Ahmad Sabalbal1
Firas Kobeissy
Evelyne Baroud
Samer El Hayek- 1Department of Psychiatry, American University of Beirut Medical Center, Beirut, Lebanon
- 2Department of Psychiatry, Lebanese American University, Beirut, Lebanon
- 3Center for Neurotrauma, Multiomics & Biomarkers, Department of Neurobiology, Neuroscience Institute, Morehouse School of Medicine, Atlanta, GA, United States
- 4Department of Emergency Medicine, McKnight Brain Institute, University of Florida, Gainesville, FL, United States
- 5American Center for Psychiatry and Neurology, Dubai, United Arab Emirates
Introduction: The rising global prevalence and potential harms of cannabis use among adolescents and young adults are cause for concern. This systematic review focuses on the Arab world, compiling research on cannabis consumption among school and university students, where use has significantly increased but remains inadequately evaluated.
Methods: The review was registered in PROSPERO (CRD42021285103). Following PRISMA 2020 guidelines, two researchers searched PubMed, Embase, Scopus, and PsycInfo from inception to 9 May 2024, with no filters or language restrictions. Grey literature was identified through structured searches in Google Scholar and ProQuest Dissertations & Theses Global on 30 August 2024, as well as through reference list screening and citation tracking of the included articles. Keywords used included “cannabis”, “student”, and “Arab”.
Results: From 5,820 potentially eligible records, 31 manuscripts were identified and 17 records were retrieved from the grey literature. A total of 48 cross-sectional studies from 13 Arab countries met the inclusion criteria and were included in the synthesis. Of these, 20 studies focused on school settings (sample sizes: 140–10,648), and 29 examined university students (sample sizes: 172–7,445). The most commonly used assessment tools were the Global School-Based Student Health Survey (GSHS) for school students and the WHO-based Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for university students. Lifetime cannabis use prevalence ranged from 0.7% in Iraq to 9.4% in Morocco among school students, and from 4.7% in Tunisia to 32% in Lebanon and Egypt among university students. Cannabis use was more prevalent among university students. Key correlates included male gender, older age, family discordance, peer pressure, lower religiosity, and psychiatric symptoms.
Discussion: These findings align with global patterns and emphasize the need for early intervention, psychoeducation, and targeted prevention strategies to mitigate cannabis-related risks among youth in the Arab world.
1 Introduction
Cannabis is the most commonly used drug worldwide, especially among young people (1). Some research suggests that it may act as a gateway to other substances (2, 3), while other studies dispute this pathway, emphasizing the role of underlying social, psychological, and environmental factors in substance use progression (4, 5). In 2021, approximately 219 million people used cannabis across nearly all countries and territories, marking a 21% increase from the 180.6 million users in 2011 (6, 7). In 2023, among individuals aged 12 and older, 59.0% (or 167.2 million people) reported using tobacco, nicotine vaping products, alcohol, or illicit drugs. Specifically, 24.9% (or 70.5 million people) used illicit drugs during that period, of which cannabinoids represented 21.8% (or 61.8 million people) (8).
Starting substance use during adolescence is a significant predictor of developing substance use disorders later in life (9). Research using neuroimaging in adolescent substance users has revealed initial evidence of functional and structural alterations in key brain regions, these changes are thought to play a significant role in the future development of substance use disorders (10). Along the same lines, youth who begin to use cannabis before the age of 18 are significantly more likely to develop cannabis use disorder. The risk is highest for those who use cannabis at least weekly, with the highest prevalence found among those who use it daily, and with substance-related issues extending into adulthood leading to negative psychiatric and personal outcomes (11).
In this regard, early cannabis use has been linked to various negative health, social, and behavioral outcomes later in life (12). The former include neurocognitive impairments, such as a decline in verbal intelligence, working memory, and attention (13). These impairments often result in poor academic performance and school dropout. Additionally, young cannabis users tend to associate with peers who engage in substance use or exhibit behavioral problems, exacerbating these issues (14). Other chronic effects include worsening of psychotic disorders in vulnerable individuals, mood disorders, and health conditions affecting the cardiovascular and respiratory systems (15).
This situation is exacerbated by the rising potency of cannabis products and extracts. Cannabis contains over 400 compounds, including more than a hundred cannabinoids that interact with the body’s endocannabinoid system. This system, a critical regulator of the stress response, is made up of neurotransmitters that bind to cannabinoid receptors located throughout the central nervous system (CNS) (16). Among other functions, it is involved in neuroprotection, modulation of nociception, neurogenesis, and pain (17). The most prevalent cannabinoids in cannabis are Δ−9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the primary modulator of the psychoactive effects of cannabis, mainly by binding to the cannabinoid 1 receptors of the CNS (18). Lately, cannabinoid products have displayed significantly elevated levels of THC, worsening their impact on users (19). This has led to a variation in available types of cannabis extracts and concentrates, including Hash, Hash oil, Butane hash oil (BHO), Wax, Dab, Shatter, Amber, and Honeycomb (20), and products specific to the Arab World such as Bango and Hashish which differ by the percentage of cannabinoid constitution (21). Another growing concern is the emergence of synthetic and semi-synthetic cannabinoids. These substances are chemically engineered to act on the same cannabinoid receptors as THC but often produce more potent and unpredictable effects (22). Synthetic cannabinoids, which gained prominence in the early 2000s, are typically structurally unrelated to natural cannabinoids. More recently, semi-synthetic cannabinoids have appeared; these are usually derived from phytocannabinoids and maintain much of their original structure with minor chemical modifications. New variants of both synthetic and semi-synthetic cannabinoids continue to emerge on drug markets worldwide, with considerable variation in their formulations, availability, and prevalence across countries. Like other new psychoactive substances, these compounds cannot be identified using standard toxicology tests (23–25).
The widespread availability and growing potency of cannabis and its related products have global implications, but the situation in the Arab World is particularly concerning. The term “Arab World” refers to a group of 22 countries in the Middle East and North Africa where Arabic is the primary language. The region extends from the Arabian Gulf in the east to the Atlantic Ocean in the west, encompassing countries in both the Middle East and North Africa (26). Although substance use trends vary across the region, the Eastern Mediterranean Region, which significantly overlaps with the Arab World, reports a high burden from substance use disorders, accounting for 4 disability-adjusted life years (DALYs) and 9 deaths per 1,000 population, significantly higher than the global averages of 2 DALYs and 4 deaths per 1,000 population (27). Notably, Egypt, Lebanon, and Morocco stand out as key players in cannabis production and distribution within the Arab World. Since the 1960s, these countries have been the major producers and suppliers of marijuana to worldwide markets (28, 29). While availability is a critical factor in understanding cannabis use trends, recent statistics in the Arab World reveal alarming rates of consumption. In Lebanon, for instance, 56% of young adults aged 18–20 reported lifetime use of cannabis (30). Another study in Egypt found lifetime prevalence reaching 20% among adolescents and young adults (31), while rates reached 13.4% and 11.8% in Morocco and Jordan, respectively (32, 33).
Given the high prevalence of cannabis use and its associated risks, particularly in regions such as the Arab World, understanding the trends, patterns, and factors influencing its consumption is essential. This is especially pressing among young populations who are at heightened risk for early initiation and subsequent substance use (34, 35). As there remains a notable gap in the current literature on cannabis use trends among young people in this region, further investigation among students in the Arab World becomes critical for informing prevention and intervention efforts.
As such, this systematic review aims to synthesize available research on cannabis use among students attending a school or university setting in the Arab World. The review aims to provide valuable insights into the prevalence, trends, characteristics, and correlates of cannabis consumption in this particularly vulnerable population.
2 Methods
The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42021285103), in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations for transparency and methodological rigor in systematic reviews.
2.1 Eligibility criteria
Studies were eligible to be included in the systematic review if they met the following inclusion criteria:
● Population: Arab adolescents and young adults actively attending a school or university setting in the Arab World (Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen).
● Exposure: The use of cannabis and its derivatives, whether current or past.
● Outcome: Prevalence, characteristics, patterns, and correlates of use.
● Study design: Cross-sectional.
Studies assessing the characteristics of cannabis use or looking at overall substance use with stratified data on the consumption of cannabis and its derivatives were included. Studies not directly assessing the above outcomes or where cannabis was described only as a correlate for non-behavioral addictions or mental health conditions were excluded. Studies should have assessed use through a validated instrument or questionnaire; those relying solely on urine drug screening (UDS) were excluded, as UDS does not provide sufficient detail on frequency, context, or patterns of use. Also, studies assessing cannabis use among adolescents or young adults who were neither Arab nor actively enrolled in a school or university setting (i.e., dropouts, refugee populations) were excluded. Furthermore, manuscripts published prior to the year 2000 were excluded, as significant legal, societal, and cultural shifts around that time have likely influenced cannabis use trends, making earlier data less comparable to more recent findings (36). Other types of quantitative studies, reviews, correspondences, case reports or series, opinions, letters to the editor, and book chapters were excluded. Lastly, studies reported as abstracts for which the authors could not identify a full text after contacting the corresponding author were excluded.
2.2 Search strategy
PubMed, Embase, Scopus, and PsycInfo databases were searched from inception to 9 May 2024. No filters or language restrictions were applied. The MeSH terms and search strategy are outlined in the Supplementary Material. To identify grey literature, on 30 August 2024, the authors conducted structured searches using the keywords (cannabis OR marijuana) AND student AND Arab in Google Scholar and ProQuest Dissertations & Theses Global (https://www.proquest.com/), screening the first 50 pages of results. The authors also hand-searched the reference lists of all the included studies and used the “cited by” function in Google Scholar to identify relevant citing articles.
2.3 Selection process
All studies obtained through the literature search were imported using EndNote software version 21. After the removal of duplicate articles, two reviewers (AS and SEH) did an independent title and abstract screening of the retrieved studies using a standardized screening guide. The same reviewers then assessed the eligibility of the resulting group of articles using a full-text screening guide. Any disagreement was resolved by discussion. Details of both screening guides are provided in the Supplementary Material.
