Differentiating the Drug Normalization Framework: a Mixed Methods Investigation of Substance Use Among Undergraduate Students in Canada

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Differentiating the Drug Normalization Framework: A Mixed Methods Investigation of Substance Use among Undergraduate Students in Canada

Katarina Kolar

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Department of Sociology University of Toronto

Differentiating the Drug Normalization Framework:

A Mixed Methods Investigation of Substance Use among Undergraduate Students in Canada

Katarina Kolar

Doctor of Philosophy

Department of Sociology

University of Toronto

2018

ABSTRACT

This study investigates substance use trends, norms, and the social integration of drugs among undergraduate students in Canada through application of the drug normalization framework. This framework is designed to assess shifts in recreational substance use patterns, attitudes, and practices. In this dissertation, I focus on two prominent psychoactive substances in the university context: (1) cannabis as the most commonly used illicit drug in Canada, and (2) the nonmedical use of prescription drugs commonly prescribed for Attention Deficit Disorder. In Chapter Two I provide a multivariate analysis of a survey of 1,713 undergraduate students attending university at three campuses in Canada: the University of Toronto, the University of Guelph, and the

University of Alberta. This chapter provides insight into cannabis normalization as differentiated by social location predictors. It illustrates the gendered character of cannabis acceptability attitudes and use rates, and provides evidence for a substance use acculturation effect experienced by students who were born abroad. In addition, this chapter evidences a complex

ii relationship of peer network cannabis use prevalence to cannabis acceptability attitudes, where high network prevalence is associated with lower acceptability attitudes than "some" network prevalence, indicating a threshold effect for cannabis acceptability. In Chapter Three I apply a

"doing gender" analysis of in-depth semi-structured interviews with 58 students from the

University of Toronto to investigate the salience of gendered norms and stigma with respect to cannabis use rates, accessibility, and acceptability attitudes. I show how the gendered differentiation of cannabis normalization remains significant despite gendered convergence in lifetime use rates of cannabis. In Chapter Four I investigate acceptability evaluations of the nonmedical use of prescription medications through analyzing a subset of 36 interviews with students from the University of Toronto. The findings of this chapter are used to critically engage with and expand the drug normalization framework's construct of drug acceptability. To conclude, I identify areas for future research and discuss the implications of these results in light of impending changes to drug policy in Canada which will render cannabis a legally regulated commercial product for recreational consumption.

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ACKNOWLEDGEMENTS

The tremendous support and generosity of my committee has fuelled my perseverance and success throughout the course of my graduate studies. Dr. Patricia Erickson - a bottomless thank you for your mentorship and support as my doctoral supervisor, and as my friend. I have learned so much from your trailblazing research on drug use and drug policy, and am truly grateful for the expertise and insight that you have generously shared with me over the years.

The landscape of harm reduction research rests on your tireless dedication to evidence-based advocacy against drug criminalization. Dr. Candace Kruttschnitt - not once did you hesitate to provide thoughtful and rigorous reviews of my work, despite commitments that regularly take you across the world. Learning from you has been an immense privilege. I cannot thank you enough for the support you offered me throughout my graduate studies. Dr. Adam Green - thank you for challenging me to expand my capacity for critical conceptual engagement like no one else has. You pushed me to think about the very structures of knowledge production, and your instruction has been integral to my development as a researcher. The encouragement and constructive evaluations you have provided together as my committee have vastly, vastly (I cannot emphasize that word enough) improved my work. Thank you for all of the time and energy that you have dedicated to helping me become a better scholar!

I am also deeply fortunate to have had the unconditional support of family and dear friends throughout my graduate program, as well as in the countless hours of research and writing that went into this dissertation. Without their love and understanding I would still be unbearably far from completing this work. Kalev Anniko, my baby daddy and true love, I cannot imagine a life without your open arms, tender heart, and bright eyes. Herbie, my growing-oh-so- fast toddler, you do not know it yet, but you are my very best motivator. Mama loves you!! My

iv parents: thank you for the years upon years of encouragement, and of course, for all of the free food and babysitting! My incredible sisters Maja and Emilija, and my very best friends Athena

Engman, Christina Chant, Louise Birdsell Bauer and Merin Oleschuk: my heart is warmer and the world a far kinder place because of you.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... iv

TABLE OF CONTENTS ...... vi

CHAPTER ONE - Introduction ...... 1 Overview of the Drug Normalization Framework ...... 3 Critiques of the Drug Normalization Framework ...... 12 Methodology Overview ...... 17 Surveys ...... 19 Interviews ...... 20 Overview of the Dissertation ...... 22 Chapter Two - Differentiating The Drug Normalization Framework: A Quantitative Assessment Of Cannabis Use Patterns, Accessibility, and Acceptability Attitudes Among University Undergraduates ...... 22 Chapter Three - Gender Disparities in Cannabis Normalization among Undergraduate Students ...... 23 Chapter Four - Study Drugs "Don't Make You Smarter": Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students ...... 24 Chapter Five - Conclusion ...... 24 References for Chapter One ...... 25

CHAPTER TWO - Differentiating The Drug Normalization Framework: A Quantitative Assessment Of Cannabis Use Patterns, Accessibility, and Acceptability Attitudes Among University Undergraduates ...... 28 Abstract ...... 28 Introduction ...... 30 Methods ...... 35 Results ...... 40 Discussion ...... 47 Conclusion ...... 51 References for Chapter Two...... 52

CHAPTER THREE - Gender Disparities in Cannabis Normalization among Undergraduate Students ...... 57 Abstract ...... 57 Introduction ...... 59 Methods ...... 66 Results ...... 69 Discussion ...... 101 Conclusion ...... 109 References for Chapter Three...... 111

CHAPTER FOUR - Study Drugs "Don't Make You Smarter": Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students ...... 116 Abstract ...... 116 Introduction ...... 117 Methods ...... 121 Results ...... 123 Discussion ...... 132 Conclusion ...... 139 References for Chapter Four ...... 143

CHAPTER FIVE - Conclusion ...... 148 Study Implications and Considerations for Future Research ...... 154 References for Chapter Five ...... 159

TABLES ...... Table 1. Descriptive Statistics ...... 41 Table 2. Recent Cannabis Use Frequency - ZINB Model ...... 43 Table 3. Cannabis Acceptability - Logistic Regression Model ...... 45 Table 4. Cannabis Accessibility - Logistic Regression Model ...... 46

FIGURES ...... Figure 1. Recent Cannabis Use Rate by Gender ...... 70

APPENDICES ...... APPENDIX A - Informed Consent Sheet For Interview Participants ...... 162 APPENDIX B - Semi-Structured Interview Schedule ...... 165

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APPENDIX C - Informed Consent Sheet For Survey Participants ...... 168 APPENDIX D - Online Survey Questionnaire ...... 170

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CHAPTER ONE - Introduction

Drug normalization studies suggest that the widespread availability and acceptability of illicit drugs among young adults, and of cannabis in particular, indicate that navigation of illicit substance use has become an increasingly common aspect of everyday life for both drug users and their nonusing peers (Aldridge, Measham, & Williams, 2011; Duff et al., 2012; Measham &

Shiner, 2009). "Cannabis, stigma and policy change: A three-campus study of normalization among university students" is a project funded by the Social Sciences and Humanities Research

Council [SSHRC] standard research grants program. As the primary research assistant and interviewer for the portion of this study conducted at the University of Toronto, I received endorsement from the lead investigators - Dr. Andrew Hathaway at the University of Guelph, Dr.

Patricia Erickson at the University of Toronto, and Dr. Geraint Osborne at the University of

Alberta - to integrate my doctoral research within this project. The larger study endeavours to contribute to understanding of the growth of illicit drug use, particularly cannabis, in the context of contemporary young adult lifestyles. Overarching project objectives include: 1) to investigate drug use perceptions and experiences of otherwise conforming young adults; 2) to empirically assess the drug normalization framework with particular reference to cannabis; and 3) to gain insight into the nature and extent of drug-related stigma in Canadian society. University undergraduate students are the focus of inquiry as the current generation of cannabis users in the mainstream young adult population: Cannabis use in the past 30 days among postsecondary students in Canada has recently been estimated at 16.0% of students (American College Health

Association, 2013). This pattern appears to have changed little in the previous decade and may indicate stabilization of student drug use practices (Adlaf et al., 2005; see also Rotermann &

Langlois, 2015).

Drug normalization (described in detail in the following section) is a framework or barometer of change intended to assess shifts in substance use trends (Parker, 2005; Parker et al.,

1998; Aldridge et al., 2011). Drug normalization is characterized by several components, including: (a) changes in rates of illicit drug use, in drug accessibility, and in availability of drug knowledge among users and nonusers; (b) cultural accommodation of drug use, as for instance is evident in the proliferation of favorable media depictions of illicit drugs; and (c) in acceptance of drug use as part of 'ordinary' life, or drug acceptability, identified in the attitudes of drug users and nonusers towards drug use (Aldridge et al., 2011; Duff et al., 2012; Hathaway, 2004a;

2004b). This perspective is mainly concerned with explaining recreational drug use, i.e. “the occasional use of certain substances in certain settings and in a controlled way” (Parker, 2005, p.206). The normalization framework considers both illicit drugs and legal psychoactive substances such as tobacco and alcohol in its investigations, and rejects the premise that illegal drug use is necessarily an indication of deviance or pathology. This allows normalization researchers to turn research attention away from deviant subcultures of heavy drug use and towards the growing prevalence of occasional recreational illicit drug use among young people that is often accompanied by consumption of alcohol and tobacco.

As part of the "Cannabis, Stigma, and Policy Change" project, my doctoral dissertation utilizes the drug normalization framework to structure empirical investigation of undergraduate student attitudes towards, and their experiences of, illicit drug use. This research includes both illicit drug consumers and abstainers, and involves (a) surveys with undergraduate students at three locations: the University of Guelph; the University of Alberta, Augustana Campus; and the

University of Toronto, St. George Campus, and (b) in-depth, semi-structured interviews with undergraduate students at the University of Toronto, St. George Campus. My dissertation

2 contributes insight into student attitudes and drug use practices in relation to two psychoactive substances that figure prominently within university contexts: (a) cannabis, being the most commonly used illicit drug among undergraduate students and the general population, and (b) non-medical use of stimulants commonly prescribed for ADHD conditions, being drugs which are used by undergraduate students to enhance concentration and maintain alertness in the pursuit of academic achievement. Beyond advancing research which addresses undergraduate student drug issues, my dissertation critically engages with the drug normalization framework itself.

OVERVIEW OF THE DRUG NORMALIZATION FRAMEWORK

The drug normalization framework was developed by Howard Parker, Judith Aldridge and Fiona Measham (1998) through longitudinal investigation of recreational drug use among

Briton youth (ages 14 through 18) who attended secondary schools in North West England. This landmark study was among the first of its kind both to research drug use longitudinally and to move beyond deviancy theories emphasizing social and developmental deficits as explanations of illicit drug use among young people. This study was recently extended and updated through recapture of original participants as young adults (at ages 22 and again at ages 27/28) (Aldridge et al., 2011). In total 1,125 unique individuals were tracked for one or more years for this study.

The longitudinal design allowed researchers to identify change over time in individual drug use, and to thereby inform understanding of changes in drug use trends.

These normalization researchers also drew on cross-sectional survey statistics to illustrate that in the 1990s, recreational drug use had spread across previously protected populations, including the middle class and young women (Aldridge et al., 2011). In comparison to the 1980s, where illicit drug trying rates were at approximately 15-20% of young adults ages 16-24 in

Britain, between 1990-1995 this rose to between 25-50% of young adults--trends that were mirrored across the Western world. Not only were youth using 'soft' drugs like cannabis, but their drug repertoire appeared to be increasing overall to include use of drugs such as psychedelics, amphetamines, and ecstasy. Such statistics indicate that a new phenomenon was emerging among youth in the 1990s, one that cannot be explained by deviancy theories relying on subcultural explanations of drug use because these youth are, by and large, considered conventional members of society (Aldridge et al., 2011; Hammersley, 2011). In other words, their drug use does not occur primarily as a form of counter-cultural protest, drug subcultures are not central to their personal identity, nor does their drug use threaten participation in mainstream society as educated and employed young adults (barring issues associated with arrest and criminal charges for illicit drug possession). It is this expansion of the prevalence of recreational drug use across the young adult population that Aldridge and colleagues (2011), and Parker and colleagues preceding them (1998), attempt to address through the drug normalization framework.

The drug normalization framework tends to be characterised by six key components

(Aldridge et al., 2011; Parker, 2005). These components are briefly summarized here:

(a) Drugs Availability and Accessibility is a component of the drug normalization framework which refers to the rise in experience of drug offer or access situations by young adults. Availability is tied to global processes of production and distribution of drugs which have resulted in their increased availability despite criminalization policies.

(b) Drug Trying Rates refers to the increase in the overall incidence of young adults ever having tried a drug. This increase also applies to previously protected populations, such as women and middle class youth, where the closure of gender and social class differences in

4 lifetime prevalence of drug trying indicate the increasingly normative nature of drug experimentation.

(c) Recent and Regular Drug Use refers to an increase in drug use as an integrated part of some social situations, as opposed to simply occasional drug trying. Regular drug use is characterized broadly by use that is integrated into everyday social scenarios and activities, such as using 'dance drugs' at parties or clubs, or using cannabis to socialize with friends. In other words, it is recreational drug use. 'Regular' or 'recreational' drug use is thus opposed to 'problem' use which involves compulsive, dependent drug use, or drug misuse patterns that result in social dislocation (through loss of employment, disconnection from family and friends, and so on).

(d) Being 'Drugwise' refers to the expansion of drug-related experiences and drug knowledge across the youth population. This applies not only to current drug users, but also to former drug users, occasional drug users, and abstainers from drug use who may have peers, friends or family members who provide connections to knowledge about drug effects, and who may act as a point of access to witnessing drug use episodes (e.g., at parties). By examining youths' access to drug knowledge and to witnessing drug experiences, this component can be used to investigate the extent to which nonusers and occasional users accommodate more regular drug users in their lives, and vice versa. As such, this component assesses the extent to which drug use knowledge has ceased to operate solely as part of a closed subcultural world.

(e) Social Accommodation of 'Sensible' Recreational Drug Use (also known as Drug

Acceptability) is a particularly essential measure of normalization (Parker, 2005, p.207). This component focuses on the attitudes of drug users and nonusers to evaluate whether there are signs of growing social accommodation or tolerance of recreational drug use. Social accommodation can be assessed by looking to individual or group evaluations of which drugs are

5 seen as un/acceptable to use, through which mode of ingestion, how often, and in which situations. Exploring shifts in how groups engage in and morally position certain kinds of drug use allows for insight into the material, symbolic, and discursive pressures driving such changes.

Social accommodation is also reflected in individuals' future intentions of using (or abstaining) from drugs into adulthood. The findings by Aldridge and colleagues (2011) confirm that even among youth who were abstainers, drug taking was considered as a potential part of their adulthood. This openness to drug use in the future is supported by the fact that 31% of abstainers at age 18 had tried illicit drugs by their 22nd year (Aldridge et al., 2011).

(f) Wider Cultural Accommodation of Recreational Drug Use is a component that looks to media and film representations as suggestive of shifts in cultural tone towards the use of particular drugs. Whereas in the 1950s and 1960s drug use was seen as a subcultural marker of identity, increasingly the use of particular drugs (cannabis especially, but also cocaine, ecstasy, and psychedelics such as mushrooms) has become a recreational activity which is accommodated into more conventional young adult life. In short, recreational drug use is being accommodated in media and youth culture where such use speaks less to a clearly demarcated subcultural identity than to a form of relatively accessible entertainment and socialization.

Cultural accommodation into the mainstream of activities previously labeled as deviant may be seen in the form of neutral or positive portrayals of drug users in news media and on television shows, by the absorption of drug imagery by fashion and music industries, as well as by growing support for law reform in opinion polls and other public forums (Aldridge et al.,

2011; Hathaway, Comeau, & Erickson, 2011). In these less deviant representations of users, drug use is positioned as a leisure activity that is continuous with a functional, conventional life, and thus does not fuel a drug-oriented and isolated subculture of problematic drug use. Cultural

6 accommodation is therefore indicated by a "blurring of the licit and illicit" (Aldridge et al., 2011, p.207).

(g) Drug Policy and Global Processes: Beyond the six core components listed above, more recent discussions of normalization have included considerations of how drug policy (the

War on Drugs in particular) responds to drug users, and what this means for normalization processes (Aldridge et al., 2011; see also Duff et al., 2012 on normalization in the context of liberalizing drug policy shifts in Canada). In the case of the War on Drugs, it is clear that such a policy of threat and punishment has failed to prevent drug use from spreading into the general young adult population, and is at the root of extensive harm and oppression experienced by marginalized communities. The role of globalization has also come into consideration within the normalization framework. For example, Parker (2005) highlights how the emergence of recreational club drug use across the world is connected to global drug trafficking and marketing processes. These macro-level considerations of drug policy and globalization processes are important for contextualizing shifts in drug normalization trends.

However, this series of components of the normalization framework are not claimed to constitute a "coherent theoretical paradigm" (Parker, 2005, p.206) that makes propositions as to what comprises the nature of the social world. Instead, the normalization framework is intended as a conceptual toolkit to monitor and understand recreational drug use both in terms of overall trends in rates of drug use, and in terms of the meanings, cultural contexts, and motivations of such use (Parker, 2005; Aldridge et al., 2011; Measham & Shiner, 2009). As a "barometer of change" (Aldridge et al., 2011, p.219), the framework provides the six components listed above as a means of assessing how drug use is changing; it does not explicitly aim to assess the

7 desirability (or lack thereof) of such changes, though the framework can be applied to inform such assessments.

In speaking to changes in youth and young adult attitudes towards and patterns of drug use, the normalization framework seeks to address the experiences and views of both drug users and those abstaining from drug use. The normalization framework makes the important connection that the views of nonusers are essential for understanding changes in drug trends as these views illustrate (i) the extent to which drug use has been accommodated among peers, (ii) the availability and accessibility of drugs knowledge and drugs themselves, and so (iii) helps to show how perspectives on drug users as deviant or normal changes over type of drug, pattern of use, and over time. In exploring these diverse facets of recreational drug use, the normalization framework continues to contribute to our understanding of drug trends and of trajectories of drug users and abstainers.

As noted above, the drug normalization framework focuses on recreational drug use, broadly defined in normalization research as "involving mostly weekend use of drugs in

(recreational) social settings and at (recreational) leisure times" (Aldridge et al., 2011, p.6).

Normalization researchers made the concept of recreational drug use central to their work as a way to push the research conversation beyond pathological or deviant drug use on which the majority of drug studies have focused, yet which characterizes but a small fraction of all illicit drug activities (Aldridge et al., 2011; Duff et al., 2012; Parker, 2005). Drugs characterized by a recreational use pattern are understood to change over time and context, for example by an increased rate of cocaine use and by the growing social accommodation of peer's cocaine use since the late 1990s in Britain (Aldridge et al., 2011; Parker, 2005).

However, drug normalization researchers acknowledge that the term recreational drug use introduces conceptual difficulties as a vague descriptor of 'socially-oriented' drug use

(Aldridge et al., 2011). Research indicates that such demarcations between problem and recreational drug use often do not operate as a simple opposition (Shildrick, 2002; Measham,

2002). For instance, occasional polydrug use in club contexts (e.g., using combinations of illicit drugs and stimulants such as ecstasy/MDMA, cocaine, amphetamines, and energy drinks; or using these in combination with alcohol) may involve extreme intoxication resulting in acute loss of self control and toxicity risks, as well as impacts on performance and wellbeing that require several days for full recovery. Such use, when purposefully bounded within specific times and places, can be socially accommodated as controlled excess, or what Measham (2002) calls a

"controlled loss of control" (p.349) and Williams & Parker (2001) call "time-out adventures"

(p.404). It is therefore important to keep in mind that the term recreational drug use is not intended to suggest that such drug use is without issues or concerns, but to act as a general descriptive demarcation between "the use of the vast majority of adolescents and young adults from the daily, dependent, and chaotic heroin and crack consumption usually characterised as

'problem drug use'" (Aldridge et al., 2011, p.6). In other words, the concept is intended to operate as a point of contrast with the forms of problematic drug use likely to draw social condemnation rather than accommodation from peers.

To investigate the meanings and practices of drug use among today's young adults, drug normalization researchers have suggested that we understand shifting drug trends within the context of a risk society where independence takes longer to achieve and consumption activities are central to identity (Aldridge et al., 2011; Parker, 2005). They argue that in comparison to their older counterparts, young adults face uncertain futures where they must navigate a rapidly

9 changing world that "requires flexibility and makes risk taking a functional necessity" (Williams

& Parker, 2001, p.399). Young adults today are more likely to have prolonged educational training, and to experience a delay in acquiring the demographic markers of 'settling down' such as home ownership, marriage, parenting, and permanent employment (Williams & Parker, 2001;

Aldridge et al., 2011). Evidence suggests these markers reduce substance use, and in their absence, normalization researchers anticipate that rates of drinking and recreational drug use of young adults will remain elevated for longer into the lifecourse than has historically been the case (Williams & Parker, 2001; Aldridge et al., 2011). Thus recreational drug use as a "leisure- consumption" activity of young adults is evolving in response to contemporary structural shifts in access to employment, education, and economic stability and independence (Parker, 2005, p.213).

It is important to make clear that the normalization of various kinds of drug use does not mean that drugs are "normalised anywhere, anytime" (Hammersley, 2011, p.413). Instead, the normalization framework indicates that certain drugs are more prevalent and tolerated than they have been previously, but that this tolerance and accommodation occurs in the context of informal social regulation. Drug users and nonusers have a strong sense of when, where, and how specific kinds of drug use are (in)appropriate. In other words, normalized drug use does not suggest normless drug use. Like Becker's (1963) treatise on the sociology of deviance, normalization theory proceeds from the idea that "deviance is not a quality of the act the person commits, but rather a consequence of the application by others of rules and sanctions to an

'offender'" (Original emphasis. Becker, 1963, p.9). In contrast to Becker's (1963) exploration of a deviant subculture of musician cannabis users, normalization theory does not assume that drug users are alienated from or seek to repudiate conventional norms and institutions. Rather, the

10 normalization framework aims to identify how a subcultural activity that was previously labeled as deviant has become accessible and acceptable for those living a conventional life through sets of norms that socially regulate drug use practices. In short, the drug normalization framework intends to be a useful tool that points to the "direction of movement" in the perceptions of some kinds of drug taking away from or towards a state of widespread social acceptability (Aldridge et al., 2011, p.219).

The drug normalization framework's focus on recreational drug use as a socially regulated activity clashes with the assumptions of the dominant biomedical paradigm to psychoactive substance use which centres around primary drug reinforcement, where a pleasurable experience of drug use results in repeated use, and the consequent development of drug addiction as fundamental to explaining drug use behaviour (Hammersley, 2005). The biomedical paradigm presumes that primary drug reinforcement overrides social regulation, and yet as is exemplified by low rates of problem drug use, this is rarely the case (Hammersley,

2005; Aldridge et al., 2011). In identifying socially conventional, non-dependent forms of drug use, the normalization framework has illustrated the shortcomings of addiction and deviance discourses on drug use which by and large sought to promote abstinence as a strategy for managing problem drug use. In order to promote the health and wellbeing of drug users, the normalization framework instead proposes a harm reduction approach to managing negative outcomes associated with drug use. Such an approach requires that we recognize non-dependent drug use as a prominent occurrence in the population, and that public health is thus best served by risk reduction strategies rather than abstinence-only programming and the criminalisation of substance use (Kirst et al., 2015).

CRITIQUES OF THE DRUG NORMALIZATION FRAMEWORK

In its attempts to account for the growing prevalence of recreational drug use among the conventional young adult population, the normalization framework emphasized how common drug experimentation had become, and how this behaviour is now found in previously protected populations, such as women and adolescents in the middle class, which indicates a closure of gender and social class differences in rates of drug trying (Parker et al., 1998; Aldridge et al.,

2011). Academic critiques have arisen in response to this emphasis on the pervasiveness and normative nature of drug trying. These critiques have tended to take three paths: that the normalization framework (a) overemphasizes the extent of drug use by young people and the degree to which this is accepted as normal, (b) tends to overlook how drug behaviour and attitudes are differentiated in favor of a relatively homogeneous representation of drug use prevalence across the young adult population, and in turn (c) neglects to explore or adequately account for how drug users continue to be impacted by experiences of stigma and the threat of legal sanction (e.g., Hammersley, 2011; Shiner & Newburn, 1997; Measham & Shiner, 2009;

Sandberg, 2012a; 2012b; Hathaway et al., 2011; Shildrick, 2002).

The first critique that the normalization framework exaggerates the extent of youthful drug use is a response to Parker and colleagues' (1995) use of lifetime measures of drug trying

(i.e., tried an illicit drug at least once) to make the case of growing prevalence in the early formulations of the framework. As Shiner & Newburn (1997) argue, lifetime measures are a blunt tool because they cannot apprehend the processual nature of drug use, and thus cannot be used to distinguish between ex-users and current users, nor between heavy users and occasional users. Shiner & Newburn (1997) point out that in contrast to statistics on lifetime use rates of over 50%, Parker and colleagues' (1995) surveys capturing recent drug use indicated that under

30% of youth (16 years of age) had used illicit drugs in the previous month. As such, Shiner &

Newburn (1997) caution that over-reliance on lifetime statistics may be misleading as to the normalcy of drug use.

While their cautionary call against statistical misrepresentation of the prevalence of drug use should be duly noted, Shiner & Newburn's (1997) critiques rest on a misrepresentation of the normalization framework. Firstly, drug trying as an increasingly accepted part of adolescence and young adulthood is only one indicator of normalization. Parker and colleagues (1995; 1998;

Aldridge et al., 2011) provide and analyze other measures, including rates of more recent use, and they differentiate this information by type of drug and extent of use. Secondly, Shiner &

Newburn (1997) claim that drug use must be "extremely widespread [and] that usage is perceived to be normal" (p.520) in order for the normalization framework to be accurate.

However, in attempting to disprove the 'normalcy' of drug use, Shiner & Newburn (1997) oversimplify how the framework itself understands the social acceptability of drug use behaviour. Parker and colleagues (1998; Aldridge et al., 2011) argue that some drug use, and cannabis in particular, is more integrated into the lives of conventional young people, but that such use remains subject to formal and informal social regulation. In other words, restrictive attitudes towards drug use--including fears of addiction and adverse health impacts among adolescents and young adults, or the social sanctioning of heavy users--do not preclude the possibility of drug normalization. Instead, these restrictive attitudes themselves shape and indicate when, how, and to what extent certain kinds of drug use are acceptable, and when/how they are not. Further, young people's awareness of various health and social risks associated with particular kinds of substance use does not necessarily mean that occasional recreational drug use is seen as "morally wrong" (Aldridge et al., 2011, p.221). This is especially clear in Parker and

13 colleagues' (1998; Aldridge et al., 2011) explorations of how drug abstainers perceive and respond to the drug use of their peers.

A second prominent critique of the normalization framework is that it tends to overlook how drug behaviour and attitudes are differentiated, in favor of a relatively homogeneous representation of drug use prevalence across the young adult population. Indeed, through its emphasis on the shrinking significance of gender and social class in drug trying rates as an indication that drug involvement is no longer limited to social location, the normalization framework has generally neglected to explore how these same factors continue to inform the meanings and practices of contemporary drug use (e.g., Shildrick, 2002; Measham et al., 2011).

Although traditional indicators of inequality are less useful in explaining lifetime drug trying rates, research illustrates that drug use frequency, type of consumption, and the acceptability of drug use continue to be shaped by these factors. For example, in her qualitative study of drug attitudes of young people between 16-26 years of age, Shildrick (2002) shows that socioeconomic position continues to differentiate the narratives of drug acceptability and experience of problematic drug use incidents. Young people who were from more disadvantaged backgrounds and who spent more time on the street tended to use a wider variety of drugs and more frequently experienced negative outcomes (Shildrick, 2002). The availability and accessibility of drugs to this group of disadvantaged young people clearly shaped their experiences of drug use. Shildrick (2002) proposes that the concept of "differentiated normalization" (2002, p.36) is a more fitting tool for understanding contemporary youthful drug use because it focuses on the ways that drug use may be normalized for different groups and different types of drug use.

Much as it initially neglected to explore socio-demographic variation in drug use patterns, meanings, and acceptability, the normalization framework also downplayed the relevance that drug subculture continues to hold in influencing the modes of use and symbols associated with particular drugs (Sandberg, 2012b; see also Measham, 2002). For instance, subcultures may initiate individuals into a circle of less readily accessible drug knowledge and use norms, thereby allowing these newly initiated individuals to spread this knowledge of drug use practices into more conventional friend networks (e.g., Kelly et al., 2013; Sandberg, 2012b; see also Pennay & Moore, 2010). Such research complicates normalization researchers' claims that subcultural worlds of drug use lack relevance for understanding conventional recreational drug use practices (e.g., Parker et al., 2005; Aldridge et al., 2011).

In order to avoid oversimplifying the relationships that young people have with substance use, normalization researchers have taken up the call from critics that it is necessary to pay closer attention to the differentiated nature of the meanings and patterns of drug use by situating these within their structural and normative contexts. Over the course of a decade, critics and normalization framework proponents have come to a point of agreement that normalization itself should be recognized as "a contingent process negotiated by distinct social groups operating in bounded situations" (Measham & Shiner, 2009, p.502). In turn, more nuanced drug normalization research has emerged which investigates, for example, the context and meaning of recreational drug use among young clubbers in Australia (Duff, 2003), the role of gender and lifecourse transitions on women's drug use careers (Measham et al., 2011), and how young people regulate their recreational drug use in response to the enduring stigmas attached to illicit drugs (Pennay & Moore, 2010).

The third major critique holds that the drug normalization framework neglects to adequately account for how drug users continue to be impacted by experiences of stigma and the threat of legal sanction, particularly with regards to cannabis use as the most frequently used illicit drug in the Western world. In its initial focus on establishing the evidence for social integration of various kinds of drug use, the normalization framework was certainly less concerned with how individuals manage the stigma of drug use and what this means for understandings of drug acceptability. Despite strong indications of the growing social tolerance of cannabis, more recent contributors to normalization research illustrate that cannabis users must still manage their exposure to stigma, guilt, and in many jurisdictions, the threat of legal sanction (Hathaway et al., 2011; Brochu, Duff, Asbridge, & Erickson, 2011; Sandberg, 2012a;

Jarvinen & Demant, 2011; Pennay & Moore, 2010). Recent adaptations of the normalization framework have responded to these criticisms, and have sought to integrate into the framework

"contingent processes such as the individual assessment of cannabis related risks, the personal negotiation of stigma and control, the emergence of norms regarding cannabis use in peer groups... and so on" (Duff et al., 2012, p.275). This allows for more in-depth understanding of how drug users understand and experience the features of normalization within the context of their everyday lives, and thus provides a means to consider the contingent impacts of micro-level features (e.g., the structure of local drug markets and inconsistencies in local drug law enforcement; how drug users manage stigma within the network of their friends, family, and employers) on personal drug use (Pennay & Moore, 2010; Duff et al., 2012). In turn, insight has been developed into how drug users manage the stigma associated with illicit substance use, how they negotiate perceived drug risks, and how these relate to attitudes towards drug use that is perceived as problematic or compulsive (Duff et al., 2012; Duff & Erickson, 2014).

Taken together, these three critiques have resulted in important developments in how the normalization framework is applied. However, in the context of undergraduate university life in

Canada, there remain several research gaps and conceptual issues within the normalization framework that need to be addressed. As illustrated in greater detail in the next section which summarizes the three chapters comprising my dissertation, quantitative research remains lacking on how rates of recent cannabis use, cannabis acceptability attitudes, and cannabis accessibility are differentiated among socially integrated young adults in the Canadian context of drug normalization. In addition, in-depth qualitative analysis of how gendered stigma informs nonmedical cannabis use practices, evaluations of cannabis acceptability, and access to illicit cannabis is required in order to explain differences in rates of cannabis use among young men and women. Further, there is a need for the drug normalization framework to explore new territories of drug use by engaging with the increasingly salient phenomenon of 'academic doping' among university students--a phenomenon that does not reflect the conceptual opposition of problem versus recreational drug use on which the normalization framework relies to understand and evaluate drug acceptability.

METHODOLOGY OVERVIEW

From November 2011 through April 2012, surveys and in-depth semi-structured interviews were conducted with undergraduate students attending classes at the following three university campuses in Canada:

1. The University of Toronto, St. George Campus, is a comprehensive public research university which consistently ranks among Canada’s top two universities. The St. George

Campus is located in the urban centre of Toronto, Canada's largest city. Approximately 40,000 undergraduate students are enrolled in programs at this campus. For both the survey and

17 interview portions of the study, University of Toronto [U of T] undergraduates were sampled from a first-year introductory sociology class with 1,393 students enrolled at the time of study implementation. Students with a wide variety of majors took the course as an elective. Most were in their first year of university, but many were in later years. Ethics approval for this project has been received from the U of T research ethics review board, Protocol Reference #26892.

Research Protocol Title: "Cannabis, stigma and policy change: A three campus study of normalization among university students". The lead investigator for the St. George Campus portion of this study is Dr. Patricia Gail Erickson.

2. The University of Guelph is a mid-size comprehensive public research university located in Guelph, Ontario. Guelph is a small city, with a population of approximately 120,000.

Approximately 18,000 undergraduates are enrolled at the University of Guelph [U of G]. U of G undergraduates were sampled from a first year introductory class in criminology provided by the sociology department, with 546 students enrolled at the time of study implementation. Ethics approval for this project has been received from the U of G research ethics review board,

Protocol Reference #11SE005. Dr. Andrew Hathaway is the principal investigator for this project, and is the lead investigator for the Guelph Campus portion of this study.

