Criminal Justice and Sexually Predators

POLICYFORUM

A Public Health Framework for Legalized Retail Marijuana Based on the US Experience: Avoiding a New Tobacco Industry Rachel Ann Barry1, Stanton Glantz1,2*

1 Center for Tobacco ControlResearchand Educationand PhilipR. Lee Institutefor HealthPolicy Studies, Universityof California,San Francisco, San Francisco, California, UnitedStatesof America,2 Department of Medicine, Universityof California, San Francisco, San Francisco, California,UnitedStatesof America

* [email protected]

SummaryPoints

• The US states that have legalized retail marijuana are using US alcohol policies as a model for regulating retail marijuana, which prioritizes business interests over public health.

• The history of major multinational corporations using aggressive marketing strategies to increase and sustain tobacco and alcohol use illustrates the risks of corporate domina- tion of a legalized marijuana market.

• To protect public health, marijuana should be treated like tobacco, not as the US treats alcohol: legal but subject to a robust demand reduction program modeled on successful evidence-based tobacco control programs.

• Because marijuana is illegal in most places, jurisdictions worldwide (including other US states) considering legalization can learn from the US experience to shape regulations that prioritize public health over profits.

Introduction While illegal in the United States, marijuana use has been increasing since 2007 [1]. In response to political campaigns to legalize retail sales, by 2016 four US states (Colorado, Washington, Alaska, and Oregon) had enacted citizen initiatives to implement regulatory frameworks for marijuana, modeled on US alcohol policies [2], where state agencies issue licenses to and regu- late private marijuana businesses [2,3,4]. Arguments for legalization have stressed the negative impact marijuana criminalization has had on social justice, public safety, and the economy [5]. Uruguay, an international leader in tobacco control [6], became the first country to legalize the sale of marijuana in 2014, and, as of July 2016, was implementing a state monopoly for mari- juana production and distribution [7]. None of the US laws [2], or pending proposals in other states [8], prioritize public health. Because marijuana is illegal in most places, jurisdictions worldwide (including other US states) considering legalization can learn from the US experi- ence to shape regulations that favor public health over profits.

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Citation: Barry RA, Glantz S (2016) A Public Health Framework for Legalized Retail Marijuana Based on the US Experience:Avoiding a New Tobacco Industry. PLoS Med 13(9): e1002131.doi:10.1371/ journal.pmed.1002131

Published: September 27, 2016

Copyright: © 2016 Barry, Glantz. This is an open access article distributedunder the terms of the Creative Commons AttributionLicense, which permits unrestricteduse, distribution,and reproduction in any medium, provided the original author and source are credited.

Funding: This work was supportedin part by National Cancer Institutegrant CA-061021and UCSF funds from SG’s Truth InitiativeDistinguished Professorship. The funders had no role in study design, data collectionand analysis, decision to publish, or preparationof the manuscript.

Competing Interests: The authors have declared that no competinginterests exist.

Provenance:Not commissioned; externally peer- reviewed

In contrast, while legal, US tobacco use has been declining [1]. To protect public health, marijuana should be treated like tobacco, legal but subject to a robust demand reduction pro- gram modeled on evidence-based tobacco control programs [9] before a large industry (akin to tobacco [10]) develops and takes control of the market and regulatory environment [11].

Likely Effect of MarijuanaCommercializationon Public Health While the harms of marijuana do not currently approach those of tobacco [12], the extent to which legal restrictions on marijuana may have functioned to limit these harms is unknown. Currently, regular heavy marijuana use is uncommon, and few users become lifetime mari- juana smokers [13]. However, marijuana use is not without risk. The risk for developing mari- juana dependence (25%) is lower than for nicotine addiction (67%) and higher than for alcohol dependence (16%) [14], but is still substantial, with rising numbers of marijuana users in high- income countries seeking treatment [15]. Reversing the historic pattern, in some places, mari- juana has become a gateway to tobacco and nicotine addiction [15].

