Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023

Objectives

Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time.

Methods

In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities.

Results

Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %).

Conclusions

Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults

The marketing of heated tobacco products (HTPs), like IQOS, influences consumers' perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. 'Go smoke-free…') across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.

Impact of exposures to Heated Tobacco Products in the media and through social connections on product perceptions and use

INTRODUCTION

Little is known about media exposures to heated tobacco products (HTPs). In this study, we examined sources of HTP exposure, including from paid and unpaid media and social connections, in relation to HTP use and use intentions.

METHODS

In the fall of 2021, we conducted a cross-sectional survey among adult online panelists (aged 18-45 years) in the US and Israel, oversampling tobacco users. The current study analyzed data from participants who responded to the question about HTP awareness or use (n=2061). Multivariable linear and logistic regression analyses examined the relationship between sources of HTP exposure, HTP use, and use intentions.

RESULTS

Among those aware of HTPs, both Israelis and Americans reported past-month HTP media exposure via advertisements (58.2% vs 48.0%), non-advertisement sources (49.7% vs 30.7%), and social connections (51.5% vs 33.6%), respectively. Factors associated with HTP awareness (n=677/2061; 32.9%) included media use frequency (AOR=1.13; 95% CI: 1.01-1.28) and social connections using HTPs (AOR=2.45; 95% CI: 1.92-3.15). Among those aware of HTPs, past-month HTP exposure via digital media advertisements (AOR=2.06; 95% CI: 1.09-3.91) and non-advertising promotion via radio, podcast, movie, television or theatre (AOR=2.30; 95% CI: 1.19-4.44) and websites (AOR=2.36; 95% CI: 1.32-4.21) were associated with current HTP use. Exposure to digital media advertisements (β=0.35; 95% CI: 0.07-0.62) and non-advertising promotion via social media (β=0.62; 95% CI: 0.34-0.91) were correlated with higher use intentions. Having social connections using HTPs was correlated with higher use (AOR=2.21; 95% CI: 1.19-4.11) and intentions (β=0.66; 95% CI: 0.42-0.91). No significant differences were found across countries.

CONCLUSIONS

Digital media (e.g. online, social media) were particularly salient correlates of HTP intentions and use. Future studies are needed that further examine media exposures to these products, as well as that examine possible regulations to limit HTP promotion via these channels.

Two-part models identifying predictors of cigarette, e-cigarette, and cannabis use and change in use over time among young adults in the US

BACKGROUND AND OBJECTIVES

Limited longitudinal research has examined differential interpersonal and intrapersonal correlates of young adult use and use frequency of cigarettes, e-cigarettes, and cannabis. This study aimed to address these limitations.

METHODS

We analyzed five waves of longitudinal data (2018-2020) among 3006 US young adults (Mage = 24.55, 44% male, 32% sexual minority, ~30% racial/ethnic minority). Two-part latent growth models examined likelihood of past-month cigarette, e-cigarette, and cannabis use (binary part) and days used (continuous part) and identified predictors (depressive symptoms, personality traits, adverse childhood experiences [ACEs], parental use) of baseline use and changes over time.

RESULTS

Regarding baseline past-month use (27% cigarettes, 38% e-cigarettes, 39% cannabis), depressive symptoms, ACEs, and parental substance use predicted use outcomes (i.e., likelihood, frequency) for each product; extraversion predicted cigarette and e-cigarette use outcomes; openness predicted e-cigarette and cannabis use outcomes; conscientiousness negatively predicted cigarette and cannabis use outcomes; and agreeableness negatively predicted cannabis use frequency. Regarding longitudinal changes, conscientiousness predicted accelerated increase of cigarette use frequency at later timepoints; depressive symptoms predicted increases in likelihood of e-cigarette use but the association weakened over time; and parental cannabis use predicted decreased cannabis use frequency but the association weakened over time.

DISCUSSION AND CONCLUSIONS

Young adult substance use interventions should target high-risk subgroups and focus on distinct factors impacting use, including chronic, escalating, and decreasing use.

SCIENTIFIC SIGNIFICANCE

This study advances the literature regarding distinct predictors of different substance use outcomes and provides unique data to inform interventions targeting young adult cigarette, e-cigarette, and cannabis use.

