Canadian cannabis survey 2017 - Summary

Introduction

The Government has introduced legislation that would create a new strict national framework for controlling the production, distribution, sale and possession of cannabis in Canada. Health Canada has begun collecting additional data to better understand how Canadians view and use cannabis. This data will be used to evaluate the impact of the legislation, if approved by Parliament and brought into force, and to develop policy and program initiatives, including public education and awareness activities.

Health Canada estimates the prevalence of cannabis use in the general population through two surveys: the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) and the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS). These general population surveys answer important questions about cannabis prevalence. For example, CTADS 2015 indicates that 12% of Canadians age 15 and older have used cannabis in the past 12 months (age 15-19 = 21%; age 20-24 = 30%; age 25+ = 10%) and CSTADS 2014/15 indicates that 17% of students in grades 7-12 have used cannabis in the past 12 months. However, these surveys are not designed to collect detailed information on cannabis use in Canada, such as the frequency of use, methods of consumption and the perceptions of cannabis use by both users and non-users. In order to obtain more fulsome information, Health Canada has developed and implemented the Canadian Cannabis Survey (CCS).

The CCS was designed using a two-step recruitment process where respondents were first recruited by phone (land line or mobile) from lists of random telephone numbers. Respondents who passed a set of screening questions were then deemed eligible and were sent a link to an online survey, either by email or SMS (short message service) to their mobile phones. Respondents were asked if they used cannabis for either medical or non-medical purposes. A separate list of questions was asked of respondents who indicated they used cannabis for non-medical purposes. The average time to complete the survey was 27 minutes for respondents who reported using cannabis within the past 12 months and 9 minutes for respondents who reported that they had not used cannabis.

The following summary presents survey findings from the first data collection cycle, which commenced March 13, 2017 and ended May 24, 2017. Survey findings were weighted by region, age groups, and gender. The results for 2017 are based on online responses from 9,215 respondents aged 16 years and older across all provinces and territories. The CCS was designed to obtain a sufficient number of respondents from key sub-populations, and quotas were determined and met in order to ensure statistical relevance of results and representativeness. A total of 9,215 responses were received, including 2,650 responses from people who indicated that they had used cannabis in the past 12 months for either non-medical or medical purposes. Gender and age breakdowns included 4,486 females, 4,695 males, 590 respondents aged 16-19 years, 1,062 respondents aged 20-24 years, and 7,563 respondents aged 25 years and older.

Data were collected on four thematic areas: knowledge, attitudes and behaviours; cannabis use and products used; driving and cannabis, and cannabis for medical purposes. A summary of the key results is provided below and the detailed results tables have been published on the Library and Archives website.

Theme 1: Knowledge, attitudes and behaviours

All respondents were asked questions about their opinions and knowledge related to cannabis. Topics included social acceptability of cannabis and other substance use, observation of cannabis use in public, how many of their friends and family had tried cannabis, and frequency of cannabis use in the home.

Social acceptability

Respondents were asked about the social acceptability of using various products occasionally. Social acceptability was determined using a 5-point Likert scale, which had the following categories: completely acceptable, somewhat acceptable, somewhat unacceptable, completely unacceptable, and no opinion.

The majority of respondents felt that, of the proposed substances (alcohol, tobacco, and cannabis), the most socially acceptable product to use was alcohol; with 56% responding that alcohol use is completely socially acceptable. Using cannabis for non-medical purposes, including smoking and consuming edibles, was considered completely acceptable by 28% of respondents, followed by vaping cannabis for non-medical purposes (26%). Use of vaping products, such as e-cigarettes, was considered completely acceptable by 21% of respondents, and tobacco use, including cigarettes, cigars or snuff, was considered completely acceptable by 19% of all respondents.

Respondents who indicated using cannabis in the past 12 months were more likely to report that occasional use of alcohol, tobacco, and cannabis were socially acceptable than non-users. Of those who had used cannabis in the past 12 months, 71% responded that alcohol use is completely acceptable compared to 52% for non-users, and 69% reported that smoking cannabis for non-medical purposes was completely acceptable compared to 17% for non-users. One third (34%) of respondents who used cannabis in the past 12 months reported that it is completely acceptable to smoke tobacco occasionally. This is more than twice the proportion observed among those who had not used cannabis in the past 12 months (14%).

