The Importance of Psychology for Shaping Legal Cannabis Regulation

Abstract

Different patterns of cannabis use can be traced directly back to different interactions between two types of variables: pharmacological and environmental. As legal cannabis expands in the U.S. and around the world, state and national regulatory agencies are gaining control over these variables. Specifically, regulatory agencies are increasingly capable of altering (1) the pharmacological properties of cannabis products, and (2) the way these products are distributed to the population. Consequently, cannabis regulatory agencies are in a unique position to use evidence from psychological science to alter cannabis consumption patterns in ways that mitigate potential harm to public health. However, most state-level legal cannabis regulatory systems in the U.S. are not yet evidence-based or public health-oriented. This applied review and commentary draws on evidence from the psychological science literature to help regulators better understand the types of behaviors they must address, and to guide empirically-supported regulation of THC-laden cannabis, whether used putatively for medical or recreational reasons. This review is organized into three parts that correspond to the three primary agents within the cannabis regulation ecosystem: (1) the cannabis consumer, (2) the cannabis industry, and (3) the cannabis regulatory agency. Within this structure, the review addresses critical psychological variables that drive cannabis consumer and industry behaviors and discusses how regulatory agencies can use this information to protect public health.

1. Introduction

Psychoactive drug use is a relational construct: patterns of behavior emerge as a function of interactions between pharmacological and contextual variables. A drug’s pharmacological effects create potentials for various patterns of use, but the extent to which a drug operates as a reinforcer depends on a host of environmental variables (e.g., requirements for obtaining a drug, other available reinforcing stimuli, and previous environmental stimuli paired with drug-taking). Thus, altering patterns of use of intoxicating substances is an exercise in altering the values of both pharmacological and environmental variables (Falk, 1996; Higgins, Heil, & Lussier, 2004). This premise provides the necessary starting point for conceptualizing how regulatory agencies can manage intoxicating and potentially addictive substances.

Regulatory agencies have the authority to mandate that legal drug producers alter a drug’s pharmacological properties as well as the array of contextual variables associated with the acquisition and consumption of that drug. Thus, at its core, drug regulation is an attempt to alter human behavior. More specifically, it is an attempt to alter the behavior of those who consume drugs and those who produce and distribute drugs. An agency implements a regulation because it assumes that regulation will affect the behavior of the intended recipient. Thus, specifying and implementing regulations presumes that the agency understands human behavior well enough to effectively guide it in a manner that benefits individual and public health.

There is growing recognition that psychological science can enhance the design of government policies and regulations. For example, the Food and Drug Administration (FDA) has highlighted the need to understand psychological variables associated with tobacco use (e.g., reinforcing potential of product constituents, perceptions of product labels) well enough to apply them to the design of tobacco regulations (Ashley & Backinger, 2012; Henningfield, Buchhalter, & Fant, 2016). Emphasis on the primacy of psychology in policy design is also occurring around issues such as energy, food, and economics (Madrian, 2014; Matjasko, Cawley, Baker-Goering, & Yokum, 2016; Oliver, 2015). The legal cannabis laws being adopted across the United States give state governments the potential to control the pharmacological constituents of cannabis products, as well as how those products are distributed to the population. Hence state regulatory bodies have the opportunity to use psychological science to inform and guide effective regulation of cannabis for the benefit of public health.

Unfortunately, most of the current legal cannabis laws in the U.S. are not evidence-based or public health-oriented (Barry & Glantz, 2018; Grbic, Goddard, & Ryder, 2017; Klieger et al., 2017; Weiss, Howlett, & Baler, 2017). In response, a body of publications has emerged outlining evidence-based “best practices” for public health-oriented legal cannabis regulation (Barry & Glantz, 2016; Barry & Glantz, 2018; Borodovsky & Budney, 2018; Budney & Borodovsky, 2017; Carnevale, Kagan, Murphy, & Esrick, 2017; Ghosh et al., 2017; Pacula, Kilmer, Wagenaar, Chaloupka, & Caulkins, 2014; Rehm & Fischer, 2015). This work has highlighted the need to implement a host of critical regulations such as child-resistant packaging, a minimum purchase age of 21, prohibiting public consumption, monitoring residual pesticides, implementing waste management procedures, creating labeling and serving size requirements, potency limits, preventing excessive marketing, prohibiting scientifically unsubstantiated health claims, and many others.

Many of the concepts presented in this review overlap with and are supported by those examined in the literature cited above. However, the goal of this review is to extend (rather than summarize) current thinking on the use of regulation to mitigate acute and chronic adverse consequences associated with cannabis misuse - regardless of whether that cannabis is putatively obtained for recreational or medical reasons (see next section for discussion of this issue). Specifically, this applied review aims to create a bridge between psychological science and public health-oriented regulation of the distribution and consumption of legal cannabis products that contain substantial amounts of delta-9-tetrahydrocannabinol (THC). From a public health standpoint, products that contain THC are of greatest concern because THC is the compound in the cannabis plant that causes intoxication, impacts perception, cognition, and judgment, and imparts significant addictive potential (Volkow, Baler, Compton, & Weiss, 2014; Volkow et al., 2016). Given the primary focus on THC-laden products, two topics fall outside the scope of this review and will receive little discussion: (1) cannabidiol (CBD) and its established or potential medical utility because CBD does not have known addictive potential or significant adverse behavioral or health effects; (2) FDA-approved, cannabinoid-based pharmaceutical medications (Dronabinol, Nabilone, Epidiolex®) because these have strong evidence supporting their medical utility and are already under explicit regulatory control.

This review presents a selective synthesis and discussion of relevant scientific literature and key psychological concepts that address the three primary agents within the cannabis regulatory ecosystem: (1) the cannabis consumer, (2) the cannabis industry, and (3) the cannabis regulatory agency. The goal is not only to provide recommendations for regulations but also to explicate principles underlying cannabis use and sale behaviors that can help regulators make more informed decisions while navigating the dynamic and evolving cannabis landscape.