2.4 Data extraction
Two reviewers (AS and SEH) independently abstracted the following data from each eligible study: objectives, sample characteristics (recruitment site, sample size, age, and gender distribution), instruments used to assess cannabis use, prevalence of cannabis use, characteristics of users, and cannabis-related outcomes or correlates. Discrepancies were resolved through discussion.
2.5 Bias assessment
To evaluate the methodological quality and risk of bias of the included studies, The National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used (37) (Supplementary Material). The tool consists of a 14-question checklist designed to assess the internal validity of cross-sectional and cohort studies. It addresses potential risks related to selection, information, or measurement bias, as well as confounding factors. Each criterion was evaluated with responses of “yes”, “no”, “not applicable”, or “not reported.” According to the quality rating guidance provided with the tool, each included study was rated as good, fair, or poor quality. Two researchers (AS and SEH) independently assessed the final studies using the tool, and any disagreements were resolved through discussion until consensus was achieved.
2.6 Data analysis
Although the authors originally planned for a quantitative synthesis of the results, it was not possible to conduct it due to the heterogeneity of the included studies. Instead, a qualitative synthesis of the data was performed.
3 Results
A total of 5,820 potentially eligible records were obtained after the electronic search of the databases (i.e., PubMed, Embase, Scopus, and PsycInfo). After the removal of duplicates, 5,790 records were processed via an initial title and abstract screening, of which 5,621 records were excluded. Of the remaining 169 articles, 138 were excluded after full-text screening for the reasons outlined in the PRISMA Flow Diagram (Figure 1). In addition to the 31 manuscripts identified via databases, 17 additional records were obtained via other methods (i.e., grey literature sources, which included Google Scholar and ProQuest Dissertations & Theses Global, references of included articles, and citation tracking). In total, 48 studies were included in the narrative synthesis. Participants were university students (n=29) or school students (n=20). One study recruited both university and school students (38). Data emanated from 13 Arab countries, mainly Egypt (n=13), Lebanon (n=8), Morocco (n=8), Palestine (n=7), Kuwait (n=5), Tunisia (n=5), Jordan (n=3), Algeria (n=2), Iraq (n=2), Mauritania (n=1), Oman (1 study), Saudi Arabia (n=1), and Sudan (1 study). Most studies were rated as fair or good according to the NIH Quality Assessment Tool. The results of the bias assessment are depicted in Tables 1, 2.
Figure 1. PRISMA 2020 flow diagram for the systematic review.
Table 1. Studies exploring cannabis use among students attending a school setting (n=20).
Table 2. Studies exploring cannabis use among students attending a university setting (n=29).
3.1 Studies exploring cannabis use among students attending a school setting
3.1.1 Characteristics of the included studies
A total of 20 studies explored the characteristics of cannabis use among students in school settings. Data emanated from eleven Arab countries: Palestine (n=6) (41–45, 50), Egypt (n=4) (47, 53–55), Morocco (n=4) (46, 50, 52, 57), Algeria (n=2) (50, 52), Iraq (n=2) (48, 51), Kuwait (n=2) (49, 51), Jordan (n=1) (40), Lebanon (n=1) (38), Mauritania (n=1) (52), Saudi Arabia (n=1) (39), and Tunisia (n=1) (56) (Table 1).
In terms of focus, 5 studies directly assessed cannabis use as a primary outcome (40, 50–52, 57) while the remaining studies had broader aims, addressing substance use in general, including cannabis.
3.1.2 Descriptive statistics
Sample sizes ranged from 140 (54) to 10,648 participants (53). Participants were generally school-aged, but some studies included students older than 18. Specifically, 3 studies (39, 48, 55) included participants with an age range reaching 19. The study with the lowest mean age was conducted by Zammit et al. in Tunisia, reporting a mean age of 13.3 years (56), while Soliman et al. had the highest mean age of 17.27 years (55). The proportion of male participants ranged widely across studies, from 31.7% (53) to 100% (39, 55). Most studies focused on students attending secondary schools (grades 7-12), but some targeted younger students (grades 6-10) or specific groups such as vocational school students (55).
3.1.3 Instruments used to assess cannabis use
The most commonly used instrument was the Global School-Based Student Health Survey (GSHS), utilized in 4 studies (50–53). Other instruments included the Cannabis Abuse Screening Test (CAST) (40), the Diagnostic Interview Schedule version IV (38), and questionnaires adapted from different sources as follows: the European School Survey Project on Alcohol and Other Drugs (ESPAD) (44, 46), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (45), the United Nations Office on Drugs and Crime (UNODC) (48), the 144-item 1998 New Jersey Triennial Public High School Survey of Drug and Alcohol Use questionnaire (49), the Addiction Severity Index Scale (53), and the World Health Organization (WHO) (54). Seven studies used self-developed instruments, tailored to local contexts and cultural sensitivities.
3.1.4 Prevalence of cannabis use
Studies used various prevalence measurements and terminologies to describe cannabis use. Some studies categorized cannabis, hashish, and marijuana separately, while others grouped them together. Accordingly, the results showed wide variations. Lifetime use of cannabis/hashish/marijuana ranged from 0.7% in Iraq (48) to 9.4% in Morocco (46). Past-year use ranged between 0.3% in Iraq (48) and 18% in Palestine (45). Past-month use displayed a broader range, from 0.3% (48) to 24% (55).
In addition, several studies examined synthetic cannabinoids. Damiri and colleagues explored a wide range of cannabinoids such as Spice and Mr. Nice Guy, reporting a combined lifetime prevalence of 12.8% (44). Shaheen et al. examined the use of Bango, Strox, and Voodo (54) while Loffredo and colleagues assessed Bango use (47).
Five studies reported cannabis as the most commonly used illicit substance among students (39, 44, 55–57). However, Rabie and colleagues found cannabis to be the second most common, after organic solvents (not formally defined, but generally referring to inhaled substances such as glue, paint thinner, or correction fluid) (53).
3.1.5 Significant correlates of cannabis use
3.1.5.1 Gender
Male students consistently reported higher cannabis use than females across all studies discussing gender differences. For instance, Zarrouq et al. reported 13.5% lifetime cannabis use in males versus 1.9% in females (57), and El Omari et al. showed similar gender differences (males 9.5% vs. females 2.1%) (46). This pattern held across countries, with statistical significance (p<0.05) reported in several studies (38, 40–43, 45, 47, 51).
3.1.5.2 Age
The age of initiation of cannabis use varied between 15 (46) and 16 (38). Older students tended to report higher cannabis use. Loffredo et al. found lifetime hashish use to be significantly lower in 12-14- and 14–16-year-old individuals, compared to the group >16 years (47). Alternatively, in Diamond et al., although past-year cannabis use was highest among 15-16-year-olds (21.9%), both those below 14 and above 17 reported less past-year use (19% and 8.5%, respectively) (45).
3.1.5.3 Family, religion, and sociocultural factors
Family and social dynamics were identified as important predictors. Cannabis use was more common among students with family problems and those not living with both parents (40–42), among students sleeping outside home (46) or not living with parents (47), and among those with family member/guardian/friend who consumed alcohol (46) or tobacco (51).
Religion was another significant factor, with lower levels of religiosity (i.e., low vs. high; secular vs. devout) linked to higher cannabis use in multiple studies (41–43, 45). Peltzer and Pengpid also noted higher cannabis use in students from socioeconomically disadvantaged backgrounds, specifically those living with food insecurity (51).
Beyond family and sociocultural factors, some studies explored the role of academic performance. El Omari and colleagues found that students absent from school or with lower grades were more likely to use cannabis (46), while Loffredo et al. and Soliman et al. linked a positive work status and working at night, respectively, with higher use (47, 55).
3.1.5.4 Mental health correlates
Peltzer & Pengpid found that students with current tobacco use, anxiety, or suicidal ideation were more likely to use cannabis (51). Similarly, Alzyoud found a positive relationship between cannabis use and having a high-risk mental status problem (40).
3.1.5.5 Attitudes, Beliefs, and Perceptions
Most students had good knowledge about cannabis. Alzyoud found that about three-quarters (77.1%) had heard about cannabis (40). Damiri et al. noted most students (74.7–97.3%) had heard about the substance (44) and 91% of participants in El Omari’s study reported good knowledge about hashish and related products (46). Alzyoud noted that a majority viewed cannabis use as a problem (69.8%), against society norms (80.0%), and problematic during adolescence (81.3%) (40). Along the same lines, Karam et al. noted that 57.3% of participants thought that the use of cannabis was a crime. Some studies highlighted the influence of attitudes on cannabis use (38). According to Alzyoud, students having positive attitudes towards use and the belief that cannabis consumption helps in forming friendships were significantly more likely to use it (40). El Omari and colleagues also found that students who perceived cannabis as harmless were more likely to report usage (46).
3.2 Studies exploring cannabis use among students attending a university setting
3.2.1 Characteristics of the included studies
A total of 29 studies explored the characteristics of cannabis use among students in university settings. Data emanated from nine Arab countries: Egypt (n=9) (61, 64, 65, 69, 72, 73, 75, 76, 80), Lebanon (n=8) (38, 66, 70, 74, 78, 79, 82, 83), Morocco (n=4) (33, 58, 67, 77), Tunisia (n=4) (62, 64, 65, 71), Kuwait (n=3) (60, 64, 65), Jordan (n=2) (32, 68), Palestine (n=1) (63), Oman (n=1) (59), and Sudan (n=1) (81).
In terms of focus, 5 studies directly assessed cannabis use as a primary outcome (64, 65, 69, 78, 80), while the remaining studies had broader aims. These studies often explored the prevalence, patterns, and correlates of various substances, with cannabis emerging as one of the most commonly discussed illicit drugs.
3.2.2 Descriptive statistics
Sample sizes ranged from 172 (83) to 7,445 participants (73). The age range of participants varied between 16 and 28 years, while the mean age ranged between 19.6 years (75, 81) and 24.24 years (64). The proportion of male participants ranged widely across studies, from 14.6% (64) to 100% (60). Few studies particularly focused on medical (70, 83) and nursing (71) students.