Opinions on the effects of cannabis use

Respondents who reported using cannabis in the past 12-months were asked if cannabis had a positive effect, negative effect, or no effect on various aspects of life. The majority reported cannabis had no effect on work or studies (72%), home life or marriage (64%), physical mobility (63%), and physical health (60%). Positive effects were reported more for mental health (55%), quality of life (55%), and friendships or social life (47%) compared to other aspects of life.

Opinions on whether cannabis use can be habit forming

Overall, 77% of all survey respondents thought that using cannabis could be habit forming. The majority of respondents who reported using cannabis in the past 12-months (64%) and non-users (80%) also thought cannabis could be habit forming.

Perception of benefits and harms

About half of all respondents indicated that cannabis had a positive effect on a person's mood (51%), creativity (45%), anxiety (50%), and sleep (49%).

Most respondents indicated that cannabis had a negative effect on a person's motivation/ambition (57%), memory (58%), concentration (59%), attention (60%), and thinking/decision making (62%).

Observation of use in public places

Respondents were asked if they had observed cannabis use in public places. Among all respondents, 47% noticed someone smoking what seemed to be cannabis in a public place and 56% noticed the odour of cannabis and suspected someone had been using it recently in the area. Other observed methods of consumption, such as vaping (14%), eating or drinking (8%), and using cannabis in another way (7%), were not noticed as frequently by respondents.

Overall, respondents who reported using cannabis in the past 12 months were more likely than non-users to observe what seemed to be someone smoking cannabis in public places (70% vs. 41% respectively).

Cannabis use among family and friends

Respondents were asked to report whether their friends and family had tried cannabis. Among all survey respondents, it was common to report their friends had tried cannabis (most of them or a few/some of them).

Cannabis use inside the home

All respondents were asked about cannabis consumption methods in the home over the past 12 months. Overall, a quarter of respondents reported someone smoking cannabis inside the home. Responses from those who had used cannabis in the past 12 months were noticeably different, with 74% responding that someone smoked cannabis inside their home, followed by eating or drinking cannabis (33%), and vaporizing cannabis (27%).

Theme 2: Cannabis use and products used

The results presented under Theme 2 refer specifically to respondents who reported using cannabis for non-medical purposes (n=2,375).

Respondents who reported using cannabis in the past 12 months for non-medical purposes were asked detailed questions about their use of cannabis for non-medical purposes. Topics included frequency of cannabis use, age of initiation of use, number of hours spent "stoned" or "high" in a typical use day, methods of consumption, types of cannabis products used, average amount spent on these products, and where users store cannabis inside the home.

Cannabis use

Respondents were asked about their cannabis use for non-medical purposes within the past 12 months. Twenty-two percent (22%) of survey respondents reported having used cannabis in the past 12 months. The survey was designed to seek an over-representation of the number of cannabis users and therefore is not meant to provide general population prevalence estimates for cannabis use. The aim of the CCS was to obtain detailed information about the habits of cannabis users and behaviours relative to cannabis use.

Past 12-month use in respondents of various demographic groups

Respondents of this survey between the ages of 16-24 years were about twice as likely to report cannabis use in the past year. Specifically, past 12-month use of cannabis among respondents aged 16-19 years and respondents aged 20-24 was 41% and 45% respectively, compared to 18% for respondents aged 25 years and older. More males (26%) reported past 12-month use compared to females (18%). Students were more likely to report using cannabis products during the past 12 months (37%) compared to respondents who were working, unemployed, retired or not in the workforce (8% - 28%). Those who reported having completed grade 8 or less or some high school as their highest level of education were most likely to report the use of cannabis in the past 12 months (31%), almost twice that of those with a university degree (16%).

Approximately 78% of respondents reported not using cannabis in the past 12 months; 83% of females and 74% of males reported not having used cannabis in the last 12 months. More than ¾ of respondents 25 years and older reported not having used cannabis in the past 12 months (82%), while more than half of youth aged 16-19 (59%) and young adults aged 20-24 (55%) reported they did not use cannabis in the past 12 months.

