Issues in the implementation and evolution of the commercial recreational cannabis market in Colorado

Exploring consumer preferences for cannabis edible products to support public health policy: A discrete choice experiment

BACKGROUND

In October 2019, cannabis edibles were legalized for sale in Canada for non-medical use. This move was intended to improve public safety by regulating contents (including a maximum 10 mg tetrahydrocannabinol (THC) per package) and packaging to prevent accidental ingestion or over consumption. This study aimed to explore consumer preferences for cannabis edibles to inform cannabis policy.

METHODS

We explored the relative importance and trade-offs consumers make for attributes of cannabis edibles using a discrete choice experiment. Attributes included type of edible, price, THC content, cannabis taste, package information, product consistency, product recommendations, and Health Canada regulation. Participants lived in Canada, were 19 years of age or older, and purchased a cannabis edible in the last 12 months. A multinomial logit (MNL) model was used for the base model, and latent class analysis to assess preference sub-groups. This study was approved by the institutional ethics committee.

RESULTS

Among 684 participants, the MNL model showed that potency was the most relevant attribute, followed by edible type. A two-group latent class model revealed two very distinct preference patterns. Preferences for group 1 (~65% of sample) were driven primarily by edible type, while for group 2 (~35% of sample) were driven almost entirely by THC potency.

CONCLUSION

This study found that consumer preferences for ~65% of consumers of cannabis edibles are being met through regulated channels. The remaining ~35% are driven by THC potency at levels that are not currently available on the licensed market. Attracting this market segment will require reviewing the risks and benefits of restricting THC package content.

U.S. State approaches to cannabis licensing

U.S. states have taken varied approaches to licensing cannabis businesses under federal prohibition, but up to now there is limited research on cross-state licensing approaches. This paper provides a systematic analysis of the current licensing strategies taken by all states that have passed medical cannabis laws (MCLs)/recreational cannabis laws (RCLs). We construct comprehensive data on cannabis business licenses offered in each state, as well as metrics for license categories, cost, and issuance volume. We then analyze patterns between these metrics, also considering how long ago states implemented MCLs/RCLs, qualitative licensing aspects, state ideology and voting preference, and state cannabis taxation data. We observe that states tend to license medical cannabis more restrictively than adult-use cannabis: i.e., by offering licenses in fewer categories, at higher cost, in lower issuance volume, and more often mandating vertical integration. Additionally, states that implemented MCLs/RCLs earlier tend to offer licenses in more categories, at lower cost, and in greater volumes. Further, though states that implemented MCLs recently lean conservative and Republican, we do not observe clear relationships between ideology or voting preference and licensing policy. In our supporting results, we observe that a greater share of states with complex licensing structures impose non-retail price cannabis taxes than states overall, and we discuss how states have changed their licensing policies over time.

Digital Medical Cannabis as Market Differentiator: Second-Generation Artificial Intelligence Systems to Improve Response

Legalized use of cannabis products and the rising interest in their therapeutic benefits have opened up new opportunities for therapy and marketing. However, the marked variability in formulations, administration modes, therapeutic regimens, and inter- and intra-subject responses make the standardization of medical cannabis-based regimens difficult. Legalization has made the cannabis market highly competitive and lowered the revenue margins. This study reviews some of the challenges in medical cannabis use and difficulties in standardizing its therapeutic regimens that hinder maximizing its beneficial effects. The development of tolerance toward cannabis and low adherence to chronic administration further impair its long-term beneficial effects. Digital medical cannabis is a cannabis product controlled by a second-generation artificial intelligence (AI) system that improves patient responses by increasing adherence and dealing with tolerance. Second-generation AI systems focus on a single patient's outcome and deal with the inter- and intra-subject variability in responses. The use of digital medical cannabis is expected to improve product standardization, maximize therapeutic benefits, reduce health care costs, and increase the revenue of companies. Digital medical cannabis offers several market differentiators for cannabis companies. This study presents a model for promoting the use of digital medical cannabis and presents its advantages for patients, clinicians, health care authorities, insurance companies, and cannabis manufacturers. Ongoing trials and real-world data on the use of these systems further support the use of digital medical cannabis for improved global health.

Overview: Exploring the onto-politics of cannabis

The composition, use, policies, and the societal position of cannabis are changing and diversifying internationally. Cannabis has emerged as an object of much controversy and is subject to varying forms of regulation. Its role and regulation are also debated in the Nordic countries. To shed light on such developments, this special issue sets out to explore how the phenomenon of cannabis, and related policies and subjectivities, are currently made, unmade, and transformed in multiple ways through discourses, practices, and materiality, and with different consequences.

A comparative analysis of laws on recreational cannabis edibles between Canada and the United States of America

BACKGROUND

The Canadian government has amended the Cannabis Act and Cannabis Regulations to legalize use of recreational cannabis edibles. Besides Canada, the United States of America (U.S.A.) is the only other country with experience regulating cannabis edibles, albeit at the state-level. Because of the potential health risks associated with consuming THC, we sought to compare laws (within Canada and the U.S. states that have legalized the recreational use of cannabis edible) that govern THC-infused cannabis edibles; and to identify any associated gaps in Canada's cannabis regulatory framework.

METHODS

For all U.S. states with laws on recreational cannabis, state-level statutes and regulations were retrieved from LexisAdvance Quicklaw and compared to requirements contained in the Canadian Cannabis Act, Cannabis Regulations, and gazetted Health Canada regulations. A comparative analysis of these documents highlighted similarities and differences in the cannabis regulatory framework of the two countries.

