization with restrictions was associated with a 94% increase in the quarterly rate of cannabis involvement in traffic injury ED visits relative to prelegalization (adjusted rate ratio [aRR], 1.94; 95% CI, 1.37-2.75). Commercialization/COVID-19 was associated with a greater increase of 223% in rates (aRR, 3.23; 95% CI, 2.42-4.33). After adjusting for time trends before legalization, only commercialization/COVID-19 was associated with increased rates. Male sex (adjusted odds ratio [aOR], 3.38; 95% CI, 2.66-4.29), living in the lowest-income neighborhood (aOR, 1.92; 95% CI, 1.39-2.67), being aged 19 to 21 years (aOR, 4.67; 95% CI, 3.27-6.67), and having a prior cannabis-related ED visit (aOR, 8.03; 95% CI, 5.85-11.02) were all positively associated with cannabis involvement during a traffic injury ED visit.


Conclusions and Relevance
This cross-sectional study found large increases in cannabis involvement in ED visits for traffic injury over time, which may have accelerated following nonmedical cannabis commercialization. Although the frequency of visits was rare, they may reflect broader changes in cannabis-impaired driving. Greater prevention efforts, including targeted education and policy measures, in regions with legal cannabis are indicated.

Cannabis-Involved Traffic Injury Emergency Department Visits After Cannabis Legalization and Commercialization.

Abstract Background Driving after cannabis use (DACU) is associated with increased risk of motor vehicle collisions. As cannabis legalization expands, DACU is emerging as a major public safety concern. Attitudes have a significant impact on behavioural decision making. As such, understanding the degree to which people have favorable or unfavorable evaluations of DACU is an important first step for informing prevention efforts. This systematic review summarizes existing evidence on attitudes toward DACU, their association with actual or intended DACU, and changes in attitudes following legalization of recreational cannabis. Methods Four electronic databases (MEDLINE, EMBASE, PsycINFO, and TRID) were searched for studies that reported attitudes or changes in attitudes toward DACU published between their inception dates and February 26 2024. A total of 1,099 records were retrieved. Studies were analyzed using an inductive thematic synthesis approach. Results Seventy studies from seven countries originating predominantly from the United States and Canada met inclusion criteria. Thematic analysis identified six themes. (I) Attitudes toward the safety and acceptability of DACU are mixed; participants in 35 studies predominantly expressed negative attitudes toward DACU (e.g., DACU is dangerous, affects driving ability, and increases crash risk). However, 20 studies reported opposing views. (II) Attitudes toward DACU vary by age, sex/gender, and cannabis use frequency; youth, men, and frequent cannabis users tended to view DACU more favorably than older participants, women, and occasional or non-users. (III) Attitudes toward DACU are associated with past DACU and intention to DACU. (IV) DACU is viewed more favorably than driving after drinking alcohol. (V) The relationship between legal status of recreational cannabis and attitudes toward DACU is unclear. (VI) Perceived risk of apprehension for DACU is low to moderate. Conclusions This review found that perceptions of DACU are primarily negative but mixed. Findings suggest that attitudes toward DACU are important targets for interventions to reduce this behaviour. 

Attitudes toward driving after cannabis use: a systematic review

BACKGROUND AND AIMS
The characteristics of cannabis-involved motor vehicle collisions are poorly understood. This study of injured drivers identifies demographic and collision characteristics associated with high tetrahydrocannabinol (THC) concentrations.


DESIGN
Prospective observational study.


SETTING
Fifteen Canadian trauma centres between January 2018 and December 2021. Cases Injured drivers (n=6956) who required blood testing as part of routine trauma care.


MEASUREMENTS
We quantified whole blood THC and blood alcohol concentration (BAC) and recorded driver sex, age and postal code, time of crash, crash type and injury severity. We defined three driver groups: High THC (THC≥5ng/mL & BAC=0); High Alcohol (BAC≥0.08% & THC=0) and THC/BAC negative (THC = 0 = BAC). We used logistic regression techniques to identify factors associated with group membership.


