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Cannabis and Public Health in an era of Legalization
October 17, 2019NYSPHA Fall Workshop
Gillian Schauer, PhD, MPH
University of WashingtonGillian Schauer Consulting
Slides not to be copied without express permission. ©Gillian Schauer Consulting, 2019
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Agenda
• Botany and history• Epidemiology• Products• Endocannabinoid System and Health Effects
– BREAK --
• Policy in the US and NY• Implications for Public Health• Overlap with other substances, nicotine, vaping
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AcknowledgementsThe CDC, CDC Foundation, National Institute on Drug Abuse,
and a number of states, who have been funders of my cannabis surveillance, policy, research, and translational work.
The findings and conclusions in this presentation are my own and do not necessarily represent the official position of any of the agencies
with whom I consult.
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Quick Primer on the plant
>90 Cannabinoids>100 Terpenes
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Marijuana Policy in the U.S.
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Marijuana policy in the US, as of July, 2019
2012
2012
2014
2014
2016
2016
2016
2018
2018
* VT and DC have legal medical marketplaces, but no planned legal non-medical/ adult use marketplaces ̂The KS Governor passed a bill to exempt CBD oil from the definition of marijuana, effectively legalizing CBD, though no THCis allowed in the product.
©Gillian Schauer Consulting, 2019
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How did we get here?
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How did we get here?
Painting of Cannabis Sativa,
AD 512
George Washington, Mt Vernon,
1700s
Medical cannabis in American pharmacy,
1850s
Jamestown Settlers, late
1600s
Global Cannabis Trade
©Gillian Schauer Consulting, 2018
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Brief Timeline of Cannabis Legalization in US States
Mar
ihuan
a Tax
Act En
acte
d Fed
erall
y
1937
1913
CA, ME,
WY,
IN ba
n mar
ijuan
a
29 St
ates B
an or C
rimina
lize m
ariju
ana
1933
OR beco
mes fir
st sta
te to
decri
minaliz
e
1973
AK, M
E, CO
, CA, O
H decri
minaliz
e
1975
NM Cont
rolle
d Sub
stanc
es Th
erap
eutic
Resea
rch Act
1978
VA le
galiz
es m
ariju
ana f
or two co
nditio
ns
1979
CA lega
lizes
med
ical m
ariju
ana (
in fu
ll)
1996
OR, AK,
WA le
galiz
e med
ical m
ariju
ana (
in fu
ll)
1998
CO an
d WA le
galiz
e adu
lt use
2012
OR, AK l
egali
ze ad
ult us
e
2014
AMA re
moves m
arihu
ana f
rom U
.S. Ph
armac
opeia
1942
War
on Dru
gs
1980
s
1906
Pure
Food a
nd D
rug A
ct Pa
ssed (
Poiso
n Act,
1907
)
Fede
ral Cont
rolle
d Sub
stanc
es Act
1970
Ogden
Mem
o (DOJ)
2009
Cole M
emo (D
OJ)
2013
Lear
y vs.
United
State
s
1969
CA, NV,
ME l
egali
ze
2016
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Ogden memo, 2009
…DOJ won’t focus on individuals who are
complying with state medical marijuana laws
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Cole memo, 2013
.…DOJ guidance to adult use states
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Sessions memo, 2018
…rescinds but does not replace Cole
memo
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Farm bill, 2018
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Hemp vs. Marijuana
HEMP MARIJUANANo longer Schedule 1 Schedule 1
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What are the health effects of marijuana (briefly)?
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Acute effects
Impaired memory, learning, and attention
Impaired motor coordination/reaction time
Altered judgment, increasing likelihood of risky behaviors
In high doses, acute psychosis and paranoia
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Longer-term effects
Cognitive development and related outcomes
Cannabis Use Disorder
Respiratory effects Mental health outcomesPregnancy outcomes
Abuse/dependence on other substances
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Therapeutic EffectsSchedule I substance
• No currently accepted medical use
Anecdotal evidence • Vocal advocacy community
Increasing scientific evidencefor medical use of cannabis or cannabinoids:
• Most promising for: pain relief, nausea relief, patient-reported symptoms from MS, rare seizure disorders; some evidence for sleep.
• 3 FDA approved synthetic THC drugs; 1 FDA approved cannabis-derived CBD drug (and related rescheduling)
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Who uses marijuana?
