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Journal of Studies on Alcohol and Drugs logoLink to Journal of Studies on Alcohol and Drugs
. 2024 Jan 23;85(1):100–108. doi: 10.15288/jsad.23-00034

Cannabis Retailer Communication About Cannabis Products, Health Benefits, and Risks: A Mystery Shopper Study of Licensed Retailers in Five U.S. Cities

Katelyn F Romm a, Patricia A Cavazos-Rehg b, River Williams c, Campbell Dopke d, Yuxian Cui d, Cassidy R LoParco d, Yan Wang d,,e, Zongshuan Duan f, Y Tony Yang g, Scott Burris h, Carla J Berg d,,e,,*
PMCID: PMC10846606  PMID: 37917012

Abstract

Objective:

As the U.S. cannabis market expands, surveillance of retailer practices, especially product health claims and risks, is crucial to protect consumers. In this study, mystery shoppers (i.e., staff not explicitly identified as researchers) examined retail personnel communication regarding product recommendations, health benefits, safety, and/or risks among U.S. cannabis retailers.

Method:

In Summer 2022, mystery shoppers audited 140 licensed cannabis retailers in 5 cities in states with established nonmedical (i.e., recreational) cannabis sales and diverse regulations (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive and bivariate analyses characterized retail personnel communication overall and across cities.

Results:

Common product recommendations for new users included edibles, pre-rolled joints, and bud/flower, and 8.6% offered free/inexpensive ways to sample products. Although Colorado, Washington, and Oregon explicitly prohibited health claims in advertising or labels, more than 90% of retailers there endorsed use for anxiety, insomnia, and/or pain. Whereas 54.3% endorsed use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%), 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%). Overall, 52.1% warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%). Almost all (≥90%) sold cannabidiol (CBD) products and endorsed their health benefits and safety, but few (<10%) sold or endorsed delta-8 tetrahydrocannabinol (THC), etc. (all of which were in Los Angeles).

Conclusions:

Ongoing cannabis retail surveillance, particularly using protocols assessing factors outside those visibly observable, is needed to inform regulatory and enforcement efforts, especially related to health claims.

Despite federal prohibition of cannabis in the United States, 21 states and 3 territories (including the District of Columbia) have legalized adult nonmedical (i.e., recreational) use, and about 40 states and 4 territories have legalized medical use as of November 2022 (Hansen et al., 2023). Cannabis retail sales have rapidly increased in the United States, from about $10 billion in 2019 to more than $20 billion in 2021 (McVey, 2021), and are estimated to be about $25 billion in 2025 (Blake, 2023).

The evolving cannabis regulatory frameworks in the United States can be informed by prior work in licit drug retail (Berg et al., 2018b) and early non-medical cannabis retail (Barry & Glantz, 2018; Berg et al., 2018b; Hudock, 2019; Lancione et al., 2020; McNamara, 2020; Schauer, 2021; Somerset, 2019; Steinberg et al., 2020; Wang & McKinley, 2019). This work supports regulations like restrictions on product types and potency; limits or bans on customer discounts; required signage indicating various policies (e.g., no onsite consumption) and warnings (e.g., use during pregnancy); and prohibition of marketing using health claims (Schauer, 2021). Moreover, protocols for retail surveillance have been crucial in evaluating the implementation and impact of tobacco and alcohol regulations, as well as retail compliance (Colbert et al., 2021; Gosselt et al., 2012; Henriksen et al., 2016; Williams et al., 2015).

Cannabis retail surveillance protocols are important and have been emerging (Bierut et al., 2017; Cao et al., 2020; Luc et al., 2020; Nicholas et al., 2020; Whitehill et al., 2020). Surveillance of products and their attributes is particularly relevant to cannabis given its diverse forms, strains, potencies, and effects, as well as other influential product attributes like price, which cannabis retailers often exploit through offering discounts/promotions (Berg et al., 2017; Berg et al., 2018c; Buller et al., 2016; Cavazos-Rehg et al., 2018; Krauss et al., 2017; Luc et al., 2020; Shi et al., 2019; Zhu et al., 2021).

Moreover, research examining cannabis retail websites, social media, and point-of-sale indicates that 40%–70% of retailers promote cannabis health benefits (e.g., managing pain, anxiety, and insomnia) (Berg et al., 2017, 2018c; Bierut et al., 2017; Boatwright & Sperry, 2020; Carlini et al., 2020; Cavazos-Rehg et al., 2018; Lau et al., 2021; Luc et al., 2020; Moreno et al., 2018; Peiper et al., 2017; Shi & Pacula, 2021). However, health benefit claims have little or no evidence base (Lau et al., 2021) and are prohibited in many states (Alcohol Policy Information System, 2023). Verbal communication of health claims may be even more common, as limited research has gone beyond visible indicators of such claims.