Driving Under the Influence of Alcohol, Cannabis, and Delta-8 THC: Perceived Likelihood, Risk Perceptions, and Behaviors

Driving under the influence (DUI) of alcohol or cannabis poses public health risks. Little is known about DUI of Delta-8 THC, a newer cannabis product. Using 2022 survey data among 189 U.S. adults ages 18-25 (58.73% male, 59.26% non-Hispanic White), multivariable logistic regression examined substance-specific (alcohol, cannabis, Delta-8) DUI perceived likelihood and risk in relation to past-year DUI among those with past-year use of each. Overall, 72.49% reported past-year alcohol use, 50.53% cannabis, and 22.46% Delta-8. Among those reporting past-year use of each respective substance, 33.58% reported DUI of alcohol, 32.63% cannabis, and 57.14% Delta-8. On average, participants had the same DUI perceived likelihood ("somewhat unlikely") across substances and perceived alcohol DUI as riskiest. Higher alcohol DUI perceived likelihood and lower perceived risk were associated with alcohol-related DUI. Greater cannabis-related perceived likelihood (but not risk) was associated with cannabis-related DUI. Neither Delta-8 DUI perceived likelihood nor risk were associated with Delta-8 DUI. In sum, perceived DUI likelihood for alcohol, cannabis, or Delta-8 tended to be similar. Among those with past-year use of each, the proportion of DUI was highest for Delta-8. Interventions should target DUI-related perceived likelihood and promote protective behavioral strategies that reduce substance-specific DUI risk.

Alcohol to-go sales policies at on-premise drinking establishments near large public US universities during the COVID-19 pandemic

AIMS

Sweeping policy changes during the COVID-19 pandemic increased alcohol availability through permitted to-go sales, potentially posing unique risks to college students. While to-go sales may make binge drinking more convenient, little remains known about these practices. Therefore, this study aimed to assess whether drinking establishments' to-go sales practices are associated with their other operational practices and state policy.

METHOD

This cross-sectional analysis included 221 randomly selected bars, nightclubs, and restaurants within two miles of a large public university. Telephone interviews assessed establishment practices, and the Alcohol Policy Information System provided state alcohol to-go laws. Regression models tested whether establishment to-go sales practices were associated with their business practices (logistic regression) and state policy (generalized estimating equations).

RESULTS

Nearly one-half (44.8%) of drinking establishments sold alcohol to-go. Establishments with higher vodka prices had nearly 30% higher odds of selling spirits to-go (aOR = 1.29) and establishments offering happy hours specials had more than twice the odds of selling beer (aOR = 2.22), wine (aOR = 2.53), and spirits to-go (aOR = 2.60). Additionally, establishments that implemented physical distance requirements had higher odds of selling wine to-go (aOR = 3.00). State to-go laws were associated with higher odds of selling wine (aOR = 3.99) and spirits to-go (aOR = 5.43) in the full sample and beer to-go (aOR = 4.92) in urban counties.

CONCLUSIONS

Establishments that sell alcohol to-go tend to engage in other practices designed to drive sales. Evaluations of alcohol to-go sales laws on risky consumption among priority populations, including college students, are urgently needed to inform decisions about how to appropriately regulate sales.

Derived psychoactive cannabis products and 4/20 specials: An assessment of popular brands and retail price discounts in Fort Worth, Texas, 2023

BACKGROUND

Retail sales of derived psychoactive cannabis products (DPCPs) have increased in the U.S. since passing the 2018 Farm Bill and is unregulated in most states. This study investigated the types and commonly sold brands of DPCPs as well as promotional pricing on April 20th, a day associated with cannabis use.

METHODS

On April 19-20, 2023, investigators conducted telephone surveys with 98 retail stores that sold DPCPs in Fort Worth, Texas (where the market was largely unregulated).

RESULTS

Delta-8, Delta-9, and Delta-10 THC products were widely available, with 97%, 72%, and 82% of stores selling each type, respectively. Fifteen additional DPCPs were identified, and selling blends containing multiple types of THC was common. Frequently sold brands included Cake, Medusa/Modus, Torch, Urb, Kik, Tyson, 3Chi, Casper, Hidden Hills, Esco Bars, Happi, Hometown Hero, STNR, Bomb Bars, Baked, Hi On Nature, Looper, and Space God. Overall, 45% reported having 4/20 specials discounting prices on DPCPs, smoking devices/accessories, or everything in the store. Several stores also sponsored 4/20 promotional events including free THC gummies and "live delta demos where people can test cartridges and try smoking flower in the store."

CONCLUSIONS

Findings highlight the growing complexity of the DPCP market, including numerous different intoxicating compounds and blends. Policymakers, researchers, and public health professionals should consider these complexities, as well as the commonly sold brands, when developing strategies to regulate DPCPs and protect consumer safety. Pricing policies may be an especially important form of harm reduction during events associated with heavy cannabis use, including 4/20.

IQOS point-of-sale marketing: a comparison between Arab and Jewish neighborhoods in Israel

Background

Philip Morris International's (PMI) IQOS, with its heatsticks (HEETS), is the heated tobacco product with the largest global market share. IQOS and/or electronic cigarettes use rate is higher among Arabs vs. Jews in Israel. This paper aims to compare IQOS point-of-sale (POS) marketing strategies, and regulatory compliance in Arab vs. Jewish neighborhoods in Israel.

