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Published in final edited form as: Int J Drug Policy. 2020 Jul 21;83:102860. doi: 10.1016/j.drugpo.2020.102860

Sales to Apparently Alcohol-intoxicated Customers and Online Responsible Vendor Training in Recreational Cannabis Stores in a Randomized Trial

David B Buller a, W Gill Woodall b, Robert Saltz c, Andrew Grayson d, Sierra Svendsen e, Gary R Cutter f
PMCID: PMC7669561  NIHMSID: NIHMS1615605  PMID: 32707476

Abstract

Background

In some U.S. states, laws prohibit sales of recreational marijuana to intoxicated customers to prevent associated harms. In alcohol markets, training in responsible sales practices is one intervention to help reduce such sales to intoxicated customers. Similar training may be beneficial in the recreational cannabis market.

Methods

An online responsible marijuana vendor (RMV) training was developed. Among its five modules, learning elements taught store personnel to recognize signs of alcohol impairment and intoxication, refuse sales, and understand the risks of driving under the influence of cannabis. A sample of n=150 recreational cannabis stores in Colorado, Oregon, and Washington State, USA were enrolled in a randomized controlled trial, half of which were randomly assigned to use the RMV training. Stores were posttested using a pseudo-customer protocol in which confederate buyers feigned obvious signs of alcohol intoxication.

Results

Deterrence of sales to intoxicated customers does not seem to exist, regardless of whether the states’ laws prohibit it. Only 16 of 146 stores (11.0%; 4 Oregon stores were eliminated that were not in business). There was no difference in refusal rates between intervention (11.6% [3.9%]) and control stores (7.6% [3.1%], F=0.71, p=0.401 [1-tailed]) or between stores that used the RMV training (6.3% [4.0%]) or not (12.0% [5.7%], F=0.91, p=0.343 [2-tailed]). In 11 visits, store personnel commented on the buyers’ behavior, or expressed concern/suspicion about buyers, but sold to them anyway.

Conclusions

Training in responsible sales practices alone did not appear to reduce sales to apparently alcohol-intoxicated customers. Legal deterrence from making these sales may be insufficient or nonexistent for store management to support adherence to this responsible sales practice. Regulatory and policy actions may be needed to increase perceived risk with such sales (i.e., clear policy and swift, severe, and certain penalties) to achieve training’s benefits.

Keywords: Cannabis, alcohol intoxication, commerce

Introduction

In 2012, voters in Colorado and Washington State voted to have their legislatures legalize sales of recreational marijuana to adults and another seven states subsequently approved sales, covering in total nearly a quarter of the U.S. population (Lancione et al., 2020); (Carnevale, Kagan, Murphy, & Esrick, 2017). Within some states, laws prohibit sales of recreational marijuana to intoxicated customers at a point-of-sale so as to reduce the risk of injury, violence, and impaired driving (Foxcroft, 2014), especially the high-risk combination of alcohol and marijuana (Dubois, Mullen, Weaver, & Bedard, 2015; Hartman et al., 2015; Marillier & Verstraete, 2019; O'Kane, Tutt, & Bauer, 2002; Ramaekers, Robbe, & O'Hanlon, 2000). Reducing access to marijuana (i.e., sales) by persons already intoxicated may be one of the best prevention strategies currently available. It does not depend on decision-making by the impaired person and avoids problems in current per se laws regarding THC blood level testing and lack of valid field testing methods (National Conference of State Legislatures, 2019; Wong, Brady, & Li, 2014).

According to deterrence theory (Nagin, 1998; Ross, 1984; Wright, 2010), sales staff should comply with prohibitions against sales to intoxicated customers after considering the rewards and costs of complying (Nagin, 1998; Ross, 1984, 1992; Shults et al., 2001; Wagenaar et al., 2000; Wright, 2010). When cost factors are maximized through greater awareness of the law/regulation and perceived risk of apprehension and punishment, compliance by premises staff should increase (Davey & Freeman, 2011; Paternoster, 2010). Research in the alcohol market suggests that training of sales personnel may increase effectiveness of these laws that prohibit sales to intoxicated customers. While studies on responsible beverage service (RBS) training have been mixed (Jones, Hughes, Atkinson, & Bellis, 2011; Ker & Chinnock, 2008) it has prevented alcohol over-service in some studies (Guide to Community Preventive Resources), lowered levels of alcohol intoxication, and been associated with fewer alcohol-involved motor vehicle crashes (Holder & Wagenaar, 1994), particularly when management support is strong (Dresser, 2000; Graham, 2000; Saltz, 1987; Scherer, Fell, Thomas, & Voas, 2015; Shults et al., 2001; Woodall, Starling, Saltz, Buller, & Stanghetta, 2018b).