In short, cannabis retail surveillance to date has highlighted compliance-related concerns and the need for retail surveillance to inform regulatory and enforcement efforts. Ongoing surveillance using approaches that provide complementary data is needed, especially as the market evolves and regulatory efforts must be reconsidered. For example, “derived psychoactive cannabis products” like Δ-8 tetrahydrocannabinol (THC) have become popular since the 2018 U.S. Federal Agriculture Improvement Act, which resulted in a “legal loophole” in cannabis regulation (LoParco et al., 2023; Rossheim et al., 2023). Although the levels of Δ-8 THC that naturally exist in the plant are very low, products are being derived and/or synthesized that are more potent and/or psychoactive than regular cannabis (or Δ-9 THC) (LoParco et al., 2023; Rossheim et al., 2023). In many states, the legality and regulatory oversight of these products is unclear, and existing regulatory language (e.g., “synthetic”) did not anticipate the range of these products (LoParco et al., 2023; Rossheim et al., 2023). Thus, assessing the marketing of these products is also crucial.

Mystery shopper protocols may yield important findings about cannabis retailer practices by assessing factors missed by traditional point-of-sale surveillance, but they have seldom been applied outside of age verification surveillance (Berg et al., 2017, 2018c, 2021; Gosselt et al., 2012; Krevor et al., 2011; Shi & Pacula, 2021). In a Colorado-based study, women claiming to suffer from pregnancy-related nausea called 400 Colorado retailers, resulting in 69% of retailers recommending cannabis and 36% endorsing its safety during pregnancy (Dickson et al., 2018). Although 81.5% recommended discussion with a health care provider, fewer (31.8%) did so without prompting (Dickson et al., 2018). Another mystery shopper study of vape shops documented that, although 29.1% posted signage with health or cessation claims, almost all personnel endorsed vaping as safe and effective in helping smokers quit (Berg et al., 2021). These examples indicate that measures of physical signage may underestimate the extent to which health claims occur, specifically via retail personnel verbal communication.

To inform regulatory and enforcement efforts, it is crucial to assess how cannabis retail personnel communicate with consumers, which may undermine regulations (e.g., minimize risks). Thus, this study used a mystery shopper approach to examine regulatory compliance and personnel communication regarding product recommendations, health benefits, safety, and/or risks among licensed cannabis retailers in five cities in different U.S. states with nonmedical cannabis sales.

Method

Study sites

The Cannabis Regulation, Marketing & Appeal (CARMA) study was launched in Spring 2022 and examines nonmedical cannabis retail, marketing, and consumer impact (Berg et al., 2023). CARMA has a particular focus on cannabis marketing in five cities representing states with the earliest established nonmedical cannabis markets (excluding Alaska): Denver, Colorado (established in 01/2014); Seattle, Washington (07/2014); Portland, Oregon (10/2015); Las Vegas, Nevada (07/2017); and Los Angeles, California (01/2018) (Berg et al., 2023).

In Spring 2022, we identified licensed nonmedical cannabis retailers in these five cities using data from state regulatory agency websites (n = 641). Online searches and phone calls were conducted to verify whether the license referred to a currently operational brick-and-mortar retail storefront, and whether the licensed retailer had a website (for website audits included in the parent study; Duan et al., 2023): 561 were open, 541 of which had websites. Next, we determined if the retailers were part of a chain and/or shared the same website: 372 were distinct. We then randomly selected about 30 locations per city using a random number generator (150 total); the sample flowchart is shown elsewhere (Berg et al., 2023). This sample included 94 (62.7%) medical/nonmedical retailers and 56 (37.3%) nonmedical-only retailers (Berg et al., 2023).

The sample size of 150 retailers (30/city) was based on power calculations to detect changes over time in this cohort of retailers, as well as differences across cities. Primary power calculations assessed power for various point-of-sale audit outcomes; for example, assuming 68% of retailers offer price promotions (Berg et al., 2018c), this sample size can detect an increase in promotions of at least 12.5% over time (Fisher et al., 2011) and can detect differences in other marketing outcomes (e.g., presence of ads, online delivery, health claims) over time and across cities.

Cannabis retail-related laws

State and local regulations were determined by systematic data collection by two legal researchers who used keyword searches in Westlaw, reviewed state and local jurisdiction legislative websites, and redundantly coded regulations, using a previously published protocol (Klieger et al., 2017). A third legal researcher oversaw the research, rectified discordant data, and ensured quality control. Table 1 provides an overview of select state/city regulations related to required health warnings and restrictions on health claims, discounting, and products.

Table 1.

