Public Consumption of Cannabis: Threats to Smokefree Environments

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Speaker Bio: Dr. Jane Steinberg, PhD, MPH​

Assistant Professor of Clinical Preventive Medicine at the Keck School of Medicine​ Research interests focus on adolescent health, tobacco control, cannabis regulation in public health and health disparities​.

The recent epidemic of vaping-related acute lung injury and death over the past year and a half among young youth and young adults is also associated with both THC and nicotine vaping. And we also know that chronic cannabis use during adolescence is associated with learning and memory deficits, substance-dependence or cannabis-dependence, which is a condition and abuse of cannabis and psychosis.

We’re looking at the impact of state cannabis policies on youth cannabis use. And there’s really mixed results. Some studies have found a higher prevalence of adult cannabis use in those states that have medical cannabis laws, but other studies have found no change, or even a decrease in youth cannabis use. I’m particularly interested in these new findings on dabbing and vaping in Colorado among youth, where cannabis has been legal for a few years now.

We coded state smokefree indoor air laws for their comprehensiveness, allowable exemptions to smokefree law, and state law changes in 2018-2019, such as addition of e-cigarettes added to a local or state smokefree law (ANRF, 2019). ​ Cannabis consumption laws were identified through Google/Nexis searches of state statutes, administrative rules, ballot measures, state bills and county/city ordinances enacted or in place between May 2018-August 2019.​

Searches limited to:

  • Indoor smokefree/indoor air requirements
  • Allowable exemptions to state smokefree law
  • Allowances for cannabis smoking/vaping in dispensaries, consumption lounges and cannabis tourism venues​ ​

-Learn about challenges in maintaining smoke free environments in cannabis-legal states

-Understand public health practices for cannabis regulation.

-Hear recommendations and policy options for protecting public health in cannabis-legal states. ​

Learn more about the USC MPH Online program at:  https://mphdegree.usc.edu/academics-overview/

Transcript

Phil Solaria:

First, I would like to thank you all for taking time out of your busy schedule to join us today. So before we begin, I would like to review what you can expect during the presentation. Now, in order to cut down on background noise, everyone is on listen-only mode. And if you are experiencing any technical difficulties, please be sure to refresh your browser.

Phil Solaria:

And if you have any questions for any of our speakers, please type them in the Q&A box in the lower right hand corner of your screen and hit send. Feel free to enter any questions as you think of them. And we’ll be sure to answer as many questions as time allows at the end of the presentation. Also, a copy of the presentation and recording will be available soon.

Phil Solaria:

Now, in a moment, I will give a brief overview about the Keck School of Medicine and the Department of Preventive Medicine, introduce our speakers, Dr. Jane Steinberg, PhD, MPH. And Virginia Seegulam, currently serves as the MaPHSA the Director of Online Student Relations at USC in her third semester of the online MPH program.

Phil Solaria:

Then we will hear from our guest speakers who will speak to their experience and knowledge on the public health profession and industry. Lastly, we will end the presentation with that brief Q&A session. Vijaya will be available at the end with Jane for questions on the student experience.

Phil Solaria:

Now, the Keck School of Medicine was established in 1885. It is the oldest medical school in Southern California. And today, it is a place of dynamic activity in patient care, scientific discovery, medical and bio-science education, and community service. Together, we are poised to lead medicine and healthcare in the 21st century for the benefit of humankind.

Phil Solaria:

The Department of Preventative Medicine at the Keck School of Medicine of USC is known as a leader in the Public Health and Population Health Sciences. It is organized in six divisions; disease prevention and global health, bioinformatics, biostatistics, cancer epidemiology and genetics, environmental health and health behavior research.

Phil Solaria:

Now, the Master of Public Health Online Program offers a rigorous curriculum that attracts dedicated and ambitious professionals with a passion to serve in the public health arena. There are six different concentrations that prospective students can choose from, including; biostatistics and epidemiology, community health promotion, geo-health, global health, health services and policy, and a generalist concentration.

Phil Solaria:

Now we will hear from Vijaya Seegulam who will introduce our guest speaker, Dr. Jane Steinberg. Thank you, Vijaya.

Vijaya Seegulam:

Thanks Phil. Hello everyone. My name is Vijaya Seegulam and I’m currently in my third semester of the Online Master of Public Health program at USC, concentrating in Biostats and Epidemiology. I also serve as the Director of Online Student Relations for the Master of Public Health Student Association.

Vijaya Seegulam:

Today, it gives me great pleasure to introduce Dr. Jane Steinberg. Dr. Steinberg is an Assistant Professor at the Keck School of Medicine of USC in the Institute for Health Promotion and Disease Prevention Research. She teaches on-campus and online graduate courses in the MPH program, and serves as the program’s practicum director.

Vijaya Seegulam:

Her research focuses on Public health Impacts of Local and State Tobacco and Cannabis Regulation and Associated Impacts on Youth and Vulnerable Communities. Currently, she’s co-investigator on a grant from the California Tobacco-Related Disease Research Program to study associations between proximity to cannabis retailers and adolescent cannabis use, and a grant from the California Tobacco Control program to develop a tobacco policy platform for community agencies.

Vijaya Seegulam:

We thank Dr. Steinberg for taking the time to speak with us today. And without further ado, here’s Dr. Steinberg.