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Population based surveys
• National Survey on Drug Use and Health (NSDUH)
• Behavioral Risk Factor Surveillance System (BRFSS)
• Monitoring the Future (MTF)• Youth Risk Behavior Survey (YRBS)• Pregnancy Risk Assessment Monitoring
System (PRAMS)
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Past 30 day marijuana use, by age, National Survey on Drug Use and
Health, 2002-2017
0
5
1 0
1 5
2 0
2 5
2 00 2 2 00 3 2 00 4 2 00 5 2 00 6 2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5 2 01 6 2 01 7 2 01 8
1 2-1 7 y ea rs
1 8-2 5 y ea rs
2 6 ye ar s an d o ld e r
%
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Daily/near daily marijuana use, by age, among past month marijuana users National Survey on Drug Use
and Health, 2002-2017
0
5
10
15
20
25
30
35
40
45
50
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
12-17 years
18-25 years
26 years and older
%
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0
1 0
2 0
3 0
4 0
5 0
6 0
2 00 0 2 00 1 2 00 2 2 00 3 2 00 4 2 00 5 2 00 6 2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5 2 01 6 2 01 7 2 01 8
Il li ci t dr ug s
Alco ho l
Ge ttin g Dru n k
C ig ar ette s
E -ciga rette s/v ap ing
M ari jua n a
Past month substance use, among 12th graders, Monitoring the Future, 2000-2018
%
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Past month use, age 12 and older, by sex, NSDUH, 2002-2018
0
2
4
6
8
1 0
1 2
1 4
2 00 2 2 00 3 2 00 4 2 00 5 2 00 6 2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5 2 01 6 2 01 7 2 01 8
M ale
Fe m ale
%
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Past month use, age 12 and older, by race/ethnicity, NSDUH, 2002-2018
0
2
4
6
8
1 0
1 2
1 4
1 6
1 8
2 0
2 00 2 2 00 3 2 00 4 2 00 5 2 00 6 2 00 7 2 00 8 2 00 9 2 01 0 2 01 1 2 01 2 2 01 3 2 01 4 2 01 5 2 01 6 2 01 7 2 01 8
NH White
NH Bla ck
NH Ame rican Ind ian /Alask a Na tiv e
NH Asian
NH Mu lti rac ia l
Hisp an ic/La tino
NH= non-Hispanic
%
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Past month marijuana use, adults ≥ 18 years, by highest level of education, NSDUH, 2002-2014
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Past month marijuana use, adults ≥ 18 years, by current employment status, NSDUH, 2002-2014
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Past month marijuana use, adults ≥ 12 years, by geographic region, NSDUH, 2002-2014
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A deeper dive into specific populations…
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ØThe brain develops into young adulthood.
ØMarijuana use in adolescences and young adulthood can change the way the brain develops, and impact memory, learning, and attention.
ØTHC is fat soluble – crosses the blood/brain barrier in utero, passes into breast milk during breastfeeding.
ØTHC may disrupt the endocannabinoid system – which is important for a healthy pregnancy and fetal brain development.
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COLLEGE STUDENTS
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PREGNANT AND BREASTFEEDING WOMEN
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Prevalence of marijuana use among women of reproductive age, NSDUH, 2007-2012
Source: Ko JY, Farr SL, Tong VT, et al. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol, 2015; 213:201.e-1-10.
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Prevalence of marijuana use among women of reproductive age, by age, NSDUH, 2007-2012
Source: Ko JY, Farr SL, Tong VT, et al. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol, 2015; 213:201.e-1-10.
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
Pr egna nt Non pre gnant Pr egna nt Non pre gnant
Past mo nth use Past 2-12 mo nth use
18- 25
26- 34
35- 44
%
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Prevalence of daily/near daily marijuana use and marijuana abuse/dependence, NSDUH, 2007-2012
Source: Ko JY, Farr SL, Tong VT, et al. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol, 2015; 213:201.e-1-10.
0
2
4
6
8
1 0
1 2
1 4
1 6
1 8
2 0
Pregnant Nonpregnant
Da ily/nea r da ily use
Meet DS M criteriaforabuse/dependence
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Past month cannabis use among pregnant and nonpregnantwomen, NSDUH 2002-03 vs. 2016-17
Source: Volkow, Han, Compton, McCance-Katz, 2019, JAMA
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Past month daily/near daily cannabis use among pregnant and nonpregnant women, NSDUH 2002-03 vs. 2016-17
Source: Volkow, Han, Compton, McCance-Katz, 2019, JAMA
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Possible reasons for use in pregnancy?
Source: Volkow, Han, Compton, McCance-Katz, 2019, JAMA
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How is marijuana consumed?