Before proceeding, one issue that warrants clarification is whether or not discussions about cannabis regulation should treat current medical cannabis laws and current definitions of medical cannabis consumption as being distinct from recreational cannabis laws and recreational cannabis consumption. As of January 2020, 33 U.S. States have medical laws and 11 have recreational laws. The position held in this review is that the psychological concepts presented, and the regulatory recommendations derived from those concepts, are equally applicable to the cannabis distribution and consumption behaviors currently permitted by both types of laws and concomitant regulations. Although a comprehensive discussion of this position is beyond the scope of this paper, a concise listing of the reasons for this assertion is as follows. First, THC-laden products sold in most medical and recreational dispensaries are essentially the same. Thus, the potential for adverse consequences and the development of use disorders is similar regardless of where or why one purchases the product. Moreover, medical cannabis laws rarely place the types of medically-oriented legal constraints on consumption (e.g., specifying which products can be purchased or which products should be used for a particular medical condition) that would allow one to make a clear distinction between patterns of medical vs. recreational consumption. Second, the great majority of cannabis consumers who report using cannabis for medical reasons also report using cannabis for recreation (Pacula, Jacobson, & Maksabedian, 2016). Third, currently, there are no controlled clinical trial data that support the efficacy of THC-laden cannabis plant material for the vast majority of medical conditions approved by medical cannabis laws (Hill, 2019; Pratt et al., 2019). Because of this lack of clinical data, state medical cannabis laws cannot and do not provide evidence-based clinical guidelines for the THC-laden products that are being distributed to the population (e.g., THC dose, frequency, route, and duration of administration). Indeed, it is not possible to effectively educate consumers about product efficacy and safety profiles – a standard practice in rigorous medical regulatory systems. Last, many medical cannabis programs lack the regulatory constraints found in standard medical systems (e.g., established patient-physician relationship, distribution of non-combustible products, effective limits on supply and refills, physician training requirements, drug monitoring requirements)(Williams, Olfson, Kim, Martins, & Kleber, 2016). In sum, this review asserts that current definitions of “medical” and “recreational” cannabis lack clear and meaningful distinctions. Thus, regulatory issues and actions designed to protect the public from the potential harms of legally available THC-laden cannabis apply comparably to current medical and recreational laws, to the distribution of cannabis in medical or recreational dispensaries, and to consumers that seek cannabis for medical or recreational reasons.

Because this was a review of published literature, and human subjects were not involved, this work was exempt from IRB review.

2. Cannabis Consumption Behavior

Knowing why individuals use cannabis and how different patterns of cannabis use emerge provides essential information for effective development of cannabis regulations that can mitigate harm. Here, three complementary conceptualizations of cannabis initiation and continued use are discussed: (1) Reinforcement-based (2) Self-reported reasons, and (3) Cannabis culture, self-concept, and identity-based. By understanding and integrating all three conceptualizations, readers may gain a broader and more comprehensive perspective of the multidimensional nature of cannabis use behaviors and their associated effects.

2.1. Cannabis use: Reinforcement-based paradigms

Understanding why people use cannabis (or any intoxicating substance that humans use) requires an understanding of fundamental principles underlying processes of reinforcement and learning. Specifically, humans learn that certain stimuli (e.g., food, water, sex, and intoxicating substances) generate pleasurable effects, and consequently, they seek to repeat the specific behaviors (e.g., drug-taking) that generated those effects. Stimuli are considered “reinforcing” when their effects increase the probability or frequency of stimuli-seeking behaviors. Decades of research demonstrates that cannabis can operate as a reinforcer and that its reinforcing potential is primarily related to the action of the compound delta-9-tetrahydrocannabinol (THC) (Cooper & Haney, 2008, 2009a). Higher potency (i.e., %THC) produces greater reinforcing potential, and the method used to ingest cannabis can alter the reinforcing potential as well (Cooper & Haney, 2009b; Spindle et al., 2018). Additionally, different varieties of the cannabis plant contain varying concentrations and ratios of multiple cannabinoids in addition to THC (Aizpurua-Olaizola et al., 2014; Gul et al., 2015). The cannabis plant also contains a class of compounds called “terpenes” which are linked to the varying tastes and smells of cannabis (e.g., citrus, pine, berry) (Fischedick J, 2015; Gilbert & DiVerdi, 2018; Piper, 2018; Russo, 2011). Manipulating concentrations of the various compounds and terpenes could alter the reinforcing potential of cannabis, although such effects are only well documented for THC.

Behavioral economics, defined as the systematic evaluation of responding under constraints (Bickel, Green, & Vuchinich, 1995), is often used to identify the value of a reinforcer by isolating the effects that environmental variables have on responding for that reinforcer. When one examines drug use (including cannabis) from a behavioral economic perspective, it becomes clear that drug-seeking behavior changes in a highly predictable and ordered manner in response to varying degrees of environmental constraints (Bickel, Green, & Vuchinich, 1995; Higgins et al., 2004). An example environmental constraint of primary relevance to drug regulation is the “cost” of obtaining a reinforcer. Cost, as understood from a behavioral economic perspective, includes the monetary cost of the reinforcer as well as the time and effort required to obtain the reinforcer.

The strength of desire for a drug can be quantified by examining the relationship between escalating costs associated with drug use and actual drug consumption (i.e., the “demand” for the drug), (Aston & Cassidy, 2019). Drug consumption that persists in the face of escalating time, effort, or financial costs associated with obtaining the drug, suggests that the drug has high reinforcing value and the potential to generate unhealthy behavior (Bickel, DeGrandpre, & Higgins, 1993; Bickel, Johnson, Koffarnus, MacKillop, & Murphy, 2014). As a general principle, adding environmental constraints that increase the cost of obtaining a drug (e.g., increasing the effort or time required, raising the price, reducing the potency, or providing reinforcing non-drug alternatives) will decrease drug use, whereas removing these constraints increases drug use (Higgins et al., 2004).

Cannabis use behaviors conform to many of the same patterns observed for alcohol and tobacco in response to varying degrees of environmental constraints (Aston & Cassidy, 2019). Daily cannabis consumers will generally continue to buy the same total number of high-quality cannabis joints when the price per joint ranges anywhere from 0-$13 (i.e., demand is relatively inelastic in this price range) (Collins, Vincent, Yu, Liu, & Epstein, 2014). Beginning at approximately $15 per joint, every subsequent increase in price results in a smaller total number of joints purchased (i.e., demand becomes elastic). This nonlinear relationship between consumption of a drug and the cost of a drug has been observed for multiple reinforcers, including tobacco and alcohol (MacKillop et al., 2012; MacKillop et al., 2010) and it is an important dynamic to consider during regulation design or impact assessment. Specifically, these data demonstrate that increasing the cost of cannabis from amount X to amount Y may have less of an impact on cannabis purchase and consumption patterns in the population than an equidistant increase in the cost from amount Y to amount Z.