This situation will likely change as legal barriers that have kept major corporations out of the market [10] are removed. Unlike small-scale growers and marijuana retailers, large corpo- rations seek profits through consolidation, market expansion, product engineering, interna- tional branding, and promotion of heavy use to maximize sales, and use lobbying, campaign contributions, and public relations to create a favorable regulatory environment [2,11,16,17,18,19]. By 2016, US marijuana companies had developed highly potent products [15] and were advertising via the Internet [11] and developing marketing strategies to rebrand marijuana for a more sophisticated audience [20]. Without effective controls in place, it is likely that a large marijuana industry, akin to tobacco and alcohol, will quickly emerge and work to manipulate regulatory frameworks and use aggressive marketing strategies to increase and sus- tain marijuana use [10,11] with a corresponding increase in social and health costs.

Public perception of the low risk of marijuana [21] is discordant with available evidence. Marijuana smoke has a similar toxicity profile as tobacco smoke [22] and, regardless of whether marijuana is more or less dangerous than tobacco, it is not harmless [2]. The California Envi- ronmental Protection Agency has identified marijuana smoke as a cause of cancer [23], and marijuana smokers are at increased risk of respiratory disease [24,25]. Epidemiological studies in Europe have found associations between smoking marijuana and increased risk of cardiovas- cular disease, heart attack, and stroke in young adults [15,26]. One minute of exposure to mari- juana smoke significantly impairs vascular function in a rat model [27]. In humans, impaired vascular function is associated with adverse cardiovascular outcomes including atherosclerosis and myocardial infarction [27,28,29].

Acute risks associated with highly potent marijuana products (i.e., cannabinoid concen- trates, edibles) include anxiety, panic attacks, and hallucinations [15]. Other health risks associ- ated with use include long-lasting detrimental changes in cognitive function [13,15], poor educational outcomes, accidental childhood ingestion and adult intoxication [26], and auto fatalities [30,31].

US AlcoholPolicy Is Not a GoodModel for RegulatingMarijuana The fact that US marijuana legalization is modeled on US alcohol policies is not reassuring. In 2014, 61% of US college students (age 18–25) reported using alcohol in the past 30 days, com- pared to 19% for marijuana and 13% for tobacco [32]. Binge drinking is a serious problem, with 41% of young Americans reporting heavy episodic drinking in the past year [33].

Aggressive alcohol marketing likely contributes to this pattern [34]. Even though the alcohol industry’s voluntary rules prohibit advertising on broadcast, cable, radio, print, and digital

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communications if more than 30% of the audience is under age 21, this standard permits them to advertise in media outlets with substantial youth audiences [35], including Sports Illustrated and Rolling Stone, resulting in American youth (ages 12–20) being exposed to 45% more beer and 27% more spirits advertisements than legal drinking-aged adults [36]. If such alcohol mar- keting regulations were applied universally to marijuana, consumption would likely be higher, not lower, than it is now [26].

Using a Public HealthFramework fromEvidence-BasedTobacco Control to RegulateRetailMarijuana Table 1 compares the situation in the four US states that have legalized retail marijuana to a public health standard based on successes and failures in tobacco and alcohol control. A public health framework for marijuana legalization would designate the health department as the lead agency with, like tobacco, a mandate to protect the public by minimizing all (not just youth) use. The health department would implement policies to protect nonusers, prevent initiation, and encourage users to quit, as well as regulate the manufacturing, marketing, and distribution of marijuana products, with other agencies (such as tax authorities) playing supporting roles.

Because public health regulations are often in direct conflict with the interests of profit- driven corporations [19], it is important to protect the policy process from industry influence. In contrast to what states that have legalized retail marijuana have done to date, a public health framework would require that expert advisory committees involved in regulatory oversight and public education policymaking processes consist solely of public health officials and experts and limit the marijuana industry’s role in decision-making to participation as a member of the “public.” Including the tobacco industry on advisory committees when developing tobacco reg- ulations blocks, delays, and weakens public health policies [37]. The World Health Organiza- tion Framework Convention on Tobacco Control, a global public health treaty ratified by 180 parties as of April 2016, recognizes the need to protect the policymaking process from industry interference:

“[Governments] should not allow any person employed by the tobacco industry or any entity working to further its interests to be a member of any government body, committee or advisory group that sets or implements tobacco control or public health policy.” [37, Article 5.3]

A marijuana regulatory framework that prioritizes public health would have similar provisions.

