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. 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, 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,flood tray 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 high school 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,grow table 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.
The classification of child-appealing was informed by laws in other states and constructed with authors’ own understanding, which may not reflect California lawmakers’ intention or completely align with recently released new regulations. Further, there might be inevitable measurement errors even after two field workers discussed and resolved discrepancies between them. Lastly, this study only gathered data on RMDs in closest proximity to public schools. Results may not be generalizable to RMDs around private schools or children’s homes. To improve representativeness, future research is encouraged to audit a random sample of RMDs. Traumatic brain injury is a significant public health concern as it is a leading cause of mortality, morbidity and disability in the United States. According to the World Health Organization, TBI is expected to become the third leading cause of death and disability in the world by 2020. In the United States TBI contributes to a third of all injury-related deaths. The leading causes of injuries resulting in TBI prevalence are traffic related, such as motor vehicle crashes, or non-traffic related, such as falls. Notably, up to 51% of all TBI patients have substance use exposure at the time of injury.Current existing research suggest that in general, substance-exposed patients may have worse TBI outcomes, including greater rates of mortality and severity of injury. Research has also shown that substance use exposed TBI patients suffer worse functional outcomes, which can result in socioeconomic burden to patients and the nation at large. This healthcare burden has been calculated to be approximately $76.5 billion in 2010 alone. There is a substantial body of research elucidating the role alcohol plays in injuries that lead to TBI prevalence and outcomes. Specifically, alcohol use results in impairments such as diminished motor control, blurred vision, and poor decision making, which has been shown to increase the risk of traffic related injury. This research has been used to create public health policies and prevention programs that have made a significant health impact, such as reducing the number of alcohol-impaired drivers. Other substances have not been as well studied. For example, marijuana is a drug that despite being federally and legally regulated, remains the most widely used drug in the U.S. Marijuana use has been shown to result in similar cognitive impairments as alcohol use, such as lack of coordination, inability to pay attention, and decision-making abilities, suggesting marijuana users are similarly at increased risk for TBI. There is some indirect evidence of this, in that it has been shown that marijuana users in general are about 25% more likely to be involved in a motor vehicle crash and that the older adult marijuana users have a greater risk for falls. However, concrete data linking marijuana exposure at time of injury and TBI prevalence and severity is scarce. Adding to the concern, national surveys on drug use and health have documented an increase in individual daily marijuana use over the last 5 years. As the number of states legalizing marijuana for both medical and recreational use increases, it is imperative to resolve the ambiguity within the research available regarding the relationships between marijuana exposure at time of injury, mechanism of injury, and TBI prevalence and severity.
This study found that the presence of THC was significantly associated with lower GCS scores and a potentially more severe TBI, but this relationship was significant without controlling for other predicting variables. Furthermore, a significant relationship was found between GCS scores, age, and blood alcohol levels at the time of presentation in the ED. Older participants were found to have higher GCS scores, indicating a less serious brain injury. Study participants who had higher blood alcohol levels were found to have lower GCS scores, indicating a more serious brain injury. Age and higher blood alcohol levels were found to be associated, with higher blood alcohol levels noted in younger patients. A linear regression showed different results when examining the relationship between the presence of THC and GCS scores, hence TBI severity. When controlling for all other variables, the presence of THC was not found to be an independent predictor of TBI severity. Alternatively, being male, having elevated blood alcohol levels and having other drugs present on admission were all found to have a significant influence on GCS scores and TBI severity, with GCS scores being lower for all three variables, implying a more serious TBI. Similarly, having a diagnosis of cancer, mental or personality disorder and alcohol use disorder were found to have an influence on GCS scores. Participants with a diagnosis of cancer or mental/personality disorder were found to have lower GCS scores, again, implying a more serious TBI. Conversely, participants with a diagnosis or history of alcohol use disorder had higher GCS scores, indicating a less serious TBI. While the presence of THC initially did show a hypothesized relationship to GCS score , the relationship became insignificant when adjusted for all the other covariates variables. Because of the large percentage of missing data, the validity of findings, such as THC prevalence rate in this TBI population, should be cautiously interpreted for all the included hypothesized explanatory variables. Further research with datasets that are larger and more complete are needed to fully understand and examine the relationship between marijuana and TBI severity. This study importantly underscores the need for better data to enable better research regarding the relationship between marijuana and TBI severity. Traumatic brain injury is a significant public health concern as it is a leading cause of mortality, morbidity and disability in the United States . According to the World Health Organization, TBI is expected to become the third leading cause of death and disability in the world by 2020. In the United States TBI contributes to a third of all injury related deaths .