4/5/2021 Mail - [email protected] [EXTERNAL] Letter re: smokefree multi-unit housing proposal

Liz Williams

Thu 4/1/2021 5:04 PM

To:Public Comment ;

 1 attachments (559 KB)

Letter to Corte Madera_MUH_04.01.21.pdf;

Dear Mayor Beckman and Councilmembers,

Americans for Nonsmokers’ Rights would like to submit the aached leer regarding the proposed smokefree mul-unit housing ordinance and our concern with the provision to exempt marijuana smoking and vaping.

Sincerely,

Liz Williams | Project & Policy Manager Americans for Nonsmokers' Rights |nonsmokersrights.org

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https://west.exch090.serverdata.net/owa/#path=/mail 1/1

April 1, 2021

Mayor Eli Beckman 300 Tamalpais Dr. Corte Madera, CA 94925

Dear Mayor Beckman and Councilmembers,

Americans for Nonsmokers’ Rights is writing to express our support for strengthening the city’s smokefree multi-unit housing law in order to protect the health and safety of all multi-unit residents and to help ensure everyone’s right to a smokefree living environment.

We strongly oppose exempting marijuana smoking and vaping from the proposed ordinance. In order to have a 100% smokefree multi-unit housing, the ordinance must include the smoking and vaping of both tobacco and marijuana products.

Residents in Corte Madera should be able to breathe air that is free from all types of secondhand smoke exposure. Secondhand smoke from combusted marijuana contains fine particulate matter which is a form of indoor air pollution, which can be breathed deeply into the lungs and can cause lung irritation, asthma attacks, and makes respiratory infections more likely.i,ii Exposure to fine particulate matter can exacerbate health problems especially for people with respiratory conditions like asthma, bronchitis, or Chronic Obstructive Pulmonary Disease (COPD).iii,iv

The current body of science shows that both tobacco and marijuana smoke have similar chemical composition and suggests that they may have harmful cardiovascular health effects, such as atherosclerosis (partially blocked arteries), heart attack, and stroke.v In peer-reviewed research studies, tobacco and marijuana smoke have both been shown to impair blood vessel functionvi and secondhand marijuana smoke contains many of the same carcinogens and toxic chemicals as secondhand tobacco smoke.vii

Marijuana should not be smoked or vaped inside multi-unit residences, just like it should not be smoked or vaped inside workplaces, because marijuana secondhand smoke and aerosol are a source of indoor pollution that poses health risks to non-users. While marijuana is now legal, it should not be used in ways that harm other people.

Corte Madera’s ordinance should reiterate California state law, which prohibits marijuana smoking wherever tobacco smoking is prohibited by law. Rather than allowing marijuana smoking inside multi-unit residents, communities should instead explore opportunities for outdoor use that could both meet the access and safety needs of marijuana consumers while also reducing exposure to drifting secondhand smoke to protect the health of multi-unit residents.

Corte Madera has the opportunity to be a public health leader by protecting residents from the harmful effects of secondhand tobacco and marijuana smoke by prohibiting smoking in all multi-

2530 San Pablo Avenue, Suite J, Berkeley, CA 94702 | 510.841.3032 | 510.841.3071 Fax | nonsmokersrights.org ANR is a 501(c)(4) nonprofit lobbying organization and contributions are not tax deductible Tax ID #94-2598713 unit residences, including apartments and condominiums. Smokefree multi-unit housing is a powerful way to have a broad, positive community impact by reducing secondhand exposure where many people spend much of their time—especially children, the elderly, and people with disabilities—and can suffer from persistent levels of exposure.

The Centers for Disease Control and Prevention (CDC) estimates that nearly 5 million California multi-unit housing residents who keep a smokefree home are still exposed to a neighbor’s secondhand smoke. The U.S. Surgeon General confirmed that there is no risk-free level of exposure to secondhand smoke, and that exposure can have both short and long term health risks, especially for people with existing health conditions like asthma and other respiratory conditions, heart disease, and cancer.

Action needs to be taken because secondhand smoke does not stay in the unit of a person who smokes. Secondhand smoke can drift through multi-unit buildings and enter common areas and units occupied by non-smokers, where it becomes a nuisance and health risk to other residents. Research shows that up to 65% of the air in an apartment unit can come from other units in the building, and that secondhand smoke drifts under doors, through windows, hallways, and ventilation ducts, and through gaps around outlets, pipes, fixtures, and walls.