RESULTS

Currently, twelve jurisdictions in the U.S.A. authorize recreational cannabis use, but only ten states outline specific requirements for edibles. Overall, regulatory requirements for cannabis edibles are largely similar in Canada and the U.S.A.; however, requirements on test result reporting and data collection are different. Canada's limits on per package tetrahydrocannabinol and labelling requirements tend to be more conservative when compared to the U.S.A.

CONCLUSION

To further prevent accidental consumption, Canada should require cannabis manufacturers to directly imprint edibles with a cannabis symbol, which four American states currently mandate.

The importance of psychology for shaping legal cannabis regulation

Different patterns of cannabis use can be traced directly back to different interactions between 2 types of variables: pharmacological and environmental. As legal cannabis expands in the U.S. and around the world, state and national regulatory agencies are gaining control over these variables. Specifically, regulatory agencies are increasingly capable of altering (a) the pharmacological properties of cannabis products and (b) the way these products are distributed to the population. Consequently, cannabis regulatory agencies are in a unique position to use evidence from psychological science to alter cannabis consumption patterns in ways that mitigate potential harm to public health. However, most state-level legal cannabis regulatory systems in the U.S. are not yet evidence-based or public health-oriented. This applied review and commentary draws on evidence from the psychological science literature to help regulators better understand the types of behaviors they must address and guide empirically supported regulation of THC-laden cannabis, whether used putatively for medical or recreational reasons. This review is organized into 3 parts that correspond to the 3 primary agents within the cannabis regulation ecosystem: (a) the cannabis consumer, (b) the cannabis industry, and (c) the cannabis regulatory agency. Within this structure, the review addresses critical psychological variables that drive cannabis consumer and industry behaviors and discusses how regulatory agencies can use this information to protect public health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Household Rules regarding Cannabis Use and Tobacco Smoking in Denver Airbnb Venues

Cannabis legalization threatens to undermine clean indoor air norms. We investigated the prevalence and nature of tobacco and cannabis use rules in Airbnb venues in Denver, Colorado, where recreational cannabis was legalized in 2014. The study used publicly available Inside Airbnb data for all Denver listings (N = 4,511) collected on 06/29/2019. We analyzed reported tobacco smoking and cannabis use house rules. Tobacco smoking with or without conditions was allowed in 9.7% of venues. Of all venues, 23.7% included details about cannabis use. Of these, 75.9% allowed cannabis use without or with conditions. Of the venues that allowed cannabis use, 30.5% also allowed tobacco smoking. Of the venues that did not allow cannabis use, 0.4% allowed tobacco smoking. Additional multilevel regression models revealed that venues in higher income neighborhoods were less likely to allow cannabis and tobacco use. A substantial number of Airbnb listings in Denver, Colorado permit cannabis use and venues permitting cannabis use may be more likely to also permit tobacco smoking. Findings support the idea that cannabis legalization threatens clean indoor air norms. Airbnb should consider including cannabis use in house rules in jurisdictions that have legalized cannabis to help guests identify spaces with clean air.

Seeking safety: a focus group study of young adults' cannabis-related attitudes, and behavior in a state with legalized recreational cannabis

BACKGROUND

Only July 1, 2017, Nevada became the fifth US state to allow the legal sale of recreational cannabis products for adults ages of 21 and over. This study investigates young adults' cannabis-related attitudes, perceptions, and behaviors in a state where recreational and medical cannabis use was recently legalized.

METHODS

We conducted 8 focus groups stratified by cannabis use (regular users, occasional users, and nonusers) with 32 college students ages 18 to 24. Data were analyzed using the inductive qualitative thematic analysis method.

RESULTS

Four themes emerged during analyses: "sort of legal," "mitigating harm through legalization," "Increasing acceptance," and "seeking safety when purchasing cannabis." Despite their limited knowledge of cannabis regulation, the majority of the participants supported recreational cannabis legalization from a harm reduction perspective. Most participants did not believe that cannabis legalization had affected their use behavior. However, participants, especially cannabis users, perceived that recreational cannabis legalization created a context where cannabis use was legally, socially, and behaviorally "safer" than in an illegal context, even for those below the legal age of sale.

CONCLUSIONS

Most studies focus on the role of perceived health risk on cannabis use. If there are population-level long-term effects of recreational cannabis legalization on use behavior, findings suggest that they will be mediated by the perceived legal, social, and behavioral risk of using cannabis.

Facing the option for the legalisation of cannabis use and supply in New Zealand: An overview of relevant evidence, concepts and considerations

ISSUES

Non-medical cannabis policies are changing, including towards legalisation-with-regulation frameworks. New Zealand will hold a public referendum on cannabis legalisation in 2020. We reviewed data on cannabis use and health/social harms; policy reform options; experiences with and outcomes of reforms elsewhere; and other relevant considerations towards informing policy choices in the upcoming referendum.

APPROACH

Relevant epidemiological, health, social, criminal justice and policy studies and data were identified and comprehensively reviewed.

KEY FINDINGS

Cannabis use is common (including in New Zealand) and associated with risks for health and social harms, mainly concentrated in young users; key harms are attributable to criminalisation. 'Decriminalisation' reforms have produced ambivalent results. Existing cannabis legalisation frameworks vary considerably in main parameters. Legalisation offers some distinct advantages, for example regulated use, products and user education, yet outcomes depend on essential regulation parameters, including commercialisation, and policy ecologies. While major changes in use are not observed, legalisation experiences are inconclusive to date, including mixed health and social outcomes, with select harms increasing and resilient illegal markets. It is unclear whether legalisation reduces cannabis exposure or social harms (e.g. from enforcement) for youth.