Dr. Jane Steinberg:

Thank you Vijaya for that very warm welcome. Hi everyone. Hi students. I hope some of my students from practicum and the community organizing class are here. But happy to have all students here today. And I hope you guys are doing well and hanging in there during this very surreal time and not stressing too much about finals.

Dr. Jane Steinberg:

Excuse me, I have a bit of a cold, so you may hear me clearing my throat a few times. But yeah, just to give a little background why am I doing this work, why am I interested in it. After cannabis became legalized, particularly in California where I live, I was very interested… As a tobacco control researcher, I was very interested to see how legalization was going to come about. And particularly with an eye in public health, how public health practices were, or were not being implemented with cannabis legalization.

Dr. Jane Steinberg:

From that, I decided to take a look at the nexus between the tobacco control efforts that we’ve been involved with, particularly smoke-free laws and seeing what happens with cannabis public use laws. So this led to a research collaboration. The title of my talk today is: Public Consumption of Cannabis, Potential Threats to Smoke-free Environments in Cannabis-Legal States.

Dr. Jane Steinberg:

SO I would first want to thank my collaborators. Some you hopefully know from Keck, in our MPH Program and Preventive Medicine, Dr. Baezconde-Garbanati, Dr. Jennifer Unger, who’s an established tobacco control researcher. And Dr. Baezconde-Garbanati is a co-investigator on the Tobacco Control Grant that I’m on with her. And she has a long history in the area of reducing health disparities and tobacco control. And Dr. Michael Cousineau, who’s a health policy researcher and has a strong interest in public health policies related to cannabis.

Dr. Jane Steinberg:

This project would not have been possible without collaboration with a fantastic organization called NRF, the American Non-smokers Rights Foundation. They’re located in Berkeley. And they were instrumental in helping us find local ordinances, state-level ordinances, on tobacco laws and cannabis laws.

Dr. Jane Steinberg:

So if you get a chance to look at their website, if this is a topic that you’re interested in, you will see that they have a wealth of information on the state of tobacco control laws locally and nationally. And now they’re exploring cannabis laws as well.

Dr. Jane Steinberg:

I wanted to give you a little roadmap before we begin. I wanted to give you a little background on cannabis legalization nationally. Then talk about some of the key challenges in regulating public cannabis use. To give you some data and it’s particularly impacts and is important to us studying public health, looking at cannabis and tobacco use among youth. Some of the study methods that we used for our study, the results. Some health concerns that we have with cannabis, legalization and smoke-free laws. Some ongoing challenges and some recommendations and policy options.

Dr. Jane Steinberg:

So, to put this in context, since 2012, over half of all U.S states have legalized cannabis either for medical or recreational use. And from now on, I’m not going to call it recreational, the official word is adult use, over 21. A key challenge however, for a cannabis-legal states and their cities is establishing where residents can legally smoke cannabis or consume aerosolized, or what we refer to as vaped cannabis.

Dr. Jane Steinberg:

And part of the challenge is that states have strong smoke-free laws that often ban all types of smoking. But if cannabis is now legal, the question is, if it’s legal, where can people use it? A growing public health concern is that states and localities, we are seeing, they’re creating carve-outs exemptions allowances in their state or local smoke-free laws by developing ballot measures or local ordinances to allow public cannabis smoking or vaping.

Dr. Jane Steinberg:

Why is this a problem? Because these actions, and we’re already seeing this, can weaken smoke-free laws, expose the public, potentially, to second-hand cannabis by-products and re-normalize smoking, which is particularly an issue among young people. We’ve made significant progress since the 1970s and ’80s to significantly decrease smoking. And there’s a real concern that this public cannabis use and the increase in vaping of nicotine products among youth is renewed formalizing smoking.

Dr. Jane Steinberg:

We conducted a comprehensive review of state smoke-free laws and cannabis use allowances in the first eight states that legalized adult cannabis use in the U.S. And when I say eight states, there are more than eight states that legalized it, but the eight states that have dispensaries. And I’ll talk about that in a minute.

Dr. Jane Steinberg:

All right. So now we’re going to do a little background on cannabis legalization in the country. At the federal level, cannabis, whether it’s medical, or adult use recreational, is considered it is illegal at the federal level. However, medical use of cannabis is legal in 33 states. Since 2012, 11 states, Guam and Washington DC have legalized adult use cannabis for individuals that are 21 and older.

Dr. Jane Steinberg:

And, Alaska, California, Colorado, Illinois, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont and Washington are the 11 States that have, in their, state statutes that cannabis is legal for adult use. But the asterisks are the states that currently have dispensaries or cannabis stores. The other states will, at some point, Michigan and Vermont and Maine, will be.

Dr. Jane Steinberg:

So what does cannabis legalization allow? It allows personal use. It allows limits on growing. So you can grow a certain amount of cannabis in your backyard or on your property, private property. It allows relief for past cannabis-related arrests and convictions. I’ll talk about that in a little bit. And it establishes a regulatory or a legal framework for the commercial retail market. So eight states above us as I noted have established retail stores, such as dispensaries for adult use and medical use as of this past May.

Dr. Jane Steinberg:

There are some key challenges when we talk about regulated cannabis use. And the first one is, where can it be used? So we know the public consumption of cannabis conflicts with many states smoke-free laws that already prohibits smoking and vaping in public places, such as bars and restaurants. And federal and state laws that prohibit cannabis use in workplaces, public places, multi-unit, or federal housing.