In this study, our team assessed sales to apparently alcohol-intoxicated customers in three state recreational marijuana markets, i.e., Oregon which prohibited such sales, Washington State that prohibited intoxicated customers from being on the premises, and Colorado that had no regulation (Colorado Department of Revenue, 2020; Oregon Liquor Control Commission, 2020; Washington State Liquor and Cannabis Board, 2020). We also tested a responsible marijuana vendor (RMV) training. State requirements for RMV training varied, with no training required in Washington State; a voluntary training program initiated during the study (incentivized by mitigation of penalties) in Colorado; and required training in Oregon that could be met by reading a booklet from Oregon Liquor Control Commission (OLCC). We tested the hypothesis that a RMV training will reduce sales to visibly alcohol-intoxicated customers over control stores receiving usual and customary training (UCT).

Materials and Methods

Experimental Design

Recreational marijuana stores in Colorado and Washington State (n=175) were enrolled in a randomized controlled trial in 2016. Stores were pretested using a pseudo-underage customer protocol where confederates 21 or older who appeared young attempted to enter the store and purchase marijuana without a state-approved ID (Buller, Woodall, Saltz, & Starling, 2016). The project biostatistician randomly assigned 75 stores to a UCT control group stratified by state and region (outlying areas v. Denver and Seattle) after the baseline assessment. At UCT stores, most training was performed in-house (Hartman et al. 2016). The other 100 stores were assigned to the intervention group and owners/managers were invited to use the Train To Tend® RMV training. The imbalanced randomization accounted for anticipated store loss to follow-up. Stores that had 80% or more of their personnel complete the training received $350 or a tablet computer. Stores were posttested with the pseudo-underage customer protocol and results are reported elsewhere (Buller et al., 2020).

After the completion of posttesting in the main trial in 2018, the Oregon sample was added in a supplemental study of refusal of sales to intoxicated customers. Oregon stores were not included in the main trial because the OLCC requested that we delay study activities while they initiated the market. The Oregon stores were assigned immediately to the UCT control group (n=25) or intervention group (n=25) that was invited to use Train To Tend. In Oregon, OLCC required store personnel to read a printed booklet and pass a test on sales practices. A subsample of stores from Colorado and Washington State in the main trial were selected by the project biostatistician and, along with the Oregon stores, were posttested by a pseudo alcohol-intoxicated customer protocol. Each store was visited once by a confederate buyer who attempted to enter and purchase marijuana while feigning signs of alcohol intoxication. Stores were kept blind to all assessments; intervention stores were aware of the Train To Tend training. All stores were debriefed about the study purpose and procedures. State marijuana regulators and local law enforcement agencies were notified about assessments, indicating they would not result in enforcement actions. The study design and protocols were approved by the Western Institutional Review Board; the National Institutes of Health issued a Certificate of Confidentiality for this research.

Sample

Stores were initially selected at random by the project biostatistician from publicly-available lists of state-licensed recreational marijuana stores in Colorado (n=85 stores), Washington State (n=90 stores), and Oregon (n=50 stores; Portland [n=20], outlying region [n=26]). For the pseudo alcohol-intoxicated customer assessment, the project biostatistician randomly selected subsamples of stores from the main trial stratified by state (Colorado n=52; Washington State (n=52), region (Denver and Seattle n=47; outlying areas n=57), and treatment condition (n=50 RMV training; n=50 controls) and constrained to over-sample stores in the intervention condition that completed the training (n=13 in Colorado and n=14 in Washington State). The total sample size (n=154) was pre-determined by the project biostatistician to achieve 80% power for an increase of 9% refusal rate at p<0.05 (1-tailed), the smallest difference detectable with a sample size affordable in the supplemental budget.

