How are Canadian cannabis dispensaries counselling breastfeeding consumers?

Abstract

Objectives

This study aimed to identify recommendations given to breastfeeding individuals by Canadian cannabis dispensary employees, since the legalization of recreational cannabis in 2018.

Methods

This was a nationwide cross-sectional study conducted from November 2020 to January 2021. A mystery caller approach was used to identify recommendations given to breastfeeding individuals seeking a product for “relaxation.” This study was modelled on similar studies which assessed recommendations given to pregnant women looking for cannabis products to manage nausea and vomiting (Vastis V, Shea AK, Vincent S, Metz TD. 275: Are canadian cannabis dispensaries counselling pregnant women appropriately? Am. J. Obstet. Gynecol. 2020;222: S187.(Abst). Lusero I, Paltrow LM, Rosenbloom N. Recommendations from cannabis dispensaries about first-trimester cannabis use Obstet Gynecol 2018;132:781–2.). The primary outcome was the recommendation of a cannabis product. Secondary outcomes included stated benefits of cannabis, recommended discussion with health care provider, length of call, rationale for recommendation, and reported source of information on which the recommendation was based.

Results

The majority (79.4%) of employees of the 714 Canadian dispensaries contacted recommended against a cannabis product for “relaxation” while breastfeeding. The recommendations from dispensary employees were often (80%) provided without a specific reason, whereas a minority referenced published research (2%) and opinion (17.6%). Cannabis products were rarely (3.3%) classified as safe in breastfeeding. Approximately 76.6% of dispensary employees recommended contacting a health care provider, while 2.4% recommended against.

Conclusions

Although a high proportion of dispensary employees recommended against using a cannabis product during lactation, there were still 20.6% that did recommend use, which contrasts the current public health guidelines and is not supported by the paediatric and obstetric societies. These findings highlight the need for further education about the safety of cannabis products while breastfeeding.

Graphical Abstract

Graphical Abstract.

Cannabis use in Canada has increased since its legalization in 2018 (1). Among women specifically, the prevalence has increased from 11.1% in 2017 (2) to 14% in 2019 (3). As cannabis use increases, the number of dispensaries in Canada has grown exponentially from an estimated 217 dispensaries in March 2019 to more than 1000 in July 2020 (4). Although each province has set their own educational programming required for dispensary employees, it is important to understand what information breastfeeding women may be obtaining when seeking advice regarding cannabis products.

Recent literature has shown that 2.6% of lactating women in Canada report using cannabis (5). In states that have legalized cannabis, preconception and postpartum cannabis use has increased (6). Similar trends have been noted in Canada. In British Columbia, preconception use of cannabis and during pregnancy has increased since legalization (7). This use is concerning as it has been shown that delta nine- tetrahydrocannabinol (THC) accumulates in breast milk and may be detected up to 6 days following cannabis use (8). The long-term implications of exposure to cannabis in breast-fed infants have not been well studied. There are some reports that exposure through breast milk may negatively influence motor development of the exposed offspring (9). Mothers who use cannabis during the post-partum period may also stop breastfeeding earlier than their non-user counterparts (10). Many professional governing bodies, including the Society of Obstetrics and Gynecology of Canada and the American Academy of Pediatrics, do not recommend that women use cannabis when pregnant or while breastfeeding (10–12).

Previous studies have explored recommendations that employees from cannabis dispensaries have provided to pregnant women. An important study done in a state with legalized recreational cannabis, Colorado, reported that only 30% of employees from dispensaries recommended against a cannabis product. In comparison, a recent Canadian study noted that 93% of dispensary employees recommended against cannabis use while pregnant (13,14). Differences in counselling practices may arise from variation in the training provided to employees as well as from personal experience.

What has not yet been explored, are recommendations that dispensary employees are providing to breastfeeding women. The policy of each dispensary should align with federal regulations, but determining the actual information given to customers can be difficult to ascertain and may be reflective of the employees’ opinion.

The objectives of this study were: (1) to identify the proportion of employees from recreational cannabis dispensaries in Canada that recommended cannabis products for “relaxation” to breast feeding customers seeking advice; (2) to characterize the recommendation given; and (3) to identify if customers were referred to a health care provider for further information.

METHODS

This was a cross-sectional study of licensed recreational Canadian cannabis dispensaries. The study protocol was reviewed and approved by the Hamilton Integrated Research Ethics Board (number 5999). This study protocol was based on a similar study conducted to characterize recommendations for cannabis use for nausea and vomiting in pregnancy (13,14).

The target population consisted of all licensed dispensaries in Canada as of November 2020. The list of dispensaries was collected through provincial specific websites; a total of 797 recreational dispensaries were identified at the time of the study.

