Although the state required only a limited health warning in hard-to-read 6-point font on packages, whose text was defined in the ballot initiative, jurisdictions required additional health warnings in stores and 4 jurisdictions required additional health warnings on packages. No jurisdiction required warnings on advertising. Although the state prohibited only misleading or unsubstantiated health claims, 1 county, Mono, prohibited all health-related claims on marijuana labels, any advertising or marketing, and in retailer names.Seventy-four jurisdictions limited advertising in some way, primarily through limited business signage. Fourteen jurisdictions prohibited billboards and other outdoor advertising. Five jurisdictions limited advertising on television, on the radio, online, or in print, and 5 jurisdictions prohibited advertisements attractive to youths more explicitly than the state’s prohibition. The state did not require warnings on advertisements and used regulation to weaken Proposition 64’s prohibition on billboards on state and interstate highways that cross state borders, limiting its application to roads within 15 miles of the state border.State law does require that advertisements be 1000 feet from schools, daycare centers, playgrounds, or youth centers, and that advertising and marketing not be designed to appeal to underage consumers.Twenty-seven jurisdictions allowed on-site consumption of marijuana in some form at retail locations, all of which allowed either smoking , vaping , or both on the premises, 3 of which allow use by staff only. Thirteen jurisdictions explicitly established a permit system for marijuana-related temporary events,farming shelving while 21 jurisdictions banned them and most jurisdictions were silent. The state allows both on-site consumption and marijuana-related temporary events if locally permitted. Although California laws prohibit smoking marijuana in most workplaces or in any place where smoking cigarettes is prohibited by law, these local exceptions are now in effect.

Of jurisdictions legalizing any commercial marijuana activity , 154 did not tax marijuana activity locally; 119 passed a “general” tax, which in California is a tax that the governing authority can use for any purpose;passed a general tax with an advisory committee guiding revenue use; 3 passed a tax that earmarked revenue, dedicated in different cases to police and law enforcement, fire services, parks and recreation, repairing city streets, or enhancing community centers; and 6 passed “fees.” Cathedral City taxed the highest-potency marijuana concentrates, such as “shatter” , at 8 times the price of lower-potency products. Little local revenue was captured for prevention or reinvestment in low-income communities. Only 5 jurisdictions prohibited discounting, such as redemption of coupons, discount days, or other promotions, and none implemented a minimum price law, all of which are price policies that have been used in tobacco control. The state levied a 15% excise tax on retail sales in addition to a cultivation tax, much of which is slated for investment in prevention of substance use by youths and in communities but did not constrain discounting other than prohibiting distribution of free products, nor did it create a floor price.Fifty-three jurisdictions added some form of prescriber conflict of interest rule, such as no marijuana prescribers may work as staff or be owners or employees in retail outlets. The state prohibited those involved in marijuana regulation, enforcement, or appeals from holding marijuana licenses or financial interest, and persons licensed for testing laboratories may not hold other marijuana licenses. Neither state nor local government prohibited those with marijuana financial interests from participation in advisory bodies, and such participation is occurring.Our review reveals important gaps in the regulatory scheme for marijuana in California cities and counties. Many fundamental lessons from tobacco control to reduce demand, limit harm, and prevent marijuana use by youths have gone largely ignored, leaving state law setting the standard. Nevertheless, in communities that have opted to legalize marijuana, examples are emerging of local policy innovation for reducing demand and protecting youths. Limits on retail outlets are the most common. The first prohibition on flavored products was passed in 2018, as was the first ban on vaped marijuana later in 2019.

However, limitations of high-potency or flavored marijuana product types, industry practices associated with risk of addiction and psychosis, and risk of youth initiation have received little local attention. Most state residents are exposed to aggressive marketing practices such as prominent billboards promoting marijuana use. They are not informed by clear and salient health warnings such as those used on marijuana products in Canada or tobacco products in the United States. Local onsite consumption permits have been associated with smoke-filled lounges and outdoor marijuana events, such as legal sales at concerts, fairs, or park events, which may threaten decades of progress in smoke-free workplaces and outdoor air. State laws and regulations neglected to limit retail outlets. State, like local, provisions on marketing and advertising are relatively weak, even when taking into account protections on commercial speech. The state does tax and invests some tax revenue in prevention of substance use and other community-based investments. State law and regulation does not restrict manufacturing or sale of flavored products—a well-recognized industry strategy to attract youths—despite promoting a large-scale “Flavors Hook Kids” campaign for tobacco products in the same time period.It allowed products of any potency, even those with more than 90% THC, as well as marijuana-infused sodas mimicking “alcopops” and a wide range of edible marijuana products. The entire legal marijuana market is being permitted by state and local regulators to shift to high-potency flower and concentrates in California and elsewhere.Similar manipulation of nicotine content to increase addiction was a tobacco industry strategy condemned in the landmark 2006 decision US v Philip Morris. This strategy has permitted, for example, even products such as a grape-flavored vaping cartridge in a hot pink memory stick–like device, with the equivalent of 78 unmetered “standard” 5-mg THC doses37 in 1/50th of 1 ounce to be sold legally. These, like flavored electronic cigarettes, may increase the risk of addiction in youths. Many California communities reacted to legalization of marijuana by delaying or rejecting local commercial activity. The state then partially overrode voter-approved Proposition 64 guarantees of local control, promulgating regulation allowing any delivery licensee to deliver marijuana products anywhere in the state.This measure was challenged by local government and continues in the courts. These conflicts may reflect disparate visions for legalization: one prioritizing industry growth, revenue, and elimination of illicit sales; a second rejecting legalization or wishing it to occur elsewhere; and a third allowing legal commerce but prioritizing public health and demand reduction.This study has certain strengths, including the near-complete coverage of California jurisdictions,hemp drying racks as well as providing the first snapshot of California local law. Findings are also consistent with recent work on local policy in Washington state.Nevertheless, limitations should also be noted. This study describes local regulations 1 year after adult-use sales of marijuana began.

