Threaten, Distract, and Discredit: Cannabis Industry Rhetoric to Defeat Regulation of High-THC Cannabis Products in Washington State.

OBJECTIVE: Washington State legislators have attempted to regulate high delta-9-tetrahydrocannabinol (THC) cannabis to reduce cannabis-related harms. Historically, industry actors of other health-compromising products have influenced governments' adoption of evidence-based regulation policies. A better understanding of the industry rhetoric can be used by public health advocates to develop counterarguments and disseminate alternative narratives that protect the public's health. We analyzed the arguments used by cannabis industry actors opposing regulations to de-incentivize the availability and use of high-THC products in Washington State. METHOD: We analyzed 41 testimonies transcribed from 33 cannabis industry actors in 3 public bill hearings and one legislative work session that occurred between 2020 and 2023. Using a deductive thematic analysis, informed by industry actors' arguments opposing regulation of alcohol, tobacco, and high-sugar beverages, we developed a codebook to analyze and identify themes within cannabis industry rhetorical strategies. RESULTS: We identified three main rhetorical strategies used by cannabis industry actors to oppose THC content regulation: threaten, distract, discredit. The most frequently used rhetorical strategy was threats to economic benefits, public health, and the will of the people. The other two most apparent strategies were distracting from the bill's focus by introducing a tangential topic and discrediting the science that supported regulation of cannabis products with high THC concentration or its advocates. CONCLUSIONS: Cannabis industry actors have leveraged several arguments used by industry actors of other health-compromising products to undermine initiatives to advance public health. They have also adapted rhetoric from other industries to the unique conditions of the cannabis regulatory landscape.

Identifying policy options to regulate high potency cannabis: A multiple stakeholder concept mapping study in Washington State, USA.

BACKGROUND: Cannabis legalization in some U.S.A. states has catapulted the mass production of concentrates, with tetrahydrocannabinol (THC) concentrations ranging from 50-90%. A major public health concern is that these products will increase cannabis-related harms such as use disorders, psychotic symptoms, and accidental poisonings. This paper describes and contextualizes the results of a study requested by the WA State Legislature to understand perspectives of WA stakeholders on the topic. METHODS: Concept Mapping (CM), a mixed-methods research approach that supports people-centered policy decisions was utilized. The goal of the study was to explore stakeholders' concern levels and support of policies to address the availability of high THC cannabis products. For analysis purposes, stakeholders were categorized into three groups: community, professionals, and cannabis advocates. RESULTS: CM generated an inventory of policy ideas for regulating high-potency cannabis from a variety of stakeholders. Notably, stakeholders from community and professional groups supported environmental policy changes such as such as taxation, increasing minimum age for high concentration cannabis products, and advertising prohibition. Meanwhile, cannabis advocates (mostly industry actors) opposed taxation per THC content, proposed lowering taxes, and supported policies with low population impact such as educating parents, teachers, and youth. CONCLUSION: Support for regulating high concentration THC products varied by stakeholder group. Consistent with how other health compromising industries have historically acted, cannabis industry stakeholders rejected regulation of their products. Future studies should explore non-cannabis industry stakeholders' willingness to work towards minimizing the influence of the cannabis industry in policy development processes to assure public health regulations prevail.

Cannabis Industry Marketing Violations in Washington State, 2014-2019.

OBJECTIVE: The purpose of this study was to describe marketing violations from the cannabis industry in Washington State. METHOD: The study team obtained records of all Washington State cannabis marketing violations from October 2014 to September 2015, immediately following the legal cannabis market opening, and May 2017 to July 2019. A code book was developed based on the Washington State regulations related to marijuana advertising. Each marketing violation was coded according to ad characteristics including ad size, location, or type; content; business practices; and lack of mandatory health warnings. RESULTS: A total of 328 violations were analyzed, from 183 different businesses. Marketing violations occurred most frequently in content posted online or directly in front of cannabis stores. Community members were as likely to identify violations as officers from the Washington State Liquor and Cannabis Board (WSLCB), the state agency in charge of regulation and enforcement of cannabis businesses. Very few violations were reported from competing members of the cannabis industry. Violations reported by the community were mostly related to content appealing to minors, whereas WSLCB officers were more likely to identify violations related to ad location in public spaces and ad size. CONCLUSIONS: This study shows the conflict between prevention and profit in the nascent cannabis industry and the importance of community involvement in the regulation of cannabis marketing.