Select state and local regulations regarding cannabis retail for 5 cities/states, 2022

graphic file with name jsad.23-00034tbl1.jpg

Variable Denver, CO Seattle, WA Portland, OR Las Vegas, NV Los Angeles, CA
State policy history
State policy Passed by public vote in Nov. 2012; effective Dec. 10, 2012 Passed by public vote in Nov. 2012; effective Dec. 6, 2012 Passed by public vote in Nov. 2014; effective Jul. 1, 2015 Passed by public vote in Nov. 2016; effective Jan. 1, 2017 Passed by public vote in Nov. 2016; effective Nov. 9, 2016
Sales began Jan. 2014 Jul. 2014 Oct. 2015 Jul. 2017 Jan. 2018
Health warnings and claims
Required health warnings Use during pregnancy, DUI Use during pregnancy Use during pregnancy, poisoning risk Use during pregnancy, DUI, impact on children/youth, information about delayed effects of edibles and potential negative interactions with alcohol and other drugs Use during pregnancy, health risks
Restrictions on health claims Prohibited: health or physical benefit claims; deceptive, false, or misleading claims.
Either the label affixed to container or marketing layer shall include “This product was produced without regulatory oversight for health, safety, or efficacy.”		 Prohibited: advertising that the use of cannabis has curative or therapeutic effects; statements that are false or misleading Prohibited: labels containing untruthful or misleading statements including health claims not supported by totality of publicly available scientific evidence, and without significant scientific agreement, among experts qualified by scientific training and experience to evaluate Prohibited: false or misleading advertising No specific language about health claims
Discounting restrictions
Free samples or giveaways No indication Prohibited Prohibited Prohibited Prohibited
Discounts or coupons No indication May not sell products below acquisition cost; selling price must be indicative of true value when sold without any other product or services; conditional sales prohibited; discounting by producers/processors prohibited Allowed, but cannot sell products at nominal price for promotional purposes; discount if retail sale is made in conjunction with sale of another items, including other cannabis items or hemp items No indication Retailers not allowed to sell products for less than costs for purpose of destroying competition
Product restrictions
Restricted products Prohibited: cannabis products that are alcoholic beverages Prohibited: specific cannabis-infused products (e.g., food requiring refrigeration) Prohibited: products with flavors that would appeal to children Prohibited: cannabis product forms that would appeal to children Prohibited: cannabis products that are alcoholic beverages, including hemp-derived cannabis, as well as other products (e.g., nicotine, caffeine) that enhance potency
Limits on potency No indication specific to potency THC limits of 10 mg/single serving, or 10 servings or 100 mg/unit THC limits are 10 mg/serving or 100 mg/container (except topicals 6%/container, tinctures 1,000 mg/container, concentrates or extracts 2,000 mg/container) No indication specific to potency No indication specific to potency
CBD, synthetic THC, derived psychoactive cannabis products CBD products allowed; synthetic THC allowed (or not addressed) CBD products allowed; synthetic THC prohibited CBD products allowed; synthetic THC allowed (or not addressed) CBD products allowed; synthetic THC prohibited CBD products allowed; synthetic THC allowed (or not addressed)
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Notes: DUI = driving under the influence; CBD = cannabidiol; THC = tetrahydrocannabinol.

Mystery shopper data collection

In July–August 2022, mystery shopper audits were conducted in Los Angeles, Las Vegas, Denver, Portland, and Seattle. Mystery shopper audits were completed in 140 of the 150 retailers (10 in Las Vegas were not completed because of research staff illness). Data collectors were two paid MPH student research staff (ages 23–25, female). The mystery shopper protocol was adapted from previously used strategies and was executed by single staff at each store (Berg et al., 2021). Data were recorded via electronic assessment forms on iPads/iPhones after exiting stores. Before data collection (July 2022), staff participated in a 2-day training, involving didactics, mock audits, field practice, group debriefing, and online quiz assessments. Once data collection began in each city, staff checked within the first day with the first and second authors (CB, KR) to address data collection issues and ensure data quality. Below, we specify the factors assessed by the mystery shoppers.

Product availability and suggestions. Using a soft script, mystery shoppers assessed product recommendations by first stating, “I don't think I'm ready to purchase anything yet, but I just wanted to come in and get a chance to see what types of products you carry and what might work best for me. I've not used marijuana (before or in a long time).” Then they asked, (a) “What products do you all suggest when someone is new to marijuana?”; (b) “If I wanted to try something small and inexpensive, what would you suggest?”; (c) “I was considering getting my friend a quirky birthday present—are there products that people often buy as fun presents for friends?”; and (d) “Is there a way to sample any products—for free or cheaply?” They also coded the product type and potency of the most potent cannabis product and the product type and cost of the cheapest single ready-to-use product.

