Study on Cannabis
Health Warning Messages Focus Groups
Research Report

Contents

Executive Summary
Introduction
Detailed Findings
Conclusions
Appendix A: Discussion Guide
Appendix B: Health Warning Messages
Appendix C: Screener

Executive Summary

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the Cannabis Warning Message Testing focus groups.

The Government of Canada has committed to legalize, strictly regulate and restrict access to cannabis. On June 21, 2018, Bill C-45, an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (the Cannabis Act) received Royal Assent. To support implementation of the Act, regulations will need to be enacted in a range of areas, including the packaging and labelling of cannabis, to ensure that the risks and harms of cannabis are appropriately addressed under the legal framework.

As part of the regulations that will support the coming into force of the Cannabis Act, the Government of Canada is requiring that mandatory health warning messages be included on the package of all cannabis products. The purpose of the health warning messages is to warn people of the potential health effects of using cannabis.

Focus groups were required to explore the views of the general population, with a special attention to youth, on the effectiveness of health warning messages. Feedback from the research will enable Health Canada to develop appropriate messages that meet packaging and labelling requirements. The total cost to conduct this research was $113,971.80 including HST.

To meet these objectives, Earnscliffe conducted a comprehensive wave of qualitative research. In total, there were twenty qualitative sessions with four different segments of the Canadian population: young adults (18-24); youth (13-15); youth (16-17); and, adults (25+).

The research took place in Toronto, ON (May 28); Quebec City, QC (May 29), Saskatoon (May 29), Vancouver (May 30) and St. John's (June 5). The focus groups in Quebec City were conducted in French. The sessions were all one hour in length.

The research explored the effectiveness of the health warning messages. More specifically, it sought to determine whether the messages stand out from the 'noise' of other information on the label, such as brand elements, whether they are large enough to read, and are easy to understand. The research also tested the effectiveness of the plain packaging requirements (restrictions on the use of branding, logos, colour and other features) in reducing the appeal of the products to youth and others in increasing the effectiveness of the health warning messages and other mandatory labelling elements.

For the purposes of this report, it is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group and interview research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.

Reactions to Health Warning Messages

• Overall reaction to the messages was mixed. For the most part, reaction related to participants' views of cannabis. Participants were generally either pre-disposed to fearing cannabis (and by default, receptive to most/all warnings) or pre-disposed to being comfortable with it (and presented a range of different reactions depending on experience, knowledge and desire/intention).
• In terms of the language used, it was generally felt to be clear and understandable although there were a few terms that were not well understood by all youth (mainly those 13-15): THC, psychosis, and schizophrenia.
• Participants who were more comfortable with cannabis argued that messaging would be much more credible if it were supported with facts and referenced appropriately. They felt that several of these messages employed a fear-mongering approach which, if accepted as truth, begged questions about the government's decision to legalize cannabis.
  • For these participants, simply stating facts (statistics) was not all that persuasive or credible. They called for evidence of harms or risks to be referenced to have any credibility.
• With respect to the message that cannabis smoke is harmful, most agreed that any smoke is bad and most understood this statement to mean that cannabis smoke is particularly bad.
  • Highlighting the relativity to tobacco seems to make this message more effective, particularly for those aware of mixing tobacco with cannabis.
  • There were a few who interpreted this as being about the effect of the drug, rather than about the inhaling of smoke. For these people, the primary message meant simply "cannabis is harmful."
  • Some participants understood it to mean that the choice to smoke cannabis involved risks associated with smoking, but pointed out that there are ways of using cannabis that do not involve smoking and therefore, the context of the message would bear an impact on the perceived relevance of it.
• While most accepted the premise that it is not sensible to drive after using cannabis, there were some, often in the youth groups (13-17) who argued cannabis can have a calming effect on some drivers. However, when pressed, most tended not to want to be the passenger in a vehicle being driven by someone who is high. 
  • Youth, in particular, found the second sentence pertaining to the number of deaths and injuries related to driving under the influence was persuasive, but others felt the statistics were rather low compared to deaths related to drunk driving.
• Participants did not immediately agree with the statement that cannabis is addictive. Some argued that there is no active ingredient in cannabis that causes addiction and described it more as a mental dependence on the routine of getting high. The statistics in the three secondary messages were not all that persuasive.
• When it came to the message that regular use of cannabis can increase the risk of psychosis and schizophrenia, participants tended to fall into one of two camps: those that had heard or accept this as fact already and find it a powerful message; and, those that are skeptical or not yet convinced but for whom "if that really is true" the warning has the potential to be powerful. This was one of the messages that would most motivate participants (of all ages) to do something (i.e., look for more information about this online).

