Transcultural Aspects of Cannabis Use: a Descriptive Overview of Cannabis Use across Cultures

This narrative review summarises cultural aspects of cannabis use across different (sub)cultures, nations, and gender, racial, and ethnic groups. Specifically, we aimed to overview historical and traditional contexts of cannabis use and physical and mental health-related correlates, as well as emerging cannabis-related policies and their impacts on medicinal and recreational use of cannabis. In addition, we discuss how cultural factors may affect cannabis use behaviours and sociocultural underpinnings of cannabis use disorder trajectories. Cannabis is the most widely cultivated, trafficked, and used illicit drug worldwide, although cannabis is being legalised in many jurisdictions. More than 4% of individuals globally have used cannabis in the last year. Being traditionally used for religious and ritualistic purposes, today cannabis use is interwoven with, and influenced by, social, legal, economic, and cultural environments which often differ across countries and cultures. Notably, empirical data on distinct aspects of cannabis use are lacking in selected underrepresented countries, geographical regions, and minority groups. Emerging global policies and legislative frameworks related to cannabis use have impacted the prevalence and attitudes toward cannabis in different subcultures, but not all in the same way. Therefore, it remains to be elucidated how and why distinct cultures differ in terms of cannabis use. In order to understand complex and bidirectional relationships between cannabis use and cultures, we recommend the use of cross-cultural frameworks for the study of cannabis use and its consequences and to inform vulnerable people, clinical practitioners, and legislators from different world regions.


Introduction
Cannabis 1 is the most commonly used psychoactive regulated substance in distinct world regions with different cultures, with an estimated 4% (209 million) of the world's population having used cannabis in the last year, according to the World Drug Report [1]. Cannabis is the most widely used drug in the USA after alcohol and tobacco [2]. In Europe, 48 million males and 31 million females (27.3% of Europe's adult population) report ever having used cannabis for recreational purposes [3]. In Asia, it is estimated that the annual prevalence of cannabis use is 2%, representing roughly one-third (54 million people) of the people who use cannabis worldwide [4]. Cannabis also has a high prevalence of use in Australia and is the most widely used illicit drug (11.6% of individuals report past-year use [5]). However, only one in six Australian people who use cannabis report daily use [5,6]. Moreover, cannabis is Africa's most consumed illegal substance, and Africans constitute a third of the people worldwide who use and cultivate cannabis [7].
Although cannabis use prevalence differs across countries and cultures, it is challenging to tease apart patterns of cannabis use in distinct world regions with specific cultures and norms due to cultural differences in geographical regions worldwide [8]. In this review paper, we consider various cultural aspects of cannabis use and discuss how cannabis use patterns and attitudes may be influenced by different cultural contexts.
A sole "national culture" in a distinct geographical region is often considered as the prevalent value framework that subjects all individuals within that society to the same cultural norms [9]. However, subnational cultural groups can be heterogenous-there may exist multiple subcultures within the same country or geographical region substantially influenced by religion, geography, social class, ethnicity, cohort, and gender [8]. This heterogeneity could potentially form and impact different values and behavioural patterns related to social and psychological phenomena, such as cannabis use [10••]. To be more specific, increases in the prevalence of cannabis use globally could potentially reflect multiple complex changes in the cultural, societal, and legal landscape surrounding cannabis [11].
The reasons and motives for individuals to use cannabis are often multifactorial and may vary across different populations and cultures. These can include desires to achieve subjective effects, including mood enhancement, conformity, perception-alteration, mind-expansion, and positive social and interpersonal effects, although coping strategies such as negative reinforcement motivations (e.g. to escape from negative mood or uncomfortable states) also exist [12].
The Cannabis sativa plant produces over 400 chemical entities, 140 of which are unique to the plant as they are psychoactive in function and are usually referred to as "cannabinoids"levels of which vary across different plants [13 •]. Research to date has focused mainly on the two most common cannabinoids: Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the most abundant cannabinoid across most varieties of cannabis and is the primary intoxicating compound of the plant and the most widely studied [14].
To briefly overview the health-related effects of cannabis use based on empirical evidence, heavy cannabis use (defined as (near) daily use [15]) has been linked to adverse mental health measures, such as psychotic illness, cannabis use disorder (CUD), and cognitive impairment [16]. Studies have also found significant associations between cannabis use and depression, suicidality, and anxiety, although confounding factors may in part explain these relationships [17,18]. Physical health concerns have also been linked to long-term cannabis use. These concerns include testicular cancer, gastrointestinal problems, cardiovascular concerns (evidence mainly from case reports), and respiratory conditions, although not with lung cancer [19,20]. Studies show that long-term, regular cannabis use is associated with impairments in cognitive domains, including learning, memory, and decision-making [21]. Moreover, cannabis use is a risk factor for motor vehicle accidents [22]. Although a portion of cannabis-using populations will not experience significant harm from their use, 10-30% report developing symptoms suggesting dependence, including experiencing withdrawal symptoms, and consequences consistent with a CUD [23]. Furthermore, a recent meta-analysis showed that among people who use cannabis, 22% develop tolerance to the drug and fulfill diagnostic criteria for CUD [24•].
Conversely, emerging anecdotal and scientific evidence points to the therapeutic potential of cannabinoids. Cannabinoid-based medicine has been approved as a treatment option for nausea and vomiting in relation to chemotherapy, pain, and spasticity in patients with multiple sclerosis and as an antiepileptic for rare paediatric patients with epilepsies [25]. CBD has also shown potential as a treatment for schizophrenia as well as various substance use disorders, including those related to alcohol, opioids, and cannabis [13,26,27].
Given the high global prevalence of cannabis use and the related harms, it is crucial to understand psycho-sociocultural considerations related to cannabis use. Since cannabis is a drug that has been initially used for traditional, ritualistic, and religious purposes, and in some societies, its consumption may still relate to social and cultural norms and influences, it is important to understand how different cultures and cannabis use may influence one another. Together, 1 3 public beliefs and general narratives of people who use cannabis about motives of consumption can be seen as a "cannabis culture". There may be cannabis-related traditions, symbols, rituals, and narratives that are distinctive across societies and cultures [28]. Also, cultural aspects of cannabis use could potentially contribute to and stem from major global changes in cannabis regulation that are underway and make it easier to access the drug [29].
We contend that one key aspect often missing from conceptualisations, attempts for development, and implementation of prevention and intervention programs and research practices within the field is the role of culture. Based on Purnell's Model for Cultural Competence [30], major influences that shape peoples' worldviews and the degree to which they identify with their cultural group of origin are called the primary and secondary characteristics of the culture. This theoretical model suggests that the primary characteristics of culture comprise nationality, race, colour, gender, age, and religious affiliations [31].
The overarching aim of this paper is to outline primary characteristics and dimensions of culture (as proposed by Purnell's theoretical model [30]) related to cannabis use from a cross-cultural perspective and provide an overview of the variations across populations and cultures. Moreover, this paper provides a brief historical and cultural account of cannabis across different cultures in light of different social, legal, and cross-cultural differences in cannabis use and discusses different perspectives in this context.

