Item 01 2024-01874 Cannabis Social Consumption Pilot Program Ordinance — Sacramento City Council, November 19, 2024

City of Sacramento
City Council - 2PM Report
915 I Street Sacramento, CA 95814
www.cityofsacramento.org
File ID: 2024-01874 11/19/2024 Discussion Item 1.

Cannabis Social Consumption Pilot Program Ordinance
File ID: 2024-01874
Location: Citywide
Recommendation: Adopt an Ordinance amending various sections of chapter 5.150, adding chapter 8.133 to, and deleting chapter 9.08 of the Sacramento City Code, relating to the consumption of cannabis and cannabis products.

Contact: Leyne Milstein, Assistant City Manager, (916) 808-8491, [email protected], Office of the City Manager; Peter Coletto, Director of Finance, (916) 808-5416, [email protected], Department of Finance; Fiona Mattson, Program Specialist, (916) 808-8925, [email protected], Office of Cannabis Management Presenter: Fiona Mattson, Program Specialist, (916) 808-8925, [email protected], Office of Cannabis Management
Attachments:
1-Description/Analysis
2-Article: “Trends in Marijuana Use among Adolescents in the United States” 3-Article: “Regular cannabis smoking and carotid artery calcification in the Multi-Ethnic Study of Atherosclerosis”
4-CDPH Marijuana and California Youth
5-Ordinance (Clean)
6-Ordinance (Redline)
Description/Analysis
Issue Detail: Since the passage of Proposition 64, the consumption of cannabis and cannabis products by multiple individuals in a designated areas (“social consumption”) has been a point of discussion. Currently, social consumption is allowed in the city at special cannabis events that are at locations that are state-licensed and approved by Council in accordance with California Business and Professions Code section 26200(e) and Sacramento City Code section 5.150.360.C. To date, Cal Expo is the only authorized space for the social consumption of cannabis. Extending designated social consumption areas to include lounges at storefront cannabis dispensaries can provide additional legal space to consume cannabis in a way that doesn't impact the non-cannabis

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File ID: 2024-01874 11/19/2024 Discussion Item 1.
consuming public, and which is away from those who are under 21.

The Office of Cannabis Management (OCM) staff have conducted extensive outreach regarding cannabis consumption. A careholder meeting was held on consumption lounges in December 2021, where OCM presented information to interested parties on licensing limitations under state law, sought to clarify misconceptions of what consumption lounges could include, and received input on how careholders envisioned onsite consumption in Sacramento.

On August 30, 2022, the Law and Legislation Committee (Committee) hosted a workshop with a panel of regulators from West Hollywood, Palm Springs, and San Francsico to discuss consumption lounges in their jurisdictions and to answer questions around community concerns, revenues, and the cost of regulatory oversight, enforcement challenges, and lessons learned.

Following that, OCM hosted two community engagement meetings on cannabis consumption lounges - a virtual meeting on April 12, 2023, and an in-person meeting on April 25, 2023. OCM also made a presentation on consumption lounges and events at the quarterly meeting of the City’s Property and Improvement Districts (PBIDs) on April 19, 2023.

After these meetings, OCM conducted an online survey with the same questions and options presented at the April 25, 2023, in-person meeting for interested parties including permitted businesses, current and potential applicants, PBIDS, neighborhood associations, and any individual who had previously attended a careholder meeting or signed up for alerts for cannabis news. The survey was sent to approximately 3,000 interested parties and OCM received 481 responses. While responses varied on details, respondents were virtually unanimous in their support of expanding public cannabis consumption to either dedicated consumption lounges and/or to temporary events outside of Cal Expo.

Between October 2022 and July 2023, OCM engaged in fact-finding by meeting with regulators and visits to consumption lounges in San Francisco, Oakland, Palm Springs, West Hollywood, and Coachella. OCM also spoke with the facilities’ owners or managers about the challenges and benefits of operating a consumption lounge from the businesses’ perspective.

On September 19, 2023, staff presented the information from the community and PBID meetings, the survey results, and fact-finding to the Committee. After public comment and a robust Committee discussion, the Committee directed staff to first bring back a framework for a consumption lounge pilot, and secondarily to bring forward a framework for cannabis events outside of Cal Expo.

On May 21, 2024, staff presented a social consumption permitting framework to the Committee that would create two permit “add-on” types in the form of conditions on storefront dispensary permits to allow consumption lounges:

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File ID: 2024-01874 11/19/2024 Discussion Item 1.
· Type 1 (Ingestible Products Only or “Non-smoking”) - would allow for cannabis-infused drinks, such as mocktails, canned/bottled drinks and cannabis infused-edibles, such as cookies, popcorn, chips, chocolate, and gummies.
· Type 2 (Inhalable and Ingestible Products or “All cannabis consumption”) - would allow for all Type 1 activities and the ability to smoke cannabis products such as flower, pre-rolls, and concentrates.

Both types would allow for the sale of prepackaged, non-cannabis-infused, non-alcoholic food and beverages.

By Committee direction, Type 2 conditioned facilities would be required to have negative pressure smoking rooms designed to limit to the extent possible leakage of smoke and particulate matter into the non-smoking room(s) and have HVAC systems separated from the rest of the facility that do not recirculate and have a high rate of air exchange. On May 21, 2024, the Committee also directed that the Type 2 conditions be open to all storefront permittees.

On September 17, 2024, staff presented to the Committee a cannabis consumption permitting framework that would be available to all storefront dispensaries. The Committee forwarded the pilot program concept for social consumption to Council for consideration but requested a Council workshop soliciting the expertise of public health experts regarding cannabis consumption statewide public health trends prior to Council consideration of social consumption.

On October 22, 2024, Amanda Reiman, PhD, MSW, the Chief Knowledge Officer for New Frontier Data presented to Council about cannabis consumption statewide public health trends. Council also heard a presentation from Suzaynn Schick, PhD, Associated Professor of Medicine for the University of California San Francisco School of Medicine regarding secondhand smoke in dispensaries.

After the October 22, 2024, workshop, staff were made aware of two recent studies that apply to the issues discussed at the October 22, 2024, Council workshop and are included as Attachments 2 and 3 respectively:
· “Trends in Marijuana Use among Adolescents in the United States” which shows a decline in youth cannabis youth post-legalization; and
· “Regular cannabis smoking and carotid artery calcification in the Multi-Ethnic Study of Atherosclerosis” that concluded there “were no statistically significant associations between a history of regular cannabis smoking (primary analysis), duration, or recency of cannabis smoking, and the prevalence of carotid calcified plaque." As a result of the Council workshop, staff have added requirements for warning signs relative to the health effects of inhaled cannabis to the proposed ordinance.

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File ID: 2024-01874 11/19/2024 Discussion Item 1.

Assembly Bill (AB) 1775 will be effective on January 1, 2025, and allows for the preparation of and sale of non-cannabis-infused, non-alcoholic food and beverages products in the consumption area in compliance with all applicable provisions of the California Retail Food Code and the sale of tickets for live entertainment. The pilot program before Council allows for the sale of pre-packaged non- cannabis-infused, non-alcoholic food and beverages and sale of tickets for live entertainment. A regulatory scheme for on-site food and beverage preparation will require additional staff research and time, as well as engagement with the County of Sacramento to determine needs and requirements for additional permits and inspections as related to commercial kitchens. Any live entertainment events at cannabis social consumption lounges must meet all other City live event requirements.

Additionally, AB 1775 added employee health protections including:
· Giving employees the right to wear masks where cannabis is smoked - including N95 and NIOSH rated masks - at the employee’s discretion.
· Requiring employers to provide guidance regarding secondhand cannabis smoke in writing from the Department of Public Health to employees working where cannabis is smoked. · Requiring consumption lounges where smoking is allowed to include secondhand smoke in their analysis of potential work hazards for purposes of their injury and illness prevention programs required by Section 3203 of Title 8 of the California Code of Regulations.

Additional local health and safety regulations beyond the State requirements in AB 1775 include the ventilation requirements for Type 2 permits outlined above and the following documentation required to obtain a permit:
· Consumption Lounge Operation Plan - This document would describe in detail, including but not limited to:
o Patron and product flow;
o Employee training;
o Emergency plans;
o Patron time and dosing limitations in the lounge;
o Employee time in lounge and rotating staff schedules; o Employee respirator and masking options the employer will provide; and o Hours of operation.
· Impaired Driving Prevention Plan - This document would describe in detail how the business would ensure patrons leave the consumption lounge and have access to safe transportation (i.e. over consumption educational components, access to regional transit, ridesharing

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options, establishing “no-tow” zones).
· Ventilation Plan (Type 2 only) - This document would describe in detail the HVAC/ventilation system that is implemented, maintained and complies with the California Mechanical Code.

Senate Bill 540 provides additional requirements for storefront dispensaries or microbusiness selling, or person delivering, cannabis or cannabis products to a consumer. These permit types will be required to provide an informational brochure that addresses the following and will be developed by the Department of Cannabis Control in consultation with the Department of Public Health on and after March 1, 2025.
· Information about the pharmacological effects of cannabis use. · Information on the implications and risks associated with, but not limited to, all of the following:
o High potency cannabis products.
o The potential for THC to exacerbate certain mental health conditions. o Cannabis use by minors.
o Cannabis use by pregnant and breastfeeding persons.\
Should Council approve the proposed ordinance, next steps are outlined below:
· Develop minimum thresholds for employee time in lounge and rotating staff schedules and patron time and dosing limitations in the lounge to be included in the required the Consumption Lounge Operation Plan;
· Solicit and implement a request for proposal for an education and outreach campaign to engage the public on cannabis safe use. Additionally, the program will include a harm reduction model for youth (21 to 25 years of age) and will provide education materials and signage on how to reduce or responsibility use cannabis. · Complete a fee study, which can be included in the comprehensive cannabis fee study, and a Resolution will be brought back to Council for consideration. · The Planning Division is preparing a draft ordinance relating to Title 17 cannabis zoning amendments for all cannabis land uses. The public review process of the draft ordinance is anticipated to begin in January 2025.

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File ID: 2024-01874 11/19/2024 Discussion Item 1.

Staff is recommending that if Council moves forward with social consumption that it be a five-year pilot program.

Policy Considerations: State law allows for the City to permit social consumption at storefront dispensaries. Social consumption would allow people to consume cannabis in a way that does not impact the non-cannabis consuming public; especially, away from those who are under 21. A pilot program will enable the City to evaluate the impacts of social consumption, including impacts on the local cannabis industry and surrounding businesses, public safety, and transportation.

Economic Impacts: The addition of cannabis consumption lounges may increase economic activity in the cannabis marketplace, as well as drive cannabis tourism and enhance surrounding businesses to the lounge.

Environmental Considerations: This action is exempt from the California Environmental Quality Act (CEQA) because it is the adoption of an ordinance, rule, or regulation that requires discretionary review, including environmental review, and approval of permits, licenses, or other authorizations to engage in commercial cannabis activity (CEQA Guidelines section 15061(B)(1), California Business and Professions Code section 26055(h)) and because it does not have the potential for causing a significant effect on the environment (CEQA Guidelines section 15061(b)(3)).

Sustainability: Not applicable.

Commission/Committee Action: The Committee has met numerous times on the issue of social consumption, engaged in robust fact-finding and on September 17, 2024, voted to forward the pilot program for social consumption to Council for consideration and requested a workshop soliciting the expertise of public health experts regarding cannabis consumption statewide public health trends, which was heard on October 22, 2024.

Rationale for Recommendation: Staff is recommending Council adopt an ordinance for a cannabis social consumption pilot program (Attachment 5 and 6). This will allow staff to collect and evaluate data, respond to questions and concerns as they arise, and take enforcement action if needed. Staff is recommending the pilot program for five years. This would give storefront permits the opportunity to decide whether to invest funds and explore the strategies for a potentially temporary business opportunity. Furthermore, this will allow the City to address any risks and/or unintended consequences of a pilot program.

Financial Considerations: The addition of social consumption options may increase cannabis sales which would increase revenues into the General/Measure U fund and the Measure L Children’s Fund.

Local Business Enterprise (LBE): Not applicable.

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Citation: Yang, J.; Mejia, M.C.; Sacca,
L.; Hennekens, C.H.; Kitsantas, P .

Trends in Marijuana Use among
Adolescents in the United States.

Pediatr. Rep. 2024, 16, 872–879.
https://doi.org/10.3390/
pediatric16040074
Academic Editor: Maurizio Aricò
Received: 13 September 2024
Revised: 2 October 2024
Accepted: 8 October 2024
Published: 15 October 2024
Copyright: © 2024 by the authors.

Licensee MDPI, Basel, Switzerland.

This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/

4.0/).

Article
Trends in Marijuana Use among Adolescents in the United States Jack Yang, Maria C. Mejia
, Lea Sacca
, Charles H. Hennekens and Panagiota Kitsantas *
Department of Population Health and Social Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA; [email protected] (J.Y.); [email protected] (M.C.M.); [email protected] (L.S.); [email protected] (C.H.H.) * Correspondence: [email protected]; Tel.: +1-(561)-297-0545 Abstract: Background: Marijuana is a widely used substance in the United States (US) and worldwide.

We explored trends in self-reported marijuana use among US adolescents overall as well as by gender, race/ethnicity, and school grade. Methods: Biennial data from the Youth Risk Behavior Survey from 2011 to 2021 included 88,183 adolescents in grades 9th through 12th. We used percentage change as a measure of effect and the chi-square test for significance. All analyses were conducted at the national level. Results: The percentage of adolescents who reported current marijuana use dropped significantly from 23.1% in 2011 to 15.8% in 2021 (p < 0.05). The self-report of trying marijuana for the first time before age 13 also decreased significantly from 8.1% in 2011 to 4.9% in 2021 (p < 0.05).

For current use, there were similar significant decreases by race/ethnicity, with Asian, Hispanic, and White adolescents experiencing the steepest declines. In 2021, the percentage of Black adolescents self-reporting marijuana use was significantly higher (20.5%) compared to White (14.8%), Hispanic (16.7%), and Asian (5.1%) adolescents. Although current marijuana use declined significantly for both girls and boys over time, in 2021 girls were more likely (17.8%) to currently use marijuana than boys (13.6%). In 2011, the opposite was true, with boys (25.9%) being more likely to use marijuana than girls (20.1%). Conclusions: In US adolescents in 2021, there were decreases in self-reports of marijuana use compared to 2011. Behavioral interventions within school and family environments may be critical in mitigating the risk of marijuana use.

Keywords: adolescents; marijuana; cannabis; students; United States

1. Introduction
Marijuana has become one of the most frequently used illicit substances among adoles- cents in the United States (US) [1,2]. Regular or high marijuana usage during adolescence, which constitutes a crucial period for neural development, has been linked to poor cogni- tive outcomes, such as disadvantaged learning, working memory tests, and attention, even when considering years of school and verbal intelligence [3–6]. Other detriments associated with marijuana use in adolescents include being 2–3.5 times more likely to report a lower grade point average and a 4-fold increase in adult psychosis diagnoses [ 7,8]. Research shows that marijuana use negatively impacts brain functioning by decreasing synaptic pruning, which leads to a greater volume of gray matter and overall lowers the efficiency of communication between higher-order areas of the brain [9].