Dispensaries were contacted from November 2020 to January 2021, using a mystery caller approach. Four investigators (SK, SS, SV, and VV) contacted all licensed dispensaries using a script in which the callers stated they were breastfeeding and looking for a natural product for relaxation (Appendix 1). Each dispensary was contacted a maximum of three times during listed business hours. If all attempts were unsuccessful, the dispensary was labelled as unavailable. If no phone number was listed or if the number was not in service, the dispensary was also listed as unavailable. The calls were transcribed onto electronic data sheets and recordings were made if transcription was unable to be completed in real time, due to speed of the conversation. All recordings were deleted at completion of data collection. All dispensaries will be notified of involvement in study through mail.

Throughout the telephone call, if a cannabis product was recommended by the employee, this was recorded as “recommendation made.” If it was stated that recommendations were against the policy of the dispensary, medical advice could not be given, or they did not feel comfortable or qualified but still discussed a product, this was recorded as “recommendations not made.” If no recommendation was made, the employee was asked if possession of a medical card prompted a recommendation. During all completed calls, employees were asked by the caller if they should discuss cannabis use with a heath care provider, if not already stated. The responses were documented as “recommended without prompting,” “recommended with prompting,” “no recommendation after prompting,” or “not discussed despite prompting.” If a recommendation was made, this was further classified by reason for recommendation. The recommendation was classified as “personal opinion” if the employee stated it was a personal opinion or used anecdotes, or classified as “referenced research,” “referenced dispensary policy,” or “did not specify.”

The primary outcome was the recommendation of a cannabis product for relaxation by the dispensary employee. Secondary outcomes included stated benefits of cannabis while breastfeeding, recommended discussion with health care provider, length of telephone call, rationale for product recommended and reported source of information on which the recommendation was based.

We hypothesized that 50% of dispensaries would recommend a cannabis product for breastfeeding individuals. A sample of 259 was identified to yield a two-sided 95% CI with a 5% margin. The proportions of the primary and secondary outcomes were summarized as percentages and categorized by province and territory.

RESULTS

Investigators contacted the 797 licensed recreational cannabis dispensaries in Canada from November 2020 to January 2021 and 714 answered (89.5%) (Figure 1). One employee per dispensary was spoken to during the conversation. This sample surpassed the target sample size of 259. The average length of conversation was 70 s (range 12–749 s, median 78 s), and employees in Ontario spoke for the longest with an average of 165 s (range 12–749 s, median 138 s).

Figure 1.

Study population flow diagram.

Of the dispensaries that were contacted, we found that 79.4% (567/714) of employees recommended against use of cannabis products while breastfeeding. In Quebec, New Brunswick, and Prince Edward Island, 100% of dispensary employees recommended against cannabis use while breastfeeding. The largest proportion of the listed licensed dispensaries were in Alberta and Ontario (65.5%). In Alberta, 26.5% (77/290) of dispensary employees recommended a cannabis product, whereas 16.9% (30/177) Ontario dispensary employees did (Table 1).

Table 1.

Dispensary recommendations by province and territory

	Total (% of total)	BC	AB	SK	MN	ON	QB	NFL	PEI	NB	NS	YK	NT	NV
Dispensary successfully contacted	714 (100)	24(3.3)	290 (40.6)	49 (6.8)	48 (6.7)	177 (24.8)	47 (6.6)	27 (3.8)	4(0.6)	20(2.8)	18(2.5)	5 (0.7)	5(0.7)	0
Primary outcome   Recommendation of cannabis	147 (20.6)	3 (0.4)	77 (10.8)	13 (1.8)	9 (1.3)	30 (4.2)	0	4 (0.6)	0	0	8 (1.1)	2 (0.3)	1 (0.14)	0
Secondary outcome   Basis of recommendation
Personal opinion	26 (3.6)	0	19 (2.7)	1 (0.1)	1 (0.1)	4 (0.6)	0	1 (0.1)	0	0	0	0	0	0
Referenced research	3 (0.4)	0	2 (0.3)	0	0	1 (0.1)	0	0	0	0	0	0	0	0
Referenced dispensary policy	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Did not specify	118 (16.5)	3 (0.4)	56 (7.8)	12 (1.7)	8 (1.1)	25 (3.5)	0	3 (0.4)	0	0	8 (1.1)	2 (0.3)	1 (0.1)	0
Secondary outcome   HCP recommendation
Recommended HCP without prompting	547 (76.6)	14 (1.9)	289 (40.5)	31 (4.3)	41 (5.7)	85 (11.9)	45 (6.3)	25 (3.5)	3 (0.4)	3 (0.4)	9 (1.3)	1 (0.1)	0	0
Recommended HCP with prompting	92 (12.9)	0	0	3 (0.4)	2 (0.3)	86 (12)	1 (0.1)	0	0	0	1 (0.1)	0	0	0
Did not recommend HCP	17 (2.4)	5 (0.7)	1 (0.1)	0	0	5 (0.7)	0	0	0	0	2 (0.3)	0	4 (0.6)	0
Did not comment on HCP with prompting	42 (5.9)	5 (0.7)	1 (0.1)	15 (2.1)	5 (0.7)	1 (0.1)	1 (0.1)	2 (0.3)	1 (0.1)	0	6 (0.8)	4 (0.6)	1 (0.1)	0
Secondary outcome   Reported safety of cannabis use
Stated cannabis was safe	24 (3.4)	0	13 (1.8)	2 (0.3)	0	7 (0.98)	0	1 (0.1)	0	0	1 (0.1)	0	0	0
Stated harm to caller	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Stated harm to infant	6 (0.8)	0	0	0	0	5 (0.7)	1 (0.1)	0	0	0	0	0	0	0
Benefit to infant	0	0	0	0	0	0	0	0	0	0	1 (0.1)	0	0	0
Mean length of call (seconds)		54.4	93.5	58.6	52.4	165	85	45	68	53	89	40	37	0