Dr. Jane Steinberg:

Cannabis use, however, is generally allowed and it’s often confined to a private property or outside the view or smell of the public. Well, we know as an aside, at least in California where, legal people smell cannabis all the time outside, but there’s very little enforcement. But this is an issue in terms of allowable use. So landlords of private multi-unit housing can prohibit medical or adult cannabis use on their property. Just because it’s legal does not mean that they can allow it, will always allow it.

Dr. Jane Steinberg:

And a real issue for vulnerable communities and communities of color is that residents of publicly-funded housing, such as Section 8, are prohibited from cannabis use on their property. And they risk fines and eviction, even if it’s used medically and even if the public housing is in cannabis-legal states. And we know that, primarily, Latino and African-American communities, who happened to be lower income, do tend to live in public housing. And so there’s a huge disparity there. And I will talk about that in a little minute.

Dr. Jane Steinberg:

And there is related important health equity implications for these communities who we know were negatively impacted by U.S drug laws being in terms of disproportionate arrest and incarceration.

Dr. Jane Steinberg:

Another key challenge in regulating cannabis use is the public health piece that we’re going to talk about and focus here is protecting the public from second-hand cannabis exposure. Research has clearly now documented that exposure to second-hand cannabis products, meaning cannabis smoke, vape, impairs cardiovascular function and it increases risk of coronary heart disease or stroke.

Dr. Jane Steinberg:

We know that second-hand cannabis products do contain some of the same carcinogenic compounds and fine inhalable particulates that are found in tobacco smoke. An exposure to second-hand cannabis can cause or exacerbate respiratory symptoms, especially for people who have respiratory conditions such as asthma, bronchitis, COPD, chronic obstructive pulmonary disease. And as an added note, there’s also emerging research that people who vape cannabis, smoke cannabis, chronic users who happen to have COVID, who are sick with COVID, often have worse outcomes because their lungs are already compromised from acute or chronic, I should say, chronic cannabis use. But this is new research that’s coming out.

Dr. Jane Steinberg:

We also know that heavy passive of exposure to marijuana smoke, this means someone in the area of someone who’s smoking, particularly indoors, can result in measurable concentrations of THC in the non-user’s blood serum and urine. Does that mean that they get high? We don’t know. But there have been studies of kids who live in families where there’s a lot of cannabis use and kids do have elevated levels of THC.

Dr. Jane Steinberg:

So, taken together, I just want to note that the research is still new in this area of cannabis second-hand smoke. Some people say, well, Dr. Steinberg gets much less harmful than exposure to tobacco smoke. That is probably true. However, exposure to cannabis smoke is not harmless, and there’s growing research that there could be many arms. So I always want to include that.

Dr. Jane Steinberg:

An area I’m particularly interested in many of us in public health are, one of the challenges in regulating cannabis use is protecting our youth. As the trend towards legalization grows, public perceptions, particularly among young people, are that cannabis smoke and vape is less harmful and more socially acceptable than tobacco with fewer perceived consequences than for alcohol.

Dr. Jane Steinberg:

Now, there may be some truth to that, but when you’re talking to youth, it’s really important not to make the connection between… We’re not talking about comparisons to tobacco or comparisons to alcohol, right? Because some are higher-risks are lower. But looking at cannabis by itself, there are a number of harms that are particularly relevant for youth. So just lessened perceived risks of cannabis related harms may result in earlier age of use, rate or frequency of use and reduced motivation to cease or reduce use.

Dr. Jane Steinberg:

The recent epidemic of vaping-related acute lung injury and death over the past year and a half among young youth and young adults is also associated with both THC and nicotine vaping. And we also know that chronic cannabis use during adolescence is associated with learning and memory deficits, substance-dependence or cannabis-dependence, which is a condition and abuse of cannabis and psychosis.

Dr. Jane Steinberg:

And a new report just came out that I wanted to talk to you about. Youth dabbing in Colorado from the Colorado Healthy Kids Survey… And just as a note, dabbing is a type of cannabis consumption which is very high concentration of THC. The THC is the active ingredient that gets you high. The THC levels in cannabis products are much higher than they were in your parents, or even your grandparents day.

Dr. Jane Steinberg:

I grew up in Berkeley in the 1970s, and people were… My friend’s parents were growing it in their backyard. It was very accepted back then, but the levels were much, much lower. This was just low grade products. Now we have super-high concentrates. The study from the Colorado Healthy Kids Survey showed a doubling of cannabis vaping and quintupled the rates of dabbing or use of this high concentrates between 2015 to 2019.

Dr. Jane Steinberg:

So in 2015, 4.3% of kids, high school kids in Colorado that answered the survey were using high concentrated cannabis. That 4%, now is 20% in 2019. Similarly, kids in 2015, 5% of them vaped cannabis. And in 2019, 11%. So, we are seeing a significant increases in this use of cannabis concentrates. And we don’t know yet… Studies are coming out on what is the impact of these high-potency products on the teen brain, or the adult brain for that matter.

Dr. Jane Steinberg:

But we’re particularly about the teen brain, because as you know, teens brains are still not fully formed and there are a lot of potential implications. We know that younger age of use of any substances often leads to problems. And that’s the stage for later addiction. So if you’re interested in this topic, kind of keep your eyes open for this whole issue of high-concentrated products and what are the health impacts.