The Kids Are Not All Right: E-cigarettes, Cannabis Co-Use, and an Emerging Public Health Crisis--A Commentary on Roberts et al. (2022).

The Roberts et al. commentary highlights the "looming public health emergency" of e-cigarettes and cannabis co-use among young people and the urgency to make deliberate efforts to address dual use now. We agree and want to further elaborate on some of their comments.

Cannabis Retail Staff ("Budtenders") Attitudes Towards Cannabis Effects on Health and Experiences Interacting with Consumers - Washington State, USA.

Cannabis legalization in Washington State has increased the availability, consumption, and potency of cannabis products for adults. Public health education promoting safe use for adult consumers has lagged behind these trends. This study assesses the potential of cannabis retail workers (budtenders) to engage in responsible use education with adult consumers at point of sale. Focus groups explored how budtenders perceive their professional role, including educating consumers about cannabis over intoxication, storage, and risks of use before driving and during pregnancy. Transcripts were analyzed to develop a coding scheme, which was then applied with an iterative review by the research team. Budtenders identified three main professional roles: creating a good experience for customers; being compliant with the state law and regulations, and educating customers on products. Budtenders did not believe their job involved discussing use during pregnancy or while driving or safe storage. They prioritized customers' autonomy over education on these topics, and they did not necessarily consider these behaviors to be harmful. Budtenders are committed to keeping minors outside stores and educating consumers on how to avoid over intoxication and exposure to cannabis contaminants. Future research could build on this to develop point-of-sale education to reduce cannabis use risks.

A Taxonomy of Consumers' Perspectives on the Function of Cannabis in Their Lives: A Qualitative Study in WA State, USA.

US state-level policy often divides legal cannabis use into medical and recreational categories. However, research suggests medical and non-medical cannabis consumption often overlaps and consumers' relationship with cannabis may change. This study aimed to understand cannabis consumption from the perspective of consumers. Focus group participants shared their perspectives on motivations, settings, and contexts for consumption. A three-category taxonomy of cannabis consumption emerged from the data - Casual, intentional, and therapeutic. Within each category, there is potential for high- and low-risk behaviors. In the casual group, participants rarely purchased cannabis and only partook if it was freely available. Participants in the intentional group were knowledgeable about the effects produced by different strains, THC levels, and product types, and were frequently self-aware. In the therapeutic group, participants consumed cannabis for physical or mental health conditions. Our findings suggest the medical/non-medical dichotomy used in policy development, clinical care, and research may not reflect how regular consumers perceive the function of cannabis in their lives. Our findings suggest more research is needed to identify cannabis' role in improving quality of life, when it increases behavioral risk, and the intersection of cannabis and disability.

Anytime is the Right Time: A Content Analysis of Marijuana Ads in Freely Distributed Print Media in Western Washington State, USA.

Background: Cannabis advertisement content in print media has not yet been studied, despite youth high exposure to them. This study analyzes cannabis ads content in two publications in Western Washington State, USA. Methods: Content analysis of 305 cannabis advertisements published in 2017 in two free print publications was performed with support of NVivo software. A deductive approach was utilized, leveraging alcohol advertisement studies' coding frames and adding cannabis-specific codes in an iterative process. Coding was performed using a two-step analytical procedure. Results: Ads depicted the use of cannabis as part of everyday life and coopted mainstream events such as holidays to promote sales. Ads of cannabis products emphasized lifestyles that conveyed enjoyment of time in nature; such as scenes of people sitting by waterfalls, contemplating natural landscapes, paddle boarding, and canoeing. A sizeable proportion of the cannabis ads shared with alcohol ads an emphasis on the personal and social rewards of using these products, rather than product features, such as quality and taste. Conclusions: In WA State, cannabis use ads content tend to focus on solitude and outdoor recreation rather than parties and team sports, a common theme in alcohol ads. While the themes differ from alcohol, marijuana marketing mimics strategies used by alcohol industries, such as promoting the identification of their products with lifestyles and values considered appealing to attract new consumers. Many ads presented content known to appeal to youth, with content designed to elicit responses based on emotions rather than cognition.

Age differences in outcomes among patients in the "Stimulant Abuser Groups to Engage in 12-Step" (STAGE-12) intervention.