Finally, behavioral economic indices are highly predictive of the frequency and severity of cannabis use, which makes them potentially useful sources of information about the severity of cannabis use in the population. For example, relative to cannabis consumers without symptoms of cannabis dependence, those with dependence consume twice as much cannabis when cannabis is free, and their patterns of consumption remain stable despite increases in price (i.e., less elasticity) (Aston, Farris, MacKillop, & Metrik, 2017; Aston, Metrik, & MacKillop, 2015). Cannabis purchase behaviors also vary in relation to the perceived quality of cannabis and the extent to which cannabis is available from legal and illegal sources (Amlung et al., 2019; Vincent et al., 2017). The relevance of these concepts and their application to cannabis regulation is discussed in subsequent sections.

2.2. Cannabis use: Self-Reported Reasons

One can glean additional understanding of cannabis use behavior by asking individuals about their reasons for using cannabis. Multivariate analyses of self-reported reasons for cannabis use have identified several distinct motivation clusters that can provide insight into the heterogeneity and complexity of cannabis use patterns and contexts (Buckner & Zvolensky, 2014; Lee, Neighbors, Hendershot, & Grossbard, 2009; Simons, Correia, Carey, & Borsari, 1998). For example, some individuals use cannabis primarily to cope with anxiety-provoking situations; others use it to enhance enjoyment of social gatherings or celebrations; some report using cannabis because they feel pressured to conform; others are curious and want to experiment, or use simply because it was available at the time; still others may use cannabis because they want to change or enhance the experience of solitary activities and situations like sleep, relaxation, or boredom.

Careful consideration of these motives is warranted when developing regulations because they are robust predictors of distinct patterns and stages of cannabis use – ranging from innocuous to pathological. Most individuals who try cannabis will never progress past infrequent, experimental, or opportunistic use (Coffey, Lynskey, Wolfe, & Patton, 2000; Kandel & Chen, 2000; Patrick, Bray, & Berglund, 2016; Perkonigg et al., 2008). However, a subset of those who try cannabis will transition to more frequent use. Yet, even among those who begin consuming cannabis frequently, not everyone develops problematic use. For example, among frequent (at least three times per week) cannabis consumers (ages 18 – 30) who did not meet the criteria for DSM-IV cannabis dependence, only one third developed dependence during three years of follow-up (van der Pol et al., 2013). More importantly, in these analyses, using cannabis to cope with negative emotions emerged as one of the primary predictors of dependence onset. Specifically, compared to individuals with other motives for using cannabis, those who reported using cannabis to cope with negative emotions at baseline were significantly more likely to develop dependence (van der Pol et al., 2013). This finding warrants further emphasis as numerous studies have reported the same results: using cannabis to cope with negative affect is consistently associated with more frequent cannabis use, problems stemming from cannabis use (e.g., social, employment, or legal problems), and overall worse mental health compared with those who report other motives for using cannabis (Benschop et al., 2015; Bravo et al., 2019; Bresin & Mekawi, 2019; Brodbeck, Matter, Page, & Moggi, 2007; Colder, Lee, Frndak, Read, & Wieczorek, 2019; Glodosky & Cuttler, 2019; Moitra, Christopher, Anderson, & Stein, 2015; Patrick et al., 2016; Patrick, Schulenberg, O’Malley, Johnston, & Bachman, 2011; Peraza et al., 2019; Schultz, Bassett, Messina, & Correia, 2019). However, when considering these data, it is important to distinguish between a marker and a cause. The strength of the association between cannabis coping motives and worse mental health makes coping motives a highly informative data point that regulators can use to target actions to protect this vulnerable sub-population or to monitor population health. Yet this association does not suggest that poor mental health is an inevitable consequence of cannabis misuse, nor does it invalidate the possibility of reverse causation (i.e., those with prior mental health issues seek out and misuse cannabis). What is clear is that those who report using cannabis to cope with negative affect are also the individuals most likely to report mental health issues, cannabis use disorder, and related consequences.

2.3. Cannabis use: Cannabis culture, self-concept, and identity

Much like legal drugs such as alcohol and tobacco (Lindgren, Neighbors, Gasser, Ramirez, & Cvencek, 2017), cannabis can become a part of a person’s self-image and identity, i.e., “cannabis user” becomes a central feature of how that person views him or herself (Hammersley, Jenkins, & Reid, 2009; Montes & Napper, 2019; Mostaghim & Hathaway, 2013). Cannabis-user identities emerge in part through repeated exposure to, and reinforcement from the unique collection of cannabis-specific norms, values, attitudes, rituals, stories, and symbols that comprise the broader cannabis culture (Sandberg, 2012). Unsurprisingly, individuals who adopt or embrace cannabis-based identities and cannabis culture are more likely to be high-frequency consumers, experience consequences related to their use, and have greater difficulty quitting (Holm, Sandberg, Kolind, & Hesse, 2013; Holm, Tolstrup, Thylstrup, & Hesse, 2015; Liebregts et al., 2015; Montes & Napper, 2019).

These data suggest that identity development, which occurs primarily during adolescence, also warrants careful consideration by cannabis regulatory agencies. Because adolescents experiment with different identities by adopting new behaviors, attitudes, and beliefs (Meeus, Iedema, Helsen, & Vollebergh, 1999), they are particularly impressionable, and the development of their self-image is easily influenced by their environment. This is the reason why, for example, tobacco companies were so successful in using marketing campaigns (e.g., Joe Camel, Marlboro Man) to target and attract youth to begin smoking (Arnett, 2001; Arnett & Terhanian, 1998; Krugman, Quinn, Sung, & Morrison, 2005; Shadel, Tharp-Taylor, & Fryer, 2008, 2009)

Importantly, the qualitative features of the prototypical cannabis-based identity may change in tandem with broader societal changes in cannabis-related norms and attitudes. In addition to traditional “stoner” or “hippie” archetypes, new cannabis-based iconography, customs, fashions, and overall identities may emerge in the coming years. Yet, even if modern cannabis-based identities are perceived as more innocuous than traditional ones, regulators may still consider monitoring and mitigating their promotion for a simple reason: merely agreeing with basic statements such as “Smoking marijuana is part of my self-image,” “Smoking marijuana is who I am,” or “Smoking marijuana is part of my personality,” predicts higher frequency and severity of cannabis use (Blevins et al., 2018; Pearson, Bravo, Conner, & Marijuana Outcomes Study, 2017).

