The Cannabis Policy Scale: A New Research and Surveillance Tool for U.S. States.

OBJECTIVE: Rapid shifts toward cannabis liberalization in the United States have created immense policy variability that is challenging to measure. We developed composite measures to characterize the restrictiveness of U.S. state cannabis policy environments. METHOD: Nine panelists, consisting of four research team members and five expert policy consultants, nominated distinct cannabis policies pertaining to cannabis prohibition, medicalization, and legalization for recreational use. For each of the 17 nominated policies, panelists developed implementation ratings and rated each policy's relative efficacy for reducing excessive cannabis use by adults, youth use, and impaired driving. Cannabis Policy Scale scores were then calculated for each state-year for all 50 states from 1999 to 2019 by weighting policies by their efficacy and implementation ratings, and then summing over policies. RESULTS: Median Cannabis Policy Scale scores remained stable until 2008, when they started declining (representing policy liberalization), with steeper declines after 2012. In 2019, state Cannabis Policy Scale scores targeting excessive use among the general population ranged from 29.6 to 66.7 for recreational cannabis legalization states, and from 72.4 to 93.4 for medical cannabis legalization states. Cannabis Policy Scale scores using youth-specific and driving-specific efficacy ratings showed similar trends. CONCLUSIONS: The Cannabis Policy Scale reflects trends toward liberalization of cannabis policy in many U.S. states. Even within crude policy phenotypes (e.g., medical cannabis programs), Cannabis Policy Scale scores varied considerably between states and over time. The Cannabis Policy Scale is a new measure that can add nuance to cannabis policy research and help assess cannabis policy-outcome relationships.

Rating the comparative efficacy of state-level cannabis policies on recreational cannabis markets in the United States.

BACKGROUND: Cannabis policy is developing faster than empirical evidence about policy effects. With a panel of experts in substance use policy development and research, we identified key cannabis policies and their provisions enacted by U.S. states; rated their theoretical efficacy in a restrictive form for reducing problematic use and impaired driving in the context of a recreational cannabis market as judged by experts; and rated the strength of evidence for each policy. METHODS: Using a modified Delphi approach, 9 panelists rated the comparative efficacy of 18 state cannabis policies for reducing youth use of cannabis, excessive cannabis use among the general population, and cannabis-impaired driving. Each outcome was rated separately using a Likert scale, and panelists also rated the strength of evidence supporting each efficacy rating. Investigators provided descriptions of each policy so that the nine panelists had similar conceptions of each policy. RESULTS: State monopoly (state owns all production, manufacturing, wholesale, and retail operations) was rated as the most effective policy for all three outcome areas. Restrictions on retail physical availability, taxes, retail price restrictions, and retail operations restrictions were also highly rated for all three outcomes. Policies regulating cannabis businesses and products were judged more effective than policies targeting consumer use and behavior. Panelists reported there was little or no direct evidence from the cannabis policy literature for most of the included policies. CONCLUSION: These ratings can facilitate research as well as policy-making decisions. A relatively small number of policies were judged to be highly effective across all three domains, indicating that for the most part adult excessive use, youth use, and impaired driving can all be reduced with the same set of policies; these policies tended to target the behaviors of businesses rather than consumers. The low levels of direct evidence available to inform policy ratings, as reported by the policy panelists, makes clear the need for ongoing and sustained cannabis policy research.

Relationships of Cannabis Policy Liberalization With Alcohol Use and Co-Use With Cannabis: A Narrative Review.

