New report: Public Health Language for Recreational Cannabis Laws

We have published research (study 1, study 2, study 3) describing how existing laws legalizing recreational marijuana – including California Proposition 64 -- do not prioritize public health. Several people have pointed out to me that, to date, most of the legislation has been drafted by marijuana legalization advocates who were prioritizing business interests over public health and that they have been dominating the discussion because there have not been analyses and models of how to write marijuana legislation that prioritized health.

Dan Orenstein and I have tried to contribute to this discussion with our new report, Public Health Language for Recreational Cannabis Laws, which lays out the evidence basis for regulations based on public health best practices from tobacco and alcohol and provides some specific implementing language. The full report is available on the University of California eScholarship site at https://escholarship.org/uc/item/05d5g5db .

Since this is a rapidly developing area, we particularly welcome specific feedback on the report and, particularly, the language that we developed to implement these health policies.

Here is the executive summary:

Cannabis legalization for recreational use (also called “adult use”) is a reality in a growing number of US states despite continued federal prohibition and limited scientific research on the long-term and short-term health effects of cannabis use. There may be benefits to legalization, but there are also significant public health risks, including many that strongly echo those caused by tobacco and alcohol. Public health best practices drawn from tobacco and alcohol control strategies can inform regulatory approaches to legalized cannabis that prioritize public health over industry profit. This report presents supporting evidence and legislative language based on public health principles to minimize negative public health impacts of cannabis legalization and prevent the nascent legal cannabis industry from repeating harmful practices of the tobacco and alcohol industries.

The three areas analyzed here represent some of the most significant challenges and important opportunities in regulating recreational cannabis:

Packaging and Labeling
Advertising
Public Use and Social/On-site Consumption.

Packaging is a powerful marketing tool for most products.

For products restricted to adults, packaging is also a means of unlawfully targeting underage persons.
This effect extends beyond retail shelves to other locations where consumers use or possess the product (e.g., at home).
The most effective approach to preventing inappropriate marketing to youth via packaging is fully standardized “plain packaging.”
Plain packaging excludes all logos, colors, and branding other than plain text identifying the brand and product variant.

To protect public health, recreational cannabis packaging should be fully standardized and free of branding and other features attractive to minors. Based on tobacco control evidence, plain packaging:

improves health warning effectiveness and visibility
increases perceptions of harm
reduces product appeal among adolescents and young adults
amplifies the reach and impact of public health media campaigns.

To further educate consumers, cannabis packaging should also carry highly visible and effective health warnings. The best evidence from tobacco control indicates that the most effective health warnings are:

visually prominent
written clearly and simply
changed regularly to maintain consumer attention
designed to incorporate pictorial content in addition to text.

Evidence for the health effects of cannabis is more limited than for tobacco or alcohol, particularly for certain types of cannabis products, such as vaporized extracts, edibles, and concentrates. However, many health risks are or are likely to be comparable to tobacco due to the similarities between tobacco and cannabis smoke and devices for vaporizing plant material or liquid extracts. As a result, specific content of cannabis health warnings should:

use the best available existing evidence base for cannabis, beginning with the 2017 National Academies of Sciences, Engineering and Medicine report
incorporate additional evidence from other closely related products, such as tobacco and e-cigarettes
be regularly reviewed to ensure consistency with the latest scientific evidence
include risks associated with motor vehicle accidents, problem use or dependence, use at an early age, lower birth weight when used during pregnancy, and development of schizophrenia or other psychoses
include additional respiratory and cardiovascular risks for inhaled products
include risks related to accidental consumption and delayed intoxication
incorporate a universal warning symbol to alert consumers and prevent accidental consumption, as some products will be unfamiliar to many consumers and may closely resemble non-cannabis products.

Cannabis marketing and advertising quickly follows cannabis legalization based on experience in states that have legalized recreational and medical cannabis.

In the absence of strong regulation, cannabis advertising is likely to be highly visible, including to minors.
Based on evidence from tobacco products, advertising and promotional activities have a causal relationship to onset and continuation of smoking among adolescents and young adults.

This causal link justifies a precautionary approach to preventing a similar pattern for cannabis as the industry gains power and marketing expertise. While restrictions on advertising and marketing are likely to face legal challenge, state legal authority to protect public health and prevent underage use is strong and justifies a robust approach, including:

banning elements attractive to minors
prohibiting depiction of cannabis use
barring depiction, promotion, or encouragement of excessive or rapid consumption, intoxication, or use for intoxicating effects
requiring a warning statement on all advertisements
disallowing all outdoor advertising near sensitive areas, other than limited on-site signage
strictly limiting internet and social media advertising
restricting event sponsorships and branded non-cannabis merchandise

prohibiting paid product placement in media.

Public use and social/on-site consumption of cannabis raises pressing concerns including:

normalization of cannabis use
re-normalization of smoking behavior generally
secondhand and third-hand smoke or vapor exposure.

Cannabis-specific evidence is limited, but, in concert with evidence from tobacco, is more than sufficient to support a restrictive approach to cannabis consumption consistent with best practices for smokefree environments.

The real and present potential risk of rolling back or weakening existing smokefree laws for tobacco further supports adding cannabis in all inhaled forms to existing prohibitions in comprehensive smokefree laws.
As additional evidence develops, modifications may be warranted, but creation of social/on-site consumption locations raises serious concerns about exposure and ventilation.
Social/on-site consumption also raises issues echoing those from alcohol control, including intoxicated driving, server and retailer training and liability, outlet density, and proximity to sensitive locations.
A health-protective approach to public consumption and social/on-site consumption in initial cannabis legalization would preserve the opportunity to modify restrictions based on future evidence, while the history of tobacco control demonstrates that weak restrictions may take years or decades to strengthen even when supported by compelling evidence.

The full report is at https://escholarship.org/uc/item/05d5g5db .