Assessment of Incorporation of Lessons From Tobacco Control in City and County Laws Regulating Legal Marijuana in California

Young adult retail purchases of cannabis, product category preferences and sales trends in California 2018-21: Differences compared with older adults

AIMS

The aim of this study is to identify cannabis products according to their appeal among young adults and measure product sales trends.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective comparative study using point-of-sale data from licensed recreational cannabis retailers that include buyer age with birth year entered by retailers, set in California, USA. Cannabis purchases by young adults (aged 21-24, GenZ) were compared with older adults (age 25+) over 4 years (2018-21).

MEASUREMENTS

Sales for six cannabis product categories were analyzed using a commercial data set with imputations and a raw data set. Age-appeal metrics were dollar and unit sales to young adults, and dollar and unit share ratios (young adults/older adults), where a share ratio of 100 denotes age-appeal comparability. A product category was considered more young-adult appealing than others if its mean on a metric was at least one standard deviation above the grand mean across all product categories.

FINDINGS

Flower (cannabis plant material) and vapor pen appealed to young adults based on absolute dollar sales, dominating young-adult spending compared with other cannabis products (37.24 and 31.83%, respectively). Vapor pen and concentrate appealed to young adults based on dollar share ratios of 152, meaning these products comprised a 52% greater share of young-adult cannabis spending relative to older-adult spending (31.83/20.97% and 10.47/6.88%, respectively). Less appealing to young adults were pre-roll, edible/beverage and absorbable products (tincture/sublingual, capsule and topical). Flower showed the largest dollar sales growth (B = +$3.50 million/month), next to vapor pen (B = +$1.55 million/month). Vapor pen tied for highest growth in the percent of product dollars from the largest package size (B = +0.85%/month) and showed the steepest price decline (B = -0.53 price per gram/month).

CONCLUSIONS

In California, USA, from 2018 to 2021, relative to older adults, young adults spent a greater share of their cannabis dollars on vapor pen and concentrate (products with high potency of delta-9-tetrahydrocannabinol).

Associations of Local Cannabis Control Policies With Harmful Cannabis Exposures Reported to the California Poison Control System

BACKGROUND

Cannabis exposures reported to the California Poison Control System increased following the initiation of recreational cannabis sales on 1 January 2018 (i.e., "commercialization"). We evaluated whether local cannabis control policies adopted by 2021 were associated with shifts in harmful cannabis exposures.

METHODS

Using cannabis control policies collected for all 539 California cities and counties in 2020-2021, we applied a differences-in-differences design with negative binomial regression to test the association of policies with harmful cannabis exposures reported to California Poison Control System (2011-2020), before and after commercialization. We considered three policy categories: bans on storefront recreational retail cannabis businesses, overall restrictiveness, and specific recommended provisions (restricting product types or potency, packaging and labeling restrictions, and server training requirements).

RESULTS

Localities that ultimately banned storefront recreational retail cannabis businesses had fewer harmful cannabis exposures for children aged <13 years (rate ratio = 0.82; 95% confidence interval = 0.65, 1.02), but not for people aged >13 years (rate ratio = 0.97; 95% confidence interval = 0.85, 1.11). Of 167 localities ultimately permitting recreational cannabis sales, overall restrictiveness was not associated with harmful cannabis exposures among children aged <13 years, but for people aged >13 years, a 1-standard deviation increase in ultimate restrictiveness was associated with fewer harmful cannabis exposures (rate ratio = 0.93; 95% confidence interval = 0.86, 1.01). For recommended provisions, estimates were generally too imprecise to detect associations with harmful cannabis exposures.

CONCLUSION

Bans on storefront retail and other restrictive approaches to regulating recreational cannabis may be associated with fewer harmful cannabis exposures for some age groups following statewide commercialization.

Countering online marketing and user endorsements with enhanced cannabis warning labels: An online experiment among at-risk youth and young adults

