Advertising Restrictions on Cannabis Products for Nonmedical Use: Necessary but Not Sufficient?

Associations between e-cigarette marketing exposure and vaping nicotine and cannabis among U.S. adults, 2021

INTRODUCTION

Little is known about the influence of e-cigarette marketing on cannabis vaping behaviors. This study examined the associations between e-cigarette marketing exposure and nicotine and cannabis vaping among adults.

METHODS

This cross-sectional study included a U.S. nationally representative sample of adults from the Wave 6 survey of the Population Assessment of Tobacco and Health Study. We used multinomial logistic regressions to examine the associations between past 30-day e-cigarette marketing exposure and past 30-day vaping behavior (sole- and dual-vaping of nicotine and cannabis) overall and stratified by age.

RESULTS

Overall, 52.0 % of respondents reported e-cigarette marketing exposure, and 89.8 %, 5.6 %, 3.2 %, and 1.4 % reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dual-vaping, respectively. E-cigarette marketing exposure was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [aRR], 1.31; 95 % confidence interval [CI], 1.09-1.57) and dual-vaping versus no vaping (aRR, 1.26; 95 % CI, 1.01-1.57). This association was found among those aged 18-24 and 25-34 years. It was also associated with increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (aRR, 1.28; 95 % CI, 1.04-1.58). This association was found among those aged 18-24 years.

DISCUSSION

E-cigarette marketing exposure was associated with sole-cannabis vaping and dual-vaping, not sole-nicotine vaping among U.S. adults. Such associations were mainly driven by young adults aged 18-24 and 25-34 years. Greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in marketing restrictions for cannabis may contribute to e-cigarette marketing influence on cannabis vaping.

Associations between e-cigarette marketing exposure and vaping nicotine and cannabis among U.S. adults, 2021

Importance

Vaping has become an increasingly common method for consuming nicotine and cannabis, a trend potentially influenced by e-cigarette marketing. However, little is known about the influence of e-cigarette marketing on cannabis vaping behaviors.

Objective

To examine the associations between e-cigarette marketing exposure and nicotine and cannabis vaping behaviors among adults.

Design Setting and Participants

This cross-sectional study included a U.S. nationally representative sample of adults (≥18 years) from the Wave 6 survey of the Population Assessment of Tobacco and Health (PATH) Study, conducted from March to November 2021.

Exposure

Past 30-day e-cigarette marketing exposure (overall and by ten marketing channels).

Main Outcomes and Measures

Past 30-day vaping behavior (sole- and dual-vaping of nicotine and cannabis) overall and stratified by age.

Results

The study included 30,516 respondents (48.0% male and 63.9% non-Hispanic White). Overall, 52.0% of respondents reported past 30-day e-cigarette marketing exposure, and 89.8%, 5.6%, 3.2%, and 1.4% reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dual-vaping, respectively. Multinominal logistic regression results show exposure to e-cigarette marketing was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [aRR], 1.31; 95% confidence interval [CI], 1.09-1.57) and dual-vaping versus no vaping (aRR, 1.26; 95% CI, 1.01-1.57). Stratification analysis found these associations among those aged 18-24 and 25-34 years but not older adults (≥35 years). Those exposed to e-cigarette marketing also had increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (aRR, 1.28; 95% CI, 1.04-1.58). Stratification analysis found this association only among those aged 18-24 years. E-cigarette marketing exposure via several channels (retail stores, billboards, events, newspapers/magazines) was associated with increased odds of reporting sole-cannabis vaping.

Conclusions and Relevance

E-cigarette marketing exposure was only associated with sole-cannabis vaping and dual-vaping, not sole-nicotine vaping among U.S. adults. Such associations were mainly driven by young adults aged 18-24 and 25-35 years and were found for multiple marketing channels. Greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in such marketing restrictions for cannabis may contribute to continued influence of e-cigarette marketing on cannabis vaping.

Analysis of social media compliance with cannabis advertising regulations: evidence from recreational dispensaries in Illinois 1-year post-legalization

BACKGROUND

In the USA, an increasing number of states have legalized commercial recreational cannabis markets, allowing a private industry to sell cannabis to those 21 and older at retail locations known as dispensaries. Research on tobacco and alcohol suggests this new industry will use aggressive marketing tactics to attract new users and promote greater intensity of use. Of concern is that cannabis company advertising campaigns may be appealing to youth, promote false or misleading health claims, and disproportionately target low-income and minority communities. In this study, we evaluated recreational cannabis dispensary compliance with advertising regulations on social media in the state of Illinois.

METHODS

Primary data were collected from a census of recreational dispensary Facebook and Twitter business pages during the first year of recreational sales in 2020. A quantitative content analysis was conducted to systematically analyze the data; a codebook that detailed a protocol for classifying posts was developed prior to the analysis using advertising regulations outlined in the Illinois Cannabis Regulation and Tax Act. Violations of advertising regulations were organized into three categories: advertisements that may be appealing to youth (< 21 years old), advertisements that make health claims, and other advertising violations. The data were analyzed cross-sectionally and longitudinally. Additionally, differences in compliance were assessed by dispensary and neighborhood characteristics.

