The economic geography of medical cannabis dispensaries in California

State licenses for medical marijuana dispensaries: neighborhood-level determinants of applicant quality in Missouri

BACKGROUND

When state governments impose quotas on commercial marijuana licenses, regulatory commissions use an application process to assess the feasibility of prospective businesses. Decisions on license applications are often met with formal appeals and legal challenges from rejected applicants. Although prior research has examined substate disparities in the availability of marijuana dispensaries, less attention has been given to the quality of license applications. The present study analyzed the relationship between neighborhood-level characteristics and the quality of prospective dispensary businesses.

METHODS

During Missouri's first applicant pool for medical marijuana dispensaries in 2019, a total of 606 census tracts contained the location site of at least one dispensary applicant. Using data from the Missouri Department of Health and Senior Services and the American Community Survey, fractional and binary logistic regression models were used to estimate the relationship between census-tract characteristics and application outcomes.

RESULTS

License applications received higher evaluation scores when proposed dispensary sites were in census tracts with greater population densities and no majority in racial/ethnic composition. Census tracts with poorer socioeconomic conditions attracted a disproportionate share of low-scoring applicants from the bottom quartile of scores. These effects were stronger for certain application subsections, particularly those assessing the quality of an applicant's business plan and on-site security.

CONCLUSIONS

Some communities tend to attract prospective license holders who possess better quality resources, business practices, and industry experience. State disparities in commercial licensing requirements and application processes may lead to the inequities in legal product access found in some prior studies.

Distribution of legal retail cannabis stores in Canada by neighbourhood deprivation

OBJECTIVES

In legal cannabis markets, the distribution of retail stores has the potential to influence transitions from illegal to legal sources as well as consumer patterns of use. The current study examined the distribution of legal cannabis stores in Canada according to level of neighbourhood deprivation.

METHODS

Postal code data for all legal cannabis stores in Canada were collected from government websites from October 2018 to September 2021. This data was linked to the Institut National de Santé Publique du Québec measures for material and social neighbourhood deprivation. Descriptive data are reported, including differences across provinces with different retail systems.

RESULTS

At the national level, there were approximately 8.0 retail cannabis stores per 100,000 individuals age 15+ in September 2021. The distribution of stores was closely aligned with the expected distribution across levels of material deprivation: for example, 19.5% of stores were located in neighbourhoods with the lowest level of material deprivation versus 19.1% in the highest level. More cannabis stores were located in the 'most socially deprived' or 'socially deprived' neighbourhoods (37.2% and 22.1%, respectively), characterized by a higher proportion of residents who live alone, are unmarried, or in single-parent families. The distribution of stores in provinces and territories were generally consistent with national patterns with a few exceptions.

CONCLUSION

In the first 3 years following cannabis legalization in Canada, retail cannabis stores were evenly distributed across materially deprived neighbourhoods but were more common in socially deprived neighbourhoods. Future monitoring of retail store locations is required as the legal retail market evolves in Canada.

Comparison of perceptions in Canada and USA regarding cannabis and edibles

BACKGROUND

Canada took a national approach to recreational cannabis that resulted in official legalization on October 17, 2018. In the United States (US), the approach has been more piecemeal, with individual states passing their own laws regulating adult use. The objective of this study was to compare the two jurisdictions.

METHODS

Two exploratory, quantitative surveys were administered in May of 2021 in both Canada and the US. One thousand forty-seven Canadian and 1037 US residents (age 19 and older) were surveyed on approaches to and attendant regulations of consumer cannabis. Tests of significance were performed to analyze differences between two groups.

RESULTS

No statistically significant differences exist between the two countries in terms of cannabis legalization acceptance. Usage rates among adults was similar with 45% of Canadians and 42% of Americans confirming they consume cannabis. Respondents maintain that they intend to increase their usage, with edibles attracting a rising level of interest from consumers.

CONCLUSIONS

Results suggest that public policy in both Canada and the USA needs to change to reflect rapidly evolving acceptance of cannabis products in North America to realize potential economic returns.

Dispensaries and Medical Marijuana Certifications and Indications: Unveiling the Geographic Connections in Pennsylvania, USA

Introduction

Pennsylvania opened its first medical marijuana (MMJ) dispensary in 2018. Qualifying conditions include six conditions determined to have no or insufficient evidence to support or refute MMJ effectiveness. We conducted a study to describe MMJ dispensary access in Pennsylvania and to determine whether dispensary proximity was associated with MMJ certifications and community demographics.

Methods

Using data from the Pennsylvania Department of Health, we geocoded MMJ dispensary locations and linked them to US Census Bureau data. We created dispensary access measures from the population-weighted centroid of Zip Code Tabulation Areas (ZCTAs): distance to nearest dispensary and density of dispensaries within a 15-min drive. We evaluated associations between dispensary access and the proportion of adults who received MMJ certification and the proportion of certifications for low evidence conditions (amyotrophic lateral sclerosis, epilepsy, glaucoma, Huntington's disease, opioid use disorder, and Parkinson's disease) using negative binomial modeling, adjusting for community features. To evaluate associations racial and ethnic composition of communities and distance to nearest dispensary, we used logistic regression to estimate the odds ratios (OR) and 95% confidence intervals (CI), adjusting for median income.

Results

Distance and density of MMJ dispensaries were associated with the proportion of the ZCTA population certified and the proportion of certifications for insufficient evidence conditions. Compared to ZCTAs with no dispensary within 15 min, the proportion of adults certified increased by up to 31% and the proportion of certifications for insufficient evidence decreased by up to 22% for ZCTAs with two dispensaries. From 2018 to 2021, the odds of being within five miles of a dispensary was up to 20 times higher in ZCTAs with the highest proportions of individuals who were not White (2019: OR: 20.14, CI: 10.7-37.8) and more than double in ZCTAs with the highest proportion of Hispanic individuals (2018: OR: 2.81, CI: 1.51-5.24), compared to ZCTAs with the lowest proportions.

Conclusions

Greater dispensary access was associated with the proportions of certified residents and certifications for low evidence conditions. Whether these patterns are due to differences in accessibility or demand is unknown. Associations between community demographics and dispensary proximity may indicate MMJ access differences.

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

Recreational marijuana legalization and marijuana and alcohol co-use among adolescents: Differential associations among racial and ethnic groups

We examined associations of the 2016 legalization of recreational marijuana (RML) in California with marijuana and alcohol co-use among race/ethnic groups using successive cross-sections from 7th, 9th, and 11th graders (N = 3,319,329) in the 2010-11 to 2018-19 California Healthy Kids Surveys. Multilevel logistic regressions indicated a stronger positive association between RML and co-use among non-Hispanic/Latine White youth (OR = 1.21) relative to Hispanic/Latine (OR = 1.02) or Black youth (OR = 0.85). Among drinkers who had not consumed five or more drinks on any occasion in the past 30-days (non-heavy drinkers), the positive association between RML and co-use was stronger among American Indian/Alaska Native youth (OR = 2.19) compared to non-Hispanic/Latine Whites (OR = 1.56). For heavier drinkers it was stronger for Native Hawaiian/Pacific Islanders (OR = 1.47). Among marijuana users, there was a stronger inverse association between RML and co-use among Black youth (OR = 0.72) compared to non-Hispanic/Latine White youth (OR = 0.84). RML may increase the risk of co-use to a greater extent among non-Hispanic/Latine White youth than other race/ethnic groups in California, but broadly increases the risk among youth who engage in alcohol use or heavy drinking.