As cannabis legalization expands and online marketing intensifies, this study examines whether online social cues can amplify youth-targeted cannabis advertising and whether cannabis warning labels (CWLs) can counteract these influences. A U.S. online sample of 970 adolescents and 1776 young adults susceptible to cannabis use were recruited from Qualtrics in summer 2022. Each participant was randomly assigned to one of the 3 (CWLs: none vs. textual vs. pictorial) by 3 (comments: none vs. anti-cannabis vs. pro-cannabis) conditions in an online experiment. Participants were exposed to three online marketing posts promoting marijuana edibles (randomly selected from a large pool, N = 1260), each with either no warning label, a textual warning, or a pictorial warning (text and picture), and with either five comments (pro- or anti-cannabis in valence) or none. Results showed that among adolescents, pro-cannabis comments increased product appeal (vs. anti-cannabis comments: b = 0.18, p = .025; vs. no comments: b = 0.21, p = .021), and did so more than young adults. For adolescents, only pictorial warnings reduced product appeal (b = -0.20, p = .028). For young adults, both pictorial (b = -0.18, p = .002) and textual warnings (b = -0.12, p = .029) reduced product appeal. Furthermore, both textual (adolescents: b = -0.20, p = .004; young adults: b = -0.15, p = .005) and pictorial (adolescents: b = -0.30, p < .001; young adults: b = -0.18, p = .001) warnings reduced cannabis use intentions. Findings support requiring enhanced CWLs accompany online marketing ads.

Young Adult Depression and Cannabis Use: Associations Before and After Recreational Legalization

INTRODUCTION

The co-occurrence of depression with cannabis use worsens both mood and substance use disorder outcomes, with young adults particularly at risk of co-occurrence. This research investigates whether the association of state-level prevalence rates of young adult (age 18-25) depression and cannabis use in the U.S. changed following enactment of recreational (adult use) cannabis legalization between 2008 and 2019.

METHODS

Annual, state prevalence data on past-year major depressive episode (hereafter, depression) and past-month cannabis use were extracted from the National Survey on Drug Use and Health (N=600 state-year observations). Moderated regression models tested whether the association of depression with cannabis use differed before versus after recreational legalization by comparing prevalence rates of depression and cannabis use in states that enacted recreational legalization to those that did not, while fixing state, year, and medical legalization effects. Data were accessed and analyzed in 2023.

RESULTS

Prevalence rates of both depression and cannabis use increased throughout the study period. The positive statistical effect of depression on cannabis use more than doubled in magnitude after legalization (β=0.564, 95% CI=0.291, 0.838) as compared to before (β=0.229, 95% CI=0.049, 0.409), representing a significant change (β=0.335, 95% CI=0.093, 0.577).

CONCLUSIONS

These results suggest that the association between prevalence rates of young adult depression and cannabis use strengthened following recreational legalization in the U.S. This is potentially due to increases in cannabis accessibility and the acceptance of the health benefits of cannabis, which may enhance the use of cannabis as a coping mechanism among young adults with depression.

Cannabis Vape Product Sales in California Following CDC's Initial Advisory About Lung Injuries

Introduction: The 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) is believed to have been caused by vitamin E acetate, an additive used in some cannabis vaporizer products. Previous studies have primarily focused on changes in sales of electronic nicotine delivery systems following the initial advisory issued by the Centers for Disease Control (CDC) on August 17, 2019. The present study is intended to examine variation by age groups in sales of regulated cannabis vape products in the state of California before, during, and after the outbreak. Methods: Weekly sales revenue of cannabis vape products (from January 1, 2018, to December 31, 2020) was obtained from a sample of recreational cannabis retailers licensed in California. An interrupted time series analysis, using AutoRegressive, Integrated, Moving Average methods, was employed to estimate changes in the sales and market share of cannabis vape products in the weeks following the CDC advisory. Results: The total volume of regulated cannabis vape product sales increased substantially over the 3-year study period (2018-2020). Sales and market share of cannabis vape products, however, declined in both young and older adults immediately following the advisory, rebounding to pre-EVALI levels only for the young adults. For sales, the potential EVALI effect following the CDC's advisory equates to an 8.0% and 2.2% decline below expected levels in the older and young adults, respectively. Conclusions: The differential age effect on sales may reflect concerns regarding health effects of cannabis vaping products and greater awareness of the outbreak among older adults. Findings highlight the importance of informing consumers about health risks associated with using cannabis vape products acquired from regulated versus illicit sources.

