Abstract
Purpose
After marijuana commercialization, the presence of recreational marijuana dispensaries (RMDs) was rapidly increasing. The point-of-sale marketing poses concerns about children’s exposure. This study examined advertising and promotions that potentially appeal to children and access restrictions in RMDs around California schools.
Methods
This was a cross-sectional and observational study conducted in June-September 2018. Trained fieldworkers audited retail environments in 163 RMDs in closest proximity to 333 randomly sampled public schools in California.
Results
About 44% schools had RMDs located within 3 miles. Regarding the interior marketing, 74% RMDs had at least one instance of child-appealing products, packages, paraphernalia, or advertisements. RMDs closer to a school had a higher proportion with interior child-appealing marketing. Over three quarters of RMDs had generic promotional activities; particularly, 28% violated the free-sample ban. Regarding the exterior marketing, only 2% RMDs had those appealing to children. Over 60% RMDs had exterior signs indicative of marijuana. Approximately a third had generic advertisements and 13% had advertisements bigger than 1,600 square inches. Regarding access restrictions, almost all RMDs complied with age verification, but 84% had no age limit signs and only 40% had security personnel.
Conclusions
Despite minimal point-of-sale marketing practices appealing to children on the exterior of RMDs around California schools, such practices were abundant on the interior. Marketing practices not specifically appealing to children were also common on both the interior and exterior of RMDs. Dispensaries’ violation of age verification law, lack of security personnel, and presence of child-appealing marketing should be continuously monitored and prevented.
Keywords: Marijuana dispensary, store auditing, point-of-sale, marketing, children
INTRODUCTION
Recreational marijuana commercialization is gaining momentum in the US. Among the 11 states and Washington DC that have legalized recreational marijuana since 2012, retail markets have been opened or anticipated in 10 states, where over a quarter of the US population live. The presence of recreational marijuana dispensaries (RMDs) increased rapidly following the commercialization. (1) Children are at a high risk of initiating marijuana use and developing adverse consequences related to marijuana. (2) The rapidly evolving environment poses considerable concerns about children’s exposure to marijuana and related marketing and creates significant challenges for pediatricians preventing, treating, and educating about marijuana-related harms among children. (3)
As stated in its most recent policy statement about marijuana commercialization, the American Academy of Pediatrics “strongly recommends strict enforcement of rules and regulations that limit access and marketing and advertising to youth”. (3) The presence of RMDs in neighborhoods and point-of-sale marketing such as advertising and promotional activities in RMDs might increase the visibility and awareness of marijuana products among children, whose perceptions and behaviors may be influenced. A study in Oregon found that dispensary storefront was the most common source of advertising seen after commercialization. (4) Self-reported exposure to medical marijuana advertising was found to be related to higher levels of use and intentions of future use among children in California schools. (5) Products, packages, and advertisements that are designed to be appealing to children are particularly concerning. Tobacco and alcohol literature repeatedly suggested that children are common targets of marketing. (6–10) Despite the fact that all the states with marijuana commercialization have some form of prohibitions on child-appealing products and marketing, it remains undocumented as to what extent the marijuana industry is complying.
This study is the first to comprehensively assess point-of-sale marketing practices in RMDs with a focus on those relevant to children. Unlike previous marijuana research relying on individual self-reported exposure measures, (4, 5) we adopted the direct and objective observation approach that has been commonly used in tobacco and alcohol studies on retail outlets. (11–14) We audited RMDs near a representative and large sample of schools in California, the largest legal retail market in the US where over 10 million children can be potentially influenced. We identified product and packaging characteristics, advertising and promotional activities, and access restrictions in these dispensaries.
METHODS
Study Design and Sample
This was a cross-sectional and observational study conducted in June-September in 2018. We obtained a list of public schools in California that participated in the 2017–18 California Student Tobacco Survey (CSTS). The CSTS schools were drawn using a two-stage stratified random sampling approach. California was first stratified into 22 regions. Schools within each region were then randomly selected, proportional to the number of students enrolled within the region. A total of 623 schools across California were sampled and invited, with 403 schools agreeing to participate. Among these 403 schools, 44 schools opted out before the survey was conducted, and 26 schools participated in the survey but were excluded from CSTS data due to low response rate. The final effective school sample size was 333, among which 256 were high schools and 77 were middle schools. The total number of students participating in the survey was 151,404, making it the largest school-based surveys in California. Our study focused on RMDs near these 333 schools.