Emerging adults (roughly 18-29years) with substance use disorders can benefit from participation in twelve-step mutual-help organizations (TSMHO), however their attendance and participation in such groups is relatively low. Twelve-step facilitation therapies, such as the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), may increase attendance and involvement, and lead to decreased substance use. AIMS: Analyses examined whether age moderated the STAGE-12 effects on substance use and TSMHO meeting attendance and participation. DESIGN: We utilized data from a multisite randomized controlled trial, with assessments at baseline, mid-treatment (week 4), end-of-treatment (week 8), and 3- and 6- months post-randomization. PARTICIPANTS: Participants were adults with DSM-IV diagnosed stimulant abuse or dependence (N=450) enrolling in 10 intensive outpatient substance use treatment programs across the U.S. ANALYSIS: A zero-inflated negative binomial random-effects regression model was utilized to examine age-by-treatment interactions on substance use and meeting attendance and involvement. FINDINGS: Younger age was associated with larger treatment effects for stimulant use. Specifically, younger age was associated with greater odds of remaining abstinent from stimulants in STAGE-12 versus Treatment-as-Usual; however, among those who were not abstinent during treatment, younger age was related to greater rates of stimulant use at follow-up for those in STAGE-12 compared to TAU. There was no main effect of age on stimulant use. Younger age was also related to somewhat greater active involvement in different types of TSMHO activities among those in STAGE-12 versus TAU. There were no age-by-treatment interactions for other types of substance use or for treatment attendance, however, in contrast to stimulant use; younger age was associated with lower odds of abstinence from non-stimulant drugs at follow-up, regardless of treatment condition. These results suggest that STAGE-12 can be beneficial for some emerging adults with stimulant use disorder, and ongoing assessment of continued use is of particular importance.

Drug helplines and adult marijuana users: An assessment in Washington, Colorado, Oregon, and Alaska.

Drug helplines are well-known and widely utilized resources for those seeking help with managing their substance use. Using "secret shoppers," a preliminary assessment of the drug helplines in 4 states was performed. Eleven calls were placed to the helpline staff, where the secret shopper posed as an adult users of marijuana interested in decreasing their marijuana use and asked questions about cannabinoids and methods of marijuana consumption. In 100% of the calls placed, helpline staff had no knowledge about the effects and interactions of marijuana's 2 main components (tetrahydrocannabinol [THC] and cannabidiol [CBD]), neither could they explain the risk differential of smoking, eating, or vaporizing marijuana. In all but one of the calls placed, helpline responders were respectful and empathic. The assessment suggests that drug helplines are equipped with a respectful, empathetic, and nonjudgmental staff who lack important knowledge to best serve those seeking help for marijuana use.

Medicinal Cannabis: A Survey Among Health Care Providers in Washington State

INTRODUCTION: Washington State allows marijuana use for medical (since 1998) and recreational (since 2012) purposes. The benefits of medicinal cannabis (MC) can be maximized if clinicians educate patients about dosing, routes of administration, side effects, and plant composition. However, little is known about clinicians' knowledge and practices in Washington State. METHODS: An anonymous online survey assessed providers' MC knowledge, beliefs, clinical practices, and training needs. The survey was disseminated through health care providers' professional organizations in Washington State. Descriptive analysis compared providers who had and had not authorized MC for patients. Survey results informed the approach and content of an online training on best clinical practices of MC. RESULTS: Four hundred ninety-four health care providers responded to the survey. Approximately two-third were women, aged 30 to 60 years, and working in family or internal medicine. More than half of the respondents were legally allowed to write MC authorizations per Washington State law, and 27% of those had issued written MC authorizations. Overall, respondents reported low knowledge and comfort level related to recommending MC. Respondents rated MC knowledge as important and supported inclusion of MC training in medical/health provider curriculum. Most Washington State providers have not received education on scientific basis of MC or training on best clinical practices of MC. Clinicians who had issued MC authorizations were more likely to have received MC training than those who had not issued MC authorization. DISCUSSION: The potential of MCs to benefit some patients is hindered by the lack of comfort of clinicians to recommend it. Training opportunities are badly needed to address these issues.

A comparison of African American and Caucasian stimulant users in 12-step facilitation treatment.