3. The University of Alberta, Augustana Campus, is located in 'small town' Camrose,

Alberta, in a rural area southeast of the city of Edmonton. Camrose has approximately 17,000 residents. Approximately 1000 undergraduate students attend this campus. Due to the small class sizes at Augustana Campus, several classes were sampled for survey and interview participants.

University of Alberta [U of A] undergraduates were sampled from first-year introductory classes in sociology, anthropology, and politics, as well as from a second-year class in criminology, and two third-year classes in law and sociology. A total of 215 students were enrolled in these classes

18 at the time of study implementation. Ethics approval for this project has been received from the

U of A research ethics review board, Protocol Reference #Pro00024191. Dr. Geraint Osborne is the lead investigator for the Augustana Campus portion of this study.

i. Surveys:

Students at all three campuses in this study self-administered an online drug use and attitudes survey adapted from a pilot that was implemented at the University of Guelph in 2010.

The survey drew on items in past studies dealing mainly with adult cannabis users, and covered use patterns, social contexts, stigma, and reported positive and negative effects (Hathaway, 2003;

2004a; 2004b). In addition, several items were adapted from Parker and colleagues' (1998) survey study of drug normalization among British youth. These items include checklists and closed-ended questions about perceptions of social and legal stigma, drug trying and use patterns, and social accommodation versus disapproval of drug use in the peer group, among parents, around campus, in the local community, and beyond (see survey questionnaire in

Appendix D). The survey replicated the demographic items from the nation-wide Canadian

Campus Survey, allowing for broad comparison with university student demographics across

Canada (Adlaf et al., 2005).

Ethical concerns arising in this research concern the illegality of cannabis and other drugs, and sensitivity of questions pertaining to their use. To ensure that participants were protected from identification, survey data were gathered anonymously. The survey was securely hosted on Fluid Surveys for all three campuses, an online platform providing researchers with survey hosting services. Students were given a website link to access the survey. Participation was entirely voluntary. A bonus of 2 percent was added to each student’s course grade as

19 incentive for participating. On average, students took about 30 minutes to complete the survey.

In total, 1757 valid cases are available for analysis:

 Of the 1,393 students sampled from the U of T St. George Campus, 1,227 participated in

the survey: a response rate of 88 percent.

 Of the 546 students sampled from the U of G, 396 participated in the survey: a response

rate of 73 percent.

 Of the 215 students from the U of A Augustana Campus, 134 participated in the survey: a

response rate of 62 percent.

ii. Interviews

Interviews were implemented using a semi-structured interview guide (see Appendix B).

All three research locations applied the same interview guide. The interview guide was developed collaboratively by the research team, including myself, to explore young people's perceptions and experiences of drug use, as well as to elicit the meanings that they ascribe to use of drugs. Although other drug use is also explored in the interviews, the interview guide was designed to focus on cannabis as the most frequently used illicit drug.

Drugs availability, accessibility, and use patterns were assessed through questions on whether and how often students themselves used drugs; in what contexts these drugs were used; and how accessible drugs were to them. Acceptability was investigated through questions on how students perceived various kinds of drug use; how they perceived legal sanctions against drug use to impact their lives and the lives of friends and family; and for drug users, how they managed the stigma of drug use. Nonusers were also asked about potential drug-related

20 experiences (e.g., attending social events where friends, family members, or acquaintances were using drugs).

Upon completion of the online survey, students at all three campus locations were prompted with online and in-class reminders about the option to participate in interviews that further explored drug use attitudes if they were interested in doing so. Students were assured that participation was entirely voluntary, confidential, and that their identity would be protected through anonymisation of interviews. As such, all participant names provided in this dissertation are pseudonyms. During the consent process, participants were told they could stop the interview at any time and that they did not need to answer any questions they did not wish to answer. For their time and contribution to the research, students were provided with a $20 honorarium. As a result of the study focus on young adults, students had to be below 27 years of age in order to participate. Interviews were recorded and then transcribed verbatim. I conducted and transcribed

58 semi-structured in-depth interviews with drug using and non-using undergraduate students at

U of T's St. George Campus. Thirty-six of these interviews were conducted with women, 21 with men, and 1 with a gender diverse student. Of these interview participants, 32 reported using illicit drugs (including cannabis), 20 reported being nonusers of illicit drugs, and 6 identified as former users of illicit drugs (i.e., as using illicit drugs experimentally or regularly in the past, but no longer use or intend to use drugs).

I use Nvivo 10 to analyse interview data from the U of T sample in order to develop in- depth understanding of the complexities of drug normalization. These analyses are intended to serve exploratory, descriptive and explanatory purposes (Marshall & Rossman, 2006). Through these analyses, I explore and describe the meanings, patterns, and themes of substance use that are salient for participants. These analyses also seek to explain how social forces, such as

21 gendered expectations and contextual university pressures, inform drug normalization. Taken together, I use these findings to provide contributions on how the drug normalization framework should be conceptually adapted to account for various complexities identified in my analyses, as well as to make policy recommendations on addressing undergraduate student drug use.

OVERVIEW OF THE DISSERTATION

Five chapters comprise this dissertation, beginning with an introductory chapter and ending with a concluding chapter. Chapters Two, Three and Four are designed as standalone research articles. Chapter Two has been peer-reviewed and accepted for publication in the core area journal Substance Use & Misuse. Chapter Four has been peer-reviewed and successfully published in the international journal Contemporary Drug Problems (Kolar, 2015). Although written to stand as independent papers, chapters two through four share the aims of expanding the limited research available on drug normalization as a differentiated social process and of providing new insights into drug use practices among undergraduate students in Canada. Below I provide a brief description of the remaining chapters in this dissertation.

Chapter Two - Differentiating The Drug Normalization Framework: A Quantitative Assessment Of Cannabis Use Patterns, Accessibility, and Acceptability Attitudes Among University Undergraduates

In Chapter Two, I contribute a quantitative assessment of cannabis normalization as differentiated by social location factors, focusing especially on gender and nativity/immigration as important variables to consider in the differentiation of normalization. This chapter estimates three statistical models to investigate cannabis normalization: (1) a zero-inflated negative binomial regression model of undergraduate cannabis use frequency in the previous month; (2) a logistic regression model of cannabis acceptability attitudes; and (3) a logistic regression model

22 of cannabis accessibility. This chapter represents the only multivariate statistical analysis of drug normalization in the Canadian context. Impending regulatory changes in Canadian drug policy are positioned to result in the implementation of a legal regulatory framework for recreational nonmedical cannabis use and commercial provision in 2018 (Task Force on Marijuana

Regulation and Legalization, 2016). As such, this chapter provides a crucial data point on cannabis use rates, acceptability attitudes, and accessibility during a period of criminal prohibition of nonmedical cannabis which will directly inform future comparative studies of the impacts of policy change on cannabis normalization .

Chapter Three - Gender Disparities in Cannabis Normalization among Undergraduate Students

In Chapter Three, I conduct thematic coding analysis of in-depth interviews and supplement this with data from the drug normalization survey in order to illustrate the salience of gendered norms and stigma with respect to cannabis use rates, accessibility, and acceptability attitudes of undergraduates. I also analyze how immigration differentiates cannabis normalization. The chapter concludes with consideration of how changing cannabis laws in

Canada are positioned to impact gendered cannabis use practices, and also the acceptability attitudes of immigrant students. International qualitative investigations on the relationship of gender and cannabis use are rare, and are all but absent in Canada. Given the high prevalence of cannabis use among young adults and the disproportionate impact of stigma on women who use illicit drugs, it is timely for a gender-focused analysis to be applied to an investigation of drug normalization in the Canadian context.

Chapter Four - Study Drugs "Don't Make You Smarter": Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students

In Chapter Four, I analyze a subset of 36 interviews with undergraduate students at U of

T to identify how they evaluate the acceptability of nonmedical use of prescription medications as study aids in the university context. This chapter critically engages with the drug normalization framework's foundational analytic opposition between problem versus recreational drug use by showing that nonmedical prescription drug use belongs to neither of these categories. In so doing, this chapter considers how the normalization framework should be expanded to include common drug use practices that are characterized by an achievement- oriented (in contrast to a recreational) evaluation of drug acceptability among students. This chapter represents the only qualitative contribution on nonmedical prescription drug use that includes the perspectives of both using and nonusing students. As such, it uniquely identifies social and contextual pressures among nonusers which result in their consideration of initiating nonmedical prescription drug use in the pursuit of scholastic success.

Chapter Five - Conclusion

In Chapter Five, I summarize key findings of the previous chapters and discuss the major implications of this project for drug normalization research and wider substance use scholarship.

I conclude with consideration of policy implications and suggestions for future research.

REFERENCES FOR CHAPTER ONE

Adlaf, E. M., Demers, A., and Gliksman, L. (2005). Canadian Campus Survey 2004. Toronto: Centre for Addiction and Mental Health. Retrieved from http://www.camh.net/research/population_life_course.html

Aldridge, J., Measham, F., and Williams, L. (2011). Illegal Leisure Revisited. London: Routledge.

American College Health Association. (2013). National College Health Assessment II: Canadian Reference Group Data Report. Hanover, MD: American College Health Association.

Becker, H. (1991). Outsiders: Studies in the Sociology of Deviance. New York: Free Press. (Original work published 1963).

Brochu, S., Duff, C., Asbridge, M., and Erickson, P. (2011). "There's What's on Paper and then There's What Happens, Out on the Sidewalk": Cannabis Users’ Knowledge and Opinions Of Canadian Drug Laws. Journal of Drug Issues, 41, 1, 95-115.

Duff, C. (2003). Drugs and Youth Cultures: Is Australia Experiencing the 'Normalization' of Adolescent Drug Use? Journal of Youth Studies, 6, 4, 433-46.

Duff, C. (2005). Party Drugs and Party People: Examining the 'Normalization' of Recreational Drug Use in Melbourne, Australia. International Journal of Drug Policy, 16, 161-70.

Duff, C., and Erickson, P. (2014). Cannabis, Risk and Normalisation: Evidence from a Canadian Study of Socially Integrated, Adult Cannabis Users. Health, Risk & Society, 16, 3, 210- 26.

Duff, C., Asbridge, M., Brochu, S., Cousineau, M., Hathaway, A., Marsh, D., and Erickson, P. (2012). A Canadian Perspective on Cannabis Normalization among Adults. Addiction Research & Theory, 20, 4, 271-83.

Hammersley, R. (2011). Developing a sociology of normal substance use. International Journal of Drug Policy, 22, 413-14.

Hathaway, A. (2004a). Cannabis Users’ Informal Rules For Managing Stigma and Risk. Deviant Behavior, 25, 559-77.

Hathaway, A. (2004b). Cannabis Careers Reconsidered: Transitions and Trajectories of Committed Longterm Users. Contemporary Drug Problems, 31, 401-23.

Hathaway, A., Comeau, N., and Erickson, P. (2011). Cannabis Normalization and Stigma: Contemporary Practices of Moral Regulation. Criminology & Criminal Justice, 11, 5, 451-69.

Jarvinen, M., and Demant, J. (2011). The Normalisation of Cannabis Use among Young People: Symbolic Boundary Work in Focus Groups. Health, Risk & Society, 13, 2, 165-82.

Kelly, B. C., Wells, B. E., Leclair, A., Tracy, D., Parsons, J. T., and Golub, S. A. (2013). Prescription Drug Misuse among Young Adults: Looking Across Youth Cultures. Drug & Alcohol Review, 32, 288-94.

Kirst, M., Kolar, K., Chaiton, M., Schwartz, R., Emerson, B., ... Thomas, G. (2015). A Common Public Health-Oriented Policy Framework for Cannabis, Alcohol and Tobacco In Canada? Canadian Journal of Public Health, 106, 8, e474-e476.

Kolar, K. (2015). Study Drugs "Don't Make You Smarter": Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students. Contemporary Drug Problems, 42, 4, 314-30.

Marshall, C., and Rossman, G. (2006). Designing Qualitative Research (fourth edition). Thousand Oaks: Sage Publications.

Measham, F. (2002). "Doing Gender"--"Doing Drugs": Conceptualizing the Gendering of Drugs Cultures. Contemporary Drug Problems, 29, 335-73.

Measham, F., and Shiner, M. (2009). The Legacy of ‘Normalisation’: The Role of Classical and Contemporary Criminological Theory in Understanding Young People's Drug Use. International Journal of Drug Policy, 20, 6, 502-8.

Parker, H., Measham, F., and Aldridge, J. (1995). Drugs Futures: Changing Patterns of Drug Use amongst English Youth. London: Institute for the Study of Drug Dependence.

Parker, H. (2005). Normalization as Barometer: Recreational Drug Use and the Consumption of Leisure by Young Britons. Addiction Research & Theory, 13, 3, 205-15.

Parker, H., Aldridge, J., and Measham, F. (1998). Illegal Leisure: the Normalization of Adolescent Drug Use. London: Routledge.

Pennay, A., and Moore, D. (2010). Exploring the Micro-Politics of Normalisation: Narratives of Pleasure, Self-Control and Desire on a Sample of Young Australian 'Party Drug' Users. Addiction Research & Theory, 18, 5, 557-71.

Rotermann, M., and Langlois, K. (2015). Prevalence and Correlates of Marijuana Use in Canada, 2012. Health Reports, 26, 4, 10-15.

Sandberg, S. (2012a). Is Cannabis Use Normalized, Celebrated, or Neutralized? Analysing Talk as Action. Addiction Research & Theory, 20, 5, 372-81.

Sandberg, S. (2012b). Cannabis Culture: A Stable Subculture in a Changing World. Criminology & Criminal Justice, 13, 1, 63-79.

Shildrick, T. (2002). Young People, Illicit Drug Use and the Question of Normalization. Journal of Youth Studies, 5, 1, 35-48.

Shiner, M., and Newburn, T. (1997). Definitely, Maybe Not? The Normalisation of Recreational Drug Use amongst Young People. Sociology, 31, 3, 511-39.

Task Force on Marijuana Regulation and Legalization. (2016). Toward the Legalization, Regulation and Restriction of Access to Marijuana. Discussion Paper. Ottawa: Government of Canada. Retrieved from http://healthycanadians.gc.ca/health-system- systeme-sante/consultations/legalization-marijuana-legalisation/document-eng.php

Williams, L., and Parker, H. (2001). Alcohol, Cannabis, Ecstasy and Cocaine: Drugs of Reasoned Choice amongst Young Adult Recreational Drug Users in England. International Journal of Drug Policy, 12, 397-413.

CHAPTER TWO - Differentiating The Drug Normalization Framework: A Quantitative Assessment Of Cannabis Use Patterns, Accessibility, and Acceptability Attitudes Among University Undergraduates

ABSTRACT

Background/Objectives: The drug normalization framework investigates the social integration of substance use. This chapter contributes a quantitative assessment of cannabis normalization as differentiated by social location predictors.

Methods: Logistic and zero-inflated negative binomial regression models assess three areas of cannabis normalization: accessibility, acceptability, and recent use. Peer network cannabis use prevalence, gender, nativity, campus locale and living arrangement are explored as focal predictors of variation in normalization among 1,713 cannabis using and non-using undergraduate students in Canada.

Results: Women report lower odds of positive cannabis acceptability attitudes. While women report lower rates of recent cannabis use, gender is not a significant predictor for lifetime prevalence. Being a recent immigrant significantly predicts lower recent use, lower odds of favorable attitudes to cannabis, and reduced accessibility in comparison to students born in

Canada. Longer-term immigrants do not show significant differences from students born in

Canada on accessibility and acceptability, suggesting a substance use acculturation effect. Lower peer cannabis use prevalence exhibits a protective effect against use. In comparison to students who report that "some" of their peer network uses cannabis, those with "all" users in their network exhibit lower acceptability attitudes. This suggests a threshold relationship between peer use prevalence and acceptability.

Conclusions/Importance: This chapter provides a data point for assessing future shifts in cannabis normalization prior to impending changes in Canadian drug policy that will legalize

28 recreational cannabis use. Results show that normalization components of recent use, acceptability, and accessibility are differentiated by gender, nativity, and peer network cannabis use prevalence.

INTRODUCTION

Since its development over twenty years ago, the drug normalization framework has evolved into a multifaceted conceptual and methodological toolkit for assessing shifts in recreational substance use trends, particularly in relation to social contexts of drug acceptability

(Erickson & Hathaway, 2010; Parker, 2005; Parker et al., 1998; Aldridge et al., 2011; Sznitman

& Taubman, 2016). Normalization researchers argue the widespread availability and acceptability of drugs (and especially cannabis) among "socially conventional" young people indicates that navigation of recreational substance use has become an increasingly common aspect of life for drug users and their non-using peers (Duff et al., 2012; Aldridge et al., 2011;

Measham & Shiner, 2009). Early normalization research has since been critiqued for its homogeneous representation of recreational drug use across the young adult population (Parker et al., 1998; Shildrick, 2002; Measham et al., 2011; Sznitman & Taubman, 2016). Because normalization research identified social location1 as no longer being protective from lifetime drug involvement, it neglected to explore how social location nevertheless continues to inform the meanings and practices of contemporary drug use (Shildrick, 2002; Measham et al., 2011).

This chapter responds to calls for "differentiating" the normalization framework by quantitatively assessing how cannabis acceptability, accessibility and recent use rates among undergraduate students in Canada are impacted by social and contextual factors including gender, nativity, peer network cannabis use prevalence, campus locale and living arrangement (Shildrick, 2002;

Measham & Shiner, 2009; Aldridge et al., 2011; Measham et al., 2011; Hamilton et al., 2009;

2012; Li-Yin et al., 2002; Adlaf et al., 2003; 2005). This chapter also provides an invaluable data point on cannabis normalization prior to impending changes to drug policy in Canada which will

1 Social location structures individual access to particular opportunities and groups, and exposes individuals to specific risks at an aggregate level. Examples of social location factors include gender, race/ethnicity, and income. 30 legalize nonmedical cannabis possession and create a regulatory framework for nonmedical cannabis production, distribution and sales (Kirst et al., 2015; Task Force on Marijuana

Legalization and Regulation, 2016).2 These national drug policy changes are estimated to be implemented in 2018 (Task Force on Marijuana Legalization and Regulation, 2016). The analyses herein are essential for informing future comparative research on cannabis use, accessibility and acceptability in a new drug policy era.

The Drug Normalization Framework:

The drug normalization framework is typically characterized by seven components:

(1) Drug Trying: lifetime drug use prevalence.

(2) Drugs Availability and Accessibility: experience of drug offer or access situations among users and non-users.

(3) Recent and Regular Drug Use: rates of use beyond lifetime prevalence.

(4) Being "Drugwise": expansion of drug-related experiences and knowledge among users and non-users.

(5) Social Accommodation: recreational drug use as an integrated or tolerated part of everyday social scenarios among users and non-users. This particularly important measure of normalization is also known as "drug acceptability" (Parker, 2005, p.207).

(6) Cultural Accommodation: mainstream media representations of drug use and attitudes towards drugs in the general population.

(7) Drug Policy and Global Processes: macro-level considerations of how drug policy and globalization impact substance use and accessibility (Aldridge et al., 2011; Duff et al., 2012;

Hathaway et al., 2011; 2016; Parker, 2005; Sznitman & Taubman, 2016).

2 Regulations allowing access to cannabis for medical reasons were introduced in Canada in 2001 (Health Canada, 2016). Cannabis possession without a medical document provided by an authorized health care practitioner remained illegal. 31

Normalization research maintains an investigative focus on recreational drug use and its social integration among "mainstream" populations. As such, this framework breaks from substance use theories limited to examining subcultures of heavy illicit drug use or addiction, as well as from those which approach drug use as a fundamentally pathological or deviant behavior

(Aldridge et al., 2011; Hammersley, 2011; Sznitman & Taubman, 2016). Deviance or addiction- focused approaches cannot explain why the vast majority of drug use does not result in addiction, crime, progression from "soft" drugs like cannabis to "hard" drugs like heroin, or other problematic outcomes (Erickson, 2015; Hammersley, 2011; Sznitman & Taubman, 2016).

Differentiating Drug Normalization:

Although early normalization studies illustrated the decreasing importance of indicators of inequality for explaining lifetime drug prevalence, research on recreational drug use has since shown that use rates and drug acceptability continue to be shaped by social location (Parker et al., 1998; Shildrick, 2002; Measham et al., 2011; Sznitman & Taubman, 2016). Shildrick (2002) proposes that "differentiated normalization" (2002, p.36) is a more fitting concept for understanding contemporary drug use because it focuses on the various ways that drugs may be normalized for different groups. Critics and normalization proponents have come to a point of agreement that drug normalization should be recognized as "a contingent process negotiated by distinct social groups operating in bounded situations" (Measham & Shiner, 2009, p.502). In turn, more nuanced normalization research has emerged which investigates, for example, the context and meanings of recreational drug use among clubbers in Australia (Duff, 2003; 2005), the role of gender and lifecourse transitions in women's drug use (Measham et al., 2011), and how young people regulate their recreational drug use in response to enduring stigmas attached to illicit drugs (Pennay & Moore, 2010).

Existing survey research tends to focus on lifetime prevalence or use rates while neglecting other important facets of normalization such as drug acceptability and accessibility

(Sznitman & Taubman, 2016). Further, survey research has not explored drug normalization as a differentiated phenomenon. In the Canadian context, there is a total absence of multivariate statistical analyses of normalization, and existing survey data is inadequate for addressing this gap due to lack of questions pertaining to drug normalization (e.g., Canadian Tobacco, Alcohol and Drugs Survey (Statistics Canada, 2016b); National College Health Assessment Survey

(American College Health Association, 2013)). This chapter seeks to address these gaps in the normalization literature.

University undergraduate students are the focus of inquiry as the current generation of cannabis users in the "conventional" young adult population. In Canada, 16% of postsecondary students have used cannabis in the past 30 days, and 45% of Canadians ages 15 years or older have tried cannabis (American College Health Association, 2013; Rotermann & Langlois, 2015;

Statistics Canada, 2017). This pattern appears to have changed little in the previous decade and may indicate stabilization of student cannabis use practices (Adlaf et al., 2005). At the time of the study in 2011-2012, cannabis possession was and continues to be prohibited under a criminal law framework in Canada, with the exception of those who have medical marijuana licenses

(Kirst et al., 2015). Drug normalization literature and research on cannabis was reviewed to identify potentially important covariates. This analysis investigates gender, nativity, peer network cannabis use prevalence, campus locale, and student living arrangement as focal explanatory variables for cannabis normalization components of acceptability, accessibility and recent use rates:

Gender: Although the gender gap in lifetime prevalence is closing for alcohol, tobacco, and some illicit drugs, women continue to experience more severe stigma for substance use (Aldridge et al., 2011; Ahmad et al., 2008; Ettorre, 2004; Measham, 2002). Thus normalization processes are likely to remain gendered.

Nativity: Research suggests that as immigrants experience increased acculturation, they adopt the norms and behaviours of the mainstream social reference group of their new country (Bui, 2013).

These findings hold for risk behaviours such as illicit drug use (Almeida et al., 2012; Bui, 2013).

In comparison to those born in Canada, immigrants are far less likely to engage in substance use, but this difference decreases generationally and over time for first-generation immigrants

(Hamilton et al., 2009; Hamilton et al., 2012; Li-Yin et al., 2002). Due to lack of research addressing substance use among students who are immigrants, it is unclear to what extent this pattern of substance use acculturation applies, particularly among students who are recent immigrants (i.e., those who have lived in Canada for 4 years or less).

Campus Locale: Whether a campus is located in an urban, suburban or rural area may influence normalization. A survey of Canadian youth and young adults found that those in non-rural areas were 1.7 times more likely to be current cannabis users (Health Canada, 2007). Yet this survey found no significant difference in attitudes regarding dangerousness of cannabis between those living in rural and non-rural locations (Health Canada, 2006). Research from the United States suggests that drug use among rural youth is on the rise (Martino et al., 2008).

Living Arrangement: Among university students in Canada, living on campus is associated with higher odds of cannabis use than living off-campus without family (Adlaf et al., 2003; 2005).

Odds of use are lowest for those who live off-campus with family members; these students are nearly 2 times less likely to use cannabis than those living on campus (Adlaf et al., 2003; 2005).

This research suggests that living independently from family may facilitate access and positive attitudes towards cannabis.

Peer Network Cannabis Use: Central to the normalization framework is investigation of the social accommodation of recreational drug use into conventional activities, such as using 'dance drugs' at parties, or using cannabis to socialize with friends (Duff 2005; Duff et al., 2012;

Hathaway et al., 2011). Cannabis use in one's peer network provides an interactional entry point for students to witness drug effects; be exposed to acceptability norms regarding ways of ingesting cannabis, how often cannabis is used and when such use is appropriate; and gain knowledge on accessing cannabis in a black market.

METHODS

(a) Data Collection and Sampling

To assess cannabis normalization among a diverse sample of undergraduates in Canada, a self-administered web-based drug use and attitude survey was implemented from November

2011 through March 2012 (N=1,757). The questionnaire was adapted from Parker and colleagues' (1998) study of drug normalization among British youth, and from past studies on cannabis use (blinded references). Students were given a website link to access the survey.

Participation was voluntary. A bonus of 2% was added to student’s course grade as incentive for participating. Students took approximately 30 minutes to complete the survey. Students were sampled from three university campuses:

1) University of Toronto (St. George Campus) is a large public research university located in

Toronto, Canada's largest city. Undergraduates were sampled from a first-year sociology class with 1,393 students enrolled at time of study implementation. The survey response rate was 88%

(n=1,227).

2) University of Guelph is a mid-size public research university located in Guelph, a municipality in Ontario with a population of 120,000. Undergraduates were sampled from a first-year class in criminology provided by the sociology department, with 546 students enrolled at time of implementation. The survey response rate was 73% (n=396).

3) University of Alberta (Augustana Campus) is located in Camrose, Alberta, a rural area with

17,000 residents. Due to small class sizes, several classes in sociology and criminology were sampled. A total of 215 students were enrolled in these classes at time of implementation, with a survey response rate of 62% (n=134).

Researchers employed a convenience sampling strategy aimed at accessing a broad cross- section of undergraduates. The sampled classes were selected because they are taken as popular electives by students enrolled in a variety of majors in the Arts and Sciences, and who are at different levels of program completion. Ethical concerns in this study pertain to the illegality of cannabis and other drugs in Canada. Students were encouraged to complete questionnaires where privacy could be protected. Informed consent was gathered at the beginning of the survey. Ethics approval for this project was received from the research ethics boards at U of T, U of G, and U of

(b) Outcome Variables

These three outcome variables correspond to the three statistical models below which assess different components of drug normalization:

1. Recent Cannabis Use Frequency is a continuous variable. All participants were asked to report the number of days they had used cannabis "in the previous month".

2. Cannabis Acceptability is assessed using a dichotomous variable asking participants if they

"do not have a problem with other people using cannabis" or they "do not think people should use cannabis".

3. Cannabis Accessibility: Only students who have ever used cannabis (n=797) were asked whether they could access cannabis "at the moment". This measure is coded as "Yes" or

"No/Unsure".3

1. Proportion of Cannabis Abstainers in Peer Network: To assess extent of cannabis use prevalence in a student's peer network, participants were asked to report the "proportion of students you hang around with who abstain from using cannabis". Responses are coded on a 4- item scale: "None of them", "Up to half of them", "Most of them", or "All of them".

2. Gender: Although biological sex is an inadequate measure for assessing gendered experience, it is the only survey variable available for this. Use of sex as a proxy for gender is common in survey research on drug use. Due to the low number of students who self-identified as transgender (n=5), this group is not included in the analysis.

3. Nativity: To assess substance use acculturation, the nativity measure distinguishes between being "Born in Canada", a "Recent Immigrant" (i.e., immigrated in previous 4 years), and a

"Longer-term Immigrant" (i.e., living in Canada for 5+ years).

4. Campus Locale: U of T is coded as an "urban" campus, U of G as "suburban", and U of A as

"rural".

3 This survey item may face limitations because it could be interpreted by students as referring to the location where they are completing the survey, rather than reflect ability to access cannabis generally. This survey has been successfully piloted at the University of Guelph prior to full implementation. We have found that the accessibility item accurately reflects student ability to access cannabis, as most students report accessing cannabis by contacting friends or dealers using phone calls, email or text messaging, which is not limiting to immediate location. 37

5. Living Arrangement is coded as living in "off-campus housing" (but not with parents or family); "with parents or family" (off-campus); or in "student residence".

6. Other important controls identified in the substance use literature include race/ethnicity (5 categories: White; East Asian; South Asian; Black; Other), age (3 categories: 16-18; 19-21;

22+), Alcohol Use in Previous Month (No/Yes), Tobacco Use in Previous Month (No/Yes), and

Other Illicit Drug Use, Lifetime (No/Yes. This category excludes cannabis) (e.g., Rotermann &

Langlois, 2015; Barry et al., 2016; McCabe et al., 2007).

(d) Analyses

Problematic cannabis use is likely limited to a small minority of students in this sample as only 10-20% of those who use cannabis on a daily basis are estimated to develop a use disorder (Borgelt et al., 2013). Students who may have a cannabis use disorder are excluded from the inferential analyses as these models are intended to explain attitudes and patterns of recreational, non-problem cannabis use. These models are thus inadequate for explaining substance use disorders. A problem cannabis use indicator was developed using survey measures that reflect recent literature on distinguishing between recreational and potentially problematic cannabis use patterns (e.g., recent use frequency; use having a harmful effect on health or personal relationships; strong urges to use, etc.) (Asbridge et al., 2014; Gordon et al., 2013;

American Psychiatric Association, 2013). Using this indicator, 39 cases (2.2%) were excluded from the original sample of N=1,757.

To quantitatively explore drug normalization as a differentiated process among undergraduates, this chapter includes three sets of analyses conducted using STATA 14.2 software (StataCorp, 2015). Missing values were retained in all models. Cannabis acceptability and accessibility are modeled using logistic regression. Recent use (i.e., number of days cannabis

38 was used in the previous month) is modeled using zero-inflated negative binomial regression

[ZINB] for event count data. Focal predictors for these models include gender, nativity, student living arrangement, campus locale and prevalence of peer network cannabis use. Control variables include age, race/ethnicity, and other substance use for all models. The cannabis accessibility logistic regression model includes recent cannabis use as a two-part control variable. As recommended by Hosmer and colleagues (2013, p.107), count covariates with a high frequency of zero values and right skewness should be included in logistic regression models as two terms: one dichotomous zero/nonzero indicator (i.e., whether cannabis was used in the previous month), and one indicator for the actual recorded value (i.e., number of days cannabis was used in the previous month). The cannabis acceptability logistic regression model includes lifetime cannabis use as a control variable. All models were assessed using collinearity and goodness of fit tests and examination of residuals (Menard, 2010; Homser et al., 2013; Long

& Freese, 2014; DeMaris, 2004).

Although cannabis use is prevalent among undergraduates, a ZINB model was selected for modeling recent cannabis use frequency because a large proportion of students have either never tried cannabis or do not currently use it, resulting in a non-normal distribution with a high number of zero values. ZINB models can be used to analyze count data with excess zeros and overdispersion (Long & Freese, 2014). ZINB models assume that zeros arise from two sources.

'Structural zeros' come from a population not 'at risk' for the event of interest, here being cannabis use in the previous month, because they identify as cannabis non-users. 'Sampling zeros' come from a population which is 'at risk' for this event, but people with zero counts in this group simply did not engage in cannabis use in the past month due to "the stochastic nature of the event process" (DeMaris, 2004, p.370; Simons et al., 2006; Bandyopadhyay et al., 2011). In

39 other words, an individual in the sampling zero group might have a zero count, but there is a nonzero probability that she has a positive count (Long & Freese, 2014). In zero-inflated models, structural zeros are generated by a binary component modeling 0's (usually a logit model), whereas sampling zeros are generated in a count component (i.e., negative binomial regression for ZINB) (Hilbe, 2014).

RESULTS

(a) Descriptive Statistics

Half of the sample (n=916) had never used cannabis at the time of this study, and 23.2%

(n=397) of those who had ever used cannabis did not do so in the previous month. Of the 23.2%

(n=397) who used at least one day in the previous month, the mean number of days used was 7.4

(SD 8.9). Only students who had ever used cannabis (n=797) were asked about their ability to access it at the moment; a majority (n=631; 79.3%) indicated that cannabis was readily accessible. Most students indicated cannabis use was an acceptable behavior (n=1,163; 67.9%).

Only 14.8% (n=254) of students reported having a peer network (i.e., "students you hang out with") which entirely abstains from cannabis.

