Review

Effects of increasing cannabis potency on adolescent health

Jack Wilson, Tom P Freeman, Clare J Mackie

Cannabis is the most prevalent illicit drug used by adolescents worldwide. Over the past 40 years, changes in cannabis Lancet Child Adolesc Health 2018
potency through rising concentrations of Δ-9-tetrahydrocannabiol (THC), decreases in cannabidiol, or both, have Published Online
occurred. Epidemiological and experimental evidence demonstrates that cannabis with high THC concentrations and December 17, 2018
http://dx.doi.org/10.1016/
negligible cannabidiol concentrations is associated with an increased risk of psychotic outcomes, an effect on spatial
S2352-4642(18)30342-0
working memory and prose recall, and increased reports of the severity of cannabis dependence. However, many
Addictions Department,
studies have failed to address cannabis use in adolescence, the peak age at which individuals typically try cannabis Institute of Psychiatry,
and probably the most vulnerable age to experience its harmful effects. In this Review, we highlight the influence that Psychology and Neuroscience,
changing cannabis products have on adolescent health and the implications they carry for policy and prevention King’s College London, London,
UK (J Wilson, T P Freeman PhD,
measures as legal cannabis markets continue to emerge worldwide.
C J Mackie PhD); Department of
Psychology, University of Bath,
Introduction people and discusses the importance of shifts in social Bath, UK (T P Freeman); and
Cannabis is the most widely used illicit drug worldwide, determinants on late adolescent development.9 South London and Maudsley
NHS Foundation Trust,
with approximately 183·3 million users who make up First, this Review focuses on the role of cannabis in the
Bethlem Royal Hospital,
nearly 4% of the global population.1 Despite a relatively endocannabinoid system, commonly discussed cannabis Beckenham, UK (C J Mackie)
stable prevalence of cannabis use globally, the drug is constituents, and global trends in cannabis potency. Correspondence to:
being used by individuals with greater frequency, for Second, we examine whether adolescents appear to be Dr Clare Mackie, National
instance in the USA where one in 17 adolescents aged more susceptible to rising concentrations of THC (and Addiction Centre, Institute of
Psychiatry, Psychology
17–18 years reported daily cannabis use, a rate that has lower concentrations of cannabidiol) in cannabis. Third,
and Neuroscience, King’s College
risen since 2007.2 It is estimated that 13 million people we review evidence concerning the possible effect of London, London SE5 8AF, UK
worldwide meet the clinical criteria for cannabis use increasing cannabis potency on adolescent neuro­ clare.mackie@kcl.ac.uk
disorder (ie, a problematic pattern of persistent use cognition and mental health. Last, the Review highlights
causing clinically significant impairment or distress) the importance of cannabis potency for clinical and
accounting for a global burden of disease of 2 million educational policy and practice, as well as making
disability-adjusted life-years.3 This burden peaks in late recommendations for future research.
adolescence (ages 20–24 years) and is highest in the USA,
Canada, Australia, New Zealand, and western European Global changes in cannabis potency and markets
countries such as the UK.3 In Europe, the number of first- The effects of cannabis and its exogenous cannabinoids
time clients starting specialist drug treatment for cannabis (including THC and cannabidiol) occur primarily through
increased from 43 000 in 2005, to 76 000 in 2015,4 with
rising trends in 16 of the 22 European countries that
provided eligible data.5 Even though the reason for this Key messages
trend is unclear, it could be because of factors such as • Problematic cannabis use typically peaks in adolescence—
greater detection rates of disorders, improved pathways an age group that could be particularly vulnerable to its
for referral, and changes in stigma towards mental health harmful effects
and treatment. An alternative explanation, however, • Cannabis markets are dominated by high-potency
suggests that this might result from an increase in cannabis (high in Δ-9-tetrahydrocannabinol [THC] and
cannabis potency through rising concentrations of low in cannabidiol), with THC content steadily increasing
Δ-9-tetrahydrocannabinol (THC) and decreasing canna­ worldwide
bidiol concentrations.6 Widespread policy changes in parts • Compared with low-potency cannabis, high-potency
of the USA and Canada led to the legalisation of medicinal cannabis appears to be associated with a greater risk of