A public health framework would avoid regulatory complexity that favors corporations with financial resources to hire lawyers and lobbyists to create and manipulate weak or unenforce- able policies [11]. To simplify regulatory efforts, including licensing enforcement, implementa- tion of underage access laws, prevention and education programs, and taxation, a public health framework would create a unitary market, in which all legal sales, regardless of whether use is intended for recreational or medical purposes, follow the same rules [38]. Unlike Colorado, Oregon, and Alaska, in 2015, Washington State accomplished this public health goal when it merged its retail and medical markets [39].

Earmarked funds to support comprehensive prevention and control programs over time, which are not included in the four US states’ regulatory regimes, will be critical to reduce mari- juana prevalence, marijuana-related diseases, and costs arising from marijuana use. A public health framework would set taxes high enough to discourage use and cover the full cost of legalization, including a broad-based marijuana prevention and control program. Using a

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public health approach, the prevention program would implement social norm change strat- egies, modeled on evidence-based tobacco control programs, aimed at the population as a

Table 1. Public health framework versus state marijuanaregulations.

PublicHealthStandard Colorado Washington Alaska Oregon

Lead Agency

Department of Health ✓ X X X X

Advisory Committees

Membership solely of public healthexperts ✓ ✓ -- X ✓

No decision-makingauthorityfor marijuanaindustryor vested interests ✓ X -- X X

Regulatory Complexity

Createsa single systemof retailmarijuana ✓ X ✓ X X

Tax Revenue

Tax covers full costs ✓ X X -- X

Dedicatedrevenue to marijuana prevention, control,and research ✓ X ✓ -- X

Prevention and Control Programs

Mediacampaign Aimedat generalpopulation(not just youth) ✓ X X -- X

Modeledon social normchange ✓ X X -- X

Smokefree Laws

Prohibitany public use of marijuana ✓ ✓ ✓ ✓ ✓

Prohibitmarijuanause wherever tobaccosmoking is prohibited ✓ ✓ ✓ X ✓

Protect local control ✓ ✓ ✓ ✓ ✓

Prohibit indooruse in marijuana retailstoresor marijuanaclubs ✓ X ✓ X ✓

Marketing and Advertising

Prohibit free or discountedsamples ✓ X ✓ ✓ ✓

Prohibitcartooncharacters ✓ ✓ ✓ ✓ ✓

Prohibitsportand culturalevent sponsorship ✓ X X X X

Prohibitproductplacement in popularmediaand cobrandedmerchandise ✓ X X X X

Prohibit therapeuticclaims ✓ ✓ ✓ ✓ ✓

Prohibitoutdooradvertising on billboards ✓ ✓ X X X

Prohibitadvertisingon television and radio ✓ X ✓ X X

Restrictadvertisingin printand digitalcommunications with 15% threshold ✓ X X X X

LicensingRules

Imposeseriouspenaltieson retailers’underagesales ✓ ✓ ✓ -- ✓

Prohibitsale of tobaccoor alcohol in marijuana retailstores ✓ ✓ ✓ ✓ ✓

Prohibit tobaccoand alcohol retailersfromholdingmarijuanalicense ✓ X X X X

Retail Sales

Requireretaileruse age verification system(ID scanners)at point of sale ✓ X X X X

Prohibit retailerswithin1,000feet of underage-sensitive areas ✓ X ✓ X X

Prohibitelectroniccommerce(internet,mail order, text messaging, social media) ✓ ✓ ✓ ✓ ✓

Product Standards

Requirestrongpotency limitsand productquality testing ✓ X X X ✓

Prohibitproductscontaining additives (nicotine,alcohol,caffeine, or toxic chemicals)

✓ ✓ X ✓ ✓

Prohibitsflavored productsappealingto underagepersons ✓ X ✓ X X

Warning Labels

Requirewarninglabels modeledon stateof the art tobacco labels ✓ X X X X

Key: ✓ Requiredby law or regulation; X Not requiredby law or regulation;--Pending legislative approval or rulemakingprocess

doi:10.1371/journal.pmed.1002131.t001

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whole—not just users or youth [9]. Demand reduction strategies applied to marijuana would include: 1) countering pro-marijuana business influence in the community; 2) reducing exposure to secondhand marijuana smoke and aerosol and other marijuana products (including protecting workers vulnerable to these exposures); 3) controlling availability of marijuana and marijuana products; and 4) promoting services to help marijuana users quit.