Dr. Jane Steinberg:

We also know that the popularity of e-cigarettes and vaping devices among youth, and increased rates of vaping in the U-S, has steadily increased, with the most significant rise between 2017 and 2018. Which was particularly due to aggressive marketing of JUUL products. And now there are other companies, there are Puff Bars and other flavored-vaping products. They’re very appealing to youth. We know that adolescent co-use of tobacco and cannabis at the same time has been found to be greater than tobacco use alone. This was a study done by our colleagues here [ECTEK 00:30:49].

Dr. Jane Steinberg:

We’re looking at the impact of state cannabis policies on youth cannabis use. And there’s really mixed results. Some studies have found a higher prevalence of adult cannabis use in those states that have medical cannabis laws, but other studies have found no change, or even a decrease in youth cannabis use. I’m particularly interested in these new findings on dabbing and vaping in Colorado among youth, where cannabis has been legal for a few years now. And be curious to see if this trend continues in other cannabis-legal or not legal state. So I think in a few years, we’re going to have a better handle on the connection between state policies and use.

Dr. Jane Steinberg:

All right, so this is a particularly interesting slide. As you see, there’s a fairly precipitous decline in cigarette smoking since the nineties. But if you take a look at marijuana use, it really started climbing in 2005, and has sort of continued. But the really important data to look at are the vaping products. Vaping of nicotine and vaping of marijuana, which showed huge jumps at the time that these products were really being marketed and sold in the U.S a little after between 2017 and 2019.

Dr. Jane Steinberg:

The Monitoring the Future studied… The Monitoring the Future is a national representative sample of high school students across the U.S through the University of Michigan. And they noted that the increases in teen vaping of marijuana from 2018 to 2019 ranked among the largest single-year increase that was ever observed by Monitoring the Future in the past 45 years among all of the outcomes they’ve measured.

Dr. Jane Steinberg:

So what’s going to be very important to look at is this graph in the next three to five years, to see what happens to these increases, particularly as states are implementing tobacco flavor bans. In fact, right now, the California Assembly is going to be voting on a statewide potential ban on the sale of all flavored tobacco products, including menthol. There’s a lot of opposition, not surprisingly, from the tobacco industry and the cannabis industry. We will see what actually happens in terms of this flavor ban.

Dr. Jane Steinberg:

The flavor ban is particularly targeted right now to nicotine. Right? or to tobacco products. But we know that kids are vaping both cannabis and tobacco products. So it’ll be interesting to see where this trend line goes. I’m going have some water. So, one second.

Dr. Jane Steinberg:

I want to talk a little bit about the methods of our study. To really understand the current landscape of smoke-free and cannabis policies, what we did is we assessed current smoke-free and public-use cannabis laws in those first eight states that legalized adult use cannabis, and that had the dispensaries, Alaska, California, Colorado, Illinois, Massachusetts, Nevada, Oregon and Washington.

Dr. Jane Steinberg:

And what we did is we coated states smoke-free indoor air laws for how comprehensive they were. The CDC has definitions of what a comprehensive smoke-free law is, which I’ll talk about in a moment. We also looked at allowable exemptions or allowances exemptions for smoke-free laws, as well as looking at any state law changes that happen between 2018 to 2019, such as the addition of e-cigarettes that were added to a local or a state smoke-free law. So there’s been a number of… Or tobacco flavor ban.

Dr. Jane Steinberg:

I live in Culver City, California. We just instituted tobacco flavor in the city. So that’s going to be added to our local smoke-free law or ordinance. Cannabis consumption laws we identified through Google Nexis searches of state statutes, administrative rules, ballot measures, state bills, county/city ordinances that were enacted or in place between May 2018 and August 2019.

Dr. Jane Steinberg:

And our searches were really limited to those areas that we were interested in studying such as indoor smoke-free and indoor air requirements, any allowances or exemptions to the state smoke-free law, allowances for cannabis smoking or vaping and dispensaries, consumption lounges and cannabis tour tourism venues, which I’ll talk about in a moment. And our study was published in American Journal of Public Health, and I’m happy to send anyone the article if they’re interested.

Dr. Jane Steinberg:

As you can see here, most states are what we call a hundred percent smoke-free. And that a hundred percent smoke-free designation was created by the Americans for Nonsmokers Rights, with some overlap with CDC. And a hundred percent smoke-free, if you look at the bottom of this chart, the key, it really means smoking is prohibited in workplaces, restaurants, bars and gambling sites. So, per our graph, most states that have cannabis dispensaries are a hundred percent smoke-free, where smoking is prohibited in these sites, workplaces, restaurants, bars, gambling.

Dr. Jane Steinberg:

If you look at the last or the first one, what’s interesting is that, while Alaska requires it’s workplaces, restaurants, bars and gambling sites to be smoke-free, it also allows a local jurisdiction to opt out of the state smoke-free law if it’s approved locally. So this is a real issue for tobacco control and public health advocates. Because, depending on the composition of a city council in Alaska, they can opt out of the state smoke-free law, which can create some real public health issues if smoking is allowed in a city in Alaska workplaces restaurants in the Lake. So there’s some very important public health implications there.