Study Procedures
Six trained field workers audited retail environments in RMDs in closest proximity to the 333 schools (auditing procedures depicted in Figure A1). We first identified dispensaries using crowdsourced online websites, including Weedmaps, Wheresweed, Leafly, and Yelp. State licensing records were not used because they could not provide a complete list of dispensaries at the time of data collection. Specifically, 1) Marijuana commercialization in California took effect in January 2018. During the study period, California was in a transition stage when annual licenses were just issued, and most were not approved. 2) The licensing policy in California was not enforced, with a large portion of dispensaries operating without licenses. 3) For licensed dispensaries, the registered and actual business name and address often mismatched. Alternatively, we utilized crowdsourced databases, which were considered as reliable, up-to-date, and comprehensive sources of dispensary directories. (15) To identify the dispensary closest to a school, field workers entered school zip code (or city) in the online searchable databases. The street addresses of all the dispensaries with the school zip code (or city) were geocoded and mapped in ArcGIS (ESRI, Redlands, CA) to compute their distances to the school. Field workers then called the dispensary with the shortest distance to verify its address and operational status. These procedures were repeated if a dispensary was permanently closed or not verifiable via multiple calls until an active dispensary was identified.
The primary focus was RMDs. Yet, medical marijuana dispensaries (MMDs) that require a doctors’ recommendation or state patient ID cards coexisted in California in 2018. (16) During call verifications, if dispensary staff indicated that a doctors’ recommendation or a patient ID was required to enter the dispensary and make purchase, the dispensary was categorized as a MMD.i Fieldworkers also verified dispensary classification during the subsequent auditing. For those verified as MMDs, we repeated the aforementioned procedures until an active RMD was identified.
The six trained workers in teams of two audited verified RMDs.ii On average, each RMD visit took 10–15 minutes. The 103 RMDs had unique RMD-school pairs and the 60 RMDs were the closest ones to two or more schools out of the remaining 230 schools. In the main analysis, we reported observations in the unique RMDs (N=163). In the secondary analysis, we reported observations on RMDs using school as the unit of analysis (school N=333). The 60 RMDs shared by two or more schools were counted multiple times or over-weighted in the secondary analysis, reflecting their potential to influence children in multiple schools.
The Human Research Protections Program at the University of California San Diego deemed this research non-human-subject and required no review.
Measurements
We developed a web/smartphone-based surveillance tool for RMD auditing. This “Standardized Marijuana Dispensary Assessment – Children Focused (SMDA-CF)” was adapted from the validated Standardized Tobacco Assessment for Retail Settings - Vape Shops (vSTARS) (13) and Marijuana Retail Surveillance Tool (MRST) (17), with a particular focus on child-relevant marketing practices. The tool was also informed by California’s Medicinal and Adult-Use Cannabis Regulation and Safety Act.(18)
We validated SMDA-CF through a pilot test on 18 RMDs in California. To calculate inter-rater reliability, two workers in a team independently audited the same dispensaries. Reliability analysis indicated moderate to high reliability for SMDA-CF as a whole (median kappa score for all items = 0.8, ranging from 0.1 to 1) (Table A1). Because of the concerns about some low-reliability items, in the formal field work of auditing 163 RMDs, the two workers in a team audited dispensaries together and discussed to resolve discrepancies before submitting observations.
Primarily based on SMDA-CF, the following measures were developed. Interior and exterior items were distinguished when applicable.
School and neighborhood characteristics
Data on school-level characteristics were extracted from the 2015–2016 Common Core of Data provided by the National Center for Educational Statistics. Data on census tract characteristics were extracted from the 2012–2016 American Community Survey five-year estimates.
Proximity of dispensaries
The dispensary-to-school distance was calculated using the “As the Crow Flies” method, the shortest route between two points on the surface of earth. In California, RMDs are required to be located at least 600-feet away from K-12 schools. We also reported network distance by mode of transportation (walking, cycling, and driving).
Products and advertisements appealing to children
California bans products and marketing “attractive to children”, “designed to be appealing to children or easily confused with commercially sold candy or foods”, or “in a manner to encourage persons under 21 years of age to consume”. (18) Because these regulatory texts are rather vague, the definition and operationalization of what child-appealing is in this study were primarily informed by specific details in laws from other states, particularly Nevada and Washington (Table A2). Specifically, we defined child-appealing products, packages, paraphernalia, and advertisements as those characterized by promotional characters (e.g. cartoons, animals, toys, or children), shaped like commercially sold products usually consumed by children (e.g., gummy bears, lollipop, fruits), or using bright colors (in products, mostly edibles) or bubble-like fonts (on packages, branding, advertisements, or signage) (Technical Note A1). We examined the overall availability as well as the availability by dispensary-to-school distance.