Reactions to Proposed Packaging

• The packaging was met with generally favourable, though at times quizzical, reaction. Participants described the overall look as somewhat understated, neutral, sleek, and, in some groups, cool (particularly among young adults). In large part, this was attributed to the black background although many remarked that the lack of brand elements was interesting. When asked, most tended to feel that that was appropriate; so as not to entice the wrong people (i.e., children).
• The more quizzical reactions tended to revolve around the size, shape and material of the package. Many participants did not believe it was an intuitive design and questioned the use of paper stock (carton) as opposed to a re-sealable bag. They assumed that there would be a re-sealable bag inside with the cannabis to protect it, but also to reduce the odour and potential of cannabis waste.
• The other thing that was a little surprising for most was that the contents of the package were not clearly marked. Many expected the box to be a green colour which would more readily suggest a package of cannabis or that it would have a large symbol (i.e., a cannabis leaf), prominently on the package.
• Most felt the symbol should be larger - it was not the most attention-grabbing element on the package. In fact, many in most groups did not notice the symbol until asked.
• The most attention-grabbing element of the package was the health warning message in the yellow box. The yellow box on the black package was noticeable although many argued that the placement could be a little more prominent and that the font could be larger.
• One of the most consistent comments offered was that the instruction to "keep out of reach of children" was not given the prominence that it deserves. Even bold lettering would be an improvement for a message that is universally accepted as important.
• There were also some suggestions of adding more warning messages to the blank sides of the package. Some complained that the example provided (i.e., do not use if pregnant or breastfeeding) was too narrow and did not speak to all who may be potential consumers of cannabis. Others argued that if there were too many warning messages on the package, consumers would become immune. They felt that one message that changed regularly would be more impactful.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-174600/001/CY

Contract award date: April 17, 2018

I hereby certify as a Representative of Earnscliffe Strategy Group that the final deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Date: October 9, 2018

Signed:

Stephanie Constable
Principal, Earnscliffe

Introduction

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the Cannabis Warning Message Testing focus groups.

The Government of Canada has committed to legalize, strictly regulate and restrict access to cannabis. On June 21, 2018, Bill C-45, an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (the Cannabis Act) received Royal Assent. To support implementation of the Act, regulations will need to be enacted in a range of areas, including the packaging and labelling of cannabis, to ensure that the risks and harms of cannabis are appropriately addressed under the legal framework.

As part of the regulations that will support the coming into force of the Cannabis Act, the Government of Canada is requiring that mandatory health warning messages be included on the package of all cannabis products. The purpose of the health warning messages is to warn people of the potential health effects of using cannabis.

Focus groups were required to explore the views of the general population, with a special attention to youth, on the effectiveness of THC health warning messages. Feedback from the research will enable Health Canada to develop appropriate messages that meet packaging and labelling requirements.

The objectives of the research were to test how effective the health warning messages are. More specifically, do they stand out from the 'noise' of other information on the label, such as brand elements, are they large enough to read, and are they easy to understand. The research also sought to test how effective the plain packaging requirements - restrictions on the use of branding, logos, colour and other features - are at reducing the appeal of the products to youth and, for others segments of the population, at increasing the effectiveness of the health warning messages and other mandatory labelling elements.

The specific objectives of the research were to:

• Evaluate each of the potential messages and determine if the content is:
• Visible and clearly understood by the audience(s);
• Credible, relevant and of value to the audience(s);
• Appealing and appropriate to the audience(s);
• Memorable in the minds of the audience(s); and,
• Able to motivate the audience(s) to take intended action(s).
• Evaluate the packaging concepts to gather feedback on the restriction of brand elements and colours and their effect on the appeal of the packaging.
• To elicit suggestions for potential changes to ensure the messages resonate with the target audiences.

To meet these objectives, Earnscliffe conducted a comprehensive wave of qualitative research. In total, there were twenty qualitative sessions with four different segments of the Canadian population: young adults (18-24); youth (13-15); youth (16-17); and, adults (25+).

The research took place in Toronto, ON (May 28); Quebec City, QC (May 29), Saskatoon (May 29), Vancouver (May 30) and St. John's (June 5). The focus groups in Quebec City were conducted in French. The sessions were all one hour in length. Written consent was obtained from parents for youth participation in the focus groups.

The research explored the health warning messages' effectiveness, credibility and clarity, and the extent to which they would motivate participants to take action. The research also gathered views on the plain packaging, focusing in particular on participants' reaction to the symbol, messages and lack of branding or colour.

Appended to this report are the screeners, discussion guides and messages.

For the purposes of this report, it is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn, and findings cannot reliably be generalized beyond their number.

Detailed Findings

This qualitative report is divided into two sections. The first section summarizes reactions to the health warning messages; the second section explores reactions to the proposed packaging.

Reactions to Health Warning Messages

Participants were provided with an exercise sheet that included a series of health warning messages. Each message included a primary sentence with one or multiple secondary sentences.

Overall reaction to the health warning messages was mixed.

Reaction tended to correlate very highly with participants' views of cannabis. Participants were either pre-disposed to be fearful of cannabis - and, by default, receptive to most/all warnings - or pre-disposed to be comfortable with cannabis. Those pre-disposed to be comfortable with cannabis presented a range of different reactions depending on experience, knowledge and desire/intention.

This being said, all of the health warning messages did have the ability to impact some participants, but if the aim is to maximize the number of people whose behaviour may be affected, adjusting the messages that are challenged by those pre-disposed to be comfortable with cannabis will not reduce the impact on those fearful of cannabis and can therefore only improve the overall effectiveness.

Those comfortable with cannabis claimed to be more open to messaging that took the approach of "enjoy responsibly" rather than simply "beware!".

As we will see later in the detailed observations, three of the primary messages were accepted as both generally credible, worked on their own without the need for supporting messages, and deemed important for at least certain people to keep in mind. Those included messages that warned about the effects of cannabis on expectant mothers; the risk of driving while under the influence; and, the health risks associated with cannabis use for youth, in particular.