A public health framework would protect the public from secondhand smoke exposure by including marijuana in existing national and local smokefree laws for tobacco products, includ- ing e-cigarettes. Local governments would have authority to adopt stronger regulations than the state or nation. There would be no exemptions for indoor use in hospitality venues, mari- juana retail stores, or lounges, including for “vaped” marijuana.

To protect the public from industry strategies to increase and sustain marijuana use, a pub- lic health framework would prohibit or severely restrict (within constitutional limitations) marketing and advertising, including prohibitions on free or discounted samples, the use of cartoon characters, event sponsorship, product placement in popular media, cobranded mer- chandise, and therapeutic claims (unless approved by the government agency that regulates such claims). Marketing would be prohibited on television, radio, billboards, and public transit and restricted in print and digital communications (e.g., internet and social media) with the percentage of youth between ages 12 and 20 as the maximum underage audience composition for permitted advertising (roughly 15% in the US) [35]. These advertising restrictions are justi- fied and would likely pass US Constitutional muster because they are implemented for impor- tant public health purposes, are evidence-based [35], and have worked to promote similar goals in other contexts. Legal sellers of the newly legal marijuana products would be permitted to communicate relevant product information to their legal adult customers.

A scenario in which a public health regulatory framework is applied to marijuana would require licensees to pay for strong licensing provisions for retailers, with active enforcement and license revocation for underage sales. As has been done in the four US states (Table 1), out- lets would be limited to the sale of marijuana only to avoid the proliferation and normalization of sales in convenience stores or “big box” retailers. No retailer that sold tobacco or alcohol would be granted a license to sell marijuana products. Based on best public health practices for tobacco retailers [40], marijuana retail stores would be prohibited within 1,000 feet of under- age-sensitive areas including postsecondary schools, with limits on new licenses in areas that already have a significant number of retail outlets. Electronic commerce, including internet, mail order, text messaging, and social media sales, would be prohibited because these forms of nontraditional sales are difficult to regulate, age-verification is practically impossible [41], and they can easily avoid taxation [42].

Central to a public health framework would be assigning the health department with the authority to enact strong potency limits, dosage, serving size, and product quality testing for marijuana and marijuana products (e.g., edibles, tinctures, oils), with a clear mission to protect public health. Additives that could increase potency, toxicity, or addictive potential, or that would create unsafe combinations with other psychoactive substances, including nicotine and alcohol, would be illegal. Unlike US restrictions on marijuana products, flavors (that largely appeal to children), would be prohibited.

A public health model applied to marijuana would include health warning labels that follow state-of-the-art tobacco requirements implemented in several countries outside of the United States, including Uruguay, Brazil, Canada, and Australia [43]. Public health-oriented labels would: 1) be large, (at least 50% of packaging) on front and back and not limited to the sides, prominently featured, and contain dissuasive imagery in addition to text; 2) be clear and direct and communicate accurate information to the user regarding health risks associated with mari- juana use and secondhand exposure; and 3) use language appropriate for low-literacy adults.

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Health messages would include risk of dependence [2], cardiovascular [2,44,45], respiratory [25], and neurological disease [46], and cancer [23], and would warn against driving a vehicle or operating equipment, as well as the risks of co-use with tobacco or alcohol.

While there is already adequate scientific evidence to raise concern about a wide range of adverse health effects, there is more to learn. Earmarked funds from marijuana taxes would also provide an ongoing revenue stream for research that would guide marijuana prevention and control efforts and mitigate the human and economic costs of marijuana use, as well as better define medical uses as the basis for proper regulation of marijuana for therapeutic purposes.

