WA HCA - Washington State Prevention Summit - A Couple of Things About Cannabis
(November 4, 2020) - Summary

NW PTTC - A Couple of Things About Cannabis - Slide 7 - Excerpt
[ Event Details ]

During the annual state prevention summit, public health and prevention practitioners heard “A Couple of Things About Cannabis” and got an early look at a report on cannabis potency.

Here are some observations from the Wednesday November 4th Washington State Health Care Authority (WA HCA) Washington State Prevention Summit session titled, “A Couple of Things About Cannabis.”

My top 3 takeaways:

  • NW PTTC Co-Director Brittany Cooper briefed participants on the Center’s “cannabis toolkit” and “the 5 Ps,” five policy arenas where advocates focused cannabis prevention efforts.
    • The NW PTTC cannabis toolkit was geared towards “prevention practitioners, with information on cannabis policies and regulations in the region,” Cooper stated. The information was organized "to better educate stakeholders about some of the different elements that form stronger, versus weaker, cannabis policy. And this is all within the frame of prevention: preventing misuse by adults and especially focusing on use by underage, minor youth." Cooper said the documents and accompanying website were useful for comparing differences between state cannabis policies, "and where there [are] opportunities to strengthen those policies, what role could prevention practitioners play in trying to educate other stakeholders” or lobby for “specific policies or regulations in hopes that we can leverage them to enhance our prevention efforts in preventing, especially youth, from using" (audio - 6m).
      • Cooper acknowledged the session’s focus on Washington state policies while adding it remained "relevant especially for those of us who are living, kind of, on the borders which includes myself" and so as to “learn from other regions.”
      • Cooper reviewed the toolkit website and associated resources including “A Guidance Document for Northwest Substance Misuse Prevention Practitioners.” That text provided “overall guidance” and “contextualizes” the background information while also “comparing and contrasting” with other states.
        • The document also covered state policymaking and topics such as “Equity and Social Justice in Regulatory Frameworks” and “Unintended Consequences.”
        • The concluding section stated, in part, “Legalization of cannabis use and sales for nonmedical purposes is relatively new. The public health impacts of doing so are not yet well understood. Regulatory design has relied heavily on examples from alcohol and tobacco as a start, but cannabis is a different product with unique characteristics, including medical use. Only time will tell what broad and general approaches will work best for minimizing risks for young people and vulnerable populations. In the absence of certain knowledge, prevention stakeholders should work toward what they and their partners believe to be the most appropriate regulatory approaches for prevention, including in each of the “5 P” areas: Places for Access, Products, Promotion, Public Safety, and Price. Assuring that high-quality information on cannabis use and harms is important so that we know whether or how much public health and safety has been affected.”
      • Cooper commented that a page comparing the policies of legal cannabis states was available as a PDF document as well as a website which focused on “how the different states are...implementing different regulations and policies” in addition to the “5 Ps...and how they can inform your efforts.”
        • Idaho cannabis laws and policy were excluded from the comparison. As noted by the National Organization for the Reform of Marijuana Laws (NORML), prohibited cannabis activities in Idaho include use or possession of paraphernalia as “a misdemeanor punishable by up to 1 year imprisonment and/or a fine up to $1,000” and an individual's presence “at or on the premises where marijuana is cultivated or held for distribution, transportation, delivery, or use is a misdemeanor punishable by up to 90 days imprisonment and/or a fine up to $300.” 
    • Cooper described the “5 Ps” as “regulatory components that are most relevant to preventing cannabis use by youth and unsafe use by adults.” She added that her remarks and the documents reflected how “legalization of cannabis is relatively new." Cooper acknowledged a reliance on tobacco and alcohol research as well as regulatory approaches applied in those domains, and intended to “point out where perhaps cannabis is unique and maybe it won’t apply” (audio - 3m).
      • Public Health and Safety. Cooper said this was "how regulatory authority is used, for instance track and trace systems”; penalties and enforcement; “and how strongly they enforce” laws and regulations.
      • Placement and Access. Cooper described this as "where people can legally purchase, possess, and use cannabis. It also includes where cannabis retailers can be located. And so for prevention's sake we're interested in limiting public use and minors’ access to cannabis."
      • Products and Potency. "These are the regulations that can focus on the types of products, their potency, appearance, packaging and labeling” and could impact “how attractive, or how accessible, how available” cannabis was to minors, Cooper observed.