Methods

We integrated data from two separate studies including a cross-sectional survey with IQOS retailers (December 2020-April 2021) and audits of POS that sold IQOS/HEETS (April 2021-July 2021) in 5 large cities in Israel, after marketing restrictions including a POS display ban and plain packaging became effective in Israel (January 2020). The survey included 69 POS (21 Arab, 48 Jewish neighborhoods) and the audits included 129 POS (48 Arab, 81 Jewish neighborhoods). Comparisons of IQOS marketing strategies between POS in Arab and Jewish neighborhoods were conducted using Chi-Square test, Fisher's exact test or Mann-Whitney test, as appropriate. Thematic analysis was used to analyze open-ended questions.

Results

Most marketing strategies, such as promotions to customers, were uniform across POS in Arab and Jewish neighborhoods. The most noteworthy differences were that a higher proportion of retailers from Arab neighborhoods were invited to IQOS parties (47.6% vs. 21.7%, p<0.05) and reported personal communication with a PMI representative (80.0% vs. 51.2%, p<0.05). Additionally, PMI representatives assisted POS in both Arab and Jewish neighborhoods in implementing the display ban by providing free compliant cabinets and product placement instructions, and directly interacted with customers. POS in Arab neighborhoods were more compliant with the display ban (25.5% vs. 8.8%, p<0.05), but less compliant with plain packaging (62.5% vs. 79.3%, p<0.05).

Conclusions

There were not many notable differences in IQOS marketing across POS in Arab vs. Jewish neighborhoods, but PMI utilized marketing elements of cultural significance, especially for POS in Arab neighborhoods, such as more personal communication and invitation to social events. Continuous surveillance of tobacco POS marketing and legislation compliance is needed, with a special focus on demographic/location-based differences.

Delta-8 THC Retail Availability, Price, and Minimum Purchase Age

Background: Retail sales of Delta-8 tetrahydrocannabinol (THC) products have increased in the U.S. market since the passing of the 2018 Farm Bill, and there is currently little regulation of marketing/sales and limited related safety standards in many states. After thousands of calls to poison control centers (40% for individuals under 18 years old and 70% requiring health care facility evaluation), the Food and Drug Administration issued warnings on Delta-8 THC products, stating their psychoactive effects and that some manufacturers may synthesize Delta-8 using unsafe household chemicals. The current study describes the Delta-8 THC retail sales environment in Fort Worth, Texas. Given its relatively inexpensive manufacturing and that low prices are a major determinant of cannabis use, the price of Delta-8 THC products was examined. This study also examined whether retail outlets in areas with greater socioeconomic deprivation had higher odds of selling Delta-8 THC products. This is important because if Delta-8 THC retailers are disproportionately located in more socioeconomically deprived communities, residents of these communities can more easily access these products and may have higher risk of adverse consequences. Methods: Potential Delta-8 THC retailers were selected by identifying lists of current retail locations with alcohol, cannabidiol, and/or tobacco licenses in Fort Worth. Trained research assistants called outlets in September and October 2021 to query about sales of products containing Delta-8 THC. The response rate was 69% (n=1,223). Outlets' 9-digit zip codes were merged with Area Deprivation Index scores. Products and purported minimum age were described. Chi-squared and Student's t-tests were used. Results: Eleven percent of outlets (n=133) reported selling Delta-8 THC. Ninety-six percent sold vapes and/or "flower" (i.e., hemp leaves coated with Delta-8 THC distillate) and 76% sold edibles. Among the least expensive products available, edibles cost, on average, $8.58 less than flower/vapes (p<0.001). Outlets that sold Delta-8 THC were located in areas with greater deprivation (p=0.02). Most reported a minimum purchase age of 21; however, 4% reported 18 years or no minimum age. Conclusions: Delta-8 THC retail outlets were disproportionately located in areas with more socioeconomic deprivation. Legal intervention such as zoning, minimum age, and tax laws may help reduce Delta-8 THC-related disparities.

Driving under the influence of cannabis versus alcohol: A mixed-methods study examining perceptions and related risk behaviors among US and Israeli adults

BACKGROUND

Despite the dangers of driving under the influence (DUI), little is known about DUI substance-specific risk perceptions or risk factors for riding with drunk/drugged drivers (RDD).

METHODS

In this sequential exploratory mixed-methods study, we conducted: 1) multivariable analyses of cross-sectional survey data from 2222 US and Israeli adults to identify correlates of perceived cannabis- vs. alcohol-related DUI risks (linear regression) and past-month RDD involving alcohol-only, cannabis-only, or both (alcohol-cannabis) (multinomial logistic regression); and 2) deductive-inductive thematic analyses of qualitative interview data from 84 participants to identify themes elaborating on survey findings regarding DUI-related risk perceptions.