3.2.3 Instruments used to assess cannabis use
The most frequently used instrument was the WHO-based Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), employed in 3 studies (33, 59, 82). Three other studies also used instruments derived from the WHO (32, 60, 81). The CAST was used in two studies (62, 71), as well as the Drug Use Disorders Identification Test (DUDIT) (61, 75). Two studies used a questionnaire based on the Mini-International Psychiatric Interview (67, 79). The other studies used different established or self-developed questionnaires, as detailed in Table 2.
3.2.4 Prevalence of cannabis use
As with studies tackling schools, studies in university settings used various prevalence measurements and terminologies to describe cannabis use. Although results showed wide variations, prevalence numbers were consistently higher compared to school settings.
Lifetime use of cannabis ranged from 4.7% in Tunisia (62) to 32% in Lebanon (83) and Egypt (78). Lifetime hashish and marijuana use reached a peak of 7.2% in Jordan (68) and 19.38% in Lebanon (66), respectively. Past-year cannabis use reached 20.2% in Tunisia (71). Past-month cannabis/hashish/marijuana use displayed a broader range, from 0% for marijuana (68) to 6.5% for hashish (68).
Several studies examined synthetic cannabinoids. Damiri and colleagues explored a wide range of cannabinoids such as Mr. Nice Guy, Mastaloon/Mabsatoon, and Eve/Mariam (63). Although Eve is commonly used as a street name for 3,4-methylenedioxymethamphetamine (MDMA) or ecstasy, it was classified as a synthetic cannabinoid in the study. Hashim et al. (69) reported the current use of Strox to be 6.8%. Kabbash et al. found past month Bhang use of 1.4% (72). In a more recent study, the same team noted a lifetime prevalence of Bhang and synthetic cannabinoids of 1.6 and 0.4%, respectively (73). Naguib et al. highlighted that the illicit drugs regularly used were Strox (33.3%), Bhang (30%), and Voodoo (30%) (80).
Twelve studies reported cannabis/hashish as the most commonly used illicit substance (33, 58, 60–62, 72, 74, 75, 80–83). Only Alsammak and colleagues found cannabis to be the second most common, after sleeping drugs (not formally defined, but mentioned to include benzodiazepines) (32), and Kjiri et al. had similar findings among female users (77).
Cannabis dependence significantly varied from 0.2% (74) to 75.6% (67), while the percentage of cannabis users requiring intensive intervention as per ASSIST scores reached 5.6% (33).
3.2.5 Significant correlates of cannabis use
3.2.5.1 Gender
Consistently, male students reported higher cannabis use than their female counterparts (38, 59, 67, 69, 72, 74, 77, 80, 82). Only Kabbash et al. and Moaouad et al. did not find a significant gender difference in cannabis use (73, 79). Fekih-Romdhane and colleagues found females to score significantly higher than males on the Cannabis Use Intention Questionnaire (64).
3.2.5.2 Age
Older students tended to report higher cannabis use. Gourani found that lifetime cannabis use significantly increased with age, with those aged 22–24 reporting a rate of 22.3% compared to 2.3% among those aged 18-20 (67). Similar significant findings were discussed by Salameh and colleagues, with 20.3% versus 8.9% rates among the age groups >21 and 17-18, respectively (82).
Three studies highlighted that most users started their cannabis use around the age of 17 (38, 60, 67), and two others noted cannabis as the most common first illicit substance to be tried by students (58, 61).
3.2.5.3 Family and sociocultural factors
Cannabis use was significantly more common in those living alone or with friends compared to those living with families (67), those with a family history of conflict, those with a family history of substance use, and those encouraged by peers (80). Along the same lines, a good relationship with parents was significantly protective towards cannabis use (82).
Other identified correlates included academic performance, where lower achievement was significantly associated with higher cannabis use (67). Additionally, Bajwa et al. found cannabis use to be significantly more common among those attending private versus public universities (60). Talih and colleagues also noted significantly increasing rates of cannabis use throughout the four medical school years (83).
3.2.5.4 Mental health correlates
Beyond demographic and social factors, substance co-dependence and mental health conditions were frequently associated with cannabis use. For instance, a higher consumption of tobacco or narghile (i.e., shisha) was found to be significantly associated with increased cannabis use (82). Bassiony et al. found cannabis use to be a significant predictor of tramadol use (61). Ghandour et al. noted that, compared to non-users, both medical and nonmedical users of prescription medications were more likely to report lifetime marijuana use (66). Those with cannabis dependence were significantly more likely to have depression than non-dependent users (67). Lastly, a history of childhood abuse was significantly associated with cannabinoid use (80).
3.2.5.5 Attitudes, beliefs, and perceptions
Damiri and colleagues noted a high level of familiarity with cannabis and related products among most (86.7%) illicit drug users (63). Recreational use was significantly associated with higher perceived knowledge and attitude scores about cannabis use (78). In parallel, more favorable attitudes toward cannabis were associated with higher usage scores (64). One study found mostly negative attitudes toward self-initiation of Hashish/Bang and strong disagreement towards their use (72). Hashim et al. noted achieving euphoria (28.9%), treating depression (23.7%), and experimentation (23.7%) as the most common reasons to use Strox (69).
4 Discussion
This systematic review offers valuable insights into the phenomenon of cannabis use among school and university students in the Arab World. The 48 analyzed studies spanned many Arab nations, primarily emanating from Egypt, Lebanon, Morocco, and Palestine. Most studies provided information on the prevalence of cannabinoid use, characteristics of users, and correlates of consumption. Sample sizes ranged from small groups of less than 200 students to large-scale cross-sectional designs involving over 5,000 participants. The mean age of students ranged from 13 to 24 years, with a male-dominated demographic in most studies. A variety of instruments were used to assess cannabis use including standardized questionnaires, such as ASSIST, and self-developed customized local surveys.
The prevalence of cannabis use varied widely across studies, ranging from less than 2% to over 30%, depending on the methodology, type of prevalence measured, and the specific cannabinoid considered. This variation also reflects differences in social and cultural attitudes toward substance use, reporting behaviors, and legal frameworks across Arab nations. Regardless, most studies identified cannabis as the most commonly used illicit substance among school and university students. Significant correlates of use included gender, with males more likely reporting use than females; age, with older students displaying higher usage rates; and attitudes, with more liberal views toward drug use being associated with higher consumption. Other relevant predictors included family dynamics, peer influence, religiosity, and academic performance.
Overall, these findings indicate a complex interplay of sociocultural and geographical factors that influence cannabis use among students in the Arab World. The results highlight potential avenues for future intervention strategies and policy formulations.
4.1 Cannabis use across school and university settings
Although cannabis consumption was noted to be a significant issue across both school and university settings, the prevalence of use was higher in the latter group. This was evidenced by lifetime use reaching as high as 32% among university students (78, 83), compared to 9.4% in schools (46). This variation may be attributed to various factors, including older age. Indeed, in the included studies, age was found to be a significant correlate of cannabis use, with older students consistently displaying higher rates of cannabis use compared to their younger counterparts (45, 47, 67, 82). This finding echoes international data. For instance, an 8-year longitudinal Canadian study noted older age as one risk factor for daily cannabis use in younger adults (84). Along the same lines, in 2023, marijuana use among individuals aged 18 and older in the USA was reported at 50.5% for lifetime use, 22.9% for past year use, and 16.3% for past month use. In contrast, among those aged 12 to 17, the rates were significantly lower, with 13.4% reporting lifetime use, 11.2% past year use, and 6% past month use (85).
Other factors contributing to this variation in results between school and university settings include greater peer influence at the university (86, 87), increased accessibility of cannabis, especially in the context of legislative changes and higher exposure to more permissive social norms (88, 89) compared to the closely-knit school environments, and potentially greater independence (90).
These findings highlight that the transitional years between school and university constitute a crucial point of intervention during which students might be at increased risk of initiating or increasing cannabis use. Cannabis use should be systematically assessed during this period, particularly among high-risk individuals.
4.2 Cannabis use across Arab countries
Differences in the rates of cannabis use were evident between Arab nations. Some countries, such as Egypt, Lebanon, and Morocco consistently reported some of the highest prevalence rates in both school and university settings. In Egypt, cannabis farming is partially authorized (91). Lebanon and Morocco are known for their historical ties to cannabis cultivation and have been key exporters of hashish for the past five decades. In Lebanon’s Beqaa Valley and Morocco’s Rif region, cannabis cultivation has represented a lifeline for disadvantaged farmers, driven by local, regional, and international demand. The suitable climate, marginalized economic status of these areas, and global prohibition efforts have paradoxically sustained cannabis cultivation as a dynamic part of these countries’ economies (28). In Morocco’s competitive cannabis industry, various regions specialize in different forms of hashish. The stability of the market contrasts with Lebanon, where geopolitical instability has resulted in a disorganized market supply (28). However, Lebanon made a significant shift in 2020 by legalizing cannabis for medical and industrial purposes, becoming the first Arab nation to do so (92). This legalization could potentially increase recreational use, particularly among the youth population.
On the other hand, studies from countries such as Iraq and Saudi Arabia noted substantially lower rates of cannabis use. This can be attributed to religious factors, as Islam’s strict prohibition against the use of intoxicating substances, including cannabis, can contribute to lower prevalence rates. In conservative societies that portray drugs as morally corrupting, legal frameworks align with religious doctrine by implementing strict penalties for substance use, which acts as a deterrent for individuals from engaging in cannabis use (93–95). In that regard, although religious and legal prohibitions might suppress cannabis use, the reported rates are likely underestimated due to individuals’ reluctance to openly disclose consumption for fear of repercussions. Furthermore, as globalization progresses, even nations with strict bans, such as Saudi Arabia, are increasingly exposed to Western cultures that depict drug use as socially accepted behavior (96). This has raised concerns about potential increases in cannabis and drug consumption, particularly among vulnerable youth, although several reviews from the US and Europe highlighted mixed effects on the prevalence of cannabis use and its effects among youth and adolescents following legalization and policy changes (97, 98). This is modulated by several interrelated factors, including laws and the extent of their application, socioeconomic status, and sociocultural background (98).
