The latest World Drug Report unequivocally ranks cannabis as the leading cause of substance use disorders in almost half of all surveyed countries (1). Due to the high prevalence of use, individuals seek attention for a wide range of adverse medical and mental health outcomes (2–4), intensifying a public health concern that continues to fuel the rising demand for treatment globally (5). While several individuals reportedly self-medicate with cannabis (6), evidentiary support as a therapeutic is unclear (7) and may indeed promote an elevated risk of suicidal ideations (8). Moreover, persistent cannabis use is associated with poor educational and social outcomes (2, 9), rising numbers of legal risks, vehicular accidents (10) and addiction (2, 11).

Jamaica has a significant history of cannabis use, chronicled by inextricably interwoven socio-cultural, economic and political processes (12). Contemporary scholarly publications examining cannabis use among the general population have provided critical insights. The most recent national survey indicated that 40% to 60% of adolescents and 60% to 80% of adults found it easy to access cannabis (13). Additionally, close to 30% of Jamaicans reported cannabis use at least once in their lives, with two out of three individuals progressing to chronic cannabis use (14). Moreover, greater than 40% of Jamaican drivers who currently smoke cannabis, admitted to driving under its influence, with over 85% engaging in heavy use (15). Cannabis was found to be the most commonly used drug among Jamaican polysubstance users (14). Reduced perceived risk of use, easy access, and early initiation of cannabis use in childhood and adolescence were identified as significant predictors of this harmful polysubstance habit (16). Amidst the current national cannabis policy, possession of small quantities (two ounces) for personal and medicinal use is decriminalized and permitted in Jamaica (17). Further investigation regarding the frequency, social contexts, knowledge and perceptions of cannabis use is likely to prove pivotal in predicting problematic cannabis use (PCU) within the Jamaican population.

To date, a few international studies have sought to highlight the beliefs and attitudes associated with PCU – defined as use that leads to negative health or social consequences (18–20). The lack of perceived need for treatment is consistently a significant barrier to seeking treatment for substance use disorders (21, 22). This becomes even more pertinent in the context of evolving cannabis policies, where shifting attitudes towards the risks and availability of cannabis could impact perceptions of needing treatment for PCU (23, 24). Indeed, recent research supports this point in reporting a higher likelihood of PCU among individuals who self-medicated with cannabis for physical, mental and sleep health reasons (25). Regarding sociodemographic and socioeconomic factors, prior research highlights an increased likelihood of PCU among males, younger populations, individuals with lower levels of education, unemployed persons and households with lower earned income (26–29). While recent data indicates an early age of onset and more frequent cannabis use as being correlated with PCU (30, 31), these individuals are more likely to make light of the associated harms (29, 32). Notwithstanding, most of these studies have utilized specific and smaller-sized samples, with no known literature derived from a general population within the Caribbean.

To address this gap, this study examined nationally representative data to achieve the following objectives: (1) determine the prevalence of cannabis use and PCU among Jamaicans; (2) examine the quantity of cannabis use among individuals with severe PCU; and (3) investigate the sociodemographic factors, psychosocial correlates, and respondent knowledge and perceptions associated with severe PCU. The data gathered is expected to reveal distinct profiles of problematic patterns of cannabis use behaviors among the Jamaican populace, which can inform targeted interventions and policies, especially in light of its strong national socio-cultural acceptance (12).

