Young adult retail purchases of cannabis, product category preferences and sales trends in California 2018-21: Differences compared with older adults.

AIMS: The aim of this study is to identify cannabis products according to their appeal among young adults and measure product sales trends. DESIGN, SETTING AND PARTICIPANTS: This was a retrospective comparative study using point-of-sale data from licensed recreational cannabis retailers that include buyer age with birth year entered by retailers, set in California, USA. Cannabis purchases by young adults (aged 21-24, GenZ) were compared with older adults (age 25+) over 4 years (2018-21). MEASUREMENTS: Sales for six cannabis product categories were analyzed using a commercial data set with imputations and a raw data set. Age-appeal metrics were dollar and unit sales to young adults, and dollar and unit share ratios (young adults/older adults), where a share ratio of 100 denotes age-appeal comparability. A product category was considered more young-adult appealing than others if its mean on a metric was at least one standard deviation above the grand mean across all product categories. FINDINGS: Flower (cannabis plant material) and vapor pen appealed to young adults based on absolute dollar sales, dominating young-adult spending compared with other cannabis products (37.24 and 31.83%, respectively). Vapor pen and concentrate appealed to young adults based on dollar share ratios of 152, meaning these products comprised a 52% greater share of young-adult cannabis spending relative to older-adult spending (31.83/20.97% and 10.47/6.88%, respectively). Less appealing to young adults were pre-roll, edible/beverage and absorbable products (tincture/sublingual, capsule and topical). Flower showed the largest dollar sales growth (B = +$3.50 million/month), next to vapor pen (B = +$1.55 million/month). Vapor pen tied for highest growth in the percent of product dollars from the largest package size (B = +0.85%/month) and showed the steepest price decline (B = -0.53 price per gram/month). CONCLUSIONS: In California, USA, from 2018 to 2021, relative to older adults, young adults spent a greater share of their cannabis dollars on vapor pen and concentrate (products with high potency of delta-9-tetrahydrocannabinol).

Multi-year analysis of the global preclinical antibacterial pipeline: trends and gaps.

Antimicrobial resistance (AMR) is a major global health threat estimated to have caused the deaths of 1.27 million people in 2019, which is more than HIV/AIDS and malaria deaths combined. AMR also has significant consequences on the global economy. If not properly addressed, AMR could immensely impact the world's economy, further increasing the poverty burden in low- and middle-income countries. To mitigate the risk of a post-antibiotic society, where the ability to effectively treat common bacterial infections is being severely threatened, it is necessary to establish a continuous supply of new and novel antibacterial medicines. However, there are gaps in the current pipeline that will prove difficult to address, given the time required to develop new agents. To understand the status of upstream antibiotic development and the challenges faced by drug developers in the early development stage, the World Health Organization has regularly assessed the preclinical and clinical antibacterial development pipeline. The review identifies potential new classes of antibiotics or novel mechanisms of action that can better address resistant bacterial strains. This proactive approach is necessary to stay ahead of evolving resistance patterns and to support the availability of effective treatment options. This review examines the trends in preclinical development and attempts to identify gaps and potential opportunities to overcome the numerous hurdles in the early stages of the antibacterial research and development space.

Implementation and Performance of a Point-of-Care COVID-19 Test Program in 4,000 California Schools.

OBJECTIVE: To evaluate the feasibility and accuracy of an unprecedented COVID-19 antigen testing program in schools, which required a healthcare provider order, laboratory director, a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver, as well as training of school personnel. STUDY DESIGN: Descriptive report of a point-of-care, school-based antigen testing program in California from 8/1/2021 through 5/30/2022, in which participants grades K-12 self-swabbed and school personnel performed testing. Participants included 944,009 students, personnel, and community members from 4,022 California K-12 schools. Outcomes measured include sensitivity and specificity (with polymerase chain reaction [PCR] as comparator), of the Abbott BinaxNOW™ antigen test, number of tests performed, and active infections identified. RESULTS: Of 102,022 paired PCR/antigen tests, the overall sensitivity and specificity for the antigen test was 81.2% (95%CI:80.5%-81.8%) and 99.6% (95%CI:99.5%-99.6%), respectively using cycle threshold (Ct) values <30. During January through March 2022, the highest prevalence period, the positive predictive value (PPV) of antigen testing was 94.7% and the negative predictive value was 94.2%. Overall, 4,022 school sites were enrolled and 3,987,840 million antigen tests were performed on 944,009 individuals. A total of 162,927 positive antigen tests were reported in 135,163 individuals (14.3% of persons tested). CONCLUSIONS: Rapidly implementing a school-based testing program in thousands of schools is feasible. Self-swabbing and testing by school personnel can yield accurate results. On-site COVID-19 testing is no longer necessary in schools, but this model provides a framework for future infectious disease threats.