3. Cannabis Industry Behaviors

Legal cannabis is now a multibillion-dollar for-profit industry in North America (ArcView, 2019). Like any other for-profit actor operating within a capitalist economic system, a normative, logical, and primary objective of a cannabis company is profit maximization. Systems that incentivize profit maximization reliably generate specific types of industry behaviors - regardless of the type of industry. Because of the universality, predictability, and potential harm of these behaviors, they are consistently deemed a significant determinant of overall population health (Freudenberg & Galea, 2008; Gilmore, Savell, & Collin, 2011). At present, the cannabis industry is engaging in two fundamental types of corporate behavior that stem directly from the incentive to maximize profits: (1) using advertising and marketing to promote consumption and (2) avoiding or taking advantage of state government-imposed regulations. Below, both types of behaviors are discussed.

3.1. Cannabis Industry Behavior: Promoting cannabis consumption via advertising and marketing

Simply put, more cannabis consumption generates more revenue. Thus, if a company’s goal is to generate revenue, then that company’s goal is to generate as much cannabis consumption as possible (Barry & Glantz, 2016; Kilmer, 2014; Subritzky, Pettigrew, & Lenton, 2015). For example, because heavy, daily cannabis consumers (10-20% of all consumers) are responsible for approximately 60-80% of total cannabis consumption, cannabis companies are incentivized to encourage heavy, daily cannabis consumption (Callaghan et al., 2019; Caulkins, 2017; Caulkins, Kilmer, & Kleiman, 2016). One of the ways to promote heavy consumption is through marketing and advertising (Caulkins & Kilmer, 2016a; Kilmer, 2014), and the current landscape for legal cannabis has been labeled “a natural laboratory for marketing strategy research”(Olsen & Smith, 2019). Understanding the ways cannabis is or could be marketed can allow regulators to make more informed decisions about the types of advertising to permit and prohibit. Below, marketing and advertising strategies that operate on at least four different psychological processes that relate to consumption are described: (1) cues and cravings (2) costs (3) perceptions of safety and health (4) motives, lifestyles, and self-image.

3.1.1. Cues and craving

As a person’s drug use escalates, classical conditioning processes will pair common antecedent environmental stimuli with the reinforcing consequences of the drug. Eventually, these stimuli will come to signal the availability of reinforcement and will increase the likelihood that drug use occurs (Field & Cox, 2008). A robust literature has demonstrated that such processes occur with cannabis. Regular cannabis consumers have strong neurophysiological reactivity to cannabis-related stimuli or “cues” (e.g., words, images, smells, tastes, paraphernalia) and pay more attention to such stimuli than less frequent consumers (Cousijn et al., 2013; Field, Eastwood, Bradley, & Mogg, 2006; Henry, Kaye, Bryan, Hutchison, & Ito, 2014; Norberg, Kavanagh, Olivier, & Lyras, 2016; Ruglass, Shevorykin, Dambreville, & Melara, 2019). This cue reactivity can elicit cravings for cannabis, which in turn is associated with greater willingness to continue purchasing cannabis despite increases in price (Aston et al., 2015; Lundahl & Greenwald, 2015, 2016; Lundahl & Johanson, 2011; McRae-Clark et al., 2011; Metrik et al., 2016; Strickland, Lile, & Stoops, 2019). Therefore, these cue and craving dynamics are primary targets for advertising and marketing strategies (Martin et al., 2013). By using cannabis-related stimuli in their advertisements, the cannabis industry leverages conditioned cue-reinforcer associations to raise the probability of inducing people to buy their product. A non-exhaustive list of current examples include the use of images and language describing cannabis paraphernalia and product types (e.g., buds, dabs, bowls, bongs, edibles) and descriptions of the intoxicating effects of the product such as “uplifting, creative euphoric high,” “blissful,” or “strong soaring long-lasting high” (Cavazos-Rehg et al., 2019; Cavazos-Rehg, Krauss, Sowles, & Bierut, 2016; Fiala, Dilley, Firth, & Maher, 2018).

3.1.2. Reducing costs

Like the alcohol and tobacco industries (Chaloupka, Cummings, Morley, & Horan, 2002; Kuo, Wechsler, Greenberg, & Lee, 2003), cannabis companies are promoting increased consumption by engaging in a variety of practices that lower the “cost” (i.e., time, effort, or money) required to obtain cannabis. Discounts, coupons, loyalty programs, “buy-one-get-one-free” specials, and free samples, as well as effort- and time-based strategies such as providing delivery services and easy online ordering represent a few such practices (Berg, Henriksen, Cavazos-Rehg, Schauer, & Freisthler, 2018; Cavazos-Rehg et al., 2019; Cavazos-Rehg et al., 2016). Given that the tobacco and alcohol industries adopted many of the same practices, and that these practices result in increased consumption (Chaloupka et al., 2002; Kuo et al., 2003; Slater, Chaloupka, Wakefield, Johnston, & O’Malley, 2007), as well as the behavioral economic literature demonstrating the strong relationship between cost and consumption, it is reasonable to assume that allowing such cost-based practices to proliferate will likely increase cannabis consumption in the population.

3.1.3. Perceptions of Health and Safety

Product consumption may also be promoted using health-related terminology and statements. Tobacco companies sell “light” cigarettes to imply a healthier cigarette (Gilpin, Emery, White, & Pierce, 2002; Pollay, 2000; Pollay & Dewhirst, 2002) and the food and dietary supplement industries promote largely unverified claims of health benefits (Mehta et al., 2012; Morris & Avorn, 2003; U.S. FDA, 2019). Similarly, cannabis retailers are making scientifically unsubstantiated claims about the health benefits of cannabis while simultaneously failing to display appropriate health-related warnings (Berg et al., 2018; Bierut, Krauss, Sowles, & Cavazos-Rehg, 2017; Boatwright & Sperry, 2018; Caputi, 2020; Cavazos-Rehg et al., 2019; Moreno et al., 2018). A related marketing strategy is the use of the word “natural” for promotion purposes. There is evidence of a “natural-is-better” bias, which suggests that people have a disproportionate preference for products marketed as “natural” (Meier, Dillard, & Lappas, 2019) perhaps due to the word’s conditioned associations with terms like health or safety. The belief that cannabis is safe and beneficial to one’s health simply because it is natural is common among cannabis consumers and is an integral part of cannabis culture (Coomber, Oliver, & Morris, 2003; Lau et al., 2015; Popova et al., 2017; Sandberg, 2012; Swift, Gates, & Dillon, 2005). Like the tobacco and dietary supplement industries (O’Connor, Lewis, Adkison, Bansal-Travers, & Cummings, 2017; Zakaryan & Martin, 2012), cannabis companies are currently leveraging this “natural-is-better” bias in their advertising of THC-laden products, not just CBD products (Ayers, Caputi, & Leas, 2019; Carlini, Harwick, & Garrett, 2019; Graves, 2011).