IMPLICATIONS/CONCLUSIONS

No conclusive overall evidence on the outcomes of legalisation elsewhere exists, nor is evidence easily transferable to other settings. Legalisation offers direct social justice benefits for adults, yet overall public health impacts are uncertain. Legalisation may not categorically improve health or social outcomes for youth. Legalisation remains a well-intended, while experimental policy option towards more measured and sensible cannabis control and overall greater policy coherence, requiring close monitoring and possible adjustments depending on setting-specific outcomes.

Cannabis-Infused Edible Products in Colorado: Food Safety and Public Health Implications

Cannabis-infused "edibles" are a popular means of cannabis use, and the variety of edible food products available to consumers continues to grow. Although there has been much discussion on dose standardization, childproof packaging, and the prevention of overconsumption, the important topic of food safety has received less attention.We discuss potential food safety hazards associated with cannabis-infused edible food products, drawing on examples from Colorado, and describe edible-associated foodborne illness outbreaks and other contamination events.It is important for public health agencies, particularly environmental health and enteric disease programs, to be familiar with the cannabis industry, including regulatory partners, signs and symptoms of cannabis ingestion, the scope of edible products sold and consumed, and the food safety risks unique to cannabis products.

Assessing the public health impacts of legalizing recreational cannabis use: the US experience

The sale of cannabis for adult recreational use has been made legal in nine US states since 2012, and nationally in Uruguay in 2013 and Canada in 2018. We review US research on the effects of legalization on cannabis use among adults and adolescents and on cannabis-related harms; the impact of legalizing adult recreational use on cannabis price, availability, potency and use; and regulatory policies that may increase or limit adverse effects of legalization. The legalization of recreational cannabis use in the US has substantially reduced the price of cannabis, increased its potency, and made cannabis more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth. It has also increased emergency department attendances and hospitalizations for some cannabis-related harms. The relatively modest effects on cannabis use to date probably reflect restrictions on the number and locations of retail cannabis outlets and the constraints on commercialization under a continued federal prohibition of cannabis. Future evaluations of legalization should monitor: cannabis sales volumes, prices and content of tetrahydrocannabinol; prevalence and frequency of cannabis use among adolescents and adults in household and high school surveys; car crash fatalities and injuries involving drivers who are cannabis-impaired; emergency department presentations related to cannabis; the demand for treatment of cannabis use disorders; and the prevalence of regular cannabis use among vulnerable young people in mental health services, schools and the criminal justice system. Governments that propose to legalize and regulate cannabis use need to fund research to monitor the impacts of these policy changes on public health, and take advantage of this research to develop ways of regulating can-nabis use that minimize adverse effects on public health.

Understanding motivations for large US cannabis firms' participation in the cannabis space: Qualitative study exploring views of key decision-makers

INTRODUCTION AND AIMS

Large for-profit firms supply the majority of US state-legal cannabis stores and some firms have attempted to shape cannabis-related policies. Understanding firms' motivations for participation in the cannabis space is critical, given firms' possible links to cannabis usage patterns. Key decision-makers (KDM) in the cannabis space may have information unavailable to lower ranking staff, and may influence firm decision-making and consequently US cannabis usage practises. We present the findings of a qualitative study investigating the views of KDMs in the cannabis market, on large cannabis firms' motivations for participation in the space.

DESIGN AND METHODS

Data were collected through 37 semi-structured interviews with a convenience sample of KDMs in the US cannabis space, representing both for-profit and non-profit organisations. Thematic analysis, with an inductive approach, was used to analyse the data.

RESULTS

KDMs reported three non-exclusive motivations for large cannabis firms' participation in the space; to seek profit, to mitigate social inequity and to provide cannabis as medicine. Within the theme relating to profit, findings suggest that for-profit and non-profit organisations in the space may be cognisant of the other's goals, representing a symbiotic relationship.

DISCUSSION AND CONCLUSIONS

We suggest that firms may have reasons to enter the space not necessarily centred on increasing use. Although non-profits and for-profits have different agendas, the bottom line for both groups is to expand access. Policy-makers should be aware of that fact, and set policies which consider the two groups as a unified whole.

Beyond the Bud: Emerging Methods of Cannabis Consumption for Youth

Cannabis continues to be the most widely used illicit substance among youth, as many teens view the risks of cannabis consumption to be low. With cannabis laws becoming lax and dispensaries becoming more prevalent throughout the United States, highly concentrated Δ-9-tetrahydrocannibinol (THC) is becoming readily available. This article examines the available literature on consumption of concentrated THC, focusing on potential consequences of concentrate use among youth. Various methods for consuming concentrated THC, including ingestion of edibles, vaping, and dabbing, are discussed, along with associated risks of each consumption method. Recommendations for health professionals are provided.