Clinician perspectives on adolescent cannabis-related beliefs and behaviors following recreational cannabis legalization.

BACKGROUND: As more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them. METHODS: This qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents' cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022-12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis. RESULTS: The 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment. CONCLUSIONS: Clinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work.

Countering online marketing and user endorsements with enhanced cannabis warning labels: An online experiment among at-risk youth and young adults.

As cannabis legalization expands and online marketing intensifies, this study examines whether online social cues can amplify youth-targeted cannabis advertising and whether cannabis warning labels (CWLs) can counteract these influences. A U.S. online sample of 970 adolescents and 1776 young adults susceptible to cannabis use were recruited from Qualtrics in summer 2022. Each participant was randomly assigned to one of the 3 (CWLs: none vs. textual vs. pictorial) by 3 (comments: none vs. anti-cannabis vs. pro-cannabis) conditions in an online experiment. Participants were exposed to three online marketing posts promoting marijuana edibles (randomly selected from a large pool, N = 1260), each with either no warning label, a textual warning, or a pictorial warning (text and picture), and with either five comments (pro- or anti-cannabis in valence) or none. Results showed that among adolescents, pro-cannabis comments increased product appeal (vs. anti-cannabis comments: b = 0.18, p = .025; vs. no comments: b = 0.21, p = .021), and did so more than young adults. For adolescents, only pictorial warnings reduced product appeal (b = -0.20, p = .028). For young adults, both pictorial (b = -0.18, p = .002) and textual warnings (b = -0.12, p = .029) reduced product appeal. Furthermore, both textual (adolescents: b = -0.20, p = .004; young adults: b = -0.15, p = .005) and pictorial (adolescents: b = -0.30, p < .001; young adults: b = -0.18, p = .001) warnings reduced cannabis use intentions. Findings support requiring enhanced CWLs accompany online marketing ads.

Cannabis Vape Product Sales in California Following CDC's Initial Advisory About Lung Injuries.

Introduction: The 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) is believed to have been caused by vitamin E acetate, an additive used in some cannabis vaporizer products. Previous studies have primarily focused on changes in sales of electronic nicotine delivery systems following the initial advisory issued by the Centers for Disease Control (CDC) on August 17, 2019. The present study is intended to examine variation by age groups in sales of regulated cannabis vape products in the state of California before, during, and after the outbreak. Methods: Weekly sales revenue of cannabis vape products (from January 1, 2018, to December 31, 2020) was obtained from a sample of recreational cannabis retailers licensed in California. An interrupted time series analysis, using AutoRegressive, Integrated, Moving Average methods, was employed to estimate changes in the sales and market share of cannabis vape products in the weeks following the CDC advisory. Results: The total volume of regulated cannabis vape product sales increased substantially over the 3-year study period (2018-2020). Sales and market share of cannabis vape products, however, declined in both young and older adults immediately following the advisory, rebounding to pre-EVALI levels only for the young adults. For sales, the potential EVALI effect following the CDC's advisory equates to an 8.0% and 2.2% decline below expected levels in the older and young adults, respectively. Conclusions: The differential age effect on sales may reflect concerns regarding health effects of cannabis vaping products and greater awareness of the outbreak among older adults. Findings highlight the importance of informing consumers about health risks associated with using cannabis vape products acquired from regulated versus illicit sources.

Neonatal outcomes associated with in utero cannabis exposure: a population-based retrospective cohort study.