      • Promotion and Advertising. She explained this area referenced promotion “strategies that are used to advertise the retail stores themselves and their products and to ultimately gain customers.” To the extent “strategies and techniques that are used to advertise could potentially be appealing to youth,” she encouraged prevention supporters to introduce “regulations that would reduce that appeal to youth."
      • Pricing. This meant “both in terms of the actual price itself and then also the taxes that go along with that.” Cooper felt prevention advocates should seek “to maintain higher prices for cannabis products in order to deter under age youth."
    • A breakout session talking about cannabis pricing was reviewed by session member Danika Troupe, a Program Manager for Community Health Outreach Programs at United General District 304, which covered a Skagit County Public Hospital District (audio - 3m).
      • Troupe acknowledged that Washington’s 37% excise tax on cannabis was “pretty high” as compared with Oregon’s “retail tax of 17%” and wondered “if marijuana might be an exception to this rule" of higher price deterring youth access. Participants in Troupe’s session felt that “no one's making moonshine in their bathtub and growing tobacco in their backyard" to provide to minors, but the illicit cannabis market was still accessible to youth, leading them to question whether “price is going to have an impact.”
      • Cooper responded that “all of those points you make are good” and didn’t “really know for sure from a research standpoint.” Haggerty followed up to say “we are higher priced than a lot of areas in the nation, that is true, and I think that industry pushes against that because that is difficult in a business climate.” He had found that subject to be “a source of tension with the industry."
      • Cooper added that retail discounts didn’t have “much regulation that I’m aware of.” Troupe concluded "we want that excise tax" but "it's a balance, too" as the State shouldn’t push prices so high that “the underground market” remained “a thriving business.”
    • Haggerty noted a chat comment from Okanogan County Community Coalition Executive Director Stacey Okland: “One thing that was happening in Omak was people over 21 were buying mj and then selling it to kids in the parking lot of the retail store…not sure what the mark up was from the store price… they advertised this via facebook groups.”
    • He then mentioned a comment from Hailey Croci, American Lung Association Tobacco Control Coordinator and a representative of TOGETHER! for Youth in Chelan-Douglas Counties, who inquired as to whether there was “a general understanding of where the 37% excise tax goes?" Haggerty said some information could be found in the NW PTTC documents and added, "while there has been more money going...to prevention from cannabis sales, it's not at the level that we voted on when we voted in I-502, that's what I would say." He suggested prevention advocates should tell lawmakers “that we want to maintain the I-502 distribution.” Cooper added that the allotment of revenue towards prevention was impacted by legislative action annually. Haggerty urged excise taxes be allocated “to protect the most vulnerable populations, particularly young people" (audio - 2m).
  • NW PTTC Co-Director Kevin Haggerty told attendees about a draft report on health risks of “high potency” cannabis products.
    • The Report (audio - 5m). Haggerty introduced the “Cannabis Concentration and Health Risks” report produced for the WA HCA PRSC which was still "being finalized."
      • A WA HCA PRSC sub-group organized and led by Beatriz Carlini, a UW School of Public Health Affiliate Associate Professor, set out to define a “scientific consensus” on “the role of high potency cannabis on health risks.” The effort was developed with “support” from representatives of WSLCB, WA HCA, the Washington State Department of Health (DOH), and Prevention Works in Seattle (Prevention WINS).
      • Haggerty noted that "some of this work comes out of the fact that there's been some work at trying to regulate the level of [tetrahydrocannabinol] THC concentration in cannabis," but did not elaborate on the work he was referencing.
        • In 2019, WSLCB organized a Potency Tax Work Group---which included Haggerty, Carlini, and Prevention WINS Coordinator Liz Wilhelm---to meet a legislative mandate to “determine the feasibility of and make recommendations for varying the marijuana excise tax rate based on product potency.” A final report was produced by the agency after receiving a feasibility study from BOTEC Analysis. The final report stated that “transitioning to a potency-based tax for cannabis was not feasible at this time in Washington State. Some work group members from the public health community were in favor of a tax structure that would discourage consumption of high potency cannabis, but did not have confidence that this tax would guarantee those outcomes. Many work group members noted that the idea of a potency-based cannabis tax could be of value for states that had not yet legalized or implemented their tax framework, but would present a costly infrastructural change to a state like ours that has.”
