CANNABIS LEGALIZATION IN STATE LEGISLATURES: PUBLIC HEALTH OPPORTUNITY AND RISK.

Cannabis is widely used in the U.S. and internationally despite its illicit status, but that illicit status is changing. In the U.S., 33 states and the District of Columbia have legalized medical cannabis, and 11 states and D.C. have legalized adult use cannabis. A majority of state medical cannabis laws and all but two state adult use laws are the result of citizen ballot initiatives, but state legislatures are beginning to seriously consider adult use legislation. From a public health perspective, cannabis legalization presents a mix of potential risks and benefits, but a legislative approach offers an opportunity to improve on existing legalization models passed using the initiative process that strongly favor business interests over public health. To assess whether state legislatures are acting on this opportunity, this article examines provisions of proposed adult use cannabis legalization bills active in state legislatures as of February 2019 to evaluate the inclusion of key public health best practices based on successful tobacco and alcohol control public health policy frameworks. Given public support for legalization, further adoption of state adult use cannabis laws is likely, but legalization should not be viewed as a binary choice between total prohibition and laissez faire commercialization. The extent to which adult use cannabis laws incorporate or reject public health best practices will strongly affect their impact, and health advocates should work to influence the construction of such laws to prioritize public health and learn from past successes and failures in regulating other substances.

The Grassroots of Grass: Cannabis Legalization Ballot Initiative Campaign Contributions and Outcomes, 2004-2016.

CONTEXT: As of November 2018, medical cannabis was legal in 33 US states and recreational cannabis in 10, mostly enacted via ballot initiative. METHODS: We identified 32 cannabis legalization initiatives from 2004 to 2016 and obtained campaign contribution and state political and demographic data. After exploratory analyses of 15 potential independent variables, we quantified effects of 4 factors (initiative year, voter turnout, population born before 1946, advocate funding advantage) on voter support and likelihood of passage. FINDINGS: A small number of campaign contributors dominated both sides of the issue, with little involvement by health advocates. Time and turnout, not money, were the factors most associated with electoral outcomes, consistent with increases in public opinion favoring cannabis legalization over time. Year, turnout, and population age were associated with voter support, while year, turnout, and advocate funding advantage were associated with likelihood of passage. When adjusting for an anomalous result, initiative year was the only variable that remained significantly associated with odds of passage, with a 1-year increase in initiative date associated with 2.02 times higher odds of passage (p < .01). CONCLUSION: These results underscore the importance of health advocate participation in developing cannabis legalization frameworks.

Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control.

State legalization and regulation of cannabis, despite continued federal illegality, is a massive shift in regulatory approach. Manufactured cannabis, including concentrates, extracts, edibles, tinctures, topicals and other products, has received less attention than more commonly used dried flower, but represents emerging regulatory challenges due to additives, potency, consumption methods, and abuse and misuse potential. In November 2017, the California Department of Public Health (CDPH) released initial cannabis manufacturing regulations as part of a new state regulatory structure. As the largest U.S. medical cannabis market (and largest legal adult use market in the world beginning in 2018), California's regulatory approach will potentially influence national and global policy. Comparing CDPH's initial regulations to tobacco control best practices reveals that, while the regulations recognize the need to protect public health, prioritizing public health over business interests requires stronger approaches to labeling, packaging, and product formulations. Based on tobacco best practices, we recommend that cannabis regulations incorporate large and proportionately sized informational labels, a prominent universal cannabis symbol, rotating and pictorial health warnings, mandatory plain packaging, a comprehensive ban on characterizing flavors and addictive additives, and strict limits on the potency of inhalable products and those easily confused with non-cannabis products.

Major trends in public health law and practice: a network national report.

Since its inception in September 2010, the Network for Public Health Law has responded to hundreds of public health legal technical assistance claims from around the country. Based on a review of these data, a series of major trends in public health practice and the law are analyzed, including issues concerning: the Affordable Care Act, tobacco control, emergency legal preparedness, health information privacy, food policy, vaccination, drug overdose prevention, sports injury law, public health accreditation, and maternal breastfeeding. These and other emerging themes in public health law demonstrate the essential role of law and practice in advancing the public's health.

Reconsidering the legality of cigarette smoking advertisements on television public health and the law.

Television advertisements depicting the use of electronic cigarettes have recently exposed minors to images of smoking behaviors. While these advertisements are currently legal, existing laws should be interpreted or expanded to ban the commercial depiction of smoking behaviors with any product that resembles a cigarette to shield minors from potentially influential advertising.

When law is not law: setting aside legal provisions during declared emergencies.

During an emergency, laws designed for normal operations and circumstances may sometimes hinder response efforts, potentially endangering the public's health rather than protecting it. Pursuant to declared states of emergency, however, officials may be authorized to waive or suspend some provisions of state law to address emergency conditions. Such authority can play a critical role in response efforts, but this authority varies significantly between states. States should carefully consider how their existing laws may affect response during a declared emergency and whether adoption of waiver authority would improve their legal structure. Where waiver provisions are in place, officials should ensure they understand its proper scope and utility.

Congress, courts, and commerce: upholding the individual mandate to protect the public's health.

Among multiple legal challenges to the Patient Protection and Affordable Care Act (PPACA) is the premise that PPACA's "individual mandate" (requiring all individuals to obtain health insurance by 2014 or face civil penalties) is inviolate of Congress' interstate commerce powers because Congress lacks the power to regulate commercial "inactivity." Several courts initially considering this argument have rejected it, but federal district courts in Virginia and Florida have concurred, leading to numerous appeals and prospective review of the United States Supreme Court. Despite creative arguments, the dispositive constitutional question is not whether Congress' interstate commerce power extends to commercial inactivity. Rather, it is whether Congress may regulate individual decisions with significant economic ramifications in the interests of protecting and promoting the public's health. This article offers a counter-interpretation of the scope of Congress' interstate commerce power to regulate in furtherance of the public's health.