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Marijuana Products and Modes of Use• Combusted products
(e.g., joints, pipes, bongs, bowls, blunts, spliffs)
• Vaporizers (e.g., electronic vapingdevices, or older models that are heat-not-burn)
• Edibles (e.g., brownies, cookies, candies)
• Drinks (e.g., elixirs, syrups, hot chocolates)
• Dabbing (e.g., using concentrates and waxes)
• Other ways©Gillian Schauer Consulting, 2018
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DEA Seizure Data
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Prevalence of marijuana mode of use, among past month marijuana users in 12 U.S. states,
BRFSS, 2016
%
Unpublished data, Schauer et al., 2016, from BRFSS
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Important gaps and limitations in marijuana surveillance
• Funding• Data on mode or method of use• Quantity/amount used questions• Type of product used (CBD/THC)
– Comment on CBD and surveillance• Medical marijuana questions• Driving question limitations• General lack of cognitively tested questions• Rapidly evolving marketplace
Surveillance is one of the most important things we can do prior to legalization!
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HEALTH EFFECTS AND THE ENDOCANNABINOID SYSTEM
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Cannabis Policy and Public Health Considerations
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Cannabis Policy in the U.S., as of July, 2019
2012
2012
2014
2014
2016
2016
2016
2018
2018
* VT and DC have legal m edical m arketplaces, but no legal adult use m arketplaces
^ The KS Governor passed a bill to exem pt CBD oil from the definition of m arijuana, effectively legalizing CBD, though no THC is allow ed in the product.
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What do these policies look like on the ground?
2012
2012
2014
2014
2016
2016
2016
2018
2018
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Legalization of MJ-derived CBD/Low-THC
• Often focus on CBD/low-THC oils
• Allow clinicians to “recommend” CBD…
• Laws often do not address how CBD oil is made, purchased or shipped
• Typically no marketplace
• Typically no regulatory agency
• Typically no product testing or oversight
• Legalization often looks more like decriminalization of CBD/low-THC products
• Regulations have traditionally been separate from hemp-derived products…though this is changing.
*Notable exception to all of this: Iowa
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Medical Legalization Policies• Public health is often the regulatory agency• Wide range of regulations in terms of:
• Marketplaces/number of outlets • Types of available products• Product preapprovals• Product/ingredient restrictions• Registries, cards, and fees• Who can dispense products• Homegrows• Lab testing
• Wide range of indications (not all based on science)
• Often paves the way for non-medical framework
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• Multi-State Collaborative on Cannabis and Public Health (est. 2013)
• Data Collection: • Quarterly updates from State Public Health Agencies and
Regulatory partners• Review of ballot measures, laws, rules & regulations
• Data Validity: • Snapshot in time – as of July, 2019• Cross checked by state agencies directly
• Analyses: • Overall, similarities and differences
Non-Medical Use Policy Tracking - Methods
Data presented with permission from participating states.
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Non-Medical/Adult Use States
*DC, VT not included in subsequent data, IL included when possible
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• Regulatory Authority: • Typically Depts. of Revenue/Taxation/Consumer Affairs
AND/OR Liquor/Alcohol/Beverage Control Boards (WA, AK, OR)
• Public health has had retail regulatory role in 2 states (CA, OR)
• 7 states (AK, CA, ME, MA, NV, OR, WA) have rule making/advisory boards; public health on all but 1 (WA); industry on all but 1 (WA)
• What’s Legal? • Most states have ~1oz possession or 7-8g concentrate (ME and
MI have 2.5 oz total)• MA and OR have higher home possession (10 oz and 8 oz)• Non-medical home grows allowed in all states (~6 plants; MI has
12), with exception of WA (and IL is not currently planning to allow them).
Policy Basics
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• Taxes: • Excise taxes vary widely: ~10-15% (ME, MA, MI, NV) to 37% (WA)• AK is only state with no user-based excise tax (only
growing/processing taxes)• IL is only state with tiered tax based on THC content
• Vertical integration• Allowed in all states except for WA (limitations in CA)
• Funding for Public Health Agency:• 7 states (AK, CA, CO, MA, OR, WA) have funding for public health
agency. Wide range in $$ ($1.5M to $18M annually). • Not protected. May supplant other funds.• Public health funding typically for surveillance, public education,
lab testing work
Policy Basics
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• Local Control to Ban/Amend Policy• Allowed in all states (with some tax implications
and restrictions on extent of local control)
• Medical Marijuana Marketplace• AK is only state without existing medical
marketplace• WA is only state with fully merged markets• All other states have or moving towards parallel
regulation
• Delivery• Allowed (with restrictions) in 3 states (CA, NV,
OR); pending in 2 states (CO, MI)
Policy Basics
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• Universal Symbol• Required in 6 states (CA, CO, MA, NV, OR, WA);
poison control line sticker also required for infused products in WA, similar adopted in MA
• Warning Labels• Required in all states, but vary widely• Most commonly include warnings against: youth
use, operating machinery/driving/impairment
• Some include warnings about: dependence (AK, WA) delayed effects from edibles (CO, MA, NV, WA)
Packaging and Labeling
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• Childproof packaging• Required in all states; resealable requirements in most states, some
also require opaque, childproof exist bag.