Dr. Jane Steinberg:

Nevada, as you see, is the only state that exempts bars and gambling casinos from its smoke-free law. If anyone has been to Nevada before… I haven’t been in a few years, but it used to be kind of… There was a lot of smoke. But now, if you’ve been in Las Vegas, many casinos in Las Vegas ban smoking. Because… It’s due to a business decision.

Dr. Jane Steinberg:

What’s also interesting to see, I thought was really interesting, is that states can create allowable exemptions to their smoke-free law to allow smoking or vaping and tobacco and vape shop, cigar bars, private clubs, casinos, brothel, strip clubs, or hotel rooms, which may designate a certain percentage of their hotel rooms where smoking is allowed, unless it’s prohibited by an individual business policy or local law. So it’s still… There are still many businesses that have decided to keep all their hotels smoke-free, to keep all their rooms smoke-free.

Dr. Jane Steinberg:

What I thought was interesting here, if you look at Illinois, which has a very strong state smoke-free law, they do allow smoking in private rooms, and nursing homes, and long-term care facilities. Which I thought was really interesting, particularly since you have older vulnerable adults. But again, a particular long-term care nursing facility, because of their business policy, could ban smoking. But this is just to show you what the state law is.

Dr. Jane Steinberg:

Okay. All states, except for Washington, exempt tobacco or vape shops from their smoke-free law. So most states, where you go in, you sample the products. So that’s why you see these exemptions.

Dr. Jane Steinberg:

Okay. I want to talk a little bit about commercial settings that have been developed specifically for public cannabis use. And I grouped them into three main areas, but there is more, or actually four. Cannabis consumption lounges. These are places where patrons can smoke and vape cannabis indoors. Here in LA, we have a few consumption lounges in West Hollywood. More are popping up. There’s some in San Francisco in the Bay Area. You’ll see in a slide in a bit what states allow consumption lounges in which don’t.

Dr. Jane Steinberg:

Dispensaries are cannabis retail stores that are increasingly allowing onsite smoking, vaping and eating edibles for customers to sample the products. There’s a real concern here among employee exposure to cannabis, right? People that are cleaning the facilities, those who work there. But the industry and the work and the employers note that people need to sample the products. So there’s some issues about how to do this safely.

Dr. Jane Steinberg:

Cannabis tourism is a rapidly growing industry. You see here on the right cannabis tourism buses that take people to and from dispensaries where they can smoke and vape on the bus. And there’s also companies called Puff, Pass, Paint. Where you can paint, in a small setting with others, puff and path. It’s really interesting as we talk about this now in era of COVID. Right? How is this going to look in the future? And what is the future of these indoor air smoking facilities? A lot of concern among the industry, but those of us in public health are now saying, okay, maybe time to look at this a little differently.

Dr. Jane Steinberg:

All right. So here is a table of cannabis use allowances in states that regulate cannabis retail, which are on the left, Y-axis. The variables we looked at was, if you look across the top, are vape devices included in a state smoke-free law? Does the state prohibit public cannabis use smoking or vaping? Is onsite cannabis smoking or vaping allowed in its dispensaries? Are social consumption allows judges allowed? And, is cannabis use allowed in these indoor cannabis tourist venues? And when I say cannabis use throughout here, I don’t mean edibles, I mean smoking or vaping.

Dr. Jane Steinberg:

As you can see, with the exception of Nevada, all states include vaping devices in their state smoke-free law. This loophole could allow smoking and vaping of cannabis in places where smoking and vaping tobacco is currently allowed. So these loopholes are what we in other public health organizations are really looking for. And a loophole just means a gap in the law that could allow for cannabis use.

Dr. Jane Steinberg:

And I forgot to put an X in those last two boxes. So Oregon and Washington currently do not allow indoor cannabis tourist venues. That doesn’t mean that it doesn’t occur, but in their state law, there’s nothing in there that allows it. All states though, just to kind of provide some context, all states have on their books a prohibition of public cannabis smoking or vaping. Now we know, as I talked about before, you walked down the street in many cities in California and you smell cannabis everywhere.

Dr. Jane Steinberg:

So just because it’s on the books, it does not mean that people aren’t doing it. There’s not a lot of enforcement. But in California, Proposition 64 was the statute that legalized adult use cannabis. It bans cannabis use wherever smoking and vaping are banned. However, as I’ve said, states have gotten around this law.

Dr. Jane Steinberg:

Onsite smoking and vaping in dispensaries here. This is an issue. Alaska, California, Colorado and Illinois allow a local jurisdiction to create an exemption to their state’s smoke-free law to allow onsite cannabis smoking and vaping. These exemptions are really important as, I’m learning. Because these are carve-outs. These are ways that states can get around their smoke-free law to allow youth in a dispensary. And California and Colorado have some of…

Dr. Jane Steinberg:

Interestingly or ironically, California, Colorado have some of the country’s strongest indoor air smoke-free laws, yet they’re also the states that you see here that allow onsite vaping of cannabis in these multiple indoor retail sites. So that is a public health concern and a new development. And the social consumption laws, we see Alaska, California, Colorado and Illinois allowed this. And indoor tourist venues, California, Colorado, and Illinois.

Dr. Jane Steinberg:

So again, it’ll be interesting to see post-COVID, what this looks like. I know other states have been eager to open up cannabis consumption in their venues because sales are obviously much better if people could use the products. But now, with COVID, this is a concern.