Another common marketing strategy is the promotion of purported psychological health benefits associated with product use. Over the years, tobacco companies have touted the psychological health benefits of nicotine (e.g., improved concentration, anxiety reduction, improved mood, delayed onset of neurodegenerative diseases)(Ling & Glantz, 2019), and alcohol companies have promoted drinking as a means of reducing stress or social anxiety (Jones & Donovan, 2001). Currently, THC-laden cannabis products are being promoted and advertised as a means of treating symptoms of psychological distress and mental illness (Bierut et al., 2017; Caputi, 2020; Cavazos-Rehg et al., 2019) despite the lack of controlled clinical data to support such claims (Borodovsky & Budney, 2018). Adult consumers may use legal intoxicants such as alcohol or cannabis for any reason they choose – this includes the perceived psychological benefits. However, given the current lack of evidence-based clinical efficacy or clinical guidelines (e.g., choosing appropriate products, routes of administration, and doses), permitting medical or recreational cannabis retailers to make claims about the psychologically therapeutic effects of THC-laden cannabis products remains orthogonal to standard public health-oriented regulatory practice. It is also worth noting that individuals with mental and chronic medical illnesses are highly vulnerable populations because they generate a substantial proportion of total cannabis-related revenue and are thus likely targets for marketing campaigns (Borodovsky & Budney, 2018; Budney, Sofis, & Borodovsky, 2019; Kepple, Mulholland, Freisthler, & Schaper, 2016; Lev-Ran, Le Foll, McKenzie, George, & Rehm, 2013). Thus, promoting THC-laden cannabis use as a means of psychological health – regardless of whether this occurs in the context of medical or recreational laws– is of serious concern.

3.1.4. Marketing with motives, lifestyles, and self-image

Tobacco and alcohol companies also generate product-based lifestyles, cultures, and identities to increase product consumption. This is accomplished by saturating a person’s environment with stimuli that promote contingencies between a product and various sources of reinforcement (Falk, 1996). For example, advertisements promote contingencies between product use and an enhanced experience of daily activities. Other advertisements pair a product with socially-mediated reinforcers such as peer-acceptance, status, and attractiveness – psychological mechanisms that are known to generate substance use (Strickland & Smith, 2014). The associations that are promoted frequently overlap with the multiple types of motivations discussed previously (e.g., using to celebrate or manage stress) because this allows a single product to be integrated into multiple, distinct aspects of a person’s life. Advertising may also be targeted to match the primary motivations of specific subpopulations (e.g., targeting adolescent social experimentation, identity development, and peer status-seeking) (Casswell, 2004; Cook, Wayne, Keithly, & Connolly, 2003; Hurtz, Henriksen, Wang, Feighery, & Fortmann, 2007; Ling & Glantz, 2002; McClure, Stoolmiller, Tanski, Worth, & Sargent, 2009; McCreanor, Greenaway, Moewaka Barnes, Borell, & Gregory, 2005; Sargent et al., 1997; Schooler, Basil, & Altman, 1996).

The cannabis industry appears to be adopting these strategies. By saturating communities with advertisements and products through multiple communication and distribution mechanisms (social media platforms, radio, tv, magazines, outdoor events, street signs, flyers, billboards, as well as brand-based clothing, paraphernalia, and household items), the cannabis industry actively promotes cannabis-based lifestyles, culture, and identity-formation (Ayers et al., 2019; Berg et al., 2018; Carlini et al., 2019; Cavazos-Rehg et al., 2016; Fiala et al., 2018; Olsen & Smith, 2019; Trangenstein, Whitehill, Jenkins, Jernigan, & Moreno, 2019). For example, Carlini and colleagues have demonstrated the pervasiveness of scenic, outdoor, nature-based lifestyle advertising in Washington State (e.g., images of individuals consuming cannabis near waterfalls in the forest)(Carlini et al., 2019). Cannabis companies are also capitalizing on the data illustrating the lifestyle reasons that people provide for using cannabis: exercise, relaxation, socialization, concentration, and sexual activity (Carlini et al., 2019; Green, Kavanagh, & Young, 2003; Olsen & Smith, 2019; Osborne & Fogel, 2008; YorkWilliams et al., 2019). For example, consider one cannabis company’s “Beginner’s Guide to Marijuana” which states that: “People use marijuana to heal, boost creativity, relax, inspire, socialize, energize and improve focus. It’s an affordable and natural way to maintain balance between your body’s essential functions like eating, sleeping, and healing. Using marijuana enhances, excites, and elevates your everyday routine—even already pleasurable activities like relaxing or exercising.”(Eaze ©, 2019).

One of the ways that motives, lifestyles, and self-image are leveraged for advertising is through the creation of psychological profiles of consumers. These profiles represent distinct clusters of commonly co-occurring tastes, beliefs, attitudes, psychosocial needs, and behaviors that exist in various population subgroups (Cook, Wayne, Keithly, & Connolly, 2003). They are used to increase the efficacy of advertising through more precise consumer targeting and matching. For example, the tobacco industry developed data-driven consumer personality profiles such as “Pleasure seekers,” “Unsettled dreamers,” “Social strivers,” “Masculine, Rugged, Old-Fashioned,” and “Modern, Sophisticated, High class” (Cook, Wayne, Keithly, & Connolly, 2003). Using such profiles, tobacco companies could tailor the content of their advertising and marketing for maximum congruence and appeal. These personality profiles are now emerging in the cannabis industry as a means of segmenting the cannabis market. Current examples of cannabis consumer personality profiles include “Social enjoyers,” “Wellness inquisitors,” “Versatile connoisseurs,” and “Approval seekers”(Chadha et al., 2019).