Methods
Articles for this narrative review were obtained by searching PubMed and Google Scholar databases. We considered relevant studies regardless of study design and year of publication (the review concluded in November 2022). However, we included only research reported in English. Additional articles were obtained from reference lists of existing papers and reviews. We also searched the relevant grey literature (UNODC, NIDA, EMCDDA) for the most up-to-date information on cannabis use prevalence and legal status internationally. Our aim was to provide a developmentally informed overview of existing studies and to highlight important areas of future research to enhance our understanding of the roles of different characteristics and dimensions of culture on cannabis use [30].

History of Cannabis Use: Ritualistic, Medicinal, and Recreational Modes of Consumption
In Asia, cannabis use dates back millennia. Cannabis seeds accompanied the migration of nomadic peoples and were involved in commercial exchanges. Possibly the first reported medical use of cannabis was in 2700 B.C. in the Chinese pen-ts'ao, the world's oldest pharmacopoeia. Hindu myths before Christ suggest that the god Shiva, the supreme Godhead of many sects, supposedly favoured cannabis, which had a religious role as an agent for mystic inspiration and experience. Under names such as Vijaya, cannabis has been used for thousands of years in ayurvedic medicine in India (i.e. a holistic system of traditional medicine native to India) to reduce pain, nausea, and anxiety, improve appetite and sleep quality, relax muscles, and produce a feeling of euphoria. Moreover, several traditional and therapeutic indications of cannabis are mentioned in the texts of the Indian Hindus, Assyrians, Greeks, and Romans [32]. In ancient Egypt, cannabis tinctures and anointments were consumed for spiritual and healing purposes. Known as a hieroglyphic word Shemshemet (sm-sm-t), cannabis was considered to have been created by the god of the sun, Ra, and was traditionally used in death ceremonies as well as for multiple medicinal purposes [33,34].
In Europe, in the early nineteenth century, some physicians used cannabis seeds for homoeopathic medications. In 1840, William Brooke O'Shaughnessy, an Irish physician, introduced cannabis to Western medicine after having lived in Calcutta, India, and publishing his observations, including a case where cannabis stopped convulsions in a child [35]. In the second half of the nineteenth century, over 100 scientific articles were published in Europe and the USA about cannabis and its potential therapeutic effects, leading to increased medicinal use of cannabis in Western medicine in the late nineteenth and early twentieth century [36]. A series of legal obstacles, namely "the Marihuana Tax Act in 1937" [37], removal of cannabis from the American pharmacopoeia in 1941, and the 1961 United Nations Single Convention on Narcotic Drugs [38] that placed cannabis under the strictest control regime (Schedule IV) along with heroin, limited medicinal use and experimental research of cannabis.
In 1964, Raphael Mechoulam isolated and determined the structure of the main psychoactive phytocannabinoid, THC. This work stimulated exploration of a novel neural signalling system, the endocannabinoid system [39]. This discovery resulted in better knowledge of the plant's chemical compounds, and a significant increase in scientific interest in cannabis happened in 1965. The number of research projects and publications on cannabis grew significantly in the early 1970s. Studies on cannabis increased again in the early 1990s, with the description of Devane and Mechoulam about specific receptors in the nervous system responsible for the pharmacological effects of THC, followed by the isolation of anandamide, an endogenous cannabinoid. Endogenous cannabinoids or "endocannabinoids" are natural ligands of cannabinoids, mainly responsible for the pharmacological effects of THC, which bind to these receptors [39].
After the passing of the Controlled Substance Act (CSA; also known for promoting the "War on Drugs" movement) in the USA in 1971, cannabis was listed as a Schedule I substance, and its consumption was tightly restricted and not socially or legally accepted, even under medical supervision [40]. The US government spent billions of dollars to legally address, often through arrest and incarceration, non-violent cannabis-related crimes and restrict cannabis research and medicinal applications through the enforcement of prohibitionist laws [41]. Outside of the USA, the legal climate surrounding cannabis use had become rather restrictive during the 1970s. For example, in August 1971, the French president George Pompidou invited European governments-namely the Netherlands, West Germany, Belgium, Luxemburg, Italy, and the UK-to participate in a collaborative effort to "combat" drugs, including cannabis [42]. By this time, the Dutch government was considering reframing its restrictive regulations on cannabis, differentiating it from drugs considered more harmful [42]. Influenced by the US government and the United Nations, in July 1973, Nepal closed down all its cannabis shops and cancelled all cannabis dealers and farming licenses, as did Afghanistan in the same year [43]. Despite the imposition of legal restrictions on the production and consumption of cannabis products in Africa, by the end of the 1970s, cannabis had become established as a popular illegal drug across Africa [44].
