Cannabis Retail Market Indicators in Five Legal States in the United States: A Public Health Perspective.

PURPOSE: Adult-use cannabis markets are operating in multiple US states and abroad. Sales and licensing data for alcohol and tobacco are often used to understand consumption patterns and evaluate policy changes. Cannabis market data may provide similar insights, although these newly legal markets are complex and evolving, and the state data structures can differ. This study describes variations in market indicators and discusses the utility of cannabis market metrics from a public health perspective. METHODS: We collected data from 5 early-adopting adult-use cannabis states: Alaska, Colorado, Massachusetts, Oregon, and Washington. Analyses focused on licensed retail outlets and retail sales revenues (pretax). Monthly data were collected from the opening of each state's adult-use market through June 2022. Joinpoint software was used to assess state trends and identify points of inflection in trends. Average sales per retailer for June 2019 and June 2022 were compared. Also described are retailers and revenue per population for 2022. FINDINGS: All states showed 4 distinct periods of growth in retail licensee numbers. The greatest increases typically occurred in the first 3 to 4 months. Growth rates slowed to <1% per month for Colorado, Oregon, and Washington at months 25, 24, and 34, respectively. The number of cannabis retailers per 100,000 residents in June 2022 ranged widely, from 16.8 in Oregon to 3.0 in Massachusetts. Colorado, Oregon, and Washington each showed 4 distinct trend periods in adult-use retail sales: early rapid growth lasting <1 year, subsequent varied growth periods, and then declining sales in the most recent months, following early coronavirus disease 2019 period increases. Sales in Alaska and Massachusetts displayed more stable, consistent growth patterns. Sales per state resident for July 2021 to June 2022 also ranged widely, from $382.97 in Alaska to $180.94 in Washington. IMPLICATIONS: We found some consistencies and some variations in both point-in-time measures and trends in states' adult-use cannabis markets. Differences may relate to varied state policies and general contexts (eg, economies). Market data can be useful for public health monitoring, including understanding the effects of policies intended to protect health and safety. States providing publicly accessible cannabis market data create opportunities for such use. Our results underscore the importance of considering individual state regulatory frameworks and implementation timelines in studies of cannabis legalization.

Marijuana and tobacco cigarettes: Estimating their behavioral economic relationship using purchasing tasks.

Although marijuana and tobacco are commonly coused, the nature of their relationship has not been fully elucidated. Behavioral economics has characterized the relationship between concurrently available commodities but has not been applied to marijuana and tobacco couse. U.S. adults ≥18 years who coused marijuana and tobacco cigarettes were recruited via Mechanical Turk, a crowdsourcing service by Amazon. Participants (N = 82) completed online purchasing tasks assessing hypothetical marijuana or tobacco cigarette puff consumption across a range of per-puff prices; 2 single-commodity tasks assessed these when only 1 commodity was available, and 2 cross-commodity tasks assessed these in the presence of a concurrently available fixed-price commodity. Purchasing tasks generated measures of demand elasticity, that is, sensitivity of consumption to prices. In single-commodity tasks, consumption of tobacco cigarette puffs (elasticity of demand: α = 0.0075; 95% confidence interval [0.0066, 0.0085], R² = 0.72) and of marijuana puffs (α = .0044; 95% confidence interval [0.0038, 0.0049], R² = 0.71) declined significantly with increases in price per puff. In cross-commodity tasks when both tobacco cigarette puffs and marijuana puffs were available, demand for 1 commodity was independent of price increases in the other commodity (ps > .05). Results revealed that, in this small sample, marijuana and tobacco cigarettes did not substitute for each other and did not complement each other; instead, they were independent of each other. These preliminary results can inform future studies assessing the economic relationship between tobacco and marijuana in the quickly changing policy climate in the United States. (PsycINFO Database Record

How Tobacco Quitline Callers in 38 US States Reported Hearing About Quitline Services, 2010-2013.