Train To Tend Responsible Marijuana Vendor Training

The Train To Tend RMV training was a multimedia online training. Content was presented in five modules: 1) The Laws , 2) ID Checking, 3) Health Effects, 4) Customer Service, and 5) Rules of the Trade. Train To Tend utilized the Criterion Referenced Instructional Framework of skill-based learning (Mager, 1962) and addressed learning levels in Bloom’s taxonomy (Bloom, Krathwohl, Engelhart, Furst, & Hill, 1966). Common elements were “infogadgets,” a set of tabs with text and still graphics on a single topic, and custom-built interactive activities and simulations following Horton’s (2006) “absorb,” “do,” “connect” skills instruction. Trainees completed four 10-item end-of-module quizzes and a 50-item final exam. Minimum “passing” scores were set by state regulators (70% for Colorado and Oregon; 80% for Washington State). Train To Tend was reviewed by state regulators; it is a Colorado Marijuana Enforcement Division (MED)-approved RMV training. Description of the content and production process were reported elsewhere (Buller, Woodall, Saltz, Grayson, & Buller, 2019).

Skills to recognize and refuse sales to intoxicated customers were taught in Module 4: 1) Signs of Intoxication Infogadget – teaches signs of alcohol intoxication (McKnight, Langston, Marques, & Tippetts, 1997); 2) Sober or Impaired Interactive Activity – practice identifying signs of alcohol intoxication by viewing actors portrayals with feedback; 3) Refusal Skills Infogadget – presents refusal skills (e.g., staying positive; asking for manager’s help); 4) Refusal Skills Interactive Activity – practice refusal skills by viewing an apparently alcohol-intoxicated customer requesting to buy marijuana, selecting response, and receiving feedback; and 5) Driving Under the Influence of Drugs Infogadget – presents how marijuana impairs driving, especially with polysubstance use.

Thirty-six (48.0%) of the 75 stores in the intervention group used the Train To Tend RMV training (i.e., at least 1 individual completed it; 92.4% of employees who signed in to the training completed it). Trained employees were 40.5% female, 78.4% non-Hispanic white, 6.1% Hispanic white; and 45.6% 21-26 years old, 42.5% 27-39 years old, and 11.9% 40 or older. Mean completion time was 160.5 minutes (sd=74.7). Most trainees (78.5%) reported they had also received training at their store by another employee (81.3%) or manager/owner (77.5%; 48.4% in a group; 26.9% from outside trainer).

Pseudo Alcohol-Intoxicated Customer Assessment

Sales to alcohol-intoxicated customers were assessed by confederate buyers who were trained to feign alcohol intoxication while visiting a store and requesting to purchase an inexpensive marijuana product (i.e., pre-rolled joint). Similar protocols have been used to assess alcohol premises (McKnight, 1993; McKnight & Streff, 1994; Woodall, Buller, Saltz, Starling, & Stanghetta, 2017; Woodall, Starling, Saltz, Buller, & Stanghetta, 2014, 2018a; Woodall et al., 2018b). Male and female legal-age individuals (≥21 years old) were hired as confederates and chosen for prior acting experience. The signs of alcohol intoxications trained were fumbling with keys/cash, swaying, slurred speech, and stumbling, which indicate a high level of alcohol intoxication (McKnight et al., 1997). These are clear, unambiguous signs of alcohol intoxication that users of Train To Tend were instructed on recognizing. Thus, the protocol presented the seller with the most overt situation in which sales should be refused.

