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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


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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

%

22

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


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


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


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Possible reasons for use in pregnancy?


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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


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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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mailto:[email protected]

mailto:[email protected]

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