Legal Cannabis Market Research Articles

Cannabis flower prices and transitions to legal sources after legalization in Canada, 2019–2020

BackgroundThe post-tax price of legal cannabis has the potential to influence whether consumers transition from the illegal to legal cannabis market. The aims of the study were to: 1) estimate the percentage who report purchasing dried flower at different sources; 2) estimate the unit price of dried flower; and 3) examine the association between price and legality of purchase source. MethodsRepeat cross-sectional survey data come from Canadian respondents from the International Cannabis Policy Study conducted in 2019 and 2020. Respondents were recruited through online commercial panels, of legal age to purchase cannabis (up to 65 years), and purchased dried flower in the past 12-months (n = 4923). Weighted binary logistic regression models examined the association between price and legality of source. ResultsThe proportion of consumers last purchasing dried flower from legal sources increased from 2019 to 2020 (45.7% vs 58.1%) and in the past 12-months, the average percent of dried flower consumers reported purchasing from legal sources increased from 2019 to 2020 (55.7% vs 67.5%). The mean price of legal dried flower decreased in 2020 ($12.63 vs $11.16; p < 0.001), but remained more expensive than illegal dried flower in both years ($12.63 vs $9.04 in 2019; p < 0.001, $11.16 vs $9.41 in 2020; p < 0.001). ConclusionsTwo years after legalization in Canada, the price of dried flower from legal sources decreased, along with a greater percentage of consumers purchasing from legal sources than after one year. Price and retail policies must continue to encourage the transition to the legal market in Canada.

Changes in California cannabis exposures following recreational legalization and the COVID-19 pandemic

Introduction Since 2012, eighteen states and the District of Columbia have legalized recreational cannabis. Past research suggests this policy change is associated with increased cannabis exposures however this has not yet been studied in California, despite its status as the world’s largest legal cannabis market. Methods This observational, retrospective study analyzed trends in cannabis exposures reported to the California Poison Control System (CPCS) from 2010 to 2020. We assessed shifts in exposures before and after the legalization of recreational cannabis in November 2016, the establishment of recreational retail sales in January 2018, and the institution of a statewide shelter-in-place order due to the COVID-19 pandemic in March 2020 using interrupted time-series analysis and reviewed all records to identify specific products associated with exposures. Results Between 2010 and 2020 edible exposures increased from near zero to 79% of exposures in 2020. Cannabis exposures significantly increased following recreational legalization in 2016 (by an estimated 2.07 exposures per month [CI: 0.60, 3.55]; p < 0.01) and initiation of retail sales in 2018 (0.85 [CI: 0.12, 1.58]; p < 0.05). There was no significant change in cannabis exposures following the first shelter-in-place order of the COVID-19 pandemic (1.59 [CI: −1.61, 3.68]; p = 0.43). Cannabis exposures for those thirteen and under increased significantly both after recreational legalization (1.04 [CI: 0.38, 1.70]) and after the opening of the retail sales market (0.73 [CI: 0.34, 1.12]), but not following the shelter-in-place order (1.59 [CI: −1.61, 3.68]), nor was there a significant change for those older than thirteen. Conclusions Our findings suggest that cannabis legalization is linked to increased exposures, particularly for products such as gummies and candy edibles among children under the age of thirteen. Clinicians should be aware of these risks and communicate them to patients, and policymakers should consider stronger regulations on packaging to reduce these exposures. Key points Question: How have cannabis exposures changed following legalization of recreational use, the opening of the recreational retail sales market, and the institution of shelter-in-place orders during the COVID-19 pandemic? Findings: In this retrospective review of 10,757 cases reported to the California Poison Control System (CPCS) between 2010 and 2020, exposures increased significantly after the legalization of recreational cannabis use and the opening of the recreational retail sales market, particularly among children, who primarily consumed candies and gummies. Meaning: Stronger regulation of cannabis edibles that mimic other products is warranted to decrease exposures among children.