From prohibition to regulation: A comparative analysis of the emergence and related outcomes of new legal cannabis policy models (Colorado, Washington State and Uruguay)

An effective approach to drug regulation is a growing concern. Since 2012, 10 US States and Uruguay have taken the step to revoke prohibition and legalize the recreational cannabis market. Based on the findings from a study ('Cannalex') carried out in 2015-2017 in Colorado, Washington and Uruguay by the French Monitoring Centre for Drugs and Drug Addiction (OFDT) and the Institute of Security and Justice (INHESJ), relying on a hundred of in-depth interviews analyzed in line with the existing official statistics and studies, this paper shows heterogeneous policy-making models and contexts for reform. It also examines the early outcomes of the cannabis policy change. A mixed picture is emerging from the regulatory regimes currently implemented. This paper discusses the reform processes and their early outcomes, with a specific focus on the less documented area: the political processes that led to legalizing cannabis, analyzed with qualitative data. It argues that the different outcomes reported across Colorado, Washington and Uruguay are framed by the regulatory options that were taken, depending on specific dynamics of reform. The discussion focuses on some hot topics raised by the effective regulations, stressing that the array of cannabis regulatory options is a public debate that has just begun.

Social and public health implications of the legalisation of recreational cannabis: A literature review

BACKGROUND

After many years of legal struggles for the legalisation of recreational use of cannabis, the Constitutional Court of South Africa ruled in favour of the applicants in September 2018. Although the ruling issued caution regarding the social challenges accompanying this legalisation, it did not address how the country would deal with the societal consequences of this ruling.

AIM

The aim of this article was to discuss the social and public health implications of the legalisation of recreational cannabis on South Africa.

METHODS

Literature review on the social, health and legal impacts of legalisation of cannabis, considering experiences of other countries that have legalised cannabis.

RESULTS

The legalisation brings a range of significant negative consequences, which include an expected increase in the number of users and the subsequent undesirable effects on the physical, mental and social health of communities.

CONCLUSION

In terms of financial, infrastructural and human resources, South Africa cannot afford the consequences of the legalisation of recreational cannabis. Poor communities, children and the youth will carry the brunt of the scourge of cannabis use.

Public health implications of legalising the production and sale of cannabis for medicinal and recreational use

We assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Third, we describe how jurisdictions that have legalised recreational use have regulated production and sale of cannabis. Fourth, we evaluate the effects of cannabis legalisation on cannabis use and harms and on the use of alcohol, tobacco, and other drugs. Fifth, we use alcohol and tobacco policy examples to identify possible long-term public health effects of cannabis legalisation. Finally, we outline policy approaches that could minimise harms to public health arising from the legalisation of a commercial cannabis industry.

Cannabis and youth protection in Colorado's commercial adult-use market: A qualitative investigation

INTRODUCTION

Arguments both for and against the legalization of cannabis often include the issue of youth protection. At the time of writing 5-years after the implementation of the Coloradan recreational cannabis market (CRCM), no statistically significant increase in consumption had been identified. This paper aimed to provide a thick descriptive account of youth prevention objectives stipulated in the pre-implementation phase of the CRCM and compare these with the real-world experience of regulators and other stakeholders involved with market implementation.

METHODOLOGY AND METHODS

A qualitative descriptive methodology was used that involved the following methods: document analysis, deductive coding, thematic analysis, and thick description. Two data sets relevant to youth protection in the context of a legal cannabis market in Colorado were examined. Data set 1 (DS1) examined government documents (n = 13) related to the pre-implementation phase from November 2012 - December 2013. Data set 2 (DS2) consisted of semi-structured face-to-face interviews conducted with key stakeholders (n = 32) in 2016 and 2017.

RESULTS

Five themes emerged including advertising restrictions (DS1), education (DS1), appropriation of funds (DS2), impact assessment (DS2), and evolving messages in prevention education campaigns (DS2).

DISCUSSION

Multiple lessons for other jurisdictions were highlighted in the study.

Making "Weedish Fish": An Exploratory Analysis of Cannabis Recipes on Pinterest

Background: The expansion of legalized medical and recreational cannabis has created growing interest in cannabis infused edibles. Information about the preparation of edibles is readily available to the public on social media with little to no oversight. Objectives: To determine how recipes for cannabis edibles are promoted on the social media platform Pinterest. Methods: We performed a content analysis of 500 cannabis edible recipe pins collected in December 2017. Pins were coded for promotional content, user engagement, recipe presence and type, cannabis dosage and serving size, and presence of health and risk information. Results: A plurality of pins showed visuals of cannabis content (47.8%), and pins frequently depicted images of desserts infused with cannabis (40.0%). Almost half of all of pins (46.8%) included or linked out to a recipe for edibles, with recipes for desserts and baked goods being most common (40.0%). Cannabis dosages and serving sizes were often vague or missing, and health and safety warnings were almost entirely absent from pins. Conclusion/importance: Recipes for cannabis edibles are easily accessible through Pinterest. Information about dosage, serving size, health effects, and responsible usage are all but absent. Pins largely originate in locations where cannabis is legalized; however, content is accessible without regard to state or national borders. Public health agencies and organizations should consider publishing information about health effects and responsible usage that flow parallel to social media content promoting edibles.

Beyond deficit and harm reduction: Incorporating the spectrum of wellness as an interpretive framework for cannabis consumption

The cannabis academic literature is informed by dominant deficit, public health and harm reduction frameworks. However, a large majority of cannabis consumption appears to place outside the scope of these models that prioritise the identification and limitation of negative impacts. As such there are apparent analytical blind spots pertaining to: non-problematic use of cannabis (as defined by Global Commission on Drug Policy); the intersection of medical and recreational intents of use; and pleasure. This paper explores the academic and grey literature relating to the spectrum of wellness to assess its suitability as a framework for cannabis scholars. For millennia cannabis use has been associated with wellness models, particularly at the nexus of mind, body, and spirit. Despite this seemingly obvious match, the academic literature that incorporates cannabis consumption patterns into wellness conceptions is thin. The spectrum of wellness has both advantages and disadvantages compared to existing models and may be useful as a complementary framework that allows for broader examination of cannabis consumer activity.