RESULTS

54.0 % reported past-month alcohol use, 16.7 % cannabis use, 4.2 % alcohol-only RDD, 5.5 % cannabis-only RDD, and 7.9 % alcohol-cannabis RDD. Being from the US, not having children at home, and cannabis non-use correlated with lower perceived cannabis vs. alcohol DUI risk. Lower perceived cannabis vs. alcohol DUI risk correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. cannabis-only) RDD. Alcohol use correlated with alcohol-only (vs. no) RDD and alcohol-cannabis (vs. cannabis-only) RDD. Cannabis use correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. alcohol-only) RDD. Being from the US correlated with alcohol-only (vs. alcohol-cannabis and none) RDD and cannabis-only (vs. alcohol-cannabis) RDD; being from Israel correlated with alcohol-cannabis (vs. no) RDD. Qualitative data indicated most participants perceived greater risk of DUI of alcohol vs. cannabis and desired more effective DUI-related prevention and regulatory efforts.

CONCLUSIONS

Prevention interventions targeting DUI- and RDD-related risk perceptions are needed, particularly for high-risk populations.

Cannabis Retailer Communication About Cannabis Products, Health Benefits, and Risks: A Mystery Shopper Study of Licensed Retailers in Five U.S. Cities

OBJECTIVE

As the U.S. cannabis market expands, surveillance of retailer practices, especially product health claims and risks, is crucial to protect consumers. In this study, mystery shoppers (i.e., staff not explicitly identified as researchers) examined retail personnel communication regarding product recommendations, health benefits, safety, and/or risks among U.S. cannabis retailers.

METHOD

In Summer 2022, mystery shoppers audited 140 licensed cannabis retailers in 5 cities in states with established nonmedical (i.e., recreational) cannabis sales and diverse regulations (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive and bivariate analyses characterized retail personnel communication overall and across cities.

RESULTS

Common product recommendations for new users included edibles, pre-rolled joints, and bud/flower, and 8.6% offered free/inexpensive ways to sample products. Although Colorado, Washington, and Oregon explicitly prohibited health claims in advertising or labels, more than 90% of retailers there endorsed use for anxiety, insomnia, and/or pain. Whereas 54.3% endorsed use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%), 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%). Overall, 52.1% warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%). Almost all (≥90%) sold cannabidiol (CBD) products and endorsed their health benefits and safety, but few (<10%) sold or endorsed delta-8 tetrahydrocannabinol (THC), etc. (all of which were in Los Angeles).

CONCLUSIONS

Ongoing cannabis retail surveillance, particularly using protocols assessing factors outside those visibly observable, is needed to inform regulatory and enforcement efforts, especially related to health claims.

Kratom Retail Availability in Fort Worth, Texas

Kratom use is associated with cannabis use, so retail availability may also be related. Kratom and Delta-8 THC (a psychoactive cannabis product) are federally unregulated, marketed as "natural," and often used for pain relief and/or relaxation. Kratom may have greater retail availability in more socioeconomically deprived areas because harmful substances are frequently marketed to lower-income communities. This study examined kratom retail availability in Fort Worth, Texas. Locations with alcohol, tobacco, and/or CBD licenses were called in July 2022: 1,025/1,223 (84%) answered the phone. T-tests examined potential differences in socioeconomic deprivation scores surrounding outlets by whether they sold kratom. Cross-tabulations examined overlap in kratom and Delta-8 THC availability. Kratom was available in 6% of locations. Most kratom retailers had a tobacco license (92%). However, most stores with a tobacco license did not sell kratom (14%), whereas most stores with a CBD license did (55%). Kratom availability was not associated with area deprivation scores. Most kratom retailers (95%) sold Delta-8 THC and two-thirds (65%) of Delta-8 THC retailers sold kratom. This study was the first to examine retail availability of kratom. Findings indicate the presence of niche stores specializing in the retail of federally unregulated substances.

Exposure to e-cigarette advertisements and non-advertising content in relation to use behaviors and perceptions among US and Israeli adults

INTRODUCTION

As e-cigarette marketing strategies diversify, it is important to examine exposure to and impact of e-cigarette advertisements and non-advertising content (e.g. on social media) via multiple media channels among adults in different regulatory contexts.

METHODS

Using 2021 cross-sectional data among 2222 adults in the US (n=1128) and Israel (n=1094), multivariable regression examined past-month e-cigarette advertisement and non-advertising content exposure in relation to past-month e-cigarette use (logistic regression), as well as use intentions and risk perceptions (linear regressions), controlling for sociodemographics and tobacco use.