PURPOSE: The liberalization of cannabis policies has the potential to affect the use of other substances and the harms from using them, particularly alcohol. Although a previous review of this literature found conflicting results regarding the relationship between cannabis policy and alcohol-related outcomes, cannabis policies have continued to evolve rapidly in the years since that review. SEARCH METHODS: The authors conducted a narrative review of studies published between January 1, 2015, and December 31, 2020, that assessed the effects of cannabis policies on the use of alcohol in the United States or Canada. SEARCH RESULTS: The initial search identified 3,446 unique monographs. Of these, 23 met all inclusion criteria and were included in the review, and five captured simultaneous or concurrent use of alcohol and cannabis. DISCUSSION AND CONCLUSIONS: Associations between cannabis policy liberalization and alcohol use, alcohol-related outcomes, and the co-use of alcohol and cannabis were inconclusive, with studies finding positive associations, no associations, and negative associations. Although several studies found that cannabis policy liberalization was associated with decreases in alcohol use measures, these same studies showed no impact of the cannabis policy on cannabis use itself. The lack of a consistent association was robust to subject age, outcome measure (e.g., use, medical utilization, driving), and type of cannabis policy; however, this may be due to the small number of studies for each type of outcome. This paper discusses several notable limitations of the evidence base and offers suggestions for improving consistency and comparability of research going forward, including a stronger classification of cannabis policy, inclusion of measures of the alcohol policy environment, verification of the impact of cannabis policy on cannabis use, and consideration of mediation effects.

Trends in Cannabis Involvement and Risk of Alcohol Involvement in Motor Vehicle Crash Fatalities in the United States, 2000‒2018.

Objectives. To assess cannabis and alcohol involvement among motor vehicle crash (MVC) fatalities in the United States. Methods. In this repeated cross-sectional analysis, we used data from the Fatality Analysis Reporting System from 2000 to 2018. Fatalities were cannabis-involved if an involved driver tested positive for a cannabinoid and alcohol-involved based on the highest blood alcohol concentration (BAC) of an involved driver. Multinomial mixed-effects logistic regression models assessed cannabis as a risk factor for alcohol by BAC level. Results. While trends in fatalities involving alcohol have remained stable, the percentage of fatalities involving cannabis and cannabis and alcohol increased from 9.0% in 2000 to 21.5% in 2018, and 4.8% in 2000 to 10.3% in 2018, respectively. In adjusted analyses, fatalities involving cannabis had 1.56 (95% confidence interval [CI] = 1.48, 1.65), 1.62 (95% CI = 1.52, 1.72), and 1.46 (95% CI = 1.42, 1.50) times the odds of involving BACs of 0.01% to 0.049%, 0.05% to 0.079%, and 0.08% or higher, respectively. Conclusions. The percentage of fatalities involving cannabis and coinvolving cannabis and alcohol doubled from 2000 to 2018, and cannabis was associated with alcohol coinvolvement. Further research is warranted to understand cannabis- and alcohol-involved MVC fatalities. (Am J Public Health. 2021;111(11):1976-1985. https://doi.org/10.2105/AJPH.2021.306466).

Current U.S. State Cannabis Sales Limits Allow Large Doses for Use or Diversion.

INTRODUCTION: Legal limits on the amount of cannabis sold per transaction in states with recreational cannabis may promote moderate use and limit diversion. However, state sales limits are heterogeneous and difficult to interpret in terms of tetrahydrocannabinol dose equivalents. METHODS: This cross-sectional study examined how transaction sales limits on recreational cannabis translate to tetrahydrocannabinol doses among U.S. states allowing commercial cannabis sales as of January 1, 2020. Weight-based quantity limits by cannabis type (flower/bud, concentrates, and edibles) were converted into grams of tetrahydrocannabinol content per transaction using known potency values in 2020. RESULTS: Weight-based sales limits for flower and concentrate vary considerably across states (range=1.0-2.5 oz for flower and 3.5-15.0 g for concentrate), whereas limits for edible cannabis are heterogeneous. A total of 4 states have independent limits for each product category, and 6 states place limits across all products sold in the transaction. Because no states impose limits on the potency of flower or concentrates, the small differences in the weight-based limits translate into large differences in grams of tetrahydrocannabinol allowed to be sold. Assuming a typical dose of 10 mg of tetrahydrocannabinol, current laws allow for sales of up to 560 (Alaska) to 2,283 (Michigan) doses per transaction on the basis of median product potencies. CONCLUSIONS: All states allow a large number of tetrahydrocannabinol doses per transaction, larger than what is typically consumed by daily users over a month. States concerned about public health and diversion should consider reducing sales limits and basing them on total tetrahydrocannabinol content across all purchased products.