Interestingly, several studies analyzed the prevalence of region-specific cannabinoid products and referenced local slang nomenclature. These included Bhang/Bango, informal terms referring to natural cannabis. In Egypt, other commonly reported names refer to synthetic cannabinoid products, such as Voodoo and Strox. The latter is currently the most popular synthetic cannabinoid in Egypt and is typically composed of dried plant material (sometimes including toxic plants such as Atropa belladonna, Datura, or Hyoscyamus), sprayed with unidentified synthetic cannabinoids (99). In Palestine, other local nomenclatures were reported, including Eve/Mariam, Hydro, Mastalon, Mabsoton, and Mr. Nice Guy. While no published studies have specifically analyzed the composition of these substances, Mr. Nice Guy is widely recognized in the market as a synthetic cannabinoid product. The remaining nomenclatures are also believed to refer to synthetic cannabinoids, although their exact composition remains undocumented and requires further investigation.
The cultural acceptance of cannabis in historically significant regions such as Lebanon and Morocco, combined with globalization and evolving international policies – including the decriminalization and legalization of cannabis for medical or recreational use, may contribute to increased cannabis use among youth in the Arab World. These findings underscore the need for culturally sensitive intervention strategies that account for not only the sociocultural, religious, and legal contexts of each Arab nation, but also the evolving global trends and perceptions towards cannabis.
4.3 Prevalence of cannabis use
Lifetime prevalence rates of cannabis use in the Arab World ranged from 0.7% (48) to 32% (78, 83), indicating significant variability across countries, which can be attributed to the abovementioned factors. Most results clustered around the range of 5-15%. In comparison, marijuana use in the US in 2023 was reported to be much higher, with 50.5% of individuals aged 18 and above reporting lifetime use. In contrast, among those aged 12 to 17, the rate is more comparable at 13.4% (85). A systematic review of the prevalence of cannabis vaping among adolescents in the US and Canada in 2019–2020 identified a lifetime pooled prevalence of 13.6% (100). In sub-Saharan Africa, a meta-analysis of 53 studies noted a lifetime prevalence of cannabis use among adolescents to be 7.9% (101). A systematic review focusing on medical students in India identified a pooled prevalence of cannabis use of 8.2% (102). These differences highlight the importance of considering socio-cultural and legal contexts when interpreting cannabis use data.
In the included studies, cannabis was often found the most commonly used illicit substance among school and university students, a trend observed globally as well. For instance, according to the Monitoring the Future Survey, cannabis has remained the most frequently used illicit substance among school students in the US over at least the past decade (103). Similarly, the latest European statistics indicate that cannabis is the most commonly consumed illicit drug among young adults (104). Among specific subgroups, such as medical students, cannabis also ranks as the most frequently used illicit substance (105).
Additionally, findings from the analyzed studies noted that early initiation of cannabis use was a critical factor in continued use into later years. Compared to late initiators, early cannabis users tend to have more externalizing mental health symptoms, a history of trauma, and concerns about violence (106). Predictors of early adolescent onset cannabis use include anxiety symptoms (107), cigarette use, and drinking to the point of intoxication (108). In their comprehensive review, Padoan and colleagues raise concerns about pediatric cannabis use. They highlight short-term effects including social isolation, mood changes, and suicidal tendencies, as well as long-term consequences, such as neurocognitive impairment, psychiatric disorders, respiratory issues, cardiovascular complications, and immunotoxicity (109).
Given these risks, special attention should be given to students at increased risk for early cannabis use, including those with exposure to other substances or a predisposition to mental health conditions. Proactive preventive measures and early intervention programs should be tailored to address the needs of this vulnerable population, particularly in regions with shifting legal and sociocultural landscapes.
4.4 Gender, family dynamics, and sociocultural factors
Consistent with previous research (110, 111), the present review reaffirms that being male is a significant predictor of cannabis use. Sex-based differences in the endocannabinoid system have been documented (110), while gender-related disparities may be influenced by societal norms, with substance use being more socially accepted and permissible for boys and men than for girls and women (111). This discrepancy has major repercussions, as males consistently report more cannabis-related negative consequences than females (112).
Family dynamics, specifically parental conflict or not living with parents, emerged as a key influence on cannabis use. Peer pressure was also found to be a significant factor associated with cannabis use. These findings echo international research. For instance, an 8-year longitudinal investigation in Canada identified higher levels of family stress, among other risk factors, as significantly increasing the odds of daily cannabis use among young adults (84). In another Canadian study, among 14- to 18-year-olds, higher levels of parental monitoring were associated with lower odds of cannabis use, while having peers who smoked cigarettes increased the odds (113). The importance of peer influence on adolescent cannabis use has been established in a substantial body of research worldwide (114, 115). One systematic review identified friends’ cannabis use as the strongest predictor of personal cannabis use. Adolescents were also more likely to consume cannabis if they felt disconnected from school peers and had cannabis-using friends, especially at younger ages (87). One study in the US highlighted that first-year university students were more likely to select peers with similar past-month marijuana use. Furthermore, a student’s past-month marijuana use became more similar to their peers’ use over time (86).
Sociocultural factors, such as lower religiosity, poor academic performance, and disadvantaged socioeconomic status, also emerged as predictors of cannabis use. Research has established that religion moderates cannabis use (116), with higher religiosity being associated with lower use (117, 118). Early-age cannabis use increases the probability of poor cognitive function, and persistent consumption can be a barrier to academic achievement (119, 120). Lastly, consumption has been consistently higher among adolescents with the most socioeconomic adversities (121, 122).
These findings highlight the complex influences on adolescent and young adult cannabis use, including male gender, family dynamics, peer pressure, and sociocultural factors. Interventions should focus on strengthening family relationships, promoting peer resistance skills, and providing support for disadvantaged youth. Additionally, school- and college-based programs should educate students about the risks of early cannabis use, fostering a supportive environment to mitigate these risks effectively.
4.5 Mental health and cannabis use
The role of mental health was explored in several studies, revealing an association between cannabis use and psychiatric manifestations such as anxiety (51, 64), depression (64, 67), and suicidal ideations (51). These findings align with a broader body of evidence linking cannabis use in youth to various mental health conditions, including mood (123, 124) and anxiety disorders (125, 126), as well as increased risk of suicidality (127, 128). Importantly, cannabis use has also been associated with an increased risk of psychosis and schizophrenia, particularly among individuals with a genetic or familial vulnerability. However, this relationship is complex and may be moderated by factors such as age of initiation, frequency of use, and cannabis potency (129, 130). A recent scoping review by Baral et al. further emphasized the mental health consequences of cannabis use among young individuals (131), reinforcing the need for greater awareness among students, families, and healthcare providers.
Beyond mental health, a substantial body of research underscores the broader consequences of early and sustained cannabis use. Evidence indicates negative outcomes including impaired cognitive functioning, reduced physical health, and compromised overall well-being (132). Cannabis use is also associated with poorer academic outcomes, including decreased school performance, lower academic achievement, and higher rates of absenteeism (133). In the long term, chronic use has been linked to a trajectory of social and economic disadvantage, including increased likelihood of being poor, unmarried, underemployed, and experiencing anxiety (134). Moreover, growing evidence implicates cannabis use as a potential contributing factor to the onset or worsening of psychiatric disorders, particularly among adolescents and individuals at elevated risk (135, 136).
Taken together, these findings highlight the urgent need for proactive, evidence-informed public health responses. In this context, the current systematic review carries important implications for policy, practice, and future research concerning cannabis use among students in the Arab World.
The high prevalence of use among university students highlights the pressing need for early, school-based, family, and community intervention strategies, ideally beginning in secondary school. These should include age-appropriate, evidence-based prevention programs targeting high-risk individuals—particularly male students facing family difficulties, mental health challenges, and peer pressure. Effective programs should adopt a comprehensive approach that includes anti-drug education, refusal skills, social-skills training, and self-management strategies (137), while also fostering resilience and promoting positive youth development (138). Embedding family interventions within school settings through proactive parental engagement is also recommended (139), particularly in the Arab World, where collectivist norms prevail. In this context, strategies should be culturally adapted and gender-sensitive to enhance their relevance and impact. A holistic approach is essential, addressing not only substance use but also underlying risk factors such as adverse childhood experiences, mental health disorders particularly comorbid depression, anxiety, and other substance use disorders, and social inequities (138).
In addition, public health strategies must reflect cultural and regional variations in cannabis use patterns and product types. Tailored interventions should consider socioeconomic factors, particularly in Arab countries with legalized or regulated cannabis farming. In such contexts, policies must ensure that cannabis cultivation for medical or economic purposes does not inadvertently promote recreational use among youth. Interventions should also remain adaptable to emerging trends and substances of concern. This adaptability is crucial, as patterns of cannabis use are evolving, with increasing use of high-potency products, vaping, and both synthetic and semi-synthetic cannabinoids among youth (7, 140). Failure to update prevention strategies risks missing emerging forms of use or newly prevalent substances.
Given that spiritual interventions have been shown to be effective in supporting individuals with substance use problems (141), incorporating religious values into prevention efforts may enhance both community acceptance and intervention uptake, particularly in the Arab World, where religion plays a pivotal role in shaping norms and behaviors. Engaging faith leaders and religious institutions could reinforce anti-drug messaging, facilitate culturally congruent education, and help reduce the stigma associated with seeking help for substance use (142, 143).
Finally, future research should prioritize longitudinal studies to assess changes in cannabis use patterns over time and to clarify causal relationships between risk factors and consumption among youth. There is also a critical need to culturally validate assessment instruments in the Arab region, as many tools currently in use lack psychometric validation in this context (144). Strengthening measurement tools will improve the accuracy and comparability of findings and support the development of more effective, culturally appropriate interventions.