Generic advertisements and promotions not specifically appealing to children
These measures included general practices not specifically relevant to children: availability and types of promotions (free samples are banned in California), branded marketing materials, health promotional or warning messages related to marijuana, and images or wording indicative of marijuana. Field workers also visually measured the size of the biggest exterior advertisement. Although California does not restrict size of advertisements in RMDs, some other states do. For instance, Washington requires advertisements to be no larger than 1,600 square inches.
Access restrictions
These measures included exterior signs about age limit, compliance with age verification before customers entering sales area (required in California), and presence of security personnel and surveillance cameras (required in California).
Other potential sources of exposure to marijuana
These measures included smelling marijuana before entering premises, and observations of on- and off-premise consumption (on-premise consumption is banned in most cities in California).
RESULTS
School/Neighborhood Characteristics and Dispensary Distance to Schools
The following analysis was conducted at school level (school N=333).
School and neighborhood characteristics (Table 1)
Table 1.
Characteristics of Schools and School Neighborhoods (School N = 333)
| Mean/% (std) | |
|---|---|
| School Characteristics | |
| Total Students, number. Mean (std) | 1,662.5 (794.5) |
| Race/ethnicity. % (std) | |
| White | 26.1 (22.5) |
| Hispanic | 52.0 (27.4) |
| Asian | 11.8 (13.9) |
| Black | 5.9 (7.9) |
| Students Eligible for Free or Reduced-Price Lunch. % (std) | 55.4 (27.2) |
| Urbanicity1, % | |
| Urban | 43.2 |
| Suburban | 50.2 |
| Rural | 6.6 |
| Neighborhood (Census Tract) Characteristics | |
| Total Population, number. Mean (std) | 4,966.6 (2003.5) |
| Population Under Age 21. % (std) | 28.3 (8.8) |
| Race/ethnicity. % (std) | |
| White | 40.3 (26.2) |
| Hispanic | 37.0 (25.8) |
| Asian | 14.0 (14.5) |
| Black | 5.2 (8.6) |
| Poverty Rate. % (std) | 13.4 (15.7) |
| Median Household Income, $. Mean (std) | 32,578.7 (15,762.9) |
| Median Household Income Below the Median of All California Census Tracts, % | 49.0 |
| Residents Living One Year or Longer. % (std) | 98.8 (0.9) |
| House Occupancy. % (std) | |
| Vacant House | 7.8 (9.8) |
| Owner Occupied | 49.8 (22.7) |
| Renter Occupied | 42.3 (22.4) |
Urbanicity classification for public schools was obtained from the National Center for Education Statistics (NCES). There are four basic locale types in NCES: city, suburban, town, and rural. In this study, we grouped “suburban” and “town” into “suburban”.
The students in these schools were predominantly Hispanic (52.0%) and White (26.1%). Most schools were in urban (43.2%) or suburban (50.2%) areas. Half of the census tracts where these schools were located were lower-income areas (census tracts with median income below the median of all California tracts).
Proximity of dispensaries (Table 2)
Table 2.
“As the Crow Flies” Distance between School and the Closest Recreational Marijuana Dispensary (School N = 333)
| As the Crow Flies Distance between Dispensary and School | All Schools (N=333) | Urban (N=144) | Suburban (N=167) | Rural (N=22) |
|---|---|---|---|---|
| N (%) | ||||
| Less than 600 ft# | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| 600–2,640 ft (0.5 mile) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| 2,640–5,280 ft (1 mile) | 65 (19.5) | 40 (27.8) | 25 (15.0) | 0 (0) |
| 5,280–10,560 ft (2 miles) | 45 (13.5) | 21 (14.6) | 21 (12.6) | 3 (13.6) |
| 10,560–15,840 ft (3 miles) | 36 (10.8) | 14 (9.7) | 20 (12.0) | 2 (9.1) |
| More than 15,840 ft (3 miles) | 187 (56.2) | 69 (47.9) | 101 (60.5) | 17 (77.3) |
| Mean/Median (std/interquartile range) | ||||
| Ft. Mean (std) | 49,881.8 (80,885.6) | 50,936.5 (84,656.3) | 39,3480 (51,649.4) | 122,939.1 (164,507.9) |
| Ft. Median (interquartile range) | 20,211.5 (47,770.6) | 14,692.8 (51,564.3) | 22,000.3 (39,905.2) | 68,132.4 (133,316.8) |
Banned in California.