Monitoring trends in marijuana use for adolescents in the US is especially important given the increasing number of US states that are legalizing recreational marijuana and the low perceived risk in this population [2,10]. It is important to examine marijuana use at a national level and by gender and other demographics to gain a better understanding of these trends [11].

In this original research, we utilized the Youth Risk Behavior Survey (YRBS) data from 2011 to 2021 to explore temporal trends in marijuana use among US adolescents overall as well as by gender, race/ethnicity, and school grade.

Pediatr. Rep. 2024, 16, 872–879. https://doi.org/10.3390/pediatric16040074 https://www.mdpi.com/journal/pediatrrep Pediatr. Rep. 2024, 16 873

2. Materials and Methods
The YRBS, which is a cross-sectional survey, is provided by the US Centers for Disease Control and Prevention and includes self-reports of marijuana use among adolescents in grades 9 through 12 from 2011 to 2021. The YRBS is conducted biennially among students in grades 9 to 12 who are sampled from randomly selected public and private schools [12].

All students in sampled schools and classes are eligible to participate in these surveys.

The YRBS monitors health behaviors in large samples of US adolescents that contribute to their leading avoidable causes of premature morbidity and mortality. This survey includes public, parochial, and private schools across the US. In 2021, the student response rate was

79.1%. Detailed descriptions have been reported previously [12].

The total study sample comprised 88,183 US high school students and included data from 2011 ( n = 15,031), 2013 ( n = 13,314), 2015 ( n = 15,250), 2017 ( n = 14,386), 2019 (n = 13,305), and 2021 (n = 16,897).

The exposure variables for self-reported marijuana use, also referred to as pot or weed, included (1) ever used, defined as one or more times during their life; (2) first used before age 13 years; and (3) current use, defined as one or more times during the 30 days before the survey. The survey also included self-reported data on race/ethnicity (Black, Asian, Hispanic/Latino, and White), school grade (9th, 10th, 11th, and 12th), and gender (boy/girl) [13].

Descriptive statistics were conducted using percentages as the measures of effect and used the chi-square test for statistical significance. We considered a two-sided p value <0.05 to be statistically significant. All of the data analyses were conducted using the Youth Online system which allows access to the YRBS data for the years 2011–2021 [13].

3. Results
The percentage of adolescents with ever using marijuana significantly decreased from

39.9% in 2011 to 27.8% in 2021 ( p < 0.05). Similarly, the proportion of adolescents who reported current marijuana use dropped from 23.1% in 2011 to 15.8% in 2021 ( p < 0.05) (Figure 1). A significant decrease was also observed between 2011 and 2021 for trying marijuana for the first time before age 13 (from 8.1% in 2011 to 4.9% in 2021, p < 0.05).

Overall, from 2011 to 2013, we observed an increase in use for all these behaviors, a decline from 2015 to 2017 with a slight peak in 2019 (except for tried marijuana before age 13 which continued to decline), and a rapid decrease in 2021.

Pediatr. Rep. 2024, 16, FOR PEER REVIEW 3

Figure 1. Marijuana use in adolescents, Youth Risk Behavior Survey 2011–2021.

Concerning race/ethnicity, a decline in marijuana use was observed across all racial/ethnic groups between 2011 and 2021 (Figure 2). In 2021 , however, the proportion of Black adolescents reporting marijuana use was higher (20.5%) when compared to White (14.8%), Hispanic (16.7%) , or Asian (5.1%) adolescents. This was also true for all of the other years except for 2019.

Figure 2. Current marijuana use in adolescents by race/ethnicity, Youth Risk Behavior Survey 2011– 2021.

By grade, in 2021, the current use of marijuana was higher for adolescents in grades 12 (22.4%) followed by those in grade 11 (18.7%) than lower grades (Figure 3). A significant decrease was observed from 2011 to 2021 across all grades, particularly for 9t h grade.

Overall, a significant decline in current marijuana use was observed across time for all grades except for an increase in 2013 for grade 10 and a slight increase again in 2019. 2011 2013 2015 2017 2019 2021
Ever used marijuana 39.9 40.7 38.6 35.6 36.8 27.8
Current use of marijuana 23.1 23.4 21.7 19.8 21.7 15.8
Tried marijuana before age 13 8.1 8.6 7.5 6.8 5.6 4.9
0 5
10 15
20 25
30 35
40 45
50 Percentage
2011 2013 2015 2017 2019 2021
Asian 13.6 16.4 8.2 7.3 8.5 5.1
Black 25.1 28.9 27.1 25.3 21.7 20.5
Hispanic 24.4 27.6 24.5 23.4 22.4 16.7
White 21.7 20.4 19.9 17.7 22.1 14.8
5 10
15 20
25 30
35 40
45 Percentage of current use
of marijuana
Figure 1. Marijuana use in adolescents, Youth Risk Behavior Survey 2011–2021.

Pediatr. Rep. 2024, 16 874
Concerning race/ethnicity , a decline in marijuana use was observed across all racial/ethnic groups between 2011 and 2021 (Figure 2). In 2021, however, the proportion of Black ado- lescents reporting marijuana use was higher (20.5%) when compared to White (14.8%), Hispanic (16.7%), or Asian (5.1%) adolescents. This was also true for all of the other years except for 2019.

Pediatr. Rep. 2024, 16, FOR PEER REVIEW 3

Figure 1. Marijuana use in adolescents, Youth Risk Behavior Survey 2011–2021.

Figure 2. Current marijuana use in adolescents by race/ethnicity, Youth Risk Behavior Survey 2011– 2021.

Overall, a significant decline in current marijuana use was observed across time for all grades except for an increase in 2013 for grade 10 and a slight increase again in 2019. 2011 2013 2015 2017 2019 2021
Ever used marijuana 39.9 40.7 38.6 35.6 36.8 27.8
Current use of marijuana 23.1 23.4 21.7 19.8 21.7 15.8
Tried marijuana before age 13 8.1 8.6 7.5 6.8 5.6 4.9
0 5
10 15
20 25
30 35
40 45
50 Percentage
2011 2013 2015 2017 2019 2021
Asian 13.6 16.4 8.2 7.3 8.5 5.1
Black 25.1 28.9 27.1 25.3 21.7 20.5
Hispanic 24.4 27.6 24.5 23.4 22.4 16.7
White 21.7 20.4 19.9 17.7 22.1 14.8
5 10
15 20
25 30
35 40
45 Percentage of current use
of marijuana
Figure 2. Current marijuana use in adolescents by race/ethnicity, Youth Risk Behavior Survey 2011–2021.

Overall, a significant decline in current marijuana use was observed across time for all grades except for an increase in 2013 for grade 10 and a slight increase again in 2019.

Pediatr. Rep. 2024, 16, FOR PEER REVIEW 4

Figure 3. Current marijuana use in adolescents by grade, Youth Risk Behavior Survey 2011–2021.

With regard to gender, although current marijuana use declined significantly for both girls and boys over time, in 2021 girls were more likely (17.8%) to currently use marijuana than boys (13.6%) (Figure 4 and Table 1) , while the opposite was true for the year 2011 , with boys being more likely to use marijuana than girls (25.9% versus 20.1%) (Figure 4).

Table 1 displays differences in marijuana use behaviors between boys and girls for 2021 , which is the most recent year available. Girls were significantly more likely to report ever using marijuana (30.9%) than boys (24.8%) , but no significant differences were observed in marijuana use before age 13. For both girls and boys, Black adolescents followed by Hispanic adolescents were more likely to currently use marijuana, start using marijuana before the age of 13, and have ever used marijuana compared to other racial/ethnic groups.

Current use and ever use of marijuana were particularly high among adolescents in grades 11 and 12, and the percentages of use were significantly higher among girls than boys across all grades except for grade 12 ( p-value < 0 .05). Although girls in grades 9 and 11 were significantly more likely to have used marijuana before age 13 (p-value < 0.05), boys in grade 12 were more likely (6.4%) than girls (3.2%) to report this behavior ( p-value <

0.05).

Figure 4.Marijuana use in adolescents by gender, Youth Risk Behavior Survey 2011–2021. 2011 2013 2015 2017 2019 2021
Grade 9 18 17.7 15.2 13.1 14.6 9.1
Grade 10 21.6 23.5 20 18.7 19.8 13.3
Grade 11 25.5 25.5 24.8 22.6 24.9 18.7
Grade 12 28 27.7 27.6 25.7 28.3 22.4
5 10
15 20
25 30
35 40
45 Percentage of current use
of marijuana
2011 2013 2015 2017 2019 2021
Boys 25.9 25 23.2 20 22.5 13.6
Girls 20.1 21.9 20.1 19.6 20.8 17.8
0 5
10 15
20 25
30 35
40 45
Percentage of current use
of marijuana
Figure 3. Current marijuana use in adolescents by grade, Youth Risk Behavior Survey 2011–2021.

With regard to gender, although current marijuana use declined significantly for both girls and boys over time, in 2021 girls were more likely (17.8%) to currently use marijuana Pediatr. Rep. 2024, 16 875
than boys (13.6%) (Figure 4 and Table 1), while the opposite was true for the year 2011, with boys being more likely to use marijuana than girls (25.9% versus 20.1%) (Figure 4).

Table 1 displays differences in marijuana use behaviors between boys and girls for 2021, which is the most recent year available. Girls were significantly more likely to report ever using marijuana (30.9%) than boys (24.8%), but no significant differences were observed in marijuana use before age 13. For both girls and boys, Black adolescents followed by Hispanic adolescents were more likely to currently use marijuana, start using marijuana before the age of 13, and have ever used marijuana compared to other racial/ethnic groups.

Current use and ever use of marijuana were particularly high among adolescents in grades 11 and 12, and the percentages of use were significantly higher among girls than boys across all grades except for grade 12 ( p-value < 0.05). Although girls in grades 9 and 11 were significantly more likely to have used marijuana before age 13 (p-value < 0.05), boys in grade 12 were more likely (6.4%) than girls (3.2%) to report this behavior (p-value < 0.05).

Pediatr. Rep. 2024, 16, FOR PEER REVIEW 4

Figure 3. Current marijuana use in adolescents by grade, Youth Risk Behavior Survey 2011–2021.

0.05).

Figure 4.Marijuana use in adolescents by gender, Youth Risk Behavior Survey 2011–2021. 2011 2013 2015 2017 2019 2021
Grade 9 18 17.7 15.2 13.1 14.6 9.1
Grade 10 21.6 23.5 20 18.7 19.8 13.3
Grade 11 25.5 25.5 24.8 22.6 24.9 18.7
Grade 12 28 27.7 27.6 25.7 28.3 22.4
5 10
15 20
25 30
35 40
45 Percentage of current use
of marijuana
2011 2013 2015 2017 2019 2021
Boys 25.9 25 23.2 20 22.5 13.6
Girls 20.1 21.9 20.1 19.6 20.8 17.8
0 5
10 15
20 25
30 35
40 45
Percentage of current use
of marijuana
Figure 4. Marijuana use in adolescents by gender, Youth Risk Behavior Survey 2011–2021.

Table 1. Marijuana use among United States adolescents by gender, Youth Risk Behavior Survey 2021.

Year 2021
Girls
% (95% CI)
Boys
% (95% CI) p-Value
Current use of marijuana 17.8 (15.8–20.1) 13.6 (12.1–15.3) 0.00 Black 24.8 (20.5–29.6) 16.4 (13.2–20.1) 0.00
Asian 4.7 (2.6–8.3) 5.5 (3.6–8.3) 0.57
Hispanic/Latino 19.1 (15.6–23.1) 13.4 (11.2–15.9) 0.00
White 16.3 (14.4–18.5) 13.6 (11.8–15.5) 0.01
Grade
9 11.0 (8.8–13.8) 7.2 (5.6–9.1) 0.00
10 16.7 (13.8–20.0) 9.7 (8.1–11.6) 0.00
11 20.8 (17.8–24.1) 16.7 (14.4–19.4) 0.01
12 22.8 (20.0–25.9) 22.0 (19.5–24.8) 0.60
Ever used marijuana 30.9 (28.0–33.8) 24.8 (22.6–27.1) 0.00 Pediatr. Rep. 2024, 16 876
Table 1. Cont.

Year 2021
Girls
% (95% CI)
Boys
% (95% CI) p-Value
Race/Ethnicity
Black 37.1 (31.1–43.6) 29.7 (24.4–35.7) 0.01
Asian 9.0 (6.5–12.4) 10.5 (7.6–14.2) 0.39
Hispanic/Latino 34.8 (30.7–39.2) 27.4 (22.8–32.4) 0.00
White 29.0 (26.9–31.2) 23.5 (21.3–25.8) 0.00
Grade
9 17.8 (14.8–21.2) 13.5 (10.8–16.7) 0.01
10 28.1 (24.7–31.8) 20.0 (17.3–23.0) 0.00
11 35.6 (31.3–40.1) 30.7 (26.6–35.1) 0.04
12 42.2 (37.2–47.3) 36.5 (33.3–39.8) 0.06
Marijuana use before age 13 4.7 (3.9–5.8) 4.8 (3.9–5.9) 0.95 Race/Ethnicity
Black 5.3 (3.6–7.8) 9.2 (7.4–11.4) 0.00
Asian 0.7 (0.4–1.3) 1.6 (0.7–3.4) 0.21
Hispanic/Latino 6.1 (4.0–9.1) 5.6 (4.2–7.4) 0.66
White 4.0 (3.2–5.1) 3.5 (2.6–4.6) 0.39
Grade
9 5.8 (4.5–7.5) 4.1 (3.0–5.5) 0.01
10 5.0 (3.8–6.6) 3.3 (2.6–4.2) 0.02
11 4.8 (3.9–5.9) 5.2 (3.7–7.2) 0.68
12 3.2 (2.1–4.8) 6.4 (4.9–8.4) 0.00

4. Discussion
The results of this study show declining trends in marijuana use among US high school adolescents from 2011 to 2021. The decline in marijuana use within this population is part of a broader trend in decreasing substance use during the same period [ 2,14].

The significant decreases observed in both the “ever used marijuana” and “currently use marijuana” categories highlight a promising reduction in adolescent marijuana use, with usage dropping to approximately 70% of the levels recorded in 2011. Similarly, the percentage of adolescents who tried marijuana before age 13 decreased to about 60% of the 2011 levels. However, despite these encouraging trends, the study reveals persistent disparities in marijuana use when considering demographic factors such as grade level, gender, and race/ethnicity.

