UW ADAI - Symposium - 2022 - Public Health Outcomes in Legal Markets
(September 16, 2022) - Summary

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[ Event Details ]

A researcher suggested changes in availability and acceptance of high THC products contributed to increased use by adults and youth, and gave ideas for monitoring and reducing this trend.

Here are some observations from the Friday September 16th University of Washington Addictions, Drugs, and Alcohol Institute (UW ADAI) 2022 Symposium on “High-THC Cannabis in Legal Regulated Markets.”

My top 3 takeaways:

  • Dilley shared a presentation on "High [tetrahydrocannabinol] THC Products: Public Health Outcomes in Legal Markets," surveying both youth and adult cannabis consumption patterns and poison center cases involving cannabis products (audio - 18m, video).
    • Dilley kicked off her presentation at the symposium by telling attendees that she’d speak “about high THC products from a public health lens and especially from the perspective of the data that we can access readily within public health systems.” More specifically, she planned to interrogate how “a legal cannabis market [may] affect consumption of high THC products in populations, and health and safety outcomes.” She credited the prior speaker, Jonathan Caulkins, Professor of Operations Research and Public Policy at the Heinz College of Information Systems and Public Policy at Carnegie Mellon University (CMU), for the “foundational information” about policy options to reduce availability and use of the products to “protect public health and mitigate harms.”
    • Leveraging data from “public health surveillance systems or data that we can access,” Dilley acknowledged that some sources of information “don't include any information about specific products.” Additionally, she was “going to focus mainly on pre-[coronavirus] pandemic data periods.”
      • Her first source was sales and licensing data from cannabis regulators when stores began opening in July 2014. She indicated “it took a few years for the market to get up and running” but there were “400 or thereabouts retailers that are operating within the state and that's been holding fairly steady.” Compared to other early states to legalize like Alaska, Colorado, and Oregon, Washington had “fewer per capita cannabis…retail licenses operating,” observed Dilley.
      • She noted that “the proportion of sales that are for higher THC products, like concentrates and edibles, increases as a share of the market over time” since 2014. Mirroring trends mentioned by Caulkins, cannabis flower remained the dominant product type.
    • To evaluate consumption behavior, Dilley used the Behavioral Risk Factor Surveillance System (BRFSS), an “ongoing telephone survey of adults” used to “monitor all kinds of health behaviors,” along with HYS statistics, “one of the leading school-based health surveys in the United States.”
      • She felt that “the most important thing to take away is that the percentage of adults” consuming “cannabis in the past 30 days” had been increasing over time between 2012, when Initiative 502 was passed, and 2019, going from eight percent to 17%.
      • In 2015, BRFSS included a question about what type of cannabis adults were consuming each month, Dilley explained. The data showed less flower consumption, going from 85% “down to 70% in 2019,” and increased use of edible and vapor products, which “went up from 17% in 2015, up to 27% in 2019.”
      • Parsing HYS data for trends in youth cannabis use was more “complicated” for Dilley, who said that “for today, just assume it's kind of a flat line.” Like BRFSS, HYS questions had been expanded to ask minors “how did you usually use” cannabis products, she mentioned, and showed a similar “drop in the percentage of kids who said they're usually smoking it, and then modest increases in” use of vapor and edible or infused beverages between 2014 and 2018. Cannabis “dabs,” were added in 2018, Dilley remarked, and a “fairly high percentage of kids are saying they use dabs.” 
        • On May 31st, Segawa’s briefing on 2021 HYS results revealed a “pretty substantial decrease” in cannabis use by youth in the 30 days preceding their survey by three percent of 8th graders, seven percent of 10th graders, and “16% of 12th graders.” Question changes and survey gaps from the pandemic had broken the trendlines used by officials, however the 2012 HYS factsheet for cannabis—the last survey prior to cannabis legalization in the state—showed cannabis use rates for 8th, 10th, and 12th graders had been at nine percent, 19%, and 27% respectively.
      • Dilley told attendees that 2021 HYS results were similar to youth survey data from Oregon, which also showed that “Oregon's 11th graders…went from 93%” cannabis smoking in 2017, “down to 80% of kids in 2019.” Over this time she pointed out that “kids who use cannabis who said they vaporized it went from 11% up to 44%.” While the question format and grades surveyed weren’t an exact match, she commented that HYS data indicated similar changes in behavior. 