Globally, CAST has been used to estimate the prevalence of problematic cannabis use among adolescents, young adults and general populations. The prevalence among adolescents ranged from 1.4% to 7.3% across several European countries in the most recent European School Survey Project on Alcohol and Other Drugs study (52). In Norway, approximately 6% of young adults in a population survey had a CAST score equal to or greater than 7 to meet the criteria for severe PCU (53). In comparison to a general population survey in France, the prevalence of severe PCU among those who reported cannabis use in the past year in Jamaica is approximately ten times higher (5.5% and 53.5% respectively) (35). The high proclivity to use among Jamaicans is likely multi-factorial. Jamaica is well-known for its strong cultural connection to cannabis use and cultivation, particularly within the Rastafari faith and traditional folk medicine (12, 54). In 2015, the country became the first nation in the Caribbean to revise its Dangerous Drugs Act (DDA) to decriminalize personal possession and allow home cultivation for personal use (17). As a result, adults can legally possess up to 2 ounces of cannabis and grow up to five plants per household. The amendment also permitted Rastafarians to use cannabis for religious purposes without restrictions and established the Cannabis Licensing Authority to oversee the production and sale of cannabis products for medicinal use. Legal cannabis dispensaries have since been established across the island, where adults can purchase cannabis with a doctor’s recommendation (17). Accordingly, the changes made to the DDA are likely to have significantly contributed to normalizing the status of cannabis in Jamaica. To the best of the researchers’ knowledge, this study is the first to report the prevalence of severe PCU and assess its associated factors in Jamaica and the Caribbean region.

Of interest, individuals with severe PCU smoked an average of 2 cannabis joints daily. While factors such as dosage, delta-9-tetrahydrocannabinol (THC) potency and method of administration may influence standardized measures of cannabis consumption (55), limited research has considered the impact of quantity on harm outcomes. This study addresses this gap by fulfilling critical parameters in deriving a measure from respondents in a general population, using an internationally validated screening tool (CAST). In addition, the findings presented were accrued in a legal and socio-culturally tolerant LMIC setting and are likely to be of value in public health and research, considering that the latest iteration of the Global Burden of Disease indicates that the burden of problematic use is shifting towards developing nations (56).

Indeed, the high frequency of severe PCU among Jamaicans, especially men, represents a unique and worrying public health issue associated with substantial co-morbidity and disability (57, 58). Numerous drug research studies conducted both internationally (59–62) and in Jamaica (13, 14, 63, 64), have demonstrated a similar sex pattern, suggesting that societal norms and sex roles are likely significant factors. As such, the observed difference in this study can be invariably attributed to the higher tendency for risk-taking behavior seen in males (65), often viewed as an enhanced demonstration of masculinity, and the concomitant societal prejudice associated with female drug use (66, 67).

Focusing on other factors, this study highlighted two important and inter-related elements to developing severe PCU - age of initiation and current age. The current finding, that beginning cannabis use in childhood and adolescence is associated with developing problematic use in later life, is well-supported by earlier literature (68–71). More compelling, however, is that initiating use in early adulthood (18-25 years) was strongly predictive of developing severe PCU and alarmingly comparable to starting use in adolescence among the Jamaican population. While early use is associated with greater health consequences, poorer academic or work performance, and a higher probability of developing a polysubstance habit (2), cannabis use during early adulthood might have negative impacts on psychosocial well-being, increase disease risk in later adulthood, and complicate typical life goals such as raising children and achieving career success (72). It is notable, therefore, that Jamaican adults, particularly middle-aged ones, demonstrated a considerably higher prevalence of severe PCU as compared to adolescents. These findings succinctly indicate that associations exist not only for adolescents, but also for individuals who commence cannabis use during early adulthood, and underscore the importance of developing distinct national public education initiatives that cater to and provide information regarding the impact of cannabis use across two different but critical developmental life periods.

Pre-existing evidence suggests that cannabis law reform leads to increased use among the general population (73). In this study, respondents who indicated cannabis access as easy were more likely to report severe PCU. The present findings extend prior drug research in Jamaica in demonstrating the ease of access to cannabis as a driving cause of substance use (13) and abuse (16). Moreover, a number of studies report an earlier age of first use and elevated levels of problematic use in territories that enact laws that increase the avenues through which to acquire cannabis, whether by home cultivation or via established medical dispensaries (74–77). Ergo, the access mechanisms for cannabis influenced by decriminalization in Jamaica, to permit the cultivation of up to five cannabis plants for personal use and the formation of a legal medicinal cannabis industry, as similar contributors to this study’s reported levels of use and problematic use in the population, cannot be summarily dismissed. Undoubtedly, this advancement has made it even easier to access cannabis.

