Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: panel data study.

OBJECTIVE: To examine county level associations between the prevalence of medical and recreational cannabis stores (referred to as dispensaries) and opioid related mortality rates. DESIGN: Panel regression methods. SETTING: 812 counties in the United States in the 23 states that allowed legal forms of cannabis dispensaries to operate by the end of 2017. PARTICIPANTS: The study used US mortality data from the Centers for Disease Control and Prevention combined with US census data and data from Weedmaps.com on storefront dispensary operations. Data were analyzed at the county level by using panel regression methods. MAIN OUTCOME MEASURE: The main outcome measures were the log transformed, age adjusted mortality rates associated with all opioid types combined, and with subcategories of prescription opioids, heroin, and synthetic opioids other than methadone. The associations of medical dispensary and recreational dispensary counts with age adjusted mortality rates were also analyzed. RESULTS: County level dispensary count (natural logarithm) is negatively related to the log transformed, age adjusted mortality rate associated with all opioid types (ß=-0.17, 95% confidence interval -0.23 to -0.11). According to this estimate, an increase from one to two storefront dispensaries in a county is associated with an estimated 17% reduction in all opioid related mortality rates. Dispensary count has a particularly strong negative association with deaths caused by synthetic opioids other than methadone (ß=-0.21, 95% confidence interval -0.27 to -0.14), with an estimated 21% reduction in mortality rates associated with an increase from one to two dispensaries. Similar associations were found for medical versus recreational storefront dispensary counts on synthetic (non-methadone) opioid related mortality rates. CONCLUSIONS: Higher medical and recreational storefront dispensary counts are associated with reduced opioid related death rates, particularly deaths associated with synthetic opioids such as fentanyl. While the associations documented cannot be assumed to be causal, they suggest a potential association between increased prevalence of medical and recreational cannabis dispensaries and reduced opioid related mortality rates. This study highlights the importance of considering the complex supply side of related drug markets and how this shapes opioid use and misuse.

A Comparison of E-Cigarette Use Patterns and Smoking Cessation Behavior among Vapers by Primary Place of Purchase.

BACKGROUND: E-cigarettes are purchased through multiple channels, including general retail, online, and specialty smoke and vape shops. We examine how e-cigarette users' primary purchase place relates to e-cigarette use and smoking cessation behaviors. METHODS: Probability-based samples of the U.S. population who were current e-cigarette users were surveyed in 2014 (N = 879) and 2016 (N = 743), with responses combined for most analyses. E-cigarette use and smoking cessation behaviors were compared across users' primary purchase place. RESULTS: Higher percentages of vape shop (59.1%) and internet (42.9%) customers were current daily users of e-cigarettes compared to retail (19.7%) and smoke shop (23.2%) customers (p-values < 0.001). Higher percentages of vape shop (40.2%) and internet (35.1%) customers were also former smokers, compared to 17.7% of retail and 19.3% of smoke shop customers (p's < 0.001). Among those smoking 12 months prior to survey, smoking cessation rates were higher for vape shop (22.2%) and internet customers (22.5%) than for retail customers (10.7%, p = 0.010 and p = 0.022, respectively), even though retail customers were more likely to use FDA-approved smoking cessation aids. The percentage of customers purchasing from vape shops increased from 20.4% in 2014 to 37.6% in 2016, surpassing general retail (27.7%) as the most likely channel in 2016. CONCLUSIONS: E-cigarette customers differed in significant ways by channels of purchase, most notably in their smoking cessation behaviors. Previous population studies have relied mostly on retail channel data, which accounted for less than 30% of all products sold by 2016. Future studies of e-cigarette use should consider a broader set of channels.

Evolution of Electronic Cigarette Brands From 2013-2014 to 2016-2017: Analysis of Brand Websites.

BACKGROUND: The electronic cigarette (e-cigarette) industry has grown in size and organizational complexity in recent years, most notably with the entry of major tobacco companies in 2012 and the proliferation of vape shops. Many brands maintain retail websites that present e-cigarette marketing claims and sell directly to consumers. Understanding of the evolving composition of different types of e-cigarette brand websites is currently underdeveloped. OBJECTIVE: This paper presents how e-cigarette brand websites surveyed in 2013-2014 evolved by 2016-2017, and how the websites run by different types of e-cigarette producers currently differ. METHODS: In 2016-2017, we revisited 466 e-cigarette brand websites surveyed in 2013-2014, 288 of which were extant, and identified 145 new English-language websites. We compared product designs, marketing claims, and age-based warnings presented by types of e-cigarette producers: major tobacco companies, independent vape shops, and independent internet-only companies. RESULTS: Among the 433 websites examined in 2016-2017, 12 were owned by major tobacco companies, 162 operated a physical vape shop, and 259 were internet-only operations. Closed-system product designs were sold by 83% (10/12) of tobacco-owned brands. In comparison, 29.0% (47/162, P<.001) of vape shop and 55.2% (143/259, P=.06) of internet-only brands sold closed-system designs. Compared with vape shop and internet-only brands, tobacco-owned brands offered a smaller set of product models (P values <.001) and a narrower range of flavors (P values <.01), with greater emphasis on the traditional combustible cigarette flavors of tobacco and menthol (P values <.001). Tobacco-owned brands also offered a narrower range of nicotine options than the vape shops (P=.002) and were less likely to offer nicotine-free e-liquid compared with internet-only and vape shop brands (P values <.001). Finally, 83% (10/12) of tobacco-owned brand websites featured age verification pop-up windows. In comparison, only 50.2% (130/259) of internet-only brands (P=.01) and 60.5% (98/162) of vape shop brands (P=.06) featured age verification windows. Websites surveyed in both 2013-2014 and 2016-2017 became more likely to sell open-system mods (P<.001) and sold an increased number of product models (P<.001), flavors (P<.001), and nicotine options (P<.001). Prevalence of several types of claims decreased significantly, including indirect claims regarding smoking cessation (P<.001), claims regarding e-cigarettes as healthier (P<.001), less expensive (P<.001), and usable in more places (P<.001) compared with combustible cigarettes. CONCLUSIONS: The number of e-cigarette brands has not appeared to increase since 2014, even as website messaging evolved, with brands owned by tobacco companies and vape shops pulling in opposite directions. Brands owned by tobacco companies offered a limited range of e-cigarette products, whereas brands owned by vape shops emphasized a panoply of flavor and nicotine options. Furthermore, the Food and Drug Administration's regulatory action may influence the types of e-cigarette products offered and the market shares of various companies.