and recreational cannabis, potentially changing the psychotic symptoms, depression, anxiety, and cannabis
availability of cannabis products to millions of young dependence
people, and to marked increases in the potency of cannabis • Adolescents only partially titrate their use of high-potency
products.7,8 As such, understanding the effects of variation cannabis, which can result in the consumption of high
in cannabis potency on adolescent mental health, concentrations of THC
cognition, and development is of paramount importance. • Alongside more accurate measures of cannabis potency,
This knowledge will not only inform the causation models further research must adopt longitudinal, cognitive, and
of cannabis use and psychiatric comor­bidity but will also neuroimaging measures to gain a better understanding of
allow for the design of evidence-based prevention the health effects of cannabis use in adolescence
programmes targeting adolescent cannabis use. WHO • With cannabis policy rapidly changing, up-to-date evidence
defines adolescence as the age range of 10–19 years, and should inform decisions on potency taxes or potency
young people as those aged 10–24 years. This Review thresholds, as well as define the legal age of purchase
includes research referring to both adolescents and young

www.thelancet.com/child-adolescent Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30342-0 1

 Review
A B
C D
Figure: Examples of cannabis products
(A) Sinsemilla or skunk (14% THC, <1% cannabidiol). (B) Herbal cannabis (3%
THC, <1% cannabidiol). (C) Hash or resin (4% THC, 2% cannabidiol). (D) Cannabis
concentrates (69% THC, 1% cannabidiol). Data shown are medians from the UK
(A–C)and USA (D).17,18 THC=Δ-9-tetrahydrocannabinol. © Reproduced with
permission from David Potter and Tom Freeman
interaction with the endocannabinoid system.10 The endo­
cannabinoid system includes cannabinoid receptors 1 and
2 (CB1R and CB2R), their endogenous ligands including
anandamide and 2-arachidonoyl­ glycerol, and enzymes
such as fatty acid amide hydrolase, which breaks down
these ligands. The endocannabinoid system regulates
numerous biological processes involved in development
and neuroplasticity early in life and it plays a critical role
in regulating synaptic plasticity.10 CB1Rs are densely
located in key brain regions involved in cognition, reward,
and adolescent neurodevelopment, such as the hippo­
campus, baso­lateral amygdala, nucleus accumbens, and
the prefrontal cortex.11 The endo­ cannabinoid system
occupies a broad spatial area of the developing brain and
plays a key role in age-related brain changes throughout
life.10 During the important time of neuromaturation,
the brain might be more vulnerable to disturbances
from exogenous cannabinoids, which could have a supra­
physiological effect on endocannabinoid receptors, and
thus alter normal brain functioning.12
Although cannabis contains many cannabinoids, the
most commonly discussed in research, media, and
among consumers are THC and cannabidiol. THC acts
as a partial agonist to CB1 receptors, whereas cannabidiol
has low affinity for CB1R but can attenuate CB1R agonist
effects and inhibit the reuptake and hydrolysis of endo­
cannabinoids.11 These effects of cannabidiol have been
proposed as potential pathways to be targeted for the
treatment of disorders such as psychosis. THC is the
main psychoactive component responsible for the feeling
of getting high that users seek, and has been found to
have dose-dependent effects on memory, attention, and
2 www.thelancet.com/child-adolescent Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30342-0
verbal fluency, as well as contributing to transient
paranoid-like symptoms in laboratory studies.13 By
contrast, cannabidiol is non-intoxicating and has been
found to offset the harmful effects of THC on memory
impairment and psychotic symptoms.14,15 Concentrations
of THC and cannabidiol are known to vary across
cannabis plants, due to variations in genetics, growing
conditions, preparation, and extraction.16 For instance,
unfertilised female plants yield a more potent product, as
the plant converts its energy to cannabinoid synthesis
rather than into seed production.16 Referred to as
sinsemilla (Spanish for without seeds; figure), and
commonly called skunk in the UK or nederwiet in the
Netherlands, this highly potent type of cannabis has been
found to contain THC ranging from 1·9% to 22·5%,
with negligible cannabidiol.17 Seeded herbal cannabis is a
less potent type and its THC can range between 1·8%
and 5·7%, whereas resin (compressed preparations of
plant matter) can vary greatly in THC content (0–29·3%).