RESULTS

Overall, 20.3% reported past-month e-cigarette use (15.5% US, 25.2% Israel), 46.1% any advertisement exposure (28.7% digital media, 25.2% traditional media, 16.8% retail settings), and 34.1% any non-advertising exposure (19.4% social media, 13.6% websites, 12.3% movie/television/theater, 5.8% radio/podcasts). Exposure to digital media advertisements (AOR=1.95; 95% CI: 1.42-2.66), traditional media advertisements (AOR=2.00; 95% CI=1.49-2.68), and social media non-advertising (AOR=1.72; 95% CI: 1.25-2.36) correlated with e-cigarette use. Exposure to traditional media advertisements (β=0.23; 95% CI: 0.08-0.38) and social media non-advertising (β=0.26; 95% CI: 0.09-0.43) correlated with use intentions. Exposure to digital media advertisements (β= -0.32; 95% CI: -0.57 - -0.08), retail setting advertisements (β= -0.30; 95% CI: -0.58 - -0.03), and radio/podcast non-advertising (β= -0.44; 95% CI: -0.84 - -0.03) correlated with lower perceived addictiveness. Radio/podcast non-advertising exposure (β= -0.50; 95% CI: -0.84 - -0.16) correlated with lower perceived harm. However, retail setting advertisement exposure was associated with e-cigarette non-use (AOR=0.61; 95% CI: 0.42-0.87), and traditional media advertisement (β=0.38; 95% CI: 0.15-0.61) and social media non-advertising exposure (β=0.40; 95% CI: 0.14-0.66) correlated with greater perceived addictiveness.

CONCLUSIONS

E-cigarette-related promotional content exposure across media platforms impacts perceptions and use, thus warranting regulation.

Health warning labels on heated tobacco products and their impact on use intentions and risk perceptions: a cross-sectional study of adult tobacco users in the US and Israel

BACKGROUND

Health warning labels (HWLs) represent an evidence-based tobacco control strategy; however, their application to heated tobacco products (HTPs) and related impacts are understudied. This study examined the impact of HTP HWLs on HTP use intentions and risk perceptions among current tobacco users.

METHODS

We analyzed cross-sectional survey data from adults in the US and Israel reporting past-month tobacco use and awareness of HTPs (N = 424). Multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of HTP HWLs (i.e., more concerned about HTP use, reassured, no effect [referent]) among those who noticed HTP HWLs (multinomial regressions); and (2) HWL impacts in relation to HTP use intentions and perceived addictiveness and harm (linear regressions).

RESULTS

Among participants who noticed HTP HWLs (n = 372, 87.7%), 27.7% reported HWLs increased their concerns about HTP use, 22.6% were reassured about use, and 49.7% reported no effect. Factors associated with increased concern (vs. no effect) included other tobacco product use (aOR = 2.10, 95% CI 1.21-3.64) and being female (aOR = 1.77, 95% CI 1.03-3.05). Factors associated with being reassured about HTPs use (vs. no effect) included current HTP use (aOR = 2.11, 95% CI 1.11-4.00) and being from Israel (vs. US: aOR = 3.85, 95% CI 1.85-7.69), female (aOR = 1.91, 95% CI 1.07-3.42), and less educated (< college education: aOR = 2.57, 95% CI 1.42-4.63). Reporting that HWLs on HTPs increased concern (β = 0.46, 95% CI 0.03-0.89) and reassured of use (β = 0.94, 95% CI 0.47-1.41) were positively associated with HTP use intentions; no associations with risk perceptions were found.

CONCLUSIONS

Findings indicate that most tobacco users noticed HWLs on HTPs, but the majority reported no effect or being reassured of using HTPs, effects that were magnified for specific subgroups. Both increased concern and reassurance correlated with greater use intentions. Additional research should evaluate HTP HWL impacts and ensure effectiveness in communicating risks and discouraging use.

Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors

BACKGROUND

Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months.

METHODS

Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home.

RESULTS

In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers.

CONCLUSIONS

SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.

The U.S. hemp-derived cannabinoid industry and the potential of self-regulation: Using social media to assess an evolving health risk

BACKGROUND

Facing statewide bans and increasing oversight in the U.S., representatives from the hemp-derived cannabinoid industry, product advocates, and consumers have been discussing self-policing and self-regulation. Prominent examples of these discussions are found online in Reddit groups.

METHODS

We conducted a qualitative thematic analysis of Reddit posts between September 2020 to August 2022, focusing on the conversations surrounding regulation and consumer safety. Approximately 3800 posts were collected and subject to initial analysis. Thematic analysis was guided by literature on self-regulation and consumer health, from the anthropology of pharmaceuticals and the commercial determinants of health.

RESULTS

The hemp-derived cannabinoid community is discussing self-regulation, shared standards, and transparency. Self-regulation is desired by many, in hopes to stave off prohibition or restrictive government regulation and simultaneously protect consumer health. However, there is little agreement as to what these standards should be, who should oversee them, or how basic concepts should be defined. Subreddit moderators note the ease at which unlicensed or untested products can enter retail store shelves or the informal market, thereby putting health at risk. Given the lack of collective agreement, the absence of state and federal oversight, and the possibilities for consumer deception, consumer frustration and confusion are rampant. With limited access to trustworthy and verifiable information about product safety, purchasers ultimately resort to experimenting on their own bodies to assess risks and benefits.