A considerable change in US cannabis policy history took place in 1996 when California allowed the medicinal use of cannabis (also known as California Proposition 215) [45]. Later, Colorado and Washington were the first US states to legalise the recreational use of cannabis [46]. After the USA, Uruguay was the first country globally to explicitly regulate recreational cannabis use in 2013 [47]. During the same decade, increasingly more US states established laws permitting cannabis use for medical and recreational purposes. As of April 2023, 38 US states, three territories, and the District of Columbia had laws permitting the medical use of cannabis [48]. As of June 2023, legal provisions allowing the production and sales of cannabis for non-medical (i.e. recreational) use had been approved in Canada, Uruguay, and Thailand, as well as in 23 states, two territories, and the District of Columbia in the USA 2 [49•].
The World Drug Report also shows that the global prevalence of cannabis use has increased in the past decade, from 147 million individuals (~2.5%) in 2010 to more than 210 million individuals (~4%) in 2022 [1]. There has been a considerable global increase in the past-year prevalence of cannabis use, and the proportion of past-year cannabis use reported by adolescents reached 43% in 2021 from 34% in 2016 [50]. The COVID-19 pandemic has also influenced trends in cannabis use. Amid the COVID-19 lockdowns in early 2020, a global survey reported that the use of cannabis had increased by 63% globally [51]. Furthermore, during the COVID-19 pandemic, feelings of boredom, depression, and anxiety, as well as the accessibility to cannabis, may have contributed to increases in the use of cannabis [52].
Importantly, longitudinal studies examining cannabis potency in the USA and Europe report significant increases in cannabis potency (i.e. higher THC concentration and lower CBD concentration) during the last two decades [53]. Findings suggest a higher risk of cannabis-use-related negative consequences on physical and mental health as well as dependency occurs with cannabis having such chemical constituents [54]. Given the high association of cannabis potency increment with an increased risk of mental health disorders [55••], this constitutes a significant public health concern regarding cannabis use.
To summarise, cannabis use dates back to at least the third millennium BC in written history for different traditional, medicinal, and recreational purposes throughout the world. The legislative changes in cannabis-related laws and unprecedented global issues, such as the COVID-19 pandemic, have influenced cannabis-use patterns globally, contributing to intertwined historical and cultural relationships involving cannabis use.

Social Class and Cannabis Use
Cannabis use has become a cultural phenomenon in industrialised countries in the 1960s among White and middle-class youth [56]. For some, cannabis became a marker of their identities and a culture that resisted existing mainstream and social norms in Western societies. Cannabis use was associated with specific musical preferences, milieus, and lifestyles. In the wake of the youth rebellion of the 1960s, a so-called hang-loose ethic, and the advent of hippies, the substance took root in broader groups throughout Western societies [57]. In other words, the rituals, symbols, and stories of the contemporary cannabis culture were arguably shaped by and interwoven with the ideology of the social and cultural movements of the 1960s and 1970s in Western cultures. In most Western countries, cannabis was introduced and fostered by young people who were politically in opposition with their societies' norms, advocating for the 1 3 values of the broader culture entwined with Eastern philosophy and political opposition [28]. Hence, the introduction of cannabis consumption, and recreational use particularly, coincided with significant cultural changes in this period [58]. In the early 2000s, cannabis consumption contributed to "hip-hop culture", often expressed along with a distinctive sort of style, clothing, language expressions, and lifestyle [59]. More recently, findings from a recent Swedish study indicate that young people tend to associate cannabis with freedom of choice, coping with demands of self-realisation, achievement, and happiness. Societal tendencies to depict cannabis as a "forbidden fruit" may enhance positive attitudes toward cannabis use [60].