As with reaction to the messages overall, the use of statistics was mixed, although, the more detailed analysis that follows suggests that the use of statistics was particularly helpful (and persuasive) for youth. Generally, however, those pre-disposed to be fearful of cannabis were generally comfortable with the statistics provided and accepted them. Those pre-disposed to be comfortable with cannabis, however, felt that the health warning messages would be much more credible if they were supported and referenced appropriately. For these participants, simply stating facts (statistics) was not all that persuasive or credible and suggested a fear-mongering approach which, if accepted as truth, begged questions about the government's decision to legalize cannabis.

In terms of the language used, it was generally felt to be clear and understandable although there were a few terms that were not well understood by all youth (mainly those 13-15): THC, psychosis, and schizophrenia.

Detailed Observations

The following summarizes specific reactions to each of the primary and secondary health warning messages.

Included under the general observations is a statement about whether participants would be likely to take action as a result of reading this message. For the purposes of reporting, "taking action" was described to participants as doing something as a result of the message (i.e., research on the internet or talking to somebody, etc.).

Warning: Cannabis smoke is harmful

General observations:

The secondary sentence tended to be seen as more powerful than the primary sentence.
This health warning message was not among the more likely to encourage participants to take action.

• Reactions to this message were very much influenced by participants' views of cannabis.
• Those more comfortable with cannabis, often disputed the notion that cannabis smoke was particularly bad. They equivocated that any smoke is technically bad for you; arguing that this was an example of fear-mongering.
• Many questioned whether the smoking of a "natural plant" was harmful, arguing that cannabis (or a joint) did not often contain the same harmful chemicals or additives that cigarettes do making the inhalation less harmful. This was often the case for youth (16-17) who were the least likely to find this statement credible/believable.
• Furthermore, some also pointed out that there are ways of using cannabis that do not involve smoking (including vaping which some feel is healthier than smoking).
• Those fearful of cannabis, agreed that any smoke is bad and understood this statement to mean that cannabis smoke was particularly bad.
  • Some interpreted this as being about the effect of the drug, rather than about the inhaling of smoke. For these participants, the primary message meant simply "cannabis is harmful."

Recommendations:

• "Enjoy responsibly" approaches that may be more effective include:
• "If you are intending to use cannabis, be aware that the different ways of taking the drug have different health risks."
• "Beyond the risks of using cannabis in any form, the act of smoking cannabis has additional harmful effects on your lungs."
• Additionally, pointing out the specific dangerous chemicals that are unique to smoking cannabis may help improve the effectiveness of the primary and secondary message.

Warning: Do not use if pregnant or breastfeeding

General observations:

The primary sentence was very compelling on its own.
This health warning message was among the most likely to encourage participants (of all ages) to take action.

• While some might argue that this message would not appeal or be relevant to youth, many youth (both 13-15 and 16-17) indicated they would be interested to learn more about the risks associated with cannabis use and pregnancy/breastfeeding so that they could talk to people they knew in this situation. They were also curious about the biology and risks associated with cannabis substances found in breast milk as this was new information.


• This health warning message was deemed the most credible and believable of all the messages tested (across all audiences).
• It was felt to be common sense. Very few participants needed the substantiation provided in the secondary sentences. In fact, for some participants, the secondary sentences introduced elements that diminished the credibility of the message:
• For example, some participants questioned whether a lower birth weight was the worst outcome (2a), arguing that they could imagine more harmful ramifications of smoking cannabis on a newborn child (i.e., physical, mental, developmental, etc.).
• Similarly, some participants questioned how cannabis substances could be found in breast milk (2b) and the health risks associated with transmission of cannabis substances this way.

Recommendations:

• The primary message may be adequate on its own.
• If coupled with a secondary sentence, referring to a more alarming risk than lower birth weight might be more persuasive. Similarly, providing a suggestion as to the health risk associated with cannabis-contaminated breast milk might be more persuasive than simply stating substances can be found in breast milk.

Warning: Do not drive or operate machinery after using cannabis

General observations:

The primary sentence was very compelling on its own.
This health warning message was among the most likely to encourage participants (of all ages) to take action.

• This health warning message was deemed very credible and believable. In terms of ratings, this was the second highest rated in terms of credibility/believability.
• While most accepted the premise that it is not sensible to drive after using cannabis, there were some, often in the youth groups (13-17), who argued cannabis can have a calming effect on some drivers. However, when pressed, most tended not to want to be the passenger in a vehicle being driven by someone who is high.
• Also worth noting, a few participants were confused as to the reference to operating machinery, questioning what machinery this referred to.
• Reaction to the secondary sentences was somewhat mixed. There was preference for the second secondary sentence (3b).
• The challenge with the first (3a) was that it used unsupported/unreferenced statistics.
  • Some felt that statistics from 2012 were outdated.
  • Others, did not feel the number of deaths/injuries referenced were all that significant particularly as compared to deaths related to drunk driving.
  • Important to note, however, youth (13-17) tended to find the statistics very persuasive. Reference to 4,000 injuries and 75 deaths linked to cannabis use did feel significant.
• Views of the second secondary sentence (3b) were much more favourable in the sense that most participants (of all ages) felt it was credible/believable.
  • Impairment of coordination, attention, and reaction time, were certainly behaviours most had observed in those they know who have used cannabis.
  • The implication that someone under the influence does not have the wherewithal to operate a vehicle was credible and understood.