RESULTS

The results of the analysis revealed substantial and persistent non-compliance throughout the entire study period. Overall, nearly one third of posts had at least one violation and approximately one in ten posts met the criteria for appealing to youth or contained health claims. The majority of posts with health claims included health claims that were not qualifying conditions for medical cannabis access in the state of Illinois. No differences in compliance by neighborhood and dispensary characteristics were found.

CONCLUSIONS

The findings from this study suggest that systematic monitoring and enforcement is needed to ensure compliance with advertising regulations.

Health Claims About Cannabidiol Products: A Retrospective Analysis of U.S. Food and Drug Administration Warning Letters from 2015 to 2019

Background: Cannabidiol (CBD) products are increasingly available to consumers in the United States and are subject to regulation by the U.S. Food and Drug Administration (FDA). CBD products cannot be marketed as unapproved new drugs with claims of therapeutic benefit. In addition, because CBD is the active ingredient in a FDA-approved CBD product, Epidiolex, CBD cannot be marketed as, or in, food products or dietary supplements. The FDA has issued Warning Letters to promote voluntary regulatory compliance. These letters provide insights as to the types of violations for CBD products detected in the U.S. market. Objective: The goal of this retrospective study was to content analyze Warning Letters issued by the FDA to identify illicit marketing of CBD products. Design: Warning Letters issued by the FDA between 2015 and 2019 were content analyzed using a deductive approach. We extracted year of issuance, issuing office, and claim types that are currently prohibited by the FDA, including (i) unapproved new drug, (ii) misbranded drug, (iii) false and/or misleading, (iv) FDA-approved/endorsed, (v) dietary supplement, and (vi) adulterated food product. In addition, we documented the disease or conditions the product claimed to affect, pharmacological effects, and location of violation. Results: Of the 39 Warning Letters issued, 97% were for violations made on company websites and 56% were for social media accounts. Almost all letters (97%) cited violations of marketing CBD as an unapproved new drug. These illicit therapeutic claims were made for >125 unique health problems, including cancer (87.2%), diabetes (71.8%), inflammation (66.7%), pain (66.7%), and arthritis (66.7%). The majority of letters (79.5%) also cited illicit marketing of CBD as a dietary supplement or food product. CBD was promoted as having 16 unique pharmacological effects, including anti-inflammatory (53.8%), anticancer (43.6%), and antipsychotic (30.8%). Conclusions: CBD products have been unlawfully advertised online as unauthorized drugs with health claims that promote therapeutic benefits and as dietary supplements. Efforts are needed to regulate and monitor illicit advertising so consumers are not misled about the risks and benefits of CBD use.

Vape shop owners'/managers' attitudes about CBD, THC, and marijuana legal markets

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Vape shop owners/managers perceive minimal risk and therapeutic benefits of CBD.

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They held diverse perspectives regarding marijuana retail and its potential impact.

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Some owners/merchants do not consider the CBD or THC markets in their business.

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Others indicated high levels of enthusiasm for the growing retail marijuana market.

Over the past decade in the US there have been marked pivotal changes in the policy and retail environment regarding cannabinoids, particularly cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC). Many vape shops may carry products relevant to these two markets. This study interviewed vape shop owners/managers to assess their perceptions of consumer interests/behaviors regarding CBD and THC and of the impact of legalized marijuana retail on vape shops. The current study involved phone-based semi-structured interviews of 45 vape shop owners/managers in six metropolitan statistical areas (MSAs; Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, and Seattle) during Summer 2018. Overall, 82.2% of participants were male, 77.8% were non-Hispanic White, 64.4% were managers, 8.9% reported past 30-day smoking, and 95.6% reported past 30-day vaping. Overall, 44.4% sold e-liquids containing CBD. Vape shop owners/managers indicated minimal perceived risk and some beliefs in therapeutic benefits of CBD products; however, there was a broader range of perspectives regarding marijuana retail and selling marijuana for recreational use. Some chose to distance themselves from marijuana products, their use, and the possibility of entering marijuana retail if it were to evolve in their state, while some indicated high levels of enthusiasm for the growing retail marijuana market. Future research should examine how vape shops and other retailers of CBD and marijuana communicate with consumers about products and modes of using such products, as well as how various industry sectors (e.g., vape shops) adapt or evolve with increasing regulation of nicotine and increasing legalization of marijuana retail.

Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis

RATIONALE

Certifications for medical cannabis are generally restricted to a small number of specific medical conditions, yet patients frequently report symptoms of pain, anxiety, and depression as reasons for use. This is a critical concern for researchers, healthcare providers, and policymakers, yet research in this area is currently obstructed by the lack of a focused review or empirical synthesis on patient-reported reasons for medical cannabis use.