3.2. Cannabis Industry Behavior: Stalling regulation and exploiting legal loopholes

If many of the cannabis industry’s behaviors are aimed at increasing heavy cannabis consumption, and heavy cannabis consumption is considered antithetical to public health, then state government and regulatory agencies may implement various policies and regulations to curb specific cannabis industry behaviors. Documented experiences with the tobacco and alcohol industries suggest that during and after the implementation of revenue-depleting regulations, such industries engage in several predictable, reactionary, anti-regulation behaviors. Two specific types of these behaviors are: (1) stalling proposed regulations, and (2) capitalizing on loopholes in current regulations. Both behaviors are now occurring in the cannabis industry and are discussed below.

3.2.1. Stalling regulation using doubt-based rhetoric

Companies often attempt to stall the implementation of regulations by using doubt-based rhetorical devices that invalidate the evidence or rationale underlying proposed regulations. Use of this tactic has been documented in multiple industries including not only tobacco and alcohol, but also oil, coal, chemical/pesticide, food, and firearm (Bohme, Zorabedian, & Egilman, 2005; Brownell & Warner, 2009; Fabbri, Lai, Grundy, & Bero, 2018; Freudenberg, 2005; Martino, Miller, Coomber, Hancock, & Kypri, 2017; Rosenstock & Lee, 2002; Schlichting, 2013). Doubt-based rhetorical devices leverage a facade of scientific neutrality and deliberately stir scientific controversy by highlighting a lack of evidence and questioning the validity of unfavorable scientific results (Drope & Chapman, 2001; Landman, Cortese, & Glantz, 2008; Michaels & Monforton, 2005; Ong & Glantz, 2000, 2001; Rosenstock & Lee, 2002). For example, tobacco industry representatives frequently claimed that there was insufficient evidence to conclude that smoking caused cancer. In addition, these companies specifically focused on criticizing epidemiological analyses using the classic “correlation does not equal causation” argument (Francis, Shea, & Samet, 2006; Robertson & Hurt, 2010).

Actors within the cannabis industry seem to be adopting similar strategies. Consider the issue of cannabis use during pregnancy. Although this topic has received limited study, the evidence does suggest potential harm to the fetus (Metz et al., 2017; Sharapova et al., 2018) and, in light of the lack of safety data, the American College of Obstetricians and Gynecologists has warned against the use of cannabis during pregnancy as a precaution (American College of Obstetricians and Gynecologists, 2017). Yet, the Council on Responsible Cannabis Regulation has made the following statement:

“At present, there is insufficient information [emphasis added] as to the effects of cannabis use on pregnant women, fertility, or breast milk, so any warning addressing these areas is speculative at best. [emphasis added] “(Grossman, Livingston, Wellington, & Barnes, 2017).

On the topic of mental health, both the American Psychiatric Association and National Alliance on Mental Illness have advised against the use of cannabis as a treatment for mental illnesses (The National Alliance on Mental Illness, 2016; Zaman, Rosenthal, Renner, Kleber, & Milin, 2013). Yet, the National Cannabis Industry Association has communicated the following to the U.S. Food and Drug Administration:

“A small number of epidemiological [emphasis added] studies have associated long-term cannabis use with mental illness. However, these are all association studies that, by design, could not establish a causal link [emphasis added].”(National Cannabis Industry Association, 2019).

3.2.2. Creative Compliance

Corporate regulation and governance researchers have consistently noted that companies – regardless of the type of industry – often attempt to generate revenue by exploiting legal loopholes and operating in legal “gray zones.” This form of corporate behavior is called “Creative Compliance,” and is defined as “…those regulated avoid having to break the rules and do so by circumventing the scope of a rule while still breaching the spirit of the rule.”(Baldwin, Cave, & Lodge, 2012). In the cannabis industry, two notable types of creative compliance are occurring.

One type of creative compliance in the cannabis industry is the exploitation of “gifting” provisions in legal cannabis laws. Broadly speaking, a “gifting” provision protects individuals from being prosecuted if they give away their cannabis for free. These types of provisions have spawned a series of non-licensed cannabis retailers in multiple U.S. states (e.g., Massachusetts, Michigan, Washington D.C.). These retailers allow customers to purchase trivial products (e.g., stickers, baseball cards) at excessive prices, and then provide the customer with a complimentary “gift” of cannabis (Chappell & Jackman, 2018; Hager, 2018; Noble, 2019; The Associated Press, 2018).

The second form of creative compliance that is occurring is known as “looping.” Looping is informally defined here as the practice of purchasing the maximum amount of cannabis permitted by state law multiple times within a short timeframe. A recent example from Colorado helps clarify the concept. Colorado cannabis regulations previously dictated that a maximum of one ounce of cannabis could be sold to a customer during a single transaction. However, these regulations did not define what constituted a “single transaction.” Looping occurred when customers purchased the maximum amount of cannabis permitted, left the store, then returned to the same store shortly thereafter to make a “new” purchase. In theory, cannabis companies are supposed to prevent this behavior among their customers. In practice, cannabis retailers are strongly incentivized to “look the other way” because they stand to make substantial extra revenue without technically breaking the law (Kennedy, 2019).

3.3. Cannabis Industry Behavior Summary

Systems that incentivize profit maximization generate predictable industry behaviors. These behaviors include advertising to promote product consumption and preventing or shirking regulation. The cannabis industry is no exception. Recognizing this premise allows a regulatory agency to anticipate and manage such behaviors. Of note, as is likely clear from the analysis above, this review offers a decidedly public health-oriented perspective on cannabis regulation. However, it is important for readers to understand that valid arguments can be made in defense of implementing more loosely regulated for-profit models. For example, more cannabis advertising generates more sales, which generates more tax revenue that can be reinvested back into beneficial community programs.

4. The Cannabis Regulatory Agency

4.1. Communication: Public perception, consumer messaging, and social norms

Direct communication with the public (e.g., awareness or preventive messaging campaigns) is a crucial component of regulation because regulatory agencies are part of the ecosystem that shapes public attitudes and social norms (MacCoun, 1993; Toomey & Wagenaar, 1999). Informal social controls such as the norms surrounding substance use may be just as important, or even more important than formal controls like policies and regulations (Caulkins, 2017). Perhaps this is why some have noted that “…the ‘personality’ of the regulatory agency may matter more than the specific regulations.” (Caulkins & Kilmer, 2016b). However, in order to shape social norms, a regulatory agency’s messages must be effective, and in order for its messages to be effective, an agency must be perceived as credible by the public (Osman et al., 2018; Pornpitakpan, 2004; Ranney et al., 2018; Schmidt et al., 2018; Schmidt, Ranney, Pepper, & Goldstein, 2016).