Recommendations:

• The primary message may be compelling enough to consider using on its own.
• If being paired with one of these two secondary sentences, the sentence about the impairment of judgement may be more effective, but the risk of physical harm has the potential to be more compelling if the statistics do not lead one to conclude there is actually little or no problem.

Warning: Cannabis can be addictive

General observations:

The primary sentence was not universally accepted and could be improved with evidence.
This health warning message was among the least likely to encourage participants to take action.

• Some participants across all age groups, and young adults (18-24), in particular, did not immediately agree with the message that cannabis is addictive.
• Those that found this message less credible argued that there is no active ingredient in cannabis that causes addiction and described it more as a mental dependence on the routine of getting high. Some also made the case that there are more problematic things to be addicted to.
• The statistics in the three secondary messages were not all that persuasive.
• For example, "1 in 11" (4b) did not strike participants as being all that high; there was a sense that most could beat those odds.
• Furthermore, referencing "up to half" (4a) or "up to 1 in 2 people" (4c) did not come across as all that concrete which reinforced participants' views that some of the statistics felt made up (and lacked supporting evidence or appropriate references).

Recommendations:

• An "enjoy responsibly" message that could help this be more effective might be to encourage people to keep an eye out for signs you are overusing (i.e., avoiding other things in life that deserve your attention; spending less time with friends and loved ones; missing or underperforming at school or work; etc.).
• Because most agreed that it was possible that cannabis could lead to an undesirable habit, it might be helpful to provide a rule of thumb about how often might be too often.
• Finally, proving that cannabis is addictive would go a long way to improving the effectiveness of messages about addiction; repeated warning messages to this effect do not seem to be moving the needle in terms of acceptance of this as fact.

Warning: Regular use of cannabis can increase the risk of psychosis and schizophrenia

General observations:

The primary sentence was somewhat confusing (language not well understood).
This health warning message was among the most likely to motivate participants (of all ages) to take action.

• When it came to the message that regular use of cannabis can increase the risk of psychosis and schizophrenia, participants tended to fall into one of two camps: those that had heard or accept this as fact already and find it a powerful message; and, those that are skeptical or not yet convinced but for whom "if that really is true," the warning has the potential to be powerful. Indeed, most judge this to be an extremely undesirable and frightening outcome of cannabis use.
• Many of those comfortable with cannabis were aware of this, but, experience (first hand or of people they know) suggests this outcome only happens in rare, unusual cases (i.e., individuals have family history with these illnesses). Some felt that this outcome may have been inevitable or likely for them regardless of cannabis use.
• Some participants, of all ages, also suggested that they knew of people who turned to cannabis to deal with mental health issues (i.e., anxiety) rather than the reverse causality.
• Medical examples are also paradoxical for some because some find it hard to reconcile that doctors would risk exposing people to psychosis or schizophrenia by prescribing cannabis. As a result, it reinforces the notion that there must be a way to avoid or mitigate this consequence.
• There was a certain level of confusion around the secondary sentences:
• Most found the suggestion that young persons were particularly at risk (5c) to be credible/believable and persuasive. It was also felt to be clear and direct in its construction.
• The other two primary sentences were confusing for some who were not familiar with the term, THC.
• The construction of the second secondary sentence (5b) was felt to be particularly awkward. Many were not exactly sure of the point the sentence was making.
• Some felt the first secondary sentence (5a) was a reiteration of the primary sentence; it did not add any new information.

Recommendations:

• An "enjoy responsibly" message that may help make warnings about psychosis or schizophrenia more effective among those comfortable with cannabis could be there are some things that we know that make people more susceptible (i.e., family history, starting as a teen, using daily for x years, etc.) and perhaps even that some develop it without being in one of these high-risk groups. The only way to be sure it will not happen is to not use it, but by waiting until your brain has finished developing and only using small amounts infrequently, you may reduce your risk.

Warning: Adolescents are at a great risk of harms from cannabis

General observations:

The primary sentence was very compelling on its own.
This health warning message was among the most likely to motivate participants (of all ages) to take action.

• Most participants understood and found this health warning message to be compelling. Indeed, the primary sentence could very easily stand on its own. Participants, of all ages, agree that adolescents are at greater risk of harms from cannabis.
• The credibility of the secondary statements was questionable and none seemed to add a dimension to the primary sentence that made it any more compelling.
• Unprompted, participants explain their acceptance of this health warning message by stating that they are aware that cannabis can pose risks on developing brains.
• Again, most are not immediately accepting of the suggestion that cannabis is addictive (6b and 6c); and, many question the likelihood and severity of that outcome.
• The statistics provided in the third secondary sentence (6c) were also not felt to be terribly compelling in the sense that "1 in 6" did not appear all that high.

Recommendations:

• An "enjoy responsibly" message that may help make warnings about the risks associated with use of cannabis by youth should be tied to impacts of cannabis on developing brains.
• It could also be more impactful if tied to outcomes mentioned earlier such as: underperformance in school or at work; avoidance of important things in life; spending less time with friends and loved ones; impacts on sport; etc.

