The organizations studied provided limited consumer-focused information regarding how to use cannabis in ways that will minimize health-related harms. Although the content of the Tweets did often relate to health issues (18% of Tweets), the nature of the Tweets in the dataset was primarily of a promotional or information-sharing style and rarely included specific advice, education, or instruction for followers. Given the pro-cannabis sentiment of much of the cannabis-related Tweets from the general public [12], Twitter users would benefit from more public-health driven content containing educational information related to health impacts of cannabis use. Some examples of educational messages designed to target the general public and to help maximize safety and health when using cannabis include, “start low and go slow” as well as, “use cannabis in a safe and familiar environment with people you trust” and, “if you are a new consumer, look for a product with less than 100 mg/g (10%) THC, with equal or higher levels of CBD,” etc. [13].

The use of cannabis for recreational purposes remains illegal federally in the United States, with some states adopting laws that permit legal recreational and/or medical use. As of July 2019, 11 states in the U.S. had passed laws permitting the use of cannabis for adults, whereas at the end of the period of data collection for this study there were 8 states where use was legal [14]. In Canada, a national approach to legalization was taken, with the use of cannabis for recreational purposes becoming legal on October 17, 2018 [15]. These different approaches to legalization undoubtedly affect how the organizations in our sample communicate with the public about cannabis use.

While health-related topics, population-level issues, and Tweets about research on cannabis were more common in the U.S. organizations studied, Tweeting about legislation, legalization, and regulation were more common in the Canadian organizations. It is possible that the impending policy change to legalize cannabis in Canada (at the time period studied) offered a unique policy window where non-governmental organizations could propose benefits of legalization and approaches to regulation that would be considered by policy makers, and where governmental organizations could advertise consultations and public dialogue about cannabis without fear of promoting criminalized activity, making discussion about legislative changes both more timely and relevant. In the absence of legislative change at the national level or indications of consideration of a national policy change, the U.S. organizations studied may have opted to Tweet information about other topics more salient to their followers and less politically objectionable. When approaching legalization, though, health-related topics become increasingly relevant to the general public and the relatively lower frequency of posting about health outcomes in Canadian organizations may represent a critical absence of useful information for Canadian Twitter users. Further, legalization is in itself a public health issue, and one that non-governmental organizations could be advancing discussion of, even without any actual or impending policy decisions from government. 

Based on our findings, it appears that in both countries public health and governmental organizations are not capitalizing on social media’s interactive potential and could be providing more direct information that is related to what Twitter users are discussing. [7] The organizations included in our study rarely posted about cannabis on Twitter, with the exception of NIDA, CAMH, CPHA, and HC and when they did post cannabis-related content it was primarily sharing research findings, reports, or links that contain information such as issues for youth and young adults, driving and cannabis use, neurological impacts of cannabis use, and medical cannabis.

There are other substances that have a heavily imbalanced “pro use” presence on social media, such as alcohol [16, 17], and this warrants further discussion as the public may benefit from public health and mental health/substance use organizations offering more information about how to use a variety of substances in ways that maximize health and safety, not just cannabis. Future research investigating other substance use-related content from health organizations may be needed. In addition, investigating how social media strategy is crafted and to what aim within such organizations is warranted.

Paul and Dredze report findings about the interactions between public health departments and Twitter users. [5] The departments in their study posted on average once per day and re-Tweets constituted 22.5% of all their Tweets; only 1.5% of Tweets were in response to a Tweet made by a follower. [5] This one-way social media communication pattern represents a missed opportunity to engage with Twitter users about information they may be seeking. Public health and governmental organizations would be well advised to incorporate social media into their substance use communication strategy, and given the recent switch to allow up to 280 characters on Twitter, this may be more feasible than it was previously. [5, 18]