Institutional Work and Brand Strategy in the Contested Cannabis Market

How can brands adopt institutional work towards establishing themselves in a highly contested market? Defining contested markets as fields in which the plural logics of the market are in tension with each other and/or with societal level logics, our research explores the institutional work of one pioneer brand – MedMen – in the legal cannabis market in the United States. Analysis of MedMen's marketing communication campaigns and corporate press releases between 2018 and 2020 reveal vesting, mimicry, and constructing consumer identities as the main types of institutional work the brand has adopted. Our findings inform extant research on market dynamics by documenting the types of institutional work brands can strategically adopt to establish themselves in contested markets.

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

This study describes the legal recreational cannabis market across Canada over the 2 years following legalisation. We compared changes in access to the legal cannabis retail market for all provinces and territories (jurisdictions) in Canada and explored differences between jurisdictions. We collected data for all legal cannabis stores in Canada over five time periods following legalisation in October 2018. We examined the following measures by jurisdiction and retail model (public vs. private operation): absolute and per capita store numbers, hours of operation and store access across neighbourhoods. Two years following legalisation, there were a total of 1183 legal cannabis stores open across Canada (3.7 stores per 100 000 individuals aged 15+). There was wide variation between jurisdictions in access to retail stores, with the lowest stores per capita in Quebec and Ontario (0.6 and 1.6 per 100 000), and the highest in Alberta and Yukon (14.3 per 100 000 in both). Jurisdictions with private retail models had more stores (4.8 vs. 1.0 per 100 000), held greater median weekly hours (80 vs. 69) and experienced greater store growth over time compared to public models. After adjusting for confounders, there were 1.96 times (95% confidence intervals: 1.84, 2.09) more cannabis stores within 1000 m of the lowest- compared to the highest-income quintile neighbourhoods. While access to the recreational cannabis retail market has increased following legalisation, there is substantial variation in access between jurisdictions and evidence of concentration in lower-income neighbourhoods. These differences may contribute to disparities in cannabis use and harms.

Implementing Regulation in an Emerging Industry: A Multi-Province Perspective

The decriminalization of cannabis in Canada has required a host of regulatory changes at the federal, provincial, and municipal levels. Provinces have operationalized the development of legal markets in very different ways, offering an opportunity to perform comparative analysis of business responses. This article outlines and delineates the various regulatory frameworks that have been employed at the provincial level, discusses how they have impacted the development of the legal cannabis market, and considers how they have resulted in some further regulatory changes. After reviewing coevolution as a conceptual framework, the implementation of legalization of recreational cannabis is discussed, followed by an exploration of different provincial approaches at a general level. The effects of that framework on the first phase of legal market operations are explored, with a focus on issues emanating from regulatory choices through discussions of five regions: British Columbia, the Prairies, Ontario, Quebec, and New Brunswick; each section exemplifying different priorities in the regulatory choices. Several themes emerge in the discussion. First, provincial approaches to retail licence approval have created severe bottlenecks, affecting consumer access to legal recreational cannabis. Additionally, the regulatory framework for those licences has resulted in a chilling effect on many potential entrepreneurs. Second, a reduction in black market sales has not yet occurred, largely due to the failure of some provinces to adequately provide retail licences and support legal distribution channels, or to operationalize the retail sales network. Third, many provinces struggled with operationalizing wholesale distribution to the retail stores, initially leading to administrative restrictions on store licences. Finally, issues of fairness and equity, effective displacement of the illegal market, government’s role as a market regulator and participant, and other issues that emerge from the critical comparison of the provincial markets are addressed.

Illegal drug market responses to state recreational cannabis laws.

