The rapidly evolving environment poses considerable concerns about children’s exposure to marijuana and related marketing and creates significant challenges for pediatricians preventing, treating, and educating about marijuana-related harms among children. As stated in its most recent policy statement about marijuana commercialization, the American Academy of Pediatrics “strongly recommends strict enforcement of rules and regulations that limit access and marketing and advertising to youth”. The presence of RMDs in neighborhoods and point-of-sale marketing such as advertising and promotional activities in RMDs might increase the visibility and awareness of marijuana products among children, whose perceptions and behaviors may be influenced. A study in Oregon found that dispensary storefront was the most common source of advertising seen after commercialization. Self-reported exposure to medical marijuana advertising was found to be related to higher levels of use and intentions of future use among children in California schools. Products, packages, and advertisements that are designed to be appealing to children are particularly concerning. Tobacco and alcohol literature repeatedly suggested that children are common targets of marketing. Despite the fact that all the states with marijuana commercialization have some form of prohibitions on child-appealing products and marketing, it remains undocumented as to what extent the marijuana industry is complying. This study is the first to comprehensively assess point-of-sale marketing practices in RMDs with a focus on those relevant to children. Unlike previous marijuana research relying on individual self-reported exposure measures, we adopted the direct and objective observation approach that has been commonly used in tobacco and alcohol studies on retail outlets. We audited RMDs near a representative and large sample of schools in California,cannabis grow setup the largest legal retail market in the US where over 10 million children can be potentially influenced.
We identified product and packaging characteristics, advertising and promotional activities, and access restrictions in these dispensaries. This was a cross-sectional and observational study conducted in June-September in 2018. We obtained a list of public schools in California that participated in the 2017–18 California Student Tobacco Survey . California was first stratified into 22 regions. Schools within each region were then randomly selected, proportional to the number of students enrolled within the region. A total of 623 schools across California were sampled and invited, with 403 schools agreeing to participate. Among these 403 schools, 44 schools opted out before the survey was conducted, and 26 schools participated in the survey but were excluded from CSTS data due to low response rate. The final effective school sample size was 333, among which 256 were high schools and 77 were middle schools. The total number of students participating in the survey was 151,404, making it the largest school-based surveys in California. Our study focused on RMDs near these 333 schools.Six trained field workers audited retail environments in RMDs in closest proximity to the 333 schools . We first identified dispensaries using crowd sourced online websites, including Weedmaps, Wheresweed, Leafly, and Yelp. State licensing records were not used because they could not provide a complete list of dispensaries at the time of data collection. Specifically, 1) Marijuana commercialization in California took effect in January 2018. During the study period, California was in a transition stage when annual licenses were just issued, and most were not approved. 2) The licensing policy in California was not enforced, with a large portion of dispensaries operating without licenses. 3) For licensed dispensaries, the registered and actual business name and address often mismatched.
Alternatively, we utilized crowd sourced databases, which were considered as reliable, up-to-date, and comprehensive sources of dispensary directories. To identify the dispensary closest to a school, field workers entered school zip code in the online searchable databases. The street addresses of all the dispensaries with the school zip code were geocoded and mapped in ArcGIS to compute their distances to the school. Field workers then called the dispensary with the shortest distance to verify its address and operational status. These procedures were repeated if a dispensary was permanently closed or not verifiable via multiple calls until an active dispensary was identified. The primary focus was RMDs. Yet, medical marijuana dispensaries that require a doctors’ recommendation or state patient ID cards coexisted in California in 2018. During call verifications, if dispensary staff indicated that a doctors’ recommendation or a patient ID was required to enter the dispensary and make purchase, the dispensary was categorized as a MMD.i Fieldworkers also verified dispensary classification during the subsequent auditing. For those verified as MMDs, we repeated the aforementioned procedures until an active RMD was identified. The six trained workers in teams of two audited verified RMDs.ii On average, each RMD visit took 10–15 minutes. The 103 RMDs had unique RMD-school pairs and the 60 RMDs were the closest ones to two or more schools out of the remaining 230 schools. In the main analysis, we reported observations in the unique RMDs . In the secondary analysis, we reported observations on RMDs using school as the unit of analysis . The 60 RMDs shared by two or more schools were counted multiple times or over-weighted in the secondary analysis, reflecting their potential to influence children in multiple schools. The Human Research Protections Program at the University of California San Diego deemed this research non-human-subject and required no review.