Calculated with the “As the Crow Flies” method, the median dispensary-to-school distance was 20,211.5 feet or 3.8 miles. No RMDs were located within a 600-feet radius of schools. About 19.5% RMDs were located within a 0.5- to 1-mile walkable distance, and 24.3% RMDs were within 1 to 3 miles that are easily reachable by bike or vehicles. In total, 44% schools had RMDs located within 3 miles. After we stratified schools by urbanicity status, a larger proportion of urban schools (52.1%) had their nearest RMDs located within 3 miles compared to suburban schools (39.5%) and rural schools (22.7%). Network distance by mode of transportation is reported in Table A3. After accounting for road networks, over a third of the schools had RMDs located within a 3-mile walking/cycling/driving distance.
Main Analysis Results
The main analysis used unique dispensaries as the unit of analysis (dispensary N=163).
Products and advertisements appealing to children on the interior of RMDs (Table 3)
Table 3.
Advertising and Promotional Activities in Recreational Marijuana Dispensaries around California Schools (Dispensary N = 163)
| Interior, N (%) | Exterior, N (%) | |
|---|---|---|
|
Products and Advertisements Appealing to Children | ||
| Child-appealing Products/Packages# | ||
| Yes | 97 (59.5) | NA |
| No | 66 (40.5) | |
| Child-appealing Paraphernalia# | ||
| Yes | 58 (35.6) | NA |
| No | 105 (64.4) | |
| Child-appealing Advertisements# | ||
| Yes | 44 (27.0) | 1(.6) |
| No | 119 (73.0) | 162 (99.4) |
| Child-appealing Products/Packages, Paraphernalia on the Exterior or Visible from the Exterior# | NA | |
| Yes | 2 (1.2) | |
| No | 161 (98.8) | |
| Summary of Child-appealing Marketing Categories | ||
| None | 42 (25.8) | 160 (98.2) |
| Child-appealing Marketing in 1 Category | 63 (38.7) | 3 (1.8) |
| Child-appealing Marketing in 2 Categories | 38 (23.3) | NA |
| Child-appealing Marketing in 3 Categories | 20 (l2.3) | |
|
Generic Advertisements and Promotions Not Specifically Appealing to Children | ||
| Product and Price Promotions | ||
| Yes (any of the following) | 124 (76.1) | 3 (1.8) |
| Daily/Weekly Deals | 66 (40.5) | NA |
| First-time Purchase Deals | 47 (28.8) | |
| Product Discounts | 45 (27.6) | |
| Free Samples# | 45 (27.6) | |
| Loyalty Programs | 36 (22.1) | |
| Early Bird/Happy Hour Specials | 21 (12.9) | |
| Social Medical Review or Referral | 6 (3.7) | |
| Other | 9 (5.5) | |
| No | 39 (23.9) | 160 (98.2) |
| Branded Marketing Materials | ||
| Yes | 64 (39.3) | 4 (2.5) |
| No | 99 (60.7) | 159 (97.6) |
| Signs, Posters, Advertisements, or Giveaway Materials That | ||
| Promote Health Benefits | 44 (27.0) | 2 (1.2) |
| Display Health Warnings | 24 (14.7) | 3 (1.8) |
| Both | 6 (3.7) | 0 (0) |
| Neither | 101 (62.0) | 158 (96.9) |
| Images or Wording Indicative of Marijuana | NA | |
| Yes | 102 (62.6) | |
| No | 61 (37.4) | |
| Size of the Biggest Advertisement, Square Inches | ||
| No Advertisement | NA | 105 (64.4) |
| Below 288 | 25 (15.3) | |
| Between 288 and 1,600 | 12 (7.4) | |
| Between 1,600 and 4,800 | 14 (8.6) | |
| Over 4,800 | 7 (4.3) | |
Banned in California.
On the interior, 59.5% RMDs had child-appealing products/packages, 35.6% had child-appealing paraphernalia, and 27.0% had child-appealing advertisements. Summing up the three categories, nearly three quarters (74.2%) of the RMDs had child-appealing marketing practices in at least one category. Figure A2 presents maps of RMDs by the availability of interior child-appealing marketing. Table 4 suggests that there appeared to be a negative relationship between the availability of interior child-appealing marketing and dispensary-to-school distance: the closer RMDs were to a school, the higher the proportion of RMDs had interior child-appealing marketing.