While we found a net decline in the percentage of marijuana use among students between 2011 and 2021 for all grade levels, there was consistently higher usage for older grades throughout all years, especially among 12th graders. The consistent observation that 12th graders have the highest rates of marijuana use across all survey years suggests that older adolescents may have greater access to marijuana, possibly due to more devel- oped peer networks and increased independence [15]. As adolescents progress through high school, the likelihood of exposure to marijuana through social circles may increase, contributing to the elevated usage rates among 12th graders. This trend underscores the importance of targeted interventions for older adolescents, who may be at greater risk of regular marijuana use.

Pediatr. Rep. 2024, 16 877
One of the most significant findings of this study is the shift in marijuana use trends by gender, with girls surpassing boys in reported marijuana use by 2021. This change is consistent with earlier reports suggesting a narrowing of the gender gap in substance use [16]. The increase in marijuana use among girls could be attributed to evolving social dynamics, including more integrated friend groups where girls may experience greater exposure to marijuana offers from male peers [ 17]. This trend is concerning given that early initiation and regular use of marijuana during adolescence are associated with an increased risk of developing cannabis use disorder later in life. Future research should explore the underlying factors driving this gender shift and examine the potential long-term implications for female adolescents.

The data also highlight significant racial/ethnic disparities in marijuana use among adolescents. Black adolescents consistently reported higher rates of current marijuana use compared to their Hispanic, White, and Asian peers throughout the study period.

This finding aligns with previous research indicating that minority groups, particularly Black adolescents, may perceive lower risks associated with marijuana use, which could contribute to higher usage rates [18]. In contrast, Asian adolescents reported the lowest rates of marijuana use, which may be related to stronger disapproval from parents and peers and higher perceived risks associated with drug use [19]. Addressing these disparities requires culturally sensitive prevention strategies that account for the unique social and cultural factors influencing marijuana use among different racial/ethnic groups.

While the overall decrease in US high school adolescent’s marijuana usage from 2011 to 2021 is encouraging, it is crucial to sustain and build on these gains through continued public health efforts. Behavioral interventions that promote positive connections within school and family environments are essential in mitigating the risk of marijuana use [20].

Interventions such as parenteral communication, monitoring, and modeling, as well as schools providing effective health education and promoting a positive school climate should be further encouraged to continue the decline in marijuana use [21]. Schools should prioritize effective health education programs that clarify the medical benefits and potential harms of marijuana use, particularly as legalization efforts continue to expand across the US [22]. Early prevention programs that focus on delaying the initiation of marijuana use and reducing its appeal to adolescents could further contribute to the downward trend observed in this study.

The findings regarding the increase in marijuana use among girls warrant partic- ular attention. Given the potential for increased vulnerability to the adverse effects of marijuana use, including the risk of developing cannabis use disorder [16], public health initiatives should include targeted messaging and interventions for female adolescents.

Understanding the social and environmental factors that contribute to this trend is critical for developing effective prevention strategies.

Despite the strengths of this study, several limitations should be noted. The reliance on self-reported data introduces potential biases, such as social desirability and recall biases, which may affect the accuracy of reported marijuana use. The cross-sectional design limits the ability to establish causality between observed trends and influencing factors.

Additionally, the study lacks detailed contextual information on marijuana use, such as frequency and potency, and does not account for variations in state legalization, which may influence trends. While the YRBSS provides a nationally representative sample, the findings may not be fully generalizable to all adolescents, particularly those outside traditional school settings. Moreover, the study does not consider other potential factors, such as socioeconomic status or peer influence, that could impact marijuana use. These limitations highlight the need for further research, especially longitudinal studies, to better understand the factors driving adolescent marijuana use and to inform effective prevention strategies.

5. Conclusions
In the US, the current landscape of marijuana legalization in adults adds a complex layer to the issues of adolescent marijuana use. As more states continue to legalize recre- Pediatr. Rep. 2024, 16 878
ational marijuana, the accessibility and perceived normalcy of the drug may increase, particularly for adolescents who may view its legal status as an indication of safety or acceptability. Marijuana legalization can influence adolescent behavior through reduced risk perception and increased availability, which may counteract efforts to reduce use in this vulnerable population.

In conclusion, the data from the YRBS underscore the importance of ongoing surveil- lance and intervention efforts to reduce marijuana use among US adolescents. By address- ing the specific needs of different demographic groups, including grade levels, genders, and racial/ethnic communities, public health initiatives can more effectively combat the risks associated with adolescent marijuana use and promote healthier outcomes for fu- ture generations.

Author Contributions: Conceptualization, J.Y. and P .K.; Methodology, J.Y. and P .K.; Formal Analysis, J.Y., P .K.; Writing—Original Draft Preparation, J.Y., P .K., and M.C.M.; Writing—Review and Editing, J.Y., P .K., M.C.M., L.S., and C.H.H.; Visualization, J.Y., P .K., and M.C.M. All authors have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Institutional Review Board Statement: The IRB considered this original research to be exempt.

Informed Consent Statement: Not applicable.

Data Availability Statement: The data presented in the study are openly available in Youth Risk Behavior Survey at https://nccd.cdc.gov/Youthonline/App/Default.aspx (15 July 2024).

Conflicts of Interest: The authors declare no conflicts of interest.

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20. Allen, M.L.; Garcia-Huidobro, D.; Porta, C.; Curran, D.; Patel, R.; Miller, J.; Borowsky, I. Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review. Pediatrics 2016, 138, e20154425. [CrossRef] [PubMed]

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Psychol. Addict. Behav. 2015, 29, 613–619. [CrossRef] [PubMed] Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. https://doi.org/10.1177/1358863X241287690
Vascular Medicine
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DOI: 10.1177/1358863X241287690
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Background
In recent years, the increasing use of cannabis (Cannabis sativa L., marijuana), driven by its broader legalization and acceptance for medical purposes, has resulted in a growing interest in its health implications.
1,2 Unlike tobacco, whose
negative cardiovascular effects are well-recognized,3 the car- diovascular effects of cannabis, particularly its association with atherosclerosis, remain a subject of evolving research. 4 Carotid artery calcification (CAC) is an established inde- pendent risk factor for heart disease, stroke, and myocardial infarction (MI).
5–7 Although research that measures the
Regular cannabis smoking and carotid artery
calcification in the Multi-Ethnic Study of
Atherosclerosis (MESA)
Jamie Corroon1 , Ryan Bradley2, Igor Grant3, Michael R Daniels1, Julie Denenberg1,2, Michael P Bancks4 and Matthew A Allison1 Abstract
Background: Studies on cannabis use and adverse cardiovascular outcomes have reported conflicting results. Research on its relationship to calcified arterial plaque remains limited. Methods: Cross-sectional data from 2152 participants at Exam 6 (2016–2018) in the Multi-Ethnic Study of Atherosclerosis (MESA) were analyzed, including self-reported cannabis smoking patterns and carotid artery calcification (CAC) as measured via computed tomography. Multivariable relative and absolute risk regression models were used to estimate adjusted prevalence ratios (PRs) and prevalence differences, respectively, for the presence of calcified plaque. Multivariable linear regression was then used to compare group differences in the extent of CAC in those with calcified plaque. Results: A minority of participants (n = 159, 7.4%) reported a history of regular cannabis smoking. Among all participants, 36.1% (n = 777) had detectable CAC. In models adjusted for demographics, behavioral, and clinical cardiovascular disease factors, a history of regular cannabis smoking was not associated with the prevalence of CAC in either common carotid artery (PR: 1.14, 95% CI: 0.88 to 1.49). In the subset of participants with calcified plaque, and in separate fully adjusted multivariable linear regression models, a history of regular cannabis smoking was not associated with increased calcium volume (difference = 7.7%, 95% CI: –21.8 to 48.5), calcium density (difference = 0.4%, 95% CI: –6.6 to

7.9), or Agatston score (difference = 32.1%, 95% CI: –31.8 to 155.8) in either carotid artery. Models exploring potential effect modification by age, race/ethnicity, and tobacco smoking status showed no significant association, except for higher CAC prevalence in men with a history of regular cannabis smoking. Conclusions: In a racially and ethnically diverse cohort of older adults with a moderately high prevalence of CAC, no associations were found between a history of regular cannabis smoking, duration, or recency of cannabis smoking, and the prevalence of carotid calcified plaque. These findings were consistent across age, race/ethnicity, and cigarette smoking, except for an increased prevalence in men with a history of regular cannabis smoking. Similarly, in a subgroup with CAC, no association was found between a history of regular cannabis smoking and extent of calcification as measured by volume, density, and Agatston score.

Keywords
atherosclerosis, cannabis, cardiovascular disease, carotid artery disease, marijuana 1Department of Family Medicine, University of California San Diego, La Jolla, CA, USA
2Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
3Department of Psychiatry, Center for Medicinal Cannabis Research, University of California San Diego, La Jolla, CA, USA
4Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
Corresponding author:

Jamie Corroon, Department of Family Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.

Email: [email protected]
1287690 VMJ0010.1177/1358863X241287690Vascular MedicineCorroon et al. research-article2024
Original Research Article

2 Vascular Medicine 00(0)
prevalence of calcified plaque shows a lower prevalence in the carotid arteries than in other vascular beds (i.e., carotid:

32.2% vs coronary: 55.8%), calcification in the carotid arter- ies may indicate a more extensive atherosclerotic burden, and is associated with a higher risk of both total and noncardio- vascular disease mortality compared to calcification in the coronary arteries.
8 Despite cross-sectional evidence suggesting an association between chronic cannabis use and higher prevalence of ath- erosclerosis and other cardiovascular diseases (CVDs),
9–11
including stroke, 12,13 the evidence is conflicting, and there remains a gap in determining whether cannabis use is associ- ated with calcified plaque in the carotid arteries specifically.

Notably, two published longitudinal studies failed to detect associations between lifetime cannabis use and carotid
intima–media thickness
14 or coronary or abdominal artery
calcium in never tobacco smokers. 15 Because of the strong predictive value of calcified plaque on CV events, this dis- crepancy underscores the need for further research to clarify the relationship between regular cannabis use and cardiovas- cular health, and may help elucidate mechanisms through which cannabis affects risk.

As such, the research presented here aimed to investigate associations between regular cannabis smoking and calcified plaque in the carotid arteries in a large, multiethnic cohort of US adults without history of CVD at baseline.

Methods
Study population
The Multi-Ethnic Study of Atherosclerosis (MESA) is a pro- spective cohort study of men and women aged 45–84 years who were free of clinical CVD at the time of study enrollment (n = 6814). Participants were recruited from 2000 to 2002 at six US field centers from four race/ethnic groups: non-His- panic White (38%), non-Hispanic Black/African American
(28%), Hispanic American (22%), and Chinese Americans
(12%). All participants provided written informed consent.

The original MESA study was approved by the institutional review board of each field center. Detailed methodology for MESA has been published previously.
16 Analytic sample
The analytic sample (n = 2152) was limited to all MESA par- ticipants with complete data for two questions used to define a history of regular cannabis use and lung CT scans scored for the presence of calcium in carotid arteries at Exam 6
(2016–2018).

Independent variables
Cannabis use. At Exam 6, participants responded to a series of questions about cannabis use (Supplementary Figure 1).

Participants classified as having a history of regular cannabis smoking were those who responded ‘Yes’ to the questions: (1) ‘Have you smoked more than 100 marijuana or hashish joints/ pipes in your life?’ and (2) ‘Have you ever smoked marijuana or hashish regularly (at least once per month)?’ Those classi- fied as having no history of regular smoking were those who reported ‘Yes’ or ‘No’ to the first question and ‘No’ to the second.

Participants with a history of regular smoking were subse- quently asked: ‘For how many years did you smoke marijuana or hashish regularly?’ and ‘How long has it been since you last smoked marijuana or hashish?’. Years of regular smoking were analyzed as both continuous and categorical variables. Recency of smoking was defined as any reported cannabis smoking within the preceding 31 days (Supplementary Figure 1).

To assess a multifaceted exposure including duration, fre- quency, and quantity of cannabis smoking, a composite meas- ure was created (i.e., joint/pipe years). Joint/pipe years was calculated using the midpoint for each categorical response to ‘During the time that you smoked marijuana or hashish regu- larly, how often would you usually smoke it?’ (Supplementary Methods). Joint/pipe years was calculated as follows: (mid- point value of each categorical response to ‘During the time that you smoked marijuana or hashish regularly, how often would you usually smoke it?’ × 12 months/year × ‘On the days that you smoked marijuana or hashish, how many joints or pipes would you usually smoke?’ × years of regular smok- ing) / days per year. For example: (6 times per month × 12 months/year × 3 joints/pipes per day × 10 years of regular smoking) / 365.25 = 5.9 joint/pipe years.

Covariates. Site, sex, race/ethnicity, household income, and educational attainment were assessed at the Baseline Exam, whereas all other variables were assessed at Exam 6, includ- ing age, physical activity, cigarette smoking, current alcohol use, and medication use. Height, weight, and biomarkers (total cholesterol [mg/dL], high-density lipoprotein [HDL] cholesterol [mg/dL], fasting blood glucose [mg/dL], and HbA1c [%]) were objectively measured at Exam 6 in the cen- tral laboratory (University of Vermont, Burlington, VT, USA) using standardized protocols and calibrated measure- ments. Also at this visit, resting seated systolic (SBP) and dia- stolic (DBP) blood pressure were measured in triplicate at 1-minute intervals. Readings were averaged to obtain mean SBP and DBP.

Dyslipidemia was defined as a total cholesterol to HDL ratio > 5.0 or use of lipid-lowering medication. Prediabetes was defined as fasting blood glucose 100–125 mg/dL or Hb A1c

5.7–6.4%. Diabetes was defined as fasting blood glucose ⩾ 126 mg/dL, HbA1c ⩾ 6.5%, or the use of antidiabetic
medication.

Dependent variables. The methodology for acquisition and interpretation of calcified atherosclerosis in the carotid arter- ies using lung computed tomography (CT) scans, as well as Corroon et al. 3
the reproducibility of the readings, have been reported previ- ously.17 Lung CT scans were obtained as part of an ancillary study within MESA for 2381 individuals at visit 6 and 2170 CT scans (91%) were scored for the presence of calcium.

Carotid artery calcium was assessed using either an elec- tron-beam CT scanner (Chicago, Los Angeles, and New
York) or a multidetector CT system (Baltimore, St Paul, and Winston-Salem). All scanners were cardiac-gated. Slice
thickness was 3 mm using electron-beam CT scanners and 2.5 mm using multidetector CT scanners. The scans were evalu- ated in a blinded manner by technologists specifically trained for this task, operating outside of the CT Reading Center at the University of California, San Diego. To quantify the cal- cium scores, Philips (Cardiac) Calcium Scoring (Heartbeat CS) software was used. This software calculates the total cal- cium volume in an artery or arterial segment by multiplying the lesion area in mm
3 (each lesion on each slice above the
130 Hounsfield units (HU) threshold) by the slice thickness, set at 0.5 mm. Calcium was quantified using the method
described by Agatston et al.
18 The right and left common carotid arteries were identified from their origins from the brachiocephalic trunk and thoracic aorta, respectively. V olume, density, and Agatston values from the right brachiocephalic trunk and right common
carotid artery were combined to give the presence/absence and extent of calcium in the right common carotid.