Verbal health claims and warnings. Mystery shoppers assessed use for (a) anxiety and insomnia (“What products do people typically use for anxiety or insomnia?”); (b) pain (“I've heard that some products can help with pain. I also heard that marijuana is better for pain than opiates—because of the potential for addiction. How much of this is true?”); and (c) pregnancy-related nausea (“I have a friend who is pregnant and struggling with nausea. I've considered whether to suggest marijuana. Do you have any suggestions?”). For each assessment, mystery shoppers made qualitative notes and also used a checklist to code whether the retailer indicated that using cannabis helps; explicitly stated that health care providers recommend for the condition; explicitly mentioned science, research, or evidence for the condition; said they couldn't say because of policy (i.e., can't discuss without medical certificate or working the recreational section); said it depends on person/situation; and/or said they were not supposed to provide medical endorsement but “most people say” or “for me” it helps. For the pain-related assessment, there were additional codes for personnel indicating that opioids are more dangerous/addictive than cannabis; couldn't say about danger/addiction because of policy; depends on the person/situation; and/or not supposed to provide medical endorsement but “most people say” or “for me” it is not dangerous/addictive. For pregnancy-related assessment, there was an additional code for “warns against use.”

Mystery shoppers also assessed cautions for use (“It is hard to tell how much using would impact me. How much do I need to worry about how I might act? About driving?”). Codes were provided for depends on person/situation; not supposed to say but “most people” are not greatly impacted; alcohol is more dangerous than cannabis; and/or warned against driving.

Other products (CBD, Δ-8 THC). Mystery shoppers also asked about other products, including (a) CBD products (“Do you carry CBD products? How safe are they? What are they used for?”) and (b) derived psychoactive cannabis products (“Someone told me about delta-8 THC and other products like HHC? What are they? Do you all carry them? How are they different from other THC?”). In addition to taking qualitative notes, mystery shoppers coded personnel responses: extremely safe; physical health benefits (e.g., pain); mental health benefits (e.g., anxiety, mood, sleep); and/or personnel indicated they “don't know.”

Data analysis

For each of the assessments, the first author and the two mystery shoppers reviewed the quantitatively coded data and the field notes and then determined if field notes were accurately reflected in the quantitative codes and if additional codes were warranted. Additional codes were then added (as necessary) to capture themes that emerged. The mystery shoppers then dual-coded the qualitative data to ensure that the data were captured in the pre-existing or new codes; discrepancies were rectified via group discussion with the first author.

Descriptive statistics (i.e., means, frequencies) and bivariate analyses (chi-square tests) were used to characterize the sample of retailers overall and across cities. All data management and quantitative analyses were conducted using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY). Significance was set at p < .05.

Results

Cannabis product recommendations and characteristics

In response to mystery shoppers’ request for recommendations for new users, retailers most frequently recommended bud/flower (56.4%), edibles (38.6%), or pre-rolls/joints (37.9%, Table 2); retailers in Las Vegas and Los Angeles also frequently suggested pre-rolls/joints or edibles. Recommendations for trial products and gifts were most frequently edibles (60.7% and 57.1%, respectively), followed by pre-rolls/joints (48.6% and 27.9%). The most potent products were most frequently oils (54.3%), tinctures (22.1%), or hash (11.4%), with potency up to 3,000 mg or 99% THC, which exceeded limits imposed in two of the five sites (Seattle, Portland).

Table 2.