Dr. Jane Steinberg:

Okay. So one of the health concerns with cannabis is consumption in businesses. States that have carved out these exemptions to their smoke-free laws, that I talked about to allow cannabis smoking or vaping in the businesses, are still required by law to address the issue of indoor exposure to second-hand cannabis on their premises.

Dr. Jane Steinberg:

So what we’re seeing now, a common practice, is dispensaries or consumption lounges are creating what they call ventilated indoor lounges that are separate from the main retail space. However, ASHRAE, which is the international standard setting body for indoor air quality. It’s the association of… It has to do with refrigeration and… I can’t remember the acronym. But these are engineers that indoor air quality.

Dr. Jane Steinberg:

They have a affirmed that installation of these barriers of ventilation systems to remove second-hand cannabis is not an effective method for removing the particles of various health risks due to second-hand exposure. There’s no safe level of exposure to second-hand cannabis, smoke or aerosol, they affirm. And cannabis smoke and aerosols should not be allowed indoors at all.

Dr. Jane Steinberg:

So the standard that ASHRAE uses is clean indoor air, not less harmful air. So that’s a really important distinction. And additional issues are worker exposure to cannabis by-products, as I noted before, in the dispensary or consumption lounge, lounge, bus drivers that could be exposed in cannabis tourist buses. I know the cities that allow these tourist buses have put blasts between the driver and the patrons who were smoking away. But that supposedly, from what I understand, the cannabis can seep through the glass. So it’s really not a very effective mitigation method.

Dr. Jane Steinberg:

Another health concern with cannabis is use in multi-unit housing. And our colleagues, Dr. Baezconde, Yanet Rodriguez, a number of our colleagues in preventive medicine, are doing studies in this area. And I’m happy to connect you with them if you’re interested in this topic of looking at multi-unit housing and vulnerable populations.

Dr. Jane Steinberg:

We do know that second-hand smoke, whether it’s from combustible or aerosolized tobacco and cannabis spreads throughout multi-unit dwellings. In a recent study of 251 residents in LA County who lived in multi-unit housing, over half of them experienced smoke from tobacco and cannabis entering their units. We know that multi-unit residential property owners, as well as public and other subsidized housing owners, have the legal authority to make their properties smoke-free. But a problem that we have here in LA is that there was no city-wide policy that prohibits tenants from smoking in privately-owned apartments and condominiums. So, there’s still a lot of work to be done in multi-unit housing.

Dr. Jane Steinberg:

So other ongoing challenges. Again, I noted earlier that state and local jurisdictions really do grapple with where residents can legally consume cannabis without violating smoke-free laws and compromising health. There’s important social equity and social justice issues. As I talked about before, cannabis-related arrests and incarceration rates are significantly higher among Black and Latino communities compared to their white counterparts, despite similar rates of cannabis use.

Dr. Jane Steinberg:

And really, our analysis documents and growing trends for States and local jurisdictions to create these exemptions for indoor public cannabis use in venues that are currently required to be smoke-free. And allowances for public health use. And this is a particular concern. It may really roll back existing smoke-free protections to protect public health and re-normalize smoking, particularly among youth.

Dr. Jane Steinberg:

Now, while we haven’t seen tobacco rates jump up yet among youth, in terms of tobacco, cigarette smoking, the increase in vaping is creating concerns. Depending on states, some States are seeing spikes in cigarette smoking. But nationally, it’s not uniform, it varies from state to state. Particularly states that have stronger smoke-free laws versus weaker.

Dr. Jane Steinberg:

Okay. So what’s currently happening? Just to wrap this up. There’s three additional states, Alaska, Massachusetts and Nevada, that are planning cannabis consumption lounges. In California, there’s a state-wide bill that’s being considered to allow cannabis smoking and licensed consumption cafes and lounges in venues that are currently smoke-free. So this will be a state-wide bill, as opposed to what I talked about earlier, were exemptions that cities are making. So this would be a state law that could allow consumption cafes.

Dr. Jane Steinberg:

San Francisco, most recently, voted to waive smoke-free laws to allow cannabis smoking at special events, allowing cannabis smoking in dispensaries located in multi-unit housing. So this is a big deal, because San Francisco has extremely strong smoke-free laws, but here’s an example of kind of the weakening of them to allow cannabis use. And when I say special events, these are public indoor and outdoor events.

Dr. Jane Steinberg:

The City of Eureka in Northern California voted to allow smoking lounges at cannabis retailers if they had a ventilation system. The City of Berkeley adopted recommendations to allow consumption lounges, recently, for onsite smoking and retailers. And to reel it back to the city’s 2007 smoke-free parks law to allow cannabis smoking and vaping during special events in a city park.

Dr. Jane Steinberg:

And just as a note, some might say, well, what’s the problem with rolling back the smoke-free law to allow cannabis smoking if rates of cigarette smoking are going down? By these laws being weakened, creates more opportunities to get back to smoking. Part of the reason why smoking rates have gone plunge in California and the U.S is because of these strong smoke-free laws. But just as an aside.

Dr. Jane Steinberg:

Colorado’s House of Representatives recently passed a hospitality bill to more broadly allow cannabis smoking in a wide range of indoor businesses. So again, this is what we’re seeing state by state. All right. So what are some recommendations and policy options? One would be, to amend language regarding the prohibition on outdoor cannabis use while retaining strong smoke-free indoor air laws.