In the United States, 15 states and the District of Columbia have implemented recreational cannabis laws (RCLs) legalizing recreational cannabis use. We aimed to estimate the association between RCLs and street prices, potency, quality and law enforcement seizures of illegal cannabis, methamphetamine, cocaine, heroin, oxycodone, hydrocodone, morphine, amphetamine and alprazolam. We pooled crowdsourced data from 2010-19 Price of Weed and 2010-19 StreetRx, and administrative data from the 2006-19 System to Retrieve Information from Drug Evidence (STRIDE) and the 2007-19 National Forensic Laboratory Information System (NFLIS). We employed a difference-in-differences design that exploited the staggered implementation of RCLs to compare changes in outcomes between RCL and non-RCL states. Eleven RCL and 40 non-RCL US states. The primary outcome was the natural log of prices per gram, overall and by self-reported quality. The primary policy was an indicator of RCL implementation, defined using effective dates. The street price of cannabis decreased by 9.2% [β=-0.092; 95% confidence interval (CI)=-0.15-, -0.03] in RCL states after RCL implementation, with largest declines among low-quality purchases (β=-0.195; 95% CI=-0.282, -0.108). Price declines were accompanied by a 93% (β=-0.93; 95% CI=-1.51, -0.36) reduction in law enforcement seizures of cannabis in RCL states. Among illegal opioids, including heroin, oxycodone and hydrocodone, street prices increased and law enforcement seizures decreased in RCL states. Recreational cannabis laws in US states appear to be associated with illegal drug market responses in those states, including reductions in the street price of cannabis. Changes in the street prices of illegal opioids analyzed may suggest that in states with recreational cannabis laws the markets for other illegal drugs are not independent of legal cannabis market regulation.

Foreign investment in emerging legal medicinal cannabis markets: the Jamaica case study

IntroductionThe establishment of a legal market for medicinal cannabis under the Dangerous Drugs Amendment Act 2015 has positioned Jamaica at the forefront of cannabis law reform in the developing world. Many local cannabis businesses have attracted investment from overseas, including from Canada, US and Europe.AimTo explore the opportunities and risks of foreign investment in an emerging domestic legal cannabis market in a developing country.MethodsThematic analysis of semi-structured face-to-face interviews with 22 key informants (KIs) from the Jamaican government, local cannabis industry, academia and civil society, and field observations of legal and illegal cannabis cultivators.ResultsKIs from the Jamaican public agencies and domestic cannabis entrepreneurs saw foreign investment as an essential source of capital to finance the start-up costs of legal cannabis businesses. Local cannabis entrepreneurs prioritised investors with the greatest financial resources, brand reputation and export networks. They also considered how allied an investor was with their business vision (e.g., organic cultivation, medical vs. recreational). The key benefits of partnering with a foreign investor included transfer of technical knowledge and financial capital, which enhanced production, quality assurance and seed-to-sale tracking. Some KIs expressed concern over investors’ focus on increasing production efficiency and scale at the expense of funding research and development (R&D) and clinical trials. KIs from the local industry, government agencies and civil society highlighted the risks of ‘predatory’ shareholder agreements and domestic political interference. Concerns were raised about the impact of foreign investment on the diversity of the domestic cannabis sector in Jamaica, including the commitment to transition traditional illegal small-scale cannabis cultivators to the legal sector.ConclusionWhile foreign investment has facilitated the commercialisation of the cannabis sector in Jamaica, regulatory measures are also needed to protect the domestic industry and support the transition of small-scale illegal cultivators to the legal regime. Foreign investments may alter the economic, social and political determinants of health in transitioning from illegal to legal cannabis market economy.

The rejection of cannabis legalization in New Zealand: issues with the Cannabis Legalization and Control Bill or wider concerns?

The rejection of cannabis legalization in New Zealand: issues with the Cannabis Legalization and Control Bill or wider concerns?