Table 1. Descriptive Statistics (N = 1,713) n (%) n (%) Cannabis Use Gender Never used cannabis 916 (53.5) Female 1,161 (67.8) Used, but not in previous month 397 (23.2) Male 526 (30.7) Used 1+ days in previous month 397 (23.2) Nativity Mean (SD) days used in previous month† 7.4 (8.9) Born in Canada 1,166 (68.1) Cannabis Acceptability Recent Immigrant 163 (9.5) I do not have a problem with other 1,163 (67.9) Longer-Term 349 (20.4) people using cannabis Immigrant I do not think people should use cannabis 541 (31.6) Race/Ethnicity Is cannabis accessible to you at the (users only: White 874 (51.0) moment? n=796) East Asian 354 (20.7) No/Unsure 163 (20.5) South Asian 134 (7.8) Yes 631 (79.3) Black 80 (4.7) Proportion of Cannabis Abstainers in Other 241 (14.1) Peer Network Living Arrangement None of them 111 (6.5) Off-Campus Housing 365 (21.3) Up to half of them 781 (45.6) With Parents/Family 630 (36.8) Most of them 555 (32.4) Student Residence 689 (40.2) All of them 254 (14.8) Campus Locale Alcohol Use U of T (Urban) 1,199 (70.0) Never used alcohol 194 (11.3) U of G (Suburban) 382 (22.3) Used, but not in previous month 261 (15.2) U of A (Rural) 132 (7.7) Used 1+ days in previous month 1257 (73.4) Year of Study Mean (SD) days used in previous month† 5.2 (4.4) 1st Year 1,318 (76.9) Tobacco Use 2nd Year + 368 (21.5) Never used tobacco 990 (57.8) Age Used, but not in previous month 355 (20.7) 16-18 984 (57.4) Used 1+ days in previous month 367 (21.4) 19-21 523 (30.5) Mean (SD) days used in previous month† 11.4 (11.7) 22+ 180 (10.5) Other Illicit Drug Use, Lifetime‡ 230 (13.4) Notes: n=44 cases are excluded from the overall sample (N=1,757) for this study (n=39 excluded for problematic cannabis use; n=5 transgender participants excluded, as this group was too small to retain in analysis of gender effects). Percentages that do not add to 100 are due to presence of missing values. † Of those who used 1+ days in the previous month ‡ Illicit drug use excluding cannabis (e.g., cocaine, MDMA, etc.)

(b) Recent Cannabis Use Frequency - ZINB Model

AIC and BIC values were compared to assess fit for modeling cannabis use frequency using Poisson, negative binomial, zero-inflated Poisson, and ZINB regression models, with best fit produced by ZINB (Long & Freese, 2014). As shown in Table 2, the count component of the

ZINB model (i.e., 'sampling zero' group) indicates that being female (b= -0.84, p<0.001), a recent immigrant (b= -0.71, p<0.05), a longer-term immigrant (b=-0.45, p<0.05), and having a peer network of "all cannabis abstainers" (b= -1.29, p<0.01) is significantly associated with lower recent cannabis use frequency among expected users. Recent tobacco use and lifetime illicit drug use are significantly associated with higher recent cannabis use frequency among expected users (p<0.01). In the binomial component of the model (i.e., 'structural zero' group), having "most" or "all" abstainers in one's peer network significantly predicts being a non-user

(p<0.01). Abstaining from other substances, including alcohol, tobacco, or illicit drugs, was predicted to be protective against cannabis use (p<0.001).

Table 2. Zero-Inflated Negative Binomial Model predicting Cannabis Use in the previous month

Recent Cannabis Use Frequency Predicted Nonusers of Cannabis (Negative Binomial Model) (Logit Model) Variables b (Robust SE) [95% CI] z b (Robust SE) [95% CI] z Proportion of Cannabis ------Abstainers in Peer Network: None of them Up to half of them -0.38 (0.26) [-0.90, 0.13] -1.46 -0.50 (0.39) [-1.27, 0.27] -1.28 Most of them -0.34 (0.36) [-1.05, 0.37] -0.94 1.13** (0.42) [0.30, 1.95] 2.67 All of them -1.29**(0.52) [-2.31, -0.27] -2.49 2.78*** (0.75) [1.30, 4.26] 3.69 Female -0.84*** [-1.14, -0.55] -5.64 0.33 (0.25) [-0.17, 0.83] 1.31 (0.15) Nativity: Canada-born ------Recent Immigrant -0.71* (0.36) [-1.41, -0.01] -2.00 0.23 (0.60) [-0.95, 1.41] 0.39 Longer-term Immigrant -0.45* (0.23) [-0.91, -0.01] -1.97 -0.01 (0.38) [-0.75, 0.74] -0.01 Campus Locale: U of T ------(Urban) U of G (Suburban) 0.32 (0.20) [-0.07, 0.7] 1.61 -0.41 (0.32) [-1.05, 0.22] -1.28 U of A (Rural) -0.65 (0.37) [-1.38, 0.08] -1.75 -0.19 (0.76) [-1.68, 1.29] -0.25 Living Arrangement: ------Off-Campus With Parents/Family 0.16 (0.26) [-0.34, 0.66] 0.61 0.29 (0.37) [-0.44, 1.03] 0.78 Student Residence -0.17 (0.23) [-0.62, 0.28] -0.75 -0.43 (0.40) [-1.21, 0.36] -1.06 Age: 16-18 ------19-21 -0.32 (0.18) [-0.68, 0.04] -1.72 0.12 (0.31) [-0.49, 0.74] 0.40 22+ 0.26 (0.28) [-0.28, 0.81] 0.94 0.15 (0.40) [-0.63, 0.94] 0.38 Race/Ethnicity: White ------East Asian -0.22 (0.32) [-0.85, 0.43] -0.68 0.51 (0.37) [-0.22, 1.24] 1.36 South Asian -0.04 (0.39) [-0.80, 0.72] -0.10 -0.69 (0.77) [-2.20, 0.81] -0.90 Black 0.12 (0.45) [-0.76, 1.00] 0.27 0.28 (0.67) [-1.04, 1.59] 0.41 Other 0.27 (0.21) [-0.14, 0.69] 1.29 -0.12 (0.36) [-0.83, 0.59] -0.33 Alcohol Use in Previous -0.60 (0.32) [-1.24, 0.03] -1.86 -2.02***(0.40) [-2.81, -1.24] -5.05 Month Tobacco Use in Previous 0.40** (0.16) [0.09, 0.71] 2.51 -1.57***(0.37) [-2.30, -0.84] -4.20 Month Other Illicit Drug Use, 0.83*** (0.15) [0.53, 1.13] 5.46 -1.80***(0.41) [-2.60, -1.00] -4.40 Lifetime† Notes: N=1,656; χ2(19)=152.15,* p<0.05, **p<0.01, ***p<0.001 † Illicit drug use excluding cannabis (e.g., cocaine, MDMA, etc.)

Table 3 shows results for the fully adjusted logistic regression model of cannabis acceptability. Ever having used cannabis is significantly associated with 4 times the odds of "not

43 having a problem" with other people using cannabis, in comparison to students who have never used cannabis (p<0.001). Interestingly, students with "up to half" of their peer network abstaining from cannabis have over 4 times the odds (p<0.001), and those with "most" of their peer network comprised of abstainers have twice the odds of having a favorable attitude toward cannabis in comparison to students who do not have any abstainers in their network (p<0.01).4

This interesting finding may suggest the existence of a threshold effect to drug normalization, as perceived peer network cannabis saturation (i.e., "no cannabis abstainers") is associated with more restrictive attitudes toward cannabis acceptability.

Women had lower odds of favorable attitudes in comparison to men (OR=0.66, p<0.01).

Recent immigrants had half the odds of favorable attitudes in comparison to students born in

Canada (OR=0.47, p<0.001), whereas longer-term immigrants did not exhibit significantly different attitudes from those born in Canada. This suggests a substance use acculturation effect is at play in cannabis normalization. Only South Asian students had significantly higher odds of favorable acceptability attitudes in comparison to white students (OR=2.16, p<0.01). Recent alcohol use was significantly associated with nearly twice the odds of cannabis acceptability

(p<0.001).

4 Diagnostic tests were run on all models to ensure that they are appropriately specified, including tests for multicollinearity. As such, I am confident that the results on the relationship of cannabis acceptability to perceived peer network cannabis use prevalence are not an outcome of collinearity issues between independent variables. 44

Table 3. Logistic Regression Model predicting Cannabis Acceptability Variables OR (SE) [95% CI] z Cannabis Use, Lifetime 4.05*** (0.68) [2.92, 5.61] 8.38 Proportion of Cannabis Abstainers - - - in Peer Network: None of them Up to half of them 4.78*** (1.22) [2.90, 7.87] 6.15 Most of them 2.00** (0.50) [1.23, 3.26] 2.80 All of them 0.68 (0.19) [0.39, 1.16] -1.41 Female 0.66** (0.09) [0.49, 0.89] -2.78 Nativity: Canada-born - - - Recent Immigrant 0.47*** (0.11) [0.29, 0.74] -3.19 Longer-term Immigrant 0.89 (0.16) [0.63, 1.26] -0.66 Campus Locale: U of T (Urban) - - - U of G (Suburban) 1.12 (0.23) [0.75, 1.67] 0.55 U of A (Rural) 0.90 (0.25) [0.53, 1.55] -0.36 Living Arrangement: Off-Campus - - - With Parents/Family 0.95 (0.18) [0.65, 1.39] -0.26 Student Residence 1.16 (0.23) [0.78, 1.71] 0.72 Age: 16-18 - - - 19-21 0.92 (0.14) [0.68, 1.24] -0.55 22+ 0.82 (0.21) [0.49, 1.36] -0.77 Race/Ethnicity: White - - - East Asian 1.25 (0.24) [0.85, 1.83] 1.13 South Asian 2.16** (0.56) [1.30, 3.59] 2.96 Black 1.01 (0.32) [0.54, 1.90] 0.04 Other 1.12 (0.23) [0.74, 1.67] 0.53 Alcohol Use, Previous Month 1.92***(0.29) [1.43, 2.60] 4.34 Tobacco Use, Previous Month 1.17 (0.24) [0.79, 1.74] 0.76 Other Illicit Drug Use, Lifetime† 1.56 (0.45) [0.89, 2.75] 1.55 Notes: N=1,657; χ2(20)=547.20, Pseudo R2=0.2662. * p<0.05, **p<0.01, ***p<0.001 † Illicit drug use excluding cannabis (e.g., cocaine, MDMA, etc.)

(d) Cannabis Accessibility - Logistic Regression Model

Table 4 provides results of the fully adjusted logistic regression model of cannabis accessibility. Estimation of this model includes students who reported ever having used cannabis, as only these students were asked about accessibility in the survey (n=794). Students who had used cannabis in the previous month had over twice the odds of reporting they could access cannabis (p<0.05). For every day increase of cannabis use in the previous month, the odds of having access to cannabis increases by a further 1.23 times (p<0.05). Recent immigrants have

45 significantly lower odds of access to cannabis in comparison to Canada-born students (OR=0.17, p<0.001). In comparison to students who are 18 years old or younger, those who are 22+ years old have lower odds of cannabis accessibility (OR=0.18, p<0.001). Other lifetime illicit drug use is associated with nearly twice the odds of accessibility (p<0.05); this finding may reflect the association of cannabis and other illicit drug markets that occurs under a criminal prohibition framework of cannabis (Erickson & Hathaway, 2010).

Table 4. Logistic Regression Model predicting Cannabis Accessibility (n=794 cannabis users) Variables OR (SE) [95% CI] z Used Cannabis in Previous Month 2.28* (0.77) [1.17, 4.43] 2.44 Frequency of Cannabis Use in 1.23* (0.12) [1.02, 1.48] 2.18 Previous Month (days) Proportion of Cannabis Abstainers - - - in Peer Network: None of them Up to half of them 1.29 (0.68) [0.45, 3.64] 0.47 Most of them 0.43 (0.23) [0.15, 1.24] -1.55 All of them 0.27 (0.21) [0.06, 1.21] -1.71 Female 0.91 (0.21) [0.57, 1.44] -0.40 Nativity: Canada-born - - - Recent Immigrant 0.17*** (0.09) [0.07, 0.46] -3.56 Longer-term Immigrant 0.83 (0.26) [0.45, 1.54] -0.58 Campus Locale: U of T (Urban) - - - U of G (Suburban) 0.76 (0.23) [0.42, 1.38] -0.90 U of A (Rural) 0.56 (0.23) [0.25, 1.26] -1.39 Living Arrangement: Off-Campus - - - With Parents/Family 0.83 (0.28) [0.43, 1.61] -0.56 Student Residence 0.57 (0.20) [0.28, 1.13] -1.61 Age: 16-18 - - - 19-21 0.70 (0.17) [0.44, 1.13] -1.45 22+ 0.18*** (0.07) [0.09, 0.41] -4.21 Race/Ethnicity: White - - - East Asian 0.66 (0.23) [0.33, 1.30] -1.21 South Asian 0.99 (0.54) [0.34, 2.90] -0.02 Black 0.84 (0.45) [0.30, 2.38] -0.33 Other 1.01 (0.31) [0.55, 1.86] 0.03 Alcohol Use, Previous Month 1.76 (0.61) [0.89, 3.49] 1.61 Tobacco Use, Previous Month 1.23 (0.33) [0.73, 2.07] 0.77 Other Illicit Drug Use, Lifetime† 2.01* (0.64) [1.08, 3.74] 2.19 Notes: N=765; χ2(21)=185.26, Pseudo R2=0.2420. * p<0.05, **p<0.01, ***p<0.001 † Illicit drug use excluding cannabis (e.g., cocaine, MDMA, etc.)

DISCUSSION

This study addresses research gaps in quantitative examinations of cannabis normalization, specifically with regard to use rates, acceptability and accessibility. This study contributes insight into how normalization may be differentiated by social and contextual factors, including gender, nativity, locale, peer network cannabis use prevalence, and living arrangement.

Unlike any previous studies on normalization, this study examines the relationship between nativity and cannabis acceptability and accessibility, and contributes the only multivariate assessment of cannabis normalization in the Canadian context (see Sznitman & Taubman, 2016,

Supplemental Table A).

The results show that the normalization components of recent use, acceptability and accessibility are differentiated by social and contextual factors. For example, while women are less likely to report recent cannabis use, gender is not a significant predictor of lifetime cannabis prevalence (Table 2). Cannabis acceptability (Table 3) also indicates a gendered relationship, with women reporting lower odds of positive acceptability attitudes. These findings support research claims that gender continues to be important in differentiating cannabis use practices and norms, despite gender convergence in lifetime cannabis prevalence identified in early normalization research (Parker et al., 1998; Aldridge et al., 2011; Ahmad et al., 2008; Greaves &

Poole, 2007).

Although gender did not have a significant relationship to accessibility (Table 4), this finding should not be taken to mean that cannabis is accessible in identical ways to men and women. The measure of accessibility used here (i.e., whether a student feels they can access cannabis 'at the moment') does not allow for assessment of whether accessibility pathways are gendered. For example, literature suggests that women's initiation into drug use and access to

47 illicit drugs is more closely tied to their relationships with men, whereas men's use tends to be influenced by same-gender peers (Anderson, 2001; Mehta et al., 2014; Haines et al., 2009).

Being a recent immigrant significantly predicts lower odds of having a favorable attitude to cannabis and of finding cannabis accessible in comparison to students born in Canada.

Longer-term immigrants were not significantly different from students born in Canada across accessibility and acceptability components (Tables 3 & 4). Whereas being an immigrant significantly predicts lower recent use frequency overall, being a recent immigrant showed a larger effect in this regard (Table 2). Canada ranks among countries with the highest prevalence of lifetime and past-year cannabis use in the world, and so it should be expected that immigrants to Canada are generally exposed to more positive attitudes towards cannabis and greater accessibility in comparison to their countries of origin (Canadian Centre on Substance Use and

Addiction, 2017). These findings suggest that substance use acculturation is an important process to consider in the differentiation of cannabis normalization. It remains to be investigated how students who are recent immigrants navigate cannabis-related social pressures and potential family disapproval during their time in university in Canada, and what impacts this may have on their relationships and well-being in comparison to students who are longer-term immigrants and those who are born in Canada.

Despite suggestions in previous drug research that living with family and rural locale protect against cannabis use (Adlaf et al., 2005; Health Canada, 2007), the current study found that when other factors are controlled for, student living arrangement or attending university at suburban or rural campuses does not provide protection from cannabis use, nor do these predict less favorable acceptability attitudes or more restrictive accessibility.

The findings illustrate that student perceptions of cannabis use prevalence among their peer network is a significant contextual factor differentiating normalization. In comparison to students with no abstainers in their network, those with a majority or all of their peer network abstaining from cannabis were significantly more likely to be predicted non-users (Table 2, logit model). Lower perceived peer cannabis use prevalence thus illustrates a protective effect against use, as well as against higher rates of recent use. Interestingly, prevalence of peer network cannabis use was not associated with accessibility (Table 4). In contrast to research identifying social sources of supply (i.e., friends and acquaintances) as important in providing access to cannabis within a context of legal prohibition, these results suggest that among students who have used cannabis, peer network use prevalence does not have a significant relationship to accessibility when cannabis use in the previous month is controlled (Hathaway et al., 2018;

Belackova & Vaccaro, 2013). More recent users are likely to have reliable sources for supply beyond social sharing sources, and this may explain away effects of prevalence of peer network use on accessibility. However, social supply is likely to remain an important cannabis access point for infrequent users and non-users who have not established reliable supply networks

(Hathaway et al., 2018; Belackova & Vaccaro, 2013).

Perhaps most importantly, the results provide evidence for a threshold effect in cannabis normalization, where perceived cannabis use saturation of a peer network is associated with lower acceptability attitudes (Table 3). This finding challenges assumptions that drug use saturation in a peer network is a reliable indicator of drug acceptability attitudes. In other words, this finding provides empirical evidence illustrating that evaluations of drug acceptability can

(and should) be analyzed separately from those of drug use prevalence. Although the normalization framework provides the conceptual toolkit through which to separately analyze

49 acceptability and perceived network prevalence, normalization researchers have not yet documented or attempted to explain this threshold phenomenon among recreational substance users. It is possible that being in a peer network comprised entirely of cannabis users may result in uneasiness with 'over-integration' or 'over-normalization' of cannabis into everyday social life.

Being in such a network may be associated with higher exposure to problem cannabis users, or with feeling pressured to use cannabis more frequently as a social activity, to the neglect of other activities. Such questions on cannabis acceptability thresholds in peer networks cannot be resolved here, and so remain an important avenue for future normalization research.

The present study is not without limitations. The cross-sectional survey design does not allow for causal interpretations of findings, and restricts the generalizability of these findings.

While the findings are not generalizable to all undergraduates across Canada, they are useful for empirical advancement of normalization research and for developing understanding of cannabis use perceptions and experiences among users and non-users. Data was collected using self- reports and so may be inaccurate due to recall or respondent bias, despite implementation of measures to protect student confidentiality and anonymity to reduce bias. Our survey lacked a reliable measure of student socioeconomic status. Although random sampling represents the gold standard for collecting survey data, time and funding constraints did not allow for this. Instead, this survey utilized convenience sampling of classes in order to access a wide range of students attending undergraduate programs. Only students who had ever used cannabis were asked about accessibility due to errors in the survey skip pattern. Ideally, both users and non-users would have been asked about accessibility to more thoroughly assess this component of normalization.

CONCLUSION

This study contributes to research on use patterns and normalization processes among non-problem cannabis users (who account for the vast majority of all users), and provides an invaluable data point from 2011/2012 on cannabis normalization, prior to impending legal regulatory changes in Canadian drug policy in 2018 (Kirst et al., 2015; Rehm et al., 2017; Task

Force on Marijuana Regulation and Legalization, 2016). The models above show that normalization components are differentiated in a diverse manner: gender and nativity were found to have a significant relationship with particular aspects of normalization, but not uniformly across all components. The findings show it is important to break down nativity categories in order to capture substance use acculturation effects among recent versus longer-term immigrants.

Taken together, the results support ongoing calls for differentiated assessments of normalization beyond simple consideration of substance use prevalence, and illustrate the value of quantitative analyses for exploring relationships of social and contextual factors across specific components of the drug normalization framework.

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CHAPTER THREE - Gender Disparities in Cannabis Normalization among Undergraduate Students

ABSTRACT

Objectives: This chapter provides a mixed methods investigation of the relationship of cannabis normalization with gendered norms and stigma among undergraduate university students in

Canada during a period of criminal prohibition of cannabis. Immigration is also explored in order to illustrate the Canadian cultural character of student cannabis acceptability attitudes.

Methods: A doing gender approach is applied to 58 in-depth interviews with cannabis using and non-using undergraduate students in Canada. This qualitative analysis is supplemented by data from a survey of 1,713 undergraduates.

Results: Gendered differentiation of cannabis normalization is attributed to two main sources: the impact of gendered standards of self-control, and gendered barriers to women's participation as either buyers or dealers in the illicit cannabis market. The analysis shows that by drawing on presentations of scholastic success and conventional femininity, women may expand the perceived acceptability of women's cannabis use, in turn reducing the relevance of gender in assessing cannabis acceptability. Students born abroad, like those born in Canada, see accepting attitudes towards cannabis as a "Canadian thing" due to the relatively permissive social expectations in Canada in comparison to other countries of origin.

Conclusions/Importance: This chapter underscores the theoretical utility of Deutsch's (2007) focus on "undoing" gender to provide a novel contribution to the existing literature on cannabis use. Unlike other gender-focused investigations of cannabis, this chapter also engages with the drug normalization framework, a conceptual and methodological toolkit designed to assess changes in recreational drug use trends and norms. In addition, this chapter explores the role of

57 immigration in cannabis normalization, and concludes with consideration of how changing cannabis laws in Canada are positioned to impact gendered cannabis use practices and acceptability attitudes of immigrants.

INTRODUCTION

Approximately 45% of people 15 years of age or older have ever used cannabis in

Canada (Statistics Canada, 2017). Canadian survey data indicates that differences between men and women in lifetime cannabis use are no longer significant (Health Canada, 2007; Statistics

Canada, 2017; Rotermann & Langlois, 2015). Recent survey results show that gender differences in rates of past-year cannabis use have significantly narrowed: men's past-year cannabis use remained at approximately 15% from 2013 to 2015, and women's past-year use increased significantly from 7% to 10% over this period (Statistics Canada, 2017). Although qualitative research on cannabis use is sparse, the few existing studies that employ gender-focused analyses to investigate cannabis norms, practices and meanings indicate that gender remains highly salient in cannabis use (Haines et al., 2009; Dahl & Sandberg, 2015). This qualitative research references the prevalence of cannabis use, however it has not investigated how use rates may be structured by gendered cannabis practices. In order to bring together the insights of qualitative and quantitative research on cannabis use, this chapter provides a mixed methods investigation of the salience of gendered norms with respect to cannabis use rates, accessibility, and acceptability attitudes of undergraduate students in Canada during a period of criminal prohibition of cannabis. A doing gender approach (Deutsch, 2007) is applied to 58 in-depth interviews with cannabis using and non-using undergraduate students, which is supplemented by data from a survey of 1,713 undergraduates. This chapter goes beyond existing doing gender treatments of cannabis use by taking up Deutsch's (2007) challenge to identify instances where gender differences are disrupted or approach irrelevance, and so may become undone. This chapter also explores how immigration informs cannabis practices and attitudes of undergraduate students, and so avoids the tendency of doing gender analyses of drug use to ignore other social relations of inequality. In addition, unlike other gender-focused studies of cannabis this chapter engages

59 with the drug normalization framework, a conceptual and methodological toolkit designed to assess changes in recreational drug use trends and norms (Hathaway et al., 2016; 2018; Kolar,

2015; Parker, 2005; Parker et al., 1998; Aldridge et al., 2011; Sznitman &Taubman, 2016).

Canada is currently in the process of legalizing non-medical cannabis, with a legal regulatory framework for recreational possession, use, and supply expected to be in place in

2018 (Task Force on Marijuana Legalization & Regulation, 2016). These regulatory changes represent a seismic shift away from the punitive anti-drug "Just Say No" policies of the 1980's, and more recently, of the Prime Minister Harper government from 2006-2015, and towards public health-oriented approaches to drug policy which recognize the extensive harms caused by cannabis criminalization to individuals and communities (Kirst et al., 2016; Erickson, 2015).

These impending regulatory changes are positioned to fundamentally restructure cannabis accessibility and the social consequences of use, and indicate that cannabis is entering a new era of "drug normalization" (Hathaway et al., 2018).

The drug normalization framework is designed to investigate recreational drug use trends as well as shifts in what constitutes normative drug behaviour (Parker et al., 2008; Sznitman &

Taubman, 2016).5 As a novel approach to substance use research, this framework was central to

(1) counteracting the prevailing tendency in research to position drug use as a primarily male problem or activity, and (2) identifying the growing gendered convergence in lifetime drug use rates (Parker et al., 1998; Aldridge et al., 2011; Measham et al., 2011; Hunt et al., 2015). Parker and colleagues (1998) interpreted this convergence as a strong indication that gender was on its way to becoming irrelevant to explaining drug use patterns. Thus despite gaining popularity as a conceptual framework in the 1990s, it was not until years later that normalization would be approached from a gender-focused perspective, as it became evident that gendered inequalities in

5 For a more detailed overview of the drug normalization framework, see chapters one and two. 60 drug use would persist (Measham, 2002). The concept of "differentiated normalization", which foregrounds the possibility of variation in normalization according to socioeconomic and other inequality processes, was developed in response to these and other criticisms of the framework's overly homogenous representations of drug use (Shildrick, 2002; Measham & Shiner, 2009).

Gendered convergence in lifetime prevalence of legal and illicit drugs is a relatively recent development (Greaves & Poole, 2007). While historically women have used illicit and legal drugs at lower rates than men, the gender gap in substance use rates has narrowed considerably over the past two generations for alcohol and tobacco, and more recently appears to be narrowing for other drugs, including cannabis (Ahmad et al., 2008; Greaves & Poole, 2007;

Aldridge et al., 2011; Statistics Canada, 2017). For example, in Canada in 1965, there was more than a 20% difference in prevalence between men (approximately 60%) and women

(approximately 35%) who identified as current tobacco smokers (Reid et al., 2017). Alongside a drastic reduction in smoking rates among men and women, this gender gap narrowed into the

1980s and currently hovers around 3% (men: 10.9%; women: 7.9%) for those who identify as daily smokers (Reid et al., 2017). Although alcohol use does not present as wide an initial gap as tobacco use, long term trends in alcohol use prevalence in Canada indicate that men's and women's alcohol use rates are converging, mainly through the action of recent increases in women's past-year use (74%; men: 80%), as well as in women's risky alcohol consumption

(22%; 4+ drinks per occasion, once per month or more) while men's risky use remained stable

(30%; 5+ drinks per occasion, once per month or more) (Thomas, 2012).

Cannabis is the most widely used illicit drug in Canada, and is the third most widely used psychoactive substance following alcohol and tobacco (Leos-Toro et al., 2017). Based on comparable survey data available from 2004-2015, prevalence of past-year cannabis use was

61 relatively stable from 2004-2011, at approximately 9% of adults 15 years of age or older, and then increased from 2011-2015 to approximately 12% (Rotermann & MacDonald, 2018). Gender and age disaggregated data suggests convergence in past-year use rates among men and women

18 years of age or older over the period of 2011-2015 (see Rotermann & MacDonald, 2018). A survey tracking past-year cannabis use among youth in grades 7-12 in Canada shows that use has converged such that statistically significant differences identified in 2006/2007 (Females: 21%;

Males: 26%) no longer exist in 2014/2015 (Females: 16%; Males: 16%) (Leos-Toro et al., 2017).

Gender-based analyses must be central to the pursuit of understanding the impacts of changing drug trends and norms (Hunt et al., 2015; Measham, 2002; Tuchman, 2010). Although gender is no longer a significant predictor of lifetime cannabis use prevalence, research illustrates that gender has remained relevant for understanding differences in drug use patterns and experiences across the lifecourse. For example, women tend to experience the stigma of substance use in different and more severe ways due to the gendered nature of social expectations regarding illicit activities (e.g., Ettorre, 2004; Erickson & Watson, 1990; Romo,

Marcos, Rodriguez, Cabrera, & Hernan, 2009). Women's disproportionate responsibility for care of children and ailing family members, as well as the pronounced stigma that mothers face for drug use, suggest that women are subject to unique pressures to reduce or desist from drug use across the lifecourse (Measham et al., 2011). Research on the drug use pathways of men and women has found that while men's use tends to be influenced by same-gender peers, women's participation and initiation into drug use is more closely tied to their relationships with men

(Anderson, 2001; Mehta et al., 2014; Haines et al., 2009). As a result of the gendered rates, impacts and experiences of drug use, calls continue to be made for the application of gender-

62 based analyses of substance use (e.g., Butters, 2004; Cormier, Dell, & Poole, 2004; Tuchman,

2010; Hunt et al., 2015; Tuchman, 2010).

Despite declarations on the need for gender-based analyses in substance use research which now span more than two decades, few qualitative investigations directly address the relationship between gender and cannabis, the most widely used illicit drug. Qualitative explorations of gendered aspects of substance use tend to focus on illicit recreational drug use practices more broadly (e.g., in night clubs), on the relationship of drug use to women's sexual risk taking behaviours, or on women's experiences of problem drug use and victimization (e.g.,

Bungay, Johnson, Varcoe, & Boyd, 2010; Kennedy, Grov, & Parsons, 2010; Maycock, Cronly,

& Clatts, 2015; Measham, 2002; Measham et al., 2011; Romo et al., 2009). Exceptions in

Canada include articles which provide cursory consideration of the relevance of gender to cannabis acceptability and accessibility among undergraduate nonusers of cannabis (Hathaway,

Mostaghim, Kolar, Erickson, & Osborne, 2016; Hathaway et al., 2018), and studies that explore adolescent cannabis use in terms of gendered performance and expectations within the high school context (Haines et al., 2009; Warner, Weber, & Albanes, 1999). An analysis of interviews with 19 female long-term cannabis users in the "anti-drug" culture of Norway is an important recent exception to the dearth of international qualitative research on cannabis use as a way of doing gendered performance (Dahl & Sandberg, 2015).

Gender-focused investigations of cannabis and other illicit drug use proceed mainly from a doing gender approach informed by ethnomethodological and poststructural theoretical traditions (West & Zimmerman, 1987; Nentwich & Kelan, 2014; Kelan, 2010; Deutsch, 2007).

This approach understands gender as an interactive social practice and normative construct, where an individual may be held accountable by others to the situational achievement of gender.

Gender norm reinforcement also occurs at organizational and structural levels (Miller &

Carbone-Lopez, 2015; Deutsch, 2007; Kelan, 2010). Gender is thus not considered a pre-existing property or attribute of an individual's body or self. Rather, it is analysed as a symbolic association that gets attached to an individual through the operation of multi-level social processes (e.g., individual self-stylization; interpersonal interaction; organizational gender-typing of occupational norms; cultural expectations of appropriate behavioural displays of masculinity and femininity, etc.).

While the doing gender lens has been useful for illustrating how gender performances reproduce normative ideals for men and women, the focus on gender as an "omnirelevant" master status which maintains its salience across social contexts6 has made it difficult for doing gender research to (a) go beyond accounts of gender norm reinforcement, or alternatively, of (b) simply expanding descriptive typologies of alternative versus dominant masculinities and femininities (e.g., Dahl, 2015). This has resulted in doing gender scholarship that often neglects to identify avenues for undoing gender, or the possibility of gender subversion or "irrelevance" in interaction (Deutsch, 2007; Miller & Carbone-Lopez, 2015; Nentwich & Kelan, 2014). In addition, drug use research applying the doing gender lens has often overlooked the role of other important social relations of inequality, such as immigration (e.g., Haines et al., 2009; Dahl,

2015). Although existing qualitative investigations have been important for understanding how diverse masculinities and femininities are produced and disrupted in cannabis use practices, considerable knowledge gaps remain. This chapter goes beyond descriptive gender typologies to

6 The ethnomethodological approach to doing gender proposes that in a society such as our own which essentializes gender difference, all activities are interpreted in relation to one's presumed sex category. All activities thereby become gendering activities in some way: "but we are always women or men... What this means is that our identificatory displays will provide an ever available resource for doing gender under an infinitely diverse set of circumstances" (West & Zimmerman, 1987, p.139). Thus gender becomes "omnirelevant", regardless of the social situation.

64 identify how young adults both reinforce and disrupt the gender binary in ways that expands peer social accommodation of women's cannabis use.

Another prominent gap in research on cannabis use concerns the lack of dialogue across these quantitative and qualitative substance use literatures regarding how rates of cannabis use may be informed by gendered cannabis norms regarding acceptability and accessibility. For example, existing cannabis research does not evaluate how the gendered structure of the illicit cannabis market and norms regarding cannabis possession differentially inform men's and women's use rates. This chapter brings qualitative research on cannabis norms into direct conversation with quantitative findings on cannabis use rates in order to develop more nuanced understanding of drug normalization as being differentiated by gender.

With the exception of other publications from the normalization study on which this chapter is based (Hathaway et al., 2016; 2018), and Warner and colleagues' (1999) research on adolescent cannabis attitudes conducted in 1996, existing qualitative studies on cannabis use exclusively focus on investigating the attitudes of cannabis users. This presents a third major gap in research on drug use practices and acceptability norms. According to the normalization framework, understanding the drug-related experiences and attitudes of nonusers is essential to identifying shifts in drug acceptability and the social accommodation of recreational drug use

(Aldridge et al., 2011). This chapter includes nonusers in order to provide better insight into undergraduate acceptability evaluations of cannabis.

Given the high prevalence of cannabis use identified among young adults in Canada and impending drug regulatory changes, it is timely for a gender-focused analysis to be applied to the study of cannabis normalization in the Canadian context. This analysis addresses the three major research gaps identified above: the need for gender-based analysis of cannabis normalization that

65 is not limited to provision of typologies of masculinities and femininities; the lack of mixed methods research on the relationship of gender to cannabis use rates; and the need for inclusion of nonusers in research on the social accommodation of cannabis. In addressing these gaps, this chapter advances the research literature on drug normalization as a differentiated process, that is, as "a contingent process negotiated by distinct social groups operating in bounded situations"

(Measham & Shiner, 2009, p.502; Shildrick, 2002). It also provides an important data point on drug normalization prior to legal regulation of possession and supply of non-medical cannabis in

Canada (Task Force on Marijuana Legalization & Regulation, 2016).