Statistical methods. Descriptive statistics were used to charac- terize the sample. Means and SDs were reported for continu- ous variables, whereas counts and percentages were used for nominal variables. Continuous variables were assessed for plausibility (Supplementary Methods).

The primary analysis evaluated associations between a
history of regular cannabis smoking and the prevalence and extent of calcified plaque in either carotid artery (primary outcome: presence/absence and extent of CAC). Secondary analyses included stratified analyses for the primary analysis by age, sex, race/ethnicity, and tobacco smoking status, as well as assessment of associations of the duration of monthly cannabis smoking and recency of cannabis smoking.

Exploratory analyses included a composite variable (i.e., joint/pipe years) to evaluate a multifaceted exposure to can- nabis that included duration, frequency, and quantity.

Multivariable relative and absolute risk regression models with robust standard errors were used to estimate adjusted prevalence ratios (PRs) and prevalence differences (PDs), respectively, with 95% CIs for the prevalence of calcified plaque, controlling for potential confounders. Multivariable linear regression was then used to assess the extent of carotid artery calcium in those with calcified plaque. Extent was measured as volume (mm
3), density (HU), and Agatston score.

These variables were natural log transformed due to skew.

Resulting beta coefficients were exponentiated for interpreta- tion. Multivariable linear regression was also used in second- ary and exploratory analyses to evaluate the duration of regular smoking in years and the number of joints or pipes smoked per day as continuous variables.

Variables considered as potential confounders in the multi- variable analyses were: sociodemographic variables includ- ing site, age, sex, race/ethnicity, education level, and household income (model 1); behavioral risk factors such as cigarette smoking, alcohol use, and physical activity (model 2); and body mass index (BMI) and CVD risk factors, includ- ing SBP, DBP, total cholesterol to HDL ratio, fasting blood glucose (FBG), and antilipidemic, antidiabetic, antihyperten- sive and total medications (model 3). For linear regression models assessing extent of calcified plaque as the dependent variable, a fourth model adjusted volume for density and den- sity for volume.

Assessment of collinearity between independent variables was performed in the final multivariable adjusted model using the variance inflation factor and tolerance. Statistical signifi- cance was set at p < 0.05.

Stratified analyses. Stratified analyses were used to assess dif- ferences between a history of regular cannabis smoking and the prevalence of CAC in age-defined subgroups (i.e., 59–69, 70–80, > 80 years), race/ethnicity-defined subgroups (i.e., non-Hispanic White, non-Hispanic Black, Hispanic, Chi-
nese), subgroups by biologic sex (i.e., men, women), and sub- groups based on cigarette smoking status (i.e., current, former, never). Multiplicative first-order interactions were con- structed for each in the final model. Interaction terms were considered significant in the final multivariable-adjusted model if p < 0.10.

Results
The study sample included 2152 participants, a small minor - ity of whom (n = 159, 7.4%) reported a history of regular cannabis smoking (Table 1). Those with such a history were generally younger, more likely to be men, non-Hispanic
Black, engage in more risky behaviors (higher alcohol intake, higher mean pack-year history of cigarette smoking, and higher prevalence of current cigarette smoking), but also report more physical activity than those without a history of regular cannabis smoking. Notably, they also had a lower prevalence of hypertension, dyslipidemia, diabetes, and pre- diabetes, and a similar BMI compared to participants without a history of regular cannabis smoking. Compared to the over- all cohort, the analytic sample had a statistically significantly higher prevalence of never-tobacco smokers and a greater median met-minutes per week of physical activity.

Characteristics of cannabis use
Among those who reported smoking 100 or more joints/pipes in their lifetime, a majority (80.3%) reported a history of reg- ular use (smoking at least once per month) (Table 2). The mean duration of regular cannabis smoking was 16.6 years 4 Vascular Medicine 00(0)
among this group, with non-Hispanic Black participants
reporting a slightly longer mean duration (18.6 years). More than half of those with a history of regular use reported a fre- quency of use of once a week or more (56.6%). Daily use was reported by 22.6% of those with a history of regular use and nearly 40% of Hispanic participants with such a history.

Nearly one-third of those with a history of regular use reported smoking more than one joint/pipe per day. Slightly less than 3% of the overall sample, and slightly less than 40% of par - ticipants with a history of regular smoking, reported smoking cannabis in the past month (recent use).

Prevalence of carotid artery calcium
Among all participants, 36.1% (n = 777) had detectable CAC (Table 1). When compared to participants without a history of regular cannabis smoking, those with a history had a lower preva- lence of calcified plaque (volume > 0) in the left, right, and both common carotid arteries (Table 3). For scores greater than 0, the prevalence was generally lower at each category of Agatston score, except for a score ⩾ 300 for the left common carotid.

In unadjusted relative and absolute risk regression models, a history of regular cannabis smoking compared with no his- tory was not significantly associated with relative or absolute prevalence of calcified plaque in either carotid artery (primary outcome) (PR: 0.83, 95% CI: 0.65 to 1.05; PD: –6.4%, 95% CI: –13.8 to 1.1) (Table 4). In fully adjusted models, the preva- lence ratio (PR: 1.14, 95% CI: 0.88 to 1.49) and prevalence difference (PD: 4.7%, 95% CI: –2.7 to 12.0) were accentuated.

Both findings remained nonstatistically significant.

The duration of regular cannabis smoking was not associ- ated with CAC in unadjusted or fully adjusted models.

Though an exposure–response relationship was absent in the unadjusted model, a lower prevalence difference was found with greater duration of cannabis smoking in the fully adjusted model.

Cannabis smoking in the past month (recency) by partici- pants with a history of regular smoking was not significantly associated with CAC in unadjusted (PR: 0.68, 95% CI: 0.44 to 1.06; PD: –11.6%, 95% CI: –22.7 to –0.4) or fully adjusted models (PR: 1.04, 95% CI: 0.68 to 1.61; PD: 1.2%, 95% CI:
–10.3 to 12.7).

Extent of carotid artery calcium
In fully adjusted multivariable linear regression models in the subset of participants with calcified plaque (i.e., volume > 0), a history of regular smoking was not significantly associated with increased calcium volume (difference = 7.7%, 95% CI:
–21.8 to 48.5), calcium density (difference = 0.4%, 95% CI:
–6.6 to 7.9), or Agatston score (difference = 32.1%, 95% CI:
–31.8 to 155.8) in either carotid artery (Table 5). Similarly, neither duration of regular cannabis smoking nor the number of joint/pipe years was significantly associated with any of the three outcome measures.

Stratified analyses
When stratified by sex, the prevalence of calcified plaque in either carotid artery was significantly higher among men with a history of regular cannabis smoking (PR: 1.36, 95% CI:

1.06 to 1.75) compared to no history among men. Otherwise, models exploring the potential effect measure modification between a history of regular cannabis smoking and age, race/ ethnicity, and cigarette smoking status did not support differ- ential associations (Table 6).

Discussion
In a racially and ethnically diverse cohort of older adults with a moderately high prevalence of CAC, there were no statisti- cally significant associations between a history of regular cannabis smoking (primary analysis), duration, or recency of cannabis smoking, and the prevalence of carotid calcified plaque. These findings were consistent across age, race/eth- nicity, and cigarette smoking, except for an increased preva- lence in men with a history of regular cannabis smoking.

Similarly, in a subgroup with CAC, no association was found between a history of regular smoking and extent of calcifica- tion as measured by volume, density, and Agatston score.

The cardiovascular effects of cannabis are multifaceted, involving both direct and indirect mechanisms mediated
by cannabinoid (CB1R and CB2R) and noncannabinoid
receptors.
19 CB1 receptors are predominantly located in
the central and peripheral nervous system. 20 In contrast, CB2 receptors are present on immune cells, and have been identified on macrophages and T lymphocytes within ath- erosclerotic lesions.
20–22 Activation of CB1R has been
implicated in pro-atherogenic processes such as oxidized LDL formation, endothelial dysfunction, vascular smooth muscle hyperplasia, and induction of inflammatory
responses.
22–24 In contrast, CB2R activation has been asso-
ciated with antiinflammatory and protective effects against atherosclerosis, including inhibition of macrophage chem- otaxis, reduced infiltration and accumulation of monocytes in arterial walls, and downregulation of TH1 immune
response leading to inhibition of atherosclerotic progres- sion.
19,21,24–26 These contradictory actions raise questions about the net impact of regular cannabis use on the devel- opment and progression of atherosclerosis.

If smoking cannabis increases the risk of atherosclerotic disease, one would anticipate finding consistent evidence of adverse cardiac outcomes in human research. This is not the case. Some cross-sectional studies have reported associations with increased prevalence of coronary heart disease,
10 MI,11,27,28 and stroke, 12,13,27 whereas others have reported no association.29,30 Longitudinal studies have largely reported no association with CVD risk factors such as inflammation, 31 abdominal adiposity, 32 BMI, 33 blood pressure, 33,34 lipids, 33 and glucose,33,35 as well as subclinical atherosclerosis,15 inci- dent CVD,36 and MI,14,15,31–33,36 with some exceptions.37 Corroon et al. 5
These and similar studies may be understood through the lens of a ‘Stoner’s paradox’ in which the common view of can- nabis users as sedentary, overweight, unmotivated, and lazy is contradicted by studies revealing higher rates of physical activ- ity,
38 more favorable BMI profiles,33,39 lower concentrations of certain lipid markers, 13,33 and better glycemic control. 39 It remains unclear whether these favorable factors counterbal- ance potential risks.

The null findings reported herein are consistent with our previous research in NHANES which explored associations with MI and blood pressure and hypertension,
29,30 and with an
observational study using longitudinal data from the Coronary Table 1. Characteristics of participants by history of regular cannabis smoking (n = 2152).

Overall sample No history of regular
cannabis smoking
History of regular cannabis
smoking
Characteristic (n = 2152, 100.0%) (n = 1993, 92.6%) (n = 159, 7.4%) Sociodemographics
Age, years, mean (SD) 73.5 (8.5) 74.0 (8.5) 67.5 (5.7)
Men, n (%) 1003 (46.6) 896 (45.0) 107 (67.3)
Race/ethnicity, n (%)
Non-Hispanic White 826 (38.4) 762 (38.2) 64 (40.3)
Non-Hispanic Black 557 (25.9) 486 (24.4) 71 (44.7)
Hispanic 461 (21.4) 438 (22.0) 23 (14.5)
Chinese 308 (14.3) 307 (15.4) 1 (0.6)
Education, n (%)
< Bachelor’s degree 1247 (58.1) 1167 (58.7) 80 (50.3)
Bachelor’s degree 409 (19.1) 371 (18.7) 38 (23.9)
Graduate or professional school 490 (22.8) 449 (22.6) 41 (25.8) Gross family income, n (%)
⩽ $49,999 1049 (50.5) 994 (51.8) 55 (34.8)
$50,000 to $99,999 587 (28.3) 527 (27.5) 60 (38.0)
⩾ $100,000 441 (21.2) 398 (20.7) 43 (27.2)
Lifestyle, behavioral
Alcohol intake, drinks/week, mean (SD) 0.0 (0.0, 2.0) 0.0 (0.0, 2.0) 0.0 (0.0, 7.0) Cigarette smoking status, n (%)
Never 1065 (49.5) 1029 (51.6) 36 (22.6)
Former 985 (45.8) 881 (44.2) 104 (65.4)
Current 102 (4.7) 83 (4.2) 19 (12.0)
Cigarette smoking, pack years, mean
(SD)

8.3 (17.0) 7.8 (16.4) 15.6 (22.4)
Cigarette smoking, pack years, median
(IQR)

0.0 (0.0, 18.0) 0.0 (0.0, 7.5) 6.2 (0.2, 23.5)
Physical activity, met-min/week, median
(IQR)
2820.0 (1215.0, 5910.0) 3240.0 (1395.0, 6660.0) 5445.0 (2595.0, 10,102.5) BMI, mean (SD) 28.8 (5.8) 28.8 (5.8) 28.8 (5.9)
Cardiometabolic medical history
Systolic BP, mmHg, mean (SD) 128 (21) 128 (21) 125 (19) Diastolic BP, mmHg, mean (SD) 69 (10) 69 (10) 72 (11)
Hypertension, n (%) 1596 (74.2) 1484 (74.5) 112 (70.4)
Dyslipidemia, n (%) 1136 (52.8) 1060 (53.2) 76 (47.8)
Diabetes or prediabetes, n (%) 1230 (57.2) 1148 (57.6) 82 (51.6) Carotid artery calcium, n (%) 777 (36.1) 729 (36.6) 48 (30.2) Agatston score
a, mean (IQR) 40.4 (127.5) 39.9 (127.5) 42.2 (115.5)
Medications, n (%)
Antihypertensive 1311 (60.9) 1226 (61.5) 85 (53.5)
Antilipidemic 1020 (47.4) 949 (47.6) 71 (44.7)
Antidiabetic 415 (19.3) 397 (19.9) 18 (11.3)
Total medications, mean (SD) 7.1 (4.7) 7.1 (4.7) 7.0 (4.9) aAmong those with any carotid artery calcium; left and right carotid arteries combined.

BMI, body mass index; BP , blood pressure; met-min/week, metabolic equivalent of task minutes per week; mmHg, millimeters mercury. 6 Vascular Medicine 00(0)
Artery Risk Development in Young Adults (CARDIA) study, which reported no association between cumulative cannabis exposure and increased carotid intima–media thickness,
including among individuals who never smoked tobacco.
14 A
separate study from CARDIA reported an association between cumulative cannabis exposure and coronary artery calcifica- tion, but only among tobacco smokers.
15 Less than 40% of participants with a history of regular cannabis smoking, reported smoking cannabis in the past month. This finding, consistent with our previous work in NHANES, suggests that most regular use occurs in youth and middle age, potentially indicating a decrease in use over time (‘aging out’). Thus, if recent use, in addition to a history of regular use, underlies the atherosclerotic disease process, abstinence in later life may attenuate risk. This pattern was not seen in our data, however, as participants with a history of both regular use and recent use had a lower prevalence of CAC (PR: 1.04, 95% CI: 0.68 to 1.61) compared to those
without recent use (PR: 1.19, 95% CI: 0.86 to 1.65), despite having similar ages.

In our NHANES samples of middle-aged adults (35–59
years old; 2009–2018), we observed a history of regular (i.e., monthly) use of approximately 25%, compared to approxi- mately 7% in MESA. As a loose proxy for regular use, 37.6% Table 2. Cannabis smoking characteristics of participants with a history of regular use by race/ethnicity (n = 159).