A statewide study of disparities in local policies and tobacco, vape, and cannabis retail environments

The current study: (1) assesses sociodemographic disparities in local policies related to tobacco and cannabis retail, and (2) examines the cross-sectional association between policy strength and retailer densities of tobacco, e-cigarette (vape), and cannabis retailers within California cities and county unincorporated areas (N = 539). We combined (a) American Community Survey data (2019 5-year estimates), (b) 2018 tobacco, vape, and cannabis retailer locations from a commercial data provider, (c) 2017 tobacco and vape retail environment policy data from American Lung Association, and (d) 2018 cannabis policy data from California Cannabis Local Laws Database. Conditional autoregressive models examined policy strength associations with sociodemographic composition and retailer density in California jurisdictions. Jurisdictions with larger percentages of Black and foreign-born residents had stronger tobacco and vape policies. For cannabis policy, only income had a small, significant positive association with policy strength. Contrary to hypothesis, tobacco/vape policies were not significantly associated with retailer density, but cannabis policy strength was associated with lower cannabis retailer density (relative rate = 0.58, 95% Uncertainty Interval 0.47-0.70)-this effect was completely driven by storefront bans. Thus, storefront cannabis bans were the only policy studied that was associated with lower cannabis retailer density. Further research is needed to understand policies and disparities in retail environments for tobacco, vape, and cannabis, including data on the prospective association between policy implementation and subsequent retailer density, and the role of enforcement.

Parallel trajectories of vaping and smoking cannabis and their associations with mental and physical well-being among young adults

BACKGROUND

Vaping and smoking are common modes of using cannabis (THC) among young adults, but little is known about how patterns of cannabis vaping and smoking unfold over time or how using one or both types of products may differently affect mental and physical well-being. This study examines parallel processes of cannabis vaping and smoking over 5 years and mental and physical outcomes in a sample of young adults.

METHODS

Annual surveys were conducted between 2016 and 2022 with a mostly California-based cohort of 2428 young adults. Parallel process growth mixture models examined trajectories of past-month frequency of cannabis vaping and smoking from ages 20 - 25. Classes were extracted based on parallel trajectories of vaped and smoked product use. Models assessed differences in self-reported mental (anxiety, depression) and physical (ailments, subjective overall) well-being outcomes in young adulthood across classes, adjusting for demographic characteristics and mental and physical well-being at pre-baseline (average age 19).

RESULTS

Four cannabis vaping/smoking classes emerged: low use of cannabis (84.7%), decreasing smoking, low-moderate vaping (7.1%), stable moderate smoking, decreasing vaping (4.6%), and rapid increasing dual use (3.4%). Classes were similar on physical well-being indicators in young adulthood. The rapid increasing dual use class showed higher anxiety and depressive symptoms compared to other classes.

CONCLUSION

Progression to higher frequency of both vaping and smoking cannabis in young adulthood may contribute to poorer mental well-being compared to other use patterns. Targeted efforts to reduce dual vaping and smoking in young people who use cannabis may be needed.

Impact of Recreational Cannabis Legalization on Opioid Prescribing and Opioid-Related Hospital Visits in Colorado: an Observational Study

BACKGROUND

Cannabis may be a substitute for opioids but previous studies have found conflicting results when using data from more recent years. Most studies have examined the relationship using state-level data, missing important sub-state variation in cannabis access.

OBJECTIVE

To examine cannabis legalization on opioid use at the county level, using Colorado as a case study. Colorado allowed recreational cannabis stores in January 2014. Local communities could decide whether to allow dispensaries, creating variation in the level of exposure to cannabis outlets.

DESIGN

Observational, quasi-experimental design exploiting county-level variation in allowance of recreational dispensaries.

SUBJECTS

Colorado residents MEASURES: We use licensing information from the Colorado Department of Revenue to measure county-level exposure to cannabis outlets. We use the state's Prescription Drug Monitoring Program (2013-2018) to construct opioid-prescribing measures of number of 30-day fills and total morphine equivalents, both per county resident per quarter. We construct outcomes of opioid-related inpatient visits (2011-2018) and emergency department visits (2013-2018) with Colorado Hospital Association data. We use linear models in a differences-in-differences framework that accounts for the varying exposure to medical and recreational cannabis over time. There are 2048 county-quarter observations used in the analysis.

RESULTS

We find mixed evidence of cannabis exposure on opioid-related outcomes at the county level. We find increasing exposure to recreational cannabis is associated with a statistically significant decrease in number of 30-day fills (coefficient: -117.6, p-value<0.01) and inpatient visits (coefficient: -0.8, p-value: 0.03), but not total MME nor ED visits. Counties with no medical exposure prior to recreational legalization experience greater reductions in the number of 30-day fills and MME than counties with prior medical exposure (p=0.02 for both).