Socioeconomic Status and Cannabis Use
Evidence-based research about cannabis use in different countries with a comparative approach is limited and scarce. A large survey conducted in 1999 explored national rates of cannabis use among young adults in 31 countries and their associations with per capita personal consumer expenditure (an indicator of economic prosperity), unemployment, and peer factors [56]. This study found that in wealthier countries across Europe and North America, young people used cannabis more frequently, potentially resulting from increased leisure opportunities for larger segments of the population in wealthier countries. This finding suggests that wealth and availability of cannabis may foster cannabis use, particularly among younger individuals. For instance, patterns of cannabis use in Anglo-American countries (Canada, the UK, and the USA) showed higher prevalence estimates relative to most countries in eastern and northern Europe (except the Czech Republic, Hungary, Slovenia, and Ukraine). In a separate large-scale survey involving adolescents living in different continents, prevalence of cannabis use was associated with higher income levels and lower urbanity rates in 73 low-and middle-income countries [61 •]. Apart from studies that explored the link between cannabis use and socioeconomic status at a country level, several studies show an association between cannabis use and socioeconomic status at the individual level. For instance, findings from a longitudinal study showed that people who used cannabis among 947 participants had more financial difficulties relative to those who did not use [62]. More recently, a study of a longitudinal birth cohort (from birth to age 35 years) in New Zealand reported that high-frequency cannabis use was associated with poorer indices of socioeconomic well-being such as lower income and reduced odds of attaining tertiary qualifications in both early-onset and adultonset participants [63]. Therefore, socioeconomic class factors may influence patterns of cannabis consumption and attitudes towards the drug. However, given limited empirical data investigating associations between socioeconomic status and cannabis use patterns, particularly in Asian and African countries, future studies exploring country-level differences in cannabis use and social class are important.

Public Policy, Legal Environments, and Cannabis Use
Legal policies surrounding cannabis decriminalisation and legalisation across countries are important factors related to trends and prevalence of cannabis use across societies. Several studies have investigated whether the legalisation of cannabis may influence the prevalence of cannabis use, and findings remain inconclusive [64,65]. For example, in those US states that have legalised cannabis consumption, the price of the drug has fallen, and both recreational cannabis use and CUD prevalence estimates have increased among adults [66,67]. The ease of accessing cannabis as an intoxicating substance may impact individualand population-level substance-use initiation, frequency, and amount of use, and consequently, the risk of developing CUD. However, evidence pointing to the effects of cannabis legalisation on cannabis use prevalence and related harms appears inconsistent. More recently, a prospective longitudinal study measured the effect of recreational cannabis legalisation on cannabis use frequency in samples of US twins [68]. Accounting for age, sex, and earlier cannabis use, a ~ 24% increase in mean cannabis use frequency attributable to legalisation permitting the recreational use of cannabis was observed. The findings indicate that in states with versus without legalized use residents used cannabis more frequently [68]. Another large-scale survey conducted in 38 countries with 172,894 adolescents showed that cannabis depenalisation was associated with higher odds of pastyear use and regular use in both genders [65].
On the other hand, other studies have not demonstrated links between cannabis liberalisation, risk perception, and cannabis use, among neither the general population nor those with psychological distress [69,70]. For instance, a recent study of recreational cannabis use among European individuals aged 15-34 years investigated changes in country-specific trajectories of prevalence over time and in relation to policy changes. Cannabis use was either stable or increasing among countries where cannabis legislation remained unchanged (Germany, Netherlands, Slovakia, Sweden) or had been implemented during the study period (Belgium, Norway, Portugal, Spain). On average, self-reported cannabis use seemingly increased by 0.08% per year in these countries and, by contrast, decreased in the countries where cannabis legislation had changed during the observable interval of the study period [71 ••]. Additionally, there exists limited and scarce empirical evidence in Asian and African countries about the influences of cannabis legalisation on the prevalence of use. This is particularly relevant considering that the recreational use of cannabis is still illegal in most countries in this region.
Another concern is the decline in percentages of adolescents and older adults who perceive cannabis use as risky (i.e. risk 1 3 perception), which has been suggested as potentially leading to an increase in cannabis use [72]. For instance, data from a 2002-2014 US national survey among adults who used cannabis once or twice a week fell from 50.4 to 33.3%, identifying cannabis as a low-risk drug [73,74]. The decrease in risk perception may result from governmental jurisdictions around cannabis legalisation [73], which, if not monitored, could potentially shape individuals' attitudes and cannabis use behaviours in the future.