The Rise and Fall of Alcohol Excise Taxes in U.S. States, 1933-2018.

OBJECTIVE: Higher alcohol taxation is protective against alcohol-related morbidity and mortality. All states have specific (volume-based) excise taxes for alcohol that decrease if not adjusted for inflation. These taxes have diminished substantially in real terms since their inception after National Prohibition in the United States. The purpose of this study was to examine trends in the magnitude and frequency of changes in state specific excise taxes to document their erosion. METHOD: Alcohol excise tax data were examined for all 50 states from 1933 to 2018. Tax data were obtained from the Alcohol Policy Information System, Pacific Institute for Research and Evaluation, Wine Institute, and HeinOnline. Linear and logistic regression analyses were conducted for beer, wine, and distilled spirits taxes to examine trends in the frequency and inflation-adjusted magnitude of changes in taxes from the year of alcohol tax inception. RESULTS: From 1933 until 1970, beer, wine, and distilled spirits tax rates increased in value compared with inception rates, but by 2018 alcohol taxes had declined 66%, 71%, and 70%, respectively, compared with their inception values. The erosion of taxes after 1970 was driven primarily by declines in the magnitude of tax increases through the 1970s and 1980s, followed by declines in the frequency of tax increases in subsequent decades. CONCLUSIONS: The value of alcohol excise taxes has declined since 1970 from both insufficient tax increases and later infrequent tax increases. Laws that index rates to inflation could sustain the public health benefit of reduced morbidity and mortality resulting from higher alcohol tax rates.

Alcohol Policies in U.S. States, 1999-2018.

OBJECTIVE: U.S. policymakers and public health practitioners lack composite indicators (indices) to assess and compare the restrictiveness of state-level alcohol policy environments, conceptualized as the presence of multiple policies in effect in a particular place and time. The purposes of this study were to characterize the alcohol policy environment in each U.S. state and Washington, DC, in 2018, and to examine changes during the past 20 years. METHOD: State-specific Alcohol Policy Scale (APS) scores from 1999 to 2018 were based on 29 policies, after weighting each present policy by its efficacy and degree of implementation. Modified APS scores were also calculated on the basis of two sets of mutually exclusive policy subgroups. RESULTS: APS scores in 2018 varied considerably between states, ranging from 25.6 to 67.9 on a theoretical scale of 0 to 100; the median score was 43.5 (based on a 0-100 range), and 43 states had scores less than 50. The median change in state APS scores from 1999 to 2018 was positive (+4.9, range: -7.4 to +10.3), indicating increases in the restrictiveness of policy environments, with decreases in only five states. The increases in APS scores were primarily attributable to the implementation of stronger impaired-driving laws, whereas policies to reduce excessive drinking were unchanged. There was no correlation between states' excessive drinking policy scores and their impaired-driving scores (r = .05, p = .74). CONCLUSIONS: Based on this policy scale, few states have restrictive policy environments. Although states adopted policies targeting impaired driving during the study period, there was no change in policies to reduce excessive drinking.

The Composition and Magnitude of Alcohol Taxes in States: Do They Cover Alcohol-Related Costs?

