IMPORTANCEIn response to increasing public support for cannabis legalization, understanding associations of state and federal policy changes related to cannabis legalization with patterns of cannabis use is important. A challenge for public health monitoring and research is significant variation in data availability related to cannabis use behaviors and perceptions across and within states and over time, including the availability of prelegalization vs postlegalization data. OBJECTIVE To review data available on cannabis use and related behaviors over time in Massachusetts and the US. DESIGN, SETTING, AND PARTICIPANTS This case series examined state and national surveys on public health and related behaviors and outcomes to review availability of cannabis-related data for Massachusetts for 8 key indicators over time. Additionally, the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System for all states were reviewed. The analysis was conducted between February 1, 2019, and March 18, 2020. EXPOSURES Surveys that enable state-level estimation of cannabis use and related behaviors. MAIN OUTCOMES AND MEASURES Eight key indicators related to cannabis use behaviors and perceptions: lifetime cannabis use, age of initiation, frequency of use, location of use, method of use, source of cannabis, perceptions of cannabis, and reason for use (ie, medical vs nonmedical).RESULTS There were 7 surveys that monitored cannabis use and related behaviors in Massachusetts for adolescents and adults. No surveys monitored all 8 indicators of interest, and availability over time was limited. In the most recent BRFSS, 24 states asked cannabis-related questions, meaning BRFSS data on cannabis use was lacking for more than half of the US adult population. In the Youth Risk Behavior Surveillance System, 36 states asked standard cannabis questions; most other states had at least 1 question related to cannabis use and frequency. CONCLUSIONS AND RELEVANCEThese findings of limitations of existing surveys, and particularly the lack of national questions in the BRFSS and Youth Risk Behavior Surveillance System, suggest that available data have substantial limitations for monitoring cannabis use. As cannabis policy changes continue, there is a need to remain focused on the availability of high-quality data sources that allow for critical public health research.

Background States are rapidly moving to reverse marijuana prohibition, most frequently through legalization of medical marijuana laws (MMLs), and there is concern that marijuana legalization may affect adolescent marijuana use. Methods This natural-experimental study used state Youth Risk Behavior Survey (YRBS) data collected from participants in grades 9–12 from 1991 to 2015 in 46 states ( N = 1,091,723). Taking advantage of heterogeneity across states in MML status and MML dispensary design, difference-in-difference estimates compared states with enacted MMLs/dispensaries to non-MML/dispensaries states. Multivariable logistic regression modeling was used to adjust for state and year effects, and student demographics. The main outcome assessed was past 30-day adolescent marijuana use [“any” and “heavy” (≥20)]. Results In the overall sample, the adjusted odds of adolescents reporting any past 30-day marijuana use was lower in states that enacted MMLs at any time during the study period (OR 0.94, 95% CI 0.89 to 0.99; p < .05), and in states with operational dispensaries in 2015 (OR 0.93, 95% CI 0.88 to 0.99; p < .05). Among grade cohorts, only 9th graders showed a significant effect, with lower odds of use with MML enactment. We found no effects on heavy marijuana use. Conclusions This study found no evidence between 1991 and 2015 of increases in adolescents reporting past 30-day marijuana use or heavy marijuana use associated with state MML enactment or operational MML dispensaries. In a constantly evolving marijuana policy landscape, continued monitoring of adolescent marijuana use is important for assessing policy effects.

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In their study, Matthay et al 1 identify cannabis commercialization as a risk factor associated with population-level adverse health outcomes, including self-injury and violence, among young men. This consideration of the degree of cannabis commercialization extends a critical early call to researchers, most notably that from Pacula et al, 2 to consider heterogeneity in cannabis policy assessments. The more recent delineation of the 14 Ps of cannabis policy design options for states by Kilmer 3 further clarifies cannabis policy heterogeneity, including the following options most relevant for an assessment of commercialization: profit motive, power to regulate, promotion, prevention and treatment, policing and enforcement, product types, and potency. Important differences exist among cannabis laws, regulations, implementation, and fidelity of implementation across the 36 states with legal medical-use cannabis, the 15 with legal adult-use (ie,

States across the U.S. are increasingly legalizing cannabis for recreational purposes (“adult-use”) through licensure of privately-run cannabis establishments. Legalization efforts have partially emerged in response to unequal prohibition enforcement which disproportionately affects Black and Hispanic/Latino communities. However, the extent to which people from communities most affected by prohibition are included in the legal industry is unknown. This study is a preliminary analysis of participation by race/ethnicity and gender across job titles in the Massachusetts adult-use cannabis industry from its inception through April 2020 (18-month time span). Data were extracted from cannabis establishments (i.e., licensed adult-use cannabis businesses that collectively form the cannabis industry in Massachusetts). Agent registration forms are required for board members, directors, executives, managers, employees, and volunteers across all license types (e.g. retail, cultivation, product manufacturing). As of April 2020, there were 4,907 unique agents (volunteers excluded) across 205 cannabis establishment licenses. Among agents, 77% were White, 9% were Hispanic/Latino, and 6% were Black/African American, <3% identified other racial and ethnic groups, and data were missing for approximately 6% of the sample (exceeds 100%, as persons can be included in more than one race/ethnicity). Excluding agents with missing race/ethnicity or gender (n=347) and grouping persons at two-levels: (1) white or not-white identifying, and (2) male or female, we found 53% of agents were white and male, 29% were white and female, 12% were an ethnicity and/or race(s) that did not include white (“non-white”) and male, and 5% were non-white and female. Approximately 8% of agents held senior-level positions (i.e., board members, directors, executives) versus less senior positions (i.e., employees, managers). However, white males held 72% of senior positions, white females held 17%, non-white males held 9%, and non-white females held 1%. This study is subject to limitations, including that persons who identified as white and another race(s) (n=103) are included in white-identifying categories; future work will address this limitation. Further, all data is typically reported by supervisors rather than self-reported, therefore race/ethnicity and gender are subject to misidentification. Nonetheless, findings suggest that at approximately one and a half years after retail stores opened, participation in the Massachusetts adult-use cannabis industry skews white and male, and this trend is pronounced in senior-level positions.