This systematic review has several limitations that should be acknowledged. First, many potentially relevant articles were inaccessible and, therefore, excluded. To minimize the risk of missing important data, the authors conducted a comprehensive literature search across multiple databases and grey literature sources, reviewed the references and citations of all included articles, and imposed no language restrictions. Second, the variation in how cannabis use was defined and the instruments used to measure it contributed to inconsistencies in the reported prevalence estimates, making it difficult to draw reliable comparisons between countries and settings. This lack of standardization in both conceptual and measurement approaches likely resulted in a wide range of findings. To enhance comparability, future studies should adopt standardized definitions and validated tools that accurately capture the extent of cannabis use among students in the Arab region. Third, as this review was limited to cross-sectional studies, it does not provide insights into the longitudinal progression or causality of cannabis use behaviors. Fourth, although the review provides valuable insights into cannabis use among students in schools and universities, it does not include other subgroups, such as out-of-school youth, dropouts, or refugees. These populations were intentionally excluded to maintain a consistent focus on individuals in formal educational settings. Including these groups could have introduced additional variability related to risk factors and living conditions, potentially affecting prevalence estimates. Nevertheless, these groups may be at a higher risk for cannabis use, underscoring the importance of future research specifically targeting these vulnerable populations. Lastly, the focus on the Arab World limits the generalizability of the findings to other regions with different sociocultural nuances and legal frameworks surrounding cannabis use. Future reviews might consider cross-regional comparisons to improve the understanding of cannabis consumption across diverse contexts.
In conclusion, this systematic review highlights the significant prevalence and correlates of cannabis use among school and university students across the Arab World. The findings indicate that cannabis consumption is a growing concern, especially among university students, influenced by a range of factors including country of residency, age, gender, family dynamics, and sociocultural beliefs. There is a dire need for targeted interventions that address modifiable risk factors, starting at the school level and extending into university settings, to efficiently mitigate the increasing trend of cannabis use among young people in the Arab region.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Author contributions
AS: Data curation, Investigation, Methodology, Writing – original draft. ME: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft. FK: Writing – review & editing. EB: Writing – review & editing. SH: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2025.1511563/full#supplementary-material
References
1. Wang Q and Wang H. Cannabis and tobacco use among adolescents aged 12–17 years from 16 low- and middle-income countries. J Glob Health. (2023) 13. doi: 10.7189/jogh.13.04066
2. Fergusson DM, Boden JM, and Horwood LJ. Cannabis use and other illicit drug use: testing the cannabis gateway hypothesis. Addiction. (2006) 101:556–69. doi: 10.1111/j.1360-0443.2005.01322.x
3. Wilson J, Mills K, Freeman TP, Sunderland M, Visontay R, and Marel C. Weeding out the truth: a systematic review and meta-analysis on the transition from cannabis use to opioid use and opioid use disorders, abuse or dependence. Addiction. (2022) 117:284–98. doi: 10.1111/add.15581
4. Morral AR, McCaffrey DF, and Paddock SM. Reassessing the marijuana gateway effect. Addiction. (2002) 97:1493–504. doi: 10.1046/j.1360-0443.2002.00280.x
5. Vanyukov MM, Tarter RE, Kirillova GP, Kirisci L, Reynolds MD, Kreek MJ, et al. Common liability to addiction and “gateway hypothesis”: Theoretical, empirical and evolutionary perspective. Drug Alcohol Depend. (2012) 123:3–17. doi: 10.1016/j.drugalcdep.2011.12.018
6. UNODC. World drug report 2013(2013). Available online at: https://www.unodc.org/unodc/secured/wdr/wdr2013/ (Accessed June 7, 2025).
7. UNODC. World drug report 2023(2024). Available online at: https://www.unodc.org/res/WDR-2023/WDR23_Exsum_fin_DP.pdf (Accessed June 7, 2025).
8. SAMHSA. Key substance use and mental health indicators in the United States: results from the 2023 national survey on drug use and health(2024). Available online at: https://www.samhsa.gov/data/report/2023-nsduh-annual-national-report (Accessed June 7, 2025).
9. Poudel A and Gautam S. Age of onset of substance use and psychosocial problems among individuals with substance use disorders. BMC Psychiatry. (2017) 17:10. doi: 10.1186/s12888-016-1191-0
10. Steinfeld MR and Torregrossa MM. Consequences of adolescent drug use. Trans Psychiatry. (2023) 13:313. doi: 10.1038/s41398-023-02590-4
11. Hinckley JD, Ferland J-MN, and Hurd YL. The developmental trajectory to cannabis use disorder. Am J Psychiatry. (2024) 181:353–8. doi: 10.1176/appi.ajp.20231006
12. Trujillo CA, Obando D, and Trujillo A. An examination of the association between early initiation of substance use and interrelated multilevel risk and protective factors among adolescents. PloS One. (2019) 14. doi: 10.1371/journal.pone.0225384
13. Castellanos-Ryan N, Pingault J-B, Parent S, Vitaro F, Tremblay RE, and Séguin JR. Adolescent cannabis use, change in neurocognitive function, and high-school graduation: A longitudinal study from early adolescence to young adulthood. Dev Psychopathol. (2017) 29:1253–66. doi: 10.1017/S0954579416001280
14. Grant CN and Bélanger RE. Cannabis and Canada’s children and youth. Paediatr Child Health. (2017) 22:98–102. doi: 10.1093/pch/pxx017
15. Karila L, Roux P, Rolland B, Benyamina A, Reynaud M, Aubin H-J, et al. Acute and long-term effects of cannabis use: A review. Curr Pharm Design. (2014) 20:4112–8. doi: 10.2174/13816128113199990620
16. Hill MN, McLaughlin RJ, Bingham B, Shrestha L, Lee TTY, Gray JM, et al. Endogenous cannabinoid signaling is essential for stress adaptation. Proc Natl Acad Sci. (2010) 107:9406–11. doi: 10.1073/pnas.0914661107
17. Skaper SD and Di Marzo V. Endocannabinoids in nervous system health and disease: the big picture in a nutshell. Philos Trans R Soc B: Biol Sci. (2012) 367:3193–200. doi: 10.1098/rstb.2012.0313
18. Ferland JN and Hurd YL. Deconstructing the neurobiology of cannabis use disorder. Nat Neurosci. (2020) 23:600–10. doi: 10.1038/s41593-020-0611-0
19. Stuyt E. The problem with the current high potency THC marijuana from the perspective of an addiction psychiatrist. Mo Med. (2018) 115:482–6.
20. NIDA. Cannabis (Marijuana) concentrates DrugFacts(2020). Available online at: https://nida.nih.gov/publications/drugfacts/cannabis-marijuana-concentrates (Accessed June 7, 2025).
21. Hassan SSM, Kamel AH, Awwad NS, and Aboterika AHA. Characterization of some “Hashish” Samples in the Egyptian illicit trafficking market using a thermal separation probe and gas chromatography-mass spectrometry. ACS Omega. (2023) 8:25378–84. doi: 10.1021/acsomega.3c02809
22. NIDA. Synthetic cannabinoids(2020). Available online at: https://nida.nih.gov/research-topics/synthetic-cannabinoids (Accessed June 7, 2025).
23. Alexinschi O, Siriţeanu A, and Boloş A. Cannabinoids and the challenges of new synthetic derivatives. Psihiatru ro. (2023) 75. doi: 10.26416/Psih.75.4.2023.8927
24. Caprari C, Ferri E, Vandelli MA, Citti C, and Cannazza G. An emerging trend in Novel Psychoactive Substances (NPSs): designer THC. J Cannabis Res. (2024) 6:21. doi: 10.1186/s42238-024-00226-y
25. Jørgensen CF, Rasmussen BS, Linnet K, and Thomsen R. Emergence of semi-synthetic cannabinoids in cannabis products seized in Eastern Denmark over a 6-year period. J Forensic Sci. (2024) 69:2009–17. doi: 10.1111/1556-4029.15631
27. WHO. Atlas on substance use, (2010): resources for the prevention and treatment of substance use disorders(2010). Available online at: https://www.who.int/publications/i/item/9789241500616:~:text=The%20Atlas%20entitled%20%22ATLAS%20on,data%20on%20national%20resources%20for (Accessed June 7, 2025).
28. Afsahi K and Darwich S. Hashish in Morocco and Lebanon: A comparative study. Int J Drug Policy. (2016) 31:190–8. doi: 10.1016/j.drugpo.2016.02.024
29. UNODC. World drug report 2021(2021). Available online at: https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html (Accessed June 7, 2025).
30. Ghandour L, Slim A, Abbas N, and El-Khoury J. Patterns of cannabis use, perception of harm, and perceived impact of legislative change in an online sample of young adults from Lebanon: insight on recreational users versus dual motive users. Harm Reduct J. (2024) 21:41. doi: 10.1186/s12954-024-00958-3
31. Shanahan L, Steinhoff A, Bechtiger L, Copeland WE, Ribeaud D, Eisner M, et al. Frequent teenage cannabis use: Prevalence across adolescence and associations with young adult psychopathology and functional well-being in an urban cohort. Drug Alcohol Depend. (2021) 228:109063. doi: 10.1016/j.drugalcdep.2021.109063
32. Alsammak N, Alabbasi M, Abdulhadi A, Mohammad F, Alajmi M, Alabdaly A, et al. The prevalence of substance use disorder among university students in Amman, Jordan. J Bahrain Med Soc. (2023) 35:45–66. doi: 10.26715/jbms.35_4_5
33. Essadi A, Aissaoui H, Yeznasni A, Lekfif A, Sebbar S, Atassi M, et al. Psychoactive substance use and associated factors among Mohammed first university students, Oujda, Morocco: a cross-sectional study. BMC Public Health. (2024) 24. doi: 10.1186/s12889-024-19507-5
34. Nath A, Choudhari SG, Dakhode SU, Rannaware A, Gaidhane AM, Dakhode S, et al. Substance abuse amongst adolescents: an issue of public health significance. Cureus. (2022) 14. doi: 10.7759/cureus.31193
35. Volkow ND, Han B, Einstein EB, and Compton WM. Prevalence of substance use disorders by time since first substance use among young people in the US. JAMA Pediatr. (2021) 175:640–3. doi: 10.1001/jamapediatrics.2020.6981
36. Felson J, Adamczyk A, and Thomas C. How and why have attitudes about cannabis legalization changed so much? Soc Sci Res. (2019) 78:12–27. doi: 10.1016/j.ssresearch.2018.12.011
37. National Heart, L. a. B. I. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. United States: NHLBI, NIH. National Institutes of Health (2014). Available at: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (Accessed June 7, 2025).