INTRODUCTION: Telephone-based tobacco quitlines are an evidence-based intervention, but little is known about how callers hear about quitlines and whether variations exist by demographics or state. This study assessed trends in "how-heard-abouts" (HHAs) in 38 states. METHODS: Data came from the Centers for Disease Control and Prevention's (CDC's) National Quitline Data Warehouse, which stores nonidentifiable data collected from individual callers at quitline registration and reported quarterly by states. Callers were asked how they heard about the quitline; responses were grouped into the following categories: media, health professional, family or friends, and "other." We examined trends from 2010 through 2013 (N = 1,564,437) using multivariable models that controlled for seasonality and the impact of CDC's national tobacco education campaign, Tips From Former Smokers (Tips). Using data from 2013 only, we assessed HHAs variation by demographics (sex, age, race/ethnicity, education) and state in a 38-state sample (n = 378,935 callers). RESULTS: From 2010 through 2013, the proportion of HHAs through media increased; however, this increase was not significant when we controlled for calendar quarters in which Tips aired. The proportion of HHAs through health professionals increased, whereas those through family or friends decreased. In 2013, HHAs occurred as follows: media, 45.1%; health professionals, 27.5%, family or friends, 17.0%, and other, 10.4%. Media was the predominant HHA among quitline callers of all demographic groups, followed by health professionals (except among people aged 18-24 years). Large variations in source of HHAs were observed by state. CONCLUSION: Most quitline callers in the 38-state sample heard about quitlines through the media or health care professionals. Variations in source of HHAs exist across states; implementation of best-practice quitline promotional strategies is critical to maximize reach.

Rules regarding marijuana and its use in personal residences: findings from marijuana users and nonusers recruited through social media.

Recent changes in policy and social norms related to marijuana use have increased its use and concern about how/where marijuana should be used. We aimed to characterize rules regarding marijuana and its use in homes. We recruited 1,567 US adults aged 18-34 years through Facebook advertisements to complete an online survey assessing marijuana use, social factors, perceptions of marijuana, and rules regarding marijuana and its use in the home, targeting tobacco and marijuana users to ensure the relevance of this topic. Overall, 648 (41.6%) were current marijuana users; 46.0% of participants reported that "marijuana of any type is not allowed in their home or on their property." Of those allowing marijuana on their property, 6.4% prohibited use of marijuana in their home. Of the remainder, 29.2% prohibited smoking marijuana, and 11.0% prohibited vaping, eating, or drinking marijuana. Correlates of more restrictive rules included younger age, being female, having

Quitline Use and Outcomes among Callers with and without Mental Health Conditions: A 7-Month Follow-Up Evaluation in Three States.

OBJECTIVES: To examine abstinence outcomes among tobacco users with and without a reported mental health condition (MHC) who enrolled in state tobacco quitline programs. METHODS: Data were analyzed from a 7-month follow-up survey (response rate: 41% [3,132/7,459]) of three state-funded telephone quitline programs in the United States that assessed seven self-reported MHCs at quitline registration. We examined 30-day point prevalence tobacco quit rates for callers with any MHC versus none. Data were weighted to adjust for response bias and oversampling. Multivariable logistic regression was used to examine cessation outcomes. RESULTS: Overall, 45.8% of respondents reported ≥ 1 MHC; 57.4% of those reporting a MHC reported ≥ 2 MHCs. The unadjusted quit rate for callers with any MHC was lower than for callers with no MHC (22.0% versus 31.0%, P < 0.001). After adjusting for demographics, nicotine dependence, and program engagement, callers reporting ≥ 1 MHC were less likely to be abstinent at follow-up (adjusted OR = 0.63, 95% CI = 0.51-0.78, P < 0.001). CONCLUSIONS: More intensive or tailored quitline programs may need to be developed among callers with MHCs as their quit rates appear to be lower than callers without MHCs.

Assessing the overlap between tobacco and marijuana: Trends in patterns of co-use of tobacco and marijuana in adults from 2003-2012.

BACKGROUND: As marijuana legalization and acceptability increase in the U.S., it is important to understand the potential impact on tobacco use. Accordingly, we assessed prevalence, correlates, and ten-year trends in co-use of marijuana and tobacco among U.S. adults. METHODS: Data came from 378,459 adults participating in the 2003-2012 National Survey on Drug Use and Health, an annual, cross-sectional, household survey. Data from 2011-2012 were used to compute the most recent prevalence of past 30-day marijuana and tobacco use (co-use). Data from 2003-2012 were used to compute demographic correlates of co-use, overall trends in co-use, and trends by age, race, and sex. We also assessed trends in tobacco use among marijuana users and marijuana use among tobacco users. RESULTS: From 2011 to 2012, 5.2% of participants were past month co-marijuana and tobacco users, 24.0% were tobacco-only users, and 2.3% were marijuana-only users. From 2003 to 2012, prevalence of co-use increased overall (p<.0001), and among males and females (p<.001, p<.05), those ages 26-34 (p<.001) and 50+years (p<.0001), and Whites (p<.01), Blacks (p<.05), and Hispanics (p<.01); there were no changes among adults 18-25 years. Tobacco use among marijuana users decreased between 2003 and 2012 (from 74.3% to 69.6%, p<.0001), while marijuana use increased among tobacco users (from 14.2% to 17.8, p<.0001). CONCLUSIONS: Co-use of tobacco and marijuana increased from 2003-2012, with marijuana use increasing among past-month tobacco users and tobacco use declining among past-month marijuana users. Improved surveillance of co-use is needed as marijuana legalization policies expand and become more integrated in communities.