OBJECTIVE: At least one type of tax is applied to the sale of alcoholic beverages in all U.S. states. The purpose of this study was to characterize the composition and magnitude of alcohol taxes in states and to assess the relationship between total alcohol taxes (federal plus state) and the cost of excessive drinking. METHOD: The amount of tax (in dollars per standard drink) by state was estimated from data on state ad valorem excise, specific excise, and sales taxes in 2010 obtained from the Alcohol Policy Information System and Tax Foundation. These taxes were summed, and specific excise taxes were assessed as a proportion of total state taxes. Tax data on beer were analyzed for all 50 states. Tax data for wine and distilled spirits were restricted to the 32 license states and Washington, D.C., with fully privatized distribution systems. Total alcohol taxes for the 32 license states were compared on a per-drink basis with published state estimates of the cost of excessive drinking in these states in 2010. RESULTS: Specific excise taxes accounted for a weighted median of 20.1% of total state alcohol tax revenue in the 32 license states and Washington, D.C. The median total alcohol tax per drink (based on all federal and state taxes) was $0.21, which accounted for 26.7% of the median cost to government and 10.3% of the median total economic cost of excessive drinking. CONCLUSIONS: Specific excise taxes account for one fifth of state alcohol taxes in the 32 license states; but even considering all tax types, total alcohol taxes account for only one tenth of alcohol-related costs.

Erosion of State Alcohol Excise Taxes in the United States.

OBJECTIVE: In the United States, excessive alcohol consumption is responsible for 88,000 deaths annually and cost $249 billion, or $2.05 per drink, in 2010. Specific excise taxes, the predominant form of alcohol taxation in the United States, are based on the volume of alcohol sold rather than a percentage of price and can thus degrade over time because of inflation. The objective of this study was to describe changes in inflation-adjusted state alcohol excise taxes on a beverage-specific basis. METHOD: State-level data on specific excise taxes were obtained from the Alcohol Policy Information System and the Tax Foundation. Excise tax rates were converted into the tax per standard U.S. drink (14 g of ethanol) for beer, wine, and distilled spirits, and converted into 2015 dollars using annual Consumer Price Index data. RESULTS: Across U.S. states, the average state alcohol excise tax per drink in 2015 was $0.03 for beer, $0.05 for distilled spirits, and $0.03 for wine. From 1991 to 2015, the average inflation-adjusted (in 2015 dollars) state alcohol excise tax rate declined 30% for beer, 32% for distilled spirits, and 27% for wine. Percentage declines in state excise taxes since their inception were more than twice as large as those from 1991 to 2015. CONCLUSIONS: In 2015, average state specific excise taxes were $0.05 or less per standard drink across all beverage types and have experienced substantial inflation-adjusted declines.

Who Would Pay for State Alcohol Tax Increases in the United States?

INTRODUCTION: Despite strong evidence that increasing alcohol taxes reduces alcohol-related harm, state alcohol taxes have declined in real terms during the past 3 decades. Opponents of tax increases argue that they are unfair to "responsible" drinkers and those who are financially disadvantaged. The objectives of this study were to assess the impact of hypothetical state alcohol tax increases on the cost of alcohol for adults in the United States on the basis of alcohol consumption and sociodemographic characteristics. METHODS: The increased net cost of alcohol (ie, product plus tax) from a series of hypothetical state alcohol tax increases was modeled for all 50 states using data from the 2011 Behavioral Risk Factor Surveillance System, IMPACT Databank, and the Alcohol Policy Information System. Costs were assessed by drinking pattern (excessive vs nonexcessive) and by sociodemographic characteristics. RESULTS: Among states, excessive drinkers would pay 4.8 to 6.8 times as much as nonexcessive drinkers on a per capita basis and would pay at least 72% of aggregate costs. For nonexcessive drinkers, the annual cost from even the largest hypothetical tax increase ($0.25 per drink) would average less than $10.00. Drinkers with higher household incomes and non-Hispanic white drinkers would pay higher per capita costs than people with lower incomes and racial/ethnic minorities. CONCLUSION: State-specific tax increases would cost more for excessive drinkers, those with higher incomes, and non-Hispanic whites. Costs to nonexcessive drinkers would be modest. Findings are relevant to developing evidence-based public health practice for a leading preventable cause of death.

Alcohol Policies and Alcoholic Cirrhosis Mortality in the United States.