CONCLUSIONS

Our mixed findings suggest that further increases in cannabis beyond medical access may not always reduce opioid prescribing or opioid-related hospital visits at a population level.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Using Online Crowdsourced Data to Measure the Availability of Cannabis Home Delivery: A Pilot Study

OBJECTIVE

The growing availability of cannabis products through home delivery services may affect cannabis-related health outcomes. However, research is impeded by a lack of data measuring the scale of home delivery. Prior research demonstrated that crowdsourced websites can be used to validly enumerate brick-and-mortar cannabis outlets. We piloted an extension of this method to explore the feasibility of measuring availability of cannabis home delivery.

METHOD

We tested implementation of an automated algorithm designed to webscrape data from Weedmaps, the largest crowdsourced website for cannabis retail, to count the number of legal cannabis retailers offering home delivery to the geographic centroid of each Census block group in California. We compared these estimates to the number of brick-and-mortar outlets within each block group. To assess data quality, we conducted follow-up telephone interviews with a subsample of cannabis delivery retailers.

RESULTS

We successfully implemented the webscraping. Of the 23,212 block groups assessed, 22,542 (97%) were served by at least one cannabis delivery business. Only 461 block groups (2%) contained one or more brick-and-mortar outlets. In interviews, availability varied dynamically as a function of staffing levels, order sizes, time of day, competition, and demand.

CONCLUSIONS

Webscraping crowdsourced websites could be a viable method for quantifying rapidly evolving availability of cannabis home delivery. However, key practical and conceptual challenges must be overcome to conduct a full-scale validation and develop methodological standards. Acknowledging data limitations, cannabis home delivery appears to be nearly universal in California, whereas availability of brick-and-mortar outlets is limited, underscoring the need for research on home delivery.

Local Prohibitions on Marijuana Businesses With On-Site Consumption: Evidence from New York State

As several US states have legalized recreational marijuana over the past decade, local approval of commercial marijuana activities has faced opposition in a non-negligible share of communities. A common provision in state laws often grants local governments the authority to prohibit marijuana businesses from locating within their jurisdictions. This paper analyzed determinants of local government policies in New York State following the legalization of recreational marijuana in 2021. A key feature of New York’s law authorized municipal governments to pass an “opt-out” ordinance prohibiting marijuana retail stores, on-site consumption establishments, or both. Based on results from multilevel logistic regression models, the likelihood of allowing commercial marijuana activities was higher for local governments representing communities with larger Black populations, fewer evangelical Protestants, and lower levels of household income. While slightly more municipalities prohibited on-site consumption, determinants of opt-out decisions were similar for both retail and consumption businesses.

Equity in Coverage of Local Cannabis Control Policies in California, 2020‒2021

Objectives. To assess whether cannabis control policies that may protect public health were adopted evenly across California localities with differing sociodemographic compositions. Methods. From November 2020 to January 2021, we measured cannabis control policies for 241 localities across California and linked them to data on the characteristics of the communities affected by these policies. We evaluated whether disadvantaged communities were more likely to allow cannabis businesses and less likely to be covered by policies designed to protect public health. Results. Localities with all-out bans on cannabis businesses (65% of localities) were disproportionately high-education (55.8% vs 50.5% with any college) and low-poverty (24.3% vs 34.2%), with fewer Black (4.4% vs 6.9%) and Latinx (45.6% vs 50.3%) residents. Among localities that allowed retail cannabis businesses (28%), there were more cannabis control policies in localities with more high-income and Black residents, although the specific policies varied. Conclusions. Cannabis control policies are unequally distributed across California localities. If these policies protect health, inequities may be exacerbated. Public Health Implications. Uniform adoption of recommended cannabis control policies may help limit any inequitable health impacts of cannabis legalization. (Am J Public Health. 2022;112(11):1640-1650. https://doi.org/10.2105/AJPH.2022.307041).

Geographic Accessibility of Retail Cannabis in Northern California and Prenatal Cannabis Use During the COVID-19 Pandemic

IMPORTANCE

Prenatal cannabis use is associated with health risks for mothers and their children. Prior research suggests that rates of prenatal cannabis use in Northern California increased during the COVID-19 pandemic, but it is unknown whether increases varied with the local cannabis retail and policy environment.