Reactions to Proposed Packaging

Participants were then shown a concept of a proposed package. The package was a small black cardboard box about the size of a Rubik's cube with a health warning message, cannabis symbol on the front, and other required information on the back.

Overall, the proposed package was met with generally favourable, though at times quizzical, reaction. Participants described the overall look as somewhat understated, neutral, sleek, and, in some groups, cool (particularly among young adults). In large part, this was attributed to the black background although many remarked that the lack of brand elements was interesting. When asked, most tended to feel that that was appropriate; so as not to entice the wrong people (i.e., children).

The more quizzical reactions tended to revolve around the size, shape and material of the package. Many participants did not believe it was an intuitive design and questioned the use of paper stock (carton) as opposed to a re-sealable bag. They assumed that there would be a re-sealable bag inside to hold and protect the cannabis, but also to reduce the odour and potential of cannabis waste.

The other thing that was a little surprising for most was that the contents of the package were not clearly marked. Many expected the box to be a green colour which would more readily suggest a package of cannabis or that it would have a large symbol (i.e., a cannabis leaf), prominently displayed on the package.

Most felt the symbol should be larger - it was not the most attention-grabbing element on the package. In fact, many in most groups did not notice the symbol until asked.

The most attention-grabbing element of the package was the health warning message in the yellow box. The yellow box on the black package was noticeable although many argued that the placement could be a little more prominent and that the font could be larger.

One of the most consistent comments offered was that the instruction to "keep out of reach of children" was not given the prominence that it deserves. Even bold lettering would be an improvement for a message that is universally accepted as important.

There were also some suggestions of adding more warning messages to the blank sides of the package. Some complained that the example provided (i.e., do not use if pregnant or breastfeeding) was too narrow and did not speak to all who may be potential consumers of cannabis. Others argued that if there were too many warning messages on the package, consumers would become immune. They felt that one message, per package, that changed regularly, would be more impactful. Some suggested including in the package a paper outlining the possible side effects and risks associated with cannabis use similar to what is done with medication (whether over-the-counter or prescription).

A number of participants in each group noticed and appreciated the reference to the THC and CBD levels. Those more comfortable with cannabis felt it would also be important to reference the expected effects associated with the particular strain of cannabis and the origins of the cannabis.

Conclusions

The research results indicate that when it comes to warning the public about potential effects of cannabis, reaction largely depends on pre-conceived attitudes towards the substance. Those who are not familiar with it or generally do not use it were more likely to agree with and find the warnings credible, while those who have used cannabis presented a wider range of views.

Those who were more comfortable with cannabis sought clearer evidence of harms or risks in the statements to improve their credibility - simply stating facts (statistics) was not all that persuasive or credible. Many felt that several of these messages employed a fear-mongering approach which, if accepted as truth, begged questions about the government's decision to legalize cannabis. However, three messages were widely accepted regardless of age and previous familiarity with cannabis: the suggestion of not using cannabis while pregnant; the suggestion of not operating a vehicle while under the influence; and, that adolescents (although many would prefer an age range were specified) are at greater risk of harm.

Generally, with respect to the message that cannabis smoke is harmful, most agreed that any smoke is bad. Most understood this statement to mean that cannabis smoke is particularly bad, but highlighting the relativity to tobacco seems to make this message more effective, particularly for those aware of mixing tobacco with cannabis. Some participants understood the statement to mean that the choice to smoke cannabis involved risks associated with smoking, but pointed out that there are ways of using cannabis that do not involve smoking and therefore, the context of the message would bear an impact on the perceived relevance of it.

While most accepted the premise that it is not sensible to drive after using cannabis, there were some, often in the youth groups (13-17) who argued cannabis can have a calming effect on some drivers. However, when pressed, most tended not to want to be the passenger in a vehicle being driven by someone who is high. The number of deaths and injuries related to driving under the influence was persuasive for some (mostly youth) while others found the secondary sentence about reaction time more broadly acceptable, convincing, and in line with the primary statement.

Finally, regarding the message that regular use of cannabis can increase the risk of psychosis and schizophrenia, participants tended to fall into one of two camps: those that had heard or accept this as fact already and find it a powerful message; and, those that are skeptical or not yet convinced but for whom "if that really is true" the warning has the potential to be powerful.

Overall reaction to the packaging was favourable, though at times participants were surprised by design elements and readily made suggestions. The more quizzical reactions tended to revolve around the size, shape and material of the package. Many participants did not believe it was an intuitive design and questioned the use of paper stock (carton) as opposed to a re-sealable bag. The other thing that was a little surprising for most was that the contents of the package were not clearly marked, and that the box was black, not green.

There was consensus that the symbol should be much larger. Most did not notice it on the package until asked to look for it. They also felt the warning instruction to "keep out of reach of children" was not given the prominence that it deserves.

The most attention-grabbing element of the package was the health warning message in the yellow box. The yellow box on the black package was noticeable although many argued that the placement could be a little more prominent (occupying more space on the package) and that the font could be larger.

There were also some suggestions of adding more warning messages to the blank sides of the package. Some complained that the example provided (i.e., do not use if pregnant or breastfeeding) was too narrow to relate to all cannabis users. Others argued that if there were too many warning messages on the package, consumers would become immune. They felt that one message that changed regularly would be more impactful. In terms of information participants felt was missing on the package, there were suggestions to include information about the effects consumers should expect from that strain of cannabis and the origins of the cannabis.