CONCLUSIONS

Reddit posts reflect the multiple existing tensions in the evolving industry between a genuine appeal among some for workable and consistent industry standards that could protect consumer health, a distrust of regulatory scrutiny from state or federal government, and a desire by others to maintain current profits within the existing unrestrictive free market. Our findings emphasize the urgency of developing coherent, collective, agreed upon policies structured by objective, transparent, scientifically informed regulation in order to develop a safe supply of cannabinoid products and protect consumer health.

The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco

Background

Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied.

Design and Methods

Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions).

Results

Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (β = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (β = -0.61, 95% CI:-1.05, -0.18), and harm (β = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (β = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk.

Conclusion

Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia

CONTEXT

Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018).

OBJECTIVE

We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings.

DESIGN

We analyzed 2022 survey data.

SETTING

Data were from 28 communities in Armenia and Georgia.

PARTICIPANTS

The sample comprised 1468 adults (31.6% past-month smokers).

METHODS

We conducted multivariable regressions, controlling for country and sociodemographics.

RESULTS

Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs.

CONCLUSIONS

Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

Theory-based correlates of cannabis use and intentions among US and Israeli adults: a mixed methods study

BACKGROUND

In the US and Israel, non-medical ('recreational') cannabis use is illegal at the national level; however, use rates are high and decriminalization and legalization is spreading. Thus, theory-based intervention efforts, especially for youth prevention, are crucial.

METHODS

This mixed-methods study of adults in the US (n = 1,128) and Israel (n = 1,094) analyzed: 1) cross-sectional survey data (Fall 2021) to identify theory-based correlates (risk perceptions, social norms) of past-month cannabis use, next-year use intentions, and intentions to use in the home or among children if non-medical cannabis was legal, using multivariable regression; and 2) qualitative interviews regarding perceptions of cannabis policies and use (US n = 40, Israel n = 44).

RESULTS

16.7% reported past-month use; 70.5%, 56.3%, and 82.6% indicated "not at all likely" regarding next-year use and use in the home and among children if legal. Lower perceived risk and greater social norms were associated with past-month use, greater use intentions, and greater intentions to use in the home or among children. Past-month use was more prevalent among US (vs. Israeli) participants (22.0% vs. 11.2%); however, in multivariable regression controlling for past-month use, being from Israel was associated with greater use intentions (next-year; in the home/among children). Qualitative themes indicated: concerns about use (e.g., increasing use, health risks, driving-related risks) and legalization (e.g., impact on society/economy, marketing), and perceived benefits of use (e.g., medical) and legalization (e.g., access/safety, economic, individual rights).

CONCLUSIONS

Despite differences in cannabis perceptions and use across countries, perceived risk and social norms are relevant intervention targets regardless of sociopolitical context.

Experiences of Microaggressions, Attributions, and Impact Among US Young Adults: An Intersectional Perspective Regarding Sexual/Gender and Racial/Ethnic Minorities

BACKGROUND

Understanding discrimination (e.g., microaggressions) toward sexual/gender minorities (SGM) and racial/ethnic minorities (REM) from an intersectional perspective is critical in informing interventions to reduce such experiences and their impacts.

PURPOSE

This study examined US young adults identifying as SGM, REM, both, or neither in relation to microaggression experiences, and these factors in relation to mental health.

METHODS

Using 2022 data from 932 US adults (Mage = 27.61) in an online survey study, we compared subgroups (SGM-only, REM-only, both, neither) in relation to microaggression experiences and mental health symptoms, stratified by sex (male, female). Multivariable linear regression examined: 1) sex and intersectional subgroup in relation to number of microaggressions experienced; and 2) sex, subgroup, and number of microaggression experiences in relation to mental health symptoms.

RESULTS

Among females (n = 612), 42.0% were SGM-only, 17.3% REM-only, 15.2% both, and 25.5% neither. Among males (n = 320), 25.0% were SGM-only, 25.0% REM-only, 8.4% both, and 41.6% neither. Females (vs. males) reported more microaggressions (M = 5.67, SD = 3.00 vs. M = 3.95, SD = 3.46, p < .001). Those with intersecting minority identities experienced the most microagressions (females: M = 6.98, SD = 2.64; males: M = 6.44, SD = 2.95, respectively). In multivariable analyses, females and those in any of the 3 minority-identifying subgroups experienced more microaggressions; those with intersecting minority identities experienced more microaggressions than SGM-only and REM-only. Identifying as SGM-only or both SGM and REM, as well as experiencing more microaggressions, was associated with greater mental health symptoms.

CONCLUSIONS

Intersecting minority identities increase risk for microaggressions and mental health consequences. Multilevel interventions must reduce minority subgroups' experiences of microaggressions and their impacts.