METHODS

In the spring semester of 2012, I conducted 58 semi-structured in-depth interviews with drug using and non-using undergraduate students at the University of Toronto, St. George campus. Upon completion of an online survey component of the drug normalization study, students were prompted with online and in-class reminders about the option to participate in an interview that further explored drug use attitudes by contacting study coordinators. Students were purposively sampled to include drug users and non-users, and women and men in each of these categories. Students were asked to self-report their gender so as to avoid reliance on researcher assumptions regarding gender presentation. With the exception of one participant who self-identified as transgender, all other participants used the language of biological sex (i.e., male; female) when they were asked to report their gender. As a result, the quotes from interviews provided below indicate the self-reported gender of participants as their sex.7 Women

7 Sex is generally understood to refer to the "biological attributes of humans and animals, including physical features, chromosomes, gene expression, hormones and anatomy", whereas gender refers to the "socially- constructed roles, behaviours, expressions and identities of girls, women, boys, men and gender-diverse people" 66 were oversampled (n=35) due to their underrepresentation at higher rates of cannabis use.

Participant ages ranged from 18-24 years old. As a result of the study focus on young adults, students had to be 26 years of age or younger in order to participate.

Participation was entirely voluntary. Student identity was protected through anonymization of interviews and surveys. Students completed a consent form at the beginning of the survey component, and were encouraged to complete the survey in a private setting to protect confidentiality. At the beginning of the interview component, participants were given a consent form and were told they could stop the interview at any time and could skip any questions they did not wish to answer. Students were provided with a $20 honorarium for their interview contribution. Interviews were 45 minutes long on average, were audio recorded and later transcribed. In total, 20 persons who have never used cannabis, 32 who use cannabis, and 6 who have desisted from cannabis use (i.e., those who identified as using cannabis experimentally or regularly in the past, but no longer use or intend to use cannabis) were interviewed. Of these 58 participants, 18 reported being born outside of Canada. Ethical concerns arising in this research concern the illegality of cannabis and other drugs, and sensitivity of questions pertaining to their use. Ethics approval for this project was received from the research ethics boards at the

University of Toronto [U of T] (Reference #26892), University of Guelph [U of G] (Reference

#11SE005), and the University of Alberta [U of A] (Reference #Pro00024191).

The semi-structured interview schedule included questions on cannabis use initiation, use practices, perceptions of what constitutes appropriate or inappropriate use, accessibility, perceptions regarding laws associated with cannabis prohibition and regulation, and stigma associated with cannabis use (see Appendix B). Interview transcript coding was conducted using

(Canadian Institutes of Health Research, 2015). See the limitations section below for discussion of the issue of participants conflating sex with gender when they were asked to report gender. 67 a thematic approach (Attride-Stirling, 2001). Thematic analysis of interviews was guided by issues highlighted in the literature review of doing gender scholarship on drug use, as well as research on cannabis use and drug normalization. NVivo 10 software was used for thematic coding and comparative analysis of the interview data. Anonymized excerpts from interviews are provided throughout the findings section of this chapter in order to foreground participant voices and experiences, and to provide depth and detail that is not accessible via standard survey methods. All participant names in this chapter are pseudonyms.8

It is important to note that the interview sampling process employed for this study does not allow for claims of statistical representativeness. Students self-selected into the interview portion of the study, forming a convenience sample. From this convenience sample, students were invited to participate based on purposive sampling for range of drug use/nonuse and gender in order to ensure that people are interviewed in each category (Small, 2009). After 58 interviews were completed, it was deemed that thematic saturation had been reached regarding student reports on cannabis acceptability (i.e., social accommodation of recreational use) and accessibility. This approach to sampling allows for identification of some of the social processes through which gender and cannabis practices are related (Small, 2009). Purposive sampling can be used to identify and describe the operation of specific social processes, which the researcher can then locate in relation to broader social forces (e.g., policy) to consider how these may be linked with the findings. It cannot, however, specify how statistically prevalent such processes may be. Thus the quotes and themes provided below should be approached as examples illustrative of the processes through which cannabis normalization is differentiated by gender and immigration.

8 Pseudonyms were created using an online random name generator for common names (Random Name Generator, 2018). 68

In addition to in-depth interview data, this chapter applies the results of three statistical models on cannabis acceptability, accessibility, and use rates that are estimated using drug normalization survey data in order to inform a doing gender analysis of the interviews (see

Chapter Two). The survey analysis includes 1,713 undergraduate students attending the

University of Toronto, the University of Guelph, and the University of Alberta.9 Stata 14.2 was employed for the statistical components of this chapter.

RESULTS

1) Survey Results

The logistic regression model of cannabis acceptability10 (see Table 3 in Chapter Two) illustrates that women report significantly lower odds of positive cannabis acceptability attitudes when controlling for other factors. Although women's lifetime cannabis use is not significantly different from men's, women report significantly lower rates of recent use (see Table 2 in

Chapter Two). To provide more detail on the gendered relationship of recent use rates of cannabis, Figure 1 below compares men's and women's cannabis use reported "in the previous month". 11

9 For details on survey sampling and response rates, see Chapter Two. No statistically significant differences are identified in cannabis use, acceptability, or accessibility by university locale in Chapter Two. Although this analysis of interview data focuses on UofT, it is reasonable to expect minimal differences in gendered cannabis norms across the three universities due to the lack of significance of locale identified in the statistical models of Chapter Two. 10 Cannabis acceptability is coded as a dichotomous variable asking whether the participant "do[es] not have a problem with other people using cannabis" or if they "do not think people should use cannabis". 11 As noted in Chapter Two, gender is coded in the survey by proxy through using a 3 item sex variable: male, female, or transgender. Due to the low number of participants who identify as transgender and corresponding lack of statistical power, this group was excluded from the survey analysis. 69

Figure 1:

Recent Cannabis Use Rate by Gender

60.0%

50.0%

40.0%

30.0% Men (n=526) 20.0%

Percent Gender by Percent Women (n=1,159) 10.0%

0.0%

Rate of Cannabis Use in Previous Month

Nearly half of students who completed the survey report ever using cannabis (46.5%; n=916), and 23.2% (n=397) report using cannabis in the previous month (see Table 1 in Chapter

Two). When cannabis use is disaggregated by gender, significant differences between men and women are identified in the sample (p<0.01). Whereas 57.2% of women had never used cannabis, only 46.2% of men report never using cannabis (Figure 1). Men are overrepresented at higher rates of cannabis use, with 7.0% of men in the sample reporting cannabis use 5 or more days per week in comparison to only 1.7% of women. Differences between men and women at lower levels of use are minimal, with 23.2% of men and 23.0% of women in the sample

70 reporting not using cannabis in the previous month, and 12.5% of men and 11.5% of women reporting using cannabis less than weekly in the previous month.

These patterns of cannabis use illustrate that significant differences between men's and women's use are mainly accounted for by the categories of non-use, and weekly or greater use.

These results suggest that higher rates of cannabis use continue to be gendered even among the relatively normalized cannabis use culture of undergraduate students, and despite the convergence in rates of cannabis use between men and women (Parker, 2005; Aldridge,

Measham & Williams, 2011; American College Health Association, 2013; Health Canada, 2007;

Statistics Canada, 2017). As shown in the analysis of interviews below, women report being more critically assessed for their cannabis use than men, and experiencing greater challenges in navigating the illicit cannabis market. Together, these barriers help to explain the persistence of gendered rates of recent cannabis use.

It is important to note that gender was not significantly associated with accessibility of cannabis in the survey results (see Table 4 in Chapter Two). However, the measure of accessibility that was used asks simply "whether a student feels they can access cannabis 'at the moment'", and so does not allow for assessment of whether accessibility pathways are gendered.

Substance use scholarship suggests that women's initiation into drug use and access to illicit drugs is more closely tied to their relationships with men, whereas men's use tends to be influenced by same-gender peers (Anderson, 2001; Mehta et al., 2014; Haines et al., 2009). As shown in the analysis of interviews below, gendered pathways of drug accessibility continue to exist for cannabis among undergraduates, despite the widespread reporting of high accessibility among men and women.

2) Interview Results

This analysis focuses on five themes. Theme 1 indicates the highly normalized character of cannabis use among using and non-using students by illustrating the cannabis acceptability attitudes typified by participants. In contrast to the first theme, Theme 2 examines the cannabis- related evaluations of stigma and self-control that reflect gendered norms around drug use and sobriety, and thereby shows how the cannabis normalization component of acceptability is differentiated by gender. Theme 3 draws from student narratives to identify the gendered structure of the illicit cannabis market and explore how this market structure is related to differential rates of cannabis use among men and women. This theme identifies how the normalization component of accessibility is differentiated by gender. Both themes 2 and 3 focus on identifying how women's cannabis use is constructed as more conspicuous than that of men, and thus illustrate how gender differences are reinforced among undergraduate students.12 Theme

4 identifies cannabis norms where gender difference appears to be subverted, indicating how gendered expectations can be 'undone' to some extent. The final theme, Theme 5, identifies

Canadian cultural expectations in the differentiation of cannabis normalization; here, immigration is identified as a prominent social relation informing cannabis use and acceptability attitudes among undergraduate students.

Theme 1: Cannabis Normalization

Cannabis was and continues to be regulated under a criminal prohibition framework in

Canada at the time of data collection for this study in 2011-2012. Despite decades of cannabis criminalization, social tolerance of cannabis has become widespread across the Western world,

12 An exploration of how the perceived typicality of men's cannabis use is constructed is also important for understanding the gendering of drug use, but is not the focus of this analysis. 72 and rates of cannabis use have significantly increased among otherwise socially conventional youth and young adults (Hathaway et al., 2018; Erickson, 2015; see also Chapter Two). In

Canada, rates of past-year cannabis use have doubled over the previous 30 years, from 5.6% in

1985, to 12.3% in 2015 (Rotermann & MacDonald, 2018). This growing societal acceptance of cannabis indicates that cannabis has become a more normalized activity, that is, it "has moved from the margins to the mainstream" (Hathaway et al., 2018). The widespread social acceptance of recreational cannabis use is reflected in this interview analysis. Participants, including both users and non-users of cannabis, generally stated that occasional recreational cannabis use is largely unproblematic, that non-users of cannabis are difficult to distinguish from recreational users, and that it is possible to engage in cannabis use in a responsible way. For example, when asked if there are any general differences between users and nonusers of cannabis, Todd

(Nonuser; Male; Born in Canada) states:

"I'm going to say 'no'. I mean, I just know so many people from all across the spectrum who do or don't [use cannabis], and I just think, you know, everybody, everyone from all over is probably pretty open to it. I mean even my father's actually smoked marijuana, so. I'm pretty sure even Barack Obama's smoked marijuana [laughs]. So I just think it's really, people all over."

Examples such as this indicate the perceived pervasiveness of cannabis, as well as its status as a substance that is not threatening to a conventional or successful life despite being criminally prohibited in Canada. Todd includes authority figures, such as a parent or political leader, to indicate the level to which he perceives cannabis use to be socially pervasive and accepted.

Cannabis acceptability was mainly evaluated by participants through a metric of controlled recreational use that is contrasted by compulsive or overly frequent cannabis use.

When asked if there are any responsible ways for people to use cannabis, Ronald (Nonuser;

Male; Born in Canada) emphasizes that maintaining self-control and avoiding compulsive use is

73 a key characteristic of responsible use: "There probably are [responsible ways to use cannabis].

Like, I guess most of the people I know, they smoke marijuana responsibly... 'Cause they know how to control themselves, and I think it’s acceptable unless they're addicted." For most participants, to use cannabis responsibly means that cannabis use is an activity of low priority which does not interfere with other responsibilities. This reflects findings of existing research on cannabis use and drug normalization in Canada (e.g., Brochu et al., 2011; 2018; Duff et al.,

2012; 2014; Hathaway et al., 2011; 2016).

Students tended to reject opinions that cannabis is a gateway drug or that using cannabis causes young people to become unmotivated "stoners". For example, Donna (Nonuser; Female;

Born Abroad) described cannabis users she remembers from high school, and compared them to a friend who uses cannabis:

Donna: They [i.e., the cannabis users in high school] had no ambition, they had no drive, they would just show up to school and smoke pot... they were just bumming around and not really doing anything. They were just apathetic, and I'm definitely not like that, so I guess that's why I didn't really hang out with them... Interviewer: Do you think it was because of their marijuana use that they were like that, or was that separate from their marijuana use? Donna: No I think it was separate from it... I don't think marijuana caused them to be these apathetic losers I guess. 'Cause my friend like, she's definitely not like that, even though she has done [cannabis] quite a few times. She's very driven and ambitious, and she's really outgoing and bubbly.

As shown in Chapter Two, nonusers are significantly less likely to be accepting of cannabis use overall. Nevertheless, when they were asked more nuanced questions on cannabis acceptability in the interview (e.g., "Do you think there are responsible ways of smoking cannabis"), many nonusers qualified that they were largely accepting of controlled recreational cannabis use in safe social settings, as long as they were not pressured to use cannabis themselves. For example,

Michelle (Nonuser; Female; Born Abroad) believes that cannabis use has negative physical and mental health impacts, yet despite this concern and her strong dislike of the smell of cannabis

74 smoke, she expressed tolerance for cannabis use of friends and potential romantic partners: "As long as it [i.e., cannabis use] wasn't like around me, and they weren't trying to get me to join in with them, I would be perfectly fine with that". Such sentiments on cannabis acceptability were prevalent throughout the interviews, indicating the relatively normalized status of recreational cannabis use among using and nonusing undergraduate students.

Theme 2: Gendered Self-Control

Discussion of gender disparities was limited by two factors. The first factor was the widespread sense of social tolerance of recreational cannabis use identified in the previous theme. The second factor was students’ view that anybody could be a cannabis user. The issue of gender disparities in cannabis use rarely arose, unless participants were probed to consider potential gender differences. Some students initially took up 'universalist' or 'indifferent' positions (Haines et al., 2009), stating that no gender differences exist with regards to cannabis use, and proposing that men and women do not have different attitudes toward cannabis. Yet as shown in Chapter Two, men report significantly higher acceptability attitudes and recent use rates in comparison to women. This reluctance to consider gender disparities has been identified in previous research on cannabis use, and illustrates the difficulty of engaging participants in discussion that is "reflexive about gender as a social category extending beyond their immediate experiences" (Haines et al., 2009, p. 2031).

To facilitate discussion on potential gender disparities, the interviewer asked questions on gender distributions of cannabis use or acceptability attitudes. Participants often used these probes as a launching point into considerations of disparities. For example, when asked whether

75 she thinks there is any difference in the amounts of cannabis that men and women tend to use,

Shirley (Cannabis User; Female; Born Abroad) states:

Shirley: No. Actually, I think men probably smoke more, like bigger amounts, just 'cause, I don't know, they're bigger, and they just consume more of everything... But in terms of heavy [cannabis] smokers, I don't think so. Maybe guys I think more than girls, actually. It just so happens that I happen to be with four other girls, which I think is rare, 'cause most of the other people I know who are regular [cannabis] smokers are guys. Interviewer: Why do you think guys might smoke more than girls, in general? Shirley: I don't know. I guess a sense of autonomy, they may have more of that. I don't know if that's socially constructed for guys to have more control or be more risky. Yeah. Interviewer: Are people ever surprised that you or your girlfriends smoke marijuana? Shirley: No, not really... I don't think anyone's really fazed that anyone really smokes [cannabis].

As indicated by the quote above, once students had their attention directed towards the potential existence of disparities they then began to identify gender disparities that had previously gone unnoticed in their everyday lives, and attempted to reconcile these disparities with a general sense that cannabis use among men and women is normal. This type of back and forth reflection on the existence of disparities illustrates how gender salience was elicited for consideration in interviews.

Women as Risk Averse

A prevalent sub-theme throughout the interviews concerns how women experience cannabis use in comparison to men, and how much cannabis they tend to use (or not use).

Participants often proposed that women are in general more concerned about their well-being, and by extension are more risk averse, than men. For instance, when asked why she thought that women use cannabis less than men do, Martha (Nonuser; Female; Born in Canada) responds:

I think because girls tend to think about things a whole lot more, and take it more to heart, and like think about more, like their body, and harming themselves and others. They're more aware I think... I know that like, my younger brother has tried marijuana, like once or twice, but like I've never tried. Even though we were in the same situation, he was more open to trying it, whereas I don't want anything to do with it. So I do think

that guys use it more, just 'cause... Girls are more emotional about those types of things too, whereas guys just kind of go out and just try it and "whatever" kind of thing.

Students' representations of women as more risk averse were directly associated with gendered concerns with bodily harm, and with the perception that women conduct more serious and emotional considerations of the potential impacts of risky activities. This aversion to risk is similarly expressed by Frank (Cannabis User; Male; Born in Canada), when he explained why he thought women are underrepresented among heavier cannabis users:

I generally see women as safer... I think they value their body maybe more, maybe that's the way to say it... I know a lot of girls who don't like smoking bongs... it baffles me, because that's the only way I really like to smoke. They just, they don't like the idea of it. They like to smoke joints, but that doesn't get you nearly as high as a bong. So I think there's some reason laying in there...

Such comments suggest that women are expected to think more about the consequences of their actions (e.g., potential health harms) than men, which discourages risk taking behaviour. This expectation is also captured by Shirley's reflections above on the greater sense of autonomy she attributes to her male peers in order to explain their heavier and more frequent cannabis use.

Comments on the apparently risk averse tendencies of most women were prevalent throughout the interviews, and are represented in many of the excerpts provided below.

Women as Atypical "Stoners"

The understanding of women as more risk averse is supported by participants' comments regarding the relative normality of seeing men who use cannabis, particularly at higher frequencies (who are often referred to as "pot heads" or "stoners"). For example, when describing stereotypes surrounding heavy cannabis users, participants would often identify a man. As April (Former Cannabis User; Female) states: "the stoner culture is more prevalent with guys. Where women it's more of a rarity". Participants repeatedly identified the novelty of seeing

77 heavy cannabis users who are women. According to Frank (Cannabis User; Male; Born in

Canada):

Frank: There are fewer regular stoners for females. There's less females that just, everyday that's what they're doing. At the same time, there are a lot of women, who you wouldn't expect who use it once in awhile. Interviewer: Why do you think there might be fewer regular stoners among women? Frank: ...I feel like women probably get it worse than guys, when they're seen smoking. I guess it's more detrimental to their reputation. Whereas guys, it's just not that big of a deal, but for girls it is.

Like Frank's reflections above, participants often stated that women are underrepresented among frequent cannabis users in part due to a greater concern for their reputation and their higher vulnerability to being stigmatized in comparison to men. Todd (Nonuser; Male; Born in Canada) elaborates on the stereotype that heavier cannabis users are men:

Todd: Most girls I know wouldn't want to be thought of as a pothead, or as the kind of person that, you know, people envision potheads as... With guys, I guess it's just there's a more relaxed attitude towards it. Interviewer: Why do you think that label could be perceived as worse by women? Todd: Maybe just in general because who knows a pot-head girl? Really? There's so few, and with guys, it's just like, every group of friends has their pot head, you know? [Laugh] So it's just so much more common, that nobody really thinks down about it with guys. ... [Girls] really stick out, yeah.

These excerpts show that men are expected to face less stigma for cannabis use than women, and illustrate how the lower visibility of women as frequent cannabis users in effect heightens gender salience, as women come to appear as atypical "stoners".

Women as Inexperienced Cannabis Consumers

The narratives of several cannabis-using men and women suggest that women tend to be perceived as inexperienced cannabis users. For instance, Clarence (Cannabis User; Male; Born in

Canada) indicated that women tend not to have the 'know-how' to exhibit the performance of an experienced cannabis user, and have less control over their high, which makes women less enjoyable to smoke cannabis with:

I taught this one girl from the very beginning how to smoke [cannabis]... I said: "Look, I'm going to educate you in the way that other people won't. I'm going to tell you what's wrong, what's right, what's cool, what’s not cool, so you don't look like an idiot when you're smoking" ... And I remember, I invited a few other girls over, I don't smoke with them on a regular basis, but I have smoked with them in the past, and she was there. And they'd never seen her smoke. And she smokes right in front of them, and the way that she did it was perfect. ... [the other girls] just don't smoke from a bong, and they were impressed, right? So, like I find that the majority of girls that I do smoke with, don't smoke nearly as much as I do, or as my other friends, or [are] as experienced. When I do smoke with them, they get stoned. Too stoned, right? To a point where I almost have to watch them, which I don't enjoy... I have had a few girls that smoke crazy amounts, and of course I don't experience that issue. But the ones that I do know of, don't smoke as much, they get too high, and it becomes more of like me babysitting them, right. Or them being very loud, and attracting too much attention. I don't like... being that loud group there, that has to look over, and go: "Ah I wish they were gone. I wish they would leave right now."

Clarence's reflections exemplify an attitude among more experienced cannabis users that women tend to be inexperienced users and that their excitability is an immature and undesirable behaviour. This excitability is also sometimes perceived as a lack of self control that requires supervision.

Men who use cannabis are not the only participants to describe this critical orientation to women's cannabis-related behaviour and self-presentation. For example, when asked about her preferences for smoking cannabis, Helen (Cannabis User; Female; Born in Canada) states:

Helen: I don't really smoke a lot with girls. I prefer smoking with guys, 'cause they're just more chill. Some of the girls I know would just get really tired... guys do smoke more, but whatever we'll be doing, it's just funner. Like, I don't know, they just have more energy... well [the girls are] always paranoid too. Interviewer: And the guys aren't so paranoid? Helen: Yeah. They're just like "whatever". Interviewer: What are the girls paranoid about? Helen: I don't know. I guess maybe what other people will think of them.

Women are thus presented as less capable of maintaining social engagement when using cannabis (i.e., they become "really tired", versus men being "chill" or relaxed), or as more preoccupied with social reputation and how they may be perceived (i.e., which results in them

79 being seen as "paranoid"). Helen described how this negatively impacts her experience cannabis use, which results in her preference to use cannabis with men.

Like Clarence's comments above suggest, Catherine (Former Cannabis User; Female;

Born in Canada) describes women's cannabis use as characterized by more immature and

"giggly" behaviour:

Most of the people that I'm friends with are guys. I don't have many girlfriends, but the friends I do have that are girls, I think they smoke for different reasons. I think maybe guys smoke... it's more of a "One of the guys" thing. You know, it's something cool that you do with your buddies, you all get high... And then the girls, I think they smoke it to appeal to the guys. I don't think girls ever get together and all go like, "let's just have a pot night", and hot box the house [i.e., fill an enclosed space with cannabis smoke]. That to me, that's a masculine behaviour, not a feminine one. And a lot of the girls I've seen that do get high, I mean friends of mine, they act stupid. And I don't know if this is the difference in brain chemistry, or if they're just acting stupid, but they tend to get really like, giggly.

When discussing gendered rates of cannabis use, examples such as the above repeatedly indicated how students are more critical of evaluating the ways in which women present themselves when using cannabis. This critical orientation also extends to the perceived motives for women's cannabis use, as shown in the following sub-theme.

Women as Attention-Seeking

As illustrated by Catherine's discussion above, women's cannabis use was at risk of being evaluated as inauthentic or instrumental, that is, in order to "appeal to" men or garner attention rather than to enjoy using cannabis in a social setting. This sentiment is conveyed with a sense of disapproval, particularly among participants who identify as women. For example, Ashley

(Cannabis User; Female; Born Abroad) states:

Ashley: Girls act different [when they get high], they show it in their actions. Or maybe sometimes I've noticed girls exaggerate, like even when drinking [alcohol]. Girls act drunker than they are, like even if a girl hasn't drunk that much, she'll act like she's out of it. I've noticed girls doing that a lot. Interviewer: Why do you think girls do that, instead of guys?

Ashley: Attention.

Similarly, Cynthia (Nonuser; Female; Born in Canada), describes how she and her friends compare men and women who they see smoking cannabis at parties:

Well my friends, like, we usually see the girl as like: "Oh we feel bad for her because she has to result to that [i.e., smoke cannabis] in order to get attention." Meanwhile we see the guy doing it and we're like: "Oh it's normal, it's like nothing".

Interview excerpts such as these illustrate how cannabis acceptability evaluations are often particularly critical of women's cannabis use in mixed-gender social spaces. Cynthia's reflections also speak directly to the perceived innocuousness of men's cannabis use, as identified in the

"Women as Atypical Stoners" sub-theme above.

Undertones of promiscuity were sometimes associated with women's cannabis use. For example, Karen (Cannabis User; Female; Born in Canada) reflects on how women are judged differently for cannabis use than men:

Karen: ...that's just how I've seen it [i.e., how women are judged] with people that I know. They don't really care so much if a guy's doing things like that, if they're drinking early, or if they're going out earlier in their life. But for a girl, it's just a lot tougher... And then, you know, women that do do those things, I think they stigmatize them as also being, yeah 'promiscuous' - as in they'll label them as 'sluts', 'whores', even though that has no relation. Sexuality with drug use. They automatically assume the two together... Interviewer: Have you ever heard this happen? Karen: Yeah. The way the guys speak around us, sometimes. But again, they're involved in this same act [i.e., using cannabis], and so I don't understand why. Interviewer: Do they not know that [you and your girlfriends use cannabis]? Karen: They do, but they won't like, call us those things [i.e., "sluts"]. ... They don't really like, say it to us. I guess they're telling us their opinion about other girls that they may know. Maybe they're not generalizing, but - if they're talking about other women they know, I feel like they're generalizing as well. Because if they see that girl like that, why wouldn't they see me like that? Right?

Karen's comments provide an example of indirect exposure to stigmatizing attitudes towards women's cannabis use through the gossip of friends [i.e., when she states "they don't really... say it to us"]. Direct verbal confrontations regarding the perceived inappropriateness of women's

81 cannabis use were not reported among participants. Instead, instances of generalized or indirect talk about cannabis use behaviour appears to be the more common vehicle through which such behavioural expectations are reaffirmed among peers.

Women as Vulnerable

In connection to perceptions that women's cannabis use may be an indicator of promiscuity is a belief that women are more physically vulnerable when they experience any form of intoxication. This is articulated by Marilyn (Nonuser; Female; Born in Canada), when she was asked to describe the gender distribution of cannabis use in her group of friends:

Marilyn: I think when you hear about a girl smoking marijuana often, it's kinda like - Just because of the gender differences, you kinda consider it off. Like, unnatural for a girl to be smoking marijuana. Yeah, it's mostly guys [who use cannabis]. But there are a few girls who socially do it as well, but it's usually because guys are doing it as well so they usually join in. Interviewer: Can you expand a bit on that unnatural feeling for girls that are smoking it? Marilyn: ... It's just really odd how, like a petite girl kinda thing is putting herself in a complete high, which is really dangerous as opposed to a guy... Not to be stereotypical, but I am, [the guys are] macho, they can handle it a little better than a girl could... Just because I'm a girl and I see it that way. If I was to put myself in a position of being high, and then that dangerous effect of a guy who could take advantage of me if I'm completely high. That's a reason. And I feel like a lot of my friends feel that way too. They don't smoke marijuana as often as my guy friends do for sure... I feel like my guy friends can handle [the cannabis high]. But if my girlfriends do it, I don't know, I just feel like I'm scared for them. 'Cause with their body size as well... That high could affect you more if you're more petite... Interviewer: Have the guys ever mentioned anything about that? Like what they think of girls smoking? Marilyn: [Laugh] They know that the girls are smoking, and they don't mind... They find it perfectly normal. Then again, it's just me. I don't think they [i.e., girls] should be smoking marijuana.

As noted in the "Women as Inexperienced Cannabis Consumers" sub-theme above, women are often seen as immature cannabis users. Women's perceived inability to control their high is also associated with a heightened physical vulnerability to intoxication. As the quote above indicates, this intoxicated vulnerability is sexualized for women, as it is seen as preventing women's ability

82 to protect themselves from sexual assault. The excerpt also illustrates that women are stigmatized as irresponsible for placing themselves in a position of potential vulnerability, including by other women. Comments such as this suggest that women are seen as at least partly responsible for the harms they may experience in choosing to enter the potentially risky, masculine-encoded territory of intoxication.

Theme 2, Gendered Self-Control, evidences binary gender standards for assessment of cannabis use behaviour. As indicated by participants' comments on the lack of prevalence of women who are perceived as "stoners", women's cannabis use may appear suspect and thus as more salient against the backdrop of gendered social expectations regarding what constitutes a typical cannabis user. Women who exhibit excitable behaviour are seen negatively as attention- seeking. Higher frequency cannabis use continues to be perceived as a more masculine activity by many respondents, and in turn women's cannabis use is at risk of being assessed as a source of vulnerability and a potential marker of promiscuity. The sub-themes in Theme 2 interact to reinforce the salience of gender in students' evaluations of what constitutes acceptable cannabis use. For example, because women are seen as atypical or inexperienced cannabis users and as generally more risk averse, when they use cannabis and become intoxicated they are perceived as potentially responsible for experiencing negative outcomes, including victimization. This is apparent in the "Women as Vulnerable" sub-theme. Similarly, the qualities of risk aversion and inexperience that are disproportionately attributed to women who use cannabis interact to construct women's cannabis use as having an ulterior motive. That is, because they are seen as inexperienced and risk averse, women's attempts to enjoy or experiment with cannabis are susceptible to being read through a lens of suspicion. This is particularly visible in the 'Women as Attention-Seeking' sub-theme.

Despite the gendered behavior standards described above, most interview participants nevertheless indicated that the fact that women use cannabis is unremarkable. In other words, the issue was not whether women use cannabis, but how women behave and regulate themselves when using cannabis that is placed under closer scrutiny, particularly by other women. These attitudes that women's use is common but that women are more likely to be negatively evaluated for using cannabis thus occur simultaneously. Such attitudes suggest the murky symbolic boundaries of when gender performance may be called to account for perceived transgressions.

As shown above, students often discussed self-limiting behaviour as expected and more appropriate for women's cannabis use. The evaluative standards that women face are more circumscribed than men's, thereby placing women at greater risk of being held accountable for the ways in which they use cannabis. In addition to illustrating the pressures women disproportionately face for self-regulation of cannabis use, the interviews also suggest a largely passive and subtle interactional regulation of gendered boundaries, specifically through the use of gossip and social disengagement or avoidance by those who disapprove of particular behaviors, as suggested by Helen's and Clarence's comments above.

Theme 3: Gendered Cannabis Accessibility and Supply

The majority of participants--both users and non-users, men and women--indicated they could access cannabis within a few days, if not within the hour. When asked how accessible illegal cannabis is for them, responses such as the following were common:

Less than forty-eight hours... Yeah, I'd say really accessible... Like I don't know anyone who grows it, but they just get it from their suppliers. I don’t know how the chain of command works. [Laugh] -Fred (Cannabis User; Male; Born in Canada)

Twenty minutes, half an hour. [Laugh]... It's accessible ... I don't know if I personally know any drug dealers. I probably do, but I just don't know that they're drug dealers. But I know that my best friend who uses drugs, she has a drug dealer. My other friend also has a drug dealer. I could call either of them and be like: "Can I use your dealer?" and they'd be like: "Yeah." And then the dealer can be within my presence within half an hour. -Cheryl (Nonuser; Female; Born in Canada)

Students who occasionally or experimentally use cannabis tended to describe their access as predominantly social, that is, as being shared among friends rather than being bought from dealers or acquaintances. This often involves friends 'chipping in' to help pay for the cannabis that will be used at that time (Hathaway et al., 2018).

Women as Cannabis Receivers; Men as Suppliers

As indicated in Figure 1 above, women are less likely to be frequent cannabis users. The interview findings support this, with participants reporting that women's cannabis access occurs mainly at social gatherings where cannabis is being shared. Further, interviews indicate that as a result of their lower frequency of cannabis use, women tend to access cannabis through non- monetary social sharing. Take for example Marie's (Cannabis User; Female; Born Abroad) comments on her experience with accessing cannabis:

I think girls mostly, well the girls that I know, mostly do [cannabis] in social settings if it's there. You don't really go out seeking it. You're not going to buy some for yourself. It's more so if it's available then, sure [let's smoke it]... I think a lot of guys probably buy bulk from dealers, and then have it for their friends.

Similarly, Karen (Cannabis User; Female; Born in Canada) states that although she often uses cannabis in social settings, she has rarely purchased cannabis herself: "Only about three times in my life I've purchased [cannabis] for myself. It's because it's on-hand with friends around me that

I can just ask if they have some. They'll offer it to me, or I can ask."

The interviews add depth to the survey findings provided in Chapter Two, indicating that while women and men can easily access cannabis, social sharing access to cannabis often occurs

85 through friends who are identified as men. For example, Lillian (Cannabis User; Female; Born

Abroad) states:

I've never personally bought any [cannabis]. Like it's usually my friend who will buy and I'll just bum off them, or something like that... Like the guys [in our group of friends], they usually deal the weed to us. They smoke up a lot more than we do... they're more accessible to the weed... Us girls, we would buy small amounts of weed, but they kinda deal weed, so they just have more weed with them.

Men are thus presented as more frequent cannabis users, as shown in "Women as Atypical

Stoners" sub-theme, but also as typically supplying cannabis or possessing larger amounts than women who use cannabis.

Women as Lower in the Cannabis Dealing Hierarchy

Among cannabis users who reported using cannabis more frequently, cannabis was purchased mainly from friends, acquaintances, or dealers who were identified as men.