Cannabis product recommendations and characteristics

graphic file with name jsad.23-00034tbl2.jpg

Variable Total (N = 140) (100%) n (%) Denver (n = 30) (21.4%) n (%) Seattle (n = 30) (21.4%) n (%) Portland (n = 30) (21.4%) n (%) Las Vegas (n = 20) (14.3%) n (%) LA (n = 30) (21.4%) n (%) p
Product recommendation for new user†
 Bud/flower 79 (56.4) 20 (66.7)a 25 (83.3)a 24 (80.0)a 4 (20.0)b 6 (20.0)b <.001
 Edibles 54 (38.6) 20 (66.7)a 8 (26.7)b 7 (23.3)b 5 (25.0)b 14 (46.7)a,b .002
 Pre-rolls/joints 53 (37.9) 7 (23.3) 11 (36.7) 12 (40.0) 7 (35.0) 16 (53.3) .207
 Vapes 18 (12.9) 3 (10.0) 3 (10.0) 2 (6.7) 6 (30.0) 4 (13.3) .152
Recommendation for inexpensive trial product†
 Edibles 85 (60.7) 22 (73.3) 19 (63.3) 17 (56.7) 10 (50.0) 17 (56.7) .483
 Pre-rolls/joints 68 (48.6) 14 (46.7) 13 (43.3) 16 (23.5) 8 (40.0) 17 (56.7) .732
 Bud/flower 12 (8.6) 6 (20.0) 3 (10.0) 2 (6.7) 0 (0) 1 (3.3) .087
 Vapes 11 (7.9) 2 (6.7) 1 (3.3) 1 (3.3) 4 (20.0) 3 (10.0) .198
 Topicals 1 (0.7) 0 (0) 1 (3.3) 0 (0) 0 (0) 0 (0) .449
Gift recommendation†
 Edibles 80 (57.1) 16 (52.3)a,b 15 (50.0)a,b 12 (40.0)a 13 (65.0)a,b 24 (80.0)b .023
 Pre-rolls/joints 39 (27.9) 6 (20.0) 5 (16.7) 11 (36.7) 5 (25.0) 12 (40.0) .183
 Topicals 25 (17.9) 7 (23.3) 10 (33.3) 3 (10.0) 1 (5.0) 4 (13.3) .051
 Bud/flower 6 (4.3) 2 (6.7) 2 (6.7) 0 (0) 0 (0) 2 (6.7) .481
 Vapes 6 (4.3) 2 (6.7) 0 (0) 0 (0) 1 (5.0) 3 (10.0) .238
 Apparel/paraphernalia 40 (28.6) 13 (43.3)a 11 (36.7)a 16 (53.3)a 0 (0)b 0 (0)b <.001
Most potent product
 Oils 76 (54.3) 10 (33.3)a 30 (100.0)b 29 (96.7)b 3 (15.0)a 4 (13.3)a <.001
 Tinctures 31 (22.1) 0 (0)a 0 (0)a 0 (0)a 15 (75.0)b 16 (53.3)b <.001
 Hash 16 (11.4) 11 (36.7)a 0 (0)b 1 (3.3)b 1 (5.0)b 3 (10.0)a,b <.001
 Bud/flower 8 (5.7) 6 (20.0) 0 (0) 0 (0) 0 (0) 2 (6.7) .003
 Edibles 7 (5.0) 1 (3.3) 0 (0) 0 (0) 0 (0) 6 (20.0) <.001
 E-liquids 3 (2.1) 3 (10.0) 0 (0) 0 (0) 0 (0) 0 (0) .024
Way to sample products (free or cheaply)‡,§ 12 (8.6) 5 (15.6) 0 (0) 0 (0) 1 (5.0) 6 (20.0) .009
Least expensive single dose product
 Pre-rolls/joints 92 (65.7) 19 (63.3)a,b 30 (100.0)a 25 (83.3)a,b 8 (40.0)b 10 (33.3)b <.001
 Edibles 42 (30.0) 10 (33.3)a,b 1 (3.3)a 3 (10.0)a,b 9 (45.0)b 19 (63.3)b <.001
 Beverages 6 (4.3) 1 (3.3) 0 (0) 0 (0) 3 (15.0) 2 (6.7) .067
 Bud/flower 3 (2.1) 1 (3.3) 0 (0) 2 (6.7) 0 (0) 0 (0) .300
Cost of least expensive single product, M (SD) 6.51 (3.35) 8.09 (2.77)a 4.39 (1.44)b 4.35 (2.02)b 8.24 (2.93)a,c 8.24 (4.22)a,c <.001
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Notes: Bold indicates significant differences across cities; superscript letters indicate post hoc differences.

†

Other: 5 for new user, 3 for trial product, 4 for gift.

‡

Buy 1, get 1 pre-roll free (or for a penny); samples (e.g., gummies) without tetrahydrocannabinol (THC); $5 small packs of pills.

§

All sites but Denver prohibit free samples; Washington, Oregon, and California prohibit sales below cost; bold italic text indicates potential violations.

Despite three sites prohibiting sales below cost and all but Denver prohibiting free samples, free (or nearly free) product samples were offered by 8.6% (6.4% excluding Denver). The least expensive ready-to-use single product was most often pre-rolls/joints (65.7%) or edibles (30.0%), costing an average of $6.51.

Product health claims and warnings

Although three of the states (Colorado, Washington, Oregon) explicitly prohibit health claims in advertising or labels, more than 93% of store personnel verbally endorsed cannabis use for anxiety, insomnia, and pain (Table 3). In addition, 10.7% explicitly mentioned science/research/evidence for anxiety, 17.9% insomnia, and 10.0% pain. Few or no personnel indicated that health care providers recommend cannabis use for the condition, noted that they couldn't say (because of policy or otherwise), or referenced theirs or others’ experiences (Table 3 footnote). Regarding pain and comparisons to opioids, 7.1% said they were not supposed to comment, 37.1% said it depends on the person/situation, and 5.0% said opioids were more dangerous/addictive.