An emerging cannabis product that is less common but
often extremely potent is cannabis concentrate (figure).
Concentrates are produced through a range of extraction
techniques (including use of butane, super-critical
carbon dioxide, and combined heat and pressure) and as
a result differ in texture and appearance. These
preparations have also been found to vary greatly in THC
and cannabidiol content, depending on the extraction
technique. One US study18 assessed the cannabidiol and
THC content of 57 concentrate samples at a medical
cannabis market and found that they contained between
23·7% and 75·9% THC, with all but five samples having
low levels (<5%) of cannabidiol.18
In addition to recent advances in cannabis production
and extraction techniques, new psychoactive substances
have also entered the drug market.19 Synthetic cannabinoids
elicit cannabimimetic effects similar to natural cannabis.
However, whereas THC acts as a partial agonist, synthetic
cannabinoids typically act as full agonists to cannabinoid
receptors.20 As a result, synthetic cannabinoids induce
physiological (eg, nausea) and psychiatric (eg, anxiety and
psychosis) effects that are considerably more intense than
those induced by cannabis20 and can cause more serious
adverse events, such as seizures and even death.21 A
thorough discussion of synthetic cannabinoids is beyond
the scope of this Review, which focuses on cannabis and its
constituent cannabinoids.
The cannabis markets in the USA,8 Australia,22 and
parts of Europe17,23 have been shown to be dominated by
highly potent cannabis with high concentrations of THC
and little, if any, cannabidiol. Over the past 40 years,
THC content in cannabis have steadily increased
worldwide, with average THC in 2009 being over nine
times greater than in 1970.24 This increase is consistent
with data from cannabis confiscations in the UK, where
high-potency sinsemilla cannabis made up 15% of all
cannabis seized by police for the period 1999–2002,25
50·6% for 2004–05, 84·5% for 2007–08, and 93·6%

for 2016.17 Trends towards high-potency sinsemilla
cannabis are also reflected in seizure data in the USA7
and Australia,22 with average total THC content of 12%
and 14%, respectively, along with reductions in
cannabidiol content in the USA.7 Furthermore, data
from Washington state, USA show that concentrated
cannabis extracts made up 21·2% of the market within
2 years of legal sales, suggesting a strong demand for
extremely potent forms of cannabis.8 Another notable
change in legal cannabis markets has been the dramatic
decrease in potency-adjusted price over time (both at the
retail and supply level).26 As price decreases, the price
per unit of THC also drops and this drop might
encourage purchasing behaviour and raise exposure to
THC. Therefore, increased levels of harm might be
attributed to a decline in the potency-adjusted price per
unit of THC, the increase in potency, or both.
Reasons for adolescent susceptibility to rising
cannabis potency
Adolescence is marked by a period of dramatic cognitive
development when the brain undergoes neuronal
maturation and cortical restructuring via processes of
cortical thinning, synaptic reorganisation, and myelination
of white matter tracts.27 There are major changes in the
prefrontal cortex, hippocampus, amygdala, and the
nucleus accumbens, which are areas responsible for harm
avoidance, inhibition, decision making, learning and
memory, emotion, and motivation and reward.27 While
cortical functions are still developing, already formed
reward-related circuitry leads to the propensity of
adolescents to seek novelty and reward in the face of
uncertainty or potential negative outcomes, such as
through the use of alcohol and illicit drugs.27 Their
impulsivity, stemming from their inability to control their
behaviour, is often implicated in early-onset adolescent
drug use.28 Behavioural inhibition tasks such as the stop-
signal task29 and the go/no-go30 task measure the ability (or
inability) to suppress a task-induced response to a go
stimulus. The results of neuroimaging and cognitive
studies with stop-signal and go/no-go tasks have shown
an association between impairment in neural responses
to these tasks and the risk for adolescent substance use.31–33
One such study34 concluded that adolescent cannabis
users exerted greater neurocognitive effort throughout
the tasks, despite similar performance to adolescent non-
cannabis users. During the inhibition trials of a go/no-go
task, cannabis users showed greater activation in the
right occipital gyrus and the right dorsolateral prefrontal,
bilateral medial frontal, bilateral inferior, and superior
parietal lobules, compared with the control group. These
brain regions are implicated in sustained attention,35
suggesting that users had to recruit more attentional
resources to complete the tasks successfully. During the
non-inhibitory trials, cannabis users showed greater
activity in right prefrontal, insular, and parietal cortices.