A review of social media platform policies that address cannabis promotion, marketing and sales

BACKGROUND

Cannabis marketing exposure via social media may impact use in youth and young adults. Most states with recreational cannabis lack policies regarding social media-based marketing. Thus, we examined such policies among prominent platforms, particularly those popular among youth and young adults.

METHODS

In September-October 2022, 3 research team members extracted policies applying to the general community, advertising, and any specific content regarding drug-related content for 11 social media sites: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitch, Twitter, and YouTube. Using inductive thematic analysis, they then dual-coded restrictions on cannabis-related content (e.g., paid advertising, unpaid promotion, sales). Descriptive analyses were conducted.

RESULTS

Ten (all except TikTok) referenced cannabis/marijuana, 7 (all except Discord, Instagram, TikTok, and YouTube) distinguished different cannabis-derived products, and 5 (Reddit, Snapchat, TikTok, Tumblr, Twitter) noted jurisdictional differences in cannabis regulations/legality. All prohibited sales, 9 (all except Snapchat and Tumblr) prohibited paid advertising, and 4 (Discord, Reddit, Snapchat, TikTok) prohibited unpaid promotion (e.g., user-generated content). All restricted underage access to cannabis-related content. However, policies varied and were ambiguous regarding how "promotion" was defined, whether/how jurisdictional differences in legality were addressed, how businesses may interact on social media, barriers implemented to inhibit the facilitation of sales, and enforcement protocols.

CONCLUSIONS

Social media policies regarding cannabis marketing are ambiguous and may facilitate cannabis marketing, promotion, sales, and underage exposure, thus compounding concerns regarding insufficient governmental regulations. Greater specificity in social media cannabis-related policies and enforcement is needed.

Delta-8, Delta-10, HHC, THC-O, THCP, and THCV: What Should We Call These Products?

The 2018 U.S. Federal Agriculture Improvement Act ("Farm Bill") resulted in what some have called a "legal loophole" in cannabis regulation. As different types of cannabis products proliferate, so has the terminology used to attempt to categorize them. This article presents a variety of potential descriptors to encourage dialogue about the language used to classify the multitude of psychoactive cannabinoid products that have grown in popularity since the passage of the 2018 Farm Bill. Our recommended term for these products is derived psychoactive cannabis products. The term derived helps distinguish these products from naturally grown cannabis products. Psychoactive makes clear that these products can produce psychoactive effects. Finally, cannabis products balances accuracy and understandability regarding the substance while discouraging perpetuation of the word marijuana because of its racist inception. The resulting term, derived psychoactive cannabis products, is broad enough to encapsulate all related products while being specific enough to exclude other substances. Adopting accurate and consistent terminology will reduce confusion and help establish a more cohesive scientific literature base.

Delta-8 tetrahydrocannabinol: a scoping review and commentary

BACKGROUND AND AIMS

Delta-8 tetrahydrocannabinol (THC) is a psychoactive substance from the Cannabis plant that has been rising in popularity in the United States since the 2018 US Farm Bill implicitly legalized it. This study reviewed research from peer-reviewed and non-peer-reviewed (e.g. anecdotal and news) reports related to delta-8 THC to summarize current knowledge and implications for public health and safety.

METHODS

A scoping review was conducted using PubMed, Scopus, Google Scholar and Google as search engines, leading to the identification of 103 documents that were summarized. The themes that emerged were (1) legality, (2) use (popularity, motives, psychoactivity/potency, benefits/consequences), (3) synthesis (byproducts, laboratory testing) and (4) retail (availability, price, packaging, youth-oriented marketing). A second author independently coded 20% of the documents, which verified the categorization of articles by these emergent themes.

RESULTS

Most research used animal/cell models or focused upon ways to identify the chemical structure of delta-8 THC in various products. Findings suggest that people often use delta-8 THC as a substitute for other substances. Anecdotally, delta-8 THC is a less potent psychoactive than delta-9 THC; however, several negative consequences have been reported. There is no federal age restriction for purchase/possession of delta-8 THC products. Delta-8 THC is readily accessible on-line, is typically less expensive than delta-9 THC and is often marketed in ways that would seemingly appeal to children. There are no regulations on synthesis, resulting in products being contaminated and/or yielding inconsistent effects. There have been thousands of calls to US poison control centers due to accidental delta-8 THC exposure among minors.

CONCLUSIONS

Most research on delta-8 THC is largely anecdotal, not peer-reviewed and does not involve human subjects. Future research should examine delta-8 THC use using nationally representative samples to more clearly understand the prevalence and consequences of use. Laws are needed to mitigate the risks of using delta-8 THC, particularly quality control of synthesis and minimum purchase age.