Engagement in 12-step meetings and activities has been shown to be a powerful aid to recovery from substance use disorders. However, only limited attention has been given to ethnic and racial differences in attitudes toward 12-step and involvement. This study utilized data from a large multisite trial testing the effectiveness of a 12-step facilitation therapy with stimulant-dependent treatment seekers. We compared baseline differences and treatment outcomes between African American and Caucasian participants. A select few baseline differences were found (i.e., African Americans reported higher levels of spirituality than Caucasians; African American participants indicated more perceived benefits of 12-step involvement; Caucasians were more likely to endorse future involvement in 12-step). There were no outcome differences (e.g., substance use outcomes, 12-step meeting attendance). The tested intervention produced similar outcomes for both groups, indicating that it may be useful across racial categories.

Predictors of 12-Step Attendance and Participation for Individuals With Stimulant Use Disorders.

OBJECTIVE: Few studies have examined the effectiveness of 12-step peer recovery support programs with drug use disorders, especially stimulant use, and it is difficult to know how outcomes related to 12-step attendance and participation generalize to individuals with non-alcohol substance use disorders (SUDs). METHOD: A clinical trial of 12-step facilitation (N=471) focusing on individuals with cocaine or methamphetamine use disorders allowed examination of four questions: Q1) To what extent do treatment-seeking stimulant users use 12-step programs and, which ones? Q2) Do factors previously found to predict 12-step participation among those with alcohol use disorders also predict participation among stimulant users? Q3) What specific baseline "12-step readiness" factors predict subsequent 12-step participation and attendance? And Q4) Does stimulant drug of choice differentially predict 12-step participation and attendance? RESULTS: The four outcomes variables, attendance, speaking, duties at 12-step meetings, and other peer recovery support activities, were not related to baseline demographic or substance problem history or severity. Drug of choice was associated with differential days of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance among those who reported attending, and cocaine users reported more days of attending AA or NA at 1-, 3- and 6-month follow-ups than did methamphetamine users. Pre-randomization measures of perceived benefit of 12-step groups predicted 12-step attendance at 3- and 6-month follow-ups. Pre-randomization 12-step attendance significantly predicted number of other self-help activities at end-of-treatment, 3- and 6-month follow-ups. Pre-randomization perceived benefit and problem severity both predicted number of self-help activities at end-of-treatment and 3-month follow-up. Pre-randomization perceived barriers to 12-step groups were negatively associated with self-help activities at end-of-treatment and 3-month follow-up. Whether or not one participated in any duties was predicted at all time points by pre-randomization involvement in self-help activities. CONCLUSIONS: The primary finding of this study is one of continuity: prior attendance and active involvement with 12-step programs were the main signs pointing to future involvement. Limitations and recommendations are discussed.

Interest and preferences for contingency management design among addiction treatment clientele.

BACKGROUND: Despite strong support for its efficacy, debates persist about how dissemination of contingency management is most effectively undertaken. Currently-promoted contingency management methods are empirically-validated, yet their congruence with interests and preferences of addiction treatment clientele is unknown. Such client input is a foundational support for evidence-based clinical practice. OBJECTIVE: This study documented interest in incentives and preferences for fixed-ratio vs. variable-ratio and immediate vs. distal distribution of earned incentives among clients enrolled at three community programs affiliated with the National Institute on Drug Abuse Clinical Trials Network. METHODS: This multi-site study included anonymous survey completion by an aggregate sample of 358 treatment enrollees. Analyses first ruled out site differences in survey responses, and then tested age and gender as influences on client interest in financial incentives, and preferences for fixed-ratio vs. variable-ratio reinforcement and immediate vs. distal incentive distribution. RESULTS: Interest in different types of $50 incentives (i.e. retail vouchers, transportation vouchers, cash) was highly inter-correlated, with a mean sample rating of 3.49 (0.83) on a five-point scale. While consistent across client gender, age was an inverse predictor of client interest in incentives. A majority of clients stated preference for fixed-ratio incentive magnitude and distal incentive distribution (67% and 63%, respectively), with these preferences voiced by a larger proportion of females. CONCLUSION: Sample preferences contradict currently-promoted contingency management design features. Future efforts to disseminate contingency management may be more successful if flexibly undertaken in a manner that incorporates the interests and preferences of local client populations.