Respondents indicated that of the cannabis dealers they know, very few are women. Of the dealers identified as women, most were described as selling smaller quantities of cannabis in comparison to dealers identified as men. William (Former Cannabis User; Male; Born in

Canada) states this gender disparity is a result of women being perceived as more vulnerable to robbery, and men being perceived as more risk-oriented:

Interviewer: Did you know any women who dealt anything? William: Yeah. This girl... dealt like little gram bags. Like small [amounts of cannabis] to her friends. I remember grabbing [i.e., buying] off her a couple times, but no significant dealers that were women... I think the risk factor of it, and again the rebellious factor of it. It was dangerous. I don't know, I don't want to say women were afraid of getting pumped [i.e., robbed], but I guess guys were more, like they were more eager to fight anyway, so if they did get pumped, they'd fight. Pumped being like their stuff being stolen from them... like I wonder if [women] even have the opportunity to really become dealers, like if people would like trust them to be like "Well you're like 5'4" and 110 pounds, I can't trust you with 500 dollars worth of drugs, because like three guys could roll you like that". [Snaps fingers]

Similarly, Roger (Cannabis User; Male; Born in Canada) states that women who deal cannabis are lower on the selling hierarchy, and this impacts their ability to provide cannabis at lower prices:

Interviewer: Do you know any girl dealers? You only mentioned guys. Roger: Yeah. The girl dealers - I mainly don't buy from them because they always give me really small amounts. I don't know if there's some relation, maybe I just don’t know that many girl dealers. But usually they're not really high up, like they don't get really large quantities, so they can't sell for low prices. Interviewer: Why do you think that they're lower on the selling hierarchy? Roger: It's just because they mainly deal in grams. Like they only sell dimes [i.e., $10 bags of cannabis]. And every time I buy a dime off them, it's really small.

These excerpts indicate how women's perceived physical vulnerability and risk aversion is in turn related to their lower status as drug dealers in the illicit cannabis market.

In addition to women dealers being relegated to lower tiers of the illicit cannabis market, they were sometimes blockaded from participation entirely. For example, Jeremy (Cannabis

User; Male; Born in Canada) states:

Jeremy: [Dealing cannabis] seems like it's a more guy-oriented thing to do. Or male- oriented thing to do. Have the business, and have them take the risk of selling drugs. Interviewer: So what do you mean by more guy, or male-oriented? Jeremy: It seems like a - it's really not, but it seems like it would be a guy thing to do, more than a girl thing... I only heard about it in my [student] residence, that the girl, like stands outside the room, they won't even go inside, and just all the guys go in to go buy the pot. Interviewer: 'Cause they don't want to be associated with that kind of thing? Jeremy: No, the guys won't let them in. Interviewer: Oh, the guys won't let the girls in? Jeremy: Yeah. I've heard that's happened twice that I've heard of. But I assume it happens all the time. Interviewer: Why do you think they would leave them out? Jeremy: I have no idea. Honestly. I asked them. I asked the guys, and they're like: "Nope, there’s no girls." It’s like - It was weird. I have no idea.

This excerpt indicates that women may even be actively excluded from the illicit drug market by some groups of men. The interviews thus evidence unique gendered pressures that influence engagement in the illicit cannabis market.

Women as Vulnerable Buyers in the Illicit Drug Market

Several participants reported feeling uncomfortable buying cannabis from dealers, instead preferring to purchase from or 'chip in' with friends. For instance, in the following excerpt

Phyllis (Cannabis User; Female; Born Abroad) describes why she avoids buying cannabis directly from dealers:

Phyllis: ...honestly, I'm really afraid to like, call a dealer. Especially a person I don't know. So I wouldn’t even go there, I wouldn’t even go and try to get it... Interviewer: So why wouldn't you be willing to call a dealer you don't know? Even if he's vouched for by your friend? Phyllis: I wouldn't want to get drugs from someone I have no idea who they are. And go to like, a random address somewhere, I mean I would not feel comfortable with that. Interviewer: What would you worry about happening? Phyllis: I guess just - First of all, it'd be kinda awkward meeting this person. And if - I don't really think the weed would be laced with something weird [i.e., purposefully contaminated with an unknown psychoactive substance]. But I don’t know, I would feel not comfortable. And every other time I've smoked, I've been comfortable with the people that I know.

While some wariness associated with purchasing cannabis from a dealer was common among students in this study, women tended to present more concern in this regard.

Unlike Phyllis, Rose (Cannabis User; Female) states that she is generally comfortable engaging with dealers to purchase cannabis, yet also reports experiencing a feeling of vulnerability when buying from dealers she has not met previously:

Rose: If [I was buying cannabis] just for me, I would usually just drop ten or twenty bucks, for one or two grams. I didn't mind talking to dealers, or going to pick up, as long as someone was at least behind me in the distance. Just watching me, making sure nothing happened. But, I sometimes would buy it in large amounts, from like people putting all their money together to go buy some... And I would go pick it up, yeah. Interviewer: And were these dealers friends of friends, or? Rose: I preferred people that I knew. Like someone I was at least acquainted with, preferably friends. Only a few times did I go up to a complete stranger and pick it up. Usually, someone would call the dealer, and it would be a dealer that at least someone knew. And so they would go get it. Only a few occasions would a friend be like "here's the number", and it would be like me and some other person who didn't know them at all, and we'd have to pick up from a complete stranger... I found that new dealers I didn't know, were just ... really sketchy.

Interviewer: What do you mean by sketchy? Could you describe them? Rose: It just would be like, almost like, in a way creepy. It would usually be a guy... Usually older. Most of the time they'd show up in a really beat-down car, with another friend... the time that I did do it from a complete stranger, they would sometimes ask ... "Do you want to get in the back of the car and do it with us?". I'm like: "No. No, I don't know you at all, I don't really want to." They'd be like, I dunno, dirty looking. You could tell they were users themselves, more than just marijuana ... Like a lot of times, they'd show up high too. You know, I don't feel comfortable around people I don't know very well, sometimes. Especially if they're already high.

Using cannabis with dealers is a common practice, and can be one way to build trust between dealers and buyers through shared assessment of the quality of the cannabis and casual social engagement (Sandberg, 2012). However, both Phyllis and Rose's comments illustrate the reluctance of participants who identify as women to enter situations such as this, where they feel uncomfortable and potentially vulnerable to assault.

Men who reported purchasing cannabis from dealers expressed markedly less concern or discomfort in buying from unknown dealers. For example, Frank (Cannabis User; Male; Born in

Canada) states:

Interviewer: How do you usually get cannabis? Frank: Just a dealer, yeah just a dealer. I used to go to my brother, one of his friends, something like that. Even now I might go to one of my friends who knows a guy. But usually I'll just call up a person, or text him, and me and him will drive to [the dealer] or whatever. Interviewer: How did you get in touch with this dealer? Frank: Through a friend usually. Yeah, just through different people that I know. Interviewer: So usually the dealers that you buy from are vouched for in some way? Have they ever been people that you don't know and that your friends don't know? Frank: I imagine that I've gone to someone who like, we don't really know, but it's usually on my terms. I'm showing up in my car, with my friends. If I'm in [student] residence, I usually feel pretty safe.

This excerpt presents a vivid contrast with the comments of Phyllis and Rose above. Such examples are not intended to be taken as claims that men completely disregard safety issues, but that men report these issues as being less intimidating overall, and that women express that they must navigate additional gendered threats to their safety.

Gendered Cannabis Concerns: "Laced" and "Light"

While both men and women reported preferring to purchase cannabis from sources they are familiar with, women tended to report more distrust and vulnerability when considering purchasing cannabis from unknown dealers, and are unique in reporting concern of "laced" cannabis. For example, Betty (Cannabis User; Female; Born in Canada) states that she is "really not an expert" when it comes to navigating cannabis purchasing and reports concerns of having her cannabis laced or being given less cannabis than paid for when purchasing from someone who is not a trusted friend.

For several women participants, this concern that cannabis might be laced with an unknown substance led them to avoid accepting cannabis unless the source was seen as trustworthy. Helen (Cannabis User; Female; Born in Canada) shared a cautionary tale, describing an incident when her friend had been given potentially contaminated cannabis by a stranger during a public "420" event in Toronto.13 Her friend experienced hallucinations and a prolonged high when she used this cannabis, and was highly distressed by the experience. This led Helen to reassess her own cannabis purchasing practices: she would only purchase cannabis that was "on the stem" and from trusted sources, and would not purchase ground cannabis because she believed it could be more easily contaminated.

In addition to women reporting feeling vulnerable in situations where they buy from unfamiliar dealers, several participants stated that men who are dealers will purposefully give women less cannabis than they had paid for. This results in a pressure for women to defer the act of purchasing to friends, partners, or acquaintances who are identified as men. For example,

Emily (Cannabis User; Female; Born in Canada) states:

13 In the context of this interview excerpt, "420", pronounced "four-twenty", is a term for an annual public event occurring on April 20th to celebrate cannabis culture and protest cannabis prohibition. 90

There are always instances where like, girls will buy off dealers and they'll get ripped off. So let's say like, I don't know, ten bucks for a gram, and they'll give you less than that... Like even my [ex-boyfriend] was like: "If you ever want to get [cannabis], just ask me. Don't go on your own, just ask me."

Feelings of vulnerability or fears of being given contaminated or smaller amounts of cannabis thus disproportionately pressure women to avoid purchasing cannabis directly from dealers.

Theme 3 illustrates the highly gendered social organization of the illicit cannabis market.

Responses such as Roger's and William's suggest that cannabis supply is dominated by dealers who are identified as men, and that dealing is an occupation symbolically typed as conventionally masculine. Women-identified dealers are seen as less suited to the risks of drug dealing, and participants indicated that as a result women dealers are relegated to lesser roles when selling cannabis. Women who reported purchasing cannabis directly from dealers expressed concern that they were sometimes "shorted" by dealers on the amount of cannabis they received, and that they felt uncomfortable or unsafe when buying from dealers they were unfamiliar with. These issues discourage women's participation in the illicit cannabis market, thereby reinforcing gendered boundaries and simultaneously reinforcing perceptions of women's heightened vulnerability and risk-aversion. Comments above from Karen, Marie, and Lillian also illustrate gendered stratification of social access to cannabis, with this access being mediated largely by friends and acquaintances who are identified as men. Taken together, the highly gendered hierarchy of dealing cannabis in the illicit market, the vulnerabilities expressed by women participants when purchasing from unknown dealers, and the gendered stratification of social sharing access to cannabis all help to explain why women continue to report being less frequent cannabis users (Figure 1), despite widespread normalization of social recreational use of cannabis.

Theme 4: Challenging Gendered Cannabis Norms

The doing gender approach is recognized for its ability to draw attention to how gendered norms are reinforced, yet this approach has experienced limited success in identifying the undoing of gender in particular situations (Deutsch, 2007). Identifying instances where a social difference is not being enacted is difficult for a number of reasons, chief among them the methodological issue of establishing or interpreting the significance of when difference is not being reinforced, or in other words, when someone is not being held accountable for a gender performance that may have been identified as a contravention of established social norms. This section proceeds from the understanding that gender disparities become more salient for participants when normative gender expectations are transgressed. Thematic analysis of students’ narratives allows me to identify situations where such transgressions tend to be perceived, as shown above regarding gendered expectations that disparately structure cannabis accessibility, experiences of stigma, and pressures for self-control. After thematically identifying circumstances that result in gendered expectations becoming conspicuous, I analyzed the interview data with the aim of illustrating moments when gender is more likely to recede in importance as it becomes irrelevant to evaluating the situation at hand, as well as instances of the disruption of gendered norms. The sub-themes below are provided as types of gender norm disruption exemplified within the interviews. Although these sub-themes indicate some subversion of gendered expectations, they also illustrate that gender reinforcement and the challenging of binary gendered norms are often interconnected and may occur simultaneously.

Challenging Stereotypes of Cannabis Users

When asked to describe stereotypes of cannabis users, participants typically identified a

'drop-out' culture of unmotivated men who are fixated on cannabis use to the neglect of other

92 responsibilities or aspirations. Participants generally described this as an outdated stereotype which does not accurately describe the vast majority of cannabis users. When discussing how cannabis users might be judged negatively, several women reflected on how they disrupt this stereotype. For example, Sharon (Cannabis User; Female; Born in Canada) states:

Sharon: I know a lot of people who you wouldn't expect to smoke [cannabis] that smoke... Even myself, I feel like a lot of people are like: "Oh, you smoke?" Because... I feel like I don't act like - like some people try to act like "pot heads". Like quote unquote, or like "stoners"... I feel like a lot of people get surprised when people who get good marks and have a job and stuff, I feel like a lot of people are surprised when they find that they smoke. Like "oh, it kind of goes against the stereotype". Interviewer: What is that stereotype? Sharon: What is that stereotype? I kind of think a lot of people think it's stereotype to be like, oh like: "She smokes weed, like whatever. Like she's just a stupid stoner or something."... I feel like a lot of people don't expect people who smoke [cannabis] to be smart or accomplished. And it's like, even in my English class, like we've had a couple authors come speak, and they’re published authors of good books that have won awards. And they mention like smoking [cannabis]. It's like, cool, I like that. Because it shows that there's no stereotype. Like there's no mould that you have to fit. Like anyone can smoke [cannabis].

Similarly to Sharon, several participants in this study also reported that women are presumed to be nonusers of cannabis simply for presenting as conventionally feminine, and in turn this results in women's cannabis use being judged more harshly. For example, Jacqueline (Cannabis User;

Female; Born in Canada) states:

I would say women get judged more harshly [for smoking cannabis] because there's the stereotype of being docile, and feminine, and you know, polite and well-mannered. Like those kinds of stereotypes, which are like: "Oh women smoking [cannabis]? Ugh. [Conveying disgust]". And a man, not so much.

Some women who reported using cannabis thus actively challenged the relevance of masculine, countercultural or deviant cannabis user stereotypes by standing as starkly contradictory examples, as in the form of women's socially integrated cannabis use (e.g., Sharon as a scholastically-oriented young woman attending a top-tier university). To buffer themselves from the stereotypical derogatory or deviant association of cannabis use, however, requires that

93 women symbolically attach their cannabis use to contextually relevant conventional expectations. In the university context, the interviews suggest that this includes claiming social belonging as a cannabis user through activating associations of academic success and conventional feminine gender presentation as symbolic sources of legitimacy. This strategy thus presents cannabis use as nonthreatening in the evaluation of women's self-presentation, though it simultaneously may reinforce other conventional gender expectations.

Challenging Gendered Expectations through Disregard

Some women report that although they occasionally feel social pressure to avoid using cannabis, they would disregard this pressure as irrelevant. For example, when asked if she has felt judged by the people she smokes cannabis with, Karen (Cannabis User; Female; Born in

Canada) states:

No, not by the people I smoke with... Like the times I've done it where I'm not alone, but I'm the only one smoking, that's happened before, too. Or I've been with a big group but they're only drinking and I'm smoking, um, because they don't like [cannabis], I feel a little bit awkward just because they're not involved in it, and they're looking at me like "Oh, that's not necessary. No one else is doing it, why should you?". But I feel like, you know for where we're going to right now, I want to be high for that. [Laugh] Like, we went to a concert... and I wanted to smoke weed for it, but the other people I went with, they didn't want to. So they kind of were a little bit shocked by that, but I said, you know, "You're gonna drink your alcohol, why can't I smoke my weed?" Right? ... I'm not gonna like, take their opinions and take them to heart I guess. I know who I am and, they can say what they want.

This excerpt illustrates how women may create space for themselves to use cannabis in the face of peer group attitudes that cannabis use is inappropriate in a particular situation. Karen describes taking initiative in setting the tone of what constitutes acceptable social situations for cannabis use. Because men are more typically identified as suppliers of cannabis in social situations, Karen's decision to bring cannabis to this scenario also disrupts the association of

94 cannabis possession with masculinity. To do so, however, she places herself at risk of social sanction.

Challenging Gendered Expectations by Enacting Masculine-Coded Behaviours

In response to social expectations that women are generally inexperienced or immature with regards to cannabis use, some women report that they actively attempt to counteract these stereotypes. For example, in describing her cannabis use, Ruby (Cannabis User; Female; Born in

Canada) states:

Ruby: I also try and keep up with other people. And I smoke weed a lot less than all the people that I smoke weed with. So I think I'm often more high than they are, just by that. Interviewer: Why do you try to keep up? Ruby: I've just always had a thing that "I can do it too". You know? When I started drinking, I would make sure that I could, you know, drink as much as the person that would drink the most... To show my self-worth or something like that. I think it probably started from when I was a lot younger. Like in elementary school, and I wanted to make sure that I was good in school, because I'm a girl. And I was like "Girls can be smart too, and I'm blonde. So I can be smart too!" So I was top of my class... And because of my desire to kinda bash what has been before me, I guess. I do try and hold my own and, yeah, things like that. Interviewer: So just like, challenging stereotypes...? Ruby: Yeah, exactly. And so when I started drinking, I took to Jack Daniels [i.e., whiskey], and I would drink it straight, and things like that. So yeah, it's definitely about being able to hold my own, and not, you know, pussy out.

This excerpt illustrates the efforts of some participants to meet masculine encoded standards of cannabis use behavior so as to avoid being perceived as inexperienced, or as displaying

'feminized' incompetence or reservation (i.e., to "pussy out") with regards to substance use. In this way, women may stake a claim to belonging in the social space of men's substance use.14 By

14 Although this resembles Messerschmidt's concept of "bad girl" femininity (1995, p.183), the findings here challenge Messerschmidt's suggestion that women's involvement in deviant activities is in fact a strategy for enacting a normatively appropriate femininity within the boundaries of a specific social context. In Messerschmidt's analysis, this pertained to women's involvement in gang violence within the social context of the gang. Instead, the section on "enacting masculine-coded behaviors" shows women challenging conventional expectations of femininity; they are not attempting to meet feminine standards within the social context of substance use. Doing contextually appropriate femininity in the context of social circles of cannabis use would instead involve lower levels of cannabis use in order to avoid social embarrassment associated with giggling and other "not chill" behaviour associated with lack of experience in using cannabis. Mastery of cannabis use techniques and higher 95 employing this strategy, women may oppose normative constructions of restrained femininity and illustrate that they are capable of meeting masculine-encoded standards, and so claim that they should not be excluded from social activities involving substance use. In doing so, however, women may simultaneously reinforce existing gendered assessments of cannabis use practices by granting legitimacy to these masculine encoded standards, and are placed at risk of social sanction for perceived promiscuity or gender deviance. Thus this strategy may expand social space for women's inclusion as legitimate cannabis users in a very limited way, as masculine standards of cannabis use practices remain in place as a force of evaluation and exclusion.

Challenging Gendered Personal Expectations

Participants frequently reported that their introduction to the normalization of cannabis as occurring when they either used cannabis themselves and found it to be relatively uneventful, or if nonusers, when friends or family members discussed or used cannabis around them without negative outcomes. As illustrated by the interview with Jeremy (Cannabis User, Male, Born in

Canada), this normalization may extend to experiences of changing gendered cannabis expectations:

Interviewer: Do you think that men or women might get judged more if somebody sees them smoking [cannabis]? Jeremy: Yeah, women usually get judged more. 'Cause with guys, it's: "Oh who cares? He's just a guy smoking a little bit of pot with his guy friends." But if it's a girl, it just looks - For some reason, it looks gross. I don't know why it looks gross, but it just seems like: "Oh she's supposed to be just helping out stuff, not having as much fun." Right away it happens. Interviewer: Do you think those things when you see a girl smoking [cannabis]? Jeremy: Not really with a girl smoking. Not anymore right? Same things before, but now that I smoke with the girls and stuff, it's not. Because I understand their situation. Right? It's kind of weird. So it's not really those gender stereotypes anymore. Yeah. Interviewer: Whereas before, when you didn’t know so much about [cannabis], you thought maybe?

levels of use, as shown on pages 20-22 (and as exemplified by Clarence's quote therein), is generally associated with masculinity among students, not contextually normative femininity. 96

Jeremy: Yeah. I'd think that right away, then I'd realize: "What the hell am I thinking?" Right? There's no reason to think that way.

In the above excerpt, Jeremy describes how his reactionary judgments (i.e., "right away it happens") changed over time, but how they nevertheless continue to arise on occasion and require conscious disavowal. This quote speaks to the slow process of erosion required for changing deeply ingrained gendered expectations and norms regarding cannabis. While Jeremy registers this gendered expectation, he then counteracts it as an inappropriate or illegitimate standard for evaluating behaviour.

Taken together, these strategies may diversify interpretations of women's cannabis use, allowing for women’s use to be seen as normal rather than conspicuous. Women's challenging stereotypes of cannabis users and their use of cannabis with disregard to social sanction in particular expand the limits of gendered norms by challenging masculine-encoded expectations surrounding cannabis use, especially those regarding women's presumed passivity (e.g., using cannabis only when provided by others instead of independently initiating cannabis use) and appearance (e.g., appearing feminine and achievement-oriented). By coupling cannabis use with symbolic associations of success and conventional feminine presentation, women may challenge social expectations that are generally critical of women's cannabis use. In other words, such strategies dispute the relevance of gender in assessing the acceptability of women's cannabis use through establishing that conventional women should not be interpreted as out of place or conspicuous as cannabis users.

However, these strategies do not reject a binary understanding of gender. Rather, they employ the symbolic gender binary to varying extents in making a claim to women's legitimacy as cannabis users. For example, appearing feminine while using cannabis may disrupt associations of cannabis with masculinity (or with "gross", failed femininity, as described by

Jeremy above), but to succeed in this strategy women must appeal to other normative identities

(conventional femininity, or scholastic achievement). These disruptions thus largely position cannabis as a nonthreatening object in the maintenance or achievement of a feminized or conventionally successful repertoire. Nevertheless, these strategies undo the gender binary insofar as they reduce the difference between what is perceived to constitute appropriate masculine versus feminine behaviour, specifically by de-gendering occasional, socially- integrated cannabis use as a typical indicator of masculinity. By reducing the scope of the symbolic gendered association of cannabis with masculinity, these strategies may in turn reduce the risk of gender assessment and the relevance of gender specifically for evaluating cannabis use (West & Zimmerman, 1987).

Theme 5: Cannabis Normalization as a "Canadian Thing"

Investigations of doing gender and substance use largely sidestep analyses of other axes of social difference (Miller & Carbone-Lopez, 2015; e.g., Dahl, 2015; Haines et al., 2009). To counteract this tendency, the final theme in this analysis considers the role of immigration in differentiating cannabis normalization. As indicated in Chapter Two, students who immigrated to

Canada more recently consider cannabis use significantly less acceptable than students who have either been born in Canada or those who have immigrated to Canada 5+ years ago. Although not as prominent as gendered evaluations of cannabis in the interviews, narratives regarding

"Canadian" versus "immigrant" attitudes are central to understanding how cannabis normalization is differentiated among these undergraduate students.

Students who had immigrated to Canada in order to attend university and students with friends who are recent immigrants were among those most aware of cultural differences in social

98 expectations regarding cannabis. For example, in describing where she routinely uses cannabis,

Helen (Cannabis User, Female, Born in Canada) states:

Where? I don't know... I'm kind of like a cigarette smoker this way. My friends, because I - Because of the college that I go to, it's a lot of international students. So one of my two friends is Russian, and the other is American. And the other people who smoke on the floor [of my residence] are from the UAE [i.e., United Arab Emirates]. So the people from the UAE are very nervous, because you can get arrested there, incarcerated for even residue. Right? So they're very nervous. Then I have my American friend who's also terribly nervous, because where she's from, there's a lot of punishment. There’s a lot of debate, and there's a lot of stereotypes about people who smoke weed. And then I have my Russian friend who is new to this. So she's also nervous. But then, I don't know, maybe it's a Canadian thing. Maybe it's a Canadian thing.

As indicated in the quote above, a relaxed attitude towards cannabis is associated with

"Canadian" values. This assessment is shared by students born in Canada, as well as those who are immigrants. For example, James (Cannabis User; Male; Born Abroad) states:

Interviewer: Could you tell me a little bit about the stereotypes around marijuana users? What are some of the negative judgments that people might have of marijuana users? James: For Canadian people, most of the time, they're understanding, so I don't think there's too much of that [stereotyping]. For people from Japan, because they're really conservative, it's just - Marijuana users are just like using cocaine, it's just unthinkable. So they would - I don't know. I think their perspective [i.e., people from Japan] onto people who are smoking [cannabis] will be the same as a coke addict or something.

More severe stigma and beliefs about cannabis being an addictive substance or gateway drug were attributed to cultures outside of Canada.

The interviews suggest that a process of substance use acculturation occurs through exposure to the comparatively relaxed attitudes of people in Canada towards cannabis, as well as to higher visibility and prevalence of cannabis in Canada. For example, when discussing how her parents might view her cannabis use, Sara (Cannabis User; Female; Born Abroad) states:

Sara: They don't know [that I use cannabis]. Interviewer: What do you think would happen if [your parents] found out? Sara: I don't know, maybe they'll send me back my country. [Laugh] Like it's really strict in my country... South Korea ... Like a lot of celebrities do it, but the ones that are caught,

they're like - Usually they can't come back [on] the air anymore. It's really strict. And people judge like crazy. Interviewer: So that culture is a lot more strict on marijuana use in general? Sara: I have never seen anybody smoking [cannabis in Korea]. I don't know anybody, they don't - I know that they don't do it. Compared to Canada, like nobody does it. Interviewer: So how did you decide that it wasn't as bad as what people said in South Korea? Sara: Because I see people smoking all the time [in Canada]. Whereas in Korea, like I have never heard marijuana. Like the word. Yeah.

Although cannabis possession without medical authorization is a criminal offense in Canada, by and large participants perceived this to be an ineffective or irrelevant deterrent to cannabis use.

Students were also confused about the criminally prohibited nature of cannabis in part because publically visible venues designed for cannabis use, such as "vape lounges" or "cannabis cafes", were allowed to operate commercially. In contrast, comments such as Sara's above indicate the more publically punitive character of cannabis prohibition in other countries.

The general lack of concern with cannabis-related stigma in Canada is associated with perceived invulnerability to legal consequences, despite the criminally prohibited status of cannabis at the time of this study (e.g., Brochu et al., 2018). For example, Janet (Former

Cannabis User; Female; Born in Canada) states:

Interviewer: Have the laws ever [made] you worry while you were using [cannabis]? Janet: You know what? No. Just because - I mean, I know that it’s such a Canadian thing to do. And I will have immigrant friends that come here, and be like: "I had no idea marijuana is so big in Canada. I can't believe how much pot people smoke, and how acceptable it is, and just everyone does it." And so I've even heard stories of police just being really complacent about it too. Just being like: "You know, just don't give it to me, and carry-on." [Laugh] So- And it's funny too, just 'cause with other friends that would have been like: "Maybe we should go behind this building to do it and stuff." I've been like: "Yeah right!" How often do you smell marijuana when you're in the street? You smell it all the time. Like it's everywhere. People really don't care. Like it’s very unlikely that you're going to be stopped.

The interviews suggest that students who are born in Canada and those who have spent many years in Canada identify a low risk of being apprehended for cannabis use and possession, and so

100 experience less concern regarding legal consequences for cannabis possession in comparison to students who are recent immigrants.15

It is important to note that this lack of concern with legal consequences for cannabis possession is not limited to students who identified as white. Interactions with law enforcement for cannabis possession were exceedingly rare among all students participating in this study.

University students are highly insulated from police surveillance in comparison to people who are street-involved or those who experience poverty. However, such marginalized groups are disproportionately targeted for arrest for cannabis possession in Canada, and are also disproportionately racialized (e.g., Toronto Star, 2017). In turn, this sense of invulnerability to legal ramifications for cannabis use should be expected to be more pronounced among white university students who are born in Canada than among racialized students who are born in

Canada.

DISCUSSION

According to Howard Parker's normalization thesis, drug normalization is characterized by an increase in positive attitudes towards illicit drugs that coincides with a rise in availability of drugs, in rates of use, and in acceptance of use as part of 'ordinary' life (Parker, 2005;

Aldridge, Measham & Williams, 2011). In line with previous literature proposing that normalization be understood as a process that is differentiated by social location and inequalities, the data here indicates that cannabis normalization is not experienced uniformly across groups: it remains differentiated by gender, despite the high prevalence of cannabis use documented among

15 It is difficult to assess to what extent cannabis as a "Canadian" attribute is associated with whiteness in these interviews due to lack of interview discussion on the topic of race and ethnicity. Race is not significantly associated with use rates once immigration is controlled for in the statistical model in Chapter Two. 101 undergraduate students, and is also structured by cultural exposure to cannabis acceptability norms in Canada (Shildrick, 2002; Measham & Shiner, 2009).

In the interviews, students had difficulty articulating the differences they perceived between how men and women use and access cannabis because, as several students state, they had not thought about such things before. These gender differences are subtly embedded in everyday practice, and so do not necessarily stand out against the backdrop of student cannabis- related experiences. Once probed in the interviews regarding whether or not there are gender disparities in usage rates, student reflections began to shift from expressing the ubiquity and relative uniformity of cannabis use to describing such differences.

Student expectations surrounding what constitutes socially acceptable cannabis use behaviour continue to be differentiated by gender, regardless of convergence in men's and women's cannabis use rates (Statistics Canada, 2017). The analysis above shows that men's cannabis use is taken to be typical. When women use cannabis, they are expected to be novice users, their behaviour is in danger of being labeled as conspicuous or immature, and they are at risk of being perceived as disingenuously attempting to attract attention, particularly from men.

Women who are perceived to be intoxicated are still subject to blame and sexualization for

"allowing themselves" to become more vulnerable to assault--harmful stereotypes which continue to draw from the alarmist anti-cannabis discourses of the 1930s and 1940s "reefer madness" era (Boyd, 2010).

Women's cannabis use remains the subject of more social control than men's, which reflects a typical finding in wider drug use literature (Measham, 2002; Dahl & Sandberg, 2015;

Haines et al., 2009; Boyd, 2010). Overall, women experience greater stigmatization and in turn more social pressure for self-regulation in order to avoid negative judgments by peers, as well as

102 potential social rejection (e.g., being excluded from cannabis use circles). Women face these gendered demands to moderate their cannabis use regardless of the relative pervasiveness and acceptability of cannabis in comparison to other illicit drugs in the university context. These findings on the disparate expectations for men and women speak to how the statistically significant differences in cannabis use rates are located in gendered everyday practices of self- regulation and navigation of drug acceptability.

Participants also indicate that the social organization of the illicit cannabis market is dominated by men. Women are rarely cannabis dealers in the illicit drug market, and are perceived to be more vulnerable in cannabis buying or selling scenarios. Participants report that cannabis use circles tend to be overrepresented by men, and that women's access to cannabis is often mediated by friends identified as men, which positions women to be seen as unlikely sources of cannabis in social sharing situations. In addition to women often 'opting out' of engaging with dealers in order to access cannabis, they are sometimes blockaded from participation by men. These organizational aspects of cannabis accessibility interplay to impede women's access to cannabis, and to symbolically encode cannabis possession and supply as masculine.

Impending drug policy changes in Canada will make recreational cannabis a legal consumer product. These changes are positioned to have significant consequences for women's access to cannabis by providing legally sanctioned commercial venues which will eliminate reliance on illicit cannabis market sources: 'back alley' sale arrangements will cease to be a point of intimidation. In this way, legalization of cannabis is positioned to destabilize the gendered character of cannabis accessibility pathways, and so it can be expected that while women's use will almost certainly continue to be evaluated in a more critical manner (much like women's

103 alcohol use continues to be), gendered disparities in cannabis use rates can be expected to converge further (Amos & Haglund, 2000; Hunt et al., 2015).

Although the doing gender literature on drug use is instructive as to how gender may matter, particularly through identifying the reinforcement of gender norms, it neglects to identify the extent to which gender actually figures as salient in drug attitudes and behaviours. In short, research needs to reconcile data on how much gender matters (i.e., gender differences in rates of recent drug use) with doing gender literature on how gender matters. Themes 2 and 3 above suggest that gender is salient among undergraduate student evaluations of cannabis use and in structuring cannabis accessibility. Yet students by and large maintain that women's cannabis use is itself an unremarkable fact. Looking to Figure 1 in relation to the interview findings helps us to reconcile this apparent contradiction. Figure 1 shows that women are underrepresented at higher rates of cannabis use. When the interview findings are interpreted in light of this disparity, it becomes apparent that by restricting their cannabis use (rather than abstaining from cannabis altogether), women protect themselves from the stigma associated with higher frequency and public displays of cannabis use. This stigma can thus be understood as a "pull factor" towards self-regulation that compels women to use cannabis at lower rates on average. In addition, the risks and gendered vulnerability associated with engaging in the illicit cannabis market identified in Theme 3 can be interpreted as a "push factor" towards lower rates of cannabis use, due to more restricted accessibility pathways to cannabis for women.

The interview analysis illustrates how salience of gender difference is activated when women trespass into social territory conventionally typed as masculine, as it is then that their feminized gender presentation becomes conspicuous as a potential indicator of being 'out of place'. The interviews show that women's conspicuousness is associated with: (a) women's social

104 cannabis use participation presenting as a liability to enjoying "chill" cannabis gatherings; (b) women being perceived as disingenuous or desperate for attention for simply engaging in cannabis use in mixed gender gatherings; or (c) through women's perceived feminized vulnerability that suggests complicity in one's victimization via participation or entry into masculine territories of visible intoxication and engagement in the illicit drug market. These circumstances are illustrative of social situations where the risk of gender assessment is heightened, and when the "master status" of gender may be called forward in order to hold an individual accountable for their behaviour or performance.

In contrast to Themes 2 and 3, Theme 4 provides examples of when gender may be disrupted or made less relevant to interactional evaluations of behaviour. As Dahl & Sandberg

(2015) show in their analysis of interviews with 19 experienced cannabis users who identify as women, one way to disrupt gendered norms of cannabis use is to multiply and diversify the presentation of masculinities and femininities that are associated with cannabis use. This diversification reduces the salience of the gender binary by associating variant expressions of gender with using cannabis. Kelan (2010) identifies this strategy as utilizing the "multiple logic" of gender disruption. The "multiple logic" is applied in analyses that take up a more poststructurally inclined reading of the doing gender framework as influenced by the work of

Judith Butler. Although expansion of typologies of femininities or masculinities is not the aim of the analysis conducted in this chapter, "alternative" femininities which incorporate cannabis use without subscribing to the stereotypes of either the problem cannabis user (i.e., "stoners") or the inexperienced woman user are evident in comments such as those from Sharon and Karen above.