Profiles of tobacco product use and related consumer characteristics in the US and Israel: A multiple-group latent class analysis

Despite tobacco marketing diversification, limited research has examined use profiles across countries, particularly in relation to consumer values (e.g. appeal of innovation, conscientiousness). Using 2021 data, latent class analysis assessed past-month use of seven tobacco products (cigarettes, electronic cigarettes [e-cigarettes], heated tobacco products, cigars, hookah, pipe, smokeless) among adults reporting past-month use in the United States (US n = 382) and Israel (n = 561). Multivariable multinomial regression examined consumer values and sociodemographics in relation to country-specific class membership. US classes included: primarily cigarette 58.1%; e-cigarette-no cigarette 17.5%; primarily cigar 14.9%; and poly-product 9.9%. Higher innovation correlated with e-cigarette-no cigarette and poly-product (vs. primarily cigarette) use. Other correlates included being: younger with e-cigarette-no cigarette; male, Black, and more educated with primarily cigar; and Black and Asian (vs. White) with poly-product. Israel classes included: primarily cigarette 39.0%; moderate poly-product 40.3%; high poly-product 13.4%; and hookah 7.3%. Lower conscientiousness correlated with moderate poly-product (vs. primarily cigarette) use; higher innovation correlated with high poly-product; lower innovation correlated with hookah. Other correlates included being: younger, male, and more educated with moderate poly-product; male and sexual minority with high poly-product; and Arab with hookah. Tobacco consumer segments within and across countries likely reflect different consumer values and industry marketing targets.

A national assessment of on-premise drinking establishments near public universities: Drink prices, drink specials, indoor tobacco use, and state-level alcohol laws

BACKGROUND

Inexpensive drinks and price promotions increase alcohol consumption and have been observed at on-premise drinking establishments near large colleges. Some bars may sell tobacco products and allow indoor tobacco use to encourage patrons to stay and drink more. This study examined drink prices/specials and associated practices of on-premise drinking establishments including tobacco sales and policies regarding tobacco use.

METHODS

In 2018, telephone calls about prices/practices were made to 403 randomly selected bars/nightclubs within 2 miles of large residential universities in each U.S. state. The Alcohol Policy Information System provided data on state-level alcohol laws. Multivariable linear and logistic regression models examined associations between alcohol prices/specials, state laws, and establishment practices.

RESULTS

The average price for the least expensive draft beer and a vodka shot at each location were $3.62 (SD = $1.15) and $4.77 (SD = $1.16), respectively. Most establishments (65%) had happy hour specials, 6% had 2-for-1 specials, 91% sold food, 9% sold cigarettes, 8% allowed smoking indoors, and 18% permitted electronic cigarette (e-cigarette) use indoors. Allowing e-cigarette use indoors (b = -0.54) and selling cigarettes (b = -0.79) were associated with lower vodka prices; allowing cigarette smoking indoors (b = -0.46) was associated with lower beer prices. Lower beer prices (OR = 1.38), selling food (OR = 2.97), and no state law banning happy hour specials altogether (OR = 4.24) or with full-day price reduction exemptions (OR = 12.74) were associated with higher odds of having happy hour specials. Allowing e-cigarette use indoors was associated with having 2-for-1 specials (OR = 6.38).

CONCLUSION

In bars near large public universities, beers and shots were often available for less than $5 and drink specials were prevalent. Further, some establishments allowed tobacco use indoors and/or sold cigarettes. Laws that increase alcohol taxes, set minimum drink prices, and ban the sale and indoor use of tobacco products at on-premise drinking locations are important harm reduction tools.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Testing daily-level drinking and negative consequences as predictors of next-day drinking cognitions

OBJECTIVE

Limited research has examined how alcohol use and related consequences affect drinking-related cognitions, which is important as these cognitions may contribute to future drinking. The current study examines daily associations between alcohol use and alcohol-related negative consequences with next-day Prototype Willingness Model (PWM) social reaction pathway cognitions.

METHOD

Participants ages 15-25 years (N = 124, Mean age 18.7, SD = 2.87) completed daily surveys for up to three weeks (i.e., up to 11 surveys/week) using an ecological momentary assessment design. Linear mixed models and Poisson generalized mixed models were conducted to examine whether number of alcoholic drinks or number of negative alcohol-related consequences were associated with next-day PWM social reaction cognitions, including perceived vulnerability, descriptive normative perceptions of number of drinks consumed and the percentage of friends who drink, prototype favorability, prototype similarity, and willingness (i.e., openness) to drink.

RESULTS

Within-person results indicated more alcohol use on a given day was associated with lower next-day normative perceptions of the percentage of friends who drink on that day of the week and higher prototype similarity. Furthermore, within-person results indicated that experiencing more negative alcohol-related consequences on a given day was associated with higher perceived vulnerability and lower willingness to drink the next day.

CONCLUSIONS

Findings showed that next-day social reaction PWM cognitions were associated with prior day alcohol use and negative alcohol-related consequences, suggesting that an intervention might be timed to target drinking cognitions the morning following a drinking event, particularly after experiencing negative alcohol-related consequences.