Higher Concentration of Marijuana Dispensaries in Neighborhoods with More Disadvantage Following Legalization in Washington

Washington is one of 21 states that have legalized recreational marijuana resulting in neighborhoods that have experienced a change in physical environment with the emergence of dispensaries. This study examines the selection of dispensaries into disadvantage area, incorporating local policies and neighborhood characteristics. Marijuana and alcohol sales data were from the Washington State Liquor and Cannabis Board; and neighborhood characteristics were drawn from the American Community Survey 2010-2016 5-year estimates. Using factor analysis we created a neighborhood disadvantage index where census tracts were stratified into disadvantaged tertiles; and counties were stratified by urban/rural status. We examined the association between dispensaries, neighborhood characteristics, and local marijuana policies using Negative Binomial Regression with a natural log of land area as an offset, separately for 2014-2016. Dispensaries opened in high-disadvantaged CTs in 2014 and then dispersed across the state while retaining higher concentrations in disadvantaged urban CTs. Marijuana-specific policies (allotted dispensaries and retail cap) were found to be predictors of marijuana dispensary density. This study provides evidence that marijuana dispensaries were disproportionately located in areas with greater disadvantage. State and local marijuana policies emerged as important predictors, underscoring the importance of designing thoughtful and equitable license allocation procedures and policies.

Cannabis retailer marketing strategies and regulatory compliance: A surveillance study of retailers in 5 US cities

As cannabis retail expands in the US, its surveillance is crucial to inform regulations and protect consumers. This study addresses this need by conducting point-of-sale audits examining regulatory compliance (e.g., age verification, signage), advertising/promotional strategies, products, and pricing among 150 randomly-selected cannabis retailers in 5 US cities (30/city: Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California) in Summer 2022. Descriptive and bivariate analyses characterized the retailers overall and across cities. Age verification rates were high (>90%). The majority of retailers had signage indicating restricted access (e.g., no minors; 87.3%), onsite consumption (73.3%), and distribution to minors (53.3%). Retailers were likely to post warnings regarding use during pregnancy/breastfeeding (72.0%), followed by health risks (38.0%), impacts on children/youth (18.7%), and DUI (14.0%). Overall, 28.7% posted health claims, 20.7% posted youth-oriented signage, and 18.0% had youth-oriented packaging. Price promotions were prevalent, particularly price specials (75.3%), daily/weekly/monthly specials (66.7%), and membership programs (39.3%). One-fourth had signs/promotions indicating curbside delivery/pick-up (28.0%) and/or online ordering (25.3%); 64.7% promoted their website or social media page. The most potent cannabis products were most often e-liquids (38.0%) or oils (24.7%); the least potent were often edibles (53.0%). The most expensive product was often bud/flower (58.0%); the least was joints (54.0%). The vast majority (≥81%) sold vaporizers, wrapping papers, and hookah/waterpipes/bongs, and 22.6% sold CBD products. Marketing strategies differed across cities, reflecting differences in state-specific regulations and/or gaps in compliance/enforcement. Findings underscore the need for ongoing cannabis retail surveillance to inform future regulatory and enforcement efforts.

Accuracy Differences in Cannabis Retailer Information Ascertained from Webservices and Government-Maintained State Registries Across US States Legalizing the Sale of Cannabis in 2019

Cannabis retailer locations used to investigate geographic cannabis access are frequently ascertained from two sources: 1) webservices which provide locations of cannabis retailers (e.g., Yelp) or 2) government-maintained registries. Characterizing the operating status and location information accuracy of cannabis retailer data sources on a state-by-state level can inform research examining the health implications of cannabis legalization policies. This study ascertained cannabis retailer name and location from webservices and government-maintained registries for 26 states and the District of Columbia legalizing cannabis sales in 2019. Validation subsamples were created using state-level sequential sampling. Phone surveys were conducted by trained researchers for webservice samples (n=790, November 2019 - May 2020) and government-maintained registry (n=859, February - June 2020) to ascertain information about operating status and location. Accuracy was calculated as the percent agreement among subsample and phone survey data. For operating status and location, webservice derived data was 78% (614/790) and 79% (484/611) accurate, whereas government-maintained registry derived data was 76% (657/859) and 95% (622/655) accurate, respectively. Fifty-nine percent (15/27) of states and the District of Columbia had over 80% accuracy for operating status and 48% (13/27) states had over 80% accuracy for location information with both data sources. However, government-maintained registry derived information was more accurate in 33% (9/27) states for operating status and 41% (11/27) states for location information. Both data sources had similar operating status accuracy. Research using spatial analysis may prefer government-maintained registry derived data due to high location information accuracy, whereas studies looking at broad trends across states may prefer webservice derived. State level COVID-19 restrictions had minimal impact on ascertainment of cannabis retailer operating status and location information via phone survey derived from webservices and government-maintained registries.

Population and Neighborhood Correlates of Cannabis Dispensary Locations in Oklahoma

Background

Cannabis dispensaries have proliferated exponentially in Oklahoma since the state legalized medical cannabis in 2018. Oklahoma is unique from many other legalized states given its high number of lower income, rural, and uninsured residents, who may seek medical cannabis as an alternative to traditional medical treatment.

Methods

This study examined demographic and neighborhood characteristics associated with dispensary density (n = 1,046 census tracts) in Oklahoma.

Results

Compared to census tracts with no dispensaries, those with at least one dispensary had a higher proportion of uninsured individuals living below the poverty level and a greater number of hospitals and pharmacies. Almost half (42.35%) of census tracts with at least one dispensary were classified as a rural locale. In fully adjusted models, percent uninsured, percent of household rentals, and the number of schools and pharmacies were positively associated with greater number of cannabis dispensaries, while the number of hospitals was negatively associated. In the best fitting interaction models, dispensaries were predominant in areas with a higher percentage of uninsured residents and no pharmacies, suggesting that cannabis retailers may capitalize on the health needs of communities with limited healthcare outlets or access to medical treatment.

Conclusions

Policies and regulatory actions that seek to decrease disparities in dispensary locations should be considered. Future studies should examine whether people living in communities with a scarcity of health resources are more likely to associate cannabis with medical uses than those living in communities with more resources.

Neighborhood market potentials for alcohol use and rates of child abuse and neglect

BACKGROUND

Alcohol use can lead to child abuse and neglect even if the person using alcohol does not use heavily. Yet relatively few measures that reflect alcohol use are available at smaller geographic units. We assess whether the estimated level of total alcohol use per capita is related to measures of child abuse and neglect that include substantiated reports of maltreatment, total entries into foster care, and alcohol-related entries into foster care.