Table 4.
Availability of Child-appealing Point-of-Sale Marketing in Recreational Marijuana Dispensaries by “As the Crow Flies” Distance to Schools (School N = 333)
| As the Crow Flies Distance between Dispensary and School | All RMDs N | RMDs with Any Child-appealing Marketing Activities |
|
|---|---|---|---|
| Interior N (%) | Exterior N (%) | ||
| Less than 600 ft | 0 | 0 (0) | 0 (0) |
| 600–2,640 ft (0.5 mile) | 0 | 0 (0) | 0 (0) |
| 2,640–5,280 ft (1 mile) | 65 | 52 (80.0) | 3 (4.6) |
| 5,280–10,560 ft (2 miles) | 45 | 34 (75.6) | 0 (0) |
| 10,560–15,840 ft (3 miles) | 36 | 25 (69.4) | 0 (0) |
| More than 15,840 ft (3 miles) | 187 | 121(64.7) | 2 (1.1) |
Products and advertisements appealing to children on the exterior of RMDs (Table 3)
On the exterior, only one RMD had child-appealing advertisements and only two RMDs had child-appealing products, packages, or paraphernalia.
Generic advertisements and promotions not specifically appealing to children on the interior of RMDs (Table 3)
The majority of the RMDs (76.1%) had promotional activities on the interior, with the most common activity being daily or weekly deals (40.5%), followed by first-time purchase deals (28.8%) and discounts (27.6%). It is worth noting that 27.6% RMDs offered free samples. More than a third (39.3%) had branded materials. Nearly a third (30.7%) had materials promoting health benefits, but only 18.4% displayed health warning messages.
Generic advertisements and promotions not specifically appealing to children on the exterior of RMDs (Table 3)
Very few RMDs had promotional items (1.8%), branded materials (2.5%), or materials related to health (3.0%) on the exterior. About 62.6% RMDs had images or wording indicative of marijuana. Over a third posted exterior advertisements and 12.9% had at least one advertisement larger than 1,600 square inches.
Access restrictions and other potential sources of exposure to marijuana (Table 5)
Table 5.
Access Restrictions and Other Potential Sources of Exposure to Marijuana in Recreational Marijuana Dispensaries around California Schools (Dispensary N = 163)
| N (%) | |
|---|---|
|
Access Restrictions | |
| Exterior Signs Stating Age Limit Policy | |
| No Sign | 137 (84.1) |
| Must be 18 or Older | 2 (1.2) |
| Must be 21 or Older | 24 (14.7) |
| Age Verification before Entering Sales Area^ | |
| Yes | 160 (98.2) |
| No | 3 (1.8) |
| Security Personnel^ | |
| Yes | 65 (39.9) |
| No | 98 (60.1) |
| Surveillance Cameras^ | |
| Exterior | 6 (3.7) |
| Interior | 20 (12.3) |
| Both | 137 (84.1) |
| Neither | 0 (0) |
|
Other Potential Sources of Exposure to Marijuana | |
| Smelling Marijuana before Entering Premise | |
| Yes | 41 (25.2) |
| No | 122 (74.9) |
| Anyone Using Marijuana, Observed On- Premise# | |
| Yes | 19 (11.7) |
| No | 144 (88.3) |
| Anyone Using Marijuana, Observed Off- Premise | |
| Yes | 5 (3.1) |
| No | 158 (96.9) |
Required in California
Banned in most cities in California.
Most RMDs (84.1%) placed no signs on age limit, and 1.2% placed inaccurate signs. Almost all RMDs (98.2%) checked ID before customers entered sales area. All the RMDs had surveillance cameras inside or outside, but field workers observed security personnel in only 39.9% RMDs. In a quarter of the RMDs (25.2%), marijuana was smelled before entering premises. Field workers observed on-premise consumption in 11.7% RMDs and off-premise consumption near 3.1% RMDs.
Secondary Analysis Results
Results using school as the unit of analysis are reported in Tables A4–A5 (school N=333). The results were comparable to those from the main analysis.
DISCUSSION
This study demonstrated that, in the early stage of marijuana commercialization in California, point-of-sale marketing practices that are appealing to children were minimal on the exterior of the RMDs around schools. However, such practices were abundant on the interior. Marketing practices not specifically appealing to children were common on both the interior and exterior of the RMDs.