Overall, participants were open to both the messages and the packaging, but for those who were less convinced or had questions, offering more specific evidence aside from statistics to support the warnings, and making the symbols and specific warnings more prominent appeared to help improve credibility and effectiveness.

Appendix A: Discussion Guide

Introduction

Moderator introduces herself/himself and her/his role: role of moderator is to ask questions, make sure everyone has a chance to express themselves, keep track of the time, be objective/no special interest.

• The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
• The research purpose and research sponsor, described, at a minimum. The Government of Canada is developing messages and package designs that will be applied to legal cannabis products.
• Role of participants: speak openly and frankly about opinions, remember that there are no wrong answers and no need to agree with each other
• Reminder not to reveal their family name or any other personal information during the discussion that is not pertinent to this discussion
• Results are confidential and reported all together/individuals are not identified/participation is voluntary. If there are any concerns about the confidentiality around marijuana still being an illegal substance and their own usage of it: reiterate that questions around drug usage will not be asked in this research; emphasize on how the results are analyzed and kept confidential.
• The length of the session (60 minutes)
• The presence of any observers, their role and purpose, and the means of observation (one-way mirror, teleconference/webstreaming; colleagues viewing in the back room and listening in remotely)
• The presence and purpose of any recording being made of the session (audio and video taping of the discussion
• Turn off cell phones for the duration of the discussion

Moderator will go around the table and ask participants to introduce themselves.

Message Testing

I would like to start by asking you to review a series of messages that are being proposed by the Government of Canada. I am going to pass out a sheet with the statements. Please feel free to mark it up. I would ask that you put a "√" beside the statements that resonate with you the most, put an "X" beside any statement you feel the government should not use, a "?" beside any statements you find confusing or unclear. Please feel free to mark up any word/phrases/elements with the same symbols.

List of Statements in Appendix

Moderator to distribute handout with statements. Moderator will lead a discussion reviewing each statement one by one:

• Overall, what did you think of this statement? Did you like it? Dislike it? Find it confusing or unclear?
• Is it credible? Believable? Why or why not?
• Is it relevant to you? Why or why not?
• Is the language understandable? Why or why not?
• What is the main message? Why do you say that?
• Would it motivate you to take action?
• What type of actions? Probe: talk to someone, talk to kids/parents, look for more information, etc.?
• Do you find any of these statements more compelling than others? Why do you say that?

Concept Testing

Now I would like to spend a few minutes looking at a couple of mock-up packages. Please bear in mind, these are concepts and not the final product. They were created for the purposes of our discussion today/tonight. Given I have a limited number of copies, I will ask you to group in two and share with a partner. Please review the packages in silence and make your own notes.

• Overall, what do you think of this packaging?
• What stands out most? Why?

Moderator to pay attention to see whether participants comment on the lack of brand elements and colour …

• [HANDS UP] Did anyone notice the lack of brand elements and colour on the packaging? What do you think of this? Is it appropriate? Why or why not?
• What else did you notice on the packaging?
• [HANDS UP] Did anyone notice the symbol?
• What do you think of it? What does it mean to you?
• Is it noticeable? Why or why not?
• What would you do if you saw this symbol? Why?
• What about the message/statement? [HANDS UP] Did anyone notice it?
• What do you think of it?
• Does your view of the messages/statements change now that you see what it will look like on the package? If yes, in what ways?

Wrap-Up

Moderator to check in the back room and probe on any additional areas of interest.

• This concludes what we needed to cover tonight. We really appreciate you taking the time to come down here to share your views. Your input is very important.
• Reminder to those in the first and second groups about reserving comments so as not to influence those waiting at reception for the next group.

Appendix B: Health Warning Messages

Appendix C: Screener

• Respondent's name:
• Respondent's phone number (home):
• Respondent's phone number (work) :
• Respondent's fax number:
• Respondent's email:
• Sample source: panel random client referral Interviewer:
• Date:
• Validated:
• Quality Central:
• On list:
• On quotas:

Hello, my name is _______________ and I'm calling on behalf of Earnscliffe, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada. We are looking for people who would be willing to participate in a discussion group. Participants will receive an honorarium for their participation. May I continue?

• Yes - Continue
• No - Thank and Terminate

Participation is voluntary. We are interested in hearing your opinions; no attempt will be made to sell you anything or change your point of view. The format is a 'round table' discussion led by a research professional. All opinions expressed will remain anonymous and views will be grouped together to ensure no particular individual can be identified. But before we invite you to attend, we need to ask you a few questions to ensure that we get a good mix and variety of people. May I ask you a few questions?

• Yes - Continue
• No - Thank and Terminate

S1. Do you or any member of your household work for…

If "yes" to any of the above, Thank and Terminate.

S2. Do Not Ask - Note Gender

• Male - 1 Ensure Good Mix
• Female - 2
• Prefer not to identify as either male or female - 3

S3. Could you please tell me which of the following age categories you fall into? Are you...