Table 3.

Cannabis product health claims and warnings, and hemp-derived cannabis product availability and health claims

graphic file with name jsad.23-00034tbl3.jpg

Variable Total (N = 140) (100%) n (%) Denver (n = 30) (21.4%) n (%) Seattle (n = 30) (21.4%) n (%) Portland (n = 30) (21.4%) n (%) Las Vegas (n = 20) (14.3%) n (%) LA (n = 30) (21.4%) n (%) p
Cannabis product health claims † † † – –
Recommendation/warning for anxiety‡
 Helps 133 (95.0) 28 (93.3) 29 (96.7) 27 (90.0) 19 (95.0) 30 (100.0) .477
 Mentioned science/research/evidence 15 (10.7) 1 (3.3) a,b 0 (0) a 0 (0) a 5 (25.0)b 9 (30.0)b <.001
Recommendation/warning for insomnia‡
 Helps 131 (93.6) 25 (83.3) 28 (93.3) 28 (93.3) 20 (100.0) 30 (100.0) .070
 Mentioned science/research/evidence 25 (17.9) 4 (13.3) a,b 0 (0) a 0 (0) a 7 (35.0)b,c 14 (46.7)c <.001
Recommendation/warning for pain§
 Helps 137 (97.9) 29 (96.7) 30 (100.0) 28 (93.3) 20 (100.0) 30 (100.0) .300
 Mentioned science/research/evidence 14 (10.0) 0 (0) a 0 (0) a 0 (0) a 6 (30.0)b 8 (26.7)b <.001
 Not supposed to comment on danger/addiction 10 (7.1) 2 (6.7) 5 (16.7) 3 (10.0) 0 (0) 0 (0) .080
 Danger/addiction depends on person/situation 52 (37.1) 14 (46.7) a 19 (63.3) a 19 (63.3) a 0 (0)b 0 (0)b <.001
 Opioid use is more dangerous/addictive 7 (5.0) 1 (3.3) 4 (13.3) 0 (0) 1 (5.0) 1 (3.3) .177
Recommendation/warning for nausea during pregnancy|| † † † † †
 Helps 76 (54.3) 7 (23.3) a 23 (76.7) b 16 (53.3) a,b 11 (55.0) a,b 19 (63.3) b <.001
 Mentioned science/research/evidence 4 (2.9) 0 (0) 0 (0) 0 (0) 3 (15.0) 1 (3.3) .010
 Not supposed to medically endorse 19 (13.6) 9 (30.0) 1 (3.3) 3 (10.0) 0 (0) 6 (20.0) .007
 Not supposed to medically endorse, but most people say … 18 (12.9) 3 (10.0) 2 (6.7) 6 (20.0) 0 (0) 7 (23.3) .075
 Depends on person/situation 15 (10.7) 0 (0) a 0 (0) a 0 (0) a 4 (20.0) a,b 11 (36.7) b <.001
 Warned against use 37 (26.4) 14 (46.7)a 4 (13.3)b 4 (13.3)b 7 (35.0)a,b 8 (26.7)a,b .015
Risks of use#
 Depends on person/situation 44 (31.4) 5 (16.7)a 6 (20.0)a 6 (20.0)a 6 (30.0)a,b 21 (70.0)b <.001
 Most people not greatly impacted 33 (23.6) 0 (0)a 10 (33.3)b 10 (33.3)b 5 (25.0)b 8 (26.7)b .013
Alcohol use is more dangerous 7 (5.0) 2 (6.7) 2 (6.7) 2 (6.7) 0 (0) 1 (3.3) .781
 Warned against driving after use 73 (52.1) 24 (80.0)a 13 (43.3)a,b 14 (46.7)a,b 4 (20.0)b 18 (60.0)a,b <.001
CBD products – – – – –
Sell CBD products 132 (94.3) 28 (93.3) 30 (100.0) 28 (93.3) 19 (95.0) 27 (90.0) .564
Suggest safety/health benefits
 Extremely safe 138 (98.6) 29 (96.7) 30 (100.0) 30 (100.0) 20 (100.0) 29 (96.7) .608
 Physical health benefits 137 (97.9) 30 (100.0) 30 (100.0) 28 (93.3) 20 (100.0) 29 (96.7) .300
 Mental health benefits 126 (90.0) 27 (90.0) 28 (27.0) 26 (86.7) 19 (95.0) 26 (86.7) .797
Derived psychoactive cannabis products – † – – †
Sell derived psychoactive cannabis products 9 (6.4) 0 (0)a 0 (0)a 0 (0)a 0 (0)a 9 (100.0) b <.001
Suggest safety/health benefits
 Safe (safer than other THC) 8 (5.7) 0 (0)a 0 (0) 0 (0) 2 (10.0) 6 (20.0) .002
 Physical health benefits 10 (7.1) 2 (6.7) 0 (0) 0 (0) 2 (10.0) 6 (20.0) .015
 Mental health benefits 32 (22.9) 7 (23.3)a 3 (10.0)a,b 0 (0)b 4 (20.0)a,b,c 18 (60.0)c <.001
 Don’t know 77 (55.0) 22 (73.3)a,b 15 (50.0)a,b 29 (96.7)a 3 (15.0)b 8 (26.7)b <.001
 Other 21 (15.0) 1 (3.3)a 12 (40.0)b 1 (3.3)a 5 (25.0)a,b 2 (6.7)a <.001
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Notes: Bold indicates significant differences across cities; superscript letters indicate post hoc differences; CBD = cannabidiol; THC = tetrahydrocannabinol.