        • During the 2020 legislative session, Representative Lauren Davis introduced a controversial bill, HB 2546 (“Concerning the potency of marijuana products”), which was heard by WA House COG members on January 30th. At the conclusion of that hearing---which saw six people in favor and 48 opposed to the legislation---Chair Strom Peterson stated, “this bill is not going to be moving out of this committee but the conversation certainly is.” At publication time, it was Cannabis Observer’s understanding that Davis intended to file a different potency bill in 2021.
      • Haggerty admitted “there’s a lot we don’t know,” but from what was known “there does seem to be a relationship with dose to health risks.” He said the sub-group endeavored to develop “a consensus statement on health risk related to high concentration cannabis. And we had two questions that we were looking at: is high potency cannabis more detrimental to health than lower use, lower concentration cannabis? And are marginalized or vulnerable populations disproportionately affected by high potency cannabis use?"
    • A History (audio - 3m). Haggerty made claims about cannabinoid concentrations observed prior to cannabis legalization by states, stating “in the not so distant past the average potency of THC that people were ingesting was 3-8%. High potency, in the literature, was above 10% THC. And then the market forces have redefined cannabis." He said the current retail market made it “hard to find” cannabis under 10% THC, while cannabis concentrates had THC levels “up to 60 to 90%.” He observed changes in modes of cannabis use created new methods of ingesting concentrates, accompanied by “a nearly ten-fold increase in sales from extracts,” which he attributed to products being “cheaper, and shelf stable.” In contrast, products under 10% THC had “pretty much vanished” from the legal market.
    • Research Design (audio - 3m). Haggerty felt that challenges in conducting research hampered the study of cannabis health impacts in part because it was “hard to measure the full amount of THC consistently in any product.” He said most research was “observational” of individual cannabis consumers, or “surveys and secondary analysis,” or “randomization of high potency cannabis with animals” - the “same types of designs and approaches that guide policy decisions for all substances that are used non-medically.” He called out “some industry representatives that challenge the findings, that would say, they minimize the research or criticize the research findings, that we’re misrepresenting or misinterpreting the data. Or confusing medical with non-medical use. And that we make potency sound more complicated than it is." Since “not everyone is using the same definition” for high potency cannabis, Haggerty said that studies generally “examined a dose-response relationship between THC content and health outcomes.”
    • Health Disparities (audio - 1m). “Who’s most at risk” from using high potency cannabis was a timely concern for Haggerty and those putting together the report. He asserted that individuals “who dabbed cannabis...the high concentration THC, were more likely to be Latinx, have less education, lower household income, no health insurance, and poor mental health.” He believed that when “thinking about those who are most vulnerable, they're more likely to be using high concentration products.” He allowed that “doesn't necessarily mean that they're not self-titrating,” meaning “they might be using a high concentration product to be more efficient." Overall, Haggerty claimed, "high potency cannabis disproportionately does affect more marginalized or vulnerable populations."
    • Findings (audio - 2m). The researchers concluded that "high potency cannabis is more detrimental to health than lower potency cannabis" and felt available research demonstrated that “the THC content of cannabis products contributes to adverse health effects in a dose-response manner.” At the same time, animal studies suggested “that people are able to self titrate...able to use those high concentrations at a lower range and stop using.” The report advised research or reforms on the following issues:
      • Epidemiology and consumers’ motives
      • Measurement
      • Driving
      • Adolescents
      • Reduce research constraints imposed by federal policies
    • In closing, Haggerty highlighted upcoming NW PTTC events (audio - 3m). A follow up webinar about the cannabis potency report was subsequently scheduled for December 17th. Titled “The More the Merrier? THC Potency in the Legalization Era,” the webinar would be presented by Carlini, Wilhelm, and Michael McDonell, Associate Professor at the WSU Elson S. Floyd College of Medicine. The presentation would explore “prevention and policy implications from this research report and investigate advocacy opportunities” while preparing advocates to:
      • Cite the research discussing the impacts of modern high potency THC; 
      • Identify related policy implications; and 
      • Validate opportunities for community advocacy efforts.

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