Avoiding a Private Market Privatizing tobacco and alcohol sales leads to intensified marketing efforts, lower prices, more effective distribution, and an industry that will aggressively oppose any public health effort to control use [47,48]. Avoiding a privatized marijuana market and the associated pressures to increase consumption in order to maximize profits would likely lead to lower consumer demand, consumption, and prevalence, even among youth, and would reduce the associated public health harm [49].

Governments may avoid marijuana commercialization by implementing a state monopoly over its production and distribution, similar to Uruguay’s regulatory structure for marijuana [3,50] and to the Nordic countries’ alcohol control systems [51], which are designed to protect public health over maximizing government revenue. The state would have more control over access, price, and product characteristics (including youth-appealing products or packaging, potency, and additives) and would refrain from marketing that promotes increased use [3,52]. In cases where national laws cause concern about local authority’s ability to adopt government monopolies, a public health authority could be used as an alternative [53].

It is important to avoid intrinsic conflicts of interest created by state ownership. As is the case with state-ownership of tobacco, without specific policies to prioritize public health, a state’s desire to increase revenue often supersedes public health goals to minimize use [51,52]. Beyond mitigating potential conflicts of interest inherent in state monopolies, a public health framework for marijuana would instruct the government agency that manages the monopoly to minimize individual consumption in order to maximize public health at the population level. (Similar public health goals are explicit in Nordic alcohol monopolies [51].)

While a state monopoly is an effective approach to protect public health [51,54], in practice, however, even the strongest government monopolies for alcohol (i.e., Nordic Countries) have been eroded over time by multinational companies that argue such controls are illegal protec- tionism under international and regional trade agreements [4,51]. While trade agreements have been used to threaten tobacco control and other public health policies [55], clearly identi- fying protection of public health as the goal of the state monopoly would make it more difficult to challenge these controls, especially if sales revenues were used to help fund evidence-based demand reduction policies [49] (Table 1).

Conclusion It is important that jurisdictions worldwide learn from the US experience and implement, con- currently with full legalization, a public health framework for marijuana that minimizes con- sumption to maximize public health (Table 1). A key goal of the public health framework would be to make it harder for a new, wealthy, and powerful marijuana industry to manipulate the policy environment and thwart public health efforts to minimize use and associated health problems.

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Acknowledgments This paper is based on an invited presentation at the Marijuana and Cannabinoids: A Neuro- science Research Summit held at the National Institutes of Health on March 22–23, 2016.

Author Contributions

Conceptualization:RAB SG.

Datacuration: SG.

Fundingacquisition: SG.

Investigation: RAB.

Methodology:RAB SG.

Projectadministration:SG.

Resources:SG.

Supervision:SG.

Visualization: RAB SG.

Writing –originaldraft:RAB.

Writing –review&editing: RAB SG.

References 1. Substance Abuse and MentalHealthServicesAdministration(2014)Results fromthe2013National

Survey on DrugUse and Health:Summaryof NationalFindings. Rockville, MD: Substance Abuse and MentalHealthServicesAdministration.

2. Hall W, Weier M (2015)Assessingthe Public Health Impactsof LegalizingRecreational Cannabis Use in theUSA. ClinicalPharmacology& Therapeutics 97:607–615.

3. RoomR (2014)Legalizinga Market for Cannabis for Pleasure:Colorado, Washington, Uruguayand Beyond. Addiction 109:345–351. doi: 10.1111/add.12355PMID:24180513

4. BaborT, Caetano R, Casswell S, EdwardsG,GiesbrechtN, Graham K (2010)Alcohol: No Ordinary Commodity: Researchand Public Policy ( 2nd Ed.). Oxford: Oxford UniversityPress.