BC, British Columbia; AB, Alberta; SK, Saskatchewan; MN, Manitoba; ON, Ontario; QB, Quebec; NFL, Newfoundland and Labrador, PEI, Prince Edward Island; NB, New Brunswick; NS, Nova Scotia; YK, Yukon; NT, Northwest Territories; NV, Nunavut.

When a dispensary employee recommended a product, 80% (118/147) did not specify a reason for the recommendation. Rarely, the employee would recommend a cannabis product based on research (3/147; 2%), and 17.6% (26/147) of recommendations were based on the employee’s opinion.

Cannabidiol (CBD) products were the most commonly recommended, whereas THC products were either recommended against or infrequently. Specifically, CBD products were recommended alone in 55% (81/147) cases. CBD or THC products were recommended in 22% (33/147) cases, and 13 of these cases recommended a small amount of THC to improve the effect of CBD. THC was recommended against in 22% (32/127) cases, and 10 employees (7%) stated they did not know the impact of THC while breastfeeding. In terms of cannabis types, an Indica-based type was recommended in 5% (7/147) interactions. In 18% of cases (26/147), the employee recommended cannabis but did not provide any additional recommendations. The delivery method of the product that employees suggested for breastfeeding women included inhalation, oral capsules, oils, chocolates, gels, topical creams, bath bombs, and bath salts. In all cases where a recommendation was not made, there was no change in recommendation given when the caller mentioned having a medical card. When a medical card was mentioned, the caller was occasionally directed to the provider of that card for recommendations. Only 0.8% (6/714) of dispensary employees explicitly mentioned harm to the infant from cannabis, and none mentioned possible harm to the caller. Of the dispensary employees that were contacted, only 3.3% (24/714) stated that cannabis was safe while breastfeeding, and one dispensary employee stated that cannabis was beneficial to the infant.

Most employees recommended that the caller speak with a healthcare professional (HCP), including physicians with training in cannabis, family physicians, paediatricians, obstetricians, pharmacists, and RNs. Specifically, 76.4% (546/714) of dispensary employees recommended speaking to a HCP without the caller prompting the employee, whereas 13% (93/714) recommended after prompting, 3% (19/714) of the dispensary employees cautioned that the HCP may not be receptive to cannabis use. A small proportion (2.4%; 17/714) did not recommend talking to a HCP and 5.9% (42/714) did not address the topic with prompting.

DISCUSSION

This study demonstrated that a large majority of Canadian dispensary employees recommended against the use of a cannabis product for a breastfeeding consumer. Yet, there were still 20.6% of employees that did recommend a cannabis product, which does not align with current public health guidelines. Most dispensary employees recommended consulting with a healthcare provider. When a recommendation was made, CBD products in several different formulations were primarily recommended, but the majority did not specify a reason for the recommendation.

There is a paucity of literature describing the impact and safety of cannabis use while breastfeeding. A recent systematic review identified two studies that investigated the impact of cannabis use while lactating on infant development (2). The first study showed no difference in mental or motor development, but was limited by a small sample (15). The other showed that cannabis use in the first month of breastfeeding resulted in lower motor development scores but was confounded by concurrent antenatal cannabis use (16). We could not locate any studies that looked at the effect of CBD products alone (in the absence of THC) on infant outcomes.