INTRODUCTION: Stronger alcohol policies predict decreased alcohol consumption and binge drinking in the United States. We examined the relationship between the strength of states' alcohol policies and alcoholic cirrhosis mortality rates. METHODS: We used the Alcohol Policy Scale (APS), a validated assessment of policies of the 50 US states and Washington DC, to quantify the efficacy and implementation of 29 policies. State APS scores (theoretical range, 0-100) for each year from 1999 through 2008 were compared with age-adjusted alcoholic cirrhosis death rates that occurred 3 years later. We used Poisson regression accounting for state-level clustering and adjusting for race/ethnicity, college education, insurance status, household income, religiosity, policing rates, and urbanization. RESULTS: Age-adjusted alcoholic cirrhosis mortality rates varied significantly across states; they were highest among males, among residents in states in the West census region, and in states with a high proportion of American Indians/Alaska Natives (AI/ANs). Higher APS scores were associated with lower mortality rates among females (adjusted incidence rate ratio [IRR], 0.91 per 10-point increase in APS score; 95% confidence interval [95% CI], 0.84-0.99) but not among males (adjusted IRR, 0.97; 95% CI, 0.90-1.04). Among non-AI/AN decedents, higher APS scores were also associated with lower alcoholic cirrhosis mortality rates among both sexes combined (adjusted IRR, 0.89; 95% CI, 0.82-0.97). Policies were more strongly associated with lower mortality rates among those living in the Northeast and West census regions than in other regions. CONCLUSIONS: Stronger alcohol policy environments are associated with lower alcoholic cirrhosis mortality rates. Future studies should identify underlying reasons for racial/ethnic and regional differences in this relationship.

Youth Drinking in the United States: Relationships With Alcohol Policies and Adult Drinking.

BACKGROUND: The relationship between the alcohol policy environment (ie, the combined effectiveness and implementation of multiple existing alcohol policies) and youth drinking in the United States has not been assessed. We hypothesized that stronger alcohol policy environments are inversely associated with youth drinking, and this relationship is partly explained by adult drinking. METHODS: Alcohol Policy Scale (APS) scores that characterized the strength of the state-level alcohol policy environments were assessed with repeated cross-sectional Youth Risk Behavior Survey data of representative samples of high school students in grades 9 to 12, from biennial years between 1999 and 2011. RESULTS: In fully adjusted models, a 10 percentage point increase in APS scores (representing stronger policy environments) was associated with an 8% reduction in the odds of youth drinking and a 7% reduction in the odds of youth binge drinking. After we accounted for youth-oriented alcohol policies, the subgroup of population-oriented policies was independently associated with lower odds of youth drinking (adjusted odds ratio 0.94; 95% confidence interval 0.92-0.97) and youth binge drinking (adjusted odds ratio 0.96; 95% confidence interval 0.94-0.99). State-level per capita consumption mediated the relationship between population-oriented alcohol policies and binge drinking among youth. CONCLUSIONS: Stronger alcohol policies, including those that do not target youth specifically, are related to a reduced likelihood of youth alcohol consumption. These findings suggest that efforts to reduce youth drinking should incorporate population-based policies to reduce excessive drinking among adults as part of a comprehensive approach to preventing alcohol-related harms. Future research should examine influence of alcohol policy subgroups and discrete policies.

Alcohol policies and impaired driving in the United States: Effects of driving- vs. drinking-oriented policies.

AIMS: To test the hypotheses that stronger policy environments are associated with less impaired driving and that driving-oriented and drinking-oriented policy subgroups are independently associated with impaired driving. DESIGN: State-level data on 29 policies in 50 states from 2001-2009 were used as lagged exposures in generalized linear regression models to predict self-reported impaired driving. SETTING: Fifty United States and Washington, D.C. PARTICIPANTS: A total of 1,292,245 adults (≥ 18 years old) biennially from 2002-2010. MEASURES: Alcohol Policy Scale scores representing the alcohol policy environment were created by summing policies weighted by their efficacy and degree of implementation by state-year. Past-30-day alcohol-impaired driving from 2002-2010 was obtained from the Behavioral Risk Factor Surveillance System surveys. FINDINGS: Higher Alcohol Policy Scale scores are strongly associated with lower state-level prevalence and individual-level risk of impaired driving. After accounting for driving-oriented policies, drinking-oriented policies had a robust independent association with reduced likelihood of impaired driving. Reduced binge drinking mediates the relationship between drinking-oriented policies and impaired driving, and driving-oriented policies reduce the likelihood of impaired driving among binge drinkers. CONCLUSIONS: Efforts to reduce alcohol-impaired driving should focus on reducing excessive drinking in addition to preventing driving among those who are impaired.

