An additional issue related to product regulation of marijuana edibles is the high THC potency per package without adequate requirements that these products clearly be demarcated to explicitly communicate the actual size of an individual serving to the consumer.In Colorado and Washington, product regulations allow for each package to contain up to ten 10 mg servings of THC or 100 mg of THC. Poor product labeling in Colorado and Washington contributed to an increase in calls to poison control centers and self-reports of adult intoxication.In Colorado, marijuana-related calls to the poison control center increased from 44 in 2006 to 227 in 2015,while in Washington calls increased by 79% from 111 in 2010 to 199 in 2014.Since commercialization, calls increased by 55% from 129 in 2012 to 199 in 2014.Liquor control boards in charge of approving products prior to market release allowed fruit and candy flavored marijuana products to enter the legal markets in Washington and Colorado. Despite a rule that the Washington State Liquor and Cannabis Control Board not approve any marijuana-infused edible products “especially appealing to children” such as, but not limited to, “gummy candies, lollipops, cotton candy, or brightly colored products” did not block approval of fruit flavored sodas and candy, chocolate and peanut butter flavored cookies and brownies, and chocolate truffles,including Mirth Provisions’ Legal Sparkling Rainier Cherry Soda and Nana’s Secret Soda in Orange Cream and Peach Flavors.Colorado does not have even such nominal restrictions and similar products have entered the market, including Dixie Elixir’s Crispy Cracken and Chocolate Cherry Pretzel. Marijuana edibles may be a safer alternative for adult consumers than marijuana cigarettes because they avoid combustion. However, because edibles are being produced in a wide array of flavors and variations that often are appealing to children, it is questionable whether these products contribute to less harm. Avoiding these harms could be achieved through tight regulation,plant growing stand including low limits on potency, large warning labels, accurate labeling, standardization of dosing, and standardization of packaging to avoid accidental ingestion by children and adults.

There is concern that the high potency of these products as well as their appeal to children may result in adverse health consequences.Indeed, it is likely that such youth appealing products are a major contributor to an increase in accidental childhood ingestion since legalization in Colorado402 and Washington.Prior to legalization in Colorado and Washington there were few cases involving marijuana related accidental poisonings in children. Children admitted to the emergency room for accidental marijuana ingestion increased from 0 to 14 two years following liberalization of medical marijuana laws in Colorado.Following implementation of retail marijuana laws in Colorado in 2013, an additional 14 children were admitted to the hospital for ingestion of edibles,with the first 9 occurring in the first 6 months of legalization.Washington, which modeled its product labeling and potency rules on Colorado’s,experienced a similar increase in adverse outcomes. In 2014, 45% of calls to poison control center were related to marijuana intoxication for those under age twenty – since legalization in 2012, these calls have increased from 50 in 2012 to 90 in 2014. Significantly, the highest number of calls in 2015 were regarding children under the age of five.Of the calls reported for the first nine months of 2015, 51% were in the marijuana/cannabis category, 42% were associated with infused-products, and 7% were related to marijuana oil. Youth accounted for 43% of the statewide calls during this nine-month period in 2015. National data from the United States show similar trends for accidental childhood ingestion. Between 2005-2011 there was an annual 30% increase in marijuana exposure in medical marijuana states while non-medical marijuana states showed no increase.To address the issue of accidental consumption of marijuana edibles, Colorado and Oregon enacted legislation requiring marijuana producers to place a THC warning symbol on their products . Colorado, Washington, and Oregon developed mass media campaigns aimed at preventing youth marijuana use , not general market campaigns designed to minimize overall population use as is done for tobacco. These campaigns were targeted at youth with messages on health risks of impaired memory, developmental delays, increased risk for addiction, depression, anxiety, psychosis, or other mental illnesses.

Messages related to the consequences of marijuana use include ineligibility for receiving financial aid and how marijuana-related charges may lead to school suspensions and expulsions. State health departments public awareness messages in Colorado and Washington directed to adults only cautioned adults, particularly new users, to “be safe and sensible” when using newly legal marijuana rather than discouraging use altogether. Colorado contracted with the University of Colorado to evaluate the impact of its mass media campaign on change risk perceptions and use behaviors as well as increasing knowledge of marijuana laws, health impacts of use, safe storage practices, and prevention.Adult exposure to the 2015 “Good to Know Campaign” was associated with an increased likelihood of accurately identifying retail marijuana laws compared to adults with zero exposure, with the proportion adult acute awareness increasing from 62% to 73% at follow up. There were moderate effects on knowledge of harms associated with use and perceptions of risk related to underage use , use around children , and high risk use . The survey did not question respondents whether or not the campaign impacted use behavior or thoughts on quitting, intentions to quit, or quit attempts .Taxation can both be used to raise marijuana prices artificially in order to discourage consumption,and to prevent taxpayers from subsidizing the regulatory, public education, and prevention and control program, and the marijuana education and research program and adjusted periodically for inflation. Additional tax increases could be used as a way to raise the price to reduce marijuana initiation and promote cessation. While all four US states that had legalized recreational marijuana as of October 2016 and Uruguay tax marijuana, these tax rates were not set at levels designed to cover regulatory, public health education, and medical costs associated with marijuana legalization.In Colorado,Washington,and Oregon, state legislators were directed by the ballot initiatives voters enacted to adjust the retail sales tax to make retail marijuana competitive with black market prices. Washington and Oregon ballot initiatives also include criteria for adjusting marijuana taxes to discourage use, and an additional requirement in Oregon to maximize net revenue from the marijuana tax. In Uruguay, officials of the IRRCA have determined that marijuana will be taxed at $1 per gram to compete with black market prices, despite national legislation requiring that government officials develop and fund an enforcement system and education and prevention programs.