Smokefree multi-unit buildings create a healthier living environment for all residents, including people who smoke and their families. It’s important to note that a smokefree building does not mean that people who smoke have to quit and it does not require people who smoke to move out. People who smoke simply need to go outdoors to appropriate areas to do so.

Corte Madera would be in good company by joining the California cities and counties that have already adopted laws requiring all units of all multi-unit housing properties to be 100% smokefree—including smoking and vaping marijuana—including Belvedere, Mill Valley, Novato, Rohnert Park, Ross, San Anselmo, and Tiburon.

Thank you for your leadership and desire to make Corte Madera the best place to live, work, and visit. Please feel free to contact me at if you have any questions, comments, or feedback.

Sincerely,

Cynthia Hallett, MPH President and CEO

Americans for Nonsmokers’ Rights is a national, member-based, not-for-profit organization based in Berkeley, CA that is dedicated to helping nonsmokers breathe smokefree air since 1976.

i Hillier, FC.; et al. "Concentration and particle size distribution in smoke from marijuana cigarettes with different Δ9-tetrahydrocannabinol content." Fundamental and Applied Toxicology. Volume 4, Issue 3, Part 1, June 1984, Pages 451-454. http://www.sciencedirect.com/science/article/pii/0272059084902021

ii “Air and Health: Particulate Matter.” National Environmental Public Health Tracking Network, U. S. Environmental Protection Agency. http://ephtracking.cdc.gov/showAirHealth.action#ParticulateMatter iii Grana, R; Benowitz, N; Glantz, S. “Background Paper on E-cigarettes,” Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control. December 2013. iv Brook, R.D.; et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010; 121: 2331-78. https://www.ncbi.nlm.nih.gov/pubmed/20458016 v Springer, M.L.; Glantz, S.A." Marijuana Use and Heart Disease: Potential Effects of Public Exposure to Smoke," University of California at San Francisco. April 13, 2015. https://tobacco.ucsf.edu/sites/tobacco.ucsf.edu/files/u9/MSHS%20fact%20sheet%20for%20CA%204-13-15.pdf vi Wang, X., et al., “Brief exposure to marijuana secondhand smoke impairs vascular endothelial function” (conference abstract). Circulation 2014; 130: A19538. http://circ.ahajournals.org/content/130/Suppl_2/A19538.abstract vii Moir, D., et al., A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chem Res Toxicol 21: 494-502. (2008). http://www.ncbi.nlm.nih.gov/pubmed/18062674 4/5/2021 Mail - [email protected] [EXTERNAL]

Smart Doggo

Thu 4/1/2021 6:56 PM

To:Public Comment ;

My name is Tanaya and I am a high school senior here in Marin County. I am reaching out to you to ask that you make changes to the second-hand smoke-free policy in multi-unit housing (MUH) such that it protects everyone without exceptions. This is an important topic I want to use my voice to address for the following reasons:

Secondhand marijuana smoke contains:

Many of the same chemicals and cancer causing substances as secondhand tobacco smoke, including:

Is 3 times the amount of Ammonia

Significant levels of mercury, lead, Formaldehyde, benzene, hydrogen cyanide and toluene. (American NonSmokers’ Foundation Rights)

Drifting secondhand smoke in multi-unit housing (MUH) is a top complaint.

Residents can be exposed to SHS

from family members or neighbors.

SHS travels through buildings:

Doors, windows, hallways, ventilation

system, outlets, & gaps around pipes.

Up to 65% of air in an apartmentcan come from other units.

The only way to protect health is for buildings to be completely smoke-free.

Please eliminate the second-hand exemption for medical cannabis and prohibit second-hand smoke in all multi-unit housing in 100% of multi-unit housing in Corte Madera.

https://west.exch090.serverdata.net/owa/#path=/mail 1/2 4/5/2021 Mail - [email protected]

Thank you,

Tanaya

https://west.exch090.serverdata.net/owa/#path=/mail 2/2 4/5/2021 Mail - [email protected] [EXTERNAL] smoke free ordinance-meeting april 6, 221

HEIDI MAYER

Thu 4/1/2021 11:41 PM

To:Public Comment ;

Dear Mayor Beckman and Councilmembers:

We appreciate your support for a progressive smoke-free housing ordinance last month and that you agreed to protect 100% of residents living in apartments and condos. However, the exemption for medical marijuana smoking and vaping compromises the effectiveness of the ordinance which was designed to protect all residents of multi-unit housing from the public health hazards of drifting marijuana smoke. We will support the ordinance once the exemption is removed.

