Abstract
As marijuana continues to be legalized in many states, little is known about best regulatory practice, exposing the population to significant potential harm. To assess the extent to which potential best practices, including those from tobacco control, were incorporated into state and local marijuana policies in California. California legalized medical marijuana in 1996 and adult recreational use in 2016, effective in January 2018. A cross-sectional study with data collection and analysis from February 1 to November 30, 2019, measured the adoption of potential demand reduction and youth protection best practices, including restrictions on sales, products, marketing, warnings, and taxation. Laws in effect by January 31, 2019, were verified and all 539 California local jurisdictions were studied. Adoption of potential best practices in marijuana laws for demand reduction and youth protection. The laws of 534 of California's 539 jurisdictions (99%) were successfully identified; 263 of these 534 jurisdictions (49%) allowed any retail sale of marijuana, covering 57% of the state's population. More than one-third of jurisdictions allow sales of marijuana for adult recreational use (203 of 534 [38%]); of those, 122 allow storefront dispensaries and 81 allow sales by delivery only. A total of 257 of 534 jurisdictions (48%) allow medical sales. Of 147 jurisdictions allowing medical or adult use dispensaries, 93 (63%) limited the number of licenses, with a mean of 1 store for every 19 058 residents (range, 154-355 143). The state imposed no limits on number of dispensaries or deliverers. Forty-two jurisdictions increased the state-specified distances required between dispensaries and schools. Only 8 jurisdictions allowing retail sales imposed restrictions on products exceeding state regulations; 1 prohibited sale of flavored products, 3 prohibited sale of marijuana-infused beverages, and 5 imposed additional restrictions on edible marijuana products. No jurisdictions limited potency of products sold, although 1 established a potency-linked tax. The state did not limit or tax potency, except for establishing a standard 10-mg dose of tetrahydrocannabinol for edible marijuana products, nor did they limit manufacturing or sale of flavored products. The state required only a health warning in 6-point font on packages. Twenty-seven jurisdictions required additional health warnings in stores or on packages, 27 allowed onsite consumption of marijuana products, and 13 allowed marijuana-related events. More than half of jurisdictions legalizing any cannabis commerce (154 of 289 [53%]) did not tax marijuana locally and little revenue was captured for prevention. Much of the state excise and cultivation taxes is slated for youth substance use prevention and treatment. In implementing legalization of marijuana in California, local policies varied widely. Where marijuana was legalized, many lessons from tobacco control to reduce demand, limit harm, and prevent youth use were not adopted, potentially creating greater risk of harm.
Highlights
Marijuana continues to be legalized in many states, generally with limited public health input
Valid medicinal applications exist, the National Academies of Science, Engineering, and Medicine concluded that substantial evidence suggests that marijuana use is associated with significant harms, including psychosis, schizophrenia, problem marijuana use, motor vehicle collisions, low birth weight, and respiratory symptoms.[1]
Vaping of marijuana in the past 30 days, which typically involves high-potency concentrates, increased from 5% of 12th-grade students in 2017 to 14% in 2019, with 3.5% vaping near daily in 2019.10 The potential magnitude of mental health effects associated with the growing market of high-potency marijuana products is evidenced by estimates of the population-attributable fraction of first-episode psychosis due to use of highpotency marijuana (>10% tetrahydrocannabinol [THC]) at 12% in 11 primarily European cities studied, and by elevated risk for first-episode psychosis found in individuals using these products daily.[11]
Summary
Marijuana continues to be legalized in many states, generally with limited public health input. Valid medicinal applications exist, the National Academies of Science, Engineering, and Medicine concluded that substantial evidence suggests that marijuana use is associated with significant harms, including psychosis, schizophrenia, problem marijuana use, motor vehicle collisions, low birth weight, and respiratory symptoms.[1] Evidence is emerging regarding the association of marijuana use with youths’ cognition[2,3] and cardiovascular disease,[4,5,6] as well as other areas, and the 2019 vaping epidemic demonstrated the hazards of rapid product innovation without due evaluation of safety.[7] With widespread lifetime and adolescent use of marijuana, reaching 43.6% of 12th-grade students nationally,[8] and 51.5% of 18- to 25-year-olds in 2018,9 even modest increases in risk may have a significant effect on population health. In 2014, marijuana was the leading drug used by clients entering drug treatment in a study of 22 European countries, representing 46% of all new clients, up from 29% in 2003.12 Both marijuana-related new clients and daily users in treatment more than doubled between 2003 and 2014
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