• Edibles• 10mg serving size in CA, CO, MI, NV, WA; 5mg in AK, OR, MA.• All states have provision that can’t appeal to kids (i.e., no cartoons,
limitations on gummy shapes)• Most states prohibit products that look like commercial food items,
including adulterated products. • Most states prohibit health and benefit claims on labels• Shelf-stable products only in WA
Packaging and Labeling
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Lab Testing• Third party testing:
• Exists in all states that have testing systems set up or planned
• Reference lab?• Exists in NV, pending in MA, CO
• Sampling and testing procedures: • Vary widely by state (with most testing for microbial
contamination, residual solvents, metals, and cannabinoid content). Sampling approaches vary as timing of testing.
• Cannabinoid/pesticide labeling• All states require THC content on label; 3 (CO, MA, OR, WA)
require CBD content. No states require pesticide disclosure on label, differences in pesticide testing across states.
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• Public/On-Site Consumption• Public/on-site consumption currently prohibited (MA, ME, NV, OR, WA)• Local/municipal exemptions allowed for onsite consumption/social clubs
(CA, CO, IL)• Allowed/will be allowed statewide (unless locality “opts out”) (AK, MI)
• Zoning and Advertising/Marketing• Zoning for retail locations varies [300 ft (NV) to 1000 ft (WA)] from
child/community-related locations (many localities can change)
Public Consumption, Zoning, Advertising
• In AK, CA, NV, WA: no advertising 1000 ft. from child/community-related locations
• In all states: cannot advertise health benefits, therapeutic effects, or make false statements
• Warnings on ads: MA, NV, OR; Billboard restrictions: CA, CO, WA
• Some TV/radio/print/internet ads allowed in most states, with audience restrictions
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• Public health has a seat at the table, but so does industry• Taxes vary widely, and new models may hold promise for public
health• Various medical/non-medical marketplace approaches• Warning labels and universal symbols vary widely – potential
implications?• Opportunities to improve packaging…• Onsite consumption/social clubs are an issue in every state• Advertising is an area of opportunity for public health• Public health funding….making progress, but insufficient to do
this work
Summary of state non-medical legalization policy
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Differences in state regulation between marijuana-derived CBD and hemp-derived CBD
Marijuana-derived CBD products• Regulated by marijuana
regulator (e.g., depts of revenue, taxation, etc.)
• Typically contains some THC
• Can only be sold in regulated retail stores
Hemp-derived CBD products• Typically regulated by Dept. of
Agriculture; regulatory framework not yet clear…
• Contains <0.3% THC
• Sold virtually everywhere (and in some states, it CANNOT be sold in retail cannabis stores)
Public health implications for: surveillance, social norms, vaping policy, youth access and potential use, advertising,
messaging, testing, food enforcement, etc.
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What’s happening on the ground in NY?
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How does cannabis overlap with other substances?
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Isn’t cannabis just like…
Opioids
Similarities:• Medical uses• Produced by our bodies• Impairing• Industry
Differences: • Respiratory depression• > Addiction potential• > Morbidity and Mortality
Tobacco
Similarities:• Populations • Mode of use/products• Policy overlap• Industry
Differences: • No accepted medical uses
for commercial tobacco• Not impairing• > Addiction potential• > Morbidity and Mortality
Alcohol
Similarities:• Prohibition à Legality• Policy overlap• Industry• Impairing• Addiction potential
Differences: • Mode of use• > Morbidity and Mortality
©Gillian Schauer Consulting, 2018
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Major areas of overlap between cannabis and tobacco:
• Populations
• Products / modes of consumption
• Policies
• Industry
Implications for: surveillance; policy; public education; social norms
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Source: Schauer, Berg, Kegler, Donovan, & Windle, 2016 (Data from the National Survey on Drug Use and Health)
~20% of past
m onth adult tobacco users
have past m onth
cannabis use
~70% of past month
adult cannabis
users have past month Tobacco use
Universe of Cannabis Users
Universe of Tobacco Users
Population overlap
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Methods of use: • Both primarily smoked1,2
• Emerging products look alike
• Emerging technologies crossing over…
Implications: • For surveillance• For policy• For enforcement• For messaging, public
education
Overlapping Methods of Use and Products
1: Schauer, King, Bunnell et al. (2016) Am J Prev M ed; 2: Odani,Arm our, Graffunder et al. (2018), M M W R.