Given the age limit, RMDs’ exterior marketing might be the most concerning source of exposure for children. It is reassuring that child-appealing marketing was rarely observed on the exterior of the RMDs around schools. Yet, three quarters of the RMDs had some form of child-appealing marketing on the interior, which violated the California laws. Although children should have little direct access to the interior, child-appealing items may be available to children through indirect pathways and should not be overlooked. For instance, children’s social networks such as older relatives, peers, or caregivers are their important sources of drugs. (19) A study reported that almost three quarters of underage users obtained marijuana from friends, relatives, or family members. (20) Child-appealing products, paraphernalia, or promotional materials could then be made available to children through these adults who are eligible for marijuana purchase. Particularly, about 30% RMDs violated the California law to offer free samples, which could be taken out of the dispensaries and given away to children. These child-appealing items in RMDs could be also resold to children in illicit markets by street dealers. Research on tobacco and alcohol have suggested that children are exposed to and influenced by tobacco and alcohol products and point-of-sale marketing despite the age limit for purchase (21–24). Whether and how the marketing activities inside of RMDs impact children’s perceptions and behaviors should be examined in future research.
Meanwhile, exterior retail environments not specifically relevant to children still warrant further attention. For instance, 63% RMDs had image or wording indicative of marijuana on the exterior. One third of the RMDs had generic advertisements, and some advertisements were of a relatively big size. Marijuana could be smelled outside of 25% RMDs. All of these might potentially increase perceived presence of RMDs in the neighborhoods and shape children’s social norms.
Approximately half of schools had RMDs located within a 3-mile distance that is reachable to children by walking, cycling, or driving. Some RMDs were located further away, especially in suburban or rural areas. Nonetheless, children are not free from exposure to RMDs even if RMDs are located more than 3 miles away from schools. In 2009, the average travel distance from home to school among all school children was 4.4 miles; among high school students, the average distance was even longer (5.5 miles). (25) The travel distance was also increasing over time. (26) An interesting exploratory observation indicated that, compared to RMDs located further away from schools, a larger proportion of RMDs in reachable distance to schools had interior child-appealing marketing. It is possible that RMDs intentionally targeted children if they were in closer proximity of schools. Unfortunately, our study was not able to test this hypothesis directly.
Almost all the audited RMDs followed California rules on age verification. If continuous monitoring and enforcements are not in place, however, children might get access to abundant child-appealing marketing practices inside of the dispensaries, the consequences of which could be grave. Furthermore, exterior signs of age limit were absent in over 80% RMDs and security personnel were only observed in 40% RMDs. These might increase the risks of accidental or even intentional attempts of children to enter RMD premises, who would be then exposed to interior marketing in waiting area.
Compared to laws in other states, California regulations on child-appealing marketing seem to be vague and less comprehensive during the study period. Because content restrictions are inherently subjective, it might be challenging for California RMDs to comply and for regulators to enforce without objective, operationalizable measures of “child-appealing”. Fortunately, after this study was completed, California released new regulations in January 2019 on child-relevant products and marketing. Specifically, marijuana products and packages “shall not use any depictions or images of minors” and “shall not contain the use of objects, such as toys, inflatables, movie characters, cartoon characters, or include any other display, depiction, or image designed in any manner likely to be appealing to minors”. (27) These texts are expected to provide clearer guidance to law compliance and enforcements. In addition to prohibitions in laws, California could also consider screening content materials such as packages before they are available in RMDs. For instance, Massachusetts allows manufacturers to submit artwork to a regulatory board for review to ensure non-child-appealing packaging. Standardized packaging might be another alternative, which has shown effectiveness in tobacco control outside of the US. (28)
This study has limitations. First, this study used a cross-sectional design to capture a snapshot in summer 2018, approximately half a year after California’s commercialization of marijuana. This unique transition period was characterized with a lack of law enforcement, delay of dispensary licensing, and inadequate understanding of laws. As the legal market matures and government makes endeavors on law interpretation and enforcement, we might expect a stronger compliance with laws and possibly a reduction in marketing practices. The findings may not be generalizable to other time points in California. Second, our observations were largely constrained within the regulatory regime in California and may not be generalizable to other states where different regulatory measures are in place. Third, frequency or quantity measures in each marketing category would be more informative than simple binary indicators for availability. Unfortunately, a dispensary often displays hundreds or even thousands of products, packages, paraphernalia, and advertisements. Obtaining frequency or quantity information requires the field workers to spend a considerably longer time evaluating the RMD environment, which is infeasible in practice. Fourth, California laws lacked specific details related to children during the study period. The classification of child-appealing was informed by laws in other states and constructed with authors’ own understanding, which may not reflect California lawmakers’ intention or completely align with recently released new regulations. Further, there might be inevitable measurement errors even after two field workers discussed and resolved discrepancies between them. Lastly, this study only gathered data on RMDs in closest proximity to public schools. Results may not be generalizable to RMDs around private schools or children’s homes. To improve representativeness, future research is encouraged to audit a random sample of RMDs.
