lessons from tobacco: potency, flavors, and advertising
TRANSCRIPT
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Lessons from Tobacco: Potency, Flavors, and AdvertisingLynn Silver, MD, MPHSenior AdvisorPublic Health InstituteClinical Professor, UCSFCannabis Summit January 28, 2019
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Getting it Right from the Start’s Mission
To collaboratively develop and test models of optimal cannabis policy with the goal of reducing
harms, youth and problem use. Models are based on the best scientific evidence and protection of public
health, social equity and safety.
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Why?
California’s Prop 64 legalizing recreational cannabis:
• Scant attention to public health concerns
• Failure to learn from tobacco control
• Lack of economic or social equity focus
• Leeway to local government to regulate and tax
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Why legalize?
Profound Racism in Drug Policy
Mass Incarceration
Trafficking Related Violence
Prohibition didn’t work
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Marijuana is not
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But also not
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Why Worry? Some Proven Evidence of Benefit
Chemotherapy induced nausea
Recently approved pharmaceutical Epidiolex (cannabidiol) for rare difficult to control form of epilepsy
Certain forms of chronic pain
Source NASEM 2017; FDA 2018
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But Substantial Evidence of Harm
Low birth weight
Schizophrenia and psychoses
Increased motor vehicle crashes
Respiratory illness
Problem use associated with early onset of use and frequency
Source: National Academies ofScience, Engineering, and Medicine, 2017,
Dutra, 2018, Int Rev Psychiatry
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Emerging evidence
COGNITIVE, ACADEMIC AND SOCIAL EFFECTS
ACCIDENTAL INGESTION AND OVERDOSE
CARDIOVASCULAR DISEASE
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Like Tobacco: Marijuana
Addiction is Real – About 1
in 10 users
• Approximately 4.0 million Americans met criteria for cannabis use disorders in 2015.
• 1.2 million of first time users in 2016 werebetween the ages of 12 and 17
Source: S. Weiss, NIDA and 2016 National Survey on Drug Use and Health, SAMHSA
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Use Rising in Pregnant California Women• From 2009 to 2016, cannabis use among pregnant women
increased from 4% to 7%
• 22% of pregnant females younger than 18 years and 19% of pregnant females aged 18 to 24 years screened positive for cannabis use in 2016
• Declining perception of risk for use during pregnancy - and in general
Source: Young-Wolff et al, JAMA 2017
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Frequency of Cannabis Use Before Age 17 and Adverse Outcomes at 30 years (n=2500-3700)
Consistent dose-response associations between frequency ofadolescent cannabis use and adverseoutcomes
Source: Silins E et al., The Lancet September 2014
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Three Dangerous Areas Where the Cannabis Industry is Borrowing from Big Tobacco’sPlaybook
Manipulating Potency thereby Increasing the Risk of Addiction
Creating flavored and other products aimed at attracting youth
Shameless and misleading marketing
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Vastly Increasing Potency
• Flower ~4% THC in 1995 to ~12% in 2014
• Now 16% to 30% in dispensaries• Cannabidiol content decreased from
~.28% in 2001 to <.15% in 2014• Change in the ratio of Δ9-
tetrahydrocannabinol to cannabidiol from 14 times in 1995 to ~80 times in 2014
Source: El Sohly, 2016, Biological Psychiatry
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Does this sound familiar? Judge Kessler in US v Philip Morris
“Defendants have long known that nicotine creates and sustains an addiction to smoking and that cigarette sales, and ultimately tobacco company profits, depend on creating and sustaining that addiction….. ……Defendants have designed their cigarettes to precisely control nicotine delivery levels and provide doses of nicotine sufficient to create and sustain addiction.”
Source: Kessler, G. ]in US. V Philip Morris USA Inc. (D.D.C. 2006)
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Use of High Potency Products Associated with Risk of Psychosis
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“Increased exposure to THC has also been associated with increased symptoms of cannabis use disorders,increased risk for psychosis, ….impaired cognition…. alterations in corpus callosum white matter microstructure in high-potency MJ users compared to low-potency users and controls.”
(Sources: Sagar, 2018, Int Rev Psychiatry; van der Pol, 2014, Addiction; Di Forti, 2015, The Lancet Psychiatry; Large, 2017, Evidence-Based Mental Health; D'Souza, 2004, Neuropsychopharmacology; Kowal, 2015, Psychopharmacology; Ramaekers, 2006, Neuropsychopharmacology;Rigucci et al., 2016; Rigucci 2016, Psychological Medicine; Freeman, 2015 Psychological Medicine)
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Use and Heavy Use Rising: 42% of Current Users are Daily or Almost Daily Users
22.2 Million Past Month Users of Cannabis in 201514.6 Million Past Month Users of Cannabis in 2002
Source: SAMHSA, 2015 National Survey on Drug Use and Health (September 2016)
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Flavors are used to attract youth: Why on earth when we are trying to ban flavored tobacco are we introducing legal flavored marijuana?
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Intensive Marketing
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Sex Appeal
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Snob Appeal
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Happiness
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Appeal to youth
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Joe Camel’s Appeal to Youth Resurrected (but banned in CA)
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Misleading Therapeutic Claims & Framing as “Wellness” or “Lifestyle” product“ Fortunately, cannabis has been shown to improve depression (no matter how severe), and it can do so quickly and affordably. ”
“ With a sour citrus and floral aroma, Ghost Train Haze delivers a potent dose of THC to knock out pain, depression, and appetite loss….