BACKGROUND: The full spectrum of associations between in utero cannabis exposure and adverse neonatal outcomes is still unclear. OBJECTIVE: This study aimed to evaluate the associations between in utero cannabis exposure and neonatal outcomes. STUDY DESIGN: This population-based retrospective cohort study of singleton births among Kaiser Permanente Northern California members (January 1, 2011-July 31, 2020) included parent-infant dyads in which the pregnant parent was screened for cannabis use as part of standard prenatal care, generally upon entrance into care. Data were ascertained from electronic health records. Generalized estimating equation models were adjusted for sociodemographic characteristics, other non-cannabis prenatal substance use, medical and mental health comorbidities, and adequacy of prenatal care. In utero cannabis exposure was defined as self-reported use since becoming pregnant and/or a positive urine toxicology test for cannabis at any time during pregnancy (yes/no; primary exposure). Frequency of use was self-reported and categorized as daily, weekly, monthly or less, never, or unknown (secondary exposure). Neonatal outcomes included low birthweight, small for gestational age, preterm birth, neonatal intensive care unit admission, and infant respiratory support. RESULTS: Of 364,924 infants, 22,624 (6.2%) were exposed to cannabis in utero. After adjustment for potential confounders, including in utero exposure to other substances, in utero exposure to cannabis was associated with greater odds of low birthweight (adjusted odds ratio, 1.20; 95% confidence interval, 1.12-1.28), small for gestational age (adjusted odds ratio, 1.24; 95% confidence interval, 1.18-1.30), preterm birth (<37 weeks; adjusted odds ratio, 1.06; 95% confidence interval, 1.00-1.13), and neonatal intensive care unit admission (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.11). There was a suggestive association with early preterm birth (<34 weeks; adjusted odds ratio, 1.11; 95% confidence interval, 1.00-1.23; P=.055), but no significant association with respiratory support (adjusted odds ratio, 1.07; 95% confidence interval, 0.97-1.18). Dose-response analysis found an increasing likelihood of low birthweight and small for gestational age with increasing frequency of prenatal cannabis use by the pregnant individual. Sensitivity analyses further supported an increased likelihood of low birthweight and small for gestational age, although associations with other outcomes did not reach statistical significance. CONCLUSION: In utero cannabis exposure was associated with increased likelihood of low birthweight, small for gestational age, preterm birth, and neonatal intensive care unit admission. Clinicians should counsel individuals who are pregnant or considering pregnancy about the potential adverse neonatal health outcomes associated with prenatal cannabis use.

Changes in sugar-sweetened beverage consumption in the first two years (2018 - 2020) of San Francisco's tax: A prospective longitudinal study.

BACKGROUND: Sugar sweetened beverage (SSB) taxes are a promising strategy to decrease SSB consumption, and their inequitable health impacts, while raising revenue to meet social objectives. In 2016, San Francisco passed a one cent per ounce tax on SSBs. This study compared SSB consumption in San Francisco to that in San José, before and after tax implementation in 2018. METHODS & FINDINGS: A longitudinal panel of adults (n = 1,443) was surveyed from zip codes in San Francisco and San José, CA with higher densities of Black and Latino residents, racial/ethnic groups with higher SSB consumption in California. SSB consumption was measured at baseline (11/17-1/18), one- (11/18-1/19), and two-years (11/19-1/20) after the SSB tax was implemented in January 2018. Average daily SSB consumption (in ounces) was ascertained using the BevQ-15 instrument and modeled as both continuous and binary (high consumption: ≥6 oz (178 ml) versus low consumption: <6 oz) daily beverage intake measures. Weighted generalized linear models (GLMs) estimated difference-in-differences of SSB consumption between cities by including variables for year, city, and their interaction, adjusting for demographics and sampling source. In San Francisco, average SSB consumption in the sample declined by 34.1% (-3.68 oz, p = 0.004) from baseline to 2 years post-tax, versus San José which declined 16.5% by 2 years post-tax (-1.29 oz, p = 0.157), a non-significant difference-in-differences (-17.6%, adjusted AMR = 0.79, p = 0.224). The probability of high SSB intake in San Francisco declined significantly more than in San José from baseline to 2-years post-tax (AOR[interaction] = 0.49, p = 0.031). The difference-in-differences of odds of high consumption, examining the interaction between cities, time and poverty, was far greater (AOR[city*year 2*federal poverty level] = 0.12, p = 0.010) among those living below 200% of the federal poverty level 2-years post-tax. CONCLUSIONS: Average SSB intake declined significantly in San Francisco post-tax, but the difference in differences between cities over time did not vary significantly. Likelihood of high SSB intake declined significantly more in San Francisco by year 2 and more so among low-income respondents.

Yet Again Conversations Matter: The Importance of Interpersonal Discussions, Educational Campaigns, and Advertising on Cannabis-Related Risk Perceptions, Attitudes, and Intentions in At-Risk Young Adults.