OBJECTIVE

To test whether pandemic-related increases in prenatal cannabis use were greater among pregnant individuals with greater retail availability of cannabis around their homes or among those living in jurisdictions that allowed storefront retailers.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, population-based time series study used data from pregnancies in the Kaiser Permanente Northern California health care system screened for cannabis use before (January 1, 2019, to March 31, 2020) and during (April 1 to December 31, 2020) the early COVID-19 pandemic. Proximity to the nearest retailer and number of retailers within a 15-minute drive from one's home and local cannabis storefront retailer policy (banned vs permitted) were calculated. Interrupted time series models were fit using multiplicative and additive Poisson regression, adjusting for age and race and ethnicity.

EXPOSURES

The COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

Prenatal cannabis use based on universal urine toxicology tests conducted during early pregnancy at entrance to prenatal care.

RESULTS

The sample (n = 99 127 pregnancies) included 26.2% Asian or Pacific Islander, 6.8% Black, 27.6% Hispanic, 34.4% non-Hispanic White, and 4.9% other, unknown, or multiracial individuals, with a mean (SD) age of 30.8 (5.3) years. Prenatal cannabis use before (6.8%) and during (8.2%) the pandemic was associated with closer proximity to a retailer, greater retailer density, and residing in a jurisdiction that permitted vs banned retailers. There was a greater absolute increase in cannabis use from before to during the pandemic among those within a 10-minute drive (<10 minutes: adjusted rate difference [aRD], 0.93 cases/100 patients; 95% CI, 0.56-1.29 cases/100 patients; ≥10 minutes: aRD, 0.40 cases/100 patients; 95% CI, 0.12-0.68 cases/100 patients; interaction P = .02). Otherwise, relative and absolute rates increased similarly across categories of cannabis retailer proximity/density and local policy (interaction P > .05).

CONCLUSIONS AND RELEVANCE

Prenatal cannabis use was more common among individuals living in areas with greater retail availability of cannabis. Although relative rates increased similarly during the pandemic regardless of local cannabis retail and policy environment, there was a larger absolute increase associated with living closer to a storefront cannabis retailer. Continued monitoring of local cannabis policy, the retail environment, and prenatal cannabis use is needed.

A Spatiotemporal Analysis of the Association of California City and County Cannabis Policies with Cannabis Outlet Densities

BACKGROUND

Cannabis outlets may affect health and health disparities. Local governments can regulate outlets, but little is known about the effectiveness of local policies in limiting outlet densities and discouraging disproportionate placement of outlets in vulnerable neighborhoods.

METHODS

For 241 localities in California, we measured seven policies pertaining to density or location of recreational cannabis outlets. We geocoded outlets using web-scraped data from the online finder Weedmaps between 2018 and 2020. We applied Bayesian spatiotemporal models to evaluate associations of local cannabis policies with Census block group-level outlet counts, accounting for confounders and spatial autocorrelation. We assessed whether associations differed by block group median income or racial-ethnic composition.

RESULTS

Seventy-six percent of localities banned recreational cannabis outlets. Bans were associated with fewer outlets, particularly in block groups with higher median income, fewer Hispanic residents, and more White and Asian residents. Outlets were disproportionately located in block groups with lower median income [posterior RR (95% credible interval): 0.76 (0.70, 0.82) per $10,000], more Hispanic residents [1.05 (1.02, 1.09) per 5%], and fewer Black residents [0.91 (0.83, 0.98) per 5%]. For the six policies in jurisdictions permitting outlets, two policies were associated with fewer outlets and two with more; two policy associations were uninformative. For these policies, we observed no consistent heterogeneity in associations by median income or racial-ethnic composition.

CONCLUSIONS

Some local cannabis policies in California are associated with lower cannabis outlet densities, but are unlikely to deter disproportionate placement of outlets in racial-ethnic minority and low-income neighborhoods.

Impact of cannabis legalization in the United States on trends in cannabis use and daily cannabis use among individuals who smoke cigarettes

BACKGROUND

Cannabis legalization and increases in cannabis use are occurring rapidly in the United States (US). Cannabis and tobacco are often used together, but it is unclear whether cannabis legalization will differentially affect cannabis use among those using cigarettes. This study estimated changes from 2004 to 2017 in the prevalence of cannabis use and daily cannabis use by cigarette use status and examined whether state-level cannabis policy modified these trends.

METHODS

Public and restricted-use data from the 2004-2017 National Survey on Drug Use and Health were analyzed. Weighted logistic regressions were used to examine time trends in past-30-day cannabis use and daily caunabis use by cigarette use and cannabis law status from 2004 to 2017.