Overall sample Non-Hispanic
White
Non-Hispanic
Black
Hispanic Chinese
Characteristic (n = 159, 100.0%) (n = 64, 40.3%) (n = 71, 44.7%) (n = 23, 14.5%) (n = 1, 0.6%) History of regular use, yes, n (%)
Among all participants 159 (7.4) 64 (7.8) 71 (12.8) 23 (5.0) 1 (0.3) Among those with ⩾ 100 joints/
pipes lifetime
159 (80.3) 64 (80.0) 71 (80.7) 23 (82.1) 1 (50.0)
Duration of regular use, mean (SD)
Years (n = 127) 16.6 (15.5) 15.3 (14.8) 18.6 (17.0) 15.3 (13.0) 5.0 (0.0) Frequency of regular use, n (%)
< Once a week 25 (15.7) 11 (17.2) 9 (12.7) 5 (21.7) 0 (0.0) ⩾ Once a week 90 (56.6) 38 (59.4) 43 (60.6) 8 (34.8) 1 (100.0) Daily 36 (22.6) 12 (18.8) 15 (21.1) 9 (39.1) 0 (0.0)
Missing/refused/don’t know 8 (5.0) 3 (4.7) 4 (5.6) 1 (4.4) 0 (0.0) Quantity of daily use, n (%)
⩽ 1 joints/pipes 71 (44.7) 33 (51.6) 30 (42.3) 8 (34.8) 0 (0.0) > 1 joints/pipes 52 (32.7) 14 (21.9) 28 (39.4) 10 (43.5) 0 (0.0) Missing/refused/don’t know 36 (22.6) 17 (26.6) 13 (18.3) 5 (21.7) 1 (100.0) Duration, frequency, and quantity, median (IQR)
J oint/pipe years (midpoint,
n = 151)

6.0 (6.0, 16.5) 6.0 (6.0, 16.5) 6.0 (16.5, 10.5) 11.3 (6.0, 27.5) 6.0 (6.0, 6.0) Recency of use, n (%)
Past month use (n = 151)
Among all participants 60 (2.8) 40 (3.1) 37 (4.5) 4 (0.6) 0 (0.0) Among those with history of
regular use
60 (39.7) 40 (40.4) 37 (38.5) 4 (14.3) 0 (0.0)
Table 3. Frequency and prevalence (unadjusted) for left, right, and both common carotid arteries by Agatston score category and history of regular cannabis smoking.

Agatston
score No history of regular cannabis smoking History of regular cannabis smoking Left Right Both Left Right Both
0 1620 (81.3) 1457 (73.1) 1333 (66.9) 138 (86.8) 125 (78.6) 116 (73.0) 1–99 323 (16.2) 348 (17.5) 425 (21.3) 17 (10.7) 22 (13.8) 30 (18.9) 100–299 45 (2.3) 124 (6.2) 144 (7.2) 2 (1.3) 9 (5.7) 7 (4.4) ⩾ 300 5 (0.3) 64 (3.2) 91 (4.6) 2 (1.3) 3 (1.9) 6 (3.8) Both is the sum of the, left and right carotid artery Agatston scores.

Corroon et al. 7
of participants reported using marijuana 100 times or more at Exam 30 (2015–2016) in the CARDIA cohort (unpublished
data). The difference in exposure across these studies is not easily explained.

Given that the NHANES samples and CARDIA cohort
were younger, it is possible that changes in attitudes and access to cannabis played a small role (i.e., the changes in attitudes and access may have occurred during formative years, potentially influencing their current usage patterns).

In NHANES, almost 75% of the samples were White indi-
viduals, compared to 40% in MESA. It is possible that racial and ethnic minorities are less likely to report illicit drug use in anonymous surveys due to fear of judgment or legal conse- quences and thus cannabis use is underreported in MESA.

Socioeconomic status is unlikely to explain the difference, given that the NHANES samples were more educated with
higher income. Further, the days used in the past month among participants with a history of regular use were approx- imately 15 in NHANES and almost 17 in MESA. Thus,
though the frequency may be similar, the prevalence of expo- sure is not.

The strengths of our study include the use of a racially and ethnically diverse sample, a relatively large sample size, a specified method of cannabis use (smoking), and the use of a standardized objective outcome measure. The focus on his- tory of regular smoking, including the duration and recency of smoking, is also a strength, given that repeated exposure over time, rather than recent use, is likely to be the primary contributor to chronic CVD. Furthermore, the analysis of cal- cium volume and density, alongside the Agatston score, was conducted as a strategy to enhance understanding of the potential mechanisms, should greater prevalence have been identified.

Limitations include the cross-sectional design, average age of participants (> 74 years), high attrition of MESA par- ticipants from enrollment to assessment of cannabis use and CAC at Exam 6, self-reported exposure of a federally illegal substance, and the relatively small number of MESA partici- pants who reported a history of regular cannabis smoking (n = 159, 7.4%) and a history of recent cannabis smoking (n = 60, 2.8%) relative to other US estimates,
30 which may limit
the statistical power and generalizability of our findings.

Further, though CAC is a marker of atherosclerosis, noncalci- fied plaques are also associated with cerebral events. By focusing on advanced atherosclerosis and not earlier stage disease, the study may have failed to detect existing disease that has not progressed to calcification. Our study aimed to extend the analysis to stroke outcomes, but limited data avail- ability restricted our analysis. A history of stroke was recorded for only 66 participants in the dataset. Of which, four (2.5%) occurred in participants with a history of regular cannabis smoking and 62 (3.1%) occurred in those without a history.

Table 4. Adjusted prevalence ratios and absolute prevalence differences for calcified plaque in either carotid artery by cannabis smoking characteristics.

Cannabis characteristic Unadjusted Fully adjusted
(Prevalence of
calcified plaque)
Prevalence ratio Prevalence difference Prevalence ratio Prevalence difference
History of regular
smoking
(n = 2152) (n = 1997)
No 729/1993 (36.6%) 1.00 Ref. 0.00 Ref. 1.00 Ref. 0.00 Ref.

Yes 48/159 (30.2%) 0.83 (0.65 to 1.05) –6.4 (–13.8 to 1.1) 1.14 (0.88 to 1.49) 4.7 (–2.7 to 12.0) Duration of regular
smoking, years
(n = 2120) (n = 1967)
0 729/1993 (36.6%) 1.00 Ref. 0.00 Ref. 1.00 Ref. 0.00 Ref. 1 to 5 14/47 (29.8%) 0.81 (0.52 to 1.27) –6.8 (–20.0 to 6.5) 1.35 (0.91 to 2.01) 7.9 (–4.0 to 19.8) > 5 to 10 7/26 (26.9%) 0.74 (0.39 to 1.39) –9.7 (–26.8 to 7.5) 1.42 (0.90 to 2.23) 4.6 (–10.0 to 19.3) > 10 17/54 (31.5%) 0.86 (0.58 to 1.28) –5.1 (–17.7 to 7.5) 1.00 (0.64 to 1.56) 2.1 (–10.4 to 14.7) Recency of smoking (n = 2144) (n = 1989)
No history of regular
smoking
729/1993 (36.6%) 1.00 Ref. 0.00 Ref. 1.00 Ref. 0.00 Ref.

No past month smoking 30/91 (33.0%) 0.90 (0.67 to 1.21) –3.6 (–13.5 to 6.3) 1.19 (0.86 to 1.65) 6.3 (–2.9 to 15.4) Past month smoking 15/60 (25.0%) 0.68 (0.44 to 1.06) –11.6 (–22.7 to –0.4) 1.04 (0.68 to 1.61) 1.2 (–10.3 to 12.7) All comparisons with participants who reported no history of regular smoking.

Fully adjusted model: site, age, sex, race/ethnicity, HH income, alcohol and cigarette use, physical activity, BMI, SBP , DBP , total cholesterol to HDL choles- terol ratio, FBG, antihypertensive, antilipidemic, antidiabetic, and total medications.

The p-values for multiple comparisons have been adjusted using Tukey’s method.

Bold
= p < 0.05.

BMI, body mass index; DBP , diastolic blood pressure; FBG, fasting blood glucose; HDL, high density lipoprotein; HH, household; SBP , systolic blood pres- sure.
8 Vascular Medicine 00(0)
Table 5. Adjusted percent differences and 95% confidence intervals for extent of calcified plaque in carotid arteries by cannabis smoking characteristics.

Cannabis characteristic Unadjusted Fully adjusted
Volume (mm3)
% difference
(95% CI)
Density (HU)
% difference
(95% CI)
Agatston score
% difference
(95% CI)
Volume (mm3)
% difference
(95% CI)
Density (HU)
% difference
(95% CI)
Agatston score
% difference
(95% CI)
History of regular smoking, y/n
Left common carotid 22.8 (–33.8 to 127.8) 3.0 (–13.1 to 22.1) 26.1 (–41.9 to 173.7) 13.7 (–23.1 to 68.2) 1.4 (–8.9 to 12.8) 81.4 (–20.4 to 313.5) (n = 447) (n = 447) (n = 447) (n = 415) (n = 415) (n = 415) Right common carotid –13.5 (–50.7 to 51.7) –0.7 (–13.0 to 13.3) –19.7 (–59.4 to 58.6) 10.9 (–22.2 to 58.1) –1.5 (–9.4 to 7.1) 12.2 (–47.0 to 137.4) (n = 625) (n = 625) (n = 625) (n = 574) (n = 574) (n = 574) Either common carotid –11.0 (–46.9 to 49.0) 0.0 (–10.7 to 12.0) –14.4 (–54.0 to 59.5) 7.7 (–21.8 to 48.5) 0.4 (–6.6 to 7.9) 32.1 (–31.8 to 155.8) (n = 777) (n = 777) (n = 777) (n = 715) (n = 715) (n = 715) Duration of regular smoking, years
Either common carotid –0.2 (–1.7 to 1.2) 0.2 (–0.1 to 0.5) 1.9 (–1.0 to 5.0) 0.0 (–1.4 to 1.5) 0.1 (–0.2 to 0.4) 1.5 (–1.6 to 4.6) (n = 731) (n = 731) (n = 731) (n = 706) (n = 706) (n = 706) Joint/pipe years, mid
Either common carotid 1.1 (–0.4 to 2.7) 1.5 (0.0 to 3.1) 1.3 (–0.6 to 3.2) 0.7 (–0.2 to 1.6) –0.1 (–0.3 to 0.1) 1.7 (–0.1 to 3.5) (n = 760) (n = 760) (n = 760) (n = 700) (n = 700) (n = 700) Percent change in volume, density, and Agatston score was calculated after natural log transformation and then back-transformed.

Fully adjusted model: site, age, sex, race/ethnicity, HH income, volume (mm3) for density, density (HU) for volume, alcohol and cigarette use, physical activity, BMI, SBP , DBP , total cholesterol to HDL cholesterol ratio, FBG, antihypertensive, antilipidemic, antidiabetic, and total medications.

Bold = p < 0.05.

BMI, body mass index; DBP , diastolic blood pressure; FBG, fasting blood glucose; HDL, high density lipoprotein; HH, household; HU, Hounsfield units; SBP , systolic blood pressure.

Corroon et al. 9
Notably, many cross-sectional studies reporting positive associations with CVD risks have focused on recency of use (past month) as the measure of cannabis exposure. Though ‘temporality’ is a potential limitation of the cross-sectional design, it is impossible to infer that the exposure preceded the event when the exposure is limited to the past 30 days. Hence, such findings should be interpreted with caution. Additionally, the inability to visualize the entire carotid artery on lung CT scans may have limited our ability to fully assess the extent of carotid artery calcification.

Despite these null findings, and given the conflicting
results of comparable studies, there is a critical need for pro- spective cohort studies examining associations between pat- terns of cannabis use over time and adverse cardiovascular outcomes, including calcified arterial plaque. These studies should include an analysis of the duration and frequency of cannabis use, as well as an examination of the method of use, specifically comparing combusted (i.e., smoked) versus non- combusted forms and inhaled versus noninhaled routes of administration.

Conclusion
In a racially and ethnically diverse cohort of older adults with a moderately high prevalence of carotid artery calcification, there were no statistically significant associations between a history of regular cannabis smoking (primary analysis), dura- tion, or recency of cannabis smoking, and the prevalence of carotid calcified plaque. These findings were consistent across age, race/ethnicity, and cigarette smoking, except for an increased prevalence in men with a history of regular can- nabis smoking. Similarly, in a subgroup with carotid artery calcification, no association was found between a history of regular smoking and extent of calcification as measured by volume, density, and Agatston score.

Acknowledgments
The authors thank the other investigators, staff, and participants of the MESA study for their valuable contributions. A full list of participat- ing MESA investigators and institutions can be found at http://www. mesa-nhlbi.org. This paper has been reviewed and approved by the MESA Publications and Presentations Committee.The authors also thank Gretchen Bandoli, PhD (Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA) for help with data analysis.

Data availability statement
The data that support the findings of this study are available from the Multi-Ethnic Study of Atherosclerosis (MESA) coordinating center.

Access is restricted to researchers affiliated with MESA. Inquiries for data access can be directed to the MESA coordinating center.

The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.

Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Corroon is a member of the Board of Directors of CV Table 6. Adjusted prevalence ratios and 95% confidence intervals for calcified plaque in either carotid artery, stratified by selected characteristics (n = 2000).

Characteristic History of regular cannabis smoking (Yes) p for interaction
Age 0.56
59–69 1.13 (0.81 to 1.56)
70–80 1.18 (0.76 to 1.81)
> 80 0.86 (0.38 to 1.98)
Sex 0.31
Male 1.36 (1.06 to 1.75)
Female 0.83 (0.44 to 1.57)
Race/ethnicity 0.64
Non-Hispanic White 1.16 (0.81 to 1.66)
Non-Hispanic Black 0.93 (0.59 to 1.47)
Hispanic 1.21 (0.74 to 1.97)
Chinese NA
Cigarette smoking status 0.22
Never 1.02 (0.50 to 2.07)
Former 0.90 (0.62 to 1.31)
Current 1.27 (0.81 to 2.00)
Reference = no history of regular cannabis smoking.

Statistically significant prevalence ratios in bold.

Interaction p-value calculated with one interaction term in the fully adjusted model; p-values for multiple comparisons have been adjusted using Tukey’s method.

NA, not applicable.
10 Vascular Medicine 00(0)
Sciences, Inc., a manufacturer of hemp-derived CBD products. The remaining authors have no conflicts of interest.

Funding
This research was supported by contracts from the National Heart, Lung, and Blood Institute ( 75N92020D00001, HHSN268201500003I, N01-HC-95159, 75N92020D00005, N01-HC-95160, 75N92020D00 002, N01-HC-95161, 75N92020D00003, N01-HC-95162, 75N92020D 00006, N01-HC-95163, 75N92020D00004, N01-HC-95164, 75N920 20D00007, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC- 95168, N01-HC-95169, R01HL142283 [Ancillary study], T32HL079 891) and National Center for Complementary and Alternative Medicine (K24AT011568).