5. Weitzer R (2014)LegalizingRecreational Marijuana: ComparingBallotOutcomesin Four States.J QualCrimJustice Criminol 2.

6. World HealthOrganization(2014)GlobalProgressReporton Implementationof the WHOFramework Convention on Tobacco Control.

7. Watts J (2013)Uruguay'sLikely CannabisLaw CouldSet Tone for War on Drugsin LatinAmerica. The Guardian.

8. ArcView MarketResearch,New Frontier (2016)The Stateof LegalMarijuana Markets4th Edition.

9. Shibuya K, Ciecierski C, GuindonE, BettcherDW, Evans DB, Murray CJ, et al. (2003)WHOFrame- workConvention on Tobacco Control:Development of an EvidenceBasedGlobalPublic HealthTreaty. BMJ 327:154–157.PMID:12869461

10. BarryRA, HiilamoH, GlantzSA (2014)Waiting for theOpportune Moment: TheTobacco Industryand MarijuanaLegalization.MilbankQuarterly 92:207–242.doi:10.1111/1468-0009.12055 PMID: 24890245

11. RichterKP, Levy S (2014)Big Marijuana—LessonsfromBig Tobacco. New EnglandJournalof Medi- cine 371:399–401. doi:10.1056/NEJMp1406074 PMID:24918955

12. ImtiazS, ShieldKD, Roerecke M,ChengJ, Popova S, Kurdyak P, et al. (2016)TheBurdenof Disease Attributableto CannabisUse in Canada in 2012.Addiction 111:653–662. doi:10.1111/add.13237 PMID:26598973

13. Auer R, Vittinghoff E, Yaffe K, Kunzi A, KerteszSG,Levine DA, et al. (2016)Association betweenLife- timeMarijuana Use and Cognitive Functionin MiddleAge:The Coronary ArteryRisk Development in

PLOS Medicine | DOI:10.1371/journal.pmed.1002131 September27,2016 7 / 9

Young Adults (Cardia)Study. JAMA InternMed 176:352–361.doi:10.1001/jamainternmed.2015. 7841PMID:26831916

14. CougleJR, Hakes JK, MacateeRJ, Zvolensky MJ, ChavarriaJ (2016)Probability and Correlates of Dependence amongRegularUsersof Alcohol,Nicotine,Cannabis,and Cocaine:Concurrent and Pro- spective Analysesof the NationalEpidemiologic Survey on Alcoholand RelatedConditions.J ClinPsy- chiatry 77:e444–450. doi: 10.4088/JCP.14m09469 PMID:27137428

15. World HealthOrganization.TheHealthand SocialEffects of Nonmedical CannabisUse. http://www. who.int/substance_abuse/publications/cannabis_report/en/. Accessed 16 Aug 2016

16. JerniganDH (2009)TheGlobalAlcohol Industry:An Overview. Addiction 104:6–12.doi:10.1111/j. 1360-0443.2008.02430.x PMID:19133910

17. Cook PJ (2007)Paying theTab: The Economics of AlcoholPolicy. Princeton: Princeton University Press. xiii,262 p. p.

18. HastingsG (2012)Why Corporate Power Is a Public HealthPriority. BMJ 345:e5124.doi:10.1136/ bmj.e5124PMID:22915664

19. Freudenberg N (2012)TheManufacture of Lifestyle:The Roleof Corporations in Unhealthy Living. Journalof Public HealthPolicy 33:244–256.doi:10.1057/jphp.2011.60PMID:22258282

20. KrupnikM (2016)HighTimesand AgencyUnite to Sell Marijuanato Mainstream. New York Times. New York.

21. BergCJ, StrattonE, Schauer GL,Lewis M,Wang Y, WindleM,et al. (2015)Perceived Harm,Addictive- ness, and SocialAcceptabilityof Tobacco Productsand MarijuanaamongYoung Adults:Marijuana, Hookah,and ElectronicCigarettes Win.SubstUse Misuse 50: 79–89.doi:10.3109/10826084.2014. 958857PMID:25268294

22. MoirD, RickertWS, Levasseur G, LaroseY, MaertensR, WhiteP, et al. (2008)A Comparisonof Main- streamand SidestreamMarijuana and Tobacco Cigarette Smoke ProducedunderTwo Machine Smok- ing Conditions.ChemRes Toxicol 21:494–502.PMID:18062674

23. Reproductive and CancerHazardAssessment Branch,Officeof Environmental HealthHazardAssess- ment,CaliforniaEnvironmentalProtectionAgency(2009)Evidence on theCarcinogenicity of Marijuana Smoke. Sacramento, Ca.