Age of initiation

Respondents were asked about the age at which they first tried or started using cannabis for non-medical purposes. The average age of initiating cannabis use was 18.7 years, which is comparable to the average age of 18.4 years reported in CTADS 2015. Surveys such as CSTADS, which ask questions of students in grades 7-12, report an average age of initiation of 14.2 years. Average age of initiation is highly dependent on the age range of the respondents in a survey, as well as the distribution of respondents within predetermined age groups. For the CCS, the age of initiation is much higher among the largest age group of adults age 25 and older, resulting in a higher average age of initiation overall.

Frequency of cannabis use

Respondents who had reported using cannabis over the past 12 months were asked how frequently they used the substance. A little over half of these respondents reported using cannabis less than 3 days per month (55%), and 18% reported daily cannabis use. The most common response was less than one day per month (36%), followed by daily (18%), 2-3 days per month (13%), 1-2 days per week (11%), 3-4 days per week (9%), 1 day per month (6%), and 5-6 days per week (6%).

Respondents who had reported using cannabis in the past 30 days (14% of respondents) were asked how many times they used cannabis per typical use day. The most common response was once per day (46%), followed by twice per day (21%), three times per day (14%), 4 times per day (6%) and 13% used it five or more times during the day.

Number of hours "stoned" or "high" on a typical use day

Respondents who had reported using cannabis in the past 30 days were asked about the number of hours they would spend "stoned" or "high" on a typical use day. Forty-two percent (42%) of respondents reported they would be "stoned" or "high" on a typical use day for 1 or 2 hours, followed by 3 or 4 hours (25%), less than 1 hour (19%), 5 or 6 hours (8%) or 7 or more hours (6%).

Methods of consumption

Respondents who had reported using cannabis in the past 12 months were asked about their methods of consumption for non-medical purposes. Smoking was the most common method of cannabis consumption reported by survey respondents. The main methods of consumption were: smoking (94%), eating in food (34%), vaporizing using a vape pen (20%), and vaporizing using a vaporizer (14%).

Types of cannabis products used and frequency

Cannabis users were asked about the types of cannabis products they had used in the past 12 months. The three main products used were dried flower/leaf (88%), followed by edibles (32%), and hashish/kief (24%). Respondents were also asked about the frequency at which they used these cannabis products. The most commonly reported frequency for these three products was less than 1 day a month (38%, 63%, and 45% respectively).

Of those that used hashish/kief, males were almost two times more likely to report use compared to females (30% versus 17% respectively). Respondents 16-19 and 20-24 years of age also reported more use of hashish/kief compared to those 25 years and older (38% and 36% versus 20% respectively). The least used cannabis products were oil cartridges or disposable vape pens (9%) and liquids (3%).

Average amount used on a typical use day

Respondents who had used cannabis in the past 12 months were asked to report on the average amount of cannabis used on a typical use day. Of those that had smoked or vaporized dried flower/leaf, the average amount used on a typical use day was nearly 1 gram. While those that used edible cannabis products consumed approximately 1 serving, those that used hashish/kief used an average of 0.4 grams, and those that used liquids used nearly 240 mL on a typical use day.

Sources used to obtain the cannabis product

Respondents who had used cannabis in the past 12 months were asked about the number of sources that they used to obtain cannabis. The majority of respondents reported that they obtained cannabis from one source (52%), followed by two or three sources (38%). Less common responses included growing their own (2%) and 6 or more sources (4%).

Respondents who had used cannabis in the past 12 months were also asked about who they obtained cannabis from and the location where they obtained it. The top sources to obtain cannabis were from a family member or friend (26%), shared among friends (24%), from an acquaintance (22%), and from a dealer or dispensary (19%).

The main location where respondents obtained cannabis from was at someone else's home (73%). Other responses were much less common and included a publicly accessible place (16%), a compassion club (13%), a school/university/college (5%), and a Health Canada licensed producer (4%). Six percent (6%) also indicated they obtained cannabis from an internet source (other than a Health Canada licensed producer).

Average amount spent on cannabis each month

Respondents who had used cannabis in the past 12 months reported typically spending close to $75 on cannabis products for non-medical use each month. Respondents who had used cannabis within the past 30 days reported spending close to $88 in the past 30 days to obtain cannabis for non-medical use. Females generally reported spending less on cannabis than males.