METHODS

Our sample consists of 326 Census block groups in Sacramento, California over three time points (978 space-time units). Administrative data for substantiations of child abuse and neglect and foster care entries are our outcomes. We create market potentials for alcohol use among 18- to 29-year-olds as our primary independent variable. Data are analyzed using Bayesian conditionally autoregressive spatio-temporal models.

RESULTS

Higher alcohol use potentials (as measured by total volume per capita of 18- to 29-year olds) are related to more children entering foster care due to drinking-related concerns by a parent or caregiver (RR = 1.032, 95% CI = [1.013, 1.051]), but not total substantiations for foster care entries. Neighborhoods with higher total volume of alcohol per 18- to 29-year-olds had more foster care entries when we used number of substantiations as the denominator (RR = 1.012, 95% CI = [1.0001, 1.023]) but were not related to foster care entries with alcohol misuse as a concern as a subset of all foster care entries.

CONCLUSIONS

Higher estimated volume of alcohol use per capita among young adults (aged 18 to 29) was related to more children entering foster care due to alcohol-related concerns. Reducing alcohol supply in alcohol outlets, specifically through off-premise establishments, might reduce rates for all entries into foster care or other out-of-home placement and substantiated child abuse and neglect.

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).

Spatial and temporal pattern of cannabis use disorder in California 2010-2019

As cannabis use is being legalized in an increasing number of states, it is important to understand the changing dynamic of the risk in cannabis use disorder (CUD). Shape-based time-series clustering was used to identify ZIP Code Tabulation Areas (ZCTAs) with similar changing pattern in CUD over time. We conducted a cross-sectional logistic regression analysis to investigate the most recent ZCTA socio-demographic characteristics in relation to the changing CUD rates. The emergency discharge rates generally increased during 2010-2016. Increase during 2017-2019 was found in Sacramento and Santa Barbara County. Approximately 13% of ZCTAs showed an increasing trend of hospitalization discharge during 2017-2019. Males and non-Hispanic Black had larger increase than other groups during 2017-2019. The recent growing trend was found associated with greater racial diversity and rural ZCTAs. The findings from this study hold promise for local public health officials to adjust the cannabis intervention strategies in target districts and improve overall health outcomes.

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.

Availability of medical cannabis services by racial, social, and geographic characteristics of neighborhoods in New York: a cross-sectional study

Background

Within the United States (US), because racial/ethnic disparities in cannabis arrests continue, and cannabis legalization is expanding, understanding disparities in availability of legal cannabis services is important. Few studies report mixed findings regarding disparities in availability of legal cannabis services; none examined New York. We examined disparities in availability of medical cannabis services in New York. We hypothesized that New York census tracts with few Black or Hispanic residents, high incomes, high education levels, and greater urbanicity would have more medical cannabis services.

Methods

In this cross-sectional study, we used data from the 2018 US Census Bureau 5-year American Community Survey and New York Medical Marijuana Program. Main exposures were census tract characteristics, including urban–rural classification, percentage of Black and Hispanic residents, percentage of residents with bachelor’s degrees or higher, and median household income. Main outcomes were presence of at least one medical cannabis certifying provider and dispensary in each census tract. To compare census tracts’ characteristics with (vs. without) certifying providers and dispensaries, we used chi-square tests and t-tests. To examine characteristics independently associated with (vs. without) certifying providers, we used multivariable logistic regression.

Results

Of 4858 New York census tracts, 1073 (22.1%) had medical cannabis certifying providers and 37 (0.8%) had dispensaries. Compared to urban census tracts, suburban census tracts were 62% less likely to have at least one certifying provider (aOR = 0.38; 95% CI = 0.25–0.57). For every 10% increase in the proportion of Black residents, a census tract was 5% less likely to have at least one certifying provider (aOR = 0.95; 95% CI = 0.92–0.99). For every 10% increase in the proportion of residents with bachelor’s degrees or higher, a census tract was 30% more likely to have at least one certifying provider (aOR = 1.30; 95% CI = 1.21–1.38). Census tracts with (vs. without) dispensaries were more likely to have a higher percentage of residents with bachelor’s degrees or higher (43.7% vs. 34.1%, p < 0.005).

Conclusions

In New York, medical cannabis services are least available in neighborhoods with Black residents and most available in urban neighborhoods with highly educated residents. Benefits of legal cannabis must be shared by communities disproportionately harmed by illegal cannabis.

Associations of cannabis product source and subsequent cannabis use among adolescents

BACKGROUND

Cannabis is obtained from a variety retail and illicit sources, with unknown implications for youth cannabis use. This study assessed whether source of obtaining cannabis was associated with future cannabis use among adolescents.

METHODS

High-schoolers (N = 835) completed 3 semiannual surveys, reporting use of 7 cannabis sources (i.e., free, bought from someone, from an online dispensary, with a [valid/invalid] medical card, self-grown, or other; separate dichotomous exposure variables) at wave 1 (n = 621; M[SD] age=17.14[.40]) or wave 2 (n = 622; M[SD] age=17.51[.39]). Past-6-month (yes/no) and number of past-30-day (0-30) non-medical use of any cannabis product, combustible, edible, and vaporized cannabis, blunts, and concentrates (i.e., dabs) were reported at waves 2-3. Random-effect time-lagged repeated-measures regression was used to test longitudinal associations of youth's cannabis source (waves 1-2; time-varying exposure) with cannabis use outcomes 6 months later (waves 2-3).

RESULTS

Most youth (72.1%) received cannabis for free; 50.9% bought cannabis from someone, 15.9% used a valid medical card at a brick-and-mortar dispensary, and 3.9% grew cannabis. Buying cannabis from someone (OR=1.46, 95% CI: 1.07-1.99, p = .02) or using a valid medical card (OR=1.99, 95% CI: 1.20-3.31, p = .008) conferred greater odds of any cannabis product use 6 months later. Buying from someone predicted subsequent past-30-day use frequency (RR=1.25, 95% CI:1.05-1.48, p = .01). Some associations between particular cannabis sources and products were observed.

CONCLUSIONS

Adolescents may access cannabis from several sources. Those who purchase cannabis illicitly from someone or from a brick-and-mortar dispensary using a valid medical card may be at increased risk for more persistent and frequent patterns of non-medical cannabis use.

Municipal regulation of cannabis and public health in Canada: A comparison of Alberta, Ontario, and Québec

Canada legalized nonmedical cannabis in October 2018, but significant variations in municipal regulations exist. This study explored the variations that exist and pondered their potential public health consequences. A comparative analysis was completed on the regulations and guidelines that addressed retailers' location and public consumption in the municipalities of Alberta, Ontario, and Québec. Municipal regulations that addressed the location of retailers were more numerous and extensive in Alberta and Ontario (in the context of provincial private retail models) than in Québec (government-based model). Municipalities in Alberta added more restrictions to public consumption laws as compared to municipalities in Ontario and in Québec. These additions were made to Alberta's and Ontario's provincial-level smoking and vaping bans which used tobacco-inspired frameworks, and to Québec's ban on smoking and vaping in all public spaces. The comparative analysis showed the importance of considering municipal cannabis regulations when studying the impact of legalization, given the significant variations that exist. Policy makers should be made aware of these variations in the regulation of cannabis in order to limit health harms and further social inequalities.