†

Indicates relevant policy restricting health claims, required warnings for use during pregnancy, or restrictions on sales of derived psychoactive cannabis products; bold italic text indicates potential violations, although policies unclear about whether they apply (e.g., to verbal communication, to derived psychoactive cannabis products).

‡

Explicitly states health care providers recommend for anxiety, n = 1; explicitly states health care providers recommend for insomnia, n = 1; not supposed to medically endorse, n = 2; not supposed to medically endorse but most people say …, n = 3.

§

Explicitly states health care providers recommend for pain, n = 1; not supposed to medically endorse, n = 1; depends on person/situation, n = 2; not supposed to medically endorse but most people say …, n = 2.

||

Other, n = 22: suggested to consult doctor; indicated personal use for nausea; endorsed CBD but not THC; evidence for nausea but not pregnancy specific; recommended but not via smoking.

#

Other, n = 17: functional/fine while using; recommended time frames to wait to drive; edibles are fine if drive before they take effect; depends on use history.

Other: synthetic or derived psychoactive cannabis products; illegal in this state; more euphoric and less psychoactive; “fake”; “dangerous”; described chemical/compositional differences from Δ-9 THC.

Despite all states requiring health warning signage regarding use during pregnancy, 54.3% of retailers endorsed cannabis use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%). Furthermore, more than 10% indicated that they were not supposed to medically endorse use (13.6%), referred to individuals’ positive experiences (12.9%), and/or said it depends on the person/situation (10.7%). Overall, 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%).

Regarding general use–related warnings, 31.4% said it depends on the person/situation, 23.6% that most people are not greatly affected, and 5.0% that alcohol use is more dangerous. Half (52.1%) warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%).

Hemp-derived cannabis products and health claims

In all sites, CBD products were allowed; all but Seattle and Las Vegas allowed synthetic THC. Almost all retailers (94.3%) sold CBD products; few (6.4%) sold derived psychoactive cannabis products, all of which were in Los Angeles (Table 3). Almost all personnel (≥90%) endorsed CBD's safety and physical and mental health benefits. Few indicated that products like Δ-8 THC were safe (5.7%) or had physical (7.1%) or mental (22.9%) health benefits, and 55.0% indicated that they did not know enough about these products (more frequently in Portland, Denver, and Seattle than in Los Angeles or Las Vegas).

Discussion

This study yielded novel, timely data regarding regulatory compliance and product recommendations, health claims, and warnings among licensed cannabis retailers in five U.S. cities with different state cannabis retail regulations. Study findings highlighted the ambiguity regarding how state regulations apply to verbal communication from retail personnel and the importance of addressing this concern. For example, three of the five states explicitly prohibit health claims, and all five of these states require signage warning against use during pregnancy. Although point-of-sale audits in these five cities (Berg et al., 2023) documented that about 75% of retailers complied (i.e., had no posted health claims, posted pregnancy-related warnings), the current mystery shopper study found that almost all retail personnel (>93%) verbally endorsed cannabis use for anxiety, insomnia, and pain, and more than half endorsed use for pregnancy-related nausea—reinforcing concerns raised in prior research (Bierut et al., 2017; Cavazos-Rehg et al., 2018; Dickson et al., 2018; Lau et al., 2021; Luc et al., 2020; Shi & Pacula, 2021). Given the potential impact of retail personnel communication, regulatory language must be revised to more clearly restrict personnel verbal communication, particularly communication minimizing use-related risks, undermining health warning requirements, or promoting unsubstantiated health claims (Congressional Research Service, 2022).