Unlike analyses of drug use which focus on identifying typologies of alternative and hegemonic masculinities and femininities, this chapter provides a more ethnomethodologically

105 inclined analysis of doing gender. The ethnomethodological theoretical approach to doing gender is most strongly associated with the work of West & Zimmerman (1987), and presents a "unitary logic" to understanding gender disruption (Kelan, 2010). The unitary logic of disruption holds that gender may cease to be enacted when the category loses importance in assessment of a situation or interaction.

Determining when one can declare that gender has not been made relevant in an interaction is exceedingly difficult, given the pervasiveness of subtle gendered signifiers in men's and women's conduct, clothing, and so on. However, this analysis provides an example of how gender disruption may be identified specifically in relation to expectations surrounding cannabis use as a social activity, rather than in terms of the masculinities or femininities exemplified by individuals' gender performance. As shown above, under certain circumstances the relevance of gender to the assessment of cannabis use is perceived to be illegitimate. Women's

"inconspicuous" cannabis use takes the form of use that is not interpreted as "asking for attention" or as being "immature", and as being limited to occasional use. This "inconspicuous" cannabis use space is seen as symbolically open, that is, as not strictly gender encoded. This, in turn, is the cannabis use space of gender irrelevance, where the salience of gender recedes into the background, and where calling someone to account for an inadequate gender performance is seen as inappropriate (as exemplified by Jeremy's comments above on rethinking his gendered evaluations of cannabis use). In other words, the gender binary remains in the background as a resource for assessment, but it is not called forward because occasional recreational cannabis use is seen as a behaviour that is appropriate for most young adults. The examples in Theme 4 may be read as instances where the relevance of gender is being challenged by participants, and thus as supporting the widening of the symbolic space of cannabis use that is gender irrelevant.

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Theme 5 illustrates that cannabis normalization is not only differentiated by gender but also by immigration. As shown in Chapter Two, time since immigration is associated with less critical attitudes towards cannabis use, a phenomenon identified as substance use acculturation.

The interviews support the findings of Chapter Two, illustrating that students born abroad, like those born in Canada, see relatively accepting attitudes towards cannabis as a "Canadian thing" due to the comparably permissive social expectations in Canada. The changes to cannabis policy in Canada discussed above are likely to increase the pace of substance use acculturation among immigrants. Unlike gender disparities in cannabis use which appear to be heavily impacted by an illicit drug market that is dominated by men and by subtle expectations regarding gender performance, the interviews suggest that substance use acculturation among immigrants is more so informed by fear of criminal penalty or overt social punishment. As such, the official sanctioning of recreational cannabis use by the Canadian government is positioned to more quickly undermine these fears.

LIMITATIONS

Unfortunately there is insufficient data in the interviews with which to confidently speak to potential intersections of gender with immigration regarding cannabis normalization. As argued in Chapter 2, substance use acculturation for immigrants occurs over time, with recent immigrants reporting significantly more restrictive acceptability attitudes and lower cannabis use rates than other students. As such, recent immigrants must be considered separately from those who have resided in Canada for many years when considering acceptability attitudes. Few students in the interview study report being recent immigrants, resulting in insufficient data through which to analyse the intersection of gender and immigration in cannabis normalization.

However, given the restrictive cannabis policies associated with other countries and the

107 inconsistent enforcement of cannabis laws in Canada which results in a perceived permissiveness

(Erickson, 2015; Brochu et al., 2018), we might expect more critical attitudes towards evaluations of women's cannabis use among recent immigrants.

The age range of participants in this study was restricted to young undergraduate students in order to investigate cannabis normalization among the next generation of conventional cannabis users. However, this age restriction may pose limitations to the analysis of gender norms. The norms and acceptability evaluations identified in this chapter may be specific to younger adults, such as negative assessments of women's cannabis use as being an attention- seeking behaviour. Research among older adult cannabis users and nonusers on gendered norms is required in order to assess the applicability of these findings beyond young adults.

An additional limitation in this study is the issue of respondent bias. The interviewer for these interviews is conventionally identified by others as a woman. It is possible that respondents who identify as men were more reluctant than women to discuss negative views of women's cannabis use due to fears of offending the interviewer. The interviewer attempted to reduce respondent bias by emphasizing the confidentiality and exploratory nature of the interviews, as well as by avoiding any statements that could be perceived as judgmental to participants.

Participants in this study appeared to expect the researcher to take their gender as self- evident from their social presentation, and indicated some surprise when asked to self-report their gender. Participants conflated biological sex with gender when they were asked to report their gender. This is likely the result of social convention, as it is common for forms and surveys requesting socio-demographic information to simply provide M/F as the option for "gender" identification. A more nuanced interview instrument for reporting gender would have been ideal, but this research design flaw was not evident to the researchers at the time of study

108 implementation in 2011-2012. As such, participant self-reported sex is taken as a proxy for gender identification in this study. Although this is a significant limitation resulting in loss of analytic nuance, it does not itself preclude the possibility of investigating how gendered norms surrounding cannabis use and acceptability are reinforced or disrupted.

CONCLUSION

In combining a doing gender analytic approach with the framework of drug normalization, while maintaining a critical awareness of the shortcomings of both frames as identified in the introduction, my analysis of undergraduate student evaluations of cannabis acceptability pushes for "gendering drug use(r) scholarship... in a predominantly androcentric field" (Miller & Carbone-Lopez, 2015, p.704). This analysis points to the persistence of a more critical orientation to women's cannabis use among undergraduate students. Women are disproportionately stigmatized for a failure to maintain a calm, cool, and collected front during a cannabis high. This results in women being perceived as less desirable participants in cannabis use circles. Such attitudes indicate a gendered understanding of self-control and vulnerability with regards to cannabis use, one which endures despite relative comparability and historical convergence in rates of use between men and women, and despite widespread cannabis normalization in Canada.

This chapter also shows how drug normalization components of accessibility and acceptability are differentiated by gender: the lines of social acceptability are drawn unequally in peer assessments of men's and women's cannabis use, and women must navigate unique gendered barriers in order to access cannabis. Student evaluations of women's acceptable cannabis use markedly differed from those of men's use, with peer social accommodation of women's cannabis use being much more limited. Whereas men's recreational cannabis use is

109 taken as largely unproblematic, women face greater scrutiny from peers of both genders, resulting in increased pressure for women to more strictly limit their cannabis consumption or to avoid using cannabis altogether. These pressures are increased by the highly gendered social organization of the illicit cannabis market, where the majority of dealing and buying activity is reported to be done by men. Women are discouraged from participating directly in the illicit cannabis market for a number of reasons, including experiences of being purposefully given less cannabis by dealers than was paid for. In contrast to their male peers, women also report feeling more uncomfortable and unsafe when they engage with new dealers. These gendered barriers to accessing cannabis position women as outsiders to the illicit cannabis market.

Although there have been statistically significant convergences in men's and women's rates of cannabis use, these findings show that women continue to experience qualitatively different and elevated pressures for limiting their cannabis use than men. Changes in Canadian drug policy to legalization of cannabis possession and recreational supply are positioned to decrease gender disparities in cannabis use by decreasing the gendered barriers that women face to accessing cannabis. These policy changes may also increase the speed of substance use acculturation among immigrants, as cannabis comes to be perceived as state sanctioned. Future research thus needs to consider drug normalization not only in terms of gendered differentiation, but also in terms of the impact of time since immigration on substance use acculturation.

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CHAPTER FOUR - Study Drugs "Don't Make You Smarter": Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students

ABSTRACT

Despite the growing literature on nonmedical prescription drug use among students in North

America, existing research does not investigate the potential convergences of nonusing student attitudes on drug acceptability with those of their stimulant-using peers. Analysis of 36 interviews with nonmedical stimulant prescription drug-using and nonusing undergraduate students in Canada provides insight into evaluations of drug acceptability within a competitive, top-tier research university context. Interviews are analyzed thematically with attention to practices students engage in to assess nonmedical stimulant use, and discourses students use to position the acceptability of such use. Interview results illustrate commonalities in how using and non-using students weigh the risks and advantages of nonmedical prescription stimulant use in relation to the pursuit of scholastic success. These findings are used to critically engage with the construct of drug acceptability, as conceptualized in the drug normalization framework of

Howard Parker and colleagues. To conclude, recommendations are made for future research, and implications for university policies are considered.

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INTRODUCTION

Competitive university environments became the focus of major media attention across

North America as fears aired about the prevalence of "cognitive enhancement" and "academic doping" practices among students, in the face of high rates of prescription for attention-deficit hyperactivity disorder (ADHD) conditions (e.g., DeSantis & Hane, 2010; McCabe, West, &

Wechsler, 2006; Racine & Forlini, 2010; Wilens et al. 2008; Wolff & Brand, 2013; Vrecko,

2015). Medical professionals are asking universities to make efforts to "denormalize" the nonmedical use of prescription stimulants (herein referred to as "NM-stimulant use") by educating students on harms and to gather data on the sparsely researched issue (Rosenfield,

Hebert, Stanbrook, Flegel, & MacDonald, 2011). The Government of Canada recently announced an intention to enlarge the scope of its National Anti-Drug Strategy to include the misuse of prescription drugs (Governor General of Canada, 2013). The United States illustrates similar trajectories toward targeting NM-stimulant use as a public health and safety concern

(Express Scripts, 2014; Quintero, 2012).

Research on NM-stimulant use has accordingly surfaced as the salience of this social issue grows. The research literature confirms that competitive and demanding postsecondary contexts are associated with higher rates of NM-stimulant use (Arria et al., 2008; McCabe,

Knight, Teter, & Wechsler, 2005; Peralta & Steele, 2010; Quintero, 2012; White, Becker-Blease,

& Grace-Bishop, 2006; Wolff & Brand, 2013). This analysis of 36 semistructured interviews with NM-stimulant-using and nonusing undergraduate students at the University of Toronto (U of T) responds to the repeated calls for inquiry into the "motivations, dynamics, and contexts of the growing phenomenon of 'nonmedical prescription drug use'" (Fischer & Rehm, 2007, p.

1932; Haydon, Rehm, Fischer, Monga, & Adlaf, 2005). The analysis proceeds from drug

117 normalization scholarship on changing drug trends and practices and explores how NM- stimulant-using university students and their nonusing peers make sense of such use. To date, no qualitative studies focus particularly on nonusing student evaluations of NM-stimulant use among their peers. According to the drug normalization framework, drug acceptability is an evaluative process arising from attitudes of both drug-using students and their nonusing counterparts, thus exploration of nonuser perspectives is essential for identifying the contours of drug acceptability repertoires and shifting use trends among students more generally (Aldridge,

Measham, & Williams, 2011).

The next section briefly introduces the drug normalization framework which has been central to developing the study of drug acceptability and drug use trends. An overview of NM- stimulant use prevalence estimates among students and drug effects is then provided. Thematic analysis of interviews is used to identify the drug navigation practices and discourses informing

NM-stimulant acceptability. To explain convergences in the attitudes of using and nonusing students toward NM-stimulant use as "nonrecreational" and oriented toward academic achievement, this chapter draws on literature on normative discourses of health, risk, and self- regulation that shape moral repertoires on drug use. The salience of achievement-oriented NM- stimulant use among nonusing students is here situated in social processes that position individuals as risk assessing, enterprising moral consumers (Race, 2009; Rose, 2007; Rose,

O’Malley, & Valverde, 2006; Skeggs, 2004a, 2004b). To conclude, recommendations are made for future research, and implications for university policies are considered.

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Drug Acceptability and Drug Normalization

Student navigation of drug acceptability is receiving increased attention as interest in understanding the patterns and effects of illicit drug use among conventional populations16 builds. Drug acceptability refers to individual or group evaluations of which drugs are seen as un/acceptable to use, through which mode of ingestion, how often, and in which situations.

Exploring shifts in how groups engage in and morally position certain kinds of drug use allows for insight into the material, symbolic, and discursive pressures driving such changes. The study of drug acceptability thus provides an important avenue for understanding the operation of social processes more broadly. The drug normalization framework has been central to mapping the research territory of drug acceptability (Aldridge et al., 2011; Parker, 2005). Drug normalization studies suggest that widespread availability and acceptability of illicit drugs among university students, and of cannabis in particular, indicate that navigation of drug use has become an increasingly common aspect of undergraduate experience for both illicit drug users and nonusing peers (Aldridge et al., 2011; Duff et al., 2012; Measham & Shiner, 2009). One shortcoming of normalization research is that it typically focuses on how drug users characterize drug acceptability through a binary formulation of substance use as either "problematic" or

"recreational."17 An opportunity for conceptualizing drug acceptability along more nuanced lines of assessment is suggested by the academic achievement–oriented illicit substance use of students to facilitate alertness and studying (DeSantis & Hane, 2010; Vrecko, 2013; White et al.,

2006; Wilens et al. 2008).

16 Undergraduate students are here considered "conventional" insofar as that relative to marginalized drug users, university students face lower risk of criminal sanction for their drug use. 17 "Problematic" drug use generally refers to patterns of use characterized by dependency (physiological or psychological) and/or by socially detrimental effects such as crime and poor social functioning. "Recreational" drug use is characterized in drug normalization literature as the occasional leisure-oriented use of certain substances in a controlled way (Aldridge et al., 2011; Parker, 2005). 119

Undergraduate University Context of NM-Stimulant Use Acceptability

The stressors and demands of university life prove highly taxing for students. A survey of over 38,000 Canadian postsecondary students finds that ‘‘in the previous 2 weeks’’ more than half reported feeling exhausted and overwhelmed by all they had to do (College Health

Association 2013). In the same period, one quarter of students reported feeling very lonely, very sad, and/or feeling overwhelming anxiety. At U of T specifically, a highly ranked research university, students report that large classes present intimidating environments which discourage student–faculty interaction (U of T, 2010). Financial and time constraints act as barriers to participation in cocurricular activities, which may otherwise facilitate student interaction and reduce anxiety (U of T, 2010). These extensive pressures have informed the emergence of substance-based practices to optimize alertness (e.g., energy drinks, NM-stimulant use) and to pursue leisure and pleasure (e.g., binge drinking, recreational drug use) among students (Adlaf,

Demers, & Gliksman 2005; Schulenberg & Patrick, 2012; Trunzo et al., 2014; White & Rabiner,

2012). Although stimulants commonly prescribed for ADHD may be used recreationally, the majority of students who report nonmedical use of these drugs state that they do so for academic purposes (Arria et al., 2008; Bavarian, Flay, & Smit, 2014).18 Estimates of past-year NM- stimulant use range from 0% to 25% of college students in the U.S. (Bavarian et al., 2014;

McCabe et al., 2005; Racine & Forlini, 2010; Sharp & Rosen, 2007), with one study finding a rate of 55% NM-stimulant use among a sample of fraternity members (DeSantis, Noar, & Webb,

2009). Canadian estimates for NM-stimulant use among postsecondary students are not available. However, a survey of students in Grades 7, 9, 10, and 12 in Atlantic Canada found that over 25% of those who were prescribed such medications had sold or given them away and that

18 Common names for psychostimulant medications prescribed for attention-deficit hyperactivity disorder include ritalin, biphentin, and concerta (methylphenidate); adderall (mixed-amphetamine salts); and dexedrine (dextroamphetamine; Poulin, 2007). 120 about 8% of students had engaged in past-year NM-stimulant use (Poulin, 2007). A more recent survey reports past-year use among youth ages 15–24 across Canada to be 2.4% (Canadian

Centre on Substance Abuse, 2013).

Individuals who do not qualify for ADHD diagnosis have not exhibited significant effects of these medications on test performance in comparison to those taking a placebo—though individuals may believe these drugs improve performance (Ilieva, Boland, & Farah, 2013;

Normann & Berger, 2008; Ruiz, Strain, & Langrod, 2007; Vrecko, 2013). As stated in a study that administered mixed amphetamine salts (MAS) to young adults and compared their performance on a range of cognitive tests: "a standard clinical dose of a drug that is commonly used for cognitive enhancement did not enhance cognition . . . If [MAS] does enhance cognition among healthy and adequately-rested young adults, the effects are likely to be small" (Ilieva et al., 2013, p. 504). Although NM-stimulant use may not translate into test performance improvement, this does not mean that fatigued students are simply mistaken about drug effects.

Stimulants have demonstrated effects of alertness and decreased fatigue, and so may allow for prolonged periods of studying (DeSantis & Hane, 2010; Ilieva et al., 2013; Normann & Berger,

2008; Ruiz et al., 2007).19

METHODS

In February and March 2012, 58 semi-structured interviews were conducted for a drug normalization research project with illicit drug-using undergraduate students and their nonusing

19 Stimulant medications are usually taken orally, though pills may be crushed and snorted. Typical clinical doses have been demonstrated to be safe in individuals without cardiac issues (Graham et al., 2011; Kooij et al., 2010). Low or clinical doses result in some of the effects sought after by students: alertness and decreased fatigue. Larger doses, more common with recreational use, may result in euphoria and may be accompanied by side effects such as insomnia, anxiety, and irritability (Ruiz et al., 2007). Depending on severity, overdoses may induce severe agitation, cardiac issues, and may be lethal (Rosenfield et al., 2011). Prolonged use at doses that exceed clinical applications may result in behavioral dependence (Ruiz et al., 2007). 121 peers at U of T. Students were recruited from a 1,300-person first-year social science elective course using e-mail announcements to the course list. Such class sizes are common for first- and second-year undergraduate courses at large, public, top-tier institutions in Canada such as the U of T. While social science students comprise the majority taking this course, it is also a popular elective for sciences, arts, and commerce students looking to fulfill degree breadth requirements.

Sampling was aimed at capturing variation in experiences of navigating drug use, particularly cannabis as the most common drug of use (Adlaf et al., 2005). The semi-structured interview guide was developed by the research team to explore young people’s perceptions and experiences of drug use as well as the meanings that they ascribe to use of drugs, particularly cannabis. Drug acceptability was assessed through questions on whether and how often students themselves used drugs; how accessible drugs were to them; how they perceived drug use, and legal sanctions against drug use, to impact their lives and the lives of friends and family; and for drug users, how they managed the stigma of drug use.

Prior to proceeding with interviews, the interview process was discussed with participants and participants were given consent information sheets. Participants’ questions or concerns were addressed before obtaining verbal or written consent, as preferred by the participant. Students were informed that their participation was entirely voluntary, that they could stop the interview at any time, and that they did not have to answer any questions they did not wish to answer.

Interviews were tape-recorded and transcribed. Participants were provided a CAN $20 honorarium. Ethical approval for this study was provided by the research ethics board at the U of

T (#26892).

Although this study of drug normalization was not initially designed to investigate NM- stimulant use, as interviews progressed it became apparent that the subject of NM-stimulant use

122 was being highlighted repeatedly by students. In turn, NM-stimulant use was later introduced into the semi-structured interview guide as a probe to explore the salience and evaluation of this drug practice. This resulted in 36 interviews elaborating on issues of NM-stimulant use acceptability, which are the focus of this analysis. Participants ranged from 18 to 26 years of age and included 17 women, 18 men, and 1 gender diverse student. Within this subset of interviews, the majority of participants (81%; n=29) identified as nonusers of prescription stimulants, as appears consistent with estimates of NM-stimulant use cited above. Of the 7 students who identified as engaging in NM-stimulant use, all reported use of cannabis. Three of these students also reported experimenting with illicit drugs (other than cannabis or NM-stimulant use). Of the 29 participants who did not engage in NM-stimulant use, 18 students identified as current cannabis users, 9 as nonusers of any illicit drug, and 2 as former cannabis users, that is, as having no intention to use cannabis in the future. Four of these 29 students reported having used other illicit drugs.

RESULTS

Thematic analysis of the interview data was guided by issues highlighted in the literature review of NM-stimulant use and drug normalization. Attention was directed to identifying decisions and valuations that students describe in their navigation of NM-stimulant use, and discourses that students draw upon to position assessments of NM-stimulant use. Results are grouped into three themes: (1) NM-stimulant use as a risky tool? (2) NM-stimulant use as "worth the risk," and (3) limited effectiveness of NM-stimulant use as a "study aid."20 Taken together, these themes explore the broader question of how students situate the acceptability of NM-

20 Theme 1 was identified in 20 of the 36 interviews, Theme 2 was identified in 13 interviews, and Theme 3 was identified in 11 interviews. 123 stimulant use in relation to the pursuit of success in a competitive university environment. All participant names are pseudonyms.

Theme 1: NM-stimulant use as a risky tool?

By pointing to the various risks that students refer to in their navigation of study drug use, the ‘‘NM-stimulant use as a risky tool?’’ theme identifies the forms that more acceptable

NM-stimulant use takes, namely, nonrecreational, nonpatterned, and orally ingested. Two subthemes here illustrate student positioning of NM-stimulant use risks in relation to drug acceptability. In the more acceptable NM-stimulant use: neither patterned, nor recreational sub- theme, students position patterned or recreational usage as indicative of undesirable and potentially problematic substance use behavior, as they broadly associate such behavior with drug dependency. Whereas the more acceptable NM-stimulant use: neither patterned, nor recreational subtheme suggests a shared orientation to the evaluation of NM-stimulant risks and acceptability, student comparisons of NM-stimulant use to caffeine suggest more ambivalence in situating the riskiness of NM-stimulant use. While some students compare stimulant medications to caffeine in order to illustrate the relative similarity of both licit and illicit stimulants as tools to enhance studying in the university context, other students suggest that those comparisons are untenable due to the heightened health risks associated with NM-stimulant use. The question mark in the theme name "NM-stimulant use as a risky tool?" is intended to draw attention to the uncertainty communicated by students on the effects of NM-stimulant use. Although students are concerned about negative effects of such use, there was no clear sense of what these effects actually involve.

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More acceptable NM-stimulant use: neither patterned, nor recreational.

Chloe’s reflections on NM-stimulant use among peers here captures what nonusing participants perceive as "more appropriate" use.

Chloe (NM-stimulant nonuser): I’m not totally against [NM-stimulant use] I guess, cuz if it helps you study—like they’re only using it for study purposes, and they’re using it for its real effects. They’re not like: "I’m going out [to party], I’m going to take it." It’s kinda like: "I’m studying, I need to focus, it’s a big exam." And they don’t take very big doses, so it’s kind of just like an aid. . . I’ve never used it. . . I’d rather just study on my own. Cuz I don’t know how it’s going to affect me. Interviewer: Do you think it gives people an unfair advantage or anything like that? Chloe: I wouldn’t say an unfair advantage . . . They’re people just using resources I guess. I mean, if someone didn’t have a laptop versus someone who did have a laptop, like while studying, kind of with Internet, I just consider it something like that.

Chloe differentiates recreational NM-stimulant use from study-oriented use when she expresses disapproval of "going out" as a rationale to take stimulant medications. She assesses NM- stimulant acceptability according to its capacity to act as a study aid. This suggests an explicitly productivity-oriented form of use; one that Chloe sees as appropriately corresponding to clinically intended effects of enhanced "focus" or concentration (what she terms as the "real effects") of stimulant medications. These "real effects" are contrasted by Chloe’s reference to

"big doses" which would produce the recreationally sought effect of a euphoric stimulant high.

These contrasts illustrate differences in acceptability assessments between recreational versus productivity-oriented NM-stimulant use. Chloe’s description of stimulants as an optional resource to enhance studying capacity, like "a laptop," also positions NM-stimulant use as a potential tool for increasing productivity and facilitating academic achievement. Yet there is conflict evident in Chloe’s description: she sees illicit access to stimulant medications as risky due to a lack of understanding of potential negative effects.

Pam also abruptly contrasts recreational with academic productivity-oriented NM- stimulant use. Unlike Chloe, Pam has engaged in NM-stimulant use.

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Pam: My critical reading score went up 100 points from the first time I took [the exam], so [NM-stimulant use] definitely did something. . . I just felt really aware. . . I’ve only done it once. But a few of my friends have used it not for studying, but they crush it, they snort it, and I’ve never done that. . . kids are really stupid sometimes. Interviewer: What do you think about people using prescription drugs to study? Pam: I don’t really find it cheating to be honest. . . it doesn’t make you smarter, just shuts out noise. Kids are so overworked, overstressed, and haven’t got enough sleep, that it’s like, if you wanna do that, sure. I don’t think it’s that big a deal. Some kids would be like: "It’s so unfair." But it’s not increasing your intelligence. Just maybe a little extra focus. Interviewer: So would you consider doing it again? Pam: Honestly, no, cuz my grades are good enough without it . . . Like if it’s just readily there, I don’t know if I would. It’s not something that I’d want to make a pattern out of.

Pam expresses a stark evaluative opposition between recreational and academic NM-stimulant use, with the former being described as foolish. The "snorting" mode of ingestion is indicative of recreational use, "not for studying." Although above Pam characterizes achievement-oriented

NM-stimulant use as understandable, given the pressures on time and performance in university, she is uninterested in ongoing use despite the availability of stimulant medication through her friends. This reluctance to use stimulants, despite availability, is similarly suggested by Karen

(NM-stimulant user) who states that she would only engage in NM-stimulant use again if she found herself completely unprepared for an important test.

Like Pam, Nikolas found NM-stimulant use to "be very effective" for studying. Nikolas has in NM-stimulant use on multiple occasions and describes his use as being very restricted: "I use it the least as possible. I only use it if I have to. Like if I’m in a really tight situation. But every now and then, it’s not bad. . . If there’s a pattern, that’s too often." Patterned use is suggestive of a reliance on drugs in order to perform and so is taken to be indicative of problem drug use or addiction. Despite their aversion to "patterned use," participants communicated only a vague sense of where drug use may cross into the territory of "dependence."

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Comparisons of NM-stimulant use to caffeine.

In situating the riskiness of NM-stimulant use, some students compared such drugs to caffeine as a legal stimulant. For example, Cameron (NM-stimulant nonuser) states that:

I’ve never really considered [NM-stimulant use]. . . Like I don’t even drink coffee, so I don’t believe that I need anything for my productivity. . . If I was doing something at the last minute, I’d consider doing it. So I don’t really care. And in the end, you’re still doing the work, it’s just that a drug is helping you do the work. I mean, people drink coffee, and people don’t look at them differently for drinking coffee, so. Even though Adderall [i.e., NM-stimulant use] is obviously on a more extreme magnitude, it’s still more or less the same concept to me.

Cameron discusses his ambivalence regarding NM-stimulant use in relation to stimulants as tools for productivity. His comparison to coffee suggests that academically-oriented stimulant use exists on a spectrum of acceptability, with unregulated stimulants such as caffeine being more acceptable and prescription medications as "more extreme." Yet these are all tied together by their role as tools for "helping you do the work."

Ethan (NM-stimulant nonuser) makes a similar comparison:

I don’t see anything morally wrong with [NM-stimulant use]. It’s probably not the best way to study, but if it works for them, I’m not one to judge. . . [But] I don’t want to be associated with drugs that could potentially be addictive. Or I don’t want to be using things that are really going to alter my mind state. But I’m kind of a hypocrite, cuz I do drink an energy drink before each exam, just cuz I know the effects will help. . . But I don’t want to be in a position where I’d need to use [prescription stimulants].

Ethan’s reflections highlight both the similarities between highly caffeinated drinks and NM- stimulant use and the differences between these as centered on concerns of dependency and addiction. For Ethan, NM-stimulant use is not in and of itself immoral. Rather, it is the threat that

NM-stimulant use poses to self-control ("alter my mind state") and self-sufficiency ("potentially be addictive," "need to use") which underlies Ethan’s aversions to such use.

Sam has engaged in NM-stimulant use, comparing it to "when you drink a lot of coffee, but without the jitteriness." Sam conveys ambivalence about occasional student NM-stimulant

127 use but positions such use as "not a fantastic idea. It’s not a good long-term thing at all." Unlike other participants’ caffeine comparisons, Sam compares the potential harms of NM-stimulant use to high levels of consumption of caffeinated energy drinks. For Sam, both NM-stimulant use and high levels of energy drink use are risky as long-term study optimization strategies.

Countering the ambivalence toward achievement-oriented NM-stimulant use articulated by several participants, some students found that such use was unnecessary and could not be easily compared to caffeine. Billy (NM-stimulant nonuser) states that:

Ritalin in my mind is much harder than caffeine, which is extremely mild. Also, Ritalin, it’s a prescription, obviously there’s a reason for that. So if people are abusing prescription drugs as opposed to, say, coffee, that would be different for me.

Two acceptability orientations are evident in student comparisons of prescription stimulants to caffeine. Some students used caffeine comparisons to communicate ambivalence to productivity- oriented NM-stimulant use (though not to recreational or patterned use) while situating prescription stimulants as being similar, yet riskier tools than caffeine. Other students considered

NM-stimulant use to be ill-advised due to the possibility of side effects or addiction, and so as not comparable to caffeine as a study aid.

Theme 2: NM-stimulant use as "worth the risk".

The NM-stimulant use as "worth the risk" theme expands from the previous theme to explore the logic of how participants weigh the risks and advantages of NM-stimulant use, specifically in relation to the pursuit of scholastic success. For example, when asked if NM- stimulant use gives students any advantage, Nikolas (NM-stimulant user) states that:

Yeah. Huge advantage. Like for studying, being more focused, taking in information . . . It does make you do better. It could be unfair, but at the same time . . . somebody that does it a lot, they’re going to be less healthy than I am. . . It’s just not worth the sacrifice

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for me. I don’t feel "Oh that’s unfair, and I feel bad about that." I know it’s unfair, but I accept that.

Nikolas argues that any "unfairness" associated with regular NM-stimulant use is mitigated by the fact that users are making health sacrifices. For Nikolas, health acts as a currency that one can trade for success on an individualized basis. NM-stimulant use may be unfair, but because

NM-stimulant users are in a sense "paying their dues" for success in the form of health sacrifices, this unfairness in turn becomes acceptable.

Robert (NM-stimulant nonuser), like Nicholas, expresses this tension between attaining success and maintaining health. Robert does not drink alcohol and avoids taking medication, aiming to be "substance free." When asked if he would consider NM-stimulant use, he responded with an ambivalence which contrasts with his resolve to be substance free:

Yeah, probably. . . if it’s for like future success, I mean, sure. . . if it affects my memory or something, then I probably wouldn’t. If it just like, shortens my life a little bit, then I probably wouldn’t care that much. I’d rather be like, you know, successful, than a healthy hobo on the street kind of thing.

This conceptualization of exchanging health risks for future success is apparent throughout the interviews, and particularly in the generalized disapproval of either "patterned" productivity- oriented NM-stimulant use or recreational use.

As Robert’s comment suggests, even for some students who do not use illicit drugs, NM- stimulant use was considered a possibility. Likewise, Tianna (NM-stimulant nonuser) rarely drinks alcohol and does not use illicit drugs, yet she feels that under certain circumstances, NM- stimulant use might prove acceptable:

I’ve been tempted before to use amphetamines, like Ritalin or something, close to exam time. But I’ve never done it. . . the fear of damaging my brain is always in the back of my mind. . . For me, personally, I just wouldn’t, but for anyone, sure. . . It’s not that I’m actively considering it, but there are times when I’m studying and it’s late at night, I’m tired, I need to cram in 100 more pages. . . [NM-stimulant use] looks good! You know? It

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looks fantastic. Would I love to be hyper-productive? Absolutely! What’s the crash like? You know what, when I’m tired, things like that don’t matter as much.

Although less explicitly a statement of NM-stimulant use being "worth the risk" than is apparent in Nikolas’ reflections, Tianna’s comments nevertheless elicit that sense of tension between feeling driven to succeed and the health risks and sacrifices students associate with NM- stimulant use.

Michael (NM-stimulant nonuser) generally disapproves of NM-stimulant use. He suggests that proximity to NM-stimulant users and accessibility may compel students to consider such use:

I just feel like you’re resorting to something, instead of time managing, or getting services from the [student] center. It’s like instead you’ve just chosen to take a drug to mitigate all those other things that you could’ve adjusted. But easier said than done. Like, it’s not an easy thing. Especially if you have access to it, and a group of friends who does it, and [they say] "Yeah it’s safe, I’m ok, it just helps me really focus." I definitely feel like it’s a very last resort for me.

NM-stimulant use exists as a potential resource, particularly as one of "last resort," for strained students. Maintaining self-sufficiency in academic work by avoiding risks to health that are

"unnecessary" is central to evaluations of when NM-stimulant use is "worth the risk." If the effects of prescription stimulants are short-lived and controlled, that is, they do not result in addiction or (immediate) detrimental health effects, then use is seen as more acceptable. This attitude is also captured by student aversions to patterned usage, as shown in the "NM-stimulant use as a risky tool?" theme above, where patterned use suggests a risk of substance dependence, a "disease of the will" (Valverde, 1997) that fundamentally threatens one’s capacity for self- control.

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Theme 3: Limited effectiveness of NM-stimulant use as a "study aid".

As illustrated above, participants generally positioned NM-stimulant use as being more acceptable when it is not patterned, and when it is used as a productivity tool for alertness that facilitates assignment completion or long hours of studying. Chloe’s comments on such use being like a "laptop" capture this tool-based conception of NM-stimulant use, as do student comparisons of prescription stimulants to caffeine (though this tool may be seen as "too risky," particularly by nonusers). Despite the perception that nonmedical use of stimulants may facilitate academic achievement, several participants were hesitant to identify such use as "cheating." The final theme identifies an understanding among students that NM-stimulant use provides limited compensation for health risks because it is not seen as able to enhance one’s intelligence.

Instead, NM-stimulant use can provide compensation for fatigue or lack of time by potentially increasing alertness and thus prolonging engagement in work.