Attitudes and Stigma Toward Cannabis Use
Contemporary regulation of recreational cannabis and general liberalisation of its use have influenced cultural and societal views of cannabis use and attitudes toward the substance. Cannabis has undergone what may be conceptualised as a "civilising process" and modernisation due to altered social regulations [10 ••]. However, the transformation and modernisation of cannabis in different countries have not eliminated taboos, traditions, and rituals associated with cannabis. Medicalisation and legalisation may have helped to reduce cannabis-related stigmas, but these policy changes have not necessarily shifted all social perceptions [75]. People who use cannabis may experience stigmatisation that contrasts with perspectives that include the potential of "cannabis as a 'natural' drug and a gift from the earth," medical cannabis ideologies and "cannabis for selfcare" narratives. Nonetheless, countries at different stages of cannabis legalisation and the cultural appropriation of cannabis may involve stigma and tensions connected to its shifting legal status [76]. The values and cultural meanings linked with cannabis may relate partly to the changing cannabis landscapes and the legal atmospheres, both locally and globally. Therefore, divergent cultures, legal atmospheres (i.e. social and institutional adaptations to the liberalisation of cannabis), cannabis markets, and societies' attitudes toward cannabis may be factors that contribute to differences between various countries in cultural contexts and attitudes [10••].
Overall, the existence of different cannabis policies adds further complexity to understanding cultural aspects of cannabis use across different countries and social classes, highlighting the importance of having both global perspectives and local approaches when aiming to investigate crosscultural aspects of cannabis use.

Racial and Ethnic Minorities and Cannabis Use
Social and political injustice related to cannabis prohibition, particularly to under-represented minority groups and people of colour, is one crucial factor driving cannabis legalisation in the USA [77]. Similarly, in other regions such as Europe and the UK, cannabis prohibition has exacerbated racial injustice and led to various social costs involving unequal arrest and incarceration rates in communities of colour [78]. Thus, one of the stated goals of cannabis legalisation, in general, is to effectively combat racial inequalities in cannabis legislation enforcement in terms of racial and ethnic disparities in cannabis arrests and punishments. Nevertheless, little is known about whether race and ethnicity have potential influences on cannabis-related risk or protective factors among different populations. A recent review indicates that estimates of past-month cannabis use in the USA among Asian-Americans are lower than the national average (~5%), while rates are slightly higher among Hispanic (~10%) and Native Hawaiian/Pacific Islander populations (~10%), and considerably higher among White (~13%) and Black populations (~15%) and American Indian/Alaska Native individuals, followed by African American/Black Natives (~14%) [79].
Among young adults, cannabis risk perceptions and norms, community drug use levels, parental disapproval, and peer influences have been associated with adolescents' intentions and attitudes towards cannabis use [80]. However, these factors may differ across racial and ethnic groups [81]. For instance, an epidemiological study of US adolescents from different racial/ethnic groups showed that Black, Hispanic, Native-American, and mixed-race adolescents were more likely than White adolescents to use cannabis (≥2 days/year), while Asian-American adolescents were less likely than White adolescents to use cannabis. Also, Asian-American adolescents were more likely than White adolescents to report personal and parental disapproval of cannabis use, while mixed-race and Native-American adolescents were less likely than White adolescents to report disapproval of cannabis use [82]. In another study [83 •] conducted among adolescents from multiple racial/ethnic groups, Asian-American adolescents showed the lowest rates of past-year and lifetime cannabis use. This finding may have been explained by lower access of adolescents to the cannabis market and higher cannabis risk perception, as well as the highest disapproval from their parents and peers.
A cultural factor potentially contributing to this finding is parenting style. Social psychology theories define four types of parenting styles known typically as authoritative (warmth and strictness), authoritarian (strictness but not warmth), indulgent (warmth but not strictness), and neglectful (neither warmth nor strictness) [84]. Several studies, conducted mainly in Anglo-Saxon contexts with European-American samples, suggest that the authoritative (warmth and strictness) parenting style or even, for certain minority groups, the authoritarian (strictness but not warmth) parenting style, both sharing strictness as a characteristic, have the best positive effects for adolescent cannabis-use prevention. For instance, Asian-American groups, which showed lower cannabis-use rates, may preferentially employ authoritarian (strictness but not warmth) parenting styles, and this reflects a less common parenting approach in Western countries [83•].
Interestingly, related findings may contribute to substance-use prevention strategies among Hispanic adolescents (who show higher lifetime cannabis use), as Hispanic cultures may emphasise family values, which may act as a cultural protective factor with respect to adolescent substance use [85]. At the same time, findings from a European study on indulgent parenting style (warmth but not strictness) reported this style to be as protective as the authoritative style against adolescent substance use in a European cultural context [86]. These results seem to be consistent with previous studies in Southern European countries (Spain and Portugal), where strictness and impositions in socialisation practices are culturally perceived in a negative way [87]. Thus, protective factors associated with parenting styles may depend in part on the cultural backgrounds in which parentchild relationships develop.
Furthermore, it is speculated that among people from minority racial and ethnic groups, stressors such as political unrest, social and economic discrimination, and vulnerability among disadvantaged minority populations, particularly adolescents, may contribute to the initiation and continuation of cannabis use [88]. Intentions to co-use cannabis with tobacco/nicotine also may differ across racial/ethnic groups impacted by living in close proximity to neighbourhoods of cannabis outlets [89].
Another important factor contributing to regular cannabis use in racial and ethnic minorities is cultural racism. A study examining the relationship between cultural racerelated stress and the number of years of regular cannabis use among incarcerated Black men suggests that cultural race-related stress may predict and explain years of regular cannabis use [90]. More recently, Zapolski and colleagues also found a significant effect of racial discrimination on mid-adolescent cannabis initiation in African American adolescents [91].
Together, multiple factors related to race and ethnicity may impact cannabis use. These factors should be considered when designing and implementing prevention and intervention programs for at-risk minority youth populations [83 •].