Characterizing Blunt Smokers by Their Acquisition of Cannabis

BACKGROUND

Ethnographers have reported that young, urban males embraced blunt smoking in response to the crack cocaine epidemic that ravaged their neighborhoods in the 1980s. But, recent survey data has indicated high rates of other illicit drug use among blunt smokers.

OBJECTIVES

The objective of this study was to examine the association between blunt smoking and cannabis acquisition as a potential explanation for the correlation with other illicit drug use.

METHODS

The sample consisted of participants from the 2014 National Survey on Drug Use and Health (NSDUH) who reported use of cannabis or blunts in the prior month (n = 6,040). Logistic regression was used in estimating measures of demographics, access to illicit drugs, access to medical cannabis, frequency of cannabis/blunt use, and type of blunt smoker as correlates of a cannabis purchase versus other means of acquisition (e.g. sharing it).

RESULTS

Accounting for other variables, current blunt smokers had 1.4 times the odds of purchasing cannabis relative to the cannabis users who had never smoked a blunt. Furthermore, the current blunt smokers had greater odds of purchasing cannabis frequently and making the purchases in outdoor settings. Conclusions/Importance: The findings suggest that current blunt smokers compared to other cannabis users are at greater risk of the dangers associated with illegal drug transactions. The legalization of recreational cannabis in some U.S. states is coinciding with the growth of a cannabis black market, highlighting the need for the continued assessment of cannabis acquisition in NSDUH questionnaires.

Over and under-regulation in the Colorado Cannabis industry - A data-analytic perspective

With the State of California legalizing recreational cannabis sales on January 1, 2018, the regulatory process is once more in the forefront of cannabis research. Colorado, often held up as a model of legalization policy, was the first state to implement retail sale of recreational cannabis on January 1^st, 2014. However, a combination of subsequent under-regulation and over-regulation, inconsistently applied across issues such as retail licencing, chemical testing, cannabis derivatives, municipality approval for growers, and financing, have not only held back the industry in Colorado but also negatively impacted public health, oversight, and have potentially increased the availability of illegal cannabis. We argue that a data-analytic approach to the industry is potentially the most effective way to resolve these concerns, since in the absence of consistent and reliable data, policymakers are apt to satisfy individual policy concerns without considering the industry as a whole. In this paper we present a data-analytic framework for the cannabis industry, offering a theoretically-driven justification for our approach, and describe implications for research on drug and information policy. The framework may serve as a model for other states or countries contemplating cannabis legalisation. As four new states legalised recreational cannabis in 2016, the implications of this research for policymakers has dramatically increased.

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.

Big data on a big new market: Insights from Washington State's legal cannabis market

INTRODUCTION

Voters in eight U.S. states have passed initiatives to legalize large-scale commercial production of cannabis for non-medical use. All plan or require some form of "seed-to-sale" tracking systems, which provide a view of cannabis market activity at a heretofore unimagined level of detail. Legal markets also create a range of new matters for policy makers to address.

DATA

Publicly available data were obtained on approximately 45 million individually priced items purchased in the 35 million retail transactions that took place during the first two and a half years of Washington State's legal cannabis market. Records include product type (flower, extract, lotion, liquid edible, etc.), product name, price, and potency with respect to multiple cannabinoids, notably THC and CBD. Items sold can be traced back up the supply chain through the store to the processor and producer, to the level of identifying the specific production batch and mother plant, the firm that tested the product, and test results.

METHOD

Data visualization methods are employed to describe spatial-temporal patterns of multiple correlated attributes (e.g., price and potency) broken down by product. Text-analytic methods are used to subdivide the broad category of "extracts for inhalation" into more homogeneous sub-categories. To understand the competitiveness of the legal cannabis market in Washington we calculate the Herfindahl-Hirschman index (HHI) for processors and retailers.

RESULTS

Cannabis prices fell steadily and proportionally at the processor and retailer levels. Retail and wholesale price maintained a roughly 3:1 ratio for multiple product types after some initial fluctuations. Although a wide range of edibles are sold, they account for a modest share of consumer spending; extracts for inhalation are a larger and heterogeneous market segment. The HHI indicates the cannabis market is highly competitive at the processor level, but less so for retail markets at the county level.

CONCLUSIONS

Washington's state-legal cannabis market is diverse and rapidly evolving in terms of pricing, products, and organization. Post-legalization, researchers and policy makers may need to think in terms of a family of cannabis products, akin to how we think of new psychoactive substances and amphetamine-type stimulants, not a single drug "cannabis."

American exceptionalism and the failure to learn from mistakes of the past

Commentary to: The diverging trajectories of cannabis and tobacco policies in the United States: reasons and possible implications

Medical Marijuana and Marijuana Legalization

State-level marijuana liberalization policies have been evolving for the past five decades, and yet the overall scientific evidence of the impact of these policies is widely believed to be inconclusive. In this review we summarize some of the key limitations of the studies evaluating the effects of decriminalization and medical marijuana laws on marijuana use, highlighting their inconsistencies in terms of the heterogeneity of policies, the timing of the evaluations, and the measures of use being considered. We suggest that the heterogeneity in the responsiveness of different populations to particular laws is important for interpreting the mixed findings from the literature, and we highlight the limitations of the existing literature in providing clear insights into the probable effects of marijuana legalization.