ORCID iD
Jamie Corroon https://orcid.org/0000-0003-3930-6093
Supplemental material
Supplemental material for this article is available online.

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34. Haleem A, Hwang YJ, Elton-Marshall T, et al. The longitudi- nal relationship between cannabis use and hypertension. Drug Alcohol Rev 2021; 40: 914–919.

35. Bancks MP, Pletcher MJ, Kertesz SG, et al. Marijuana use and risk of prediabetes and diabetes by middle adulthood:

The Coronary Artery Risk Development in Young Adults
(CARDIA) study. Diabetologia 2015; 58: 2736–2744.

36. Reis JP, Auer R, Bancks MP, et al. Cumulative lifetime marijuana use and incident cardiovascular disease in mid- dle age: The Coronary Artery Risk Development in Young
Adults (CARDIA) study. Am J Public Health 2017; 107:
601–606.

37. Zongo A, Lee C, Dyck JRB, et al. Medical cannabis authoriza- tion and the risk of cardiovascular events: a longitudinal cohort study. BMC Cardiovasc Disord 2021; 21: 426.

38. Ong LQ, Bellettiere J, Alvarado C, et al. Cannabis use, seden- tary behavior, and physical activity in a nationally representa- tive sample of US adults. Harm Reduct J 2021; 18: 48.

39. Rajavashisth TB, Shaheen M, Norris KC, et al. Decreased prevalence of diabetes in marijuana users: Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) III. BMJ Open 2012; 2: e000494.

Marijuana and California
Youth: Trends and Impacts
About Marijuana
Marijuana is the most commonly used drug in
the United States. It can be taken in many forms,
such as eaten in cookies and candies (i.e., edibles),
smoked, vaped, or dabbed as an oil or concentrate.

The chemical tetrahydrocannabinol (THC) that
is present in the marijuana plant is what gives the
user a feeling of being “high”. The plant contains
other chemicals such as cannabidiol (CBD) and
flavor compounds called terpenes, which may also
have an effect on the user's mood.

The amount of THC can vary widely by form.

For example, marijuana that is dabbed can have
up to ten times more THC per puff than smoked
marijuana.

The amount of THC in marijuana has
increased significantly over the last 25 years, from
about four percent in 1995 to over 15 percent
by 2018 (Figure 1). Some forms of marijuana, like
edibles and concentrates, have very high levels
of THC – up to 90 percent, making youth use of
marijuana a cause for concern.
, 43
2 1
Figure 1. Increase in THC concentration from 1995 to 2018. Source:

National Institutes on Drug Abuse (NIDA) Potency Monitoring Program, Quarterly Report # 142.

4.0 5.0

4.6 6.1 7.2

8.0 9.6

9.8 11.1 12.0

10.9 14.5

15.6 0
2 4
6 8
10 12
14 16
18 Percent THC
Marijuana and Health
Fast Fact
Marijuana can affect brain
development. Studies have
shown that youth who are
heavy users of marijuana
may have a reduction in
mental abilities that lasts
into adulthood.
5 Marijuana use among youth, particularly products with high concentrations of THC, are known to have serious health effects on the developing brain.

Y outh who use marijuana are at increased risk for mental health problems, including depression and increased risk of suicide.

Y outh who use marijuana may also suffer from poorer
academic performance, especially among those who begin
using marijuana at young ages.
,
These negative effects may continue into adulthood among users.
9 8 7
6 1
Credit:Adobe Stock Image

Trends in Marijuana Use Among California YouthTrends in Marijuana Use Among California Youth Marijuana is the most commonly used drug among California youth. In 2018, 31.4 percent of California high school students reported having ever tried marijuana.

Fast Fact
In 2018, nearly 15
percent of California
high school students
had used marijuana in
the past 30 days.
10 Figure 2. Past 30-Day Marijuana Use Among CA High School Students by Race/ Ethnicity, 2016 and 2018. Source: The California Student Tobacco Survey,

2016-2018. Notes: AI/AN = American Indian/Alaska Native; NH/OPI = Native Hawaiian/Other Pacific Islander . AI/AN data is suppressed for 2016 due to small sample size.
25%
20%
15%
10%
5%
0%

17.7% 16.7%

19.6%
2016 2018

19.0% 17.9% 17.4% 17.1% 15.8% 15.1% 14.2% 13.0% 12.5%

11.1%

5.5% 5.5%
White Black Hispanic Asian AI/AN NH/OPI Other Multiple
In 2018, 14.7 percent of high school
students in California reported
using marijuana in the previous 30
days. This was unchanged from 2016
(14.5 percent), and lower than the
national percentage of youth who
used marijuana, which was nearly
20 percent (19.3 percent) in 2018.
,1110
Marijuana use in the previous 30 days by California high school students did not increase for most racial/ethnic groups from 2016 to 2018 (Figure 2). However, use did increase for Native Hawaiian/Other Pacific Islanders.

In 2018, the most commonly reported method of usual marijuana use among high school students was smoking (64.3 percent). However, nearly a quarter of youth who used marijuana (22.3 percent) reported that vaping is the form of marijuana they usually use (Figure 3).

Use of vaped marijuana has been associated with a higher likelihood of developing substance use problems than marijuana smoking.
12 Figure 3. Usual method of marijuana use among California high school students in 2018. Source: 2018 California Student Tobacco Survey.

100%
80%

64.3%
60%
40%

22.3%
20%

6.9% 5.3%
s r e s U a an u j ri a M f o t n e rc e P

0.6% 0.0%
0%
Smoke It Vaporize It Eat It Dab It Drink It Other
Credit:Adobe Stock Image
2 Marijuana Secondhand Smoke Exposure
Fast Fact
Marijuana smoke contains more
ammonia, hydrogen cyanide, and
toxic aromatic hydrocarbons than
cigarette smoke.

Secondhand marijuana smoke contains many of the same chemicals as cigarette smoke, and has been shown to be dangerous to health even over short time periods.
13,14
In 2018, 30.7 percent of California high school students reported being in a car or room with someone else who was smoking marijuana in the previous 30 days, potentially exposing them to chemicals that are known to the State of California to cause cancer and other health effects. 15 Credit:Adobe Stock Image

Prenatal Marijuana Exposure
Figure 4 . Marijuana use during pregnancy among women with a live birth, 2016.

Source: 2016 Maternal and Infant Health Assessment (MIHA). 25%
20%
15%

10.5%
Black White Hispanic 15 -19 20 - 34 35+
Race/Ethnicty Age

10%

5.7% 5.2% 4.7% 5% 3.7% 2.5%
0%

Fast Fact
A recent study shows
that marijuana use
among pregnant women
in California increased
between 2009 and
2016.
16 Exposure to marijuana during pregnancy or through breastfeeding can ha ve serious negative effects on childhood
brain development and cognitive function. Babies exposed to marijuana before they ar e born may have long term
deficits in language comprehension, memory, and attention. 17 In 2016, 4.2 percent of women with a live birth in California used marijuana during pregnancy.

Marijuana use was higher among younger women and Black women (Figure 4). 3 Poisonings, Emergency Department Visits & Hospitalizations Fast Fact
In 2018, the year the sale
of recreational marijuana
became legal in California,
there were 1,488 calls to
Poison Control Centers
in California related to
marijuana, a 75 percent
increase in calls from 2016.

Figure 5. Number of emergency room visits for marijuana poisoning by age group in California in 2018. Source: California Office of Statewide Health Planning and Development,
Emergency Department Data.
600 517
Number of Emergency Room
Visits
500
400
300
200
100
0 198
144
39 < 5 years 5 to 9 years 10 to 14 years 15 to 19 years Age Group
Accidental or unintentional exposure to marijuana can
pose a serious risk to young children. Although rare,
marijuana ingestion among young children can result in
irregular heartbeat, low blood pressure, seizures, and
coma.
18 In 2018, the California Poison Control Center
received 329 calls about unintentional marijuana
exposure among children aged 0 to 5 years.

In 2018, the California Poison Control Center received
111 calls about unintentional marijuana exposure and
287 calls about intentional marijuana exposure among
youth aged 6 to 19 years old.

In 2018, 144 children under the age of five visited the emergency room for marijuana poisoning (Figure 5)
and 78 children under age five were hospitalized.

Credit:Adobe Stock Image
4 References

1. NIDA. Media Guide. National
Institute on Drug Abuse, 2 Jul. 2018
https://www.drugabuse.gov/publications/
media-guide. [Accessed 8 May 2020].

2. Loflin, M., & Earleywine, M. (2014).

A New Method of Cannabis Ingestion: The
Dangers of Dabs? Addictive Behaviors,
39(10), 1430-1433.

3. NIDA. Marijuana Potency.

National Institute on Drug Abuse, 1 Apr. 2020,
https://www.drugabuse.gov/drugs-abuse/marijuana/
marijuana-potency.Accessed 14 May 2020.

4. Leos-T oro, C., et al. (2020). Cannabis labelling and consumer understanding of THC levels and serving
sizes. Drug and Alcohol Dependence 208:107843.

5. NIDA. Marijuana. National Institute on Drug
Abuse, 24 Dec. 2019,https://www.drugabuse.gov/
publications/drugfacts/marijuana. [Accessed 8 May
2020].

6. Gobbi, G., et al. (2019).Association of Cannabis Use in Adolescence and Risk of Depression,Anxiety, and
Suicidality in Y oung Adulthood:A Systematic Review
and Meta-analysis. JAMA Psychiatry. 76(4):426–434.

7. Paige
, KJ. & Colder, CR. (2020). Long-T erm Effects of
Early Adolescent Marijuana Use on Attentional and
Inhibitory Control. Journal of Studies on Alcohol 16. Y oung-Wolff KC., et al. (2017). Trends in Self- reported and Biochemically T ested Marijuana Use
Among Pregnant Females in California From 2009-
2016. JAMA. 318(24):2490–2491
and Drugs. 81:2, 164-172

8. Feeney, KE. & Kampman, KM. (2016). Adverse Effects
of Marijuana Use. Linacre Q. 83(2):174:178.

9. Brook, JS., et al. (2008). The Association Between
Earlier Marijuana Use and Subsequent Academic
Achievement and Health Problems: A Longitudinal
Study. The American Journal on Addictions. 17: 155-
160.

10. Zhu S-H, et al. (2019). Results of the Statewide
2017-18 California Student T obacco Survey.

San Diego, California: Center for Research
and Intervention in T obacco Control (CRITC),
University of California, San Diego.

11. Johnston, LD., et al. (2020). Monitoring the Future National Sur
vey Results on Drug Use 1975-2019:

Overview, Key Findings on Adolescent Drug Use.

Ann Arbor: Institute for Social Research, University
of Michigan.

12. Seaman, EL., et al. (2020). Use of tobacco products/ de
vices for marijuana consumption and association
with substance use problems among US young
adults (2015–2016). Addictive Behaviors 102:106133.

13. Moir, D., et al. (2008). A Comparison of Mainstr
eam
and Sidestream Marijuana and T obacco Cigarette
Smoke Produced under T wo Machine Smoking
Conditions. Chemical Research in T oxicology. 21(2),
494-502.

14. Xiaoyin, W
., et al. (2016). One minute of marijuana
secondhand smoke exposure substantially impairs
vascular endothelial function. Journal of the
American Heart Association 5.8: e003858.

15. OEHHA. (2019). Proposition 65: No Significant
Risk Le
vels (NSRLs) for Carcinogens and Maximum
Allowable Dose Levels (MADLs) for Chemicals
Causing Reproductive T oxicity. Vol. 2019. California
Environmental Protection Agency, Office of
Environmental Health Hazard Assessment;
Sacramento, CA: 2016. [Accessed May 11, 2020].

17. Ryan, SA., et al. (2018). Marijuana use during
pr
egnancy and breastfeeding: implications for
neonatal and childhood outcomes. Pediatrics 142.3:
e20181889.

18. Richards, JR., et al. (2017). Unintentional Cannabis Ingestion in Childr
en: A Systematic Review. The
Journal of Pediatrics 190:142-152.
5 [email protected]
www.cdph.ca.gov/LetsTalkCannabis

1 ORDINANCE NO.

Adopted by the Sacramento City Council
[Date Adopted]
AN ORDINANCE AMENDING VARIOUS SECTIONS OF CHAPTER 5.150 OF, AMENDING SECTION

8.04.110 OF, ADDING CHAPTER 8.133 TO, AND DELETING CHAPTER 9.08 OF THE

SACRAMENTO CITY CODE, RELATING TO THE CONSUMPTION OF CANNABIS AND CANNABIS

PRODUCTS
BE IT ENACTED BY THE COUNCIL OF THE CITY OF SACRAMENTO:

SECTION 1.

A. Section 5.150.020 of the Sacramento City Code is hereby amended as follows:

1. A definition for “cannabis consumption lounge” or “lounge” is hereby added to read as follows:
“Cannabis consumption lounge” or “lounge” means an area on any property, other than in a private residence or at an event held pursuant to section 5.150.360.C, where cannabis or cannabis products are consumed; or any private residence where cannabis or cannabis products are allowed to be consumed for commercial gain.

2. A definition for “cannabis consumption lounge operator” is hereby added to read as follows:
“Cannabis consumption lounge operator” means a storefront cannabis dispensary permittee who is authorized to operate a cannabis consumption lounge in accordance with this chapter.

3. A definition for “smoking” is hereby added to read as follows:
“Smoking” has the same meaning as in section 8.80.030.

4. A definition for “vaping” is hereby added to read as follows:
“Vaping” means to inhale vapor from a device that heats up and vaporizes a liquid or solid.

B. Except as amended by subsection A above, all provisions of section 5.150.020 remain unchanged and in full effect.

SECTION 2.
2 Section 5.150.130 of the Sacramento City Code is hereby amended to read as follows:

5.150.130 Site management.

Notwithstanding any other provision of this code, a cannabis business permittee shall—

A. Prevent and eliminate nuisances on its site, including the unlawful consumption of cannabis or cannabis products;
B. Maintain the exterior of the site, including any parking lots under the control of the permittee, free of litter, debris, and trash;.

C. Properly store and dispose of all waste generated on the site, including chemical and organic waste, in accordance with all applicable laws and regulations; D. Make cannabis and cannabis products unusable and unrecognizable before discarding them; and
E. R emove all graffiti from the site and parking lots under the control of the permittee within 72 hours of its application.

SECTION 3.

Section 5.150.145 is hereby added to the Sacramento City Code to read as follows:

5.150.145 Consumption of cannabis in violation of the code.

A. No cannabis business, its managers, or persons with an ownership interest, shall allow any person to smoke, ingest, or otherwise consume cannabis or cannabis products on its site, except as described in this chapter.