Clouding up cognition?: Secondhand cannabis and tobacco exposure related to cognitive functioning in youth

Background

Increasing legalization of cannabis, in addition to longstanding rates of tobacco use, raises concerns for possible cognitive decrements from secondhand smoke or environmental exposure, although little research exists. We investigate the relation between cognition and secondhand and environmental cannabis and tobacco exposure in youth.

Methods

The Adolescent Brain Cognitive Development (ABCD) Study year 2 follow-up (N = 5580; 48% female) cognitive performance and secondhand or environmental cannabis or tobacco exposure data were used. Principal components analysis identified a global cognition factor. Linear mixed-effects models assessed global cognition and individual cognitive task performance by cannabis and/or tobacco environmental exposure. Sociodemographics and other potential confounds were examined. p values were adjusted using the false discovery rate method.

Results

Global cognition was not related to any exposure group after testing corrections and considering confounds. Beyond covariates and family- and site-level factors, secondhand tobacco was related to poorer visual memory (p = .02), and environmental tobacco was associated with poorer visuospatial (p = .02) and language (p = .008) skills. Secondhand cannabis was related to cognition, but not after controlling for potential confounders (p > .05). Environmental cannabis was related to better oral reading (p = .01). Including covariates attenuated effect sizes.

Conclusions

Secondhand tobacco exposure was associated with poorer visual memory, while environmental tobacco exposure was related to poorer language and visuospatial skills. Secondhand cannabis was not related to cognition after controlling for sociodemographic factors, but environmental cannabis exposure was related to better reading. Because, to our knowledge, this is the first known study of its kind and thus preliminary, secondhand cannabis should continue to be investigated to confirm results.

Recreational Marijuana Legalization and Co-use With Alcohol Among Adolescents

INTRODUCTION

Little is known about the possible impacts of recreational marijuana legalization on alcohol and marijuana co-use among underage youth. This study examines the association between recreational marijuana legalization in California in 2016 and alcohol and marijuana co-use among adolescents. Additional analyses investigate the associations between recreational marijuana legalization and co-use among past 30-day drinkers and marijuana users and the frequency of alcohol and marijuana use among co-users.

METHODS

This study used annual cross-sectional data from 7th, 9th, and 11th graders (N=3,319,329) who participated in the California Healthy Kids Survey from 2010-2011 to 2018-2019. Measures included past 30-day alcohol and marijuana use and student demographic characteristics, survey year, pre-post recreational marijuana legalization, and urbanicity. Multilevel regression analyses were conducted in 2021.

RESULTS

Recreational marijuana legalization was associated with greater odds of past 30-day alcohol and marijuana co-use in the total sample (OR=1.06, 95% CI=1.05, 1.07). Recreational marijuana legalization was more strongly associated with co-use among adolescents who reported past 30-day alcohol use (OR=1.58, 95% CI=1.52, 1.62) and heavy drinking (OR=1.25, 95% CI=1.21, 1.29) but was inversely related to co-use among past 30-day marijuana users (OR=0.76, 95% CI=0.74, 0.78). Among past 30-day co-users, there was a positive association with the frequency of marijuana use (β=0.36, SE=0.07).

CONCLUSIONS

Recreational marijuana legalization may increase the risk of alcohol and marijuana co-use among adolescents. Greater restrictions on the numbers of alcohol and marijuana retail outlets and hours of operation and advertising and higher taxes on alcohol and marijuana products may help reduce the availability of these substances to adolescents.

Cannabis Policy in the United States: Implications for Public Health

INTRODUCTION

As of January 2021, a total of 36 states and the District of Columbia (DC) have legalized medical cannabis use, and 14 states and DC have legalized adult nonmedical use. This manuscript qualitatively summarizes cannabis policies across states with legal adult use marketplaces.

METHODS

Data are from state laws and regulations, collected through January 2021, and have been verified with state officials as part of ongoing state policy tracking efforts.

RESULTS

State policies differ in how cannabis products are taxed, where revenues are allocated, restrictions on the types of available products, restrictions on additives and flavors, product packaging and labeling, advertising restrictions, where cannabis can be consumed, and approaches to social equity.

CONCLUSION

Timely, accurate, and longitudinal state and local cannabis policy data are needed to understand the implications of legalization. Careful study of policy differences across and within states is warranted, as differences may affect public health and consumer safety.

GEOGRAPHICAL ACCESS TO RECREATIONAL MARIJUANA

We investigate whether adult marijuana use in Washington responds to increased local access as measured by drive time to the nearest legal marijuana retailer as well as measures of retail density. Using survey data from the Behavioral Risk Factor Surveillance System, we find that as retailers open closer to where they live, more individuals use marijuana and more frequently. These effects are concentrated among young adults (ages 18-26), women, and rural residents. Controlling for distance to the nearest retailer, we find that whether retail density affects marijuana use depends on how it is measured.

How has access to legal cannabis changed over time? An analysis of the cannabis retail market in Canada 2 years following the legalisation of recreational cannabis

INTRODUCTION

This study describes the legal recreational cannabis market across Canada over the 2 years following legalisation. We compared changes in access to the legal cannabis retail market for all provinces and territories (jurisdictions) in Canada and explored differences between jurisdictions.

METHODS

We collected data for all legal cannabis stores in Canada over five time periods following legalisation in October 2018. We examined the following measures by jurisdiction and retail model (public vs. private operation): absolute and per capita store numbers, hours of operation and store access across neighbourhoods.

RESULTS

Two years following legalisation, there were a total of 1183 legal cannabis stores open across Canada (3.7 stores per 100 000 individuals aged 15+). There was wide variation between jurisdictions in access to retail stores, with the lowest stores per capita in Quebec and Ontario (0.6 and 1.6 per 100 000), and the highest in Alberta and Yukon (14.3 per 100 000 in both). Jurisdictions with private retail models had more stores (4.8 vs. 1.0 per 100 000), held greater median weekly hours (80 vs. 69) and experienced greater store growth over time compared to public models. After adjusting for confounders, there were 1.96 times (95% confidence intervals: 1.84, 2.09) more cannabis stores within 1000 m of the lowest- compared to the highest-income quintile neighbourhoods.

DISCUSSION AND CONCLUSIONS

While access to the recreational cannabis retail market has increased following legalisation, there is substantial variation in access between jurisdictions and evidence of concentration in lower-income neighbourhoods. These differences may contribute to disparities in cannabis use and harms.