Online survey into developing a model for a legal cannabis market in the United Kingdom

Background Despite rescheduling of cannabis to Schedule 2 and amendments to the law permitting legal availability of cannabis for the treatment of medical conditions, access to cannabis for medical use remains challenging for patients in the United Kingdom (UK). Recreational use is widespread despite laws stating users can be sentenced to prison for up to 5 years for possession. Objective The aim of the study was to develop a model for a legal cannabis market in the UK building upon the results of a preceding study in which a UK population sample determined that pharmacies are the most suitable primary legal vendor of cannabis as opposed to regulated shops or the black market. Methods An online survey was developed using Qualtrics software and advertised via the Multidisciplinary Association for Psychedelic Studies’ Facebook, Twitter and Instagram social media accounts and monthly newsletter. Results Three hundred and ninety seven individuals, a majority having used cannabis at least once, consented to participate in the study. The participants concluded that there is enough evidence for cannabis to be prescribed to treat a range of medical conditions. In addition to pharmacies providing cannabis to patients with a prescription, a majority of participants supported cannabis being sold in pharmacies for harm reduction purposes and allowing access to medicinal cannabis in cases where supporting evidence is insufficient to merit a prescription. Participants supported greater integration between dispensing pharmacies and mental health services. Overall, the participants did not oppose a consultation or screening for potential cannabis users prior to obtaining access from licensed vendors. UK participants were supportive of the concept of a cannabis card, which users can present to licensed vendors such as pharmacies, with specific recommendations (such as strains relevant to a patient’s medical condition) being coded into the card. A majority of participants supported the existence of shisha-type bars for the purchase and onsite consumption of cannabis and determined that such vendors should not be part of a pharmacy chain of stores or regulated by pharmacy regulators. The participants generally preferred that laws regarding public consumption are in line with existing smoking legislation. Participants determined that it should be legally permitted to grow cannabis at home for personal medical and non-medical purposes but not to sell for profit. Conclusion The results are suggestive of a regulatory system that medical and non-medical cannabis users can use which aims to maximise therapeutic applications, minimise harms and respect individual liberty.

The Success of Cannabis Legalization: Evidence from Banking Transactions

Using data on banking transactions, we analyze how people changed their spending behaviour when recreational cannabis became legal in Canada. In the data set, we identify people with purchases in a cannabis store after the legalization. We apply a difference-in-difference approach to compare their spending before and after legalization. People with cannabis purchases after legalization reduced significantly and persistently their cash spending and electronic transfers, indicating a shift from the black to the legal cannabis market. We also find that, across all age and gender groups, cannabis consumers spend significantly more than other people on fast food and alcohol.

Legal cannabis market shares during Canada's first year of recreational legalisation

BackgroundThis study estimated legal products’ share of Canada's total cannabis consumption during the first year of recreational legalisation, October 2018 to September 2019. MethodsGovernment data was used to estimate monthly recreational sales in dollars per capita, grams per user, and percentage share of kilograms or litres consumed. As explanatory factors, the analysis considered provincial differences in retail pricing (percentage mark-ups) and store density (stores per million users), as well as national monthly production of dry cannabis (kilograms) and cannabis oil (litres) finished products. ResultsLegal recreational products’ share of Canada's overall cannabis consumption began at 7.8% in October 2018 and grew to 23.7% by September 2019, with an average of 14.5% over the first 12 months. Sales growth was delayed by shortages of both dry cannabis products and licensed stores, but not cannabis oils. Across the 10 provinces, legal recreational shares in September 2019 varied from 13% to 70%; differences in store densities and retail prices partly explained the variation. Prince Edward Island's large 70% share seemed due to it having minimal product shortages, high store densities, and low prices. ConclusionsLegal recreational products captured market share to the extent they were available, accessible, and low-priced. Problems with those factors slowed the initial expansion of legal product sales but also suggested ways to gradually increase their market share.