Dr. Jane Steinberg:

And so, what are some ways to do this? Consideration could be made for stand-along buildings to allow sampling or use an outside area where workers and patrons would not be exposed to second-hand cannabis smoke and aerosol. To work with owners of multi-unit housing and tenants to either allow cannabis use outside of the property or other forms, particularly edibles, especially for those who are using it medically or not. This would also though necessitate important education of law enforcement on new rules, policies, to prevent disparate treatment.

Dr. Jane Steinberg:

We still know that that communities of color are being disproportionately impacted by cannabis-related arrest, even though cannabis may be legal in a particular city or state. Local and state policy should also really work to de-normalize all forms of smoking and vaping to limit the negative health impacts of youth and exposure to second-hand cannabis. And the de-normalization way is particularly relevant for young people who are still very impressionable.

Dr. Jane Steinberg:

Targeted tobacco and cannabis prevention strategies are needed for youth, particularly in cannabis-legal states. I should have put this data up. There’s a survey of youth that showed that they had been exposed to more cannabis billboards in cannabis-legal states than they were tobacco prevention messages. So there’s not a lot of cannabis prevention messaging that’s out there for youth yet.

Dr. Jane Steinberg:

COVID-19 really highlights the health impact of breathing shared air in workplaces and public places such as casinos, bars and cruise ships. Businesses that are impacted by population health risk factors, there’s a real urgent need to rethink some of the assumptions about the health and economic benefits of going smoke-free.

Dr. Jane Steinberg:

Never would we wish COVID-19 on anyone, but at the same time, it’s definitely making businesses think a little differently about their indoor air quality and practices. So it will be interesting to see in the next few years or so how that impacts at all indoor cannabis use. And here’s some resources for those of you who are interested. And I’m happy to answer questions. And here’s my contact information. Thank you.

Phil Solaria:

Perfect. Thank you Jane for sharing all of that with us. Next, I really wanted to just take some time to go over any questions that anyone might have. We did receive just a few already. If you do have any questions, please be sure to share them in our Q&A box so I can make sure that we are able to address those and we’ll get to as many as we can. We do have some questions here. We just get started.

Dr. Jane Steinberg:

I can see them. I can see the [inaudible 00:54:22].

Phil Solaria:

Oh yeah. You can? Okay. Well, great.

Dr. Jane Steinberg:

Yeah. Okay. So the first question, do cannabis lobbyists have a role in weakening laws, or is this an image issue for cities that are more known for cannabis use?

Dr. Jane Steinberg:

Excellent question, whoever it was. Yes. And I’m not… I just want to start by saying my plan here is not to demonize the cannabis industry at all. However, the cannabis industry, first of, all donates to many politicians campaigns. So there’s always a campaign re-election issue.

Dr. Jane Steinberg:

But yes, the whole reason why we have social consumption laws, onsite smoking, indoor cannabis, tourism venues, is because the cannabis lobby has done… They’ve successfully made the argument that cannabis needs to be used indoors for business purposes so that people could sample. And they’ve also managed to use the ventilation argument that takes care of the problem.

Dr. Jane Steinberg:

I would have loved if the cannabis industry was creative and talked about some of these outdoor venues for being able to use cannabis. Which I think is changing. I think the industry is changing given COVID. But this is a long way of saying yes. They absolutely had a role in changing the laws and allowing these carve-outs.

Dr. Jane Steinberg:

Is this an image issue for cities that are more known? I don’t know if it’s an image issue. I think what concerns us in public health is that, public health really hasn’t been at the table for a lot of the early policy-making. A, there’s still a lot of research that we don’t know about cannabis use of affects. It is still illegal at the federal level, which means that it’s very difficult to do research on cannabis harms as well as benefits.

Dr. Jane Steinberg:

We know that CBD has a lot of health, potential health benefits. The lack of data, lack of federal support for studying it, coupled with the cannabis industry that’s a heck of a lot stronger than the public health industry, if you will, all had a role in this. Okay. That was a long answer. Okay. It looks like that one was answered.

Dr. Jane Steinberg:

Is our state model for smoking laws detrimental nationally? Do countries with uniforms smoking lots of better health outcomes?

Dr. Jane Steinberg:

I’m not sure if our state model, if you mean California. I don’t know what it means, is it detrimental nationally? There are notes… There are a handful of national smoking policies, but the majority are done state by state. Your countries with uniform smoking laws have better health outcomes overall. Many countries are similar in that their smoking laws are… Some are better, some are worse. Right?

Dr. Jane Steinberg:

Many parts of Europe, at least France, is now totally smoke-free in public settings throughout the country. It’s not like it’s done on a city basis. But national laws, obviously, have a much stronger reach and a wider reach than state laws where you have patchwork, some may do better, some may do worse. So, I would assume that countries that have strong uniform national smoking laws have better health outcomes. I don’t know for sure. But I’m sure it’s easy to find that out.

Dr. Jane Steinberg:

How would testing be done to learn about the effects on the teen or adult brain? There already is testing done. Test in terms of cognitive memory tests are being done about cannabis use on the teen brain. I’m not sure about the adult brain. And this is still really new research, particularly with concentrates that have only been around for the last few years. So I hope that answers the questions that we had.