Density of medical and recreational cannabis outlets: racial/ethnic differences in the associations with young adult intentions to use cannabis, e-cigarettes, and cannabis mixed with tobacco/nicotine

BACKGROUND

Differences in access to medical versus recreational cannabis outlets and their associations with intentions to use cannabis have not yet been examined among young adults. This study compares the associations between densities of medical versus recreational cannabis outlets and young adults' intentions to use cannabis, electronic cigarettes, and cannabis mixed with tobacco/nicotine products. Racial/ethnic differences in these associations were examined.

METHODS

Young adults ages 18-23 (mean age = 20.9) in Los Angeles County were surveyed online in 2018 after the legalization of recreational cannabis (n = 604). Multiple linear regressions were estimated for the entire sample and stratified by race/ethnicity. Outcomes were intentions to use cannabis, electronic cigarettes, and cannabis mixed with tobacco/nicotine in the next 6 months. Density was measured as the number of medical cannabis dispensaries (MCDs), recreational cannabis retailers (RCRs), and outlets of any type within 5 miles of respondents' homes.

RESULTS

Living near more outlets of any type was not significantly associated with intentions to use in the full sample, adjusting for individual- and neighborhood-level characteristics. However, race/ethnicity-stratified models indicated that living near more outlets of any type and more RCRs were significantly associated with stronger co-use intentions among white young adults. Higher MCD density was marginally associated with stronger co-use intentions among Asian young adults. However, higher MCD density was significantly associated with lower intentions to use e-cigarettes among Hispanic young adults.

CONCLUSIONS

The results suggest racial/ethnic differences in the impact of living near cannabis outlets on intentions to use. Prevention efforts targeting young adults who live near more cannabis outlets may be especially beneficial for white and Asian young adults.

Availability of medical cannabis dispensaries and cannabis abuse/dependence-related hospitalizations in California

AIMS

To estimate associations between both current- and prior-year medical cannabis dispensary densities and hospitalizations for cannabis use disorder in California, USA between 2013 and 2016.

DESIGN

Spatial analysis of ZIP code-level hospitalization discharge data using Bayesian Poisson hierarchical space-time models over 4 years.

SETTING AND CASES

California, USA from 2013 to 2016 (6832 space-time ZIP code units).

MEASUREMENTS

We assessed associations of annual hospitalizations for cannabis use disorder [assignment of a primary or secondary code for cannabis abuse and/or dependence using ICD-9-CM or ICD-10-CM (outcome)] with the total number of medical cannabis dispensaries per square mile in a ZIP code as well as dispensary temporal and spatial lags (primary exposures). Other exposure covariates included alcohol outlet densities, manual labor and retail sales densities and ZIP code-level economic and demographic conditions.

FINDINGS

One additional dispensary per square mile was associated with a median risk ratio of 1.021 (95% credible interval 1.001, 1.041). Prior-year dispensary density did not appear to be associated with hospitalizations (median risk ratio = 1.006, 95% CrI = 0.986, 1.026). Higher median household income, higher unemployment, greater off-premises alcohol outlet density and lower on-premises alcohol outlet density and poverty were all associated with decreased ZIP code-level risk of cannabis abuse/dependence hospitalizations.

CONCLUSIONS

In California, USA, the increasing density of medical cannabis dispensaries appears to be positively associated with same-year but not next-year hospitalizations for cannabis use disorder.

Neighborhood Structural Factors and Proximal Risk for Youth Substance Use

This study examined associations of neighborhood structural factors (census-based measures, socioeconomic disadvantage, and residential stability); self-reported measures of general and substance use-specific risk factors across neighborhood, school, peer, and family domains; and sociodemographic factors with substance use among 9th grade students. Data drawn from the Seattle Social Development Project, a theory-driven longitudinal study originating in Seattle, WA, were used to estimate associations between risk factors and past month cigarette smoking, binge drinking, marijuana use, and polysubstance use among students (N = 766). Results of logistic regression models adjusting for neighborhood clustering and including all domains of risk factors simultaneously indicated that neighborhood socioeconomic disadvantage was associated with a significantly higher likelihood of cigarette smoking, binge drinking, and polysubstance use, but not marijuana use. In fully controlled models, substance use-specific risk factors across neighborhood, school, peer, and family domains were also associated with increased likelihood of substance use and results differed by the outcome considered. Results highlight substance-specific risk factors as an intervention target for reducing youth substance use and suggest that further research is needed examining mechanisms linking neighborhood socioeconomic disadvantage and youth substance use.

Recreational Marijuana Legalization and Use Among California Adolescents: Findings From a Statewide Survey

OBJECTIVE

The legalization of recreational marijuana use and retail sales raises concerns about possible effects on marijuana use among adolescents. We evaluated the effects of recreational marijuana legalization (RML) in California in November 2016 on use among adolescents and investigated subgroup differences in these effects.

METHOD

We analyzed data from successive cross-sectional samples of 7th, 9th, and 11th grade students (N = 3,330,912) who participated in the California Healthy Kids Survey from 2010-2011 to 2018-2019. Participants reported grade, sex, ethnicity, race, and lifetime and past-30-day marijuana use.

RESULTS

Multilevel analyses showed that RML was associated with increases in the likelihood of lifetime (odds ratio = 1.18, 95% CI [1.15, 1.21], p < .01) and past-30-day marijuana use (odds ratio = 1.23, 95% CI [1.20, 1.26], p < .01) relative to previous downward trends. RML was more strongly associated with increases in prevalence of marijuana use among 7th versus 9th and 11th graders, females versus males, non-Hispanic versus Hispanic youth, and White versus African American, American Indian/Native Alaskan, and multiracial youth. Overall, RML was not significantly associated with frequency of past-30-day use among users, although stronger positive associations between RML and frequency of use were found for 11th graders, Asian Americans, and African Americans. The association was weaker for females.

CONCLUSIONS

RML in California was associated with an increase in adolescent marijuana use in 2017-2018 and 2018-2019. Demographic subgroup differences in these associations were observed. Evidence-based prevention programs and greater local control on retail marijuana sales may help to reduce marijuana availability and use among adolescents.

Geolocation of Maryland Medical Marijuana Dispensaries by Community Income and Racial Characteristics: An Ecological Design

Background: Prior investigations have documented disparities in the supply side of Maryland's Medical Marijuana program. Initially a disproportionate share of licenses to cultivate and distribute medical marijuana were awarded to Non-Hispanic White owned businesses. The state has implemented measures to ameliorate the inequity by prioritizing license awards to qualified minority owned businesses. Objectives: The objective of this study is to examine the racial and income characteristics of communities where licensed dispensaries are located. We quantify the racial and income characteristics of communities where Maryland medical cannabis dispensaries are located and explore whether Maryland medical marijuana dispensaries disproportionately locate in high-income, majority-White zip codes. Method: Using data from the Maryland Medical Cannabis Commission and the American Communities Survey, we create geocodes for each of the operating dispensaries as of December 2019. We examine the distribution of medical cannabis dispensaries by zip code level household income and zip code level racial distribution. The data set encompasses 85 operating cannabis dispensaries in Maryland and 6.1 million Marylanders distributed across 468 zip codes in 2018-2019. Results: The analysis indicates that dispensaries are concentrated in zip codes whose residents are racially diverse, and with higher concentrations of retail establishments. Conclusion: Community level racial or income disparities in access to medical cannabis were not observed in Maryland. Access to medical cannabis, based on ability to pay out of pocket for the product, may be uneven.