RESULTS

Cannabis use and daily use increased significantly among those with and without cigarette smoking. Cannabis use and daily cannabis use were consistently 2-10x more common throughout this time among those with, versus without, cigarette smoking. In 2017, cannabis use and daily cannabis use were substantially more common among individuals who use cigarettes, and even greater among those who live in states where cannabis was legal for medical or recreational (i.e., non-medical) use.

CONCLUSIONS

Cannabis use and daily cannabis use are increasing among US individuals who both smoke and do not smoke cigarettes. Cannabis and daily cannabis use are more common among those who smoke cigarettes and elevated even further among those residing in states that have legalized cannabis for recreational (i.e., non-medical) use. Tobacco control efforts should be adjusted to address increases in cannabis use among Americans who smoke cigarettes.

Textual and pictorial enhancement of cannabis warning labels: An Online experiment among at-risk U.S. young adults

BACKGROUND

This study experimentally examines whether enhanced cannabis warning labels (CWLs) outperform those currently required in the U.S. in improving recall of health risks, emotional responses, and perceived message effectiveness among at-risk young adults.

METHOD

We conducted an online national survey-based experiment in October 2020. Young adults aged 18-26 years old and at-risk for cannabis use (N = 523) were randomly assigned in an online experiment, to view either currently required CWLs in California with small font and a composite health risk statement, or enhanced single-theme CWLs with varying textual and pictorial components. We performed linear regression analyses to compare the enhanced with existing CWLs on information recall, negative emotions, and perceived message effectiveness. Furthermore, information recall and negative emotions were examined as parallel mediators to better understand the mechanisms underlying effective textual and pictorial enhancement of CWLs.

RESULTS

Compared with currently required CWLs in California, both textually (b = 0.30, p = .011) and pictorially (b = 0.59, p < .001) enhanced CWLs increased recall accuracy. Pictorially enhanced CWLs outperformed their text-only counterparts (b = 0.28, p = .019) in improving information recall. Only pictorially enhanced CWLs improved perceived message effectiveness (b = 0.31, p = .008), which was mediated by negative emotions but not by information recall.

CONCLUSIONS

Given rapid expansion of the cannabis industry and declining perception of harm, currently required CWLs in the U.S. such as California's, would benefit from redesign to improve public understanding of health risks and to prevent youth use.

Concentration of Cannabis and Tobacco Retailers in Los Angeles County, California: A Spatial Analysis of Potential Effects on Youth and Ethnic Minorities

OBJECTIVE

Cannabis and tobacco retailers are believed to cluster in areas with more racial/ethnic minorities, which could account for the disproportionate use of blunts in Black and Hispanic communities. The current study examined the spatial relationship between cannabis and licensed tobacco retailers in Los Angeles County, California, and assessed whether various neighborhood and business factors influenced the spatial patterning.

METHOD

Generalized additive models were used to test the association between the location of cannabis retailers (N = 429) and their accessibility potential (AP) to tobacco retailers (N = 8,033). The covariates included cannabis licensure status, median household income, population density, percentages of racial/ ethnic minorities and young adults (18-34), unemployment status, families living in poverty, minimum completion of high school/General Educational Development (GED) credential, and industrial businesses by census tract.

RESULTS

The location of cannabis retailers was significantly associated with AP in all adjusted models (p < .005). The percentage of racial/ethnic minorities, age (18-34 years), and nonlicensure of cannabis retailers, which were positively correlated with AP (p < .05), confounded the association between AP and cannabis retailer location.

CONCLUSIONS

The concentration of unlicensed cannabis retailers and tobacco retailers in young and racially/ethnically diverse neighborhoods may increase access to and use of cigarillos for blunt smoking. Jurisdictions within Los Angeles County should consider passing ordinances requiring minimum distances between cannabis and tobacco retailers.

Concentration of Cannabis and Tobacco Retailers in Los Angeles County, California: A Spatial Analysis of Potential Effects on Youth and Ethnic Minorities

OBJECTIVE

Cannabis and tobacco retailers are believed to cluster in areas with more racial/ethnic minorities, which could account for the disproportionate use of blunts in Black and Hispanic communities. The current study examined the spatial relationship between cannabis and licensed tobacco retailers in Los Angeles County, California, and assessed whether various neighborhood and business factors influenced the spatial patterning.

METHOD

Generalized additive models were used to test the association between the location of cannabis retailers (N = 429) and their accessibility potential (AP) to tobacco retailers (N = 8,033). The covariates included cannabis licensure status, median household income, population density, percentages of racial/ ethnic minorities and young adults (18-34), unemployment status, families living in poverty, minimum completion of high school/General Educational Development (GED) credential, and industrial businesses by census tract.