Regulation continues to evolve, and we will assess change annually. Second, we examined only local marijuana laws. Other local laws addressing issues such as zoning, advertising, or smoke-free air may include relevant provisions such as global bans on billboards that were not captured. Frameworks for legalization and local control vary widely between states, and these findings cannot be generalized. However, the concerns identified and potential best practices may be broadly relevant for national, state, and local marijuana regulation, even where local authority for adoption is absent. Importantly, the fundamental questions of whether legalization leads to net public health benefit or harm and whether these “best practices” work remain unanswered. These early descriptive data provide a valuable basis for future research on health and social outcomes in association with variations in the rigor or laxity of local policy after state legalization.The effect of marijuana use on lung health has not been extensively studied, with most data coming from cross sectional and several longitudinal studies. While a significant association of marijuana smoking with symptoms of chronic bronchitis has been reported in most studies, associations with changes in lung function or other aspects of lung health over time, especially in those at risk of or with diagnosed chronic obstructive pulmonary disease , has been less studied. One found a small forced expiratory volume in 1 second decrement over a 20-year period in the relatively small number of heavy marijuana smokers, i.e., ≥20 joint-years 13 and one found a decrement in FEV1 only in former but not current marijuana smokers.Analyzing a subgroup derived from the Canadian Cohort Obstructive Lung Disease study,Tan et al found that marijuana smoking was associated with worse FEV1 decline over a median of 5.9 years in comparison with tobacco-only smokers.While the latter finding mostly related to individuals with a heavy marijuana smoking history , the design of this study might have influenced the results. In a cross-sectional analysis of participants with COPD in the Sub-Populations and Intermediate Outcome Measures In COPD Study with a tobacco smoking history of ≥20 pack years, Morris et al10 reported higher values for FEV1 percentage predicted and a lower percentage of emphysema on HRCT images in both former marijuana smokers and current marijuana smokers , compared with never marijuana smokers who smoked tobacco only, after adjustments for relevant variables. In a preliminary analysis focused on lung function change, we recently showed that ever marijuana smoking among SPIROMICS participants with ≥3 spirometry visits did not have a deleterious impact on FEV1 decline over time nor on the risk for developing spirometry-defined COPD in tobacco smokers without COPD at baseline.However, in order to examine the impact of marijuana smoking on the progression of respiratory symptoms, health status, HRCT metrics, or frequency of exacerbations in addition to the change in lung function, we analyzed a larger subgroup of SPIROMICS participants with ≥2 spirometry visits and an ever marijuana-smoking history as well as a heavy marijuana-smoking history compared to those with ≥3 spirometry visits as previously reported.We aimed to determine whether SPIROMICS FMSs and CMSs exhibit higher rates of change in respiratory symptoms, HRCT metrics, and lung function over time compared to NMSs and whether the reported cumulative lifetime exposure to marijuana would affect these changes. In addition, we evaluated whether self-reported marijuana smoking among SPIROMICS participants without spirometric evidence of COPD at baseline would affect the subsequent development of COPD.SPIROMICS is a prospective cohort study aiming to identify new COPD subgroups and intermediate markers of disease progression.Participants were followed annually over 3 years in SPIROMICS I and had an additional in-person visit in SPIROMICS II. Enrolled participants were 40–80 years old and had either normal spirometry and no tobacco-smoking history or had ≥20 pack years of tobacco smoking; the latter subgroup was further divided based on a post-bronchodilator FEV1 to forced vital capacity ratio ≥0.70 or <0.70. Current asthma was an exclusionary criterion. SPIROMICS was approved by the institutional review boards of each individual site prior to the enrollment of participants. All participants provided informed consent. For the present analysis, data were obtained from ever tobacco-smoking SPIROMICS participants who had spirometry at the baseline visit and at least one followup visit, reported marijuana use or nonuse at the baseline visit, and had no missing covariate information . These participants were divided into the following 3 groups based on their self-reported history of marijuana use: NMSs , FMSs, i.e., no marijuana smoking within the last 30 days , or CMSs, i.e., marijuana smoking within the last 30 days . Based on their baseline frequency and duration of marijuana use, participants were further categorized by their cumulative lifetime history of marijuana smoking defined in terms of joint years, calculated as the number of joints smoked per day times the number of years that marijuana was regularly smoked. Recognizing that marijuana is smoked using a variety of devices, we equated a bowlful of marijuana smoked via a pipe or a bong to one joint. Participants were not asked at the baseline visit about alternative modalities of inhaled marijuana such as vaping, hookah, and “dabbing.” Patients were also categorized into 4 joint-year groups as follows: 0 ; >0–<10 ; 10–<20 ; and ≥20 joint years. Longitudinal data over a period of at least 52 weeks were compared between the 3 groups defined by marijuana smoking status as well as between the 4 subgroups defined by the number of joint years.