Interestingly, abnormal activation of insular cortices has
www.thelancet.com/child-adolescent Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30342-0 3
Review
been found to be associated with reduced awareness of
internal and external cues, such as the ability to recognise
one’s own substance use as problematic. Research by
Lopez-Larson and colleagues36 showed that abnormal
activation of insular cortices plays a role in problematic
substance use.
Behan and colleagues31 also showed that adolescent
cannabis users were less able to inhibit their responses
in a go/no-go task compared with never-users.
Furthermore, a positive correlation between self-reported
cannabis amount in the past week or month and parietal,
bilateral cerebellar, and right frontal connectivity was
shown, suggesting that the cerebellum is compensating
when other task-related regions are not engaged. Although
compensatory efforts have yielded similar results to
controls in other studies,34 worse performances by cannabis
users observed by Behan and colleagues31 are consistent
with the hypothesis that increased engage­ ment of the
cerebellum during response inhibition is associated with
poorer task performance. Overall, the available literature
covered in this Review suggests that cannabis users require
additional neural resources to do as well as non-users in
cognitive inhibition tasks. In conclusion, and as described
in the panel, adolescent developmental processes, such as
neuromaturation, and predisposing factors, such as
cognitive inhibition, impulsivity, and reward sensitivity,
play a major role in the susceptibility of adolescents to the
harmful effects of cannabis use. Whether these preceding
risk factors influence the type of cannabis used is a
question that has yet to be investigated.
The effect of cannabis potency on adolescent
health
Epidemiological studies have consistently demonstrated
that cannabis use in adolescence is associated with an
increased risk of psychotic symptoms,40–44 anxiety,48 and
in some cases depression.49 The onset and magnitude of
the effects of cannabis use on neurological function
remains under debate. A review of longitudinal studies
reported that early cannabis use was prospectively
associated with neurocognitive decline, particularly in
IQ and episodic memory, with the greatest decline
occurring in daily users.50 However, almost all studies
surveyed for this Review have categorised users
according to frequency of cannabis use, and few studies
have used measures examining the effect of high
potency versus low potency on either neurocognitive
function or mental health outcomes. Morgan and
colleagues15 compared psychotic-like symptoms in
54 recreational cannabis users with 66 daily cannabis
users aged 16–23 years. The results showed lower
psychotic symptoms in individuals with hair samples
containing cannabidiol compared with those without;
however, this effect was only noted in recreational users
with high concentrations of THC in their hair. These
findings suggest that cannabidiol modulates the
psychotic-like effects of THC, but that frequent users
 Review
Panel: Vulnerability pathways of adolescent cannabis use and cannabis-related harms
Risk factors for cannabis use
Genetic factors
The effects of cannabis on the presence and severity of mental health symptoms is
stronger in those who are genetically vulnerable to mental health conditions.37
Impulsivity, novelty seeking, and inhibition
There is a positive association between abnormal task-specific neural connectivity in
inhibition tasks and cannabis amount used.31 Cannabis use is strongly associated with young
people (10–24 year-olds) who are more impulsive and have poor response inhibition.32,33
Neuromaturation
The brain could be more vulnerable to disturbances from exogenous cannabinoids, which
alter its normal function and development.12
Cannabis use behaviour
Potency
Concentrations of Δ-9-tetrahydrocannabinol (THC) rise and those of cannabinol fall in
international cannabis markets.8,16,18,23 Extremely potent cannabis concentrates form a
major part of new legal cannabis markets in the USA.8
Patterns of use
Inexperienced cannabis users show poor knowledge of drug potency.38 Younger cannabis
users could be less likely to titrate (adjust smoking behaviour) higher potency products.39
Cannabis-related harms
Psychosis
Frequent adolescent cannabis use is associated with a greater risk of psychotic symptoms.40–44
Earlier age of onset of cannabis use is associated with greater symptom severity.40 Those
using cannabis high in THC and low in cannabidiol are at a greater likelihood of being
diagnosed with a psychotic disorder compared with adults who have never used cannabis.45
Neurocognitive performance
Adolescent cannabis users exhibit impairments in tasks that assess sequencing ability,
cognitive processing speed, inhibition, and sustained attention.34,46,47,
Other disorders
Adolescents might have an increased risk of developing disorders from cannabis use.