Confederates worked in teams of two, alternating between acting as the buyer or observer. They visited each store between 3:45 pm and 8:30 pm on weekdays and weekend days, entering the store together, with the buyer exhibiting the signs of alcohol intoxication. If asked, they presented a state-approved valid driver’s license showing they were age-eligible to purchase recreational marijuana. If they were refused entrance, they exited the store. If they were allowed entrance, the buyer continued to show alcohol intoxication signs and attempted to purchase marijuana. The observer observed the store environment, the buyer’s alcohol intoxication signs, and the interaction between the buyer and store personnel. To avoid violating federal prohibition, buyers did not actually purchase a marijuana product. Instead, agreement by the store personnel to sell marijuana products was the outcome measure. After exiting, the buyer and observer completed data forms. Not being willing to sell or failure to gain entry to the store was coded as “refusal to sell.” The observer served as a quality control assessor of the buyer’s presentation by recording the signs of intoxication displayed by the buyer. The buyer and observer also recorded perceptions of the race/ethnicity, gender, and age of the store personnel from visual observation (average inter-rater reliability, Kappa=0.85). Race/ethnicity, gender, and age of the buyer and observer were obtained from project records.

Store Characteristics

Project staff recorded whether each store sold recreational marijuana only or recreational and medical marijuana. Observers provided descriptive data on stores during each visit, including number of personnel, signage, level of lighting, and cleanliness following the store visit.

Statistical Analysis

The primary outcome variable was refusal of sale, defined as refusal of buyer at entry (i.e., not allowed into store), before the buyer reached the counter (i.e., not allowed to attempt to make purchase) or at the buyer’s purchase attempt (i.e., not allowed to complete purchase). Multilevel models were conducted with stores nested within states and controlling for type of store (recreational sales only v. recreational and medical sales) and region (metropolitan area v. outlying area). Using an intent-to-treat approach, models tested whether refusal rates differed between gender or race/ethnicity of buyer and store personnel and between treatment group. The interaction of treatment group and state was also tested treating state as a three-level (Colorado v. Oregon v. Washington State) or two-level variable (Oregon v. Colorado/Washington State). The two-level state factor was tested because the Oregon sample was selected separately and Oregon required store personnel to read a booklet on sales practices. Given the variability in use of the training across stores, training uptake was analyzed both within the intervention group (trained v. not trained; per-protocol approach) and in the entire sample classifying control group stores as “untrained” (as-treated approach), along with its interaction with state. PROC GLIMMIX in SAS 9.3 was used to conduct the statistical tests. One-tailed tests with alpha set at 0.05 were planned a priori for the comparisons between treatment group because a) the hypothesized effect of training was directional, b) we had no evidence that RMV training was harmful, and c) RMV training would only be recommended if it had a positive impact. Two-tailed tests were used for all other comparisons because they were exploratory.

Results

Store Samples

A total of 146 out of 154 stores selected (Colorado n=50, Oregon n=46, and Washington State n=50) were assessed by the pseudo alcohol-intoxicated customer protocol (outlying areas n=80, Denver, Portland, or Seattle n=66; intervention n=75, UCT control n=71). Eight stores were lost due to business closure or license suspension (see CONSORT diagram in Figure 1). Among the assessed stores, 63 (43.2%) sold only recreational marijuana and 83 (56.8%) sold both recreational and medical marijuana. During the visits, observers recorded an average of 3.0 (sd=1.6) personnel working in the stores (71.9% non-Hispanic White, 11.0% Hispanic White, 17.1%, and other race/ethnicity; 73.3% female, mean=32.4 years old [sd=9.5]). The pseudo alcohol-intoxicated buyers were 63.6% female and 72.7% non-Hispanic white, with mean age of 43.9 years. Observers confirmed that the pseudo alcohol-intoxicated buyers displayed signs of alcohol intoxication trained (stumbling 93.8% of visits; swaying 86.3%; slurred speech 80.1%; dropped change/ID 64.4%; forgetting things 58.2%, repeating things 46.6%, lurching 38.4%).

Figure 1:

Figure 1:

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CONSORT flow diagram for pseudo alcohol-intoxicated customer assessments in randomized trial

Refusal of Sales to Pseudo Alcohol-Intoxicated Customers

Sales of marijuana to pseudo alcohol-intoxicated buyers were refused at only 16 out of 146 stores assessed (11.0%). Refusal rate did not differ by gender or race/ethnicity of the confederate buyer (female 12.9% [3.9%], male 5.2% [2.7%], F=2.64, p=0.106 [2-tailed]; non-Hispanic White 9.7% [3.1%] and other 9.5% [4.4%], F=0.00, p=0.969 [2-tailed]) and store personnel (female 8.6% [4.4%] and male 9.9% [3.0%], F=0.06, p=0.803 [2-tailed]; non-Hispanic White 9.5% [3.0%] and other 12.4% [6.8%], F=0.26, p=0.772 [2-tailed]).