Ron (NM-stimulant nonuser) locates the pressures to engage in NM-stimulant use in the organization and costs of university. To Ron, NM-stimulant use is understandable given these pressures, but it only facilitates completing assignments, not "learning" from them:

I don’t think [NM-stimulant use is] good for memory, you don’t really learn anything, you’re just finishing assignments. . . I think that [NM-stimulant use] has a whole lot to do with the school system. . . there’s a personal fear of the length it takes to graduate, and also the what’s going to happen after graduation. . . The fact that it’s expensive is really putting a toll on people, especially now that it’s a recession.

This sense that "you don’t really learn" when engaging in NM-stimulant use is echoed by Gary

(NM-stimulant user):

Everything was just happening so fast [when I took Adderall]. You’re writing, you’re stimulated, you’re concentrated. It’s not cheating, because cheating means there’s a benefit. People that take Adderall. . . don’t get me wrong, they’ll get good marks, and they’ll think they’re successful. But they’re only putting themselves through a meat grinder. Whereas the person who comes here and really just absorbs everything. And that’s the person who’s gonna be brilliant at the end of his university career.

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Thus, for Ron, and particularly for Gary, the benefits of increased alertness and concentration do not carry over to "really just absorb[ing]" the material, though this does assist in completing assignments and meeting the deadlines necessary to accrue educational credentials. This characterization positions academic NM-stimulant use as "not cheating" insofar as such use does not alter something seen as fundamental to fair evaluation and to individual character: intelligence or learning capacity. Pam’s comments above also convey this understanding that

NM-stimulant use does not "make you smarter."

A "compensatory" understanding of academically oriented NM-stimulant use acceptability is evident, such that changes in performance are not beyond what one would be capable of in rested, less stressful circumstances in the absence of NM-stimulant use. That is, if

NM-stimulant use resulted in enhancements to what students perceive to be essential aspects of one’s character, such as learning capacity or intelligence, this would suggest that NM-stimulant use could constitute "cheating" and so would be unacceptable. In contrast, enhancements to alertness or focus in the pursuit of academic achievement are not necessarily seen as unfair. This lack of fundamental concern with the unfairness of alertness optimization is partly captured by student comparisons to caffeine as an acceptable stimulant alertness aid. Rather than constituting

"cheating," some participants propose NM-stimulant use be understood as a compensatory strategy for fatigued students, albeit a riskier one than caffeine use.

DISCUSSION

Discourses Of Health And Risk In The University Context

In order to identify the evaluative metrics of drug acceptability circulating in the arena of student life, this chapter looks to the operation of discourses that converge in patterning drug- using and nonusing student repertoires of what constitutes responsible or acceptable drug use

132 practices, and what instead signals deviance, lack of moral standing, and vulnerability to addiction. Such discourses produce moral imperatives of health at the same time that they produce possible avenues for conduct, evaluation, and pressures as well as possibilities for self- cultivation (Race, 2009; Rose, 2007; Turner, 1992). Discourses of health and risk responsibilize individuals for social sources of pathology or disorder, situating them as accountable for their own life outcomes regardless of unequal access to social, symbolic, and material resources for normative self-making which also structure one’s mode of living (Gusfield, 1996; Hannah-

Moffat & O’Malley, 2007; Hunt, 2003; Skeggs, 2004a).

Participants draw upon these discourses of health and risk to articulate that students are responsible for their personal decisions about how they choose to pursue scholastic success.

Exchanging health risks for success, as through NM-stimulant use, is understood as one such decision. Failure to avoid drug dependence or associated harms is suggestive of a lack of self- discipline or sufficient care in conducting one’s consumption (Race, 2009; Valverde, 1997). Risk concerns are especially evident in student discussions of peer recreational NM-stimulant use, which are largely considered an illegitimate form of use by participants. Concerns are also evident in students’ vague descriptions of patterned use as potentially resulting in dependence.

While dependence can occur with chronic stimulant usage, the students here do not articulate how much of a pattern results in vulnerability to dependence. This analysis contradicts recent findings that NM-stimulant users in university frame stimulant use as generally lacking harmful physical side effects in order to justify their use (see DeSantis & Hane, 2010). In contrast, the current study finds that concern with health harms figures prominently in delimiting the acceptability of forms and patterns of NM-stimulant use among both users and nonusers.

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Respondents broadly hold in common an ethic of self-sufficiency for the evaluation of

NM-stimulant use acceptability. This ethic operates as a moral compass for navigating NM- stimulant acceptability in relation to university pressures, even among nonusing students. This ethic involves practices of moderation, or self-regulation of substance intake to the aim of avoiding any prolonged negative effects on performance. For several participants, this meant that sporadic NM-stimulant use as a resource of "last resort" was acceptable but ill-advised due to the more extreme nature of NM-stimulant use in comparison to popularly available legal stimulants, such as caffeine products, and the potential for harm or addiction. For others, only medically prescribed stimulant use was acceptable since NM-stimulant use presented unwarranted health risks that ultimately threatened this self-sufficiency.

The ethic of self-sufficiency is informed by responsibilizing discourses of risk and health discussed above. These discourses lend themselves to an individualized sense of struggle for achievement among students. Although students repeatedly pointed to contextual pressures centered on workload management and maintaining scholastic performance as drivers of NM- stimulant use, their responses to these pressures were very matter-of-fact. Students approached these pressures as simply those of university life and saw little alternative but to bear the pressure as best one could. The social process of pharmaceuticalization, whereby "pharmaceutical products come to be put to work in the management of an increasingly wide array of problems and experiences" (Vrecko, 2015, p. 299), is evident in the way that both users and nonusers navigate the acceptability and administration of stimulant medications in pursuit of university education and in response to these contextual pressures.

When these contextual pressures coalesce, they make it difficult for students to meet demands for academic success and so act as push factors for students to consider unsanctioned

134 resources such as NM-stimulant use. Financial pressures, particularly in the face of growing employment uncertainty postgraduation, also play a role in the sense of generalized strain experienced by students. In addition, familiarity with peer group NM-stimulant use acts as a contextual pull factor. No student suggested that peers pressure one another into NM-stimulant use. Rather, NM-stimulant use becomes more salient as a resource for personal use once peers confirm drug effects and provide potential avenues for access to medications. This social learning effect has been supported by quantitative research on student NM-stimulant use (Peralta

& Steele, 2010; Schroeder & Ford, 2012). Yet as several participants above indicate, simply because students have engaged in NM-stimulant use previously does not mean they are interested in continuing such use, even if their experiences were positive ones.

While NM-stimulant use is understood as unable to alter one’s intelligence, students may nevertheless perceive themselves to be performing more effectively during a test due to an enhanced sense of focus. Recent research reports lack of significant effects of clinical stimulant doses on student performance on a variety of cognitive tests among "adequately rested" students

(Ilieva et al., 2013). In fact, this research suggests that academically oriented NM-stimulant use may slightly reduce performance (Ilieva et al., 2013; Normann & Berger, 2008). The findings of

Ilieva, Boland, and Farah (2013) indicate that NM-stimulant use does not effectively operate as a

"doping agent" for test scores. Interestingly, this is confirmed by participant responses above that suggest some students recognize NM-stimulant use as not impacting learning capacity.

The health sacrifices associated with NM-stimulant use appear to offset student concerns of unfair advantages. Students signal the existence of an exchange economy of achievement

(afforded by extending time awake or concentration) and health risks, where one who engages in

NM-stimulant use is seen as paying dues in the form of life years or eventual health

135 compromises. Engaging in NM-stimulant use is thus positioned as an individual choice of risk assessment. Such an economy helps us to understand why students would be reluctant to call such use "cheating," which intimates a request for authoritative intervention and regulation to dispel unfair advantage. Rather, NM-stimulant use appears to be approached as a self-governing economy of advantages and built-in costs, and so one that does not compel students, users or nonusers, to call for university intervention into protecting the process of academic evaluation from the impacts of "unearned" advantages.

In sum, NM-stimulant use is evaluated as acceptable by the students here in terms of it being an exchange value–oriented productivity tool—one that must be negotiated in relation to the ethic of self-sufficiency which guides moral appraisals of NM-stimulant self-administration practices. Students are constantly in the process of navigating the health pressures of scholastic performance in terms of fatigue, stress, and lack of sleep. The patterning of student responses in how they evaluate NM-stimulant acceptability indicates that the ethic of self-sufficiency is geared toward the pursuit of two related goals among both NM-stimulant-using and nonusing students. First, self-sufficiency is conceived in terms of ableist conceptions of health, such that one is able to continue developing one’s accrual of educational capital—a goal which students suggest cannot be effectively pursued in the case of patterned, dependent, or otherwise problematic NM-stimulant usage. Second, self-sufficiency is understood in terms of eventual employability, which may require short-term exchanges of health or engagement in "risky" behavior to accrue the necessary educational capital to ensure success (and avoid becoming what

Robert derides as a "healthy hobo"). The ethic of self-sufficiency is thus a way of navigating the ongoing tensions between the accrual, exchange, and maintenance of health and educational capitals in a competitive university context.

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Yet it is clear that students do not unilaterally take up the discourses of health and risk in pursuing academic success, nor do they do this in a way that corresponds to institutionally sanctioned directives. Discourses are productive of potential ways to navigate, evaluate, and discipline conduct. Evident in student descriptions of NM-stimulant acceptability is the creative mix-and-match manner with which they navigate the multiple and contradictory demands placed upon them in university.21 Students recognize they must remain free of problematic substance use in order to pursue educational success. They also identify the pressures they face with regard to lack of sleep and the need for supplementing study habits with stimulants, legal or otherwise.

Thus, some students are complying with directives for academic success (e.g., studying for long hours) but through the use of illicit tools that subvert university codes of conduct and through an experimental juggling of health risks for success "payoffs." The self-sufficiency ethic informs how students navigate these demands, providing a way to integrate contradictory directives and to guide their experimentations with illegal and legal stimulants. Given that academic success is seen as a primary determinant of future employment, it is little wonder that even students who do not use illicit drugs and who are averse to personal NM-stimulant use have come to consider it as a viable strategy, should they find themselves in difficult circumstances.

Implications For The Drug Normalization Framework

Drug normalization is a framework or "barometer of change" (Parker, 2005) intended to assess shifts in drug use trends. Drug normalization is characterized by several components including (a) changes in rates of illicit drug use, in drug accessibility, and in availability of drug

21 In the interviews, students are not simply expressing their views on stimulant acceptability but are also constituting themselves as enterprising subjects (Callero, 2003; Skeggs, 2005). Through their narrative positioning of what signifies ‘‘responsible consumption’’ of stimulants, students perform a disciplined, calculating self that appropriately self-regulates NM-stimulant use. By attributing a moral value of self-discipline to themselves, they may make a claim to the role expectation of ‘‘good student,’’ whereas habitual or recreational NM-stimulant users are positioned as a foil for excessive or risky conduct that demands sanction. 137 knowledge among users and nonusers; (b) cultural accommodation of drug use, as for instance, is evident in the proliferation of favorable media depictions of illicit drugs; and (c) in acceptance of drug use as part of "ordinary" life, or drug acceptability, identified in the attitudes of both drug users and nonusers toward drug use (Aldridge et al., 2011; Duff et al., 2012; Hathaway, 2004).

Although the drug normalization framework has proven fruitful for expanding the scope of knowledge on drug acceptability, this framework was initially developed in the early 1990s, when productivity-oriented illicit substance use among students was not a prominent phenomenon. Thus, there are apparent limitations to applying the framework for investigation of

NM-stimulant use. Like much research on conventional population drug use, drug normalization literature proceeds from a binary approach to understanding drug acceptability according to the categories of "problematic" or "recreational" use (Aldridge et al., 2011; Parker, 2005). Due to its largely nonrecreational character (Arria et al., 2008), student NM-stimulant use for studying is unlikely to be adequately described by these binary formulations on which the drug normalization framework has relied to characterize assessments of acceptability. This limitation arises because the normalization framework was developed from this "problematic versus recreational drug use" division as an operative analytic foundation. Recreational use was initially formulated as a way to push the research conversation beyond "pathological" or "deviant" drug use on which the majority of drug studies have focused, yet which characterizes but a small fraction of all illicit drug activities (Aldridge et al., 2011; Duff et al., 2012; Parker, 2005). This analytic move was an important development in sociological work on drug issues. However, the growing salience of productivity-oriented illicit substance use now requires normalization research to attempt to account for drug use that cannot be classified as neither recreational pleasure-/leisure-oriented use nor problematic due to compulsive or damaging use patterns.

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As indicated by the phenomenon of student NM-stimulant use as a "study drug," examples of substance use are steadily emerging that do not conform to the "controlled pleasure" versus "pathology" evaluative principles initially posited by the drug normalization framework.22

The interview analysis above suggests a conceptual compatibility that allows for extension of the normalization framework to consider illicit drug use that is oriented toward productivity and achievement. The interviews illustrate that student acceptability assessments of NM-stimulant use are indeed anchored in considerations of pathological or problematic use, which corresponds with the original formulation of the normalization framework. However, beyond their references to pathological use, student assessments of academically oriented NM-stimulant use are simultaneously anchored in considerations of recreational use as largely unacceptable in the context of a competitive university environment. So while "recreational" and "achievement- oriented" drug use evaluations are assessed by comparison with one another, both of these evaluations share a foundation for acceptability assessment in the form of "pathological" drug use. These student evaluations of NM-stimulant use thus suggest that a third type of substance use be conceptually integrated into the normalization framework’s construct of acceptability assessment: productivity and achievement-oriented illicit drug use.

CONCLUSION

This chapter contributes a qualitative exploration of student navigation of NM-stimulant use acceptability. This analysis suggests that NM-stimulant use is not adequately captured by the formulations of "recreational versus problem" dichotomy of acceptability put forward by the drug normalization framework. Instead, the focus in student evaluations of NM-stimulant

22 Other research, though not addressing the drug normalization framework directly and usually limited to athletes or specific subcultures of drug use, is also engaging in the conceptual work of problematizing this dichotomy (Duff & Erickson, 2014; Monaghan, 2002; Pappa & Kennedy, 2013; Race, 2009; Vecitis, 2011). 139 acceptability is not limited to the recreational use of drugs to "get high" versus "problematic use" typified by compulsive or patterned drug behavior but includes a separate set of highly conditional evaluative standards specific to the university context: the capacity for NM-stimulant use to temporarily enhance alertness for a period of time in order to facilitate academic success.

It is the context of university pressures and goals of academic success that bring into view the parallel alignments between the repertoires of using and nonusing students on NM-stimulant use acceptability.

Where might such an orientation be traced? Beyond their familiarity with caffeine as a stimulant tool to get through long days, students are also introduced to understandings of drug effects and self-administration practices through the widespread prescription of stimulant and antidepressant medications to peers, friends, and family (Quintero, 2012; Rose, 2007). Indeed, several participants cited friends or family being prescribed such medications. As stigma for mental health medication use decreases, and as people are expected to actively participate in the pursuit of mental and physical health through psychological or psychopharmaceutical therapies, the conversation regarding self-regulation also shifts from medical to more generalized discourses of well-being and achievement (Race, 2009; Rose, 2007). Situating student approaches to NM-stimulant use within the institutional pressures of the university and within wider social processes that converge to prompt specific approaches to drug acceptability can help us to understand why favorable attitudes to productivity- oriented NM-stimulant use are gaining traction even among students who declared themselves opposed to illicit drug use.

It is important not to assume that NM-stimulant acceptability evaluations or rates of use are uniform across students. Although beyond the scope of this chapter, future work should consider how racialized, gendered, and other axes of inequality differentiate acceptability

140 evaluations and use patterns. For instance, recent reports on rates of adult ADHD prescription suggest that women have begun to outnumber men in receiving diagnoses—an inversion of the childhood diagnosis pattern (Express Scripts, 2014). Women also have been demonstrated to engage in NM-stimulant use for bodily modification and to face stigmas of use very different from those faced by men (Poole & Dell, 2005; Sharp & Rosen, 2007; Vecitis, 2011). It is unknown whether these gendered patterns transfer to NM-stimulant use in the university context.

This chapter is limited mainly to the perspectives of first-year social science students. All

NM-stimulant users in this sample described their use as being infrequent, as is consistent with quantitative research which finds that most NM-stimulant use is sporadic among university students (Arria et al., 2008). Older students, those in different disciplines, and those who engage in more frequent NM-stimulant use may suggest different evaluations of acceptability. Further comparative work is essential to expanding understanding in this regard. The sensationalization of hazardous instances or risks of student NM-stimulant use by the media and academic researchers is likely to drive "an anxious demand for. . . authoritarian techniques aimed at domesticating consumption" (Race, 2009, p. 79). In the face of what may be a brewing drug panic, it is important to advocate for proportionate policy responses to address harmful use practices; failure to do so will result in marginalization of visible drug users rather than effective reduction of harms, as the history of drug panics so clearly illustrates (Race, 2009; Young 2009).

Given the generally sporadic nature of NM-stimulant use documented among university students

(Arria et al., 2008), increasing the restrictiveness of prescribing practices looks to be positioned to disproportionately negatively affect those who require medication for treatment, rather than to deter those who are illicitly using such medications (Ruiz et al., 2007). In addition, given the lack of evidentiary support that NM-stimulant use operates as a "doping agent" to inflate test scores

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(Arria et al., 2008; Ilieva et al., 2013), punishment of study drug use as "cheating" does not appear to be a viable strategy to ensure academic integrity. Further, identifying NM-stimulant- using students requires invasive surveillance (e.g., searching of student belongings to confirm illicit possession of stimulant medications) and drug testing (e.g., urinalysis), and so encounters various legal barriers. It is doubtful that Canadian universities could justify such intrusive and costly measures, given the low level of harm currently posed by NM-stimulant use, in addition to the lack of evidence for effectiveness of "cognitive enhancement" practices.

Rather than the pursuit of punishment and surveillance, providing education on the potential harms and lack of effectiveness of "study drug" use may help to discourage students from turning to NM-stimulant use in moments of desperation. The results here suggest that universities, especially those with highly competitive environments, would do well to evaluate the roles that tuition structures, examination schedules, and grading practices play in contributing to the student "meat grinder" that compels consideration of NM-stimulant use as a compensatory strategy.

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CHAPTER FIVE - Conclusion

The collection of chapters in this dissertation critically engages with the drug normalization framework, a conceptual and methodological toolkit designed to assess shifts in recreational drug use trends, practices and attitudes, and to explain the growing social accommodation of illicit substance use that has occurred over the previous 20 years (Parker et al., 1998; Aldridge et al., 2011; Williams, 2016). This framework represents a key avenue for investigating drug use among conventional populations who account for the vast majority of all illicit drug use, and is central to advancing research beyond dominant deviance and addiction- focused approaches which only address a small minority of drug patterns and outcomes (Pennay

& Measham, 2016). However, as noted in the introduction, the inadequate “one size fits all” approach which predominates in normalization literature has resulted in oversimplified representations of recreational drug use that neglect to investigate how social location continues to shape experiences of drug-related stigma, peer social accommodation, and drug use practices.

Shildrick (2002) proposes the concept of "differentiated normalization" (2002, p.36) as a more fitting tool for understanding contemporary drug use because it refocuses analysis on identifying the ways that drug use may be normalized for different groups and different types of drug use.

My doctoral work serves as a direct response to Shildrick's (2002) recommendation, offering significant contributions to the field of substance use research by employing mixed methods to assess how drug acceptability attitudes, accessibility and recent use rates of cannabis among undergraduates are impacted by social and contextual factors such as gender, immigration, and peer network drug use prevalence. Moreover, my research also demonstrates how the acceptability of nonmedical use of prescription stimulants is shaped by the social pressures of the university context.

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Below I provide brief summaries of the key findings of each of the standalone article chapters (Chapters Two, Three, and Four) before speaking to the overarching conclusions and implications of the project as a whole. I conclude with a discussion on the opportunities for future research that are suggested by this work.

In Chapter Two, I presented the findings of a multivariate quantitative assessment of cannabis normalization in Canada, focusing on three components of the drug normalization framework: drug acceptability, accessibility and recent use rates. This chapter identifies the importance of gender as a social factor which differentiates the normalization of cannabis use. In

Canada, there has also been significant convergence in men's and women's rates of cannabis use over time, with survey data indicating that differences between men and women in lifetime cannabis use are no longer significant (Health Canada, 2007; Statistics Canada, 2017; Rotermann

& Langlois, 2015), and recent survey results showing that gender differences in past-year use have narrowed as a result of significant increases in women's use from 7% to 10% from 2013 to

2015 (Statistics Canada, 2017). The findings in Chapter Two reflect these survey results, showing that women continue to exhibit significantly lower rates of recent cannabis use than men, but do not differ in lifetime use rates (see Table 2). The finding that there is no statistically significant difference in cannabis accessibility between men and women who have used cannabis provides further evidence of gendered convergence in cannabis normalization (see Table 4).

Despite these convergences, the findings in Chapter Two illustrate an enduring gendered character of cannabis acceptability, with women reporting lower odds of positive acceptability attitudes (see Table 3). As such, this research shows that gender cannot be dismissed in the differentiation of cannabis normalization, despite convergences in the drug normalization framework components of accessibility and use rates.

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Chapter Two also contributes unique findings on the relationship of immigration to cannabis normalization, providing evidence of a substance use acculturation effect. Canada ranks among countries with the highest prevalence of lifetime and past-year cannabis use in the world, and so it should be expected that immigrants to Canada are generally exposed to more positive attitudes towards cannabis and greater accessibility in comparison to their countries of origin

(Canadian Centre on Substance Use and Addiction, 2017). The findings in Chapter Two support this expectation, showing that students who are recent immigrants (i.e., those who have lived in

Canada for 4 years or less) exhibit significantly lower cannabis acceptability attitudes and less accessibility than either students born in Canada or longer-term immigrants, with these latter two groups not being significantly different from one another in these two key normalization components (see Tables 3 and 4). Students who are recent immigrants also exhibit the lowest recent cannabis use rates, followed by longer-term immigrants, with students born in Canada exhibiting the highest rates of recent use (see Table 2). These findings indicate that substance use acculturation is an important process to consider in the differentiation of cannabis normalization.

Methodologically, these findings also show that it is necessary to disaggregate recent from longer-term immigrants in survey analysis of substance use trends, as combining these groups into a single variable will conceal separate group effects and so underestimate differences in substance use attitudes and rates from students who are born in Canada.

Finally, this chapter contributes novel evidence for a threshold effect in the social accommodation of drug use, where students who associate with a peer network comprised entirely of cannabis users exhibit significantly lower acceptability cannabis attitudes than students who report only 'some' cannabis users in their peer network (Table 3). By decoupling acceptability attitudes from peer network use prevalence, this finding directly challenges

150 underlying assumptions in the normalization framework that drug use prevalence is necessarily an indicator of more accepting attitudes towards recreational drug use.

This chapter represents the only quantitative assessment of cannabis normalization in

Canada to date, and so provides a key contribution to substance use scholarship in the Canadian context. At the time of data collection for this study in 2011-2012, cannabis possession was criminally prohibited with the exception of access to cannabis for medical purposes. Impending legislative changes to drug policy in Canada in 2018 are positioned to legalize cannabis possession for recreational purposes, and to create a system of legal regulation for commercial production and distribution of cannabis (Task Force on Marijuana Legalization & Regulation,

2016). As such, Chapter Two also establishes an invaluable datapoint on recent use rates of cannabis, accessibility, and acceptability attitudes during a period of prohibition which will be essential for informing future comparative studies on the impacts of policy changes on cannabis normalization.

Whereas Chapter Two illustrates that gender and nativity are statistically significant factors in the differentiation of cannabis normalization, Chapter Three applies thematic coding analysis of 58 semi-structured interviews with cannabis using students and their nonusing peers to qualitatively identify how gender and immigration shape student cannabis use practices and acceptability attitudes. This chapter contributes in-depth description of the gendered stigmatization and social pressures that women experience as cannabis users, persisting despite statistically significant convergences in use rates between men and women and also despite the relative pervasiveness and acceptability of cannabis in comparison to other illicit drugs in the university context. In the interviews, women are represented as more risk-averse and vulnerable in their navigation of cannabis use than men, as attention-seeking in their reasons for engaging in

151 cannabis use, and as immature and inexperienced in their self-presentation when using cannabis.

Women's cannabis use was thus shown to be subjected to more negative judgement overall among students. While this was true of both male and female respondents, female students generally reported more critical attitudes towards women's cannabis use than their male peers.

This chapter further shows how drug normalization components of accessibility and acceptability are differentiated by gender. Peer social accommodation of women's recreational cannabis use is far more critical and restrictive than of men's, indicating the operation of binary gendered standards in cannabis acceptability assessments. In addition, women must navigate unique gendered barriers in order to access cannabis in an illicit drug market that is dominated by men.

In addition, Chapter Three shows that pathways of cannabis accessibility remain highly gendered, despite findings in Chapter Two that women and men do not report significant differences in whether cannabis was accessible to them. Chapter Three shows that though women can easily access cannabis through social sharing networks, women nevertheless experience considerable barriers that prevent their equal participation as either buyers or dealers in the illicit cannabis market. Women reported concern of receiving contaminated cannabis from dealers or lower amounts than was paid for, as well as concern regarding their safety when buying directly from dealers. These issues pressured women to defer the act of purchasing cannabis to male friends or romantic partners. Students also reported that women are often relegated to lower rungs of the cannabis selling hierarchy due to widely held perceptions of women's vulnerability. This gendered stratification of illicit cannabis accessibility symbolically encodes the purchasing, use and possession of cannabis as being masculine activities.

Some students actively disrupted the gendered stigmatization of cannabis acceptability evaluations and the gendered stratification of accessibility pathways. For example, some women

152 reported undermining the stereotypical derogatory or deviant associations of cannabis use. They did so by claiming social belonging as cannabis users through drawing on academic success and conventional feminine gender presentation as symbolic sources of legitimacy and social integration. This strategy presents cannabis use as nonthreatening in the evaluation of women's self-presentation, though it simultaneously may reinforce binary gender expectations. Other women reported disregarding social pressures to avoid cannabis use, and some sought to meet masculine-encoded expectations of cannabis use as a way to illustrate to peers that they were experienced or mature cannabis users. Such strategies served to support their claims to the legitimacy of conventional women's cannabis use.

Chapter Three also sheds light on the cultural character of cannabis acceptability. Both undergraduate students born in Canada and those born abroad reported shared perceptions that accepting attitudes towards cannabis use are a "Canadian" attribute. Students born abroad identified stricter enforcement of cannabis prohibition, as well as severe social stigma, as reinforcing restrictive attitudes towards cannabis in their countries of origin. The relative absence of comparable penalties in the Canadian context, in addition to wide exposure to cannabis use among their campus peers, led students who were born abroad to re-evaluate their own attitudes to cannabis. These findings speak to the social context of substance use acculturation, an effect identified in Chapter Two.

Whereas Chapters Two and Three illustrate how cannabis normalization is differentiated by various social and contextual factors, Chapter Four explores the differentiation of drug normalization through analysis of nonmedical prescription use of stimulants [NM-stimulant use].

Through analysis of a subset of 36 interviews conducted with students at the University of

Toronto, Chapter Four demonstrates how NM-stimulant use is not adequately captured by the

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"recreational versus problem drug use" dichotomy put forward by the drug normalization framework to conceptualize drug acceptability evaluations. Students widely rejected the categorization of recreational NM-stimulant use as irresponsible. Instead, both NM-stimulant users and their nonusing peers reported a productivity-oriented acceptability evaluation of NM- stimulant use: such use was acceptable only as a means to ensure scholastic success during times of severe stress and fatigue, and then only if used sporadically. These student evaluations of NM- stimulant use suggest that the category of productivity-oriented illicit drug use should be integrated into the normalization framework’s construct of drug acceptability.

Study Implications and Considerations for Future Research

Canada is in the process of legalizing non-medical cannabis, with a legal regulatory framework for possession, use, and recreational supply expected to be in effect in 2018 (Task

Force on Marijuana Legalization & Regulation, 2016). These regulatory changes represent an unprecedented re-evaluation of the punitive anti-drug policies that first came into effect when cannabis was criminalized in Canada in 1923, and that dominated drug control efforts during the dramatic upswing in cannabis use that began in the 1960s (Erickson 1992; 1993; 2015). These new proposals also illustrate a shift towards public health-oriented approaches to drug policy which recognize the extensive harms caused by cannabis criminalization to individuals and communities (Kirst et al., 2016; Erickson, 2015). These regulatory changes will wholly restructure the accessibility of cannabis, as well as the social and legal consequences of cannabis possession and use. Such policy changes are a clear indication that cannabis is entering a new and more intensive era of drug normalization (Hathaway et al., 2018). My work provides an important datapoint during a period of cannabis prohibition in Canada, and so can be used to directly inform future evaluations of cannabis use trends and attitudes under a new regulatory

154 regime. Such information is essential to assess the impact of this radical policy change on cannabis normalization.

Gender convergence in lifetime cannabis prevalence was initially identified in early drug normalization research that was conducted in Britain (Parker et al., 1998; Aldridge et al., 2011).

Such findings suggested that gender was no longer protective from drug involvement, and in turn gender-based analysis receded from the drug normalization program of investigation for several years. However, as the findings in Chapters Two and Three illustrate, gender continues to be important in differentiating cannabis use practices, norms, and accessibility pathways, and so should be included in drug normalization assessments when possible. As shown in Chapter

Three, the social organization of the illicit cannabis market and gendered risks (i.e., women's reported feelings of vulnerability to assault and concerns of being given laced cannabis or lower amounts of cannabis than was paid for) are major contributors to the gendered differentiation of cannabis normalization. The impending regulatory changes to cannabis policy in Canada are positioned to undermine these barriers to women's participation in the social world of cannabis use. My research suggests that this policy change will likely result in further gendered convergence in cannabis use rates and accessibility, as women will be given an alternative, legally regulated access point to cannabis which will avoid many of the gendered barriers associated with participating in the illicit cannabis market. Women are thus likely to become more comfortable in individually navigating the purchase of cannabis.

Similarly, my findings on substance use acculturation among students born abroad suggest that the prohibition of cannabis has been an important deterrent to cannabis use for recent immigrants. Longer-term immigrant students, however, are less deterred by the threat of criminal penalties, as they have come to learn that in Canada such penalties often go unenforced,

155 especially in the university context. The sanctioning of recreational cannabis use by the Canadian government through legal regulation is positioned to more quickly undermine this deterrent effect. Thus it can be expected that the speed of substance use acculturation among immigrants will increase. Stigma against cannabis use may in turn also be reduced, though as the literature on informal social control of cannabis use shows, this stigma has been minimally impacted by cannabis prohibition in Canada (Brochu et al., 2011; 2018; Duff & Erickson, 2014; Hathaway

2004; Hathaway et al., 2011). The impact of liberalizing drug policy changes on substance use acculturation remains an avenue for future normalization research. Unfortunately, due to the limits of the data my dissertation could not address questions of the intersection of immigration with gender in the differentiation of drug normalization. Future research should consider how gendered stigma for cannabis use compares among students who are born in Canada and those who have recently immigrated from countries with severe social and criminal penalties for illicit cannabis use.

Although the drug normalization framework provides a conceptual toolkit for separately analyzing acceptability attitudes from the prevalence of substance use, normalization researchers have not documented or considered the existence of a threshold acceptability effect among recreational drug users. My research shows that belonging to a peer network comprised entirely of cannabis users is associated with lower acceptability attitudes than belonging to a network where only 'some' peers engage in cannabis use (see Chapter Two). This suggests that evaluations of drug acceptability should be analyzed separately from those of drug use prevalence. Failure to do so will conceal threshold effects in acceptability evaluations. Future normalization research needs to assess how this threshold effect is qualitatively reflected in the limits of social accommodation of substance use among peer groups. Future research should also

156 seek to illustrate to what extent this acceptability threshold effect exists outside of the university context or with other illicit or legally regulated psychoactive substances (e.g., MDMA, cocaine, or alcohol). Such research may identify important formal and informal controls which serve to denormalize specific patterns of substance use. This research may in turn be applied to shape effective health promotion programming and public policy to address potential substance use harms.

This dissertation also argues for the conceptual expansion of the drug normalization framework's construct of drug acceptability to include the social integration of productivity- oriented illicit drug use. The normalization framework was developed from an analytic opposition between recreational and pathological/excessive drug use. Recreational use was initially formulated as a way to push the research conversation beyond "pathological" or

"deviant" drug use on which the majority of drug studies have focused, yet which characterizes but a small fraction of all illicit drug use (Aldridge et al., 2011; Duff et al., 2012; Parker, 2005).

As I show in Chapter Four, the salience of productivity-oriented illicit substance use now requires normalization research to account for drug use that cannot be classified as recreational use (i.e., as occasional and leisure/pleasure-oriented) nor as problematic (i.e., compulsive or damaging drug use patterns). This research thereby challenges the drug normalization framework to consider the intersection of drug use practices, trends, and acceptability evaluations with the pharmaceuticalization of everyday life, whereby prescription medications are diverted for use in increasingly diverse sets of problems and experiences by conventional populations (Vrecko,

2013; 2015; Kelly, Vuolo & Marin, 2017).

Taken together, Chapters Two, Three, and Four provide critical engagement with the drug normalization framework. These chapters assess the compatibility of the drug normalization

157 framework with contemporary substance use trends. They also integrate novel insights on the differentiation of drug normalization, including identifying the gendered stigma and social organization of illicit drug markets, substance use acculturation among students born abroad, and an acceptability threshold for recreational drug use prevalence among peer groups. By demonstrating how drug normalization trends are differentiated by important social and contextual factors, this dissertation contributes to the growing literature on socially conventional, non-dependent forms of drug use. In doing so, this work illustrates the ongoing relevance of the drug normalization framework for substance use research, as well as the necessity of moving beyond addiction and deviance paradigms for investigating and understanding the social integration of substance use as the vast majority of all drug use does not result in the severe negative outcomes assumed by such discourses (Pennay & Measham, 2016; Hammersley, 2011).