Gender and Cannabis Use
Gender-related differences are significant regarding perceptions and experiences of cannabis use. In terms of experiences, females who use cannabis, in most societies, are more prone to experience social and cultural stigma than are males [92]. Illegal substance use is a gendered practice that may be intertwined with social and cultural roles, norms, gender identities, and gendered rules and regulations. Genderrelated differences in the prevalence of substance use may, in part, reflect men having greater access to substances relative to women [93]. According to data from the 2019 National Cannabis Survey conducted in Canada, past-3-month use of cannabis was more prevalent among men relative to women (20% vs 14%). Further, men were more likely to report a greater frequency of use and were twice as likely as women to report daily use of cannabis (8% of men vs 4% of women) [92]. Epidemiological studies have demonstrated that males have higher estimates of problematic cannabis use (marked by increased chronicity of cannabis use), more prolonged episodes of CUD, and use of greater amounts and dosages of cannabis [94••].
These gender-related differences may not extend to the medicinal use of cannabis. About 40% of chronic pain patients who sought legal qualification for medical cannabis to help manage their pain in Washington State were women, and nearly half of survey respondents who reported medical cannabis use to treat rheumatic condition symptoms were also women [95,96]. An archival dataset of 629 people using medical cannabis seeking treatment for various conditions suggests that females consumed high-CBD products (mainly for pain management), and more frequently than males. Meanwhile, a greater proportion of males than females consumed cannabis products with a balanced (THC:CBD) ratio more frequently [97]. Moreover, a retrospective study of a database including 61,379 people seeking medical cannabis in the USA between 2018 and 2020 suggests that the patient population has evolved over time (compared to the results of a similar report in 2006 with only 27.1% of the 1746 patients being females [98]) to include more females, as 40% of the sample who reported gender/sex were female [94 ••]. An additional qualitative study of 23 people shows gender differences in how the health effects of medical cannabis are constructed and perceived. Specifically, women described their medical cannabis use as therapeutic self-care and an "endeavour to be self-sufficient" and men were less likely to explicitly frame medical cannabis as life-preserving [99].
Aspects of cannabis use among men compared to women are likely not solely due to biological underpinnings but also to social and cultural factors that limit exposure to cannabis and decrease the likelihood of frequent cannabis use in females. These factors for women may include social and cultural norms (such as the higher social stigma associated with females who use substances [100], greater perceptions of risk, lower cannabis use among peers, and greater childcare responsibilities [101]). Findings from qualitative studies show that cannabis may also be used in ways contrary to the cultural "dominant gender norms" (i.e. masculinity) as a way to revise gender norms [102]. Canadian and Norwegian females who use cannabis have indicated that using cannabis is a demonstration of resisting dominant feminine ideals, leading them to be positioned and accepted as "one of the boys", given that cannabis use is traditionally considered as a more masculine behaviour [92,103].
Significant gender-related differences in methods of use also emerged during the last years in the USA, with more women reporting using edible (oral administration) cannabis compared to men. In contrast, men reported more frequently smoking cannabis using joints, blunts, vaporisers, and concentrates [94••]. Regarding cannabis purchase modes, a recent survey among Europeans who use cannabis showed that males often bought their own cannabis, while females preferred to obtain drugs through a friend who bought it for them with their money or to get it for free (aka "social supply") [104••]. This reinforces gender-related differences in use attitudes toward modes of cannabis purchase-illegal direct buy vs indirect buy and free acquisition, with women potentially avoiding threats to personal safety and risks of physical violence [105].
Overall, findings suggest that gender-related differences in cannabis use may relate in part to social and cultural factors and differences in sociocultural experiences with cannabis. Existing evidence collectively highlights the complexity of how gender may be expressed through cannabis use and suggests its culturally specific, multi-faceted, and changing nature. It is also noteworthy that although pieces of evidence from trans and gender-diverse populations in the USA and Brazil show a significantly higher rate of cannabis use in these populations [106][107][108], there exists a general gap in evidence-based research on gender norms, roles, relations, and cannabis use in LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) populations and subcultures. Nevertheless, existing evidence indicates that in sexual minority groups-women, in particular-factors such as minority stress, particularly stigma, are associated with elevated cannabis use frequency as well as developing CUD symptoms [109 ••]. However, there is still limited evidence for the long-term prospective effects of sexual minority stress on cannabis use.
To summarise, multiple pieces of evidence suggest influences of individuals' racial and ethnic backgrounds and their associated constructs (such as distinct parenting styles or cultural racism), as well as gender-related differences in cultural aspects of cannabis use and patterns. These findings highlight the importance of further investigations within minority groups and individuals with different gender identities using comparative cultural approaches.