Effect of Responsible Vendor Training on Refusal of Sales

The pseudo alcohol-intoxicated customer assessments were examined for RMV training effects. There was no difference in refusal rates between intervention (11.6% [3.9%]) and UCT control stores (7.6% [3.1%], F=0.71, p=0.401 [1-tailed]) in an intent-to-treat approach.

Treatment group effects did not differ by state, either when comparing the three states (p=0.377 [1-tailed]) or comparing Oregon to Colorado/Washington State (p=0.318 [1-tailed]). Also, training uptake was not associated with refusal rates. When examining just the intervention group in a per-protocol approach, stores that had at least 1 individual complete the training (6.3% [4.0%]) did not have different refusal rates than stores that did not use the training (12.0% [5.7%], F=0.91, p=0.343 [2-tailed]). Likewise, there was no difference in refusal rates between stores that were trained (8.8% [4.7%]) or not trained (9.8% [2.9%], F=0.04, p=0.849 [2-tailed]) in the entire sample, when classifying control stores as “not trained” in an as-treated approach. The effect of training uptake did not differ among three states (p=0.665 [2-tailed] for intervention stores only; p=0.833 [2-tailed] for entire sample) or when comparing Oregon to Colorado/Washington state (p=0.558 [2-tailed] for intervention stores only; p=0.609 [2-tailed] for entire sample).

Discussion

Sales of recreational marijuana to apparently alcohol-intoxicated customers appeared to be very common in the three of the first states to debut recreational marijuana sales. Deterrence of sales to intoxicated customers does not seem to exist, regardless of whether the states’ laws prohibit it. Store owners, managers, and/or personnel may believe that refusing such sales is not a priority and will not be enforced and thus penalties are unlikely or slow to materialize. This might be understandable in Colorado where there is no prohibition. But, it is surprising in Oregon where state law explicitly prohibits sales and the educational booklet on responsible sales practices that all store personnel are required to read describes the law and signs of intoxication. However, managers may be correct in their assumption, as there is no indication that regulatory or law enforcement agencies are monitoring for sales to visibly-intoxicated customers. Compliance checks instead are focusing on underage customers, public use, legal days/hours of sales, and product amounts sold, and enforcement efforts are addressing marijuana-impaired driving (CBS4, 2019; Carnevale et al., 2017; Foody, 2019; Mitchell, 2019; Tabachnik, 2019; Wiens, Lenk, Fabian, & Erickson, 2018). All this may be why adherence to any prohibition against selling to visibly-intoxicated customers is low.

Even with increased deterrence of sales to visibly-intoxicated customers, store personnel might benefit from training in how to recognize intoxication and refuse sales. There is evidence that responsible sales training increased refusal to intoxicated customers in the alcohol market (Dresser, 2000; Graham, 2000; Scherer et al., 2015; Woodall et al., 2018b). Further, after completing the RMV training, store personnel reported increased self-efficacy for responsible sales practices (Buller et al., 2019). But, our RMV training alone was not able to increase refusal of cannabis sales to apparently alcohol-intoxicated customers. Some of this might be attributed to the challenge of getting all intervention stores to use it. RMV training was not mandatory in Washington State; Colorado had a voluntary responsible vendor training program; and the training requirement in Oregon could be met by reading a booklet from OLCC. In this pragmatic trial in these policy contexts, fewer than half of the intervention stores used the training. In addition, not all employees at any store were trained. Hence, it is possible that pseudo-customers did not interact with trained employees in some stores. Some researchers have questioned the value of training in responsible sales practices given the mixed results (Buvik & Rossow, 2017) but other research indicated that high quality, mandatory RBS training produces positive outcomes (Abdon, Wallin, & Andreasson, 2011; Gripenberg, Wallin, & Andreasson, 2007; Ker & Chinnock, 2008; Scherer et al., 2015; Wallin, Gripenberg, & Andreasson, 2005). Also, past research has had methodological limitations (e.g., lack of randomized trials, unclear outcome variables, and no training fidelity data) that could explain the mixed effects (Graham, 2000; Ker & Chinnock, 2008; Shults et al., 2001). In our view, RMV training should continue to be refined. We had hoped that online training would improve training quality and fidelity and make effects more predictable compared to in-person trainers (Ker & Chinnock, 2008; Woodall et al., 2018b). Making RMV training both mandatory and standardized might lead to a reduction in marijuana sales to visibly-intoxicated customers, if regulators perform compliance checks and engage in other regulatory activities that increase deterrence.