A differentiated approach to the study of drug normalization is ideally positioned to continue to provide important insights in the rapidly changing drug policy landscape nationally and internationally.

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Kelly, B. C., Vuolo, M., and Marin, A. C. (2017). Multiple Dimensions of Peer Effects and Deviance: The Case of Prescription Drug Misuse among Young Adults. Socius, 3, 1-18.

Kirst, M., Kolar, K., Chaiton, M., Schwartz, R., Emerson, B., ... Thomas, G. (2015). A Common Public Health-Oriented Policy Framework For Cannabis, Alcohol And Tobacco In Canada? Canadian Journal of Public Health, 106(8), e474-e476.

Parker, H. (2005). Normalization As Barometer: Recreational Drug Use And The Consumption Of Leisure By Young Britons. Addiction Research & Theory, 13, 3, 205-15.

Parker, H., Aldridge, J., and Measham, F. C. (1998). Illegal Leisure: The Normalization Of Adolescent Drug Use. London: Routledge.

Pennay, A. E., and Measham, F. C. (2016). The Normalisation Thesis - 20 Years Later. Drugs: Education, Prevention and Policy, 23, 3, 187-9.

Rotermann, M. and Langlois, K. (2015). Prevalence And Correlates Of Marijuana Use In Canada, 2012. Health Reports, 26, 4, 10-15.

Shildrick, T. (2002). Young People, Illicit Drug Use And The Question Of Normalization. Journal of Youth Studies, 5, 1, 35-48.

Task Force on Marijuana Regulation and Legalization. (2016). Toward The Legalization, Regulation And Restriction Of Access To Marijuana. Discussion Paper. Ottawa: Government of Canada. Retrieved from http://healthycanadians.gc.ca/health-system- systeme-sante/consultations/legalization-marijuana-legalisation/document-eng.php

Vrecko, S. (2013). Just How Cognitive Is ‘‘Cognitive Enhancement’’? On The Emotions In University Students’ Experiences With Study Drugs. AJOB Neuroscience, 4, 4–12.

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APPENDIX A - Informed Consent Sheet For Interview Participants

Consent to participate in follow-up interview:

Cannabis, Stigma & Policy change: A Three-Campus Study of Normalization Among University Students

You are asked to participate in a research study conducted by Dr. Patricia Erickson, from the Department of Sociology at the University of Toronto

If you have any questions or concerns about the study, please feel free to contact her by telephone XXXXXX, or email: XXXXX

Your participation is completely voluntary. The decision to take part in, or refrain from taking part in, this research is up to you, and will not affect your standing in the course.

PURPOSE OF THE STUDY The purpose of the study is to add to present knowledge on the attitudes of students about the use of cannabis/marijuana and other forms of drug use that are common among students.

PROCEDURES If you volunteer to participate in this study, we would ask you to do the following things:

Take part in a taped interview that will last about an hour about your own perspective on the use of marijuana and other drugs in common use on campus. We are interested to hear from both the students who are ‘users’ as well as those who don’t use marijuana.

POTENTIAL RISKS AND DISCOMFORTS Although unlikely, it is possible the researchers may be asked to reveal your name and other information from the study under threat of punishment in a court of law. In this event, we have destroyed your contact information to protect the students and researchers by removing links between the data and identity of students.

And there is a small potential for some upset or discomfort when answering certain questions about the use of drugs. If you have questions or concerns about your own or others’ drug use, the following resources are available on campus:

Counselling Services [214 College St., Room 111, 416-978-3629]

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY There are few benefits to your participation in this interview, other than contributing to knowledge on a topic of particular importance to Canadian young people in a contentious area of policy debate. This study will advance our understanding of the patterns and social meanings around drug use as experienced by students from the perspective of both users and nonusers on this campus.

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PAYMENT FOR PARTICIPATION You will receive an honorarium of $20 for your time and contribution to this research.

CONFIDENTIALITY Every effort will be made to ensure confidentiality of any identifying information that is obtained in connection with this study. There will be no identifying information connected to the interviews or any other study data gathered. Data will be kept for seven years and then destroyed. The taped part of the interview will be kept in a locked cabinet that will be accessible to the research team only. Once transcribed, the interview will also be stored safely, on password protected computers, and the original tape will be destroyed. We will protect this information and treat all data gathered as fully confidential to the extent allowable by law.

PARTICIPATION AND WITHDRAWAL You have no obligation to take part in the study. Your decision to participate in this research or not will not affect your standing in the course. If you volunteer to take part in this study, you may withdraw at any time without consequences of any kind. You may exercise the option of removing your data from the study. You may also refuse to answer any questions you don’t want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise that warrant doing so.

RIGHTS OF RESEARCH PARTICIPANTS You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights or remedies because of your participation in this research study. This study has been reviewed and received ethics clearance through the University of Toronto Research Ethics Board. If you have questions regarding your rights as a research participant, please contact the Office of Research Ethics, [email protected], or 416-946-3273.

CONSENT OF RESEARCH PARTICIPANT

I have read the information provided for the study “Cannabis, stigma & policy change: A three- campus study of normalization among university students" as described herein. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form.

*Please note that you may give consent by either signing this form or if you prefer, simply providing consent verbally

Name of Participant ______Date ______

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APPENDIX B - Semi-Structured Interview Schedule

Demographic information:  Gender; Age; Ethnicity; Year; Program

Self-perception:  Do you use marijuana? Why or why not? (have you ever?) o How much marijuana do you smoke each month? o Do you consider yourself to be a marijuana user? Why or why not? o Where do you usually use marijuana? . Do you think the setting in which you use marijuana is important? Why? . Do you usually get together with friends just to use marijuana or is it part of larger group of activities? If so, what are these activities? . Are there places that are not appropriate for marijuana use? . how do you feel about smoking/using and going out in public? Do you think this is the same for men and women?

 How does marijuana use fit in your overall life style? (probes: party/focus/relax/friends?) o How important is it to you to be able to have a steady supply? o Would it matter to you if you could not access marijuana anymore? why? o How do you ensure that there is a steady supply at hand?

 How did you get into using marijuana?

 Has your use changed over the years? How? (Do you use cannabis with anything else ever? alcohol, other drugs? Use other substances in general?)

 Do you have a limit of how much you use? How do you decide this limit? o Is there such a thing as responsible or sensible marijuana use? If so, how do you define that? If not, why not? o Do you schedule your use around school/work? o What are some good reasons to smoke marijuana? o What are some bad reasons to smoke marijuana? o Why do you use marijuana? o What are some behaviours associated with marijuana use that you would consider risky or irresponsible? (probes: driving, before work/school, etc)

 Who do you smoke marijuana with? How/Why did you decide to smoke with those persons? o would you smoke with people you didn't know?

 Do you ever worry about whether marijuana will have negative effects on your life? Have you experienced negative effects? What about positive?

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 Do you feel there are differences beyond marijuana use itself that separates users from non-users? (e.g., do users share a different outlook or perspective that effects how they relate to life or with other people?)

 Do you think men and women might look at marijuana use in different ways or use differently? Do more men or women smoke pot with you in your group of friends? Are there more men or women who buy?

Supply:  How do you or your friends usually obtain marijuana? o How easy is it? o What rules do you follow when trying to get it? o Are there types of dealers that you would not buy from? Why?

 How do you arrange and complete the transaction? (i.e., making contact, meeting places…) o How did you become acquainted with your dealer…or aware of someone who could help you get marijuana? o What are the characteristics of the seller that you buy from? (i.e., to whom does he/she normally sell, what types of drugs, what quantities…)? Do you think most sellers are m/f?

 How much do you usually buy at one time? All for yourself, or do you share with other people? o Describe your experiences of buying and sharing marijuana with friends.

 Have you ever sold or brokered access to marijuana? i.e., helped others get it without making a profit. o If yes, Why? Do you consider yourself a drug dealer? How do you feel about people knowing that you sell it? o If no, would you consider being a broker or supplier – why or why not?

 Do the legal sanctions prohibiting marijuana use pose any problems for you or affect your patterns of buying or selling in any way?

 Does the threat of social stigma pose any problems for you or affect your patterns of buying or selling in any way? Does buying/selling create any moral dilemma? (Do you feel the same way about other substances you mentioned?)

Stigma Avoidance:  How have you managed to keep marijuana use a secret from those who should not know? o How do you decide who should not know? (probes: their political/cultural views? their relationship to you? authority?) What about for other substances you mentioned? o Do you follow certain rules/routines to avoid being caught or detected?

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o What problems, if any, have arisen as a result of being detected or keeping this part of your life hidden? o do you ever worry about what people would think if they found out that you smoked marijuana/did other drugs? Do you think men and women generally feel the same way about this? example?

Perception of non users:

 Why don’t you smoke marijuana?

 Where do you draw the line on what you will use and what you won't? (e.g., alcohol, caffeine, cigarettes, other drugs) Why? Who influenced your decisions?

 Do you think there are responsible ways of smoking marijuana?

 What are your general attitudes towards marijuana/marijuana users?

 Do you have many friends who use marijuana?

 What are your opinions regarding laws associated with marijuana?

 Would you be bothered if people are using marijuana at a party you are attending?

 Would you be bothered if your friends use marijuana around you? Why or why not?

 Would you date someone who smoked marijuana?

 Do you ever feel like an outsider for not smoking pot?

 Do you feel you will never smoke marijuana?

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APPENDIX C - Informed Consent Sheet For Survey Participants

Consent To Participate in Survey Research:

You are asked to participate in a research study conducted by Dr. Patricia Erickson, from the Department of Sociology at the University of Toronto. If you have any questions or concerns about the study, please feel free to contact her by telephone XXXXX or email: XXXXXX Your participation is completely voluntary. The decision to take part in, or refrain from taking part in, this research is up to you, and will not affect your standing in the course. PURPOSE OF THE STUDY: The purpose of the study is to add to present knowledge on the attitudes of students about the use of cannabis/marijuana and other forms of drug use that are common among students. PROCEDURES: If you volunteer to participate in this study, we would ask you to do the following things: Complete a survey questionnaire about the use of marijuana. We are interested to hear from both the ‘users’ and ‘nonusers’. Neither current use nor any history of drug use is required for your participation in the study. A summary of findings from the survey will be available and presented during class-time toward the end of the term. These will not identify you in any way. You may be interested to take part in an interview to further discuss your own perspective as a ‘user’ or ‘nonuser’. If so, we’d like to hear from you. Please contact the research team by telephone or e-mail with the contact information at the end of this consent form. POTENTIAL RISKS AND DISCOMFORTS: There is a small potential for some upset or discomfort when answering certain questions about the use of drugs. If you have questions or concerns about your own or others’ drug use, the following resources are available on campus: Counselling Services [214 College St., Room 111, 416-978-3629] POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY: There are no benefits to taking part in this on-line survey, other than contributing to knowledge on a topic of particular importance to Canadian young people in a contentious area of policy debate. This study will advance our understanding of the patterns and social meanings around drug use as experienced by students from the perspective of both users and nonusers on this campus. PAYMENT FOR PARTICIPATION: You will not receive a cash payment for completion of the survey. However, you will be awarded 2% to be added to your final grade. CONFIDENTIALITY: Every effort will be made to ensure confidentiality of any identifying information that is obtained in connection with this study. You will not be asked to give your name to take part in the survey. Only your student number will be requested in order to allocate your bonus marks upon completion of the survey, and this will be done by a teaching assistant. Upon grade allocation, all identifying information in the survey will be immediately destroyed and therefore your individual responses cannot be traced back to you. The course instructor will not have access to the anonymized survey responses until after grades have been finalized. You are advised to do the survey on a private computer. If you must use a public terminal, please remember to log-out on completion of the survey. The following precautions are additionally advised: 1. Erase

167 the history; 2. Empty the cache; 3. Close the browser. The survey data will be stored on a password protected computer, with no identifying information. Data will be kept for seven years and then destroyed. We will protect this information and treat all data gathered as fully confidential to the extent allowable by law. Although unlikely, it is possible the researcher may be asked for the data under threat of punishment in a court of law. In this event, the researcher and those who take the survey are protected by the absence of any specific linkage between the students’ names and their responses to the survey. PARTICIPATION AND WITHDRAWAL: You have no obligation to take part in the study. Your decision to participate in this research or not will not affect your standing in the course. If you volunteer to take part in this study, you may withdraw at any time without consequences of any kind. You may exercise the option of removing your data from the study. You may also refuse to answer any questions you don’t want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise that warrant doing so. RIGHTS OF RESEARCH PARTICIPANTS: You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights or remedies because of your participation in this research study. This study has been reviewed and received ethics clearance through the University of Toronto Research Ethics Board. If you have questions regarding your rights as a research participant, please contact the Office of Research Ethics, [email protected], or 416-946-3273.

I Agree I Do Not Agree

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APPENDIX D - Online Survey Questionnaire

[Note that the survey begins at Question 6 because previous Questions are consent information for each of the three participating universities]

Question 6 Have you ever used ALCOHOL before? [Y/N]

Question 7 At what age did you first use ALCOHOL? [Younger than 11, 12...25, Older than 25]

Question 8: Have you used ALCOHOL in the past 12 months? [Y/N]

Question 9: How many days did you use ALCOHOL in the past month? [0...30]

Question 10: How many days did you use ALCOHOL in the past week? [0...7]

Question 11: How many drinks did you consume on the most recent occasion you drank ALCOHOL? [1...9, 10 or more]

Question 12: Have you ever used TOBACCO before? [Y/N]

Question 13: At what age did you first use TOBACCO? [Younger than 11, 12...25, Older than 25]

Question 14: Have you used TOBACCO in the past 12 months? [Y/N]

Question 15: How many days did you use TOBACCO in the past month? [0...30]

Question 16: How many days did you use TOBACCO in the past week? [0...7]

Question 17: Have you ever used COCAINE (POWDER) before? [Y/N]

Question 18: At what age did you first use COCAINE (POWDER)? [Younger than 11, 12...25, Older than 25]

Question 19: Have you used COCAINE (POWDER)in the past 12 months? [Y/N]

Question 20: How many days did you use COCAINE (POWDER) in the past month? [0...30]

Question 21: How many days did you use COCAINE (POWDER) in the past week? [0...7]

Question 22: Have you ever used CRACK (ROCK) before? [Y/N]

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Question 23: At what age did you first use CRACK (ROCK)? [Younger than 11, 12...25, Older than 25]

Question 24: Have you used CRACK (ROCK)in the past 12 months? [Y/N]

Question 25: How many days did you use CRACK (ROCK) in the past month? [0...30]

Question 26: How many days did you use CRACK (ROCK) in the past week? [0...7]

Question 27: Have you ever used ECSTASY (MDMA) before? [Y/N]

Question 28: At what age did you first use ECSTASY (MDMA)? [Younger than 11, 12...25, Older than 25]

Question 29: Have you used ECSTASY (MDMA) in the past 12 months? [Y/N]

Question 30: How many days did you use ECSTASY (MDMA) in the past month? [0...30]

Question 31: How many days did you use ECSTASY (MDMA) in the past week? [0...7]

Question 32: Have you ever used MUSHROOMS before? [Y/N]

Question 33: At what age did you first use MUSHROOMS? [Younger than 11, 12...25, Older than 25]

Question 34: Have you used MUSHROOMS in the past 12 months? [Y/N]

Question 35: How many days did you use MUSHROOMS in the past month? [0...30]

Question 36: How many days did you use MUSHROOMS in the past week? [0...7]

Question 37: Have you ever used LSD (ACID) before? [Y/N]

Question 38: At what age did you first use LSD (ACID)? [Younger than 11, 12...25, Older than 25]

Question 39: Have you used LSD (ACID) in the past 12 months? [Y/N]

Question 40: How many days did you use LSD (ACID) in the past month? [0...30]

Question 41: How many days did you use LSD (ACID) in the past week? [0...7]

Question 42: Have you ever used AMPHETAMINE (SPEED) before? [Y/N]

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Question 43: At what age did you first use AMPHETAMINE (SPEED)? [Younger than 11, 12...25, Older than 25]

Question 44: Have you used AMPHETAMINE (SPEED) in the past 12 months? [Y/N]

Question 45: How many days did you use AMPHETAMINE (SPEED) in the past month? [0...30]

Question 46: How many days did you use AMPHETAMINE (SPEED) in the past week? [0...7]

Question 47: Have you ever used CRYSTAL METH before? [Y/N]

Question 48: At what age did you first use CRYSTAL METH? [Younger than 11, 12...25, Older than 25]

Question 49: Have you used CRYSTAL METH in the past 12 months? [Y/N]

Question 50: How many days did you use CRYSTAL METH in the past month? [0...30]

Question 51: How many days did you use CRYSTAL METH in the past week? [0...7]

Question 52: Have you ever used KETAMINE before? [Y/N]

Question 53: At what age did you first use KETAMINE ? [Younger than 11, 12...25, Older than 25]

Question 54: Have you used KETAMINE in the past 12 months? [Y/N]

Question 55: How many days did you use KETAMINE in the past month? [0...30]

Question 56: How many days did you use KETAMINE in the past week? [0...7]

Question 57: Have you ever used GHB before? [Y/N]

Question 58: At what age did you first use GHB ? [Younger than 11, 12...25, Older than 25]

Question 59: Have you used GHB in the past 12 months? [Y/N]

Question 60 How many days did you use GHB in the past month? [0...30]

Question 61 How many days did you use GHB in the past week? [0...7]

Question 62: Have you ever used HEROIN before? [Y/N]

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Question 63: At what age did you first use HEROIN? [Younger than 11, 12...25, Older than 25]

Question 64: Have you used HEROIN in the past 12 months? [Y/N]

Question 65: How many days did you use HEROIN in the past month? [0...30]

Question 66: How many days did you use HEROIN in the past week? [0...7]

Question 67: Have you ever used PAIN MEDICATION (e.g. MORPHINE, CODEINE) for recreational (i.e. Non-Medical) purposes before? [Y/N]

Question 68: At what age did you first use PAIN MEDICATION (e.g. MORPHINE, CODEINE) for recreational (i.e. Non-Medical) purposes ? [Younger than 11, 12...25, Older than 25]

Question 69: Have you used PAIN MEDICATION (e.g. MORPHINE, CODEINE) for recreational (i.e. Non-Medical) purposes in the past 12 months? [Y/N]

Question 70: How many days did you use PAIN MEDICATION (e.g. MORPHINE, CODEINE) for recreational (i.e. Non-Medical) purposes in the past month? [0...30]

Question 71: How many days did you use PAIN MEDICATION (e.g. MORPHINE, CODEINE) for recreational (i.e. Non-Medical) purposes in the past week? [0...7]

Question 72: Have you ever used SLEEPING PILLS or ANXIETY MEDICATIONS (e.g. VALIUM, ATIVAN) for recreational (i.e. Non-Medical) purposes before? [Y/N]

Question 73: At what age did you first use SLEEPING PILLS or ANXIETY MEDICATIONS (e.g. VALIUM, ATIVAN) for recreational (i.e. Non-Medical) purpose? [Younger than 11, 12...25, Older than 25]

Question 74: Have you used SLEEPING PILLS or ANXIETY MEDICATIONS (e.g. VALIUM, ATIVAN) for recreational (i.e. Non-Medical) purpose in the past 12 months? [Y/N]

Question 75: How many days did you use SLEEPING PILLS or ANXIETY MEDICATIONS (e.g. VALIUM, ATIVAN) for recreational (i.e. Non-Medical) purpose in the past month? [0...30]

Question 76: How many days did you use SLEEPING PILLS or ANXIETY MEDICATIONS (e.g. VALIUM, ATIVAN) for recreational (i.e. Non-Medical) purpose in the past week? [0...7]

Question 77: Have you ever used ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) for recreational (i.e. Non-Medical) purpose before? [Y/N]

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Question 77B: Do you ever use ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) WITHOUT A PRESCRIPTION (i.e. non-medically) to help you study? [Y/N]

Question 78: At what age did you first use ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) for recreational (i.e. Non-Medical) purpose? [Younger than 11, 12...25, Older than 25]

Question 79: Have you used ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) for recreational (i.e. Non-Medical) purpose in the past 12 months? [Y/N]

Question 80: How many days did you use ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) for recreational (i.e. Non-Medical) purpose in the past month? [0...30]

Question 81: How many days did you use ADHD MEDICATION (e.g. RITALIN, ADDERALL, DEXEDRINE) for recreational (i.e. Non-Medical) purpose in the past week? [0...7]

Question 82: Have you ever been SEARCHED or QUESTIONED for possession of illegal drugs OTHER THAN CANNABIS by law enforcement? [Y/N]

Question 83: Have you ever been ARRESTED for possession of illegal drugs OTHER THAN CANNABIS? [Y/N]

Question 84: Have you ever been FOUND GUILTY of possession of illegal drugs OTHER THAN CANNABIS? [Y/N]

Question 85: What was the outcome of the conviction? (check all that apply) [Unknown, Discharge, Fine, Probation, Jail, Community Service]

Question 86: Have you ever used CANNABIS (MARIJUANA) before? [Y/N]

Question 87: At what age did you first use CANNABIS (MARIJUANA)? [Younger than 11, 12...25, Older than 25]

Question 88: Have you used CANNABIS (MARIJUANA) in the past 12 months? [Y/N]

Question 89: How many days did you use CANNABIS (MARIJUANA) in the past month? [0...30]

Question 90: How many days did you use CANNABIS (MARIJUANA) in the past week? [0...7]

Question 91: Do you consider yourself a "pot-head"? [Y/N]

Question 92: How much money have you spent on cannabis in the LAST 30 DAYS? [none, 1- 5, 51-100, 101-150, 151-200, more than 200] 173

Question 93: On a typical day when you use cannabis, roughly how many joints do you usually have? (Count 10 puffs, 5 bong or pipe hits or 0.5 gram as equivalent to one joint)? [less than 1, 1...10, more than 10]

Question 94: How easy is it to get cannabis at the moment? [Very Easy-Within 90 minutes, Easy-Within a day, Difficult-more than one day, Very Difficult-could not get it at all, Don't Know]

Question 95: How do you ordinarily get your supply of cannabis? [I grow my own; a CLOSE friend who is connected to a larger supply network (buying on your behalf); A friend or acquaintance who buys on your behalf; A Dealer/Seller-Known to me; A Dealer/Seller- Uknown to me, not known on a personal level; A family member who is connected to a larger supply network; A gift from a friend (not purchased)]

Question 96: Has the availability of cannabis changed in the PAST 12 MONTHS? [Becoming EASIER to get; Staying about the SAME; Becoming more DIFFICULT to get; Fluctuates in availability; Don't Know]

Question 97: Thinking about all the time you've used Cannabis, would you say that getting it has become: [More Difficult; Stayed the same; Less Difficult]

Question 98: Where do you normally used Cannabis? (PLEASE CHECK ALL THAT APPLY) [In my own home; In a car (as a driver); In a car (as a passenger); At a friend or acquaintance's house; At a party at someone's house; At raves/dance parties; At resturants/cafes; At licensed premises (clubs, bars, etc); At school (college, university, etc); At my work place; In public places (Parks, Malls, walking down the street)]

Question 99: I use cannabis to make me feel good [Strongly agree; Agree; Neither Agree or Disagree; Disagree; Strongly Disagree; I do not use cannabis]

Question 100: Has your use of cannabis ever caused you problems at your workplace or school? [No problems; Minor problems; Serious problems]

Question 101: Has your use of cannabis ever caused you problems in your personal relationships or with your family? [No problems; Minor problems; Serious problems]

Question 102: Has your use of cannabis had a harmful effect on your personal health? [No problems; Minor problems; Serious problems]

Question 103: Has your use of cannabis ever caused you problems in public places like bars, concerts, or on the street [No problems; Minor problems; Serious problems]

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Question 104: How often have you had a strong desire or urge to use cannabis? [Never; Once or Twice; Monthly; Weekly; Daily or almost daily; Don't Know]

Question 105: How often have you failed to do what was normally expected of you because of your use of cannabis? [Never; Once or Twice; Monthly; Weekly; Daily or almost daily; Don't Know]

Question 106: Has a friend, or relative or anyone else ever expressed concern about your use of cannabis? [No, Never; Yes, but not in the past 12 months; Yes, in the past 12 months]

Question 107: Have you ever tried to control, cut down, or stop using cannabis? [No, Never; Yes, but not in the past 12 months; Yes, in the past 12 months]

Question 108: Have you ever missed a class or assignment due to use of cannabis? [No, Never; Yes, but not in the past 12 months; Yes, in the past 12 months]

Question 109: Have you ever been SEARCHED or QUESTIONED for possession of cannabis by law enforcement? [Y/N]

Question 110: Have you ever been ARRESTED for possession of cannabis? [Y/N]

Question 111: Have you ever been FOUND GUILTY of possession of cannabis? [Y/N]

Question 112: What was the outcome of the guilty verdict? (check all that apply) [Unknown, Discharge, Fine, Probation, Jail, Community Service]

Question 113: I have never used/no longer using cannabis due to health risk/problems [Strongly agree; Agree; Neither Agree or Disagree; Disagree; Strongly Disagree]

Question 114: Cannabis use is OK if it makes you feel good [Strongly agree; Agree; Neither Agree or Disagree; Disagree; Strongly Disagree]

Question 115: What proportion of students that you hang around with are abstainers (do not use cannabis)? [None of them; Some of them; About half of them; Most of them; All of them]

Question 116: What portion of students that you hang around with use cannabis responsibly? [None of them; Some of them; About half of them; Most of them; All of them]

Question 117: What portion of students that you hang around with use cannabis more than they should? [None of them; Some of them; About half of them; Most of them; All of them]

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Question 118: Which of the eight statements below is closest to your own view about people and cannabis?

I use cannabis myself. I think using cannabis is OK if you are careful and you know what you are doing.

I have used cannabis in the past, but do not expect to do so again. I have no problem with other people using it.

I have used cannabis in the past, but do not expect to do so again. I do not think people should use cannabis.

I have used cannabis in the past and I MIGHT again. I do not have a problem with other people using cannabis.

I have used cannabis in the past and I MIGHT again. I do not think people should use cannabis.

I have never used cannabis and I do not expect to. I have no problem with other people using cannabis

I have never used cannabis and I do not expect to. I do not think people should use cannabis.

I have never used cannabis, but I may in the future. I have no problem with other people using cannabis

Question 119: How important has drugs education in school been to you in making up your mind about drugs? [Very Important; Important; Neutral; Somewhat Important; Not at all Important]

Question 120: Which of the following people do you know have tried or used illegal drugs? (check all that apply) [Friends; Employer; Parents; Older Siblings; Younger Siblings; Partner; Older Cousins; Younger Cousins]

Question 121: Among the marijuana users you know, about what portion use marijuana in a way you consider risky? [All of them; Almost all of them; About half of them; Almost none of them; None of them]

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Question 122: Do you feel that there are differences beyond marijuana use itself that distinguishes most users from non-users? (e.g., Do users share an outlook or perspective that allows them to relate to one another differently than with non-users?) [Y/N]

Question 123: Would you consider your use of ANY drugs, including alcohol and tobacco, problematic at present? [Y/N]

Question 124: Please order the following 16 substances based on which you think are the least (where"1" is least ) to most (where "16" is most) harmful: (Pick ONLY ONE (1) answer Per each row and column)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Don't Know alcohol tobacco cannabis heroin

Recreational use of ADHD medications (e.g. Adderall, Dexedrine, Ritalin)

Recreational use of pain medications (e.g. Morphine, Codeine)

Recreational use of Sleeping/anxiety medications (e.g. ativan, valium)

Ecstasy (MDMA)

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Cocaine (Powder)

Crack (Rock)

Amphetamine

Crystal Meth

GHB

Ketamine

LSD

Mushrooms

Question 125: How important is it for you to participate in parties? [Very Important; Important; Neutral; Somewhat Important; Not at all Important]

Question 126: In the past 30 days, how many hours per day on average have you spent watching TV or Videos? [1...24]

Question 127: In the past 30 days, how many hours per day on average have you spent participating in student organizations? [1...24]

Question 128: In the past 30 days, how many hours per day on average have you spent studying outside of the classroom? [1...24]

Question 129: In the past 30 days, how many hours per day on average have you spent doing volunteer work? [1...24]

Question 130: In the past 30 days, how many hours per day on average have you spent attending class? [1...24]

Question 131: In the past 30 days, how many hours per day on average have you spent on non-academic computer use (e.g. Games, Surfing the web, etc.) [1...24]

Question 132: In the past 30 days, how many hours per day on average have you spent working for wages? [1...24]

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Question 133: In the past 30 days, how many hours per day on average have you spent playing or participating in intercollegiate sports? [1...24]

Question 134: In the past 30 days, how many hours per day on average have you spent socializing with friends? [1...24]

Question 135: In the past 30 days, how many hours per day on average have you spent on other physical activities (e.g. Jogging, Biking)? [1...24]

Question 136: In the past 30 days, how many hours per day on average have you spent participating in personal hobbies (e.g. painting, playing music, collecting)? [1...24]

Question 137: In the past 30 days, how many hours per day on average have you spent taking time for yourself? (e.g. reading, meditating, listening to music) [1...24]

Question 138: Are you currently enrolled in university as a full-time or part-time student? [Full Time/Part Time]

Question 139: Which field of study best represents the area in which you are currently enrolled? [Arts/Humanities; Science/Technology; Engineering; Social Science; Business/Commerce; Medicine/Veterinarian; Other Health Sciences; Education; Food and Hotel Administration; Other]

Question 140: What is your age? [Younger than 16, 16...26, Older than 26]

Question 141: What is your sex? [Male, Female, Intersex/Transitioning/Transgender]

Question 142: How do you describe your sexual orientation? [Heterosexual/Straight; Homosexual/ Gay or lesbian; Bisexual; Pan-sexual; Unsure/Questioning]

Question 143: Were you born in Canada? [Y/N]

Question 144: In which province or territory were you born? [Alberta... Yukon Territory]

Question 145: In which country were you born in?

Question 146: How old were you when you came to Canada? [Less than 1...26, older than 26]

Question 147: What ethnic group or family background do you most identify as? [White / Caucasian; Spanish / Hispanic / Latino; Black (African); Black (e.g. Jamaican or other Caribbean); East Asian; South Asian (East Indian, Pakistani, Sri Lankan, etc.); Persian; Arab; Jewish; Pacific Islander; Native American; Other]

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Question 148: What type of accommodation do you currently live in? [Owned house/ Apartment (alone); Owned house/Apartment (shared); Rented house/Apartment (alone); Rented house/apartment (shared); With Parents or other family (but I am not paying rent); With parents or other family (I am paying rent); With Friends (but I am not paying rent); Student Residence; Homeless]

Question 149: Do you consider your current housing situation stable (for the next 6 months) [Y/N]

Question 150: What year of your study are you currently in? [1...5, 6+]

Question 151: What has been your MAIN source of income over the last 12 months? [Parents; Self-employed; Part time paid work; Full time paid work; Student awards/Loans/Bursaries]

Question 152: What is your average annual household income (e.g. Parents, Guardian, Partner)? (do not include room mates) [Under $14,999; $15,000-$24,999; $25,000- $34,999; $35,000-$49,999; $50,000-$74,999; $75,000 and over]

Question 153: What is your current relationship status? Single; Married/Engaged; Separated/divorced/ Widowed; Common law/ living with partner; Steady relationship (3 months or more); Casual relationship/ Dating

Question 154: Are you a parent or guardian? [Y/N]

Question 155: Overall, what was your grade average last year? [A (80 and higher); B (70- 79); C (60-69); D (50-59); F (Lower than 50)]

Question 156: In general, how would you rate your health now? [Excellent; Very Good; Good; Fair; Poor]

Question 157: Over the past 3 months, have you been able to concentrate on whatever you are doing? [Much better than usual; Better than usual; Same as usual; Less than usual; Much less than usual]

Question 158: Over the past 3 months, have you lost much sleep over worry? [Not at all; No more than usual; More than usual; Much more than usual]

Question 159: Over the past 3 months, have you felt constantly under strain? [Not at all; No more than usual; More than usual; Much more than usual]

Question 160: Over the past 3 months, have you felt you couldn't get over your difficulties? [Not at all; No more than usual; More than usual; Much more than usual]

180

Question 161: Over the past 3 months, have you been feeling unhappy or depressed? [Not at all; No more than usual; More than usual; Much more than usual]

Question 162: Over the past 3 months, have you been losing confidence in yourself? [Not at all; No more than usual; More than usual; Much more than usual]

Question 163: Over the past 3 months, have you been thinking of yourself as a worthless person? [Not at all; No more than usual; More than usual; Much more than usual]

Question 164: Over the past 3 months, have you felt that you are playing a useful part in things? [Much more than usual; More than usual; Same as usual; Less than usual; Much less than usual]

Question 165: Over the past 3 months, have you felt capable of making decisions about things? [Much more than usual; More than usual; Same as usual; Less than usual; Much less than usual]

Question 166: Over the past 3 months, have you been able to enjoy your normal day to day activities? [Much more than usual; More than usual; Same as usual; Less than usual; Much less than usual]

Question 167: Over the past 3 months, have you been able to face up to your problems? [Much more than usual; More than usual; Same as usual; Less than usual; Much less than usual]

Question 168: Over the past 3 months, have you been reasonably happy, all things considered? [Much more than usual; More than usual; Same as usual; Less than usual; Much less than usual]

Question 169: How many close friends do you have? [none, 1...6, more than 6]

Question 170: In general, how would you rate your social support now? [Excellent; Very Good; Good; Fair; Poor]

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