OBJECTIVES

AND METHOD: The first aim of this project was to conduct the first systematic review and meta-analysis of empirical studies of patient-reported symptoms of pain, anxiety, and depression as reasons for medical cannabis use. The second aim was to conduct an empirical assessment of the methodological quality of extant research, test for publication bias, and test sex composition and quality scores of individual studies as possible sources of observed heterogeneity.

RESULTS

Meta-analytic results indicated that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons for medical cannabis use. No evidence for publication bias was detected, despite heterogeneity in prevalence rates. A comprehensive assessment of study quality identified a number of specific methodological limitations of the existing research, including challenges in patient recruitment, use of restrictive sampling frames, and a lack of randomized recruitment methods and validated assessment measures.

CONCLUSION

Findings are discussed with regard to possible explanations for current results, clinical considerations, and areas of future research that are needed to move the field forward.

Cannabis regulatory science: risk-benefit considerations for mental disorders

The evolving legal cannabis landscape in the US continues to present novel regulatory challenges that necessitate the development of a Cannabis Regulatory Science. Two specific issues of concern within Cannabis Regulatory Science are (1) the impact that cannabis use has on the incidence, prevalence, and severity of mental disorders, and (2) how cannabis laws and regulations modify this impact. This paper first provides several conceptual points that are useful for evaluating the relationship between cannabis use and mental disorders. Second, it selectively reviews and comments on data relevant to the relationship between cannabis use and depression, several forms of anxiety, post-traumatic stress disorder, schizophrenia, and bipolar disorder. Next, regulatory and public health parallels between the nascent cannabis industry and the pharmaceutical, tobacco, and alcohol industries are discussed. The focus is on specific types of industry practices that may harm those with or at risk for mental disorders. Recommendations are then offered for legal cannabis regulations that could mitigate this harm. Last, future research goals are discussed for building the field of Cannabis Regulatory Science and addressing the potential negative impact of cannabis on those with mental disorders.

Sweet flowers are slow, and weeds make haste: leveraging methodology from research on tobacco, alcohol, and opioid analgesics to make rapid and policy-relevant advances in cannabis science

The legalization of medical and recreational cannabis use has occurred ahead of science. The current evidence base has poor utility for determining if cannabis products can meet the standards of safety, efficacy, and quality intrinsic to modern medicine, and for informing regulation of cannabis as a legal intoxicant. Individual jurisdictions that pass cannabis reforms may not have adequate resources to support the level of new scientific research needed to inform regulatory actions; this could make it difficult to keep a rapidly growing multi-billion-dollar cannabis industry in check. Further, the present lack of evidence-based regulatory oversight for cannabis parallels the climates that gave rise to the tobacco and prescription opioid epidemics, suggesting that continued omission may result in negative public health consequences. However, translating a methodological framework developed through research on these compounds may promote rapid advances in cannabis science germane to regulatory knowledge gaps. The present review highlights specific advancements in these areas, as well as in alcohol regulation, that are prime for informing policy-relevant cannabis science, and also offers some recommendations for evidence-based regulatory policy. Resulting progress may directly inform both regulation of cannabis in both medical and licit recreational drug frameworks, and new cannabis-related public health initiatives.

Media/Marketing Influences on Adolescent and Young Adult Substance Abuse

PURPOSE OF REVIEW

We describe the state of research on substance use portrayals in marketing and media, considering exposure to tobacco, alcohol, e-cigarette, and marijuana content. Putative mechanisms are offered, and recommendations made for effective prevention strategies for mitigating the influence of these portrayals.

RECENT FINDINGS

There is consistent evidence that adolescents and young adults are highly exposed to substance use portrayals and that these portrayals are associated with subsequent substance use. Exposure via new media (social networking sites, brand websites) has risen rapidly. Social norms and cognitions appear to at least partially account for the effects of portrayals on youth substance use.

SUMMARY

Digital media has surpassed traditional marketing, which is concerning because youth have on-demand access to content and are active consumers of digital media. Developmentally appropriate media literacy interventions that include a parenting component and target multiple substances and media domains are recommended.

Media/Marketing Influences on Adolescent and Young Adult Substance Abuse

PURPOSE OF REVIEW

We describe the state of research on substance use portrayals in marketing and media, considering exposure to tobacco, alcohol, e-cigarette, and marijuana content. Putative mechanisms are offered, and recommendations made for effective prevention strategies for mitigating the influence of these portrayals.

RECENT FINDINGS

There is consistent evidence that adolescents and young adults are highly exposed to substance use portrayals and that these portrayals are associated with subsequent substance use. Exposure via new media (social networking sites, brand websites) has risen rapidly. Social norms and cognitions appear to at least partially account for the effects of portrayals on youth substance use.

SUMMARY

Digital media has surpassed traditional marketing, which is concerning because youth have on-demand access to content and are active consumers of digital media. Developmentally appropriate media literacy interventions that include a parenting component and target multiple substances and media domains are recommended.