Increases in treatment for cannabis use disorders coincide with increases in cannabis
potency.6 Clinical studies should further explore the relationship between dependence
and potency.
could be tolerant to these protective effects. In a case-
control study of inpatients presenting with first-episode
psychosis and controls aged between 18 and 65 years,
Di Forti and colleagues45 showed that individuals who
used skunk-like cannabis (high THC, minimal canna­
bidiol) daily were more than five times as likely to be
diagnosed with a psychotic disorder compared with
cannabis non-users. Moreover, frequent use of high-
potency cannabis was associated with an increased risk
of relapse following first-episode psychosis.51 These
findings are consistent with experimental evidence
suggesting that the psychotomimetic effects of THC are
dose-dependent13 and might be offset by cannabidiol.14
Overall, these studies clearly show the importance of
highlighting the risk of high-potency cannabis products,
particularly for adol­escents who might be susceptible to
the development of psychotic symptoms.
4 www.thelancet.com/child-adolescent Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30342-0
Few studies have accounted for cannabis type when
assessing depression and anxiety in adolescent cannabis
users. An anonymous global drug survey of young people
(>18 years) showed that those with a lifetime diagnosis of
depression and anxiety were significantly more likely to
use high-potency cannabis, in particular butane hash
oil.52 Butane hash oil is a frequently sold cannabis extract
with high concentrations of THC and relatively little
cannabidiol.18 However, it must be noted that this study is
of cross-sectional design and uses a lifetime diagnosis of
anxiety and depression, which makes the existence and
direction of causality difficult to establish. A second
cross-sectional study15 had similar findings, with higher
depression and anxiety scores reported in recreational
and daily cannabis users aged 16–23 years, whose hair
samples contained high concentrations of THC.
However, it is unclear whether an increase in THC
concentrates in hair samples can be attributed to an
increase in the frequency of cannabis use or to the use of
products with higher potency.
Few studies have investigated the association between
high-potency and low-potency cannabis and cannabis-
related problems. Freeman and Winstock53 used data
from the anonymous global drug survey and found that
frequent use of high-potency cannabis was associated
with a greater severity of cannabis dependence. A
16-year study in the Netherlands6 found an association
between changes in THC concentrations in cannabis
sold at national retail outlets and the number of people
entering specialist treatment for cannabis problems.
However, given that most studies were cross-sectional,
longitudinal studies are needed to investigate the
existence and direction of potential causal relationships
between cannabinoids and mental health outcomes in
young people.
Behaviours of cannabis use in adolescents
Although high-potency cannabis is associated with
greater harms compared with low-potency cannabis in
equal quantities, what must be considered is whether
cannabis users adjust (titrate) their consumption
according to THC and cannabidiol levels. A handful of
studies have explored such a possibility in cannabis
users.38,39,54 Identified by a cluster analysis based on
demographics and cannabis user and consumption
characteristics, Korf and colleagues39 found that the
“strongest high” group consisted mostly of younger
participants (mean age 22·7 years) who were least likely
to report titration (ie, reducing the number of grams
used, depth of inhalation, or pace of smoking) in response
to rising cannabis potency. Additionally, some members
of this group actually reported using more cannabis as
potency rose, further enhancing their exposure to THC.
In a subsequent Dutch study assessing titration in an
ecological setting, van der Pol and colleagues54 requested
that users bring their own externally-sourced cannabis
and discovered that its THC concentration was positively

correlated with the amount of cannabis they rolled in
their joints. However, THC concentration was negatively
correlated with inhalation volume, reducing exposure to
the compound. Therefore, those who used higher potency
cannabis tended to roll larger joints but partially engaged
in titration by lowering their inhalation volume. The
concept of partial titration was also supported by an
ecological study of adolescent cannabis users (aged
16–24 years) in the UK.38 That study found that as THC
concentrations rose, users added less cannabis in their
joints, partially reducing the effects of increased potency.