Ensure Good Mix of Ages in all sessions

• Under 18 years - 1 Ask to speak to adult 18+
• 18-24 years - 2 Continue for session 1
• 25-29 years - 3 Continue for session 4
• 30-34 years - 4 Continue for session 4
• 35-44 years - 5 Continue for session 4
• 45-54 years - 6 Continue for session 4
• 55-64 years - 7 Continue for session 4
• 65+ years - 8 Continue for session 4 Max 1
• DK/NR - 9 Thank and terminate

For those under 18, Once adult is on the line, go back to introduction

S4. Do you normally reside in the [Insert City] area?

• Yes - Continue
• No - Thank and Terminate

S5. What is your current employment status?

• Working full-time - 1 Ensure Good Mix for Session 4
• Working part-time - 2
• Self-employed - 3
• Retired - 4
• Unemployed - 5
• Student - 6
• Other - 7
• DK/NR - 9 Thank and Terminate

S6. Which of the following categories best describes your total household income? That is, the total income of all persons in your household combined, before taxes [Read list]?

Ensure good mix for session 4

• Under $20,000 - 1 Recruit 3 from $40k and below
• $20,000 to under $40,000 - 2
• $40,000 to under $60,000 - 3 Recruit 4 from $40K-$80K
• $60,000 to under $80,000 - 4
• $80,000 to under $100,000 - 5 Recruit 5 from $80K+
• $100,000 to under $150,000 - 6
• $150,000 or more - 7
• DK/NR - 9 Thank and Terminate

S7. What is the last level of education that you have completed?

• Some high school only - 1
• Completed high school - 2
• Some college/university - 3
• Completed college/university - 4
• Post-graduate studies - 5
• DK/NR - 9 Thank and Terminate

S8. Are you a parent or guardian of a child under 17 or under?

• Yes - 1 Continue
• No - 2 Skip to S16 for session 4

Please ensure a minimum of 5/12 for Session 4 (Adult 25+) are parents.

S9. Do you have a child between the ages of 13 and 17 that lives with you at least half the time?

• Yes - 1 Continue for session 2 and 3
• No - 2 Go to S16

To Parents of children 13-17:

If Recruiting Child: Continue
If Recruiting Parent (For Adults 25+): Skip to S16

Note: Do not recruit child(ren) of different age groups and/or parents from same household

S10. As part of this study, we are conducting a series of discussions with youth between the ages of 13 and 17. With your permission, we would like to invite your child to attend a discussion on [Insert date] at [Time]? It will last [Insert duration] and your child will receive [Insert amount] for their time.

These groups are being conducted on behalf of Health Canada to help them explore the topic of youth and cannabis. Please note, while it is not our intention to ask any questions about your child's own possible drug use, that subject may come up. The discussion will focus on their opinions of different messages and packaging about the potential harms/health effects of cannabis use. Your written consent for your child to participate in the discussion will be required upon arrival.
Would your child be available to attend on [Insert date] at [Time]?

• Yes - 1 Continue
• No - 2 "In that case, would you be able to participate?" - Skip to S16

S11. Is the child who would be participating a male or a female or prefers not to identify as either male or female?

• Male - 1 Ensure Good Mix
• Female - 2
• Prefer not to identify as either male or female - 3 No minimum for this group

S12. What is the age of the child who would be participating? Ensure good mix for all sessions

• 13 - 1 Continue for Session 2
• 14 - 2 Continue for Session 2
• 15 - 3 Continue for Session 2
• 16 - 4 Continue for Session 2
• 17 - 5 Continue for Session 2

S13. In order to ensure we have a mix of participants in the room, we need to ask them some qualifying questions. May we speak with your son or daughter if it is convenient to speak with them now?

• Male - 1 Wait to speak to child
• Yes, but they are not available now - 2 Reschedule
• No - 3 Thank and Terminate

[For sessions 2 and 3] To Youth (13-17):

Hello, my name is _______________ and I'm calling on behalf of Earnscliffe, a national public opinion research firm. We are organizing a series of discussion groups on issues related to youth and drugs on behalf of Health Canada (Government of Canada). Up to 12 adolescents will be taking part and for their time, participants will receive an honorarium of [Insert amount]. But before we invite you to attend, we need to ask you a few questions to ensure that we get a good mix/variety of people. May I continue?

• Yes - Continue
• No - Thank and Terminate

Participation is voluntary. We are interested in hearing your opinions; no attempt will be made to sell you anything or change your point of view. The format is a 'round table' discussion led by a research professional. All opinions expressed will remain anonymous and views will be grouped together to ensure no particular individual can be identified. It is important that you understand that all of your answers will be kept confidential, including from your parents. Your answers will be used for research purposes only and will help ensure we have a mix of participants in the room.

S14. For the purposes of this project, we need to ensure that we are speaking with youth between the ages of 13 and 17 years. Are you between the ages of 13 and 17?

• Yes - Continue
• No - Thank and Terminate

S15. How old are you?

• 13 - 4 Continue for Session 2
• 14 - 5 Continue for Session 2
• 15 - 6 Continue for Session 2
• 16 - 7 Continue for Session 3
• 17 - 8 Continue for Session 3

S16. Have you participated in a discussion or focus group before? A discussion group brings together a few people in order to know their opinion about a given subject.

• Yes - 1
• No - 2 Skip to S20
• DK/NR - 9 Thank and Terminate

S17. When was the last time you attended a discussion or focus group?