B. No cannabis business, its managers, or persons with an ownership interest, shall permit, aid, abet, or conceal the smoking, ingesting, or other consumption of cannabis or cannabis products on its site in violation of this code.

SECTION 4.

Section 5.150.430 of the Sacramento City Code is hereby amended to read as follows:

5.150.430 Limit on cannabis consumption on site.

No storefront cannabis dispensary shall allow any person to smoke, ingest, or otherwise consume cannabis or cannabis products in any form on, or within 20 feet of, the site, except as described in this chapter.

SECTION 5.
3 A. Subsection A of section 5.150.470 of the Sacramento City Code is hereby amended to read as follows:

A. Licensed Security Personnel. A dispensary must have adequate state-licensed security personnel to patrol the site and the area within 100 feet of the site to preserve the safety of persons and to protect the site from theft. All security personnel must possess a valid California Department of Consumer Affairs security guard license while on duty on the site.

B. Except as amended by subsection A above, all provisions of section 5.150.470 remain unchanged and in full effect.

SECTION 6.

A. Subsection A of section 5.150.480 of the Sacramento City Code is hereby amended to read as follows:

A. Each storefront cannabis dispensary that is not authorized to operate a cannabis consumption lounge must have a sign stating, "Smoking, ingesting, or consuming cannabis or cannabis products on this site or in a public place is prohibited." B. Except as amended by subsection A above, all provisions of section 5.150.480 remain unchanged and in full effect.

SECTION 7.

Section 5.150.510 of the Sacramento City Code is hereby amended to read as follows:

5.150.510 Alcoholic beverages and tobacco.

No storefront cannabis dispensary or manager shall cause or allow the sale, distribution, or consumption of alcoholic beverages, tobacco, or tobacco products on the site; hold or maintain a license from the State Division of Alcoholic Beverage Control for the sale of alcoholic beverages for the site; or operate a business on or adjacent to the site that sells alcoholic beverages, tobacco, or tobacco products. No person shall possess or store alcoholic beverages, tobacco, or tobacco products on the site.

SECTION 8.

Section 5.150.1200 of the Sacramento City Code is hereby amended to read as follows:

5.150.1200 Cannabis consumption prohibited.

No person shall smoke, ingest, or otherwise consume cannabis or cannabis products in any form on, or within 20 feet of, the cannabis distribution business site.

SECTION 9.
4 Article XI is hereby added to chapter 5.150 of the Sacramento City Code to read as follows:

Article XI. Cannabis Consumption Lounges

5.150.1360 Cannabis consumption lounge authorization required to operate.

A. No person shall operate a cannabis consumption lounge without having a valid storefront cannabis dispensary permit with a condition that authorizes the operation of a lounge in accordance with this article.

B. A storefront cannabis dispensary permit may be authorized to allow the operation of a cannabis consumption lounge with one of the following types of conditions:

1. Type 1 condition (non-smoking consumption). A type 1 condition on a valid storefront cannabis dispensary permit authorizes a storefront cannabis dispensary permittee to allow persons to consume cannabis and cannabis products, other than by smoking or vaping, in a cannabis consumption lounge on the site, subject to the provisions of this chapter.

2. Type 2 condition (all consumption). A type 2 condition on a valid storefront cannabis dispensary permit authorizes storefront cannabis dispensary permittee to allow persons to consume cannabis and cannabis products, including by smoking or vaping, in a cannabis consumption lounge on the site, subject to the provisions of this chapter.

5.150.1370 Cannabis consumption lounge fees.

A. The following fees are established and imposed pursuant to the provisions of this section:

1. Cannabis consumption lounge program fee;

2. Type 1 condition fee; and

3. Type 2 condition fee.

B. When applying for a new or renewal of a cannabis consumption lounge condition pursuant to this chapter, the applicant shall submit the cannabis consumption lounge program fee, plus the applicable fee for the condition that the applicant is seeking to obtain.

C. The city council shall establish by resolution the amounts of the fees specified in subsection A, and any related penalties.
5 D. The fees established and imposed in this section are separate and in addition to any storefront cannabis dispensary permit fees that apply pursuant to section

5.150.340.

5.150.1380 Cannabis consumption lounge premise restrictions.

A. Enclosed. A cannabis consumption lounge must be indoors and fully enclosed.

B. Size. A cannabis consumption lounge must be no larger than 1,500 square feet or 50% of the total floor area of the storefront cannabis dispensary site, whichever is smaller.

C. Not visible to the public. The interior of the cannabis consumption lounge must not be visible from the public right-of-way, non-age-restricted areas, the unsecured areas surrounding the buildings on the site, or the site's main entrance and lobby.

D. Partitioned. A cannabis consumption lounge must be separated from all other areas of the storefront dispensary by solid walls and doors. The wall may include glass to provide visibility between the dispensary and the lounge.

E. Soundproof. A cannabis consumption lounge must be adequately soundproofed so that the interior noise does not violate chapter 8.68 (Noise Control).

5.150.1390 Cannabis consumption lounge – type 2 ventilation requirements.

A type 2 cannabis consumption lounge must comply with the following:

A. The lounge must be designed to have negative pressure to limit, to the extent possible, leakage of smoke and particulate matter into the non-smoking areas of the site;
B. The lounge must have an HVAC system that does not recirculate air and that has a high rate of air exchange; and
C. The lounge must have an odor-absorbing ventilation and exhaust system that prevents the odor generated from inside of the lounge from being detected outside of the site or within any other area located within the same building as the lounge.

5.150.1400 Cannabis consumption lounge authorization to operate must be displayed.

A cannabis consumption lounge operator shall display a valid storefront cannabis dispensary permit with a condition that authorizes the operation of a lounge in a conspicuous place inside of the lounge so that all persons inside of the lounge may readily see it.

5.150.1410 Cannabis consumption lounge – type 1 signage. 6 A cannabis consumption lounge operator authorized to operate a type 1 cannabis consumption lounge shall display at each entrance of the lounge a sign that states, “Cannabis consumption, except smoking and vaping, is allowed inside of this lounge. No person under 21 years of age shall be in the lounge.” The sign must be in a conspicuous place so that all persons entering the lounge may readily see it. The sign must be clearly legible and not less than 8 inches by 10 inches in size.

5.150.1420 Cannabis consumption lounge – type 2 signage.

A cannabis consumption lounge operator authorized to operate a type 2 cannabis consumption lounge shall display at each entrance of the lounge a sign that states, “Cannabis consumption, including smoking and vaping, is allowed inside of this lounge. No person under 21 years of age shall be in the lounge.” The sign must be in a conspicuous place so that all persons entering the lounge may readily see it. The sign must be clearly legible and not less than 8 inches by 10 inches in size.

5.150.1430 Cannabis consumption lounge – health warnings.

A cannabis consumption lounge operator shall display signs designated by the city that address the health impacts of the consumption of cannabis. The signs must be displayed at the entrance to the lounge in a conspicuous place so that all persons may readily see it.

5.150.1440 Cannabis consumption lounge – parking area signage.

A cannabis consumption lounge operator shall display in all on- and off-site parking areas of the lounge, a sign that states, “Please be respectful of neighboring residents and businesses by leaving the area quietly;” and, where applicable, a sign that states “Notice: A permit may be required to park within the adjacent neighborhoods.” The sign must be in a conspicuous place so that all persons entering and exiting the parking areas may readily see it. The sign must be clearly legible and not less than 8 inches by 10 inches in size.

5.150.1450 Cannabis consumption lounge – waste containers.

Cannabis consumption lounge operators shall include properly maintained solid waste, organic waste, and recycling containers in sufficient numbers and locations to service the needs of the lounge.

5.150.1460 Cannabis consumption lounge operating hours.

No cannabis consumption lounge operator shall operate a lounge between 11:00 p.m. and 7:00 a.m. The city manager may impose more restrictive hours as a condition on the permit.

5.150.1470 Cannabis consumption lounge age restriction. 7 A. No person under 21 years of age shall enter or remain in a cannabis consumption lounge.

B. No cannabis consumption lounge operator shall allow any violation of this section.

5.150.1480 Cannabis consumption lounge personnel requirements.

A. Operator age limit. No person under 21 years of age shall operate a cannabis consumption lounge in any capacity, including as a manager, employee, contractor, or volunteer.

B. Education and training. The cannabis consumption lounge operator shall educate their managers, employees, and volunteers about the various types of cannabis and cannabis products allowed in the consumption lounge, including the potency, absorption time, and effects; and shall train their managers, employees, and volunteers to likewise educate customers on their purchases. The cannabis consumption lounge operator shall also train their employees to recognize signs of impairment in their customers.

C. Community-relations employee. The cannabis consumption lounge operator shall designate an employee as their onsite community-relations contact; provide their name and phone number by certified mail to all neighboring properties within 100 feet of the site; and advise them to notify the community-relations contact if there are operational problems with the lounge that impact the neighborhood. The cannabis consumption lounge operator shall also provide the name and phone number of the onsite community-relations contact to the Sacramento Police Department.

D. Manager. The cannabis consumption lounge operator’s manager shall be in the lounge whenever there is a customer in the lounge.

5.150.1490 Consumption of cannabis and cannabis products on site.

A. Consumption in lounge only. No person shall consume cannabis or cannabis products on a storefront cannabis dispensary site in any area other than the cannabis consumption lounge.

B. No cannabis consumption lounge operator shall allow any person to consume in the lounge any cannabis or cannabis product that was not purchased from the associated dispensary.

5.150.1500 Cannabis consumption lounge – prepackaged food and beverages.

A. No cannabis consumption lounge operator shall sell or provide for free any cannabis or cannabis products inside the lounge.
8 B. No cannabis consumption lounge operator may sell or provide for free any food or beverages in the lounge, unless it is prepackaged and does not contain cannabis or alcohol.

C. No cannabis consumption lounge operator shall store, display, contaminate, or commingle any prepackaged food or beverage with any cannabis or cannabis product on the site.

5.150.1510 Cannabis consumption lounge – customer conduct.

A. Closing announcement. One hour before the closing time of the lounge and at the closing time, the cannabis consumption lounge operator or their manager shall announce the closing time of the lounge and request that customers respect the residents of the adjacent neighbors by being quiet when leaving.

B. Retail limit. No cannabis consumption lounge operator or its manager, employee, or volunteer shall provide cannabis or cannabis products to obviously impaired customers.

C. Car services. A cannabis consumption lounge operator shall provide written information on ridesharing and ride-hailing car services for their customers.

D. Entry and exit of the lounge. A cannabis consumption lounge operator or its manager, employee, or volunteer shall escort customers in and out of the lounge.

5.150.1520 Repeal of article.

This article remains in effect until January 1, 2030, and on that date this article is repealed and all permit conditions that authorize the operation of a cannabis consumption lounge are void.

SECTION 10.

A. Subsection O of section 8.04.110 of the Sacramento City Code is hereby amended to read as follows:

O. A ny condition in violation of section 5.150.1360.A (cannabis consumption lounge authorization), chapter 8.132 (cultivation of cannabis), or chapter 8.133 (places where cannabis consumption is prohibited); and
B. Except as amended by subsection A above, all provisions of section 8.04.110 remain unchanged and in full effect.

SECTION 11.

Chapter 8.133 is hereby added to the Sacramento City Code to read as follows:

Chapter 8.133 PLACES WHERE CONSUMPTION OF CANNABIS IS PROHIBITED 9 8.133.010 Findings and purposes.

While recognizing a person’s right to obtain and consume cannabis and cannabis products, the city council believes that consumption should be restricted from certain places. Consuming cannabis and cannabis products in those places is a nuisance and presents a real and imminent threat to the public health, safety, and welfare.

Specifically, the open and public consumption of cannabis or cannabis products increases the public’s exposure of secondhand smoke, similar to tobacco. In or near schools and playgrounds, consumption increases the exposure of cannabis use to developing youths.

In addition, consumption within nonresidential buildings that are not regulated to safely manage such activity exposes the public to some of the public safety and welfare concerns of unpermitted cannabis businesses and illegal cultivation of cannabis.

These buildings often have fire and safety hazards created by either the lack of ventilation or unpermitted installation of air-filtration systems to conceal the odor of both cannabis flower and smoked cannabis. These buildings also often lack the security protocols necessary for the possession or storage of cannabis in large quantities, thereby substantially increasing the chance that violent criminal activity will occur.

Accordingly, the purpose of this chapter is to prohibit the open and public consumption of cannabis or cannabis products in or near schools, playgrounds, and unregulated nonresidential buildings except buildings or facilities as prescribed in chapter 5.150, including events in accordance with section 5.150.360.C.

8.133.020 Definitions.

The following definitions apply in this chapter:
“Cannabis” has the same meaning as in California Business and Professions Code section 26001.

"Cannabis business” has the same meaning as in section 5.150.010.

“Cannabis product” has the same meaning as in California Business and Professions Code section 26001, subdivision (k).

"Commercial cannabis activity” has the same meaning as in California Business and Professions Code section 26001, subdivision (m).
"Consumption” means the act of smoking, vaping, or ingesting. 10 “Smoking” has the same meaning as in section 8.80.030.

8.133.030 Consumption of cannabis and cannabis products prohibited in nonresidential buildings.

A. No person shall consume cannabis or cannabis products in any nonresidential building or facility, or any nonresidential portion of a building or facility, except as part of a commercial cannabis activity of a permitted cannabis business pursuant to chapter

5.150.

B. No person shall aid or abet the consumption of cannabis or cannabis products in violation of subsection A.

8.133.040 Violation—Penalty.

A. In addition to any other remedy allowed by law, any person who violates a provision of this chapter is subject to criminal sanctions, civil actions, and administrative penalties.

B. Civil penalties for violations of this chapter.

1. Any person who violates a provision of this chapter is liable for civil penalties of not less than $250 or more than $25,000 for each day the violation continues, except as provided in subsection B.2.

2. Any person who violates section 8.133.030.B is liable for civil penalties of an aggregate amount calculated at $1,000 per occurrence.

C. Any person who violates any provision of this chapter is guilty of a misdemeanor, punishable by a fine not to exceed $1,000, imprisonment in the county jail for a term not to exceed six months, or both.

D. Administrative penalties for a violation of a provision of this chapter are governed by chapter 1.28, except for the following:

1. The amount of the administrative penalty is an aggregate amount calculated at $1,000 per day that the violation exists; and

2. The amount of the appeal fee is set by city council resolution. 11 E. All remedies prescribed under this chapter are cumulative and the election of one or more remedies does not bar the city from the pursuit of any other remedy to enforce this chapter.

SECTION 12.

Chapter 9.08 of the Sacramento City Code is hereby deleted.