Is level of exposure to a 12-step facilitation therapy associated with treatment outcome?

This study examined whether level of exposure to Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), a 12-Step facilitative therapy, is related to treatment outcome. Data were from a large National Drug Abuse Treatment Clinical Trials Network (CTN) study comparing STAGE-12 combined with treatment-as-usual (TAU) to TAU alone. These analyses include only those randomized to STAGE-12 (n=234). Assessments occurred at baseline and 30, 60, 90, and 180 days following randomization. High-exposure patients (n=158; attended at least 2 of 3 individual, and 3 of 5 group, sessions), compared to those with less exposure (n=76), demonstrated: (1) higher odds of self-reported abstinence from, and lower rates of, stimulant and non-stimulant drug use; (2) lower probabilities of stimulant-positive urines; (3) more days of attending and lower odds of not attending 12-Step meetings; (4) greater likelihood of reporting no drug problems; (5) more days of duties at meetings; and (6) more types of 12-Step activities. Many of these differences declined over time, but several were still significant by the last follow-up. Treatment and research implications are discussed.

Treatment adherence and competency ratings among therapists, supervisors, study-related raters and external raters in a clinical trial of a 12-step facilitation for stimulant users.

This study investigated the correspondence among four groups of raters on adherence to STAGE-12, a manualized 12-step facilitation (TSF) group and individual treatment targeting stimulant abuse. The four rater groups included the study therapists, supervisors, study-related ("TSF expert") raters, and non-project related ("external") raters. Results indicated that external raters rated most critically mean adherence - the mean of all the adherence items - and global performance. External raters also demonstrated the highest degree of reliability with the designated expert. Therapists rated their own adherence lower, on average, than did supervisors and TSF expert raters, but therapist ratings also had the poorest reliability. Findings highlight the challenges in developing practical, but effective methods of fidelity monitoring for evidence based practice in clinical settings. Recommendations based on study findings are provided.

Competency-based project to review community/public health curricula.

Changes in the delivery of community/public health (C/PH) nursing have challenged nursing educators to seek innovative ways to ensure that their educational programs produce competent entry-level practitioners. This article describes how public health professionals and faculty from eight regional colleges and universities in Southeastern Wisconsin came together to better understand both what C/PH nursing content was being taught in the region, and the extent to which that content was aligned with the Public Health Nurse Competencies defined by the Quad Council in 2004. Based on self-reporting by nursing school faculty as well as a separate mapping of course objectives into the competency areas, the project found that the curricula of the participating colleges and universities adequately addressed most of the competencies in the Quad Council domains one through six. Competencies in domains seven (financial planning/management skills) and eight (leadership/systems thinking skills) were not, however, adequately addressed and plans were subsequently developed to fill those gaps. In addition to helping each institution identify strengths and gaps in its own curriculum, the project provided an unprecedented opportunity for both public health professionals and academics to build relationships, share best practices, and exchange resources.

Stimulant abuser groups to engage in 12-step: a multisite trial in the National Institute on Drug Abuse Clinical Trials Network.

AIMS: The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service. DESIGN: Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs). SETTING: Intensive outpatient substance treatment programs. PARTICIPANTS: Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated. MEASUREMENTS: Urinalysis and self-reports of substance use and 12-step attendance and activities. INTERVENTION: Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers. FINDINGS: Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU. CONCLUSIONS: The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.

Adolescent change language within a brief motivational intervention and substance use outcomes.

Homeless adolescents who used alcohol or illicit substances but were not seeking treatment (n = 54) were recorded during brief motivational interventions. Adolescent language during sessions was coded on the basis of motivational interviewing concepts (global ratings of engagement and affect, counts of commitment to change, statements about reasons for change, and statements about desire or ability to change), and ratings were tested as predictors of rates of substance use over time. Results indicate that statements about desire or ability against change, although infrequent (M = 0.61 per 5 min), were strongly and negatively predictive of changes in substance use rates (days of abstinence over the prior month) at both 1- and 3-month postbaseline assessment (ps < .001). Statements about reasons for change were associated with greater reductions in days of substance use at 1-month assessment (p < .05). Commitment language was not associated with outcomes. Results suggest that specific aspects of adolescent speech in brief interventions may be important in the prediction of change in substance use. These relationships should be examined within larger samples and other clinical contexts.