However, they did not adjust their behaviour according to
concentrations of cannabidiol in their cannabis. Measures
of titration might also be important for identifying risk of
transition to problematic use. A follow-up of the above
Dutch study done by van der Pol and colleagues found
that cannabis smoking topography (increased puff
volume and duration) predicted the severity of cannabis
dependence 1·5 years later, after adjusting for baseline
levels of dependence.54 Taken together, these findings
suggest that cannabis users might partially (but not
completely) adapt to changes in potency by titrating either
the amount they smoke or their inhalation. The
contrasting effects of cannabis between adults and
adolescents is further highlighted by Mokrysz and
colleagues.55 When measuring a range of acute effects
following the inhalation of vaporised active or placebo
cannabis, it was found that adolescent participants (aged
16–17 years) felt less stoned and experienced lower
psychotic-like symptoms and anxiety compared with
adults (aged 24–28 years). Furthermore, adults demon­
strated a greater impairment in reaction time on spatial
working memory and prose recall tasks. Where adults
expressed satiety, adolescents did not and instead wanted
more cannabis, regardless of whether they were taking
the active drug or placebo. It could therefore be suggested
that the increased drive for the rewarding properties of
cannabis is a possible contributing factor to escalating
use among young people.55 In conclusion, cannabis use
behaviour, such as understanding cannabis potency,
titration, satiety, and acute cannabis effects, is an
important factor to consider when assessing the harms of
cannabis use in adolescents. Although future research
must account for cannabis type, cannabis use behaviours
also contribute to determining the amount of THC
consumed by young people, and thus the potential harms
they are exposed to.
Limitations
Even though evidence from several US states and
countries report increases in cannabis potency,7,8,17,24 there
are several limitations in the data. First, most of the data
are based on police confiscations, which might result in
sampling bias. However, there is no reason to believe
that this sampling bias varies with time, so this probably
does not account for the increases in potency observed in
global cannabis markets. Moreover, data collected in the
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Review
Netherlands confirmed a strong increase in potency
from 2000 to 2004 in cannabis randomly sampled directly
from retail outlets.56 Second, few cannabis potency
studies address the issue of price, despite its important
role for purchasing behaviour and consumption, and the
possibility of contrasting trends in different regions or
markets. Therefore, in future studies, combining
information on potency and price will be more inform­
ative than information on potency alone.
Although clinical studies involving adult populations
can be useful in drawing conclusions from the effects of
cannabis use, it can be difficult to generalise these findings
to adolescents in the community. Moreover, unmeasured
confounding variables are a limitation common to many
observational studies, and there is a paucity of evidence
from placebo-controlled, double-blind studies.55 For
example, a major confounding factor that is not adequately
addressed in many studies to date is tobacco, which is
frequently co-administered with cannabis, and has been
found to be associated with later incidents of psychosis.57
Another major limitation in studies that has been
identified in this Review relates to the measurement of
cannabis use. Most studies evaluate the harms of cannabis
use by employing duration and frequency but neglect
measures of cannabis potency or quantification of THC
and cannabidiol concentrations. Self-reported data for
potency might be limited by the wide range of THC and
cannabidiol concentrations within cannabis products.
However, previous data have validated self-reported
cannabis type against actual THC and cannabidiol
concentrations measured in the laboratory.38 Even though
laboratory tests are more precise, they are far less feasible
for estimating long-term patterns of use (eg, by repeatedly
sampling an individual’s cannabis use across their
lifespan). We therefore recommend that the assessment
of cannabis potency should accompany questions about
frequency and duration in healthcare and research
settings. Pictorial aids (as illustrated in the figure) and
verbal descriptions might be helpful for identifying
different cannabis products. Moreover, researchers should
use laboratory tests to calculate precise concentrations of
THC and cannabidiol in cannabis where possible. Unlike
the standard units of alcohol used in the alcohol literature,
there are currently no agreed standards for measuring
cannabis.58 The implementation of standardised units of
cannabis use could vastly improve our understanding of
variation in cannabis use and its consequences on
adolescent health.