Understanding the impact of cannabis while breastfeeding is important as postpartum cannabis use by mothers has increased in regions where cannabis is legal (6). Cannabis has been shown to be excreted into breastmilk: THC can transfer into breastmilk and deposit into lipid rich tissues such as the brain due to its high lipid solubility and low molecular weight (10). A recent study demonstrated that THC and CBD were both detectable in breastmilk of individuals using inhaled or edible cannabis (17). A study in which the amount of THC consumed was standardized, THC levels peaked 1 h post-ingestion, and it was shown that an exclusively breastfed infant would ingest about 2.5% of the maternal dose (18). One study reported a THC concentration in breastmilk that was eightfold higher than maternal serum concentration (19). Another recent publication reported detection of THC in breastmilk up to 6 days after exposure (7). Additionally, if inhaled formulations of cannabis are used, the infant is exposed to cannabis through both inhalation and breastmilk, increasing the potential for harm (19).

Studies have suggested that most pregnant women seeking information about cannabis use the internet, whereas a minority receive information from their HCP (3,20). A 2018 study revealed that when pregnant patients disclosed cannabis use to a HCP, the disclosure was only addressed 48% of the time. The HCP response was often less supportive and rather punitive in nature, with suggestion of referral to child protective services and further toxicology testing (21). In breastfeeding individuals, where healthcare appointments are less frequent than those during the pregnancy, individuals may reach out to dispensaries for information on safety of use.

The training of dispensary employees in Canada is organized at a provincial/ territorial level; therefore, the local requirements may vary. Some provinces and territories require mandatory training and certification prior to employment, whereas others do not (Table 2) (22–29). The specific content of the training for each region is not specifically known, but the Ontario provincial training does indicate that there is no known safe amount to use during pregnancy and lactation. However, given that the recommendations against cannabis were common in our study, it is likely that using among breastfeeding individuals is addressed. Nevertheless, many dispensary employees expressed discomfort with providing recommendations around breastfeeding, highlighting a need for more explicit training consistent with the messaging from public health departments and governing bodies (11,12).

Table 2.

Mandatory training by province/territory

Province/territory	Training
British Columbia	Sell it Right course and exam
Alberta	SellSafe Course
Saskatchewan	CanSell SK
Manitoba	Smart Choices Cannabis Retail Certification
Ontario	CanSell Ontario
Quebec	Mandatory training as per the Cannabis regulation act
NFL	Unknown
Nova Scotia	Unknown
New Brunswick	Unknown
Prince Edward Island	Unknown
Yukon	BARS-C Course
NWT	Safe-Server training program
Nunavut	Government of Nunavut’s Cannabis Retail Employee Training Program

The main limitation of this study is that the information collected is representative of one employee for that specific dispensary, which leads to potential for bias based on personal opinion and may differ from that of the company policy. An additional limitation is that some dispensary employees did not make recommendations as age of the caller could not be confirmed via telephone. Given this, it is unclear what the recommendations may have been at that particular dispensary and if was in keeping with the other results.

This study has many strengths. Firstly, we collected data from dispensaries nationwide, giving a comprehensive look at variations across provinces and territories. Additionally, although previous studies have analyzed the recommendations for pregnant individuals, this is the first study to assess dispensary counselling around lactation, an area where safety information still requires significant investigation.

In summary, a large majority of employees working for cannabis dispensaries in Canada recommend against a cannabis product while breastfeeding. However, there were still 20.6% of cannabis dispensary employees that did recommend cannabis products to lactating individuals. Recommendations focused largely on CBD products, but the safety of this is not currently known. This study suggests that having a standardized national program with specific sessions on cannabis use and breastfeeding may be useful for employees working at dispensaries. This may also ensure there is consistency in the advice provided across Canada. Furthermore, healthcare providers should continue to ask early on regarding cannabis use in pregnancy and discuss possible perceptions that lactating mothers may have regarding both THC and CBD products. Further studies assessing employees’ perceptions of training and gaps in education should be assessed to optimize the impact of public health recommendations for cannabis and breastfeeding.

APPENDIX 1: PHONE SCRIPT

Hi, I am looking for something that can help me feel more relaxed. I have a new baby and I am breast feeding, so I would like to use something more natural. What do you recommend?

Prompts in response to no recommendation:

1. What if I have a medical card?

   • a. If asked reason she has a card, caller would state it’s for chronic pain resulting from a car accident.

2. Why not?

Prompts in response to recommendation:

1. What products?

   • a. Why?

2. How often should I use it?

3. Is it safe to take while breastfeeding?

Before closing call: should I talk to my doctor about this?

Funding

There are no funders to report for this submission.

Potential Conflicts of Interest

AS reports a research grant from Pfizer and consulting fees from Pfizer and Bio Syent, all unrelated to this manuscript. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.