Issues in the establishment of a therapeutic cannabis market under Jamaica's Dangerous Drugs Amendment Act 2015

IntroductionIn 2015, Jamaica became the first Caribbean country to decriminalise personal cannabis possession, legalise home cultivation and establish a commercial therapeutic cannabis market via the passage of the Dangerous Drugs Amendment Act (DDAA). AimTo critically analyse implementation of the legal therapeutic cannabis market under the DDAA. MethodsSynthesis of findings from semi-structured face-to-face interviews with 22 key informants (KIs) from the government, industry, academia and NGO sector, unstructured interviews with illegal growers, and field observations of licensed and illegal operators. ResultsKIs identified a number of challenges in implementing therapeutic market provisions under DDAA, including a limited buy-in from key government agencies; delays in developing a framework for quality assurance; and lack of access to banking services. Public sector actors stressed the challenges imposed by the UN drug conventions and need to maintain favourable diplomatic relationship with the US federal government, with the consequence of prioritising enforcement to prevent diversion and inversion. Implementation of the Alternative Development Programme in two traditional cannabis-growing communities experienced challenges with land titles and frictions in local communities. High compliance costs and limited skills to meet the envisioned medical standards presented barriers for traditional farmers. Many KIs conceptualised the purchasing of cannabis from the regulated market as “recreational” rather than medical, reflecting the marketing and limited information on medical applications at point of sale. Licensees’ reliance on foreign investment puts local industry at risk of predatory shareholder agreements, but also provides needed investment and expertise. ConclusionExternal international factors (e.g. UN treaties, correspondent banking with the US) and conflicting domestic government agency visions for the reform played a significant role in the DDAA implementation. As cannabis law reform spreads beyond Western jurisdictions, consideration of pre-existing social, cultural and economic conditions of developing countries will be important.

Consumer perceptions of ‘legal’ and ‘illegal’ cannabis in US states with legal cannabis sales

IntroductionIn jurisdictions that have legalized recreational cannabis, perceptions of the ‘legal’ market may influence whether consumers transition from illegal retail sources. The current study examined consumer perceptions of legal versus illegal retail sources in 6 US states with legal retail sales as of 2018: Alaska, California, Colorado, Nevada, Oregon, and Washington State. MethodsData are from Wave 1 of the International Cannabis Policy Study, an online survey conducted in 2018 among 16–65-year-olds. US respondents were asked about cannabis consumption and perceptions of legal cannabis (n = 5530). Multinomial regression models were fitted for each of five consumer perception outcomes. ResultsCompared to illegal sources, at least one third of respondents perceived legal cannabis to be higher quality (37.6%) and safer to use (40.3%). More than half reported legal cannabis was more convenient to buy (59.2%) and safer to purchase (56.1%), whereas 30.6% of respondents perceived legal cannabis as more expensive. Perceptions varied according to the length of time since legal cannabis sales began: respondents living in more ‘mature’ legal markets were more likely to perceive legal cannabis as higher quality (AOR = 1.25, 99%CI = 1.07–1.46, p = 0.0003), less expensive (AOR = 1.20, 99%CI = 1.07–1.35, p < 0.0001), more convenient to buy (AOR = 1.36, 99%CI = 1.13–1.62, p < 0.0001) and safer to purchase (AOR = 1.21, 99%CI = 1.02–1.44, p = 0.0047). ConclusionsWith the notable exception of price, consumers reported generally positive perceptions of the legal cannabis market, with more positive perceptions in US states with more ‘mature’ legal markets.

Cannabis knowledge and implications for health: Considerations regarding the legalization of non-medical cannabis.

Cannabis contains over a hundred of different cannabinoids, of which Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most well studied. The use of high-potency cannabis, containing high concentrations of THC and low concentrations of CBD, has been linked to adverse health outcomes, particularly for adolescents and young adults. Recently, an increase in cannabis potency has been observed in jurisdictions that legalized the sale of cannabis for non-medical purposes. Moreover, an increase of cannabis use and cannabis-related emergency treatment have also been observed in these jurisdictions. At the same time, risk perception regarding cannabis use has decreased in these populations. Trivializing language and an increased appearance of commercial cannabis in the public space may lead to a generalized underestimation of the risks of cannabis use. New regulation models principally focus on the creation of a legal cannabis market economy, the diversion of profits from illegal markets, and the reduction of costs associated with prohibition. However, an approach that specifically focuses on the rights to the health and safety of the individual should be considered in order to reduce the risks associated with cannabis legalization. Such an approach should promote and protect individual and social health and safety, establish a strict quality control of legal cannabis products regulated according to THC and CBD content, and eliminate all sorts of incentives to use, thus providing a more consistent, sustainable, and ethical framework for the legalization of non-medical cannabis use.