• If within the last 6 months - 1 Thank and Terminate
• If not within the last 6 months - 2 Continue
• DK/NR - 9 Thank and Terminate

S18. How many of these sessions have you attended in the last five years?

• If 4 or less - 1 Continue
• If 5 or more - 2 Thank and Terminate
• DK/NR - 9 Thank and Terminate

S19. And what was/were the main topic(s) of discussion in those groups?

If Related to Cannabis, Drugs, Government policy on drugs, Thank and Terminate

S20. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

• Very comfortable - 1 Minimum 4 per group
• Somewhat comfortable - 2 Continue
• Not very comfortable - 3 Thank and Terminate
• Not at all comfortable - 4 Thank and Terminate
• DK/NR - 9 Thank and Terminate

S21. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

• Yes - 1 Thank and Terminate
• No - 2 Continue
• DK/NR - 9 Thank and Terminate

S22. The discussion group will take place on [Insert date and time] for [Insert duration] and participants will receive [Insert amount] for their time. Would you be willing to attend?

• Yes - 1 Recruit
• No - 2 Thank and Terminate
• DK/NR - 9 Thank and Terminate

Privacy Questions
Now I have a few questions that relate to privacy, your personal information and the research process. We will need your consent on a few issues that enable us to conduct our research. As I run through these questions, please feel free to ask me any questions you would like clarified.

P1) First, we will be providing the hosting facility and session moderator with a list of respondents' names and profiles (screener responses) so that they can sign you into the group. This information will not be shared with the Government of Canada department organizing this research. Do we have your permission to do this? I assure you it will be kept strictly confidential.

• Yes - 1 Go to P2
• No - 2 Read Respondent info below

We need to provide the facility hosting the session and the moderator with the names and background of the people attending the focus group because only the individuals invited are allowed in the session and the facility and moderator must have this information for verification purposes. Please be assured that this information will be kept strictly confidential. Go to P1A

P1a) Now that I've explained this, do I have your permission to provide your name and profile to the facility?

• Yes - 1 Go to P2
• No - 2 Read Respondent info below

P2) An audio and/or video tape of the group session will be produced for research purposes. The tapes will be used only by the research professional to assist in preparing a report on the research findings and will be destroyed once the report is completed.

Do you agree to be audio and/or video taped for research purposes only?

• Yes - 1 Go to P3
• No - 2 Read Respondent info below

It is necessary for the research process for us to audio/video tape the session as the researcher needs this material to complete the report.

P2a) Now that I've explained this, do I have your permission for audio/video taping?

• Yes - 1 Go to P3
• No - 2 Read Respondent info below

P3) Each month we submit the names of individuals that have participated in our focus groups to the Marketing Research and Intelligence Association Qualitative Central system (www.mria-arim.ca). Qualitative Central serves as a centralized database to review participation in qualitative research and focus groups. You will not be contacted for any reason whatsoever as a result of being on this list.

Do we have your permission to submit your name and phone number to MRIA's Qualitative Central system?

• Yes - 1 Thank and go to invitation
• No - 2 Go to P3A

P3a) To participate in this focus group we must have your permission to add your name to the Qualitative Central system as it is the only way for us to ensure the integrity of the research process and track participation in qualitative research. The system is maintained by the industry body, the Professional Marketing Research Society, and is solely used to track your participation in qualitative research (such as focus groups). You will not be contacted for any reason whatsoever as a result of being on this list.

Now that I've explained this do I have your permission to add your name to our qualitative central list?

• Yes - 1 Thank and go to invitation
• No - 2 Thank and Terminate

As Required, Additional Info for the Interviewer:
Please be assured that this information is kept confidential and is strictly accessed and used by professional market research firms to review participation and prevent "professional respondents" from attending sessions. Research firms participating in MRIA's Qualitative Central require your consent to be eligible to participate in the focus group - the system helps ensure the integrity of the research process.

As Required, Note about MRIA:
The Marketing Research and Intelligence Association is a non-profit organization for marketing research professionals engaged in marketing, advertising, social, and political research. The Society's mission is to be the leader in promoting excellence in the practice of marketing and social research and in the value of market information.

Invitation:
Wonderful, you qualify to participate in one of our discussion sessions. As I mentioned earlier, the group discussion will take place the evening of [Insert Date and Time] for up to [Insert duration].

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at: [Provide Facility name and address].

We ask that you arrive fifteen minutes early to be sure you find parking, locate the facility and have time to check-in with the hosts. The hosts may be checking respondents' identification prior to the group, so please be sure to bring some personal identification with you (for example, a health card, a student card, or a driver's license). If you require glasses for reading make sure you bring them with you as well.

As we are only inviting a small number of people, your participation is very important to us. If for some reason you are unable to attend, please call us so that we may get someone to replace you. You can reach us at [Insert phone number] at our office. Please ask for [Name]. Someone will call you in the days leading up to the discussion to remind you.

So that we can call you to remind you about the discussion group or contact you should there be any changes, can you please confirm your name and contact information for me?

First name
Last Name
Email
Daytime phone number
Evening phone number

If the respondent refuses to give his/her first or last name or phone number please assure them that this information will be kept strictly confidential in accordance with the privacy law and that it is used strictly to contact them to confirm their attendance and to inform them of any changes to the discussion group. If they still refuse Thank and Terminate.