CONCLUSION
This study reported active and abundant point-of-sale marketing practices that are appealing to children on the interior of RMDs around schools in California. Marketing practices not specifically appealing to children were also common on both the interior and exterior of RMDs. Dispensaries’ violation of age verification laws, lack of security personnel, and presence of child-appealing marketing should be continuously monitored and prevented, particularly in dispensaries in closer proximity to schools. Future studies are also needed to examine whether and how point-of-sale marketing might impact children’s perceptions and behaviors and what policies might be effective for preventing children’s exposure.
Supplementary Material
IMPLICATION AND CONTRIBUTION.
Children are at a risk of being exposed to marijuana marketing after marijuana is commercialized. This study found abundant marketing practices appealing to children inside of marijuana dispensaries and general marketing practices outside of dispensaries around schools. Dispensaries’ violation of age verification and presence of child-appealing marketing should be continuously monitored.
Acknowledgements
We thank Patrick D. Huber, Tiffany S. Chan, Alice Ghai, Lisa C. Do, and Kevin M. Doan for fieldwork data collection.
Funding Source: This research was supported by grant 27IR-0014 (PI: Shi) from Tobacco-related Disease Research Program and grant R01DA042290 (PI: Shi) from the National Institute on Drug Abuse. This article is the sole responsibility of the authors and does not reflect the views of Tobacco-related Disease Research Program or the National Institute on Drug Abuse.
Abbreviations
- CSTS
California Student Tobacco Survey
- MMD
Medical Marijuana Dispensary
- RMD
Recreational Marijuana Dispensary
Footnotes
Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.
Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.
If a doctor’s recommendation or a patient ID was not required to enter the dispensary but customers with a doctor’s recommendation or a patient ID were eligible for reduced tax rates, the dispensary was considered to sell products to both adults and patients and categorized as RMD in this study.
As depicted in Figure A1, we also audited exterior environments of MMDs if they were the dispensaries closest to a school. A total of 59 schools had this situation. These data on MMDs are not reported in this study but available upon request.
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REFERENCES
- [1].Orens A, Light M, Lewandowski B, et al. Market size and demand for marijuana in Colorado 2017 market update. Available at https://www.colorado.gov/pacific/sites/default/files/MED%20Demand%20and%20Market%20%20Study%20%20082018.pdf. Accessed on 12/02/2018 : Marijuana Policy Group; 2018. [Google Scholar]
- [2].Volkow ND, Baler RD, Compton WM, et al. Adverse health effects of marijuana use. New Engl J Med 2014;370:2219–2227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Committee on Substance Abuse and Committee on Adolescence. The impact of marijuana policies on youth: clinical, research, and legal update. Pediatrics 2015;135:584–587. [DOI] [PubMed] [Google Scholar]
- [4].Fiala SC, Dilley JA, Firth CL, et al. Exposure to marijuana marketing after legalization of retail sales: Oregonians’ experiences, 2015–2016. Am J Public Health 2018;108:120–127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [5].D’Amico EJ, Rodriguez A, Tucker JS, et al. Planting the seed for marijuana use: changes in exposure to medical marijuana advertising and subsequent adolescent marijuana use, cognitions, and consequences over seven years. Drug Alcohol Depend 2018;188:385–391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Pollay RW. Targeting youth and concerned smokers: evidence from Canadian tobacco industry documents. Tob Control 2000;9:136–147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Ling PM, Glantz SA. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. Am J Public Health 2002;92:908–916. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Mosher JF, Johnsson D. Flavored alcoholic beverages: an international marketing campaign that targets youth. J Public Health Pol 2005;26:326–342. [DOI] [PubMed] [Google Scholar]
- [9].King C III, Siegel M, Jernigan DH, et al. Adolescent exposure to alcohol advertising in magazines: an evaluation of advertising placement in relation to underage youth readership. J Adolesc Health 2009;45:626–633. [DOI] [PubMed] [Google Scholar]