    • For adults living “living in communities where a cannabis retailer opens less than 0.8 miles from their zip code area, the current use of cannabis increased, and…frequent use increased,” she stated, while those “more than 18 miles away…don't seem to have any change in their cannabis use pattern.” Dilley claimed that “we saw something similar with youth” use. Retail stores near their home allegedly led youth to “perceive cannabis as more easy to get,” she said, “and they also change or become less prevention motivated in terms of believing that cannabis use is wrong for them or thinking that their friends believe it’s wrong, and thinking that parents think it's wrong, and thinking that adults in their community think it's wrong.” Dilley’s conclusion was that “the presence of the markets can have an effect on adult and youth behaviors.” With these datasets, Dilley reported that “data for both adults and youth” reflected “patterns of cannabis use and how those have changed as local area cannabis retailers open up.” She acknowledged that “one caveat is we've only been looking at this for cannabis products overall not by specific product type, but that's certainly our next research agenda item.”
    • “We're fortunate to have data available from U.S. poison control centers,” reported Dilley, as they were a “data source that contains information about cannabis product types.” She said calls could be made by individuals “experiencing symptoms” and wanting “to get help from a toxicologist or a nurse consultant” or from healthcare facilities that “don't know what to do about a specific exposure.” Dilley argued this information amounted to a “canary in the coal mine" and hypothesized wider problems in consumption by the general population. Acknowledging “people have become more accustomed to” searching the internet for information, she assumed they were less likely to call poison centers. Therefore, when Dilley heard “a signal coming through poison centers, I'm taking them very seriously.”
      • Evaluating nationwide poison center data on cannabis reports over time, she’d divided them between “plant based” cannabis flower and products like edibles and concentrates. Like other sources, this information was “showing that total cannabis exposure have gone up over time…​​from 2017 to 2019” and that what had been “driving that upward trend are these manufactured products, with edibles making up the greatest proportion of those.”
      • Falling into a seasonal trend of police and media sensationalism around finding cannabis in Halloween candy, Dilley described people “getting into cannabis infused edibles during Halloween and maybe getting those confused with their Halloween candy.” Analysis of “seasonal patterns of reported edible exposures by age group,” in both legal and non-legal cannabis states found “edible exposures increase about 25% among children under 10, 22% among youth ages 11 to 20, but it's during that November/December, versus the other month so…Halloween is at the beginning of that period,” however cannabis exposure “really continues throughout the holiday season.”
      • Dilley pointed out that in 2017, WSLCB officials were “getting concerned about child exposures for edibles” and expanded packaging and labeling rules for edibles to feature a Not For Kids logo, “kind of a like a Mr. Yuk type sticker” that included the phone number for the Washington Poison Center (WAPC). She was also happy about having servings of edibles individually wrapped, “so, if this were to be out on a table and a toddler got into it, they might get into the outside bag, but then they have to get into the second packaging within the inside bag.” Comparing the impact of this change to other states with cannabis markets, she said researchers focused on “those exposures that had significant health outcomes because we wanted to screen out people who just called more often because the poison center phone number was on the package.” Dilley suggested that researchers wanted to isolate “serious exposures that we thought probably would have been called in any case” to interpret revised labeling as contributing to “a 25% reduction in edible poisoning reports for children under 10, 51% reduction for ages 10 to 20, and a 23% reduction for adults 55 and older.” Besides helping youth, she theorized that “maybe that packaging also communicates to adults and helps adults…titrate their own dose more effectively.”
      • WAPC and other poison control centers are private, nonprofit entities which provide a public health service to those contacting them, and also maintain partnerships with academic, healthcare, and prevention interests. It’s Cannabis Observer’s understanding that privileged access to poison center data is reserved for selected researchers; whereas, in our experience, we were asked to pay significant fees.
    • Considering potential policy responses to the increased use of high THC products, Dilley advocated for assorted “regulatory stuff we can do.”
      • Dilley suggested revising regulations around “what can be sold, the potency of those products that can be sold, purchasing limits, maybe times of day, different places, price incentives, and Dr. Caulkins talked about taxing as a good thing, and then promotion.” She noted there had been “fewer limits on advertising early on in the legal market” and mediums for cannabis retail like billboards and sign spinners had been banned in law and rule. It was “a good example of where regulation maybe didn't directly address THC concentration” but helped limit messaging on that “approach of getting high.”
      • Furthermore, Dilley suggested “health care and behavioral health systems may need support for their screening processes and intervention processes for people that they're helping.”
      • She felt that because “we're seeing these changes in youth consumption patterns, maybe we need youth-centered social marketing campaigns and safe storage campaigns maybe with a seasonal emphasis.” Educational efforts like this “may need policies to make sure that those get out there.”

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