When the harms and benefits of a product are not well-understood, regulatory and public-health agencies are generally more willing to risk overstating product harms and understating product benefits rather than the opposite (Henningfield, Higgins, & Villanti, 2018). This tendency seems to generate a specific type of public perception and trust. For example, in a study by Schmidt and colleagues, approximately 75% of respondents answered “yes” when asked questions such as: “Do you believe what the FDA says about the risks of tobacco products?’. Yet, interestingly, only 44% of participants responded “yes” when asked: “Do you believe that if the FDA knew that certain tobacco products are less harmful than thought, they would tell the public?”(Schmidt et al., 2018). Results like these suggest that the public may believe the harm-related information disseminated by a regulatory agency, but they may also believe that regulatory agencies are not as forthcoming about the beneficial, neutral, or harm-reducing qualities of products. Although the data presented in this example are specific to tobacco (not cannabis) and to a federal (not state) agency, there are some cannabis-specific data to suggest that credibility and persuasive messaging can be achieved by acknowledging and accurately stating both the known harms and benefits of cannabis (Crano, Donaldson, Siegel, Alvaro, & O’Brien, 2019; Holm et al., 2015; Moffat, Jenkins, & Johnson, 2013).

Communication with the public can also occur indirectly by requiring cannabis companies to include or exclude particular types of information (e.g., product warning labels). In this regard, regulators are advised to begin curtailing the use of scientifically unsubstantiated health claims in advertisements, product packages, and product labels. In place of such claims, regulators could consider requiring large, unambiguously-worded, centrally-located warnings that inform consumers specifically about (1) harms to normal cognitive development (e.g., “WARNING Regular use of this product may impair brain development in individuals under the age of 25”) and (2) risks while driving under the influence (e.g., “WARNING Chance of motor vehicle accident almost doubles while under the influence of this product”) (Goodman, Leos-Toro, & Hammond, 2019; Mutti-Packer, Collyer, & Hodgins, 2018; Orenstein & Glantz, 2018; Shi, Cao, Shang, & Pacula, 2019; Stevens et al., 2019). These two specific topics - impaired driving abilities and cognitive development - are supported by data and seem to be the most broadly convincing. Additionally, it is important not to confuse the use of warning statements with the use of “disclaimers” such as: “This statement has not been evaluated by the FDA” or “This product is not approved by the FDA to treat, cure, or prevent any disease.” which have little impact on consumer perceptions (Kesselheim, Connolly, Rogers, & Avorn, 2015; Mason, Scammon, & Fang, 2007; Shi et al., 2019). Furthermore, sparsely worded product labels may be preferable as labels that contain too much information are ignored or poorly understood by consumers (Kosa, Giombi, Rains, & Cates, 2017). Finally, it may be useful for regulators to consider developing and testing the impact and efficacy of multiple message types across subgroups of the population because there likely is not a “one-size-fits-all” message (Stevens et al., 2019).

4.2. Decrease exposure to cannabis-related advertising and marketing and monitor the content of advertisements

As cannabis legalization continues to expand, people’s day-to-day environments may become increasingly saturated with cannabis-related stimuli (e.g., advertisements) that operate on a host of psychological mechanisms. The emerging literature on the effects of exposure to cannabis advertising parallel those from investigations of alcohol and tobacco advertising: more advertising exposure is associated with greater use (D’Amico, Miles, & Tucker, 2015; D’Amico, Rodriguez, Tucker, Pedersen, & Shih, 2018; Dai, 2017; Trangenstein et al., 2019).

One of the primary roles of a cannabis regulatory agency could be to prevent the integration of cannabis-related stimuli into the public’s day-to-day environment (Bickel & DeGrandpre, 1996; Pacula et al., 2014). Importantly, the notion of “day-to-day environment” can be conceptualized in terms of both offline and online exposures. If advertising is permitted, cannabis regulators might consider carefully monitoring and randomly auditing the content of both the in-person and digital advertising that is taking place (Cavazos-Rehg et al., 2019; Cavazos-Rehg et al., 2016; Krauss et al., 2017) and impose strict penalties for non-compliance. Some of the criteria that regulators could use as the basis for assessing advertising compliance include: requiring plain, non-branded packaging (Goodman et al., 2019); prohibiting the sale of branded merchandise; and prohibiting advertisements that contain content that relate specifically to (1) craving-inducing cues and (2) the explicit pairing of specific motives and/or daily life activities with use of the product. On this last point, regulators might consider preventing any advertising that explicitly promotes the use of cannabis as a means of coping with negative emotions given this motive’s strong association between cannabis use disorder.

With regard to youth, regulators are advised to consider the fact that using a substance at a young age substantially raises the probability of continued substance use years later and the onset of a use disorder (Butterworth, Slade, & Degenhardt, 2014; Chen, O’Brien, & Anthony, 2005; Everett et al., 1999; Warner & White, 2003). This vulnerability is why tobacco companies targeted youth (Krugman et al., 2005). Contextual variables exert significant control over the probability of drug use initiation and maintenance (de Wit & Sayette, 2018; Strickland & Smith, 2014), and thus regulators are advised to mitigate youth exposure to advertisements and marketing in order to prevent or delay initiation. As part of this effort, regulators might focus specifically on advertisement content aimed at encouraging the key “early-stage” motivations that drive adolescent initiation such curiosity and experimentation, identity formation, peer norms, and social reinforcement (Ling & Glantz, 2002).

4.3. Monitor and limit the reinforcing potential of cannabis products and exposure to THC

Another crucial role of a cannabis regulatory agency will be to manage the pharmacological properties (i.e., reinforcing potential) of the cannabis products that are distributed to the population. Cannabis products with high THC content (e.g., concentrates) have greater reinforcing potential and can increase the risk of developing cannabis use disorder (Arterberry, Treloar Padovano, Foster, Zucker, & Hicks, 2019; Cinnamon Bidwell, YorkWilliams, Mueller, Bryan, & Hutchison, 2018; Freeman et al., 2018). While it is difficult at present to provide exact recommendations for THC limits, it is generally advisable that regulatory decision-making favor the distribution of products with lower THC content.