Medicalisation of Cannabis
With the discovery of the endocannabinoid system [39], interest in therapeutic benefits and medicinal use of cannabis has increased, resulting in legislative, cultural, social, and market changes related to cannabis use for medicinal purposes [13•]. Cannabis-based medical products can vary from purified single cannabinoid compounds (often THC or CBD) to plant extracts containing hundreds of cannabinoid molecules (most in minuscule quantities), with multiple formulations (e.g. oils, solutions, sublingual sprays, tablets, and capsules), with multiple delivery mechanisms (e.g. oral, nasal, rectal, and inhalation) [110]. Generally, cannabinoids have been used, often with limited evidence but in some cases with regulatory approval, for many health conditions: chronic pain, chemotherapy-induced nausea and vomiting, multiple sclerosis spasticity symptoms, and epilepsy, and with limited evidence for increasing appetite and decreasing weight loss associated with HIV/AIDS, Parkinson's disease, Tourette syndrome, social anxiety disorders, symptoms of posttraumatic stress disorder, schizophrenia, cravings and anxiety for people with opioid use disorder, and following a traumatic brain injury or intracranial haemorrhage [111]. The three following beliefs are frequently repeated in public and policy debates on medical cannabis legalisation globally [111]. (I) Proponents of medical cannabis highlight the continuing emergence of largely anecdotal and scientific evidence that exhibits the potential therapeutic value of cannabinoids in treating multiple disease-related and mental health problems. (II) Opponents of medical cannabis highlight research that identifies harmful effects of recreational cannabis use, such as psychotogenic effects, risks to mental health, and addiction. (III) The concern that medical cannabis legalisation may lead to increased recreational cannabis use and detrimental public health effects (so-called spillover effects) [112].
Another important consideration that should be considered given the emergence of prescribing cannabinoids medicinally is healthcare specialists' attitudes and perspectives toward medical cannabis [113], and these should be considered across different nationalities and cultures. For instance, one cross-national study compared the attitudes of Maltese and Russian psychologists toward the therapeutic effects of medical cannabis for mental health issues and found a more positive attitude among Maltese relative to Russian psychologists [114 ••]. This finding may be explained in part by cross-cultural differences, the legal status of medical cannabis in Malta, the Russian policy of zero tolerance for the substance regardless of purpose, and prevailing drug policies in Russia [114]. A survey conducted among Russian medical students also reported zero support for cannabis legalisation for medical purposes among Russian medical professionals [115]. Another cross-national comparison study among American and Israeli social workers found that secular social workers, compared to religious ones, believed in more therapeutic benefits of cannabis for physical and mental health issues [116]. It is therefore suggested that medical cannabis popularity across countries can potentially stem from possible cross-cultural differences in the attitudes of healthcare professionals toward cannabis.
With changing beliefs and attitudes toward the therapeutic effects of cannabis, which have partially contributed to the reconsideration of cannabis-related political and legal actions, researchers, clinicians, and policymakers have advocated for an evidence-based understanding of cannabis-related harms and making cannabis consumption safer [117]. Recently, the standard THC unit has been created to measure cannabis exposure universally, across cultures and cannabis types and modes of use, to help identify how much cannabis use constitutes "risky use" across multiple settings (e.g. research, clinical practice, public health and medicinal) [118••]. Important cross-regional and cross-cultural aspects have also been outlined to calibrate standard THC units based on cannabis potency, cannabinoid content, legal status, cultural customs, modes of administration, co-use of tobacco, and different labels for the same product, as well as inter-individual differences in bioavailability [119].