38. Karam EG, Ghandour LA, Maalouf WE, Yamout K, and Salamoun MM. A rapid situation assessment (RSA) study of alcohol and drug use in Lebanon. J Med Libanais. (2010) 58:76–85. https://www.scopus.com/inward/record.uri?eid=2-s2.0-77954891482&partnerID=40&md5=7fe86c1e17c08d48ab9f4a739f623ab6 (Accessed June 7, 2025).
39. Al-Musa HM and Al-Montashri SDS. Substance abuse among male secondary school students in Abha city, Saudi Arabia: Prevalence and associated factors. Biomed Res (India). (2016) 27:1364–73.
40. Alzyoud S. Jordanian Adolescent Cannabis Use: Patterns, Risks, And Protective Factors. United States: Wayne State University (2010). Available at: https://digitalcommons.wayne.edu/oa_dissertations/74 (Accessed June 7, 2025).
41. Azaiza F, Bar-Hamburger R, and Moran M. Psychoactive substance use among Arab adolescents in Israel. J Soc Work Pract Addict. (2008) 8:21–43. doi: 10.1080/15332560802108613
42. Azaiza F, Shoham M, Bar-Hamburger R, and Abu-Asbeh K. Patterns of psychoactive substance use among Arab secondary school students in Israel. Subst Use Misuse. (2008) 43:1489–506. doi: 10.1080/10826080802237878
43. Azaiza F, Shoham M, Bar-Hamburger R, and Abu-Asbeh K. Substance use among Druze adolescent students in Israel: Identifying predictors and patterns of use. J Stud Alcohol Drugs. (2008) 69:840–7. doi: 10.15288/jsad.2008.69.840
44. Damiri BR, Salahat IA, and Aghbar MH. Pattern of substance use among schoolchildren in Palestine: a cross-sectional study. Egyptian J Forensic Sci. (2018) 8. doi: 10.1186/s41935-018-0090-6
45. Diamond GM, Farhat A, Al-Amor M, Elbedour S, Shelef K, and Bar-Hamburger R. Drug and alcohol use among the Bedouin of the Negev: Prevalence and psychosocial correlates. Addictive Behav. (2008) 33:143–51. doi: 10.1016/j.addbeh.2007.04.028
46. El Omari F, Sabir M, and Toufiq J. L’usage de drogues auprès des élèves marocains. Rapport MedSPAD. (2013).
47. Loffredo CA, Shaker YE, Jillson IA, Boulos DNK, Saleh D, Garas M, et al. Prevalence and correlates of substance use by Egyptian school youth. Int J Alcohol Drug Res. (2017) 6:37–51. doi: 10.7895/ijadr.v6i1.242
48. Mahmood N, Othman S, Al-Tawil N, and Al-Hadithi T. Substance use among high school students in Erbil City, Iraq: Prevalence and potential contributing factors. Eastern Mediterr Health J. (2019) 25:806–12. doi: 10.26719/emhj.19.022
49. Omu FE, Bader A-W, Helen D, Slabeeb S, Safar H, and Omu AE. Teenagers’ awareness of peers’ substance and drug use in Kuwait. J Addict Nurs. (2017) 28:55–62. doi: 10.1097/JAN.0000000000000166
50. Peltzer K and Pengpid S. Cannabis use and its social correlates among in-school adolescents in Algeria, Morocco, Palestine, Peru, and Tonga. Mediterr J Soc Sci. (2014) 5:558–63. http://hdl.handle.net/20.500.11910/2433 (Accessed June 7, 2025).
51. Peltzer K and Pengpid S. Cannabis and amphetamine use among adolescents in five Asian countries. Cent Asian J Glob Health. (2017) 6:288. doi: 10.5195/cajgh.2017.288
52. Peltzer K and Pengpid S. Cannabis and amphetamine use and associated factors among school-going adolescents in nine African countries. J Child Adolesc Subst Abuse. (2018) 27:112–8. doi: 10.1080/1067828X.2017.1420512
53. Rabie M, Shaker NM, Gaber E, El-Habiby M, Ismail D, El-Gaafary M, et al. Prevalence updates of substance use among Egyptian adolescents. Middle East Curr Psychiatry. (2020) 27:Article 4. doi: 10.1186/s43045-019-0013-8
54. Shaheen H, Amin S, and Abu Elsoud S. Substance use disorder and risk behaviors among secondary school adolescents in a rural area in Egypt. Menoufia Med J. (2021) 34. doi: 10.4103/mmj.mmj_323_19
55. Soliman SS, Allam HK, Habib NM, Abdallah AR, and Hassan OM. Work schedule and substance abuse in vocational students. J Public Health Res. (2022) 11:Article 2395. doi: 10.4081/jphr.2021.2395
56. Zammit N, Maatoug J, Radaoui F, Ghammam R, Bhiri S, and Ghannem H. Tobacco use: The most influential risk factor on cannabis use among middle schoolchildren in Sousse, Tunisia [Conference Abstract. Tobacco Induced Dis. (2018) 16:213. doi: 10.18332/tid/84720
57. Zarrouq B, Bendaou B, El Asri A, Achour S, Rammouz I, Aalouane R, et al. Psychoactive substances use and associated factors among middle and high school students in the North Center of Morocco: a cross-sectional questionnaire survey. BMC Public Health. (2016) 16:468. doi: 10.1186/s12889-016-3143-5
58. Abdelmounaim B, Hamid K, Abdelfattah A, Rachida A, Samia B, and Abderrahman C. Substance use among university students and affecting factors in Central Morocco: a cross-sectional Study. Acad J Health Sci. (2023) 38:146–53. doi: 10.3306/AJHS.2023.38.05.146
59. Al-Hinaai H, Al-Busaidi I, Al Farsi B, and Al Saidi Y. The prevalence of substance misuse and its effects among Omani college students: A cross-sectional study. Oman Med J. (2021) 36:1–7, Article e224. doi: 10.5001/OMJ.2021.04
60. Bajwa HZ, Al-Turki ASA, Dawas AMK, Behbehani MQ, Al-Mutairi AMA, Al-Mahmoud S, et al. Prevalence and factors associated with the use of illicit substances among male university students in Kuwait. Med Principles Pract. (2013) 22:458–63. doi: 10.1159/000350609
61. Bassiony MM, Abdelghani M, Salah El-Deen GM, Hassan MS, El-Gohari H, and Youssef UM. Opioid use disorders attributed to tramadol among Egyptian university students. J Addict Med. (2018) 12:150–5. doi: 10.1097/adm.0000000000000380
62. Chekib Z, Zammit N, Manel L, Menel M, Elghardallou M, Jihen S, et al. Illicit substance use among Tunisian college students: Prevalence and risk factors. Int J Adolesc Med Health. (2018) 30:Article 20160108. doi: 10.1515/ijamh-2016-0108
63. Damiri B, Sandouka HN, Janini EH, and Yaish ON. Prevalence and associated factors of psychoactive substance use among university students in the West Bank, Palestine. Drugs: Education Prev Policy. (2020) 27:173–82. doi: 10.1080/09687637.2019.1591341
64. Fekih-Romdhane F, Alhuwailah A, Shuwiekh HAM, Stambouli M, Hakiri A, Jaoua A, et al. Cross-national validation of the Arabic version of the cannabis use intention questionnaire (CUIQ) among university students from Egypt, Kuwait, and Tunisia. Int J Ment Health Addict 23:1677–92. (2023). doi: 10.1007/s11469-023-01192-x
65. Fekih-Romdhane F, Alhuwailah A, Shuwiekh HAM, Stambouli M, Hakiri A, Cheour M, et al. Development and initial validation of the cannabis-related psychosis risk literacy scale (CPRL): a multinational psychometric study. BMC Psychiatry. (2024) 24:Article 298. doi: 10.1186/s12888-024-05727-x
66. Ghandour LA, El Sayed DS, and Martins SS. Prevalence and patterns of commonly abused psychoactive prescription drugs in a sample of university students from Lebanon: an opportunity for cross-cultural comparisons. Drug Alcohol Depend. (2012) 121:110–7. doi: 10.1016/j.drugalcdep.2011.08.021
67. Gourani M. Approche épidémiologique de la toxicomanie en milieu universitaire à Marrakech. Marrakech: Faculté de Médecine et de Pharmacie, Universite Caddi Ayyad (2007). Available at: http://toubkal.imist.ma/handle/123456789/19513 (Accessed June 7, 2025).
68. Hamaideh S, Mudallal R, Al-Mudallal H, and Abuhammoudeh M. Prevalence, types and predictors of illicit substance use among the Hashemite University students in Jordan. Jordan Med J. (2010) 44:125–32.
69. Hashim AMM, Hassan AM, Amin GEED, and Allam MF. Prevalence of strox smoking among university students in cairo, Egypt. Open Public Health J. (2020) 13:425–9. doi: 10.2174/1874944502013010425
70. Helou M, Mouawad Y, Al Tekle GA, Serhan F, Akl M, Hallit S, et al. Quality of life and substance use in Lebanese medical students. J Subst Use. (2023) 29:969–75. doi: 10.1080/14659891.2023.2223309
71. Jebali C, Kahloul M, Ibn Hassine N, Kacem I, Hafsia M, Jaouadi MA, et al. Addictive behaviors in nursing students in a private Tunisian institute. Rev Medicale Bruxelles. (2019) 40:133–9. doi: 10.30637/2019.18-083
72. Kabbash I, Zidan O, and Saied S. Substance abuse among university students in Egypt: prevalence and correlates. East Mediterr Health J. (2022) 28:31–40. doi: 10.26719/emhj.22.001
73. Kabbash IA, Zidan OO, and Younis EA. Drug use among students of Tanta University: prevalence and correlates. J Subst Use. (2024) 29:38–44. doi: 10.1080/14659891.2022.2120430
74. Karam E, Melhem N, Mansour C, Maalouf W, Saliba S, and Chami A. Use and abuse of licit and illicit substances: prevalence and risk factors among students in Lebanon. Eur Addict Res. (2000) 6:189–97. doi: 10.1159/000052045
75. Khafagy M, Gomaa Z, and Elwasify M. Substance use patterns among university students in Egypt. Middle East Curr Psychiatry. (2021) 28:Article 59. doi: 10.1186/s43045-021-00140-6
76. Khedr EM, Elbeh KA, Elsadek AM, and Shoyb EMAA. Prevalence of psychoactive substance use among students in Aswan University. J Positive School Psychol. (2022) 6:9887–96.