Consumer agency in cannabis supply - Exploring auto-regulatory documents of the cannabis social clubs in Spain

BACKGROUND

There is growing experience with the not-for-profit, consumer-driven cannabis social club (CSC) model that builds on self-supply, self-organization and harm-reduction; these are principles upon which people who use drugs (PWUD) have been engaging for decades. Recent legalization of cannabis in a number of jurisdictions and the related challenges in regulating production, sale, taxation and health-related matters have raised interest in non-commercial models of cannabis supply. The "codes of conduct" (CsoC) of CSC federations in Spain might reveal whether a consumer-based model could overcome these challenges.

METHODS

To examine the content of the CSC auto-regulatory documents, an online search using key terms to identify the CsoC was conducted. Six documents were found; analysis of the main thematic categories and overarching themes was conducted. It was discussed how these corresponded to the areas of cannabis policy regulation and what the main limitations of the CSC model were.

RESULTS

The CsoC detailed the rules for CSC administration, not-for-profit aims, "invitation only" and other conditions of membership, collective cultivation and security as well as for operation of the consumption venue and health-related initiatives. The themes in the CsoC overlapped with cannabis regulatory areas as outlined internationally. Concern over cannabis prices and potency was missing in the CsoC. The potential strengths of the CSC model might include safe environment for peer-delivered harm reduction practice, preventing illicit transactions, quality control, shifting economic surplus to the consumers and increased consumer responsibility. The limitations of the CSC model include high threshold, disguised motives, tax revenue and the risk of both under- and over-regulation.

CONCLUSION

CSCs represent an opportunity to enhance consumer agency and responsibility. The right "to be self-supplied" with psychoactive substances can be granted to consumer associations - but authorities need to provide a framework to facilitate this voluntary self-organization, including minimum standards around public health and safety, and to involve consumers in the development of these regulations.

Medical marijuana in pediatric oncology: A review of the evidence and implications for practice

Medical marijuana (MM) has become increasingly legal at the state level and accessible to children with serious illness. Pediatric patients with cancer may be particularly receptive to MM, given purported benefits in managing cancer-related symptoms. In this review, we examine the evidence for MM as a supportive care agent in pediatric oncology. We describe the current legal status of MM, mechanism of action, common formulations, and potential benefits versus risks for pediatric oncology patients. We offer suggestions for how providers might approach MM requests. Throughout, we comment on avenues for future investigation on this growing trend in supportive care.

Variation in cannabis potency and prices in a newly legal market: evidence from 30 million cannabis sales in Washington state

AIMS

To (1) assess trends and variation in the market share of product types and potency sold in a legal cannabis retail market and (2) estimate how potency and purchase quantity influence price variation for cannabis flower.

DESIGN

Secondary analysis of publicly available data from Washington State's cannabis traceability system spanning 7 July 2014 to 30 September 2016. Descriptive statistics and linear regressions assessed variation and trends in cannabis product variety and potency. Hedonic regressions estimated how purchase quantity and potency influence cannabis flower price variation.

SETTING

Washington State, USA.

PARTICIPANTS

(1) A total of 44 482 176 million cannabis purchases, including (2) 31 052 123 cannabis flower purchases after trimming price and quantity outliers.

MEASUREMENTS

Primary outcome measures were (1) monthly expenditures on cannabis, total delta-9-tetrahydrocannabinol (THC) concentration and cannabidiol (CBD) concentration by product type and (2) excise tax-inclusive price per gram of cannabis flower. Key covariates for the hedonic price regressions included quantity purchased, THC and CBD.

FINDINGS

Traditional cannabis flowers still account for the majority of spending (66.6%), but the market share of extracts for inhalation increased by 145.8% between October 2014 and September 2016, now comprising 21.2% of sales. The average THC-level for cannabis extracts is more than triple that for cannabis flowers (68.7% compared to 20.6%). For flower products, there is a statistically significant relationship between price per gram and both THC [coefficient = 0.012; 95% confidence interval (CI) = 0.011-0.013] and CBD (coefficient = 0.017; CI = 0.015-0.019). The estimated discount elasticity is -0.06 (CI = -0.07 to -0.05).

CONCLUSIONS

In the state of Washington, USA, the legal cannabis market is currently dominated by high-THC cannabis flower, and features growing expenditures on extracts. For cannabis flower, both THC and CBD are associated with higher per-gram prices, and there are small but significant quantity discounts.

How Medical Marijuana Smoothed the Transition to Marijuana Legalization in the United States

Public support for legalizing marijuana use increased from 25% in 1995 to 60% in 2016, rising in lockstep with support for same-sex marriage. Between November 2012 and November 2016, voters in eight states passed ballot initiatives to legalize marijuana sales for nonmedical purposes-covering one-fifth of the US population. These changes are unprecedented but are not independent of the changes in medical marijuana laws that have occurred over the past 20 years. This article suggests five ways in which the passage and implementation of medical marijuana laws smoothed the transition to nonmedical legalization in the United States: (a) They demonstrated the efficacy of using voter initiatives to change marijuana supply laws, (b) enabled the psychological changes needed to destabilize the "war on drugs" policy stasis, (c) generated an evidence base that could be used to downplay concerns about nonmedical legalization, (d) created a visible and active marijuana industry, and (e) revealed that the federal government would allow state and local jurisdictions to generate tax revenue from marijuana.