A cannabis pricing mistake from California to Canada: government can’t tax cannabis optimally

ABSTRACT We apply a simple three good general equilibrium model to examine the optimality of a Pigouvian tax on a legal cannabis market which faces competition from a well-established illicit market. Despite the widespread support for Pigouvian taxes on cannabis, the availability of untaxed illicit cannabis with comparable costs and higher externalities renders taxation of legal cannabis suboptimal. Our results, derived from a relatively simple model, show that the welfare improving properties of a Pigouvian tax can be undermined by illicit market competition. Based on this simple analysis, we conclude that it is impossible for the pricing policies implemented in multiple jurisdictions (including California and Canada) to achieve the optimal, welfare maximizing outcome.

Association of Naturalistic Administration of Cannabis Flower and Concentrates With Intoxication and Impairment

The rapidly growing legal cannabis market includes new and highly potent products, the effects of which, to our knowledge, have not previously been examined in biobehavioral research studies because of federal restrictions on cannabis research. To use federally compatible, observational methods to study high-∆9-tetrahydrocannabinol (THC) legal market forms of cannabis. In this cohort study with a between-groups design that was conducted in a community and university setting, cannabis flower users and concentrate users were randomly assigned to higher- vs lower-THC products within user groups. Participants completed a baseline and an experimental mobile laboratory assessment that included 3 points: before, immediately after, and 1 hour after ad libitum legal market flower and concentrate use. Of the 133 individuals enrolled and assessed, 55 regular flower cannabis users (41.4%) and 66 regular concentrate cannabis users (49.6%) complied with the study's cannabis use instructions and had complete data across primary outcomes. Flower users were randomly assigned to use either 16% or 24% THC flower and concentrate users were randomly assigned to use either 70% or 90% THC concentrate that they purchased from a dispensary. Primary outcome measures included plasma cannabinoids, subjective drug intoxication, and neurobehavioral tasks testing attention, memory, inhibitory control, and balance. A total of 121 participants completed the study for analysis: 55 flower users (mean [SD] age, 28.8 [8.1] years; 25 women [46%]) and 66 concentrate users (mean [SD] age, 28.3 [10.4] years; 30 women [45%]). Concentrate users compared with flower users exhibited higher plasma THC levels and 11-hydroxyΔ9-THC (THC's active metabolite) across all points. After ad libitum cannabis administration, mean plasma THC levels were 0.32 (SE = 0.43) μg/mL in concentrate users (to convert to millimoles per liter, multiply by 3.18) and 0.14 (SE = 0.16) μg/mL in flower users. Most neurobehavioral measures were not altered by short-term cannabis consumption. However, delayed verbal memory (F1,203 = 32.31; P < .001) and balance function (F1,203 = 18.88; P < .001) were impaired after use. Differing outcomes for the type of product (flower vs concentrate) or potency within products were not observed. This study provides information about the association of pharmacological and neurobehavioral outcomes with legal market cannabis. Short-term use of concentrates was associated with higher levels of THC exposure. Across forms of cannabis and potencies, users' domains of verbal memory and proprioception-focused postural stability were primarily associated with THC administration.

Costs of cannabis testing compliance: Assessing mandatory testing in the California cannabis market.