- [10].Garfield CF, Chung PJ, Rathouz PJ. Alcohol advertising in magazines and adolescent readership. JAMA 2003;289:2424–2429. [DOI] [PubMed] [Google Scholar]
- [11].Henriksen L, Feighery EC, Schleicher NC, et al. Reaching youth at the point of sale: cigarette marketing is more prevalent in stores where adolescents shop frequently. Tob Control 2004;13:315–318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Wagoner KG, Song EY, King JL, et al. Availability and Placement of Electronic Nicotine Delivery Systems at the Point-of-Sale. Nicotine Tob Res 2018;20:1020–1024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Kong AY, Eaddy JL, Morrison SL, et al. Using the Vape Shop Standardized Tobacco Assessment for Retail Settings (V-STARS) to assess product availability, price promotions, and messaging in New Hampshire vape shop retailers. Tob Regul Sci 2017;3:174–182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Pasch KE, Komro KA, Perry CL, et al. Does outdoor alcohol advertising around elementary schools vary by the ethnicity of students in the school? Ethnic Health 2009;14:225–236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Pedersen ER, Zander-Cotugno M, Shih RA, et al. Online methods for locating medical marijuana dispensaries: practical considerations for future research. Cannabis 2018:22–35%V 21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Downs D Clarifying California’s rules about medical marijuana cards. Available at https://www.eastbayexpress.com/oakland/clarifying-californias-rules-about-medical-marijuana-cards/Content?oid=16276893. Accessed on 1/6/2019 Archived by WebCite at http://www.webcitation.org/75EZWr8lE. East Bay Express; 2018. [Google Scholar]
- [17].Berg CJ, Henriksen L, Cavazos-Rehg P, et al. The development and pilot testing of the marijuana retail surveillance tool (MRST): assessing marketing and point-of-sale practices among recreational marijuana retailers. Health Educ Res 2017;32:465–472. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Medicinal and Adult-Use Cannabis Regulation and Safety Act (MAUCRSA). Available at https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=BPC&division=10.&title=&part=&chapter=&artide. Accessed on 5/20/2018 Archived by WebCite at http://www.webcitation.org/75Ea68bOE. California Bureau of Cannabis Control, 2017. [Google Scholar]
- [19].Harrison PA, Fulkerson JA, Park E. The relative importance of social versus commercial sources in youth access to tobacco, alcohol, and other drugs. Prev Med 2000;31:39–48. [DOI] [PubMed] [Google Scholar]
- [20].King KA, Merianos AL, Vidourek RA. Characteristics of Marijuana Acquisition Among a National Sample of Adolescent Users. Am J Health Educ 2016;47:126–135. [Google Scholar]
- [21].Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine Tob Res 2009;11:25–35. [DOI] [PubMed] [Google Scholar]
- [22].Chambers T, Pearson AL, Stanley J, et al. Children’s exposure to alcohol marketing within supermarkets: an objective analysis using GPS technology and wearable cameras. Health Place 2017;46:274–280. [DOI] [PubMed] [Google Scholar]
- [23].Hurtz SQ, Henriksen L, Wang Y, et al. The relationship between exposure to alcohol advertising in stores, owning alcohol promotional items, and adolescent alcohol use. Alcohol Alcoholism 2007;42:143–149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [24].Ellickson PL, Collins RL, Hambarsoomians K, et al. Does alcohol advertising promote adolescent drinking? Results from a longitudinal assessment. Addiction 2005;100:235–246. [DOI] [PubMed] [Google Scholar]
- [25].McDonald NC, Brown AL, Marchetti LM, et al. U.S. school travel, 2009. An assessment of trends. Am J Prev Med 2011;41:146–151. [DOI] [PubMed] [Google Scholar]
- [26].McDonald NC. Active transportation to school - trends among US schoolchildren, 1969–2001. Am J Prev Med 2007;32:509–516. [DOI] [PubMed] [Google Scholar]
- [27].BCC. California Bureau of Cannabis Control. Title 16, Division 42. Availale at https://bcc.ca.gov/law_regs/cannabis_order_of_adoption.pdf. Accessed on July 25, 2019 2019. [Google Scholar]
- [28].Stead M, Moodie C, Angus K, et al. Is consumer response to plain/standardised tobacco packaging consistent with Framework Convention on Tobacco Control Guidelines? A systematic review of quantitative studies. Plos One 2013;8. [DOI] [PMC free article] [PubMed] [Google Scholar]
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