An Exploratory Study of Cannabis Festivals and Their Attendees in Two European Cities: Amsterdam and Berlin

This study was designed to explore the nature and features of cannabis festivals, characteristics of festival participants, and reasons for attendance. A field study in two European cities (Amsterdam and Berlin) included participant observation at the festivals, interviews with local organizers, and a survey among festival attendees (n = 728). Both festivals had common features, but also showed distinct differences. At both festivals, nine out of 10 participants were current, often daily cannabis users. Participants were mainly young adults (mean = 26.2 years), but younger in Berlin than in Amsterdam. Common reasons for festival attendance were "protest/activism" and "entertainment." Protest/activism was more likely in Berlin, among daily cannabis users, and participants aged 25+ years. Entertainment was more likely in Amsterdam, among non-daily cannabis users, and participants younger than 25 years. Although similar in political aim, cannabis festivals are characterized by distinctive local features, as well as differences in attendee profile and reasons for festival participation. Findings suggest that the latter differences are driven by differences in cannabis policy, with a stronger tendency towards protest/activism in countries with a less liberal, or more restrictive, cannabis policy. Future research should include more countries, representing a wider variation in cannabis policies.

U.S. cannabis legalization and use of vaping and edible products among youth

BACKGROUND

Alternative methods for consuming cannabis (e.g., vaping and edibles) have become more popular in the wake of U.S. cannabis legalization. Specific provisions of legal cannabis laws (LCL) (e.g., dispensary regulations) may impact the likelihood that youth will use alternative methods and the age at which they first try the method - potentially magnifying or mitigating the developmental harms of cannabis use.

METHODS

This study examined associations between LCL provisions and how youth consume cannabis. An online cannabis use survey was distributed using Facebook advertising, and data were collected from 2630 cannabis-using youth (ages 14-18). U.S. states were coded for LCL status and various LCL provisions. Regression analyses tested associations among lifetime use and age of onset of cannabis vaping and edibles and LCL provisions.

RESULTS

Longer LCL duration (OR_vaping: 2.82, 95% CI: 2.24, 3.55; OR_edibles: 3.82, 95% CI: 2.96, 4.94), and higher dispensary density (OR_vaping: 2.68, 95% CI: 2.12, 3.38; OR_edibles: 3.31, 95% CI: 2.56, 4.26), were related to higher likelihood of trying vaping and edibles. Permitting home cultivation was related to higher likelihood (OR: 1.93, 95% CI: 1.50, 2.48) and younger age of onset (β: -0.30, 95% CI: -0.45, -0.15) of edibles.

CONCLUSION

Specific provisions of LCL appear to impact the likelihood, and age at which, youth use alternative methods to consume cannabis. These methods may carry differential risks for initiation and escalation of cannabis use. Understanding associations between LCL provisions and methods of administration can inform the design of effective cannabis regulatory strategies.

Are dispensaries indispensable? Patient experiences of access to cannabis from medical cannabis dispensaries in Canada

BACKGROUND

In 2001, Canada established a federal program for cannabis for therapeutic purposes (CTP). Medical cannabis dispensaries (dispensaries) are widely accessed as a source of CTP despite storefront sales of cannabis being illegal. The discrepancy between legal status and social practice has fuelled active debate regarding the role of dispensaries. The present study aims to inform this debate by analysing CTP user experiences with different CTP sources, and comparing dispensary users to those accessing CTP from other sources.

METHODS

We compared sociodemographic characteristics, health related factors and patterns of cannabis use of 445 respondents, 215 who accessed CTP from dispensaries with 230 who accessed other sources. We compared patients' ratings of CTP sources (dispensaries, Health Canada's supplier, self-production, other producer, friend or acquaintance, street dealer) for quality and availability of product, safety and efficiency of access, cost, and feeling respected while accessing.

RESULTS

Patients using dispensaries were older, more likely to have arthritis and HIV/AIDS, and less likely to have mental health conditions than those not using dispensaries. Those accessing dispensaries used larger quantities of cannabis, placed greater value on access to specific strains, and were more likely to have legal authorization for CTP. Dispensaries were rated equally to or more favourably than other sources of CTP for quality, safety, availability, efficiency and feeling respected, and less favourably than self-production and other producer for cost.

CONCLUSION

Given the high endorsement of dispensaries by patients, future regulations should consider including dispensaries as a source of CTP and address known barriers to access such as cost and health care provider support. Further research should assess the impact of the addition of licensed producers on the role and perceived value of dispensaries within the Canadian medical cannabis system.

A Burning Problem: Cannabis Lessons Learned from Colorado

With recent increases in cannabis' popularity, including being legalized in several states, new issues have emerged related to use. Increases in the number of users, new products, and home growing all present distinct concerns. In the present review, we explored various cannabis-related concerns (i.e. use, acquiring, growing, and public health/policy) that have arisen in Colorado in order to provide information on emerging issues and future directions to mitigate negative outcomes that could occur in states considering, or that already have implemented, a legalized cannabis market. Specific to Colorado, issues have arisen related to edibles, vaporizers/'e-cannabis', concentrates, growing, quantifying use, intoxicated driving, and arrests. Understanding cannabis dosing (including dose-dependent effects and related consequences), standardizing quantities, evaluating the safety of new products, and developing harm reduction interventions are important next steps for informing public policy and promoting health and well-being. Overall, increasing our knowledge of emerging issues related to cannabis is key to promoting the benefits and combating the potential harms of cannabis, especially for states legalizing medical or recreational cannabis.