Phil Solaria:

It looks like we do have a question for Vijaya. Just curious, why are you getting your MPH?

Vijaya Seegulam:

Hi. Personally speaking, I was currently… Well, I was previously on a premed-oriented track and then I guess I kind of developed like a love of infectious diseases and learning about the origins. So I guess I found my passion. And Phil, If you know, I kind of know Phil if you help me through the entire application process. I applied and then I decided to go forth. And there’s been so many fulfilling opportunities that I’ve gotten from USC, that I don’t think I would’ve gotten anyways.But yeah, it’s been it’s been opening a lot of doors for me in the field that I want to work in the future

Phil Solaria:

And Vijaya, can you speak to a little bit about that, your experience so far online and the opportunities that just presented themselves to you?

Vijaya Seegulam:

Well, currently, I’m getting a lot of opportunities to work on my practicum here in Florida, being a COVID hotspot. I don’t think I would’ve gotten these opportunities prior, but given my exposure and some of the skills that I’ve acquired in the program. One of the classes that I’m taking is state [inaudible 01:00:04] and I’ve learned quite a bit about statistical software like SAS. It’s interesting to see how these things are being implemented as epidemiology.

Vijaya Seegulam:

So it’s been quite a fulfilling. And I also have a job opportunity on the table. So I’m not going to led that [inaudible 01:00:20] that goes great. But yeah, it’s definitely opened so many doors for me network-wise as well, because USC has such a diverse network.

Phil Solaria:

Perfect. And it looks like another question came in and I think this is for both of you. How does the practicum work and how are you involved, Dr. Steinberg? And then Vijaya, what do you think you will do for your practicum?

Dr. Jane Steinberg:

Okay, great question. Whoever asked the question, I don’t see it right here. We’re going to be doing… Hopefully, we’ll be doing a practical webinar coming up. We’ll do them at least once or twice a year to answer all of your practicum questions. Yeah, I could speak with the students separately. I don’t want to take up too much time getting into depth, but it would be helpful to hear if Vijaya has experience with the practicum.

Vijaya Seegulam:

As I mentioned, I currently live in South Florida, which is a very hot hotspot area for COVID right now. A lot of these opportunities have been sort of closed off. But remotely, there’s been so many opportunities online for me to look at in different states. And I’m currently looking at one in Boston.

Vijaya Seegulam:

But in terms of my practicum, since my concentration is Biostats/Epi, I’m primarily going to work with, once it’s approved hopefully, work with another Dr. Gradus who is affiliated with Boston University and working like a psychiatric research and doing grants. So, hopefully that works out.

Dr. Jane Steinberg:

Now I see the question. I’m the practicum director, so I help students navigate the practicum process along with Carolina Lopez, our fantastic practicum coordinator. We help create new practicum opportunities. Now with COVID, obviously, we’ve been trying to develop some new online remote opportunities. The student is eligible for their practicum once they’ve completed their core courses. So all of that, we can go into detail during the webinar and I’m happy to answer if a student wants to reach out to me. But yeah, that’s it.

Phil Solaria:

Perfect. Dr. Steinberg, there is another question, it looks like for you. Did you see that in there?

Dr. Jane Steinberg:

Yes. How has COVID has research as studied been put on hold? That’s a really interesting question. In some ways, it’s made it much harder. In other ways, it’s opening up some new avenues. For the work that we’ve been doing, the Tobacco-Related Disease Research Program grant. This is a grant where we’re looking to see if cannabis dispensaries that are located near where youth live, if you have higher, lower, the same rates of cannabis use.

Dr. Jane Steinberg:

We were doing in-person surveys in high schools, and that has had to come to an end. So we’re now doing online surveys there. So we had to quickly pivot from in-person to online. But we’re also looking separately to potentially write a grant to look at some of the community needs, not related to tobacco at all, but just COVID-19 education that is needed particularly in underserved communities, and where are some of the gaps. So that’s kind of where we are with the research.

Phil Solaria:

Perfect. Well, it looks like we’re almost out of time. So if we didn’t get to your specific question, we will be sure to reach out to you on a one-on-one situation, and we’ll be sure to answer any questions that you might have. So at this time, I would really just like to thank Jane. And thank you Vijaya for sharing your experiences. It really does mean a lot to us.

Phil Solaria:

We would like to thank everyone that is attending our live session. Hopefully, you have a better understanding of what the Master Public Health Program does entail. We hope that it helps you with your decision process. So at this time, Jane and Virginia, do you have any final thoughts that you would like to share?

Dr. Jane Steinberg:

No, but I’m happy to talk to any student who wants to talk.

Vijaya Seegulam:

I’m happy as well. Just to say that USC has given me so many opportunities and I’m also available via the links online. If anybody has any questions or wants to reach out to me, I’m also available.

Phil Solaria:

Perfect. Well, lastly, we’d like just to thank you again for taking the time out of your busy workday to hear more about today’s topic. As a reminder for next step, here is my contact information with my email address included. If you do have any other questions or if there were any that we did not get to today, we will be sure to send you a quick followup to get these answered.

Phil Solaria:

And a copy of these of this presentation will be sent to you. Post call today and we welcome you to follow us on our social media channels listed here. Thank you again. We hope you have a great rest of your week. Have a great day.