1 ORDINANCE NO.

Adopted by the Sacramento City Council
[Date Adopted]
AN ORDINANCE AMENDING VARIOUS SECTIONS OF CHAPTER 5.150 OF, AMENDING SECTION

8.04.110 OF, ADDING CHAPTER 8.133 TO, AND DELETING CHAPTER 9.08 OF THE

SACRAMENTO CITY CODE, RELATING TO THE CONSUMPTION OF CANNABIS AND CANNABIS

PRODUCTS
BE IT ENACTED BY THE COUNCIL OF THE CITY OF SACRAMENTO:

SECTION 1.

A. Section 5.150.020 of the Sacramento City Code is hereby amended as follows:

3. A definition for “smoking” is hereby added to read as follows:
“Smoking” has the same meaning as in section 8.80.030.

4. A definition for “vaping” is hereby added to read as follows:
“Vaping” means to inhale vapor from a device that heats up and vaporizes a liquid or solid.

B. Except as amended by subsection A above, all provisions of section 5.150.020 remain unchanged and in full effect.

SECTION 2.
2 Section 5.150.130 of the Sacramento City Code is hereby amended to read as follows:

5.150.130 Site management.

A. Notwithstanding any other provision of this code, Thea cannabis business permittee shall— prevent and eliminate conditions on the site that constitute a nuisance.

A. Prevent and eliminate nuisances on its site, including the unlawful consumption of cannabis or cannabis products;
B. The cannabis business permittee shall mMaintain the exterior of the site, including any parking lots under the control of the permittee, free of litter, debris, and trash;.

C. The permittee shall pProperly store and dispose of all waste generated on the site, including chemical and organic waste, in accordance with all applicable laws and regulations;. No permittee shall dispose of cannabis or cannabis products unless they have been made unusable and unrecognizable.

D. Make cannabis and cannabis products unusable and unrecognizable before discarding them; and
ED. Notwithstanding any provisions of this code to the contrary, the permittee shall rRemove all graffiti from the site and parking lots under the control of the permittee within 72 hours of its application.

SECTION 3.

Section 5.150.145 is hereby added to the Sacramento City Code to read as follows:

5.150.145 Consumption of cannabis in violation of the code.

SECTION 4.

Section 5.150.430 of the Sacramento City Code is hereby amended to read as follows:

5.150.430 Limit on Ccannabis consumption prohibited on site. 3 No storefront cannabis dispensary shall allow any person to smoke, ingest, or otherwise consume cannabis or cannabis products in any form on, or within 20 feet of, the dispensary site, except as described in this chapter.

SECTION 5.

A. Subsection A of section 5.150.470 of the Sacramento City Code is hereby amended to read as follows:

A. Licensed Security Personnel. A dispensary must have adequate state-licensed security personnel to patrol the site and the area within 100 feet of the site to preserve the safety of persons and to protect the dispensary site from theft. All security personnel must possess a valid California Department of Consumer Affairs security guard license while on duty on the site.

B. Except as amended by subsection A above, all provisions of section 5.150.470 remain unchanged and in full effect.

SECTION 6.

A. Subsection A of section 5.150.480 of the Sacramento City Code is hereby amended to read as follows:

SECTION 7.

Section 5.150.510 of the Sacramento City Code is hereby amended to read as follows:

5.150.510 Alcoholic beverages and tobacco.

No storefront cannabis dispensary or manager shall cause or allow the sale, distribution, or consumption of alcoholic beverages, tobacco, or tobacco products on the dispensary site; hold or maintain a license from the State Division of Alcoholic Beverage Control for the sale of alcoholic beverages for the site; or operate a business on or adjacent to the dispensary site that sells alcoholic beverages, tobacco, or tobacco products. No person shall possess or store alcoholic beverages, tobacco, or tobacco products on the dispensary site.

SECTION 8.

Section 5.150.1200 of the Sacramento City Code is hereby amended to read as follows:
4 5.150.1200 Cannabis consumption prohibited.

No cannabis distribution business shall allow any person toshall smoke, ingest, or otherwise consume cannabis or cannabis products in any form on, or within 20 feet of, the cannabis distribution business site.

SECTION 9.

Article XI is hereby added to chapter 5.150 of the Sacramento City Code to read as follows:

Article XI. Cannabis Consumption Lounges

5.150.1360 Cannabis consumption lounge authorization required to operate.

B. A storefront cannabis dispensary permit may be authorized to allow the operation of a cannabis consumption lounge with one of the following types of conditions:

5.150.1370 Cannabis consumption lounge fees.

A. The following fees are established and imposed pursuant to the provisions of this section:

1. C annabis consumption lounge program fee;

2. Type 1 condition fee; and

3. Type 2 condition fee.

B. When applying for a new or renewal of a cannabis consumption lounge condition pursuant to this chapter, the applicant shall submit the cannabis consumption 5 lounge program fee, plus the applicable fee for the condition that the applicant is seeking to obtain.

C. The city council shall establish by resolution the amounts of the fees specified in subsection A, and any related penalties.

D. The fees established and imposed in this section are separate and in addition to any storefront cannabis dispensary permit fees that apply pursuant to section

5.150.340.

5.150.1380 Cannabis consumption lounge premise restrictions.

A. Enclosed. A cannabis consumption lounge must be indoors and fully enclosed.

B. Size. A cannabis consumption lounge must be no larger than 1,500 square feet or 50% of the total floor area of the storefront cannabis dispensary site, whichever is smaller.

E. Soundproof. A cannabis consumption lounge must be adequately soundproofed so that the interior noise does not violate chapter 8.68 (Noise Control).

5.150.1390 Cannabis consumption lounge – type 2 ventilation requirements.

A type 2 cannabis consumption lounge must comply with the following:

5.150.1400 Cannabis consumption lounge authorization to operate must be displayed.

A cannabis consumption lounge operator shall display a valid storefront cannabis dispensary permit with a condition that authorizes the operation of a lounge in a 6 conspicuous place inside of the lounge so that all persons inside of the lounge may readily see it.

5.150.1410 Cannabis consumption lounge – type 1 signage.

A cannabis consumption lounge operator authorized to operate a type 1 cannabis consumption lounge shall display at each entrance of the lounge a sign that states, “Cannabis consumption, except smoking and vaping, is allowed inside of this lounge. No person under 21 years of age shall be in the lounge.” The sign must be in a conspicuous place so that all persons entering the lounge may readily see it. The sign must be clearly legible and not less than 8 inches by 10 inches in size.

5.150.1420 Cannabis consumption lounge – type 2 signage.

5.150.1430 Cannabis consumption lounge – health warnings.

5.150.1440 Cannabis consumption lounge – parking area signage.

5.150.1450 Cannabis consumption lounge – waste containers.

Cannabis consumption lounge operators shall include properly maintained solid waste, organic waste, and recycling containers in sufficient numbers and locations to service the needs of the lounge.

7 5.150.1460 Cannabis consumption lounge operating hours.

No cannabis consumption lounge operator shall operate a lounge between 11:00 p.m. and 7:00 a.m. The city manager may impose more restrictive hours as a condition on the permit.

5.150.1470 Cannabis consumption lounge age restriction.

A. No person under 21 years of age shall enter or remain in a cannabis consumption lounge.

B. No cannabis consumption lounge operator shall allow any violation of this section.

5.150.1480 Cannabis consumption lounge personnel requirements.

A. Operator age limit. No person under 21 years of age shall operate a cannabis consumption lounge in any capacity, including as a manager, employee, contractor, or volunteer.

B. E ducation and training. The cannabis consumption lounge operator shall educate their managers, employees, and volunteers about the various types of cannabis and cannabis products allowed in the consumption lounge, including the potency, absorption time, and effects; and shall train their managers, employees, and volunteers to likewise educate customers on their purchases. The cannabis consumption lounge operator shall also train their employees to recognize signs of impairment in their customers.

D. Manager. The cannabis consumption lounge operator’s manager shall be in the lounge whenever there is a customer in the lounge.

5.150.1490 Consumption of cannabis and cannabis products on site.

A. Consumption in lounge only. No person shall consume cannabis or cannabis products on a storefront cannabis dispensary site in any area other than the cannabis consumption lounge.
8 B. No cannabis consumption lounge operator shall allow any person to consume in the lounge any cannabis or cannabis product that was not purchased from the associated dispensary.

5.150.1500 Cannabis consumption lounge – prepackaged food and beverages.

A. No cannabis consumption lounge operator shall sell or provide for free any cannabis or cannabis products inside the lounge.

B. No cannabis consumption lounge operator may sell or provide for free any food or beverages in the lounge, unless it is prepackaged and does not contain cannabis or alcohol.

C. No cannabis consumption lounge operator shall store, display, contaminate, or commingle any prepackaged food or beverage with any cannabis or cannabis product on the site.

5.150.1510 Cannabis consumption lounge – customer conduct.

B. Retail limit. No cannabis consumption lounge operator or its manager, employee, or volunteer shall provide cannabis or cannabis products to obviously impaired customers.

C. Car services. A cannabis consumption lounge operator shall provide written information on ridesharing and ride-hailing car services for their customers.

D. Entry and exit of the lounge. A cannabis consumption lounge operator or its manager, employee, or volunteer shall escort customers in and out of the lounge.

5.150.1520 Repeal of article.

This article remains in effect until January 1, 2030, and on that date this article is repealed and all permit conditions that authorize the operation of a cannabis consumption lounge are void.

SECTION 10.

A. Subsection O of section 8.04.110 of the Sacramento City Code is hereby amended to read as follows:
9 O. A ny condition in violation of section 5.150.1360.A (cannabis consumption lounge authorization), chapter 8.132 (cultivation of cannabis), or chapter 8.133 (places where cannabis consumption is prohibited); and
B. Except as amended by subsection A above, all provisions of section 8.04.110 remain unchanged and in full effect.

SECTION 11.

Chapter 8.133 is hereby added to the Sacramento City Code to read as follows:

Chapter 8.133 PLACES WHERE CONSUMPTION OF CANNABIS IS PROHIBITED

8.133.010 Findings and purposes.

8.133.020 Definitions.

The following definitions apply in this chapter:
10 “Cannabis” has the same meaning as in California Business and Professions Code section 26001.

"Cannabis business” has the same meaning as in section 5.150.010.

“Cannabis product” has the same meaning as in California Business and Professions Code section 26001, subdivision (k).

"Commercial cannabis activity” has the same meaning as in California Business and Professions Code section 26001, subdivision (m).
"Consumption” means the act of smoking, vaping, or ingesting.

“Smoking” has the same meaning as in section 8.80.030.

8.133.030 Consumption of cannabis and cannabis products prohibited in nonresidential buildings.

5.150.

B. No person shall aid or abet the consumption of cannabis or cannabis products in violation of subsection A.

8.133.040 Violation—Penalty.

A. In addition to any other remedy allowed by law, any person who violates a provision of this chapter is subject to criminal sanctions, civil actions, and administrative penalties.

B. Civil penalties for violations of this chapter.

2. Any person who violates section 8.133.030.B is liable for civil penalties of an aggregate amount calculated at $1,000 per occurrence.

11 C. Any person who violates any provision of this chapter is guilty of a misdemeanor, punishable by a fine not to exceed $1,000, imprisonment in the county jail for a term not to exceed six months, or both.

D. Administrative penalties for a violation of a provision of this chapter are governed by chapter 1.28, except for the following:

1. The amount of the administrative penalty is an aggregate amount calculated at $1,000 per day that the violation exists; and

2. The amount of the appeal fee is set by city council resolution.

E. All remedies prescribed under this chapter are cumulative and the election of one or more remedies does not bar the city from the pursuit of any other remedy to enforce this chapter.

SECTION 12.

Chapter 9.08 of the Sacramento City Code is hereby deleted.

Chapter 9.08 PUBLIC CONSUMPTION OF MARIJUANA

9.08.010 Findings and purposes.

On November 5, 1996, the voters of the state of California approved Proposition 215 enacting Section 11362.5 of the Health and Safety Code (the “Compassionate Use Act”). That section permits, for purposes of state law, the limited use, cultivation and possession of marijuana for specified medical purposes. However, the use, cultivation and possession of marijuana for other purposes remains illegal within this state and is presently illegal under federal laws.

While recognizing the enactment of Health and Safety Code Section 11362.5, the city council believes that the open and public use of marijuana, which might otherwise be permitted by that section, is injurious to public health in many of the same ways that tobacco consumption is injurious to public health, due to exposure to second-hand smoke. Further, the open and public consumption of marijuana is potentially harmful to youths in that it sets a deleterious example regarding the use of illicit drugs. Therefore, the city council believes it is necessary to balance the uses of marijuana permitted by Section 11362.5 with the concerns for public health and safety.

9.08.020 Places where consumption of marijuana is prohibited.

A. Notwithstanding California Health and Safety Code Section 11362.5 or any preceding provisions of this chapter and Chapter 8.80 of this code, the consumption of 12 marijuana, by or through “smoking,” as defined in Section 8.80.030 of this code, is prohibited at any of the following locations to which members of the public have access:

1. Upon or within one thousand (1,000) feet of the grounds of any school or park;

2. In or within one hundred (100) feet of any building or facility to which members of the public have access, except in a health facility or clinic; or

3. Within one hundred (100) feet of any other person, other than a “primary caregiver,” as that term is defined in California Health and Safety Code Section 11362.5(e).

B. As used in this section, the following definitions shall apply:

1. “School” means any institution of learning for minors, whether public or private, including any special institution of education or any nursery, elementary, middle, junior high, or senior high school. This definition does not include a vocational or professional institution of higher education, including a junior or community college, college or university.

2. “Park” means and includes all parks, parkways, malls, plazas, greenbelts, gardens, lakes and other property owned by the city and used, operated or maintained for recreational purposes.

3. “Health facility” means a facility, place or building that is organized, maintained, and operated for the diagnosis, care, prevention, and treatment of human illness, physical and mental, including convalescence and rehabilitation, or for any one of those purposes, for one or more persons, to which the persons are admitted for a twenty-four (24) hour stay or longer.

4. “Clinic” means an organized outpatient health facility which provides medical, surgical, dental, optometric, podiatric, or psychological advice, services, or treatment to patients who remain less than twenty-four (24) hours.

9.08.030 Violation—Penalty.

A. First Violation. Any first violation of this chapter by a person shall be an infraction, and shall be subject to punishment as provided in California Government Code Section 36900(b).

B. Second and Subsequent Violations. Except as provided below, any second and subsequent violation of this chapter by a person shall be a misdemeanor, punishable by 13 a fine not to exceed one thousand dollars ($1,000.00), imprisonment in County Jail for a term not to exceed six months, or both such fine and imprisonment.

Exception: Notwithstanding the above, a violation of this chapter is an infraction when the complaint is filed charging the offense as an infraction, in which case the violation shall be subject to and punishable as provided in California Government Code Section 36900(b).

9.08.040 Nonexclusivity.

Nothing in this chapter shall limit or preclude the enforcement of other applicable laws.

Sacramento City CouncilNovember 19, 2024

Sacramento City Council
November 19, 2024