Allowing cigarette or marijuana smoking in the home and car: prevalence and correlates in a young adult sample.

Given the increased marijuana use, negative health consequences of marijuana secondhand smoke exposure (SHSe) and dearth of research regarding marijuana SHSe in personal settings, we examined the prevalence and correlates of allowing marijuana versus cigarette smoking in personal settings among 2002 online survey respondents at two southeastern US universities in 2013. Findings indicated that 14.5% allowed cigarettes in the home, 17.0% marijuana in the home, 35.9% cigarettes in cars and 27.3% marijuana in cars. Allowing cigarettes in the home was associated with younger age, racial/ethnic minority status, living off campus, personal marijuana use, parental tobacco use and positive perceptions of cigarettes (P < 0.05). Correlates of allowing marijuana in the home included older age, not having children, living off campus, positive perceptions of marijuana and personal, parental and friend marijuana use (P < 0.05). Correlates of allowing cigarettes in cars included personal cigarette and marijuana use, parental tobacco and marijuana use, more cigarette-smoking friends and positive perceptions of cigarettes (P < 0.05). Correlates of allowing marijuana in cars included being non-Hispanic black; positive perceptions of marijuana; and personal, parental and friend marijuana use (P < 0.05). Interventions must target distinct factors influencing policies regarding cigarette versus marijuana use in personal settings to address the consequences of marijuana and cigarette SHSe.

Gradual reduction of cigarette consumption as a cessation strategy: prevalence, correlates, and relationship with quitting.

INTRODUCTION: Gradually reducing cigarette consumption is an approach used to quit smoking, but has not been widely studied at a population level. The purpose of this study was to assess the prevalence and demographic characteristics of U.S. adult smokers who tried to reduce to quit, and the relationship between reducing and successful quitting. METHODS: Data came from 12,571 adults in the 2010-2011 Tobacco Use Supplement to the Current Population Survey who tried to quit smoking in the past year. Frequencies and percentages were used to assess prevalence of reducing to quit; bivariate and multiple logistic regression models were used to assess correlates of reducing to quit and successful past year cessation. Analyses were conducted in SAS-callable SUDAAN. RESULTS: Among adults who tried to quit smoking in the past year, 43.0% (n = 5,444) tried reducing to quit. Compared to those who tried to quit without reducing consumption, those reducing to quit had a significantly higher prevalence of using counseling or medication (40.2% vs. 25.0%). In adjusted multivariable models, females (vs. males), Blacks (vs. Whites), current some day smokers (vs. every day smokers), and those who used counseling or medication had greater odds of trying to reduce to quit. Reducing to quit was negatively associated with successful past-year quitting (AOR = 0.59, 95% CI = 0.48, 0.72). CONCLUSION: Reducing to quit is a common cessation strategy and, in these analyses, was associated with lower cessation success rates. More research on reducing to quit in a real-world setting is needed before widely recommending it as a cessation strategy.

Differences in smoking and cessation characteristics among adult nondaily smokers in the United States: findings from the 2009-2010 National Adult Tobacco Survey.

INTRODUCTION: Nondaily smoking in the United States is increasing. Although differences in smoking and cessation behaviors between daily and nondaily smokers have been documented, differences among nondaily smokers are poorly understood. This study provides updated national data on smoking and cessation characteristics among nondaily versus daily smokers and between subgroups of nondaily smokers. METHODS: Data were obtained from the 2009-2010 National Adult Tobacco Survey, a stratified, dual-frame telephone survey conducted in the United States. Participants were categorized into daily smokers, never-daily nondaily smokers (NDNS), recently converted (≤1 year) nondaily smokers (RCNS), and established-converted (>1 year) nondaily smokers (ECNS). Chi-square tests were used to assess differences across groups, and multivariable logistic regression was used to identify factors associated with past-year quit attempts. RESULTS: Among nondaily smokers (17.8% of the total sample), 27.1% were NDNS, 37.4% were RCNS, and 35.4% were ECNS. RCNS were the most likely to report ever having tried to quit (p < .0001), having tried to quit in the past year (p < .0001), having used cessation treatment during their last quit attempt (p < .05), and wanting to quit smoking for good (p < .001). Compared with NDNS, RCNS had more than twice the odds of trying to quit in the past year after adjusting for demographics and smoking characteristics (adjusted odds ratio = 2.1, 95% confidence interval = 1.3-3.2). No significant differences existed between NDNS and ECNS. CONCLUSIONS: RCNS are potentially more interested in quitting and should be specifically targeted with cessation interventions to avoid relapse to daily or long-term nondaily smoking.