Lessons learned in several states eight years after states legalized marijuana

There are over 20 000 peer-reviewed research articles linking marijuana use to severe mental health outcomes, ranging from depression to psychosis, and inhibited cognitive development, as well as consequences for physical health, and even negative outcomes for neonates exposed in utero. The connections between marijuana use and consequences to mental and physical health, and brain development, among other risks are often lost in conversations on legalization. Marijuana-legal states have higher rates of marijuana-related driving fatalities, greater emergency room visits, hospitalizations, and exposures, expansive criminal markets, as well as exacerbated racial disparities in industry participation and criminal justice enforcement. We compiled eight years' worth of publicly available state-level data, reports, investigatory findings, peer-reviewed studies, and government health surveys to assemble this 'lessons learned' report to bring these harms to light.

Locations of licensed and unlicensed cannabis retailers in California: A threat to health equity?

This study examined whether unlicensed and licensed cannabis retailers in California are disproportionately located in neighborhoods with minority populations or populations living below the Federal Poverty Level. We mapped the locations of licensed and unlicensed cannabis retailers in California in October 2018, combining advertisements from cannabis websites with licensing data. Demographic characteristics of neighborhoods with and without licensed and/or unlicensed cannabis retailers were compared. We identified 1110 cannabis retailers in California (448 licensed and 662 unlicensed). Relative to neighborhoods without retailers, neighborhoods with retailers had higher proportions of Hispanics, African Americans, and residents living below the poverty level. Compared with neighborhoods with only licensed retailers, neighborhoods with only unlicensed retailers had higher proportions of Hispanics and African Americans, and lower proportions of non-Hispanic whites. Neighborhoods with both licensed and unlicensed retailers had higher proportions of African Americans, Asian Americans, and people living in poverty, relative to neighborhoods with only licensed retailers. Unlicensed retailers were disproportionately located in unincorporated areas and jurisdictions that allow cannabis retailers. Minority populations in California are disproportionately exposed to unlicensed cannabis retailers, potentially exacerbating health disparities by selling unregulated products or selling to minors.

The Spillover Effect of Recreational Marijuana Legalization on Crime: Evidence From Neighboring States of Colorado and Washington State

An ongoing debate exists about the implications of recreational marijuana legalization to public safety. One important public concern is how recreational marijuana legalization may affect crime in neighboring states that have not legalized. Based on Uniform Crime Report (UCR) data from 2003 to 2017, this study used difference-in-differences (DID) analysis to examine the potential spillover effect of recreational marijuana legalization in Colorado and Washington State, with a special focus on the examination of the changes in the rates of a variety of crimes in the border counties of neighboring states relative to the nonborder counties in these states following Colorado’s and Washington’s legalization. Results provide some evidence suggesting a spillover crime reduction effect of legalization, as reflected by the significant decreases in the rates of property crime, larceny, and simple assault in the Colorado region that includes six neighboring states. Results also suggest that the effects of marijuana legalization on crime in neighboring states vary based on crime type and state.

Locating Medical and Recreational Cannabis Outlets for Research Purposes: Online Methods and Observational Study

Background

An increasing number of states have laws for the legal sale of recreational and medical cannabis out of brick-and-mortar storefront locations. Given the proliferation of cannabis outlets and their potential for impact on local economies, neighborhood structures, and individual patterns of cannabis use, it is essential to create practical and thorough methods to capture the location of such outlets for research purposes. However, methods used by researchers vary greatly between studies and often do not include important information about the retailer’s license status and storefront signage.

Objective

The aim of this study was to find methods for locating and observing cannabis outlets in Los Angeles County after the period when recreational cannabis retailers were granted licenses and allowed to be open for business.

Methods

The procedures included searches of online cannabis outlet databases, followed by methods to verify each outlet’s name, address, license information, and open status. These procedures, conducted solely online, resulted in a database of 531 outlets. To further verify each outlet’s information and collect signage data, we conducted direct observations of the 531 identified outlets.

Results

We found that 80.9% (430/531) of these outlets were open for business, of which 37.6% (162/430) were licensed to sell cannabis. Unlicensed outlets were less likely to have signage indicating the store sold cannabis, such as a green cross, which was the most prevalent form of observed signage. Co-use of cannabis and tobacco/nicotine has been found to be a substantial health concern, and we observed that 40.6% (175/430) of cannabis outlets had a tobacco/nicotine outlet within sight of the cannabis outlet. Most (350/430, 81.4%) cannabis outlets were located within the City of Los Angeles, and these outlets were more likely to be licensed than outlets outside the city.

Conclusions

The findings of this study suggest that online searches and observational methods are both necessary to best capture accurate and detailed information about cannabis outlets. The methods described here can be applied to other metropolitan areas to more accurately capture the availability of cannabis in an area.

The Associations of Neighborhood Availability of Marijuana Dispensaries and DATA-2000 Waivered Providers with Hospital Stays Related to Opioids

Background: Evidence is emerging on how state-wide marijuana legalization and increased supply of DATA-2000 waivered providers may be associated with outcomes related to opioids. It is unknown whether such associations remain at the neighborhood level. Objectives: This study examined the associations of neighborhood availability of marijuana dispensaries and DATA-2000 waivered providers with opioid-related hospital stays. Methods: Discharge-level records of inpatient (N = 264,013) and observation stays (N = 12,621) were obtained from the Washington Comprehensive Hospital Abstract Reporting System from January through June 2016. Outcomes were indicators for inpatient stays related to opioid use disorder (OUD), inpatient stays related to opioid overdose, and observation stays related to OUD. Primary predictors were the density of marijuana dispensaries and DATA-2000 waivered providers at the zip code level. Multilevel logistic regressions with random intercepts were used to examine the cross-sectional associations, controlling for other patient and neighborhood characteristics. Results: Patients living in neighborhoods with one more recreational marijuana dispensaries per square mile were more likely (OR = 1.54, p = .017) to be diagnosed with OUD in inpatient stays. Living in neighborhoods with increased density of medical marijuana dispensaries or DATA-2000 waivered providers was not associated with being diagnosed with OUD or opioid overdose in inpatient or observation stays. Conclusions: Recreational and medical marijuana dispensaries were differentially associated with opioid-related hospital stays. Further investigations are warranted to explore the causal pathways of the findings.

Access to cannabis retail stores across Canada 6 months following legalization: a descriptive study

BACKGROUND

On Oct. 17, 2018, Canada legalized recreational cannabis with the dual goals of reducing youth use and eliminating the illicit cannabis market. We examined factors associated with access to physical cannabis stores across Canada 6 months following legalization.