Although one fourth of retailers warned against cannabis use during pregnancy, more than half endorsed use for pregnancy-related nausea. These findings align with the aforementioned Colorado study, documenting that 69% of retailers recommended use for pregnancy-related nausea and 36% endorsed its safety (Dickson et al., 2018). Notably, in Denver, less than one fourth endorsed cannabis use for pregnancy-related nausea and half warned against use, whereas more than three fourths endorsed such use in Seattle and about one tenth warned against such use in Seattle and Portland. The reasons for this are unclear but may reflect changes in enforcement since the release of a Colorado-based study that highlighted these regulatory issues (Dickson et al., 2018).

In addition, about half of the retailers warned against driving after cannabis use, which is concerning given that individuals generally perceive less risk related to driving under the influence of cannabis relative to alcohol (Berg et al., 2018a; Capler et al., 2017; Romm et al., 2022) and that few (14%) retailers in these cities post warnings about driving under the influence of cannabis (Berg et al., 2023). There was also wide variability in the frequency of retail personnel providing warnings about driving after use (i.e., 20% in Las Vegas to 80% in Denver), although the reasons for these differences across cities are unclear.

Common product recommendations for new users and trial products included edibles, pre-rolled joints, and bud/flower, and oils and tinctures were frequently the most potent, with potency up to 3,000 mg or 99% THC, exceeding limits in states with potency limits (Washington, Nevada). Nearly one tenth offered free/inexpensive ways to sample products, likely indicating noncompliance with restrictions on promotions or discounts/coupons (Berg et al., 2023). Almost all (≥90%) sold CBD products and endorsed their safety and health benefits; however, few (<10%) sold or endorsed derived psychoactive cannabis products, perhaps because the availability of legal nonmedical cannabis makes derived psychoactive cannabis products less relevant. This is particularly likely given that only Washington and Nevada prohibit selling synthetic THC products, although it is not clear whether this language technically applies to derived psychoactive cannabis products like Δ-8 THC (LoParco et al., 2023; Rossheim et al., 2023). Regardless, regulatory language should be updated to use terminology that captures the broader range of these products, particularly given their rapid evolution and availability (LoParco et al., 2023; Rossheim et al., 2023).

Current findings have implications for research and practice. Ongoing research is needed to document and assess the impact of retail personnel communication on consumer perceptions of product risks and benefits, as well as their use behaviors. Research should also examine how consumers perceive the credibility of such personnel communication relative to posted warnings or warnings on packaging, given the potential for such communication to undermine these warnings. Current findings also document the need for multifaceted research and surveillance approaches to identify regulatory gaps and noncompliance, given the tension between point-of-sale audit findings suggesting higher rates of compliance relative to findings in this study (Berg et al., 2023). Most importantly, study results underscore the need for policymakers and regulatory agencies to explicitly address how regulations apply to retail personnel verbal communication regarding health risks and benefits; similar concerns have been raised regarding how regulations apply to the online retail environment (Duan et al., 2023). In addition, they must update language regarding product categories, for example, “synthetic THC,” to reflect the evolving market (LoParco et al., 2023; Rossheim et al., 2023).

Limitations

Limitations include representativeness and generalizability of findings, as this study focused on licensed cannabis retailers in five U.S. cities; these retailers and cities may not be representative of other retailers and cities, and unlicensed retailers have shown greater rates of regulatory noncompliance (Nicholas et al., 2020). However, this study represents a relatively large and diverse sample across states. Another important limitation is assessments by one mystery shopper at each retailer, which precludes evaluation of interrater reliability and introduces potential bias. However, these findings reflect similar regulatory challenges documented in dualcoded point-of-sale audits across this sample of cannabis retailers (Berg et al., 2023).

Conclusions

This study provides a timely perspective on retail practices, marketing tactics, and how nonmedical cannabis retailers across several cities operate in different regulatory contexts. Current findings highlight concerns regarding cannabis retailer verbal communication regarding cannabis use–related risks (e.g., minimizing pregnancy-related risks, driving after use) and health claims (e.g., use for anxiety, insomnia, pain, and pregnancy-related nausea). Although some differences across cities reflected regulatory variation, other differences did not, potentially pointing to ambiguities in regulations, as well as implementation and enforcement gaps—which are crucial to address as cannabis markets expand. Current results also underscore the need for surveillance methods that capture various dimensions of the retail environment.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

Legal research was conducted by Caitlin Davie, JD, Elizabeth Platt, JD, and Sabrina Ruchelli, JD, of the Center for Public Health Law Research, Temple University Beasley School of Law, Philadelphia, PA.

Footnotes

This work was supported by National Institute on Drug Abuse Grant R01DA054751-01A1 (multiple principal investigators: Carla J. Berg, Patricia A. Cavazos-Rehg).

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