Cannabis suppliers now offer joints infused with flavors such as Cotton Candy, Blueberry, Grape, Strawberry, and Watermelon (Carlini et al., 2019). Given that the addition of flavoring chemicals enhances the reinforcing potential of nicotine-based products(Audrain-McGovern, Strasser, & Wileyto, 2016), there is a significant chance that the addition of flavors increases the reinforcing potential of cannabis products. Consequently, regulators are advised to closely monitor and/or prohibit these types of significant alterations to product constituency. Additionally, although it is unclear whether naturally occurring terpenes or other cannabinoids increase the reinforcing potential of cannabis, it most probable that, if they do, the cannabis industry will seek to develop products that include combinations of compounds with the highest reinforcing potential. This type of practice has an extensive history in the tobacco and alcohol industries (Ahijevych & Garrett, 2010; Audrain-McGovern et al., 2016; Rabinoff, Caskey, Rissling, & Park, 2007).

Finally, regulators are advised to reconsider how they conceptualize “exposure” to cannabis and the metrics they use to monitor population levels of cannabis consumption. For example, rather than using the total weight of cannabis that is sold as a measure of cannabis exposure, agencies might consider tracking the total amount of THC sold to the public. To understand why this could be useful, consider the analogy of alcohol. Should a society be more concerned if its population consumes one billion gallons of beer per year or one billion gallons of distilled spirits? It is the concentration of the primary psychoactive compounds in the product – not the weight of the product - that is of primary relevance for public health. By focusing on tracking THC distribution, regulatory agencies can calculate rough but useful estimates of the total number of hours of acute cannabis intoxication being sold to the public (Caulkins, 2017).

4.4. Increase the “costs” of cannabis products

Cannabis regulatory agencies could also seek to increase the “cost” of cannabis to reduce total consumption. The literature concerning direct taxation is clear - increasing taxes on psychoactive substances with addictive potential results in decreased use in the population (Chaloupka, Straif, Leon, & Working Group, 2011; Wagenaar, Salois, & Komro, 2009). However, the added benefit of reducing use in the population via tax increases must be balanced against the simultaneous risk of increasing the size of the illicit market (Carnevale et al., 2017; Kleiman, 2015). Recent analyses suggest that legal cannabis priced at approximately $8 to $14 per gram would have minimal impact on increasing the size of the illicit market, while a price of $20 per gram may result in a more noticeable increase (Amlung et al., 2019). To the extent that a regulatory agency is in control of how cannabis is taxed, it may use these price points as a reference for calibrating and balancing tax-related decision-making.

In addition to taxes, regulatory agencies can decrease consumption by using the broader behavioral economic-based conceptualization of cost to leverage environmental constraints that require individuals to wait longer, work harder, or pay more to obtain cannabis (Bickel & DeGrandpre, 1996). For example, a regulatory agency might prohibit industry practices such as delivery services and discounts which are designed to make cannabis easily accessible. Furthermore, agencies could decrease availability by using time- and space-based restrictions such as limiting hours of dispensary operation or by using zoning and licensing restriction policies to change the geographic density and location of dispensaries. As part of this process, state-level regulators can also work with municipalities which are often able to enact their own, stricter, regulations and policies (Dilley, Hitchcock, McGroder, Greto, & Richardson, 2017). There are numerous examples in the literature showing that increased density and proximity to retail outlets is associated with greater use of a tobacco (Cantrell et al., 2016; Novak, Reardon, Raudenbush, & Buka, 2006), alcohol (Campbell et al., 2009), and cannabis products (Borodovsky & Budney, 2017; Borodovsky, Crosier, Lee, Sargent, & Budney, 2016; Borodovsky et al., 2017; Everson, Dilley, Maher, & Mack, 2019; Paschall & Grube, 2020; Shih et al., 2019). Alarmingly, there are now more retail cannabis dispensaries than there are Starbucks ® or McDonalds ® in the State of Colorado (Rocky Mountain High Intensity Drug Trafficking Area, 2016) and a study of recreational cannabis dispensaries in California determined that close to half of the schools sampled were within 3 miles of a recreational cannabis dispensary (Cao, Carrillo, Zhu, & Shi, 2019).

4.5. Managing illicit market issues

In drug policy, there is never a single, perfect answer – there are only different choices with different consequences (Rogeberg, 2018). One of the consequences of increasing the cost of legal cannabis (e.g., tax increases or restricted availability) is a greater incentive for individuals to continue buying and selling cannabis in the illicit market. Regulatory agencies have an important role to play in offsetting these consequences.

An advantage of legal cannabis (vs. illegal) is that consumers are willing to pay more for it, and it produces asymmetric switching effects: consumers are quick to switch to legal cannabis if illegal cannabis prices increase, but are slower to switch to illegal cannabis when legal cannabis prices increase (Amlung et al., 2019). This asymmetry likely stems, in part, from consumer perceptions that legal cannabis (1) is easier to access, (2) allows one to avoid potential legal consequences associated with illicit market purchases, and (3) is a higher-quality product (Amlung et al., 2019; Vincent et al., 2017). Regulatory agencies can help maintain this asymmetry by implementing robust product tracking systems that prevent the diversion of high-quality legal products out of the supply chain and into illegal channels. Less diversion can (1) reduce the general supply of cannabis in the illicit market and hence increase illicit-market prices, and (2) provide legal distributors with more exclusive access to the high-quality cannabis products that are in demand. Ensuring this exclusive access may help offset the illicit-market expansion that stems from taxation and restricted availability.

5. Conclusion

As cannabis becomes a more prominent aspect of day-to-day life in our society, it becomes increasingly necessary to integrate our knowledge of the psychological principles that underlie cannabis consumption and distribution into legal cannabis regulations. Patterns of cannabis use emerge at the intersection of unique combinations of values of pharmacological and environmental variables. Regulatory agencies can play a central role in changing patterns of cannabis use because they are in a position to alter many of these pharmacological and environmental variables. This paper selectively reviewed relevant scientific literature and examined several aspects of legal THC-laden cannabis regulation from a psychological perspective. It offered a snapshot of some of the most pressing issues and of the knowledge that can be applied to guide regulatory action and bring order to the decision-making processes that may help mitigate potential harms from cannabis misuse.

Public Significance.

Cannabis legalization is expanding, and there is a need to develop and implement evidence-based regulations. This paper reviews principles and data gleaned from psychological science that can be used to inform legal cannabis regulation. Relevant scientific literature is discussed from the perspective of the cannabis consumer, the cannabis industry, and the cannabis regulatory agency.