In addition to the limitations that some interventions stores did not use the training and the number of employees trained per store varied, the findings of this trial are subject to other limitations. The study was performed in the first three states in the United States that legalized recreational marijuana sales, which could reduce generalizability. It is unknown how the recreational marijuana regulations and markets may evolve. The posttest-only design could not adjust for baseline characteristics and refusal rates by store. In the pseudo alcohol-intoxicated customer assessment, stores were visited only once and thus do not account for variation in employees and store circumstances. The study used online training; therefore, the findings may not apply to other forms of instruction. There was no specific training of managers even though management support for responsible sales practices has been important in alcohol sales (Shults et al., 2001). By contrast, there were several strengths in the study, including a large, random sample of state-licensed stores from three states in different regions of the United States with different regulations pertaining to sales to intoxicated customers and RMV training, prospective randomization after baseline assessment, and blinding of stores and pseudo alcohol-intoxicated customer teams.

The very high rate of sales of recreational marijuana to apparently alcohol-intoxicated customers poses a large risk for harm in these new markets, calling for effective prevention interventions. Policy solutions need to create a strong deterrence to be effective, which appears to be currently lacking for laws prohibiting sales to visibly-intoxicated customers. Similar to alcohol sales, states may hesitate to check sales to intoxicated customers, due to requirements of the legal process, limited resources, and rapid decay of enforcement effects (Lenk, Toomey, Nelson, Jones-Webb, & Erickson, 2014; Wagenaar, Toomey, & Erickson, 2005). Prevention likely requires a multi-pronged effort including legal deterrence, education of managers, and training of employees.

Highlights.

  • Recreational marijuana stores will sell cannabis to visibly-intoxicated customers.

  • Responsible vendor training does not reduce sales to visibly-intoxicated customers.

  • Regulatory actions need to deter cannabis sales to intoxicated customers.

Acknowledgments

Financial Support:

The research was supported by the National Institute on Drug Abuse (DA038933). Trial registration ID number: Clinicaltrials.gov, NCT03073291

Footnotes

Conflicts of Interest:

Dr. Buller, Dr. Woodall, Mr. Grayson, Ms. Svendsen, and Ms. Liu receive a salary from Klein Buendel, Inc. Ms. Buller is an owner of Klein Buendel, Inc. Ms. Buller, Dr. Woodall, and Dr. Buller are members of Avid Will, LLC, which is licensed to market the Train To Tend® responsible marijuana vendor training; commercialization of the training was a condition of the funding through the Small Business Innovation Research Program at the National Institutes of Health. Dr. Cutter reports personal fees from Pythagoras Board membership, Brainstorm Cell Therapeutics, Teva Neuroscience, EMD Serono, Novartis, Pfizer, CSL Behring, Avexis Pharmaceuticals, Genzyme, Medimmune/Viela Bio, Receptos, Biolinerx, Sanofi-Aventis, Galmed, Opko, NHLBI, NICHD, Vivus, Genentech, Reata Pharmaceuticals, GW Pharmaceuticals, Roche, Orphazyme, Somahlution, Horizon Pharmaceuticlas, Reata Pharma, Merck/Pfizer, Klein-Buendel, Click therapeutics, Osmotica Pharmaceuticals, Medday, TG Therapeutics, Perception Neurosciences, Celgene, and Recursion Pharmaceuticals outside the submitted work. For Dr. Saltz, no conflicts of interest are declared.

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