Public attitudes and beliefs toward the issue of drugs are critical to the success of drug-related policies, which are likely to prove uncertain without their support (78). As previous studies suggest, perception of need is a crucial factor in deciding whether to seek help and is a necessary step in the process of changing addictive behaviors (21, 22, 79). The low prevalence of perceived need for treatment is consistently a major barrier to seeking treatment for substance use disorders (21, 22). Respondents in this study who had severe PCU, however, were more likely to report a high perceived need for treatment. Moreover, these persons were also more likely to be aware of the country’s national drug control and prevention agency, the National Council on Drug Abuse (NCDA). This finding is particularly notable, as previous research has contrastingly indicated that more than 80% of Jamaica’s general population were unaware of the NCDA (13). These results highlight that many of the barriers to care that people with severe PCU face at this stage are likely structural and financial. While acute drug treatment services are available in private settings that may ultimately be cost prohibitive, the only hospital-based drug treatment facility is a 6-bed unit located at the University Hospital of the West Indies in Kingston, the capital city of Jamaica (80). The available services or lack thereof, serve as a deterrent to seeking treatment and make access to care a challenge, underscoring a need for the establishment of additional hospital-based drug treatment facilities in and around the island. Additionally, the present analysis denotes that individuals with severe PCU indicated a high level of concern about the current drug situation in reporting that they perceived the national prevalence of drug use had been progressively increasing. Intervention at this stage must utilize the opportunity to incorporate the perspectives and personal lived experiences of these individuals to gain valuable insights into current trends, and to effectively translate research findings into impactful public policies and service practices that are likely to be beneficial in addressing the drug’s use (81).

Legal cannabis reforms can have varying public health impacts due to increased accessibility (82). Cumulatively, the findings of this research represent an inaugural viewpoint that encourages a public health approach. The framework galvanizes a collaborative union of key perspectives from persons with lived experience, policymakers, physicians, public health professionals, social service providers, economists and educators in developing evidence-based policies, procedures, and programs to address PCU and improve population well-being (83, 84). In tandem, the findings encourage a further call to review the current national cannabis policy to include more robust regulatory mechanisms and disseminate a public education program on the associated risks as part of an overall prevention and harm reduction effort. The data gleaned may provide the groundwork in encouraging a cannabis policy review for other territories that have similarly endorsed decriminalization or legalization.

Despite the important contribution that this study makes, it is important to consider the findings in relation to their strengths and limitations. The study’s limitations include the use of self-report measures, which rely on participants’ memory and subjectivity and may introduce a recall bias. Furthermore, many of the survey participants may have been inclined to provide answers that were deemed “socially acceptable”, potentially introducing a response bias. It is important to note that this research was unable to establish causal relationships because the data collected was cross-sectional in nature. Additionally, only four of the nineteen variables studied were psychosocial correlates. Notwithstanding, one of the strengths of the study is that the validated CAST improved the reliability of the findings, as it is widely used in national population sample studies worldwide (85). The random selection of survey respondents in the initial study and the use of a large population sample for the current study were significant strengths, producing results that may be generalized to the national population. Although the data analyzed in this study were collected in 2016, the findings are immensely valuable in laying the foundation for further research to continually fill a knowledge gap, especially in low-income and middle-income countries where global research is limited.

One out of every two Jamaicans who used cannabis in the past year reported severe problematic use. This study sheds light on these individuals’ drug-related knowledge and perceptions that may be of immense value in improving treatment options at a clinical level and in addressing the current national cannabis policy at a legislative level. Policy perspectives need to adopt a public health approach, integrate harm reduction strategies, and not solely focus on preventive measures to prevent escalating habits. This is especially important given the current legal and socio-cultural contexts of cannabis use within the Jamaican population. Finally, the average number of cannabis joints smoked daily among those with severe PCU was two. This measure of quantity may be an effective way to quantify cannabis consumption in further research examining cannabis-related problems. While more research to further validate and establish such a measure across different populations is essential, incorporating this information can play a vital role in developing accurate public health messages for the Jamaican populace and informing cannabis policy.