California bans products and marketing “attractive to children”, “designed to be appealing to children or easily confused with commercially sold candy or foods”, or “in a manner to encourage persons under 21 years of age to consume”. Because these regulatory texts are rather vague, the definition and operationalization of what child-appealing is in this study were primarily informed by specific details in laws from other states, particularly Nevada and Washington . Specifically, we defined child-appealing products, packages, paraphernalia, and advertisements as those characterized by promotional characters , shaped like commercially sold products usually consumed by children , or using bright colors or bubble-like fonts . We examined the overall availability as well as the availability by dispensary-to-school distance.These measures included general practices not specifically relevant to children: availability and types of promotions , branded marketing materials, health promotional or warning messages related to marijuana, and images or wording indicative of marijuana. Field workers also visually measured the size of the biggest exterior advertisement. Although California does not restrict size of advertisements in RMDs, some other states do. For instance, Washington requires advertisements to be no larger than 1,600 square inches. This study demonstrated that, in the early stage of marijuana commercialization in California, point-of-sale marketing practices that are appealing to children were minimal on the exterior of the RMDs around schools. However, such practices were abundant on the interior. Marketing practices not specifically appealing to children were common on both the interior and exterior of the RMDs. Given the age limit, RMDs’ exterior marketing might be the most concerning source of exposure for children. It is reassuring that child-appealing marketing was rarely observed on the exterior of the RMDs around schools. Yet, three quarters of the RMDs had some form of child-appealing marketing on the interior,outdoor cannabis grow which violated the California laws. Although children should have little direct access to the interior, child-appealing items may be available to children through indirect pathways and should not be overlooked. For instance, children’s social networks such as older relatives, peers, or caregivers are their important sources of drugs. A study reported that almost three quarters of underage users obtained marijuana from friends, relatives, or family members. Child-appealing products, paraphernalia, or promotional materials could then be made available to children through these adults who are eligible for marijuana purchase. Particularly, about 30% RMDs violated the California law to offer free samples, which could be taken out of the dispensaries and given away to children. These child-appealing items in RMDs could be also resold to children in illicit markets by street dealers. Research on tobacco and alcohol have suggested that children are exposed to and influenced by tobacco and alcohol products and point-of sale marketing despite the age limit for purchase . Whether and how the marketing activities inside of RMDs impact children’s perceptions and behaviors should be examined in future research. Meanwhile, exterior retail environments not specifically relevant to children still warrant further attention. For instance, 63% RMDs had image or wording indicative of marijuana on the exterior. One third of the RMDs had generic advertisements, and some advertisements were of a relatively big size. Marijuana could be smelled outside of 25% RMDs. All of these might potentially increase perceived presence of RMDs in the neighborhoods and shape children’s social norms.
Approximately half of schools had RMDs located within a 3-mile distance that is reachable to children by walking, cycling, or driving. Some RMDs were located further away, especially in suburban or rural areas. Nonetheless, children are not free from exposure to RMDs even if RMDs are located more than 3 miles away from schools. In 2009, the average travel distance from home to school among all school children was 4.4 miles; among highschool students, the average distance was even longer . The travel distance was also increasing over time. An interesting exploratory observation indicated that, compared to RMDs located further away from schools, a larger proportion of RMDs in reachable distance to schools had interior child-appealing marketing. It is possible that RMDs intentionally targeted children if they were in closer proximity of schools. Unfortunately, our study was not able to test this hypothesis directly. Almost all the audited RMDs followed California rules on age verification. If continuous monitoring and enforcements are not in place, however, children might get access to abundant child-appealing marketing practices inside of the dispensaries, the consequences of which could be grave. Furthermore, exterior signs of age limit were absent in over 80% RMDs and security personnel were only observed in 40% RMDs. These might increase the risks of accidental or even intentional attempts of children to enter RMD premises, who would be then exposed to interior marketing in waiting area. Compared to laws in other states, California regulations on child-appealing marketing seem to be vague and less comprehensive during the study period. Because content restrictions are inherently subjective, it might be challenging for California RMDs to comply and for regulators to enforce without objective, operationalizable measures of “child-appealing”. Fortunately, after this study was completed, California released new regulations in January 2019 on child-relevant products and marketing. Specifically, marijuana products and packages “shall not use any depictions or images of minors” and “shall not contain the use of objects, such as toys, inflatables, movie characters, cartoon characters, or include any other display, depiction, or image designed in any manner likely to be appealing to minors”. These texts are expected to provide clearer guidance to law compliance and enforcements. In addition to prohibitions in laws, California could also consider screening content materials such as packages before they are available in RMDs. For instance, Massachusetts allows manufacturers to submit artwork to a regulatory board for review to ensure non-child-appealing packaging. Standardized packaging might be another alternative, which has shown effectiveness in tobacco control outside of the US. This study has limitations. First, this study used a cross-sectional design to capture a snapshot in summer 2018, approximately half a year after California’s commercialization of marijuana. This unique transition period was characterized with a lack of law enforcement, delay of dispensary licensing, and inadequate understanding of laws. As the legal market matures and government makes endeavors on law interpretation and enforcement, we might expect a stronger compliance with laws and possibly a reduction in marketing practices. The findings may not be generalizable to other time points in California. Second, our observations were largely constrained within the regulatory regime in California and may not be generalizable to other states where different regulatory measures are in place. Third, frequency or quantity measures in each marketing category would be more informative than simple binary indicators for availability. Unfortunately, a dispensary often displays hundreds or even thousands of products, packages, paraphernalia, and advertisements. Obtaining frequency or quantity information requires the field workers to spend a considerably longer time evaluating the RMD environment, which is infeasible in practice. Fourth, California laws lacked specific details related to children during the study period.