Most U.S. states that have regulated and taxed cannabis have imposed some form of mandatory safety testing requirements. In California, the country's largest and oldest legal cannabis market, mandatory testing was first enforced by state regulators in July 2018, and additional mandatory tests were introduced at the end of 2018. All cannabis must be tested and labeled as certified by a state-licensed cannabis testing laboratory before it can be legally marketed in California. Every batch that is sold by licensed retailers must be tested for more than 100 contaminants, including 66 pesticides with tolerance levels lower than the levels allowable for any other agricultural product in California. This paper estimates the costs of compliance with mandatory cannabis testing laws and regulations, using California's testing regime as a case study. We use state government data, data collected from testing laboratories, and data collected from lab equipment suppliers to run a set of Monte Carlo simulations and estimate the cost per pound of compliance with California's new cannabis testing regulations. We find that cost per pound is highly sensitive to average batch size and testing failure rates. We present results under a variety of different assumptions about batch size and failure rates. We also find that under realistic assumptions, the loss of cannabis that must be destroyed if a batch fails testing accounts for a larger share of total testing costs than does the cost of the lab tests. Using our best estimates of average batch size (8 pounds) and failure rate (4%) in the 2019 California market, we estimate testing cost at $136 per pound of dried cannabis flower, or about 10 percent of the reported average wholesale price of legal cannabis in the state. Our findings explain effects of the testing standards on the cost of supplying legal licensed cannabis, in California, other U.S. states, and foreign jurisdictions with similar testing regimes.

Mapping cannabis potency in medical and recreational programs in the United States.

Cannabis related online searches are associated with positive attitudes toward medical cannabis, particularly when information is obtained from dispensaries. Since pain is the main reason for medicinal cannabis use, information from dispensary websites has the potential to shape the attitude of pain patients towards cannabis. This is relevant because cannabis has demonstrated efficacy in neuropathic pain with low tetrahydrocannabinol (THC) concentrations (< 5-10%), in contrast to potent cannabis (>15% THC), which is highly rewarded in the recreational realm. The role of CBD in pain is not clear, however it has gained popularity. Thus, we hypothesize that the potency of medical cannabis that is advertised online is similar to the cannabis advertised for recreational purposes, which would potentially create a misconception towards medical cannabis. The current lack of knowledge surrounding advertised potencies in the legal cannabis market limits the ability to generate clear policies regarding online advertising to protect patients that are willing to use cannabis for their condition. Thus, we evaluated the advertised THC and CBD content of cannabis products offered online in dispensaries in the United States to determine products' suitability to medicinal use and compare the strength of products offered in legal medical and recreational programs. We recorded THC and CBD concentrations for all herb cannabis products provided by dispensary websites and compared them between or within states. Four Western states (CA, CO, NM, WA) and five Northeastern states (ME, MA, NH, RI, VT) were included. A total of 8,505 cannabis products across 653 dispensaries were sampled. Despite the clear differences between medicinal and recreational uses of cannabis, the average THC concentration advertised online in medicinal programs was similar (19.2% ±6.2) to recreational programs (21.5% ±6.0) when compared between states with different programs, or between medicinal and recreational programs within the same states (CO or WA). Lower CBD concentrations accompanied higher THC products. The majority of products, regardless of medicinal or recreational programs, were advertised to have >15% THC (70.3% - 91.4% of products). These stated concentrations seem unsuitable for medicinal purposes, particularly for patients with chronic neuropathic pain. Therefore, this information could induce the misconception that high potency cannabis is safe to treat pain. This data is consistent with reports in which THC and CBD in products from legal dispensaries or in nationwide products from the illegal market were actually measured, which indicates that patients consuming these products may be at risk of acute intoxication or long-term side effects. Our study offers grounds to develop policies that help prevent misconceptions toward cannabis and reduce risks in pain patients.

Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products—California, 2019

Since August 2019, more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use-associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market. To present clinical characteristics and vaping product exposures of patients with EVALI in California. Case series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019. Standardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances. Demographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review. Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products. Patients' clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California's legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

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

IntroductionArguments 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 MethodsA 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. ResultsFive themes emerged including advertising restrictions (DS1), education (DS1), appropriation of funds (DS2), impact assessment (DS2), and evolving messages in prevention education campaigns (DS2). DiscussionMultiple lessons for other jurisdictions were highlighted in the study.