Prevalence and correlates of quitline awareness and utilization in the United States: an update from the 2009-2010 National Adult Tobacco Survey.

INTRODUCTION: Tobacco quitlines are evidence-based cessation resources that have been underutilized. The purpose of this study is to provide population-level data about quitline awareness and utilization in the United States and to assess correlates of awareness and utilization. METHODS: Data were from the 2009-2010 National Adult Tobacco Survey. Descriptive statistics were produced for national- and state-level quitline awareness and for national quitline utilization. Bivariate and multivariable logistic regressions were used to identify correlates of quitline awareness and utilization. RESULTS: Quitline awareness among the total sample was 33.9% (current smokers 53.9%, former smokers 34.0%, never-smokers 27.0%). Awareness varied by state (range: 35.8%-84.6% for current smokers). Among current smokers who tried to quit in the past year, correlates of lower awareness included being Black, non-Hispanic, and making <$50,000 annually; correlates of higher awareness included having seen a health professional, higher state tobacco program expenditures, and being female. Among smokers who made at least one quit attempt in the previous year and were aware of the quitline, quitline utilization was 7.8%. Higher state tobacco program expenditure, health professional advice, and being Black, non-Hispanic were correlated with higher utilization; older age was correlated with lower utilization. Awareness was significantly associated with use at the state level (r = .98, p < .01). CONCLUSION: Although the majority of smokers in the United States are aware of quitlines, only a small percentage of those trying to quit utilize them. State tobacco program expenditures and receipt of advice from a health professional were associated with both higher quitline awareness and higher utilization.

Applying the chronic care model to an employee benefits program: a qualitative inquiry.

OBJECTIVE: To assess how employee benefits programs may strengthen and/or complement elements of the chronic care model (CCM), a framework used by health systems to improve chronic illness care. METHODS: A qualitative inquiry consisting of semi-structured interviews with employee benefit administrators and partners from a self-insured, self-administered employee health benefits program was conducted at a large family-owned business in southwest Georgia. RESULTS: Results indicate that the employer adapted and used many health system-related elements of the CCM in the design of their benefit program. Data also suggest that the employee benefits program contributed to self-management skills and to informing and activating patients to interact with the health system. CONCLUSION: Findings suggest that employee benefits programs can use aspects of the CCM in their own benefit design, and can structure their benefits to contribute to patient-related elements from the CCM.

Results from an outreach program for health systems change in tobacco cessation.

INTRODUCTION: Washington state has experienced a dramatic reduction in adult smoking prevalence (22.4% in 1999 to 14.8% in 2010) because of a comprehensive tobacco control effort that includes a proactive health professional education and an outreach program. The outreach program uses academic detailing and online tools to increase routine identification and treatment of tobacco users. This article summarizes outcomes from the first 2 years of the program. METHOD: Outcome measures include the frequency of contact with providers, changes in the percentage of callers reporting that they had heard about the Quit Line from a health professional, and changes in provider Quit Line fax referrals. Data are compared between Initial, Expanded, and Never Outreach Counties. RESULTS: From 2008 to 2010, a total of 629 unique health care organizations and 3,989 unique health professionals received services. Between 2007 and 2010, the ratio of health professional "How Heard Abouts" to total Quit Line registrations increased by 142.6% and 95.4% in Initial and Expanded Outreach Counties, whereas Never Outreach Counties showed an 11.2% increase. Fax referrals to the Quit Line increased by 132% and 232% in Initial and Expanded Outreach Counties whereas they declined by 39% in Never Outreach Counties. DISCUSSION: Results suggests that health professionals can be an important and reliable source of referrals to a treatment resource such as a tobacco quitline. A field-based outreach program using academic detailing principles can be used to increase treatment referrals and holds application for other chronic disease areas and quality improvement programs.