METHODS

We extracted the address and operating hours of all legal cannabis stores in Canada from online government and private listings. We conducted a descriptive study examining the association between private/hybrid (mixture of government and private stores) and government-only retail models with 4 measures of physical access to cannabis: store density, weekly hours of operation, median distance to the nearest school and relative availability of cannabis stores between low- and high-income neighbourhoods.

RESULTS

Six months after legalization, there were 260 cannabis retail stores across Canada: 181 privately run stores, 55 government-run stores and 24 stores in the hybrid retail system. Compared to jurisdictions with a government-run model, jurisdictions with a private/hybrid retail model had 49% (95% confidence interval 10%-200%) more stores per capita, retailers were open on average 9.2 more hours per week, and stores were located closer to schools (median 166.7 m). In both retail models, there was over twice the concentration of cannabis stores in neighbourhoods in the lowest income quintile compared to the highest income quintile.

INTERPRETATION

Marked differences in physical access to cannabis retail are emerging between jurisdictions with private/hybrid retail models and those with government-only retail models. Ongoing surveillance including monitoring differences in cannabis use and harms across jurisdictions is needed.

Three-year retention in methadone opioid agonist treatment: A survival analysis of clients by dose, area deprivation, and availability of alcohol and cannabis outlets

OBJECTIVE

To determine the effect of clinical, socio-demographic, and contextual characteristics on treatment retention in an opioid treatment program (OTP).

METHODS

A retrospective longitudinal review of 851 clients who received methadone at the only state-funded OTP in Spokane County, Washington between 2015 and 2017. A time variable (the number of days in treatment) and a status indicator (to distinguish between clients who dropped out or censored) worked together to define retention in treatment. Our hypothesized covariates included: area deprivation, distance to the OTP, availability of cannabis retail outlets, availability of on-premise and off-premise alcohol outlets, methadone dosage, age, gender, race, and years on treatment. Cox regression within the family of survival analysis was used to model time-to-event data in the presence of censored cases.

RESULTS

The median duration of retention was 394 (95%CI = 324-464) days. In the multivariable Cox regression, factors predicting treatment retention were area deprivation (HR = 1.79, 95%CI = 1.02-3.15, p = 0.04), age (HR=0.99, 95%CI=0.98-.99, p = 0.008), dosage of methadone (HR=0.98, 95%CI=0.98-0.98, p < 0.001), and the number of years on treatment (HR=1.12, 95%CI=1.06-1.18, p < 0.001).

CONCLUSIONS

The findings of this study showed age and methadone dosage were protective factors and area deprivation and years on treatment were risk factors for treatment retention. After dichotomizing methadone dosage, a unique finding of this study was that higher dosage of methadone did not lead to increasingly smaller HRs for dropping out of treatment. Considering that opioid use disorder is a chronic condition, efforts need to be made to target factors associated with retention.

The emerging marijuana retail environment: Key lessons learned from tobacco and alcohol retail research

The emerging retail market for recreational marijuana use warrants research and surveillance as such markets are established in more US states. This research can be informed by the existing literature regarding tobacco and alcohol, which highlights the impact of spatial access to tobacco and alcohol retailers and exposure to tobacco and alcohol marketing on smoking and drinking among youth and young adults. Prior research indicates that tobacco and alcohol retailers, as well as medical marijuana dispensaries, are disproportionately located in neighborhoods characterized by socioeconomic disadvantage and by higher proportions of racial/ethnic minorities and young adults. Moreover, retail marketing or point-of-sale practices may differentially target subpopulations and differ by neighborhood demography and local policy. This literature and the methods employed for studying the tobacco and alcohol market could inform research on the retail environment for marijuana, as current gaps exist. In particular, much of the existing literature involves cross-sectional research designs; longitudinal studies are needed. Moreover, standardized measures are needed for systematic monitoring of industry marketing practices and to conduct research examining neighborhood differences in exposure to retail marketing for marijuana and its contribution to use modality and frequency, alone and in combination with nicotine and alcohol. The use of standardized measures for tobacco and alcohol marketing have been critical to develop an evidence base from cross-sectional and longitudinal studies that document the impact of retail marketing on substance use by adolescents and adults. Similar research is needed to establish an evidence base to inform federal, state, and local regulations of marijuana.

Cannabis regulatory science: risk-benefit considerations for mental disorders

The evolving legal cannabis landscape in the US continues to present novel regulatory challenges that necessitate the development of a Cannabis Regulatory Science. Two specific issues of concern within Cannabis Regulatory Science are (1) the impact that cannabis use has on the incidence, prevalence, and severity of mental disorders, and (2) how cannabis laws and regulations modify this impact. This paper first provides several conceptual points that are useful for evaluating the relationship between cannabis use and mental disorders. Second, it selectively reviews and comments on data relevant to the relationship between cannabis use and depression, several forms of anxiety, post-traumatic stress disorder, schizophrenia, and bipolar disorder. Next, regulatory and public health parallels between the nascent cannabis industry and the pharmaceutical, tobacco, and alcohol industries are discussed. The focus is on specific types of industry practices that may harm those with or at risk for mental disorders. Recommendations are then offered for legal cannabis regulations that could mitigate this harm. Last, future research goals are discussed for building the field of Cannabis Regulatory Science and addressing the potential negative impact of cannabis on those with mental disorders.

Location, location, location: Assessing the spatial patterning between marijuana licenses, alcohol outlets and neighborhood characteristics within Washington state

BACKGROUND

The availability of marijuana products is becoming increasingly prevalent across the United States (US), many states are allowing for the production, processing, and retailing of these products for medical and/or recreational use. The purpose of this study is to: (1) examine the spatial patterning of marijuana licenses, and (2) examine the impact of alcohol outlets in addition to other neighborhood characteristics on marijuana licenses within the state of Washington.

METHODS

This cross-sectional observational study examined 1458 census tracts in Washington state from 2017, using marijuana and alcohol data from the Washington State Liquor and Cannabis Board as well as neighborhood characteristics data from the American Community Survey 2011-2015 5-year estimates. We used exploratory and formal spatial regression methods, including integrated nested Laplace approximation within a Bayesian statistical framework, to address the study aims.

RESULTS

Our results indicate there is significant spatial patterning of marijuana producers and processors across the state. We also found that all marijuana licenses are located in poorer census tracts, and marijuana retailers are co-located in census tracts with off-premises alcohol outlets.

CONCLUSIONS

Our study provides empirical evidence of the relationship between marijuana licenses, alcohol outlets, and neighborhood characteristics, and has important implications for policymakers in other states currently considering legalizing marijuana-products for medical and/or recreational use.