RESULTS

The location of cannabis retailers was significantly associated with AP in all adjusted models (p < .005). The percentage of racial/ethnic minorities, age (18-34 years), and nonlicensure of cannabis retailers, which were positively correlated with AP (p < .05), confounded the association between AP and cannabis retailer location.

CONCLUSIONS

The concentration of unlicensed cannabis retailers and tobacco retailers in young and racially/ethnically diverse neighborhoods may increase access to and use of cigarillos for blunt smoking. Jurisdictions within Los Angeles County should consider passing ordinances requiring minimum distances between cannabis and tobacco retailers.

The New Jersey Perspective on Cannabis Legalization

Background:

Between 2010 and 2020, New Jersey went from treating cannabis as an illegal substance in all circumstances to allowing medical use and subsequently recreational use. The Medical Marijuana Program (MMP) was originally very strict and was progressively liberalized. After attempts to legalize recreational use failed in the legislature, voters passed a referendum to amend the New Jersey constitution to allow recreational use. Our objectives are to document this process and provide the perspectives of psychiatrists treating adolescents.

Method:

We describe the legislative process and the multiple pressures for legalization and decriminalization.

Discussion :

Issues germane to youth as a vulnerable population have been inadequately considered by policymakers, the media, and the general population. Greater attention to the process and outcome to mitigate this finding is needed.

Emerging Indoor Air Laws for Onsite Cannabis Consumption Businesses in the U.S

INTRODUCTION

Secondhand cannabis smoke, like secondhand tobacco smoke, creates unhealthy indoor air quality. Ventilation and engineering techniques cannot reduce this pollution to healthy levels, and complete smoke-free policies are the only way to provide healthy indoor environments. Even so, multiple state and local governments have begun to allow indoor smoking of cannabis in businesses.

METHODS

A systematic search of Lexis Advance, NewsBank, and government websites for U.S. state and local laws passed between November 6, 2012 and June 10, 2020 that permit and regulate onsite cannabis consumption businesses was conducted in February-July 2020.

RESULTS

In total, 6 of 11 states and the District of Columbia that legalized adult-use cannabis as of June 10, 2020 allowed onsite consumption and ≥56 localities within these 6 states allowed onsite cannabis consumption. Only 9% (5/56) of localities ban indoor smoking in these businesses; 23% (13/56) require indoor smoking to occur in physically isolated rooms. Other common local legal requirements address onsite odor control, ventilation/filtration, and building location.

CONCLUSIONS

The majority of the localities that allow onsite cannabis consumption do not explicitly prohibit smoking or vaping inside. Policymakers should be made aware that ventilation and other engineering interventions cannot fully protect workers and patrons. Health authorities and local leaders should educate policymakers on the science of secondhand smoke remediation and advocate for the same standards for secondhand cannabis smoking and vaping that apply to tobacco, particularly because other modes of cannabis administration do not pollute the air.

Sociodemographic Characteristics Associated With and Prevalence and Frequency of Cannabis Use Among Adults in the US

IMPORTANCE

Cannabis use has increased, but there are few studies on frequent and daily cannabis use among US adults. Individuals who engage in higher frequency use may suffer more health consequences.

OBJECTIVE

To examine frequency of cannabis use and associated factors among US adults.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included data from 21 US states and 2 US territories reported in the Behavioral Risk Factor Surveillance System surveys from 2016 to 2019. Cross-sectional data on US adults ages 18 years and older were used to estimate demographic, socioeconomic, and behavioral risk factors for cannabis use, taking into account the survey strata and sampling weights for the 4 years of combined data. Using a multivariable ordinal logistic analysis, the association of demographic, socioeconomic status, and behavioral risk factors with past month cannabis frequency were examined.

EXPOSURES

Sociodemographic characteristic, ie, age, gender, race and ethnicity, educational attainment, employment status, and annual household income.

MAIN OUTCOMES AND MEASURES

Ordinal categorization of number of days of cannabis use in the past 30 days in terms of nonuse, infrequent use (1-5 days), frequent use (6-29 days), and daily use.