The relationship between alcohol taxes and binge drinking: evaluating new tax measures incorporating multiple tax and beverage types.

AIMS: U.S. studies contribute heavily to the literature about the tax elasticity of demand for alcohol, and most U.S. studies have relied upon specific excise (volume-based) taxes for beer as a proxy for alcohol taxes. The purpose of this paper was to compare this conventional alcohol tax measure with more comprehensive tax measures (incorporating multiple tax and beverage types) in analyses of the relationship between alcohol taxes and adult binge drinking prevalence in U.S. states. DESIGN: Data on U.S. state excise, ad valorem and sales taxes from 2001 to 2010 were obtained from the Alcohol Policy Information System and other sources. For 510 state-year strata, we developed a series of weighted tax-per-drink measures that incorporated various combinations of tax and beverage types, and related these measures to state-level adult binge drinking prevalence data from the Behavioral Risk Factor Surveillance System surveys. FINDINGS: In analyses pooled across all years, models using the combined tax measure explained approximately 20% of state binge drinking prevalence, and documented more negative tax elasticity (-0.09, P = 0.02 versus -0.005, P = 0.63) and price elasticity (-1.40, P < 0.01 versus -0.76, P = 0.15) compared with models using only the volume-based tax. In analyses stratified by year, the R-squares for models using the beer combined tax measure were stable across the study period (P = 0.11), while the R-squares for models rely only on volume-based tax declined (P < 0.0). CONCLUSIONS: Compared with volume-based tax measures, combined tax measures (i.e. those incorporating volume-based tax and value-based taxes) yield substantial improvement in model fit and find more negative tax elasticity and price elasticity predicting adult binge drinking prevalence in U.S. states.

Patterns of change in implementation of state alcohol control policies in the United States, 1999-2011.

AIMS: To examine state alcohol control policy implementation by policy efficacy and intent. DESIGN: A descriptive longitudinal analysis of policy implementation. SETTING: The United States, 1999-2011. PARTICIPANTS: Fifty states and the District of Columbia. MEASUREMENTS: Twenty-nine state-level policies were rated based on an implementation rating (IR; range = 0.0-1.0) gathered from the Alcohol Policy Information System, government and industry reports and other sources; and expert judgment about policy efficacy for addressing binge drinking and alcohol-impaired driving among the general population and youth, respectively. FINDINGS: On average, implementation of the most effective general population policies did not change [mean IR = 0.366 in 1999; 0.375 in 2011; slope for annual change = 0.001; 95% confidence interval (CI) for the slope -0.001, 0.002]. In contrast, implementation increased over time for less effective policies (mean IR = 0.287 in 1999; 0.427 in 2011; slope for annual change compared with most effective policies = 0.009; slope 95% CI = 0.002-0.007), for youth-oriented policies (mean IR = 0.424 in 1999; 0.511 in 2011; slope for annual change compared with most effective policies = 0.007; slope 95% CI = 0.005-0.009), and for impaired driving policies (mean IR = 0.493 in 1999; 0.608 in 2011; slope for annual change compared with most effective policies = 0.0105; slope 95% CI = 0.007-0.014). CONCLUSIONS: Implementation of politically palatable state alcohol policies, such as those targeting youth and alcohol-impaired driving, and less effective policies increased during 1999-2011 in the United States, while the most effective policies that may maximally protect public health remained underused.