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The cannabis industry wants us
to believe that quality control,
testing and pesticide residues
will determine health impacts
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The biggest determinants of health impact of legalization will be:
• How many people the industry gets to use cannabis, how intensely, and at what age – just like tobacco
• How many people still go to jail for cannabis
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These three industry strategies will:• Get people to initiate and maintain use
(marketing)• Get young people to initiate use (flavors &
marketing)• Make people more likely to become addicted or
have other negative effects (potency)
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The Marijuana Regulatory Spectrum
Prohibition Grudging Toleration
Start Cautiously
Commercial Free for All
Our Approach
Source: Slide adapted from Jonathan Caulkins, 2017
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Cannabis Common Sense 101
Legalizing
Does Not Have to Mean
Letting the Industry Make and Say
Anything They Want To
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Failing to learn from tobacco
control in California’s state rules
No limits on potency in agriculture, manufacturing or retail
No limits on flavors and other product types attractive to youth
No limit on # retailers
Weak regulation and enforcement allowing rampant marketing targeting youth
Delayed investment in prevention
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Local Control: Option to Prohibit or Regulate• Cities and counties can prohibit the
retail sale of adult use marijuana• State must verify local license before
issuing state license• Local control threatened by new CA
delivery regulations (illegally?)• Personal growing and possession still
allowed
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Policy Ideas for Another Way
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Local Option – Regulate Like Tobacco Retail License
Cities and counties can allow retail sales with restrictions, such as:• Location, density, proximity• Types of products• Marketing• Etc.
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Local and State Government Should Prohibit Certain ProductsBanning flavored products & menthol
• FDA banned flavored cigarettes and jurisdictions across CA are still struggling to ban flavored tobacco
• Contra Costa County prohibited all flavored cannabis intended for inhalation or vaporization
Prohibit strain names that sound like flavors attractive to youth e.g. Bubble Gum, Girl Scout Cookie, Cherry Pie
Prohibit Products “Attractive to youth”• Mono County and Mammoth Lakes
prohibited products that would be attractive to youth or children or that resemble commercially sold candy or foods\
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Ban “Cannapops”Cannabis Infused Beverages:
• Pasadena and Mono County prohibited cannabis-infused beverages
• Modeled after “alcopops” used to initiate teen drinking
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Products: Restrict Potency
• Consider limits on flower (>15-20% THC?) and concentrate potency (>50% THC?) in cultivation, manufacturing and sales
• New Mexico limits concentrates
• Act cautiously, learn more
• Assess how THC:CBD ratios should be best regulated
• Optimal limits unclear but current trends are too dangerous too permit
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Tax on THC Potency
For example:
Raise taxes in flower by 1% for every % above 17% THC
Raise taxes on concentrates by 1% for every % above 50%
If high potency products are allowed, their use can be discouraged through taxation
policy
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Prohibit health and therapeutic claims on recreational marijuana
“Top Shelf Bubble Gum Galaxy Joint…enjoy this expertly rolled joint for its natural healing effects…perfect for those experiencing stress, pain and depression.”
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Restrict advertising to the maximum
extent possible under
the law
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Require warning labels on advertising
Warning from the [County/City] The National Academies of Science have found that smoking
marijuana during pregnancy is associated with low birth weight in babies
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Inform people of risks by requiring prominent in-store warnings and graphic package warnings
i) Are you pregnant of breastfeeding? According to the U.S. Centers for Disease Control (CDC), marijuana use during pregnancy can be harmful to your baby’s health, including causing low birth weight and developmental problems.
ii)Driving while high is a DUI. Marijuana use increases your risk of motor vehicle crashes.
iii)Not for Kids! Starting marijuana use young or using frequently can lead to problem use, and according to the CDC may harm the developing teen brain.
iv)Marijuana use may be associated with greater risk of developing schizophrenia or other psychoses. Risk is highest for frequent users.
v)Smoking marijuana long term can make breathing problems worse.This message is provided as public service by the City/County of XXX
Using or possessing marijuana or working in the marijuana industry is legally risky for any noncitizen. This includes lawful permanent residents, undocumented
persons, students, and others. Marijuana is illegal under federal law, and federal law controls immigration. If you need to take medical marijuana, see an immigration
attorney for advice.This information is provided as a public service by the City/County of XXXXX
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Uncertainty
• Best practices for cannabis regulation are still uncertain
• But we know a lot from alcohol & tobacco • The body of evidence of harm grows daily• We should start far more cautiously • It will be much harder to tighten up later
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Reduce drug related incarceration
• Enforcement of new rules should not lead to more incarceration
• Develop programs, policies & funding to ensure this
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Mobilize, Align & Engage Partners to Avoid a New Big Tobacco
• CBOs, churches, PTAs, LHDs, need to “butt in” to the cannabis regulatory process
• Bring a needed public health focus to regulation and taxation
• Mobilize existing partners and build coalitions just as we do for tobacco
• Call out conflicts of interest in process
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Control conflicts of interest
• Keep industry offadvisory and regulatory bodies
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Local Taxation Model Including
High THC and Beverage Tax
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Available to help
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Thank you
Lynn Silver, [email protected]
Thanks also to Alisa Padon, PhD, Amanda Naprawa, JD, Ted Mermin, JD, Leslie Zellers, JD, Michael Colantuono, JD, Jim Mosher, JD, Susan Weiss PhD and many others
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