RESULTS

Among the 387 179 respondents, 58 009 (27.9%) were ages 18 to 34 years, 186 923 (50.3%) were ages 35 to 64 years, and 142 225 (21.8%) were age 65 years or older (mean [SD] age, 48.3 [0.1] years). The sample included 28 345 (9.8%) Black, 36 697 (22.6%) Hispanic, and 292 210 (57.3%) White respondents. Smoking was the most common form of cannabis use. The frequency of cannabis use varied significantly by age, gender, race, marital status, education, and employment. Higher frequency cannabis use was associated with younger age (ages 18-34 years: adjusted odds ratio [aOR],4.12; 95% CI, 3.63-4.68; ages 35-64 years: aOR,2.22; 95% CI, 1.98-2.49), Black (aOR, 1.46; 95% CI, 1.33-1.71) and Native American (aOR, 1.25; 95% CI, 1.04-1.52) race, and less educational attainment (high school or less: aOR,1.09; 95% CI, 1.02-1.17; some college: aOR,1.27; 95% CI, 1.19-1.35). Being married (aOR, 0.54; 95% CI, 0.51-0.58) or identifying as Asian (aOR, 0.60; 95% CI, 0.51-0.71) or Hispanic (aOR, 0.71; 95% CI, 0.65-0.77) was associated with lower-frequency cannabis use after accounting for other baseline factors.

CONCLUSIONS AND RELEVANCE

This nationally based study found that higher-frequency cannabis use is more common among young and racial minority populations, as well as respondents with low socioeconomic status. Given the known and emerging negative health effects of cannabis use, more attention may need to be paid to high-frequency use among underserved populations in the form of screening, risk stratification, and treatment.

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps

BACKGROUND

Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability.

METHODS

Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change).

RESULTS

Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction).

CONCLUSIONS

A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.

County-Level Recreational Marijuana Policies and Local Policy Changes in Colorado and Washington State (2012-2019)

Policy Points In 2012, Colorado and Washington were the first states to legalize recreational marijuana through voter-initiated ballots. In these states, counties could restrict or ban local marijuana facilities through a variety of regulatory methods such as ordinances and zoning. County-level recreational marijuana policies in Washington and Colorado vary substantially, with 69.2% of Washington counties and 23.4% of Colorado counties allowing all types of recreational marijuana facilities as of April 1, 2019. After Colorado and Washington legalized recreational marijuana, many counties modified their marijuana policies over time, with shifts in county policy often preceded by advocacy and information-seeking activities.

CONTEXT

In 2012, Colorado and Washington were the first states to legalize recreational marijuana. Both allowed local governments to further regulate the availability of marijuana facilities in their jurisdictions. As early adopters, these states are important quasi-natural experiments to examine local marijuana policy and policy change processes, including key stakeholders and arguments.

METHODS

We conducted a policy scan of county-level recreational marijuana ordinances and regulations in Colorado and Washington. Data collected included policy documents from counties in both states and newspaper articles. We used a mixed-methods approach to describe the types of county-level recreational marijuana policies enacted by April 1, 2019; identify key policy stakeholders involved in local policy debates; and explore arguments used in support or opposition of county policies. We also selected four counties that represent three county policy environments (all marijuana facility types allowed, some marijuana facility types allowed, all marijuana facility types prohibited) and described the policy changes within these counties since recreational marijuana was legalized.

FINDINGS

By April 1, 2019, Colorado counties were less likely than Washington counties to allow marijuana facilities-48.4% of Colorado counties prohibited recreational marijuana facilities in their jurisdiction compared to 23.1% of Washington counties. Since state legalization, several counties in both states have made substantial marijuana facility policy modifications, often preceded by information-seeking activities. Primary stakeholders involved in policy debates included elected officials, law enforcement, individual growers/farmers, marijuana business license applicants, parents, and residents. Proponents referenced local economic gain, reduced crime, and potential health benefits of marijuana as arguments in favor of permitting local facilities, whereas opponents pointed to economic loss, negative health and public health issues, public safety concerns, and existing federal law. Both sides referenced local public opinion data to support their position.

CONCLUSIONS

By early 2019, a patchwork of local marijuana policies was in place in Colorado and Washington. We identify key areas of policy and public health research needed to inform future local marijuana policy decisions, including the impact of legalization on public health outcomes (particularly for youth) and public safety.

Evaluation of State Cannabis Laws and Rates of Self-harm and Assault

Importance

State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.

Objective

To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.

Design, Setting, and Participants

Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.

Exposures

Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).

Main Outcomes and Measures

Claims for self-harm and assault injuries based on International Classification of Diseases codes.

Results

The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.

Conclusions and Relevance

Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.