FINDINGS
Most injured drivers (70.2%) were THC/BAC negative; 1,274 (18.3%) had THC>0 including 186 (2.7%) in the High THC group; 1161 (16.7%) had BAC>0 including 606 (8.7%) in the high BAC group. Males and drivers <45 years had higher adjusted odds of being in the High THC group (v.s., THC/BAC negative group). Importantly, 4.6% of drivers <19 years old had THC≥5ng/mL and drivers <19 years had higher unadjusted odds of being in the High THC group than drivers aged 45-54 years old. Males, drivers aged 19-44 years, rural drivers, seriously injured drivers, and drivers injured in single-vehicle, nighttime or weekend collisions had higher adjusted odds ratios [aORs] for being in the High Alcohol group (v.s., THC/BAC negative). Drivers aged <35 or ≥ 65 years and drivers involved in multi-vehicle, daytime or weekday collisions had higher adjusted odds for being in the High THC group (v.s., High BAC group).


CONCLUSIONS
In Canada, risk factors for cannabis-related motor vehicle collisions appear to differ from those for alcohol-related motor vehicle collisions. The collision factors associated with alcohol (single vehicle, nighttime, weekend, rural, serious injury) are not associated with cannabis-related collisions. Demographic factors (young drivers, male drivers) are associated with both alcohol and cannabis-related collisions but are more strongly associated with cannabis-related collisions.


FUNDING
This study received funding from Health Canada, CIHR, Ministries of Transportation of Alberta and Ontario and Saskatchewan Government Insurance.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/add.16186

High 'N' Dry? A Comparison of Cannabis and Alcohol Use in Drivers Presenting to Hospital after a Vehicular Collision.

Background Alcohol and delta-9-tetrahydrocannabinol (THC) (main impairing ingredient of cannabis) are both crash contributors that interfere with motor vehicle operation. However, the relationship between drug concentration and crash injury severity is unclear for either drug. We aim to clarify the relationship between blood alcohol concentration (BAC) and crash injury severity, based on healthcare system utilisation, with and without THC. Methods The National Drug Driving Study is an ongoing prospective study involving 17 Canadian trauma centres. Eligible subjects included drivers aged 16+ who visited a participating trauma centre and had blood drawn as part of routine care within 6 hours of a crash. Deidentified blood samples were tested for alcohol and THC using gas chromatography-flame ionisation detection and liquid chromatography/tandem mass spectrometry. Study outcomes included admission to hospital and admitted patients’ length of hospital stay. Results 10 322 injured drivers visited a participating trauma centre between 2018 and 2023. 1649 (16.0%), 1716 (16.6%) and 463 (4.5%) drivers had detectable levels of alcohol, THC or both, respectively. Compared with sober drivers (BAC=0), drivers with 0%<BAC<0.08% had increased odds of admission (aOR=1.69, 95% CI=1.31 to 2.19), as did drivers with BAC≥0.08% (aOR=1.36, 95% CI=1.16 to 1.60). THC did not modify the relationship between alcohol and admission. Neither alcohol nor THC predicted were associated with length of stay following admission. Interpretation Alcohol increases hospital admissions after crashes but does not have a dose–response relationship with admission or length of stay. THC does not moderate this relationship.

Influence of cannabis and alcohol on motor vehicle injury severity in Canadian trauma centres: a prospective study.

The prevalence of benzodiazepines and other hypnotics and their impact on injury severity among older adults involved in motor vehicle collisions: a multicenter retrospective cohort study

Prevalence of Impairing Substance Use in Injured Drivers

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High 'N' Dry? A Comparison of Cannabis and Alcohol Use in Drivers Presenting to Hospital after a Vehicular Collision.

Influence of cannabis and alcohol on motor vehicle injury severity in Canadian trauma centres: a prospective study.

The prevalence of benzodiazepines and other hypnotics and their impact on injury severity among older adults involved in motor vehicle collisions: a multicenter retrospective cohort study

Prevalence of Impairing Substance Use in Injured Drivers