24. Volkow ND, ComptonWM,Weiss SR (2014)Adverse HealthEffects of Marijuana Use. N Engl J Med 371:879.

25. Owen KP, SutterME,Albertson TE (2014)Marijuana: RespiratoryTract Effects. ClinRev AllergyImmu- nol 46: 65–81.doi:10.1007/s12016-013-8374-y PMID:23715638

26. Hall W, Lynskey M (2016)Evaluating the Public Health Impactsof Legalizing Recreational Cannabis Use in theUSA. Addiction.

27. Yeboah J, CrouseJ, Hsu F, BurkeG, Herrington D (2007)BrachialFlow-MediatedDilationPredicts IncidentCardiovascularEvents in OlderAdults:The CardiovascularHealthStudy. Circulation 115: 2390–2397. PMID:17452608

28. Yeboah J, Sutton-TyrrellK, McBurnieM,BurkeG, Herrington D, CrouseJ (2008)Association between BrachialArteryReactivityand CardiovascularDiseaseStatus in an ElderlyCohort:TheCardiovascular HealthStudy. Atheroschlerosis 197.

29. Yeboah J, Folsom A, BurkeG,JohnsonC, Polak J, Post W, et al. (2009)PredictiveValue of Brachial Flow-Mediated Dilationfor IncidentCardiovascularEvents in a Population-BasedStudy:TheMulti-Eth- nic Studyof Atherosclerosis. Circulation 120: 502–509. doi:10.1161/CIRCULATIONAHA.109.864801 PMID:19635967

30. HartmanRL,Brown TL,Milavetz G, SpurginA, PierceRS, Gorelick DA, et al. (2016)CannabisEffects on DrivingLongitudinal Controlwithand withoutAlcohol.J Appl Toxicol.

31. RogebergO, Elvik R (2016)TheEffects of Cannabis Intoxication on MotorVehicle Collision Revisited and Revised. Addiction.

32. HaardörferR, BergC, Lewis M,McDonald B, PillaiD. Polytobacco, Alcohol,and Marijuana Use Pat- ternsin CollegeStudents:A LatentClassAnalysis. https://c.ymcdn.com/sites/www.srnt.org/resource/ resmgr/Conferences/2016_Annual_Meeting/Program/61820_SRNT_Program_web.pdf. (Accessed July 6)

33. Evans-Polce R, LanzaS, MaggsJ (2016)Heterogeneity of Alcohol,Tobacco, and OtherSubstance Use Behaviors in U.S. CollegeStudents: A LatentClass Analysis. AddictBehav 53:80–85.doi:10. 1016/j.addbeh.2015.10.010 PMID:26476004

34. Tanski SE, McClureAC, Li Z, Jackson K, MorgensternM,SargentJD (2015)CuedRecallof Alcohol Advertisingon Television and UnderageDrinkingBehavior. JAMA Pediatr 169:264–271.doi:10.1001/ jamapediatrics.2014.3345 PMID:25599526

PLOS Medicine | DOI:10.1371/journal.pmed.1002131 September27,2016 8 / 9

35. JerniganDH,OstroffJ, Ross C (2005)AlcoholAdvertising and Youth: A MeasuredApproach.Journal of Public HealthPolicy 26:312–325.PMID:16167559

36. Centeron AlcoholMarketing and Youth (2002)Overexposed: Youth a Target of AlcoholAdvertising in Magazines. Washington D.C.: Institute for HealthCareResearchand Policy, Georgetown University.

37. Conference of theParties(2003)WHOFrameworkConvention on Tobacco Control. Geneva, Switzer- land: World HealthOrganization.