Cannabis products bought or received, and at what frequency

Respondents who had used cannabis in the past 30 days were asked about the cannabis products they bought or received in the past 30 days and the frequency of these two occurrences. The most common response options selected were buying or receiving dried flower/leaf (90%) followed by edibles (15%), hashish/kief (13%), and solid concentrate (10%). For all products, the most common frequency of obtaining them was 1 day per month. The average amount purchased varied by product type. On average, users purchased or received 11.5 grams of dried flower/leaf, 4.7 servings of edibles, 4.1 grams of hashish/kief, and 1.4 cannabis oil cartridges or disposable vape pens.

Average price per unit of purchases, by product type

Respondents who had purchased cannabis in the past 30 days reported the average price per unit by product type. Over the past 30 days, respondents spent the most per unit on liquid concentrates ($43.80/gram), cannabis oil cartridges or vape pens ($43.84/cartridge), and solid concentrates ($35.84/gram). The product types that were used more frequently, such as dried flower/leaf ($11.40/gram), followed by edibles ($7.71/serving), and hashish/kief ($16.64/gram), were less expensive per unit in comparison.

Proportion of users receiving cannabis products for free

Of the respondents who had obtained cannabis in the past 30 days some reported receiving cannabis products for free. Overall, 34% of respondents obtained edibles for free, followed by hashish/kief (21%), and dried flower/leaf (17%).When looking specifically at dried flower/leaf, more females reported obtaining these products for free compared to males (24% and 12% respectively). These data suggest that edible products may be more freely distributed compared to other product types.

Frequency of cannabis use to get "high" before school or work

Respondents who had used cannabis in the past 12 months were asked about the frequency of cannabis use to get "high" before or at school or work. Overall, 52% of respondents had not used cannabis to get "high" before or at school in the past 12 months. Twenty-one percent (21%) of respondents reported using cannabis before or at school less than once a month, and 16% used cannabis before or at school weekly or daily.

The majority of respondents (79%) had not used cannabis to get "high" before or at work. Ten percent (10%) of respondents reported using cannabis before or at work less than once a month, and 8% used cannabis before or at work weekly or daily.

Where cannabis is stored inside the home

Respondents who had used cannabis in the past 12 months were asked about where they store cannabis inside the home. Among those who currently had cannabis stored at home, storage locations included unlocked cabinets or drawers (38%), locked containers (21%), child proof containers (20%) and open shelves or tables (17%).

With whom respondents used cannabis

Respondents who had used cannabis in the past 12 months were asked with whom they had used cannabis. The most common responses selected included having used with friends (81%), while alone (48%), with a spouse/partner (37%), with a family member or relative (37%) and co-workers (17%). Females were more likely than males to report using with a spouse/partner and less likely to report using with friends, coworkers, strangers or a dealer. Youth and young adults were more likely to report using cannabis with friends (94%) compared to adults (77%). Youth aged 16-19 (20%) and young adults aged 20-24 (29%) were also more likely to report using cannabis with co-workers compared to adults (14%) and also more likely to report using cannabis with strangers or a dealer compared to adults.

Theme 3: Driving and cannabis

Respondents who had used cannabis in the past 12 months were asked about their driving habits relative to cannabis use and to cannabis use in combination with alcohol/other drugs. All respondents were asked if they had been a passenger in a vehicle driven by someone who had smoked cannabis, and all respondents were also asked for their opinions on cannabis and driving.

Respondents who operated a vehicle within two hours of using cannabis, and at what frequency

The CCS specifically looked at driving after using cannabis. Among respondents who had used cannabis in the past 12 months, 39% reported that they have driven within two hours of using cannabis, and of those who had driven after using cannabis, 40% did so within the past 30 days. Males (45%) were more likely to report driving within 2 hours of using cannabis more than females (31%).

Overall, 46% of those who indicated driving within 2 hours of cannabis use reported that they had done so 1 to 10 times in the past 12 months, and 29% of those who indicated driving within 2 hours of cannabis use reported doing so more than 10 times in the past 12 months.

Respondents who operated a vehicle within two hours of using cannabis in combination with alcohol or other drugs

Respondents who indicated they had ever driven within two hours of using cannabis were also asked if they drove a vehicle within two hours of using cannabis in combination with alcohol. Fifteen percent (15%) of these respondents reported that they had driven a vehicle within two hours of using cannabis in combination with alcohol.

The same respondents were also asked if they drove a vehicle within two hours of using cannabis in combination with other drugs. Eight percent (8%) of these respondents reported that they had driven a vehicle within two hours of using cannabis in combination with other drugs.