Cross-cultural Considerations for Future Work
Today, the use of cannabis, sometimes associated with strong cultural and traditional values and meanings, is widespread and diverse such that it does not constitute a sole culture globally. Cannabis use, whether for ritualistic, recreational, or medical purposes, may be conducted within socially and culturally organised contexts [10••]. Cannabis use and related factors, such as expectancies and mode of administration, may differ across genders, racial and ethnic groups, and geographical regions, with different cannabis-related "sub-cultures". Research on cross-national differences in cannabis use is scarce. Nevertheless, it is often posited by findings from global surveys that cannabis liberalisation policies (including depenalisation, decriminalisation, and partial prohibition) may impact cannabis use prevalence and attitudes and, therefore, partially account for cross-national differences [65]. Importantly, evidence on cannabis use prevalence, sociocultural factors that may influence cannabis use patterns, and cross-national differences in cannabis use is often limited to so-called WEIRD (Western, educated, industrialised, rich, and democratic) countries. Therefore, more research is needed in other countries, particularly in African and Asian regions, regarding cultural aspects of cannabis use.
There have also been few attempts to link and integrate qualitative studies of cannabis cultures and symbolic meanings and narratives related to cannabis with evidence-based quantitative studies of cannabis-use expectancies and motivations. For instance, Prashad and colleagues proposed a novel integrative approach to understand how cultural factors influence the neurobiology of CUD, including through a cultural neuroscience-informed lens [120••]. This approach suggests that cross-cultural differences in the manifestation of CUD may be driven by cultural differences that relate to specific neural mechanisms that may, in turn, impact psychopathological manifestations of cannabis use. This model provides a framework for how to identify cultural similarities and differences for a more precise understanding of intersections between culture and the neuroscience of cannabis use and CUD [120••].
An understanding of cross-cultural differences in cannabis use is important to develop and implement prevention and treatment strategies that target CUD. Cognitive behavioural and motivational enhancement therapies are the most common psychotherapeutic approaches for the treatment of CUD and have shown promising results [121]. However, these treatment approaches often do not consistently consider and incorporate cross-cultural differences into treatment protocols, potentially compromising their effectiveness [121]. Therefore, shortcomings related to cultural adaptations of existing psychosocial treatment strategies may result in suboptimal effectiveness of existing therapies in certain cultures, and consequently, may link to global health disparities [120,122].
In addition, rapid changes in cannabis markets, such as emerging methods for purchasing cannabis via social media or the Darknet [123 •], should be considered when exploring cannabis use from a sociocultural perspective. Legislative, cultural, and cannabis market changes intertwine with conflicts between advocates of cannabis use for medical and recreational purposes. The latter often maintains specific social and (sub)cultural meanings of cannabis use, while activists of the liberal use of cannabis for medical purposes often advocate for easier access to cannabis [10••]. Regulations governing cannabis supply markets have changed both for dark and surface webs. The expansion of the so-called emerging "big canna" industry and its sponsorship of social media influencers have also changed both the market and the cultural ideas associated with cannabis use [124]. For instance, a recent study investigated how cannabis-related content is portrayed on viral and publicly available social media videos (with over 756 million views and 143 million likes) from people using TikTok, a rising video-sharing platform popular among adolescents [125•]. Most videos were non-age-restricted and portrayed cannabis use positively or delivered pro-cannabis content through humour or entertainment [125•].
Overall, changes in cannabis-use cultures, such as legislative changes, may leverage consequent changes in perception and attitude toward cannabis through the potential neutralisation of perceived risks of cannabis use globally. Future research could usefully utilise cross-national and cross-cultural evidence-based approaches to help elucidate cultural and structural factors influencing cannabis use across different cultures.

Conclusions
This manuscript outlines a brief overview of the cultural aspects of cannabis use across different cultures, nations, genders, and racial groups, as well as historical and traditional background of cannabis use motives.
In conclusion, although cannabis may be one of the least stigmatised of illicit drugs globally, with cannabis currently undergoing global illicit designation changes and with increasingly emerging interconnected and multicultural societies, interactions between culture, public policy, and cannabis use should be better understood in order to guide global policies. Cross-cultural perspectives toward cannabis use may improve public health actions and mitigate health disparities. Much remains to be understood about the complex and bidirectional relationships between cannabis use and culture, and the question of whether culture shapes or contributes to different aspects of cannabis use or whether cannabis use could, by nature, form or influence distinctive subcultures, remains open. This topic would benefit from further exploration using a cross-cultural framework to study cannabis use and its consequences, particularly paying closer attention to countries and populations currently underrepresented in research.

Conflict of Interest
The authors have no competing interests to declare that are relevant to the content of this article. Dr. Potenza discloses that he has consulted for and advised Game Day Data, Addiction Policy Forum, AXA, Idorsia, Baria-Tek, and Opiant Therapeutics; been involved in a patent application involving Novartis and Yale; received research support from the Mohegan Sun Casino, Children and Screens, and the Connecticut Council on Problem Gambling; consulted for or advised legal and gambling entities on issues related to impulse control and potentially addictive behaviours; performed grant reviews; edited journals/journal sections; given academic lectures in grand rounds, CME events and other clinical/scientific venues; and generated books or chapters for publishers of mental health texts. The other authors report no disclosures.

Human and Animal Rights and Informed Consent
No experimental procedures involving humans or animals were conducted for this article. There are no human subjects involved in this article, and informed consent is not applicable.
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