Consumer use and understanding of labelling information on edible marijuana products sold for recreational use in the states of Colorado and Washington

BACKGROUND

In 2014, the states of Colorado and Washington began allowing retail sales of marijuana for recreational use. The regulatory agencies in these states have implemented specific labelling requirements for edible marijuana products sold for recreational use to help address concerns such as delayed activation time, accidental ingestion, and proper dosing.

METHODS

We conducted 12 focus groups with 94 adult consumers and nonconsumers of edibles in Denver and Seattle to collect information on their use and understanding of labelling information on edible marijuana products sold for recreational use. Specifically, we asked participants about the usefulness, attractiveness, ease of comprehension, relevancy, and acceptability of the label information.

RESULTS

Some focus group participants look for and read specific information, such as the potency profile and serving size statement, but do not read or were unfamiliar with other labelling features. The focus groups revealed that participants have some concerns about the current labelling of edibles. In particular, participants were concerned that there is too much information on the labels so consumers may not read the label, there is no obvious indication that the product contains marijuana (e.g., a Universal Symbol), and the information on consumption advice is not clear. Participants in both locations suggested that education in a variety of formats, such as web- and video-based education, would be useful in informing consumers about the possible risks of edibles.

CONCLUSION

The focus group findings suggest that improvements are needed in the labelling of edibles to prevent unintentional ingestion among adult nonusers and help ensure proper dosing and safe consumption among adult users. These findings, along with lessons learned from Colorado and Washington, can help inform the labelling of edibles as additional states allow the sale of edibles for recreational use.

Into the void: Regulating pesticide use in Colorado's commercial cannabis markets

BACKGROUND

In 2014, Colorado implemented the world's first seed-to-sale recreational cannabis market under a commercial model. This paper aims to provide a thick descriptive account that gives insight into the issues and complexities of Colorado's pioneering and evolving attempt to regulate the use of pesticides on commercial cannabis plantations.

METHODS

The paper examines multiple data sets including: (i) Colorado State Government documents; (ii) recreational cannabis regulations; (iii) mass and niche media publications (n=175); (iv) face-to-face interviews with key stakeholders, including seniors, regulators and industry executives (n=8); and (v) field notes from relevant conferences and cultivation facility tours in Denver in October, 2016.

RESULTS

Two key issues are identified. First, a public safety threat has arisen relating to application of pesticides on cannabis with intensified toxicity in concentrated products of particular concern. Second, as a pioneering jurisdiction, Colorado faces a considerable knowledge gap. To expand collective learning on this issue, for which no regulatory template and little research exists, state regulators tapped industry and other stakeholder expertise while attempting to ensure public safety goals were achieved and regulatory capture by industry was limited.

CONCLUSION

Four years since the recreational cannabis market in Colorado was legalised, the State continues to grapple with the pesticide issue as testing regulations and cultivation standards are yet to be finalised. While more work is needed, Colorado has made significant progress in developing regulations relating to this complex matter. As governments of countries such as Canada and US states, including California, contemplate changes to recreational cannabis laws, Colorado's experience can assist regulators in other jurisdictions considering policy change.

Tasty THC: Promises and Challenges of Cannabis Edibles

Food products containing cannabis extract (edibles) have emerged as a popular and lucrative facet of the legalized market for both recreational and medicinal cannabis. The many formulations of cannabis extracts used in edibles present a unique regulatory challenge for policy makers. Though edibles are often considered a safe, discreet, and effective means of attaining the therapeutic and/or intoxicating effects of cannabis without exposure to the potentially harmful risks of cannabis smoking, little research has evaluated how ingestion differs from other methods of cannabis administration in terms of therapeutic efficacy, subjective effects, and safety. The most prominent difference between ingestion and inhalation of cannabis extracts is the delayed onset of drug effect with ingestion. Consumers often do not understand this aspect of edible use and may consume a greater than intended amount of drug before the drug has taken effect, often resulting in profoundly adverse effects. Written for the educated layperson and for policy makers, this paper explores the current state of research regarding edibles, highlighting the promises and challenges that edibles present to both users and policy makers, and describes the approaches that four states in which recreational cannabis use is legal have taken regarding regulating edibles.

Field observations of the developing legal recreational cannabis economy in Washington State

BACKGROUND

Washington State legalized the sale of recreational cannabis in 2012. This paper describes the unfolding of the market regulatory regime in an eastern portion of the state, including field descriptions to illustrate the setting.

METHODS

We made observations and conducted interviews of the local supply chain comprising a producer/processor, analytic facility, and retail establishments as well as querying the state director of the regulatory board.

RESULTS

Interviews and observations of facilities suggest an overwhelming concern for black market diversion drives state regulatory efforts. The ongoing dialogue between market actors and the state has resulted in a more equitable distribution of profits at different stages in the process. State safety regulations have thus far been shifted to independent laboratories. Banks and insurance companies have slowly begun making inroads into the industry, despite federal prohibition.

CONCLUSION

The law was conceived as a social justice remedy, but the bulk of the legal and regulatory activity surrounds cannabis marketplace management. This has been characterized by concerns for black market diversion, producer/processor profits, and a hands-off approach to safety regulation. Minor cannabis violations as a pathway to criminal justice system involvement have been reduced substantially but disproportionate enforcement upon racial/ethnic minorities continues.