The present study seeks to evaluate the relationships between cannabis-related communication and outcomes of interest such as cannabis-related risk perceptions, attitudes, and behaviors among young adults. Young adults who were at risk for cannabis use were surveyed online in 2020. Results showed that exposure to online educational messages was associated with higher intentions of engaging in peer intervention, while exposure to online advertising was related to higher intention to use cannabis. Anti-cannabis interpersonal discussion was associated with increased risk perceptions, less favorable cannabis attitudes, and a higher likelihood of peer intervention. More pro-cannabis interpersonal discussion was associated with decreased risk perceptions, more favorable cannabis attitudes, higher use intention, and decreased likelihood of peer intervention. In addition, pro-cannabis interpersonal discussion mediated the relationship between exposure to advertising and cannabis risk perceptions, intentions to use cannabis, attitudes about cannabis, and the likelihood of peer intervention. In contrast, anti-cannabis interpersonal discussion mediated the relationship between exposure to educational messages online and cannabis risk perceptions and the likelihood of peer intervention. These findings underscore the need to regulate online cannabis marketing and the importance of investing in online education campaigns to increase public understanding of the risks associated with cannabis consumption in young adulthood.

Geographic Accessibility of Retail Cannabis in Northern California and Prenatal Cannabis Use During the COVID-19 Pandemic.

Importance: Prenatal cannabis use is associated with health risks for mothers and their children. Prior research suggests that rates of prenatal cannabis use in Northern California increased during the COVID-19 pandemic, but it is unknown whether increases varied with the local cannabis retail and policy environment. Objective: To test whether pandemic-related increases in prenatal cannabis use were greater among pregnant individuals with greater retail availability of cannabis around their homes or among those living in jurisdictions that allowed storefront retailers. Design, Setting, and Participants: A cross-sectional, population-based time series study used data from pregnancies in the Kaiser Permanente Northern California health care system screened for cannabis use before (January 1, 2019, to March 31, 2020) and during (April 1 to December 31, 2020) the early COVID-19 pandemic. Proximity to the nearest retailer and number of retailers within a 15-minute drive from one's home and local cannabis storefront retailer policy (banned vs permitted) were calculated. Interrupted time series models were fit using multiplicative and additive Poisson regression, adjusting for age and race and ethnicity. Exposures: The COVID-19 pandemic. Main Outcomes and Measures: Prenatal cannabis use based on universal urine toxicology tests conducted during early pregnancy at entrance to prenatal care. Results: The sample (n = 99 127 pregnancies) included 26.2% Asian or Pacific Islander, 6.8% Black, 27.6% Hispanic, 34.4% non-Hispanic White, and 4.9% other, unknown, or multiracial individuals, with a mean (SD) age of 30.8 (5.3) years. Prenatal cannabis use before (6.8%) and during (8.2%) the pandemic was associated with closer proximity to a retailer, greater retailer density, and residing in a jurisdiction that permitted vs banned retailers. There was a greater absolute increase in cannabis use from before to during the pandemic among those within a 10-minute drive (<10 minutes: adjusted rate difference [aRD], 0.93 cases/100 patients; 95% CI, 0.56-1.29 cases/100 patients; ≥10 minutes: aRD, 0.40 cases/100 patients; 95% CI, 0.12-0.68 cases/100 patients; interaction P = .02). Otherwise, relative and absolute rates increased similarly across categories of cannabis retailer proximity/density and local policy (interaction P > .05). Conclusions and Relevance: Prenatal cannabis use was more common among individuals living in areas with greater retail availability of cannabis. Although relative rates increased similarly during the pandemic regardless of local cannabis retail and policy environment, there was a larger absolute increase associated with living closer to a storefront cannabis retailer. Continued monitoring of local cannabis policy, the retail environment, and prenatal cannabis use is needed.

Textual and pictorial enhancement of cannabis warning labels: An Online experiment among at-risk U.S. young adults.