The development and pilot testing of the marijuana retail surveillance tool (MRST): assessing marketing and point-of-sale practices among recreational marijuana retailers

As recreational marijuana expands, it is critical to develop standardized surveillance measures to study the retail environment. To this end, our research team developed and piloted a tool assessing recreational marijuana retailers in a convenience sample of 20 Denver retailers in 2016. The tool assesses: (i) compliance and security (e.g. age-of-sale signage, ID checks, security cameras); (ii) marketing (i.e. promotions, product availability and price) and (iii) contextual and neighborhood features (i.e. retailer type, facilities nearby). Most shops (90.0%) indicated the minimum age requirement, all verified age. All shops posted interior ads (M = 2.6/retailer, SD = 3.4), primarily to promote edibles and other non-smoked products. Price promotions were common in shops (73.7%), 57.9% used social media promotions and 31.6% had take-away materials (e.g. menus, party promotions). Nearly half of the shops (42.1%) advertised health claims. All shops offered bud, joints, honey oil, tinctures, kief, beverages, edibles and topicals; fewer sold clones and seeds. Six shops (31.6%) sold shop-branded apparel and/or paraphernalia. Prices for bud varied within and between stores ($20-$45/'eighth', ∼3.5 g). Twelve were recreational only, and eight were both recreational and medicinal. Liquor stores were commonly proximal. Reliability assessments with larger, representative samples are needed to create a standardized marijuana retail surveillance tool.

Patterns of Twitter Behavior Among Networks of Cannabis Dispensaries in California

Background

Twitter represents a social media platform through which medical cannabis dispensaries can rapidly promote and advertise a multitude of retail products. Yet, to date, no studies have systematically evaluated Twitter behavior among dispensaries and how these behaviors influence the formation of social networks.

Objectives

This study sought to characterize common cyberbehaviors and shared follower networks among dispensaries operating in two large cannabis markets in California.

Methods

From a targeted sample of 119 dispensaries in the San Francisco Bay Area and Greater Los Angeles, we collected metadata from the dispensary accounts using the Twitter API. For each city, we characterized the network structure of dispensaries based upon shared followers, then empirically derived communities with the Louvain modularity algorithm. Principal components factor analysis was employed to reduce 12 Twitter measures into a more parsimonious set of cyberbehavioral dimensions. Finally, quadratic discriminant analysis was implemented to verify the ability of the extracted dimensions to classify dispensaries into their derived communities.

Results

The modularity algorithm yielded three communities in each city with distinct network structures. The principal components factor analysis reduced the 12 cyberbehaviors into five dimensions that encompassed account age, posting frequency, referencing, hyperlinks, and user engagement among the dispensary accounts. In the quadratic discriminant analysis, the dimensions correctly classified 75% (46/61) of the communities in the San Francisco Bay Area and 71% (41/58) in Greater Los Angeles.

Conclusions

The most centralized and strongly connected dispensaries in both cities had newer accounts, higher daily activity, more frequent user engagement, and increased usage of embedded media, keywords, and hyperlinks. Measures derived from both network structure and cyberbehavioral dimensions can serve as key contextual indicators for the online surveillance of cannabis dispensaries and consumer markets over time.

Social factors in marijuana use for medical and recreational purposes

Of all the various treatment options for epilepsy, no other therapy comes close to the polarity that cannabis engenders. The rationale for this reaction is firmly rooted in the social factors that enshroud the use of marijuana for both medical and recreational purposes. In order to best understand how to approach this controversial treatment, it is essential to explore the social, demographic, and historical variables that have led to the current opinions on cannabis therapy and how this has converged on epilepsy treatment. Utilizing a sociological conceptual framework, this review discusses in depth the social, cultural, and historical dimensions of cannabis use in the US for medical purposes and its impact on epilepsy treatment. Moreover, it posits that cannabis therapy and the opinions surrounding its use are products of history and assesses this treatment option through the lens of our current times. This article is part of a Special Issue titled Cannabinoids and Epilepsy.

Race, Ethnicity, and Exposure to Alcohol Outlets

OBJECTIVE

Prior studies suggest that Black and Hispanic minority populations are exposed to greater concentrations of alcohol outlets, potentially contributing to health disparities between these populations and the White majority. We tested the alternative hypothesis that urban economic systems cause outlets to concentrate in low-income areas and, controlling for these effects, lower demand among minority populations leads to fewer outlets.

METHOD

Market potential for alcohol sales, a surrogate for demand, was estimated from survey and census data across census block groups for 50 California cities. Hierarchical Bayesian conditional autoregressive Poisson models then estimated relationships between observed geographic distributions of outlets and the market potential for alcohol, income, population size, and racial and ethnic composition.

RESULTS

Market potentials were significantly smaller among lower income Black, Hispanic, and Asian populations. Block groups with greater market potential and lower income had greater concentrations of outlets. When we controlled for these effects, the racial and ethnic group composition of block groups was mostly unrelated to outlet concentrations.

CONCLUSIONS

Health disparities related to exposure to alcohol outlets are primarily driven by distributions of income and population density across neighborhoods.

Risky Substance Use Environments and Addiction: A New Frontier for Environmental Justice Research

Substance use disorders are widely recognized as one of the most pressing global public health problems, and recent research indicates that environmental factors, including access and exposure to substances of abuse, neighborhood disadvantage and disorder, and environmental barriers to treatment, influence substance use behaviors. Racial and socioeconomic inequities in the factors that create risky substance use environments may engender disparities in rates of substance use disorders and treatment outcomes. Environmental justice researchers, with substantial experience in addressing racial and ethnic inequities in environmental risk from technological and other hazards, should consider similar inequities in risky substance use environments as an environmental justice issue. Research should aim at illustrating where, why, and how such inequities in risky substance use environments occur, the implications of such inequities for disparities in substance use disorders and treatment outcomes, and the implications for tobacco, alcohol, and drug policies and prevention and treatment programs.

A micro-temporal geospatial analysis of medical marijuana dispensaries and crime in Long Beach, California

AIMS

To determine whether the density of marijuana dispensaries in California, USA, in 2012-13 was related to violent and property crimes, both locally and in adjacent areas, during a time in which local law enforcement conducted operations to reduce the number of storefront medical marijuana dispensaries.

DESIGN

Data on locations of crimes and medical marijuana dispensaries as well as other covariates were collected for a sample of 333 Census block groups.

SETTING

Long Beach, California, USA from January 2012 to December 2013.

OBSERVATIONS

A total of 7992 space-time observations (from 333 Census block groups over 24 time-points).

MEASUREMENTS

Outcome measures focused on block-group counts of violent and property crimes. Predictors were numbers of local and adjacent-area medical marijuana dispensaries. Covariates included markers of alcohol availability as well as area demographic and economic characteristics.

FINDINGS

After adjustment for covariates, density of medical marijuana dispensaries was unrelated to property and violent crimes in local areas but related positively to crime in spatially adjacent areas [incident rate ratio (IRR) = 1.0248, CI (1.0097, 1.0402) for violent crime, IRR = 1.0169, CI (1.0071, 1.0268) for property crime].

CONCLUSIONS

Using law enforcement to reduce medical marijuana dispensaries in California appears to have reduced crime in residential areas near to, but not in, these locations.