Future research
As a result of the limitations of current research strategies,
there are several directions for future investigations. As
there is a gap in the research focusing on adolescence,
there is also an absence of cognitive and neuroimaging
measures when focusing on potency.59 Whereas some
studies have imaged the brains of cannabis users, they
have either been restricted to the limitations associated
 Review
Search strategy and selection criteria
This Review originated from a comprehensive search of the
literature via PubMed, Google Scholar, and the authors’ own
files. The search involved key terms such as “adolescence”,
“cannabis”, “early-onset cannabis use”, “cannabis potency”,
“cannabis harms”, and “delta-9-tetrahydrocannabiol,
THC: Cannabidiol, cannabidiol”. As research focusing on
adolescent cannabis use is scarce, this Review included
articles written in English published in the past 15 years
(January, 2003, to September, 2018), except for original
citations for measurements (eg, stop-signal task). Finally,
the decision to include articles was made on the basis of their
relevance within the scope of this Review.
with hair analysis or have not included supplementary
cognitive measures.60,61 Studies including these measures,
alongside an accurate measure of cannabis potency, would
allow for a better understanding of the neurocognitive
effects across different cannabis products, both in the
long term and short term.
With cannabis policy rapidly evolving, there is a
possibility that further countries and states will legalise
recreational cannabis use alongside existing US states and
Canada. Although it is important to recommend that age-
related restrictions for ultra-high potency products be
guided by evidence-based public health research, it is
acknowledged that the legal age of purchase of cannabis is
often based on that for alcohol. Furthermore, although
current legal frameworks in the USA allow for legal
cannabis potency and price to be set by the market, policy
makers should consider the implementation of THC unit
taxes or THC thresholds.8 For example, if harm increases
as the price per unit of THC decreases, setting an
acceptable level of tax per THC unit could help minimise
harm. By contrast, if the potency of cannabis products is
more important (irrespective of price), then setting an
upper limit on THC concentration could be more effective.
Furthermore, to fully evaluate the health consequences of
changes in cannabis use, it will be essential to determine
the extent to which cannabis can act as a substitute or a
complement to other drugs, such as tobacco or alcohol.62
Given the growing body of research on cannabis potency
and cannabis-related harms, there is now a pressing need
to understand how different types of cannabis products
affect adolescent health.
With changes in policy potentially making cannabis
increasingly accessible to adolescents in several states
and countries worldwide, effective prevention and
information is critical. Approximately half of all first-time
cannabis use occurs before the age of 18 years.63 With
evidence suggesting that risk perception is more difficult
to alter after first-time use rather than before,64 it is
important that cannabis use is targeted for prevention at
an early age, regardless of the differential risk of use in
adolescents.65 Furthermore, a Cochrane review reported
6 www.thelancet.com/child-adolescent Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30342-0
that although existing information and prevention
programmes have resulted in small reductions in drug
use, the most effective programmes have been those that
involve a combination of drug information, social skills
training (eg, goal setting and decision making), and
anti-drug resistance skills training.66
Programmes must also be evidence-based, yet despite
this, those that include information on potency or
cannabis type are scarce. An internet-delivered pro­
gramme, the Climate Schools, educated users on the
importance of Δ-9-tetrahydrocannabinol content in
cannabis. This programme was efficacious in improving
knowledge of the drug and reducing its frequency of
use.67 Future prevention programmes must allow for the
discussion of how cannabis types differ in constituents,
availability, risks, and harms, so that adolescents are
equipped with up-to-date evidence,68 allowing for the
prevention or delay of cannabis use among those most
susceptible to its detrimental effects.
Contributors
CJM had the idea for this Review. JW conducted the literature search and
wrote the initial draft. All authors contributed to the writing and editing
of the paper and agreed the final version.
Declaration of interests
All authors declare no competing interests.
Acknowledgments
This research has been supported in part by the Parents’ and Carers’
Leave Fund awarded to CJM by King’s College London. TPF was
supported by the Senior Academic Fellowship award from the Society for
the Study of Addiction. We would like to thank David Potter for giving us
permission to use the photos in the figure.
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