BACKGROUND: This study experimentally examines whether enhanced cannabis warning labels (CWLs) outperform those currently required in the U.S. in improving recall of health risks, emotional responses, and perceived message effectiveness among at-risk young adults. METHOD: We conducted an online national survey-based experiment in October 2020. Young adults aged 18-26 years old and at-risk for cannabis use (N = 523) were randomly assigned in an online experiment, to view either currently required CWLs in California with small font and a composite health risk statement, or enhanced single-theme CWLs with varying textual and pictorial components. We performed linear regression analyses to compare the enhanced with existing CWLs on information recall, negative emotions, and perceived message effectiveness. Furthermore, information recall and negative emotions were examined as parallel mediators to better understand the mechanisms underlying effective textual and pictorial enhancement of CWLs. RESULTS: Compared with currently required CWLs in California, both textually (b = 0.30, p = .011) and pictorially (b = 0.59, p < .001) enhanced CWLs increased recall accuracy. Pictorially enhanced CWLs outperformed their text-only counterparts (b = 0.28, p = .019) in improving information recall. Only pictorially enhanced CWLs improved perceived message effectiveness (b = 0.31, p = .008), which was mediated by negative emotions but not by information recall. CONCLUSIONS: Given rapid expansion of the cannabis industry and declining perception of harm, currently required CWLs in the U.S. such as California's, would benefit from redesign to improve public understanding of health risks and to prevent youth use.

Analysis of the Clinical Pipeline of Treatments for Drug-Resistant Bacterial Infections: Despite Progress, More Action Is Needed.

There is an urgent global need for new strategies and drugs to control and treat multidrug-resistant bacterial infections. In 2017, the World Health Organization (WHO) released a list of 12 antibiotic-resistant priority pathogens and began to critically analyze the antibacterial clinical pipeline. This review analyzes "traditional" and "nontraditional" antibacterial agents and modulators in clinical development current on 30 June 2021 with activity against the WHO priority pathogens mycobacteria and Clostridioides difficile. Since 2017, 12 new antibacterial drugs have been approved globally, but only vaborbactam belongs to a new antibacterial class. Also innovative is the cephalosporin derivative cefiderocol, which incorporates an iron-chelating siderophore that facilitates Gram-negative bacteria cell entry. Overall, there were 76 antibacterial agents in clinical development (45 traditional and 31 nontraditional), with 28 in phase 1, 32 in phase 2, 12 in phase 3, and 4 under regulatory evaluation. Forty-one out of 76 (54%) targeted WHO priority pathogens, 16 (21%) were against mycobacteria, 15 (20%) were against C. difficile, and 4 (5%) were nontraditional agents with broad-spectrum effects. Nineteen of the 76 antibacterial agents have new pharmacophores, and 4 of these have new modes of actions not previously exploited by marketed antibacterial drugs. Despite there being 76 antibacterial clinical candidates, this analysis indicated that there were still relatively few clinically differentiated antibacterial agents in late-stage clinical development, especially against critical-priority pathogens. We believe that future antibacterial research and development (R&D) should focus on the development of innovative and clinically differentiated candidates that have clear and feasible progression pathways to the market.

Local Laws Regulating Cannabis in California Two Years Post Legalization: Assessing Incorporation of Lessons from Tobacco Control.

Introduction: As cannabis legalization continues to spread, best regulatory practice remains ill-defined and elusive, exposing the population to potential harms. Methods: We conducted an annual, statewide, cross- sectional survey to assess cannabis-related laws in effect by January 1, 2020, in local California jurisdictions and at the state level and measured adoption of potential best practices. Results: The current laws of all 539 jurisdictions were located; 276 jurisdictions allowed any retail sales (storefront or delivery) covering 58% of the population, an increase of 20 jurisdictions (8%) from year 1 of legalization (2018). Half allowed sales of medical cannabis, whereas slightly fewer jurisdictions (n = 225) allowed adult-use sales. Only 9 jurisdictions imposed any restrictions on products stricter than state regulations. Cannabis temporary special events were allowed in 22 jurisdictions, up from 14 in the year prior. Thirty-three jurisdictions required additional health warnings for consumers. Just over half of legalizing jurisdictions taxed cannabis locally and little revenue was captured for prevention. No new jurisdictions established a potency-linked tax. Of jurisdictions allowing storefront retailers (n = 162), 114 capped outlet licenses, and 49 increased the state-specified buffers between storefronts and schools. Thirty-six allowed on-site consumption, up from 29. As of January 2020, the state had not updated its regulations of key provisions addressed in this paper. Conclusions: In year 2 of legalized adult-use cannabis sales in California, the state remained split between retail bans and legal sale. Local policy continued to vary widely on protective measures, and State policy remained misaligned with protection of youth and public health.

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps.

BACKGROUND: Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability. METHODS: Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change). RESULTS: Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction). CONCLUSIONS: A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.