Shortly after legal sales went into effect, state legislators in Colorado,Washington,and Oregon reduced marijuana taxes to compete with the black market. Colorado reduced the retail sales tax from 10% in 2014 to 8% in 2015, while Washington consolidated the state’s three-tier tax system to a single ad valorem excise tax of 37% at the retail sales level to reduce the marijuana industry’s federal income tax liability because consumers would pay the tax and so would technically not be considered part of the retailers’ gross income. Oregon also modified its wholesale tax in 2015 to a price-based excise tax of 17% of the retail sale, with up to an additional 3% tax levied at the local level, to increase state revenue through increased sales stimulated by lower prices.In the three states where marijuana taxes were reduced, state legislators were more concerned with short-term gains of competing with the black market and maximizing state revenue than long-term public health impact and costs associated with reduced use through higher taxes. There are no requirements for marijuana to be taxed based on a percentage of tetrahydrocannabinol content, which may in effect provide incentive for manufacturers to increase the THC content of cannabis.Indeed, US marijuana producers have been increasing product potency over the last 20 years.Between 1995 and 2014, marijuana potency increased from 5% to 12%, with a corresponding decline in cannabinol. The result was a THC/CBD ratio increase from a factor of 14 in 1995 to a factor of 80 in 2014.In jurisdictions with legal marijuana sales, edibles and cannabis concentrates, where THC concentration can be as high as 70%,plant grow table has increased in recent years. A weight-based tax, or a tax based on the unit of THC per weight or volume could be a solution to this problem. Another policy worth considering from the alcohol control literature is implementation of minimum unit pricing .Evidence from Canada show that MUP for alcohol is associated with reduced consumption and alcohol-related harms.Longitudinal estimates from British Colombia suggest that a 10% increase in MUP for a given alcohol product would result in a 16.1% drop in consumption.As is the case with most parts of the new regulatory framework for marijuana, implementation of MUP for marijuana should be considered at the same time as legalization in order to avoid potential legal battles with a professionalized marijuana industry. In 2012, Scotland was the first country to pass national legislation requiring MUP for all alcohol products.However, implementation of MUP in Scotland has been met with fierce opposition from the drinks industry, with claims of MUP as a violation of European Union trade law.The US states took varied approaches to regulating restrictions on marijuana business locations, none of which protect those most likely to regularly use marijuana In Colorado, local governments were prohibited by state law from granting a license to a business within 1,000 feet of a school defined as “public or private preschool or a public or private elementary, middle, junior high, or high school or institution of higher education”, alcohol or drug treatment facility, principal campus of college, university or seminary, or a residential child care facility.Although Washington lawmakers prohibited marijuana businesses within 1,000 feet of K-12 schools, recreational center or facility, child care center, public park, public transit center, library, or any game arcade, it allowed local governments to pass rules to reduce the distance requirement to a minimum of 100 feet from areas where children and adolescents are likely to congregate.As of September 2016, four Washington cities reduced the buffer zone for marijuana businesses to 500 feet, and one city reduced its buffer zone to 100 feet for parks, recreational/community centers, libraries, childcare centers, game arcades, and public transit centers.Oregon lawmakers did not prohibit retail store locations within 1,000 feet of colleges or universities despite the fact that many college students are under 21. Retail stores in Alaska were prohibited under the legalization initiative within 500 feet of child-sensitive areas, defined as facilities that provide services for persons under 21, a building in which religious services are regularly conducted, or a correctional facility. Colleges and universities are not explicitly included. Retail outlet density is positively associated with youth and young adult smoking,heavy alcohol consumption,and marijuana use.Despite the fact that use is higher in areas where there are more retail outlets, marijuana regulatory regimes in the four US states have failed to implement licensing systems to control retail density in ways that would protect vulnerable populations . Similar to tobacco and alcohol outlets marijuana businesses appear to be concentrated in low-income, minority communities. By 2016, Colorado marijuana businesses were more likely to be located in census tracts with higher proportions of racial/ethnic minorities , lower proportion of young people, lower median household incomes , higher crime rates, and higher concentrations of alcohol outlets .Similar findings were observed in California neighborhoods with medical marijuana dispensaries.Research on US state implementation of retail marijuana laws has focused on potential impacts of these laws on risk perceptions,use,health harms and stakeholder participation in the regulatory process.There is only a limited literature on the impact of marijuana policies on use and associated harms from the experiences in the Netherlands,Uruguay,and the United States.However, variability in US state medical marijuana laws makes it difficult to make strong generalizations, which likely explains why there is no scientific consensus on how legalization will impact risk perceptions or use patterns.There is limited evidence on the complexities of how a policy is implemented and when it is implemented having a dramatic effect on health-related outcomes. It is important to consider perceptions of risk when assessing the public health impacts of marijuana legalization laws.