77. Kjiri SW, Boulayoun F, Rammouz I, Cherkaoui I, and Ktiouet JE. Female drug abuse in a university setting. Eastern Mediterr Health J. (2005) 11:416–24. https://www.scopus.com/inward/record.uri?eid=2-s2.0-33645307391&partnerID=40&md5=0670089b1b2d3bf5f1907999397abd66 (Accessed June 7, 2025).
78. Mina A, Rahme C, Hallit S, and Soufia M. Development of scales to measure Lebanese university students’ perceived knowledge about and attitudes about cannabis use: initial psychometric properties. J Cannabis Res. (2022) 4:Article 34. doi: 10.1186/s42238-022-00144-x
79. Moaouad J, Kazour F, Haddad R, Rouhayem J, Chammai R, and Richa S. Chemical and behavioural addiction of medical students. Comparative study in Lebanese students. Encephale. (2012) 38:467–72. doi: 10.1016/j.encep.2011.12.010
80. Naguib YM, Sherif HA, Elbalshy AT, Edrees EA, Sabry AE, Sharif AF, et al. Prevalence and associated risk factors of cannabinoid abuse among Egyptian university students: a cross-sectional study. Environ Sci pollut Res Int. (2021) 28:68706–16. doi: 10.1007/s11356-021-15412-1
81. Osman T, Victor C, Abdulmoneim A, Mohammed H, Abdalla F, Ahmed A, et al. Epidemiology of substance use among university students in Sudan. J Addict. (2016) 2016:2476164. doi: 10.1155/2016/2476164
82. Salameh P, Rachidi S, Al-Hajje A, Awada S, Chouaib K, Saleh N, et al. Substance use among Lebanese university students: prevalence and associated factors. East Mediterr Health J. (2015) 21:332–41. doi: 10.26719/2015.21.5.332
83. Talih F, Daher M, Daou D, and Ajaltouni J. Examining burnout, depression, and attitudes regarding drug use among Lebanese medical students during the 4 years of medical school. Acad Psychiatry. (2018) 42:288–96. doi: 10.1007/s40596-017-0879-x
84. Dugas EN, Sylvestre M-P, Ewusi-Boisvert E, Chaiton M, Montreuil A, and O’Loughlin J. Early risk factors for daily cannabis use in young adults. Can J Psychiatry. (2019) 64:329–37. doi: 10.1177/0706743718804541
85. SAMHSA. 2023 National Survey on Drug Use and Health (NSDUH) releases(2023). Available online at: https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health/national-releases/2023 (Accessed June 7, 2025).
86. Barnett NP, DiGuiseppi GT, Tesdahl EA, and Meisel MK. Peer selection and influence for marijuana use in a complete network of first-year college students. Addict Behav. (2022) 124:107087. doi: 10.1016/j.addbeh.2021.107087
87. Torrejón-Guirado MC, Baena-Jiménez M, Lima-Serrano M, de Vries H, and Mercken L. The influence of peer’s social networks on adolescent’s cannabis use: a systematic review of longitudinal studies. Front Psychiatry. (2023) 14:1306439. doi: 10.3389/fpsyt.2023.1306439
88. North C and Loukas A. Marijuana use behaviors on Texas college campuses. Addict Behav. (2023) 141:107634. doi: 10.1016/j.addbeh.2023.107634
89. Wallace GT, Parnes JE, Prince MA, Conner BT, Riggs NR, George MW, et al. Associations between marijuana use patterns and recreational legislation changes in a large Colorado college student sample. Addict Res Theory. (2020) 28:211–21. doi: 10.1080/16066359.2019.1622003
90. van der Pol P, Liebregts N, de Graaf R, Korf DJ, van den Brink W, and van Laar M. Predicting the transition from frequent cannabis use to cannabis dependence: A three-year prospective study. Drug Alcohol Depend. (2013) 133:352–9. doi: 10.1016/j.drugalcdep.2013.06.009
91. Anywar G, Kakudidi E, Tugume P, and Asiimwe S. The Cannabis/Marijuana (Cannabis sativa L.) Landscape in Africa: An Overview of its Cultivation and Legal Aspects. In: Agrawal DC, Kumar R, and Dhanasekaran M, editors. Cannabis/Hemp for Sustainable Agriculture and Materials. Springer, Singapore (2022). p. 297–310. doi: 10.1007/978-981-16-8778-5_10
92. Fakhry B, Abdulrahim M, and Chahine MN. Medical cannabis in Lebanon: History & therapeutic, ethical, and social challenges. A narrative review. Arch Clin Biomed Res. (2021) 5:137–57. doi: 10.26502/acbr.50170156
93. AlMarri TSK and Oei TPS. Alcohol and substance use in the Arabian Gulf region: A review. Int J Psychol. (2009) 44:222–33. doi: 10.1080/00207590801888752
94. Ghiabi M, Maarefvand M, Bahari H, and Alavi Z. Islam and cannabis: Legalisation and religious debate in Iran. Int J Drug Policy. (2018) 56:121–7. doi: 10.1016/j.drugpo.2018.03.009
95. Shirah BH and Ahmed MM. The use of cannabis for medical purposes in the arab world. Med Cannabis Cannabinoids. (2021) 4:72–4. doi: 10.1159/000510824
96. Saquib N, Rajab AM, Saquib J, and AlMazrou A. Substance use disorders in Saudi Arabia: a scoping review. Subst Abuse Treat Prevent Policy. (2020) 15:41. doi: 10.1186/s13011-020-00285-3
97. Hammond CJ, Chaney A, Hendrickson B, and Sharma P. Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates. Int Rev Psychiatry. (2020) 32:221–34. doi: 10.1080/09540261.2020.1713056
98. Jablonska B and Negura L. Navigating the grey zone: the impact of legislative frameworks in North America and Europe on adolescent cannabis use—A systematic review. Behav Sci. (2024) 14:484. https://www.mdpi.com/2076-328X/14/6/484 (Accessed June 7, 2025).
99. Sobh ZK and Sobh HK. Strox (novel synthetic cannabinoids) in Egypt: medical and legal challenges. Arab J Forensic Sci Forensic Med. (2020) 2. doi: 10.26735/FWWK7311
100. Lim CCW, Sun T, Leung J, Chung JYC, Gartner C, Connor J, et al. Prevalence of adolescent cannabis vaping: A systematic review and meta-analysis of US and Canadian studies. JAMA Pediatr. (2022) 176:42–51. doi: 10.1001/jamapediatrics.2021.4102
101. Belete H, Mekonen T, Espinosa DC, Ambaw F, Connor J, Chan G, et al. Cannabis use in sub-Saharan Africa: A systematic review and meta-analysis. Addiction. (2023) 118:1201–15. doi: 10.1111/add.16170
102. Sahu A, Bhati N, and Sarkar S. A systematic review and meta-analysis of substance use among medical students in India. Indian J Psychiatry. (2022) 64:225–39. doi: 10.4103/Indianjpsychiatry.Indianjpsychiatry_672_21
103. Miech RA, Johnston LD, Patrick ME, O’Malley PM, Bachman JG, and Schulenberg JE. Monitoring the Future national survey results on drug use 1975–2022: Secondary school students(2023). Available online at: https://monitoringthefuture.org/results/publications/monographs/ (Accessed June 7, 2025).
104. EMCDDA. Cannabis – the current situation in Europe (European Drug Report 2024)(2024). Available online at: https://www.euda.europa.eu/publications/european-drug-report/2024/cannabis_enedr24-cannabis-figure-2.2 (Accessed June 7, 2025).
105. Roncero C, Egido A, Rodríguez-Cintas L, Pérez-Pazos J, Collazos F, and Casas M. Substance Use among Medical Students: A Literature Review 1988- 2013. Actas Esp Psiquiatr. (2015) 43:109–21. https://actaspsiquiatria.es/index.php/actas/article/view/420 (Accessed June 7, 2025).
106. Hawke LD, Wilkins L, and Henderson J. Early cannabis initiation: Substance use and mental health profiles of service-seeking youth. J Adolesc. (2020) 83:112–21. doi: 10.1016/j.adolescence.2020.06.004
107. Bataineh BS, Wilkinson AV, Sumbe A, Clendennen SL, Chen B, Messiah SE, et al. Anxiety as a predictor of the age of initiation of tobacco and cannabis use in adolescents and young adults. Addictive Behav. (2024) 148:107876. doi: 10.1016/j.addbeh.2023.107876
108. Scholes-Balog KE, Hemphill SA, Heerde JA, Toumbourou JW, and Patton GC. Childhood social environmental and behavioural predictors of early adolescent onset cannabis use. Drug Alcohol Rev. (2020) 39:384–93. doi: 10.1111/dar.13077
109. Padoan F, Colombrino C, Sciorio F, Piacentini G, Gaudino R, Pietrobelli A, et al. Concerns related to the consequences of pediatric cannabis use: A 360-degree view. Children. (2023) 10:1721. https://www.mdpi.com/2227-9067/10/11/1721 (Accessed June 7, 2025).