Respondents who were passengers in a vehicle driven by someone within two hours of using cannabis

All respondents were asked if they had been a passenger in a vehicle driven by someone who had used cannabis within the previous two hours. Overall, 39% of respondents reported having been a passenger in a vehicle driven by someone who had recently used cannabis. This behaviour was more common among cannabis users (79%) compared to non-users (27%). The frequency of this behaviour, among respondents that indicated using cannabis in the past 12 month, ranged from within the past 30 days (33%), within the past 12 months (32%), to more than 12 months ago (35%) among respondents that had used cannabis in the past 12 months.

Interaction with law enforcement related to driving

Two percent (2%) of respondents who had used cannabis in the past 12 months reported having an interaction with law enforcement related to driving under the influence while they were the driver of a vehicle.

Opinions on cannabis use and driving

Respondents were asked for their opinions on how cannabis use affects driving. Three quarters (75%) of all respondents reported that they think that cannabis use affects driving. This drops to 50% when looking at responses from respondents who reported using cannabis in the past 12 months, while less than a quarter of them responded that it depends (24%), or that it did not affect driving (19%).

Respondents were asked for their opinion on the time it takes until it is safe to drive after cannabis use. The majority of respondents did not specify the time it takes before it is safe to drive after cannabis use and 36% reported it depends on the person's tolerance, weight and quantity. A further 23% of respondents said that they did not know when it was safe to drive.

Theme 4: Cannabis for medical purposes

Respondents were asked about their use of cannabis for medical purposes. Questions were on the source of the product, type of product, frequency of use, type of strain, how much was used in a typical day, diseases and symptoms addressed by cannabis use, and changes in respondents' use of other medications as a result of cannabis use.

Medical use

Respondents were asked about their cannabis use for medical purposes in the past 12 months. Twelve percent (12%) of respondents indicated that they used cannabis for medical purposes.

Possession of medical documents

A subset of respondents who indicated that they used cannabis for medical purposes and agreed to complete the medical section of the survey (n=730) were asked if they currently had a medical document from a healthcare professional for their use of cannabis for medical purposes. The majority of them reported not having a medical document from a healthcare professional (71%).

Changes in use of other medications

Respondents that completed the medical section of the survey were asked if cannabis use for medical purposes increased, decreased, increased some and decreased some, or did not change their use of other medications. The majority of respondents who used cannabis for medical purposes reported that cannabis use helped to decrease their use of other medications (72%). Twenty-seven percent (27%) reported that it did not change their use of other medications.

Effects on disease/symptom management

The vast majority of respondents who indicated that they used cannabis for medical purposes reported that cannabis helped to manage their symptoms/disease (97%).

Proportion and frequency of cannabis use for medical purposes

Seventy-eight percent (78%) of respondents who used cannabis for medical purposes in the past 12 months reported using in the past 30 days for medical purposes.

Respondents that completed the medical section of the survey and had used cannabis for medical purposes in the past 30 days were asked about the frequency of their use on the days they used cannabis for medical purposes. Forty-one percent (41%) of these respondents reported using cannabis one time per day, 19% used cannabis two times per day, and 18% reported using cannabis five times per day or more.

Types of cannabis products used for medical purposes

Respondents who used cannabis for medical purposes in the past 12 months were asked about the types of cannabis products they used within the last year. The two main products used were dried flower/leaf (81%) and edibles (30%). Other products reportedly used by these respondents for medical purposes included cannabis oil from a Health Canada licensed producer (14%), solid concentrate (14%), liquid concentrate (11%) and tinctures (10%).

Those that were 16-19 years old (99%) and 20-24 years old (97%) were more likely to use dried flower/leaf products than those 25 years and older (77%). Respondents who used cannabis for medical purposes were also asked about the frequency at which they used these cannabis products. Dried flower/leaf had a variety of responses which ranged from daily use (34%), weekly use (29%), monthly use (20%), and less than one day a month (17%). Edibles also had a variety of responses which ranged from less than one day a month (39%), monthly use (31%), and weekly use (22%).

Average amount used on a typical use day for medical purposes

Respondents who used cannabis for medical purposes in the past 12 months were also asked to report on the average amount of cannabis used on a typical use day. Of those that had smoked or vaporized dried flower/leaf, the average amount used on a typical use day was 1.4 grams whereas those that used edible cannabis products consumed approximately 1 serving.