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• Vaping policies• Smokefree policies
àLearnings for tobacco control, too:• Licensing• Point of sale• Product limitations• Testing regulations
Policy Overlap
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What we know: • Linked to a mode of consumption
(vaping), not a substance…yet• Involved substances include THC,
CBD, and nicotine• Licit and illicit markets
State Executive Orders• Advising against vaping • Banning vaping • Banning Flavors • Requiring ingredient disclosures• Requiring point of sale warnings • Setting infrastructure for ongoing recommendations
Vaping Lung Injury
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Implications and considerations for cannabis…
• Flavors• Other additives• The device itself• Testing and quality assurance
processes in legal market• Recall processes• Unregulated markets
Vaping Lung Injury
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What do we know about secondhand marijuana smoke?
• THC has not been found to be carcinogenic, but cannabis smoke has…1
• Cannabis smoke à many of the same constituents as tobacco smoke, and some in higher concentrations.2
• CA Office of Environmental Health Hazard Assessment: marijuana is a carcinogen in 2009 (w/at least 33 carcinogens present in the smoke).3
• American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) considers marijuana smoke and indoor pollutant.
1: W HO, 2016; 2: M oir et al., 2008; 3: Reproductive and Cancer Hazard Assessm ent Branch, Office of Environm ental Health Hazard
Assessm ent, California Environm ental Protection Agency. August 2009
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Equity issues• Banned from public spaces à use at home
• Use in public and rented housing à disparities in law enforcement
Science still unclear, lacking research and surveillance data
Cannabis ≠ Commercial Tobacco
Solutions?
Why is this a complicated landscape?
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Industry: Similarities to Big Tobacco
• Commercial industry
• Advertising
• Youth Appeal
• Harm reduction language
• Marketing, point of sale issues
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• Federal prohibition and state laws are limiting now….
• Big tobacco has long been interested in the marijuana industry1
• Evidence of current interest: • Name changes to broaden brand potential• Cannabis industry people moving onto tobacco
industry boards, and vice versa• Acquisitions of stakes in cannabis companies• Acquisitions of patents on specific cannabis
strains/products
1: Barry, R.A., H illam o, H., G lantz, S.A. (2014) W aiting for the opportune m om ent: the tobacco industry and m arijuana legalization.
M ilbank Quarterly; 92(2):207-42
Big Tobacco and Big Marijuana merging?
THIS IS NOT A REAL PRODUCT
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Public health implications and actions
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Public Health Implications and Challenges• Touches many areas of public health and safety:
• Adolescent health• Reproductive/maternal/child health• Chronic disease • Tobacco control, opioid prevention, other substance use• Injury prevention and control (drugged driving, accidental consumption/ingestion)• Environmental health (pesticides, lab testing, food safety, secondhand smoke exposure)• Behavioral health • Occupational health• Equity/Disparities
• Often a new area for public health agencies (capacity building);
• Lack of data, surveillance, research to inform messaging, education, programming;
• Limited funding for public health agencies to do this work;
• Differences from other substances like tobacco, alcohol, and opioids.
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An uphill battle for public health…
Citation: Kilmer, B. Recreational Cannabis – Minimizing the Health Risks from Legalization (2017) New England Journal of Medicine; 376 (8): 705-707
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What is public health doing?• Surveillance/monitoring• Public education:
– Educating adults about the law, responsible use
– Drive high get a DUI campaigns– Campaigns for kids (and parents),
pregnant & breastfeeding women– Safe storage/edibles messages
• Building coalitions/capacity• Contributing to research• Educating policymakers
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§ Policy is far ahead of the science.
§ “Head in the sand” is no longer an option.
§ Public health must have a seat at the table (and needs to be funded).
§ Acknowledge both harms and potential benefits.
§ Cannabis is different from other substances (but has overlaps).
§ Broad coalitions across government are needed – public health does not have all the answers here…
§ Learn from other states…and countries
Main take-aways for prevention and public health
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THANK YOU!
Contact information:
[email protected]@uw.edu
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