110. Calakos KC, Bhatt S, Foster DW, and Cosgrove KP. Mechanisms underlying sex differences in cannabis use. Curr Addict Rep. (2017) 4:439–53. doi: 10.1007/s40429-017-0174-7
111. Hemsing N and Greaves L. Gender norms, roles and relations and cannabis-use patterns: A scoping review. Int J Environ Res Public Health. (2020) 17:947. https://www.mdpi.com/1660-4601/17/3/947 (Accessed June 7, 2025).
112. Grigsby TJ, Lopez A, Albers L, Rogers CJ, and Forster M. A scoping review of risk and protective factors for negative cannabis use consequences. Subst Abuse: Res Treat. (2023) 17. doi: 10.1177/11782218231166622
113. Bataineh BS, Wilkinson AV, Sumbe A, Clendennen SL, Chen B, Messiah SE, et al. Depressive symptoms and the age of initiation of tobacco and marijuana use among adolescents and young adults. Drug Alcohol Depend. (2023) 252:110971. doi: 10.1016/j.drugalcdep.2023.110971
114. Helmer SM, Burkhart G, Matias J, Buck C, Engling Cardoso F, and Vicente J. Tell Me How Much Your Friends Consume”—Personal, Behavioral, Social, and Attitudinal Factors Associated with Alcohol and Cannabis Use among European School Students. Int J Environ Res Public Health. (2021) 18:1684. https://www.mdpi.com/1660-4601/18/4/1684 (Accessed June 7, 2025).
115. Zaharakis N, Mason MJ, Mennis J, Light J, Rusby JC, Westling E, et al. School, friends, and substance use: gender differences on the influence of attitudes toward school and close friend networks on cannabis involvement. Prev Sci. (2018) 19:138–46. doi: 10.1007/s11121-017-0816-y
116. Fox AR, Skalisky J, Johnson B, Noland MD, and Mezulis AH. Religious strength of faith and marijuana use frequency predict marijuana-related impairment in college students. Psychol Religion Spirituality. (2022) 14:170–8. doi: 10.1037/rel0000391
117. Carrà G, Bartoli F, Canestro A, Capogrosso CA, Bebbington PE, and Crocamo C. Influence of intrinsic and extrinsic religiosity on youth cannabis use: A structural equation modelling analysis on national survey on drug use and health (NSDUH) 2015–2019. J Psychiatr Res. (2023) 166:178–85. doi: 10.1016/j.jpsychires.2023.09.016
118. Steinhoff A, Bechtiger L, Birchler K, Ribeaud D, Eisner M, Quednow BB, et al. Cannabis use from early adolescence to the mid-twenties in children of immigrant and nonimmigrant parents: findings from a prospective longitudinal cohort study. Int J Ment Health Addict. (2024). doi: 10.1007/s11469-024-01359-0
119. Arria AM, Caldeira KM, Bugbee BA, Vincent KB, and O’Grady KE. The academic consequences of marijuana use during college. Psychol Addict Behav. (2015) 29:564–75. doi: 10.1037/adb0000108
120. Cyrus E, Coudray MS, Kiplagat S, Mariano Y, Noel I, Galea JT, et al. A review investigating the relationship between cannabis use and adolescent cognitive functioning. Curr Opin Psychol. (2021) 38:38–48. doi: 10.1016/j.copsyc.2020.07.006
121. Gerra G, Benedetti E, Resce G, Potente R, Cutilli A, and Molinaro S. Socioeconomic Status, Parental Education, School Connectedness and Individual Socio-Cultural Resources in Vulnerability for Drug Use among Students. Int J Environ Res Public Health. (2020) 17:1306. https://www.mdpi.com/1660-4601/17/4/1306 (Accessed June 7, 2025).
122. Knaappila N, Marttunen M, Fröjd S, Lindberg N, and Kaltiala R. Changes in cannabis use according to socioeconomic status among Finnish adolescents from 2000 to 2015. J Cannabis Res. (2020) 2:44. doi: 10.1186/s42238-020-00052-y
123. Kuhns L, Kroon E, Colyer-Patel K, and Cousijn J. Associations between cannabis use, cannabis use disorder, and mood disorders: longitudinal, genetic, and neurocognitive evidence. Psychopharmacology. (2022) 239:1231–49. doi: 10.1007/s00213-021-06001-8
124. White CT, Shamim H, Al Shouli R, Habbal AB, and Mohammed L. Cannabis use and the development of depression in adolescents: is there an established linear relationship between the two? Cureus. (2022) 14. doi: 10.7759/cureus.27394
125. Lowe DJE, Sorkhou M, and George TP. Cannabis use in adolescents and anxiety symptoms and disorders: a systematic review and meta-analysis. Am J Drug Alcohol Abuse. (2024) 50:150–61. doi: 10.1080/00952990.2023.2299922
126. Stiles-Shields C, Archer J, Zhang J, Burnside A, Draxler J, Potthoff LM, et al. A scoping review of associations between cannabis use and anxiety in adolescents and young adults. Child Psychiatry Hum Dev. (2021) 54:639–58. doi: 10.1007/s10578-021-01280-w
127. Carvalho JV, Souza LS, and Moreira EC. Association between cannabis use and suicidal behavior: A systematic review of cohort studies. Psychiatry Res. (2022) 312:114555. doi: 10.1016/j.psychres.2022.114555
128. Schmidt K, Tseng I, Phan A, Fong T, and Tsuang J. A systematic review: adolescent cannabis use and suicide. Addictive Disord Their Treat. (2020) 19:146–51. doi: 10.1097/ADT.0000000000000196
129. Ganesh S and D’Souza DC. Cannabis and psychosis: recent epidemiological findings continuing the “Causality debate. Am J Psychiatry. (2022) 179:8–10. doi: 10.1176/appi.ajp.2021.21111126
130. Hasan A, von Keller R, Friemel CM, Hall W, Schneider M, Koethe D, et al. Cannabis use and psychosis: a review of reviews. Eur Arch Psychiatry Clin Neurosci. (2020) 270:403–12. doi: 10.1007/s00406-019-01068-z
131. Baral A, Hanna F, Chimoriya R, and Rana K. Cannabis use and its impact on mental health in youth in Australia and the United States: A scoping review. Epidemiologia. (2024) 5:106–21. https://www.mdpi.com/2673-3986/5/1/7 (Accessed June 7, 2025).
132. Scheier LM and Griffin KW. Youth marijuana use: a review of causes and consequences. Curr Opin Psychol. (2021) 38:11–8. doi: 10.1016/j.copsyc.2020.06.007
133. Lynskey M and Hall W. The effects of adolescent cannabis use on educational attainment: a review. Addiction. (2000) 95:1621–30. doi: 10.1046/j.1360-0443.2000.951116213.x
134. Green KM, E. DE, and Ensminger ME. Long-term consequences of adolescent cannabis use: Examining intermediary processes. Am J Drug Alcohol Abuse. (2017) 43:567–75. doi: 10.1080/00952990.2016.1258706
135. Godin SL and Shehata S. Adolescent cannabis use and later development of schizophrenia: An updated systematic review of longitudinal studies. J Clin Psychol. (2022) 78:1331–40. doi: 10.1002/jclp.23312
136. Solmi M, De Toffol M, Kim JY, Choi MJ, Stubbs B, Thompson T, et al. Balancing risks and benefits of cannabis use: umbrella review of meta-analyses of randomised controlled trials and observational studies. BMJ. (2023) 382. doi: 10.1136/bmj-2022-072348
137. Lemstra M, Norman B, Ushasri N, Cory N, Lynne W, Tanis K, et al. A systematic review of school-based marijuana and alcohol prevention programs targeting adolescents aged 10–15. Addict Res Theory. (2010) 18:84–96. doi: 10.3109/16066350802673224
138. Onyenwe CA, Onwumere C, and Odilibe IP. Public health strategies for preventing youth substance use: A review of prevention programs and conceptual approaches. Int J Biol Pharm Res Updates. (2024) 3:12–9. doi: 10.53430/ijbpru.2024.3.1.0022
139. Dishion TJ, Kavanagh K, Schneiger A, Nelson S, and Kaufman NK. Preventing early adolescent substance use: A family-centered strategy for the public middle school. Prev Sci. (2002) 3:191–201. doi: 10.1023/A:1019994500301
140. ACMD. Semi-synthetic cannabinoids related to tetrahydro-cannabinol and cannabidiol(2025). Available online at: https://www.gov.uk/government/publications/semi-synthetic-cannabinoids-related-to-tetrahydro-cannabinol-and-cannabidiol (Accessed June 7, 2025).
141. Hai AH, Franklin C, Park S, DiNitto DM, and Aurelio N. The efficacy of spiritual/religious interventions for substance use problems: A systematic review and meta-analysis of randomized controlled trials. Drug Alcohol Depend. (2019) 202:134–48. doi: 10.1016/j.drugalcdep.2019.04.045
142. Hussaini UM and Abbas US. The role of religions and communities in fighting against drug abuse in Nigeria. J Integr Sci. (2024) 4.
143. Kaufman N. Governing through partnerships: neoconservative governance and state reliance on religious NGOs in drug policy. Crit Criminol. (2021) 29:589–611. doi: 10.1007/s10612-020-09492-7
144. de Graaff AM, Cuijpers P, Leeflang M, Sferra I, Uppendahl JR, de Vries R, et al. A systematic review and meta-analysis of diagnostic test accuracy studies of self-report screening instruments for common mental disorders in Arabic-speaking adults. Global Ment Health. (2021) 8. doi: 10.1017/gmh.2021.39
Keywords: cannabis, marijuana, Arab, student, school, university
Citation: Sabalbal A, Eid M, Kobeissy F, Baroud E and El Hayek S (2025) Cannabis use among Arab students: a systematic review. Front. Psychiatry 16:1511563. doi: 10.3389/fpsyt.2025.1511563
Received: 15 October 2024; Accepted: 10 June 2025;
Published: 10 July 2025.
Edited by:
John Martin Corkery, University of Hertfordshire, United KingdomCopyright © 2025 Sabalbal, Eid, Kobeissy, Baroud and El Hayek. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Samer El Hayek, c2FtZXIuZWxoYXlla0BnbWFpbC5jb20=