38. MurphyP, Carnevale J (2016)RegulatingMarijuanain California. Sacramento, CA: Public Policy Insti- tuteof California.

39. Washington StateLegislature(2015)Bill:Hb2136.

40. LantzPM,Jacobson PD, WarnerKE, WassermanJ, Pollack HA, BersonJ, et al. (2000)Investing in Youth Tobacco Control:A Review of SmokingPrevention and ControlStrategies. Tob Control 9: 47– 63. PMID:10691758

41. MosherJ (2006)Alcohol IndustryVoluntary Regulation of Its Advertising Practices: A StatusReport.

42. ChriquiJF, RibislKM,Wallace RM,WilliamsRS, O'ConnorJC, el ArculliR (2008)A Comprehensive Review of StateLaws Governing Internetand OtherDeliverySalesof Cigarettes in theUnitedStates. NicotineTob Res 10:253–265.doi:10.1080/14622200701838232PMID:18236290

43. World HealthOrganization(2008)Guidelinesfor Implementationof Article11 of the WHOFramework Convention on Tobacco Control (Packaging and Labelling of Tobacco Products).

44. Wang X, Derakhshandeh R, Liu J, Narayan S, NabavizadehP, Le S, et al. (2016)One Minute of Mari- juanaSecondhandSmoke ExposureSubstantially ImpairsVascular EndothelialFunction.J Am Heart Assoc 5: pii:e003858. doi:003810.001161/JAHA.003116.003858.

45. ThomasG, KlonerRA, Rezkalla S (2014)Adverse Cardiovascular, Cerebrovascular, and Peripheral Vascular Effects of Marijuana Inhalation:WhatCardiologists Needto Know. Am J Cardiol 113:187– 190.doi: 10.1016/j.amjcard.2013.09.042PMID:24176069

46. MeierMH,CaspiA, AmblerA, Harrington H, HoutsR, Keefe RS, et al. (2012)Persistent Cannabis UsersShow NeuropsychologicalDeclinefromChildhoodto Midlife. ProcNatlAcad Sci U S A 109: E2657–2664. doi:10.1073/pnas.1206820109 PMID:22927402

47. GilmoreAB, Fooks G, McKee M (2011)A Review of the Impactsof Tobacco IndustryPrivatisation: Implications for Policy. GlobPublic Health 6: 621–642.doi:10.1080/17441692.2011.595727PMID: 21790502

48. GrubesicTH,Murray AT, PridemoreWA, Tabb LP, Liu Y, Wei R (2012)AlcoholBeverage Control,Pri- vatizationand the Geographic Distribution of Alcohol Outlets.BMC Public Health 12: 1015.doi: 10. 1186/1471-2458-12-1015 PMID:23170899

49. PrattA (2016)CanStateOwnershipof theTobacco IndustryReallyAdvance Tobacco Control?Tob Control 25:365–366.doi:10.1136/tobaccocontrol-2015-052594PMID:26437809

50. Pardo B (2014)CannabisPolicy Reformsin theAmericas:A Comparative Analysisof Colorado, Wash- ington,and Uruguay. IntJ DrugPolicy 25: 727–735. doi:10.1016/j.drugpo.2014.05.010PMID: 24970383

51. HoggSL, HillSE, CollinJ (2015)State-Ownershipof Tobacco Industry:A 'FundamentalConflictof Interest'or a 'Tremendous Opportunity' for Tobacco Control?Tob Control.

52. RehmJ, FischerB (2015)CannabisLegalization withStrictRegulation, the Overall SuperiorPolicy Optionfor Public Health.ClinicalPharmacology& Therapeutics 97:541–544.

53. CaulkinsJ, KilmerB, KleinmanM,MacCounR, MidgetteG, Oglesby P, et al. (2015)ConsideringMari- juanaLegalization Insights for Vermont and OtherJurisdictions. RANDInstitute.

54. Pacula RL, KilmerB, Wagenaar AC, ChaloupkaFJ, CaulkinsJP (2014)Developing Public HealthReg- ulationsfor Marijuana: LessonsfromAlcoholand Tobacco. Am J Public Health 104:1021–1028. doi: 10.2105/AJPH.2013.301766PMID:24825201

55. CrosbieE, Gonzalez M, GlantzSA (2014)HealthPreemption BehindClosedDoors:Trade Agreements and Fast-Track Authority. Am J Public Health 104:e7–e13.

PLOS Medicine | DOI:10.1371/journal.pmed.1002131 September27,2016 9 / 9

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