Sources used to obtain cannabis products for medical purposes

Respondents who used cannabis for medical purposes in the past 12 months were also asked about where they obtained cannabis for medical purposes. The top sources to obtain cannabis for medical purposes were from a family member or friend (33%), compassion club/dispensary (23%), dealer (22%), and a Health Canada licensed producer or an acquaintance (21%).

Nineteen percent (19%) of respondents who used cannabis for medical purposes reported that they accessed their cannabis through the Access to Cannabis for Medical Purposes program.

Average amount spent on cannabis for medical purposes in a typical month

Respondents who used cannabis for medical purposes in the past 12 months spent approximately $121 on cannabis for medical purposes in a typical month. When respondents who used cannabis for medical purposes in the past 30 days were asked how much they actually spent on cannabis in the past 30 days, they reported spending about $124.

Cannabis products for medical purposes bought or received, and at what frequency

Respondents who used cannabis for medical purposes in the past 30 days were asked about the cannabis products they bought or received in the past 30 days and the frequency of these two occurrences. The most common response options selected were buying or receiving dried flower/leaf (81%) followed by edibles (25%), cannabis oil from a Health Canada licensed producer (15%), and solid concentrate (11%). For all products, the most common frequency of obtaining them was one day per month.

The average amount purchased for medical use varied by product type. On average, users purchased or received 12.8 grams of dried flower/leaf, 5 servings of edibles, 108.7 milliliters of cannabis oil, and 3.0 grams of solid concentrate.

Average price per unit of cannabis purchases for medical purposes, by product type

Respondents who purchased cannabis for medical purposes in the past 30 days also reported the average price per unit by product type. Over the past 30 days, respondents who used cannabis for medical purposes spent the most per unit on liquid concentrates ($44.01/gram) and solid concentrates ($36.20/gram).

Cannabis products for medical purposes received for free

Of the respondents who obtained cannabis for medical purposes in the past 30 days some had obtained cannabis products for free. Overall, 33% of respondents who obtained cannabis for medical purposes obtained edibles for free, followed by dried flower/leaf (13%).

Opinions on cannabis use for medical purposes and driving

Respondents who used cannabis for medical purposes and completed the medical section of the survey were asked if they believed that cannabis use for medical purposes impairs one's ability to drive. More of these respondents reported that 'yes' cannabis use for medical purposes impairs one's ability to drive (41%) compared to those that reported 'no' (27%) and 'it depends' (32%). The same respondents were also asked for their opinion on the time until it was safe to drive after using cannabis. The most common response was that it depends (34%), followed by one to three hours (21%), and three to five hours (14%). Seven percent (7%) of respondents indicated that it was safe to drive immediately after cannabis use.

Driving a vehicle after using cannabis for medical purposes, and at which frequency

Driving after using cannabis for medical purposes was studied among respondents who used cannabis for medical purposes and completed the medical section of the survey. Thirty-seven percent (37%) of these respondents reported that they have driven within two hours of using cannabis for medical purposes, and of those who had driven after using half did so within the past 30 days. Male users (46%) were more likely to report driving within 2 hours of using cannabis for medical purposes more than female users were (28%).

Forty-three percent (43%) of respondents who used cannabis for medical purposes in the past 12 months reported that they had driven 1 to 10 times in the past 12 months within two hours of using cannabis for medical purposes. Thirty-seven percent (37%) of these users reported driving more than 10 times in the past 12 months within two hours of using cannabis for medical purposes.

Thirty-nine percent (39%) of respondents having used cannabis for medical purposes in the past 30 days reported that they had driven 1 to 10 times in the past 30 days after using cannabis for medical purposes, and 25% of these users reported driving more than 10 times in the past 30-days within two hours of using cannabis.

Driving a vehicle within two hours of using cannabis for medical purposes in combination with alcohol or other drugs

Respondents who used cannabis for medical purposes in the past 12 months who had reported driving after using cannabis were also asked if they drove a vehicle within two hours of using cannabis for medical purposes in combination with alcohol. Ten percent (10%) of these respondents indicated that they had driven a vehicle within two hours of using cannabis for medical purposes in combination with alcohol.