A new study shows that marijuana smoke emission rate is 3.5 times higher than that of the tobacco cigarette (including joints and cannabis vaping). You can see this and other new studies published by the State Health Department here: https://www.smokefreemarin.org/marijuana-smoking-information/

Regarding medical marijuana, the cannabis industry has created hundreds of products that do not require users to expose nonsmoking household members and neighbors to marijuana smoke or vaping fumes. These include Marinol tablets, cannabis lozenges, oils, tinctures, candy, cookies, lotions, and creams, similar to how tobacco users can use Nicorette gum or the patch, lozenges and as well as FDA-approved nicotine replacements such as inhalers instead of flammable, combustible products that cause air toxins and fires.

These are solutions that are utilized by residents of the seven other jurisdictions in Marin that have successfully enacted 100 percent smoke-free multi-unit housing ordinances with zero exemptions during the past several years.

The Smoke-free Marin Coalition offers lots of help and support for anyone needing help: https://www.smokefreemarin.org/

Thank you for considering the most vulnerable members of our community: babies, children, teens, adults and those with allergies, respiratory illness, COVID, and other health challenges by removal of this unnecessary exemption:

6:14.110 – Notwithstanding any other provision of this chapter, Smoking marijuana for medical purposes as permitted by California Health and Safety Code sections 11362.7 et seq. is not prohibited by this chapter.

Heidi Mayer member Smoke Free Marin Coalition Novato resident

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/5/2021 Mail - [email protected] [EXTERNAL] Concern with MUH Second-hand Smoke Ordiance

Emily Gallegos

Fri 4/2/2021 11:13 AM

To:Public Comment ;

Dear Corte Madera City Council and Town Staff Members:

My name is Emily Gallegos and I am a proud member of the Youth Advisory Council, a Sophomore at Redwood High School and resident here in Corte Madera. My peers in the Youth Advisory Council have spoken very positively about their recent experiences speaking in our city’s council meetings and I feel encouraged to speak about my thoughts and personal experience on the matter of second-hand smoke in multi-unit housing. I have lived in multi-unit housing for 12 years and for all of this time, I have known that my exposure to second-hand smoke was different than that of my peers (children, adolescents and families) who do not neighbor so closely to others. I do not have the option to “escape” the smoke that is produced by my neighbors and allowed by the city/town that I live in. The smoke produced by my neighbors can be inhaled by residents near us, too. The chemicals in the smoke can greatly impact residents with lung/health problems. Why should my and my neighbors' health be put at risk for someone to smoke? The State of California prohibits smokers within 20 feet from public/private property and buildings. This rule should be applied to multi-unit housing. Members of Multi-unit housing all live together in one building, but it is still considered public property outside of your door. They need to be considerate of others and their health and so should you. Even with up to 25 feet between you and someone with a lit cigarette, you could still breathe in 46 percent more of the particles compared to air without cigarette smoke. I realize you have expressed support to strengthen the second-hand smoke in multi-unit housing policy, and I can’t tell you how much I appreciate that, however, I am aware that there is an exception to smoke produced by medically-allowed marijuana/cannabis in the ordinance ( 6:14.110 ) and I am writing to ask that you consider my concern about this and change this ordinance so that you prohibit second-hand smoke in all multi-unit housing in Corte Madera-no exceptions, so that no one, so that my family and I, do not have to suffer it’s harmful effects. Thank you for giving me hope that you will do your part in protecting everyone you can from this preventable harm.

Sincerely, Emily Gallegos

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/5/2021 Mail - [email protected] [EXTERNAL] Request to close loophole in your proposed smoke free ordinance

Victor Greenfield

Fri 4/2/2021 11:52 AM

To:Public Comment ; Eli Beckman ;

Hello Mayor Beckman and Corte Madera Council,

I live in a condo and my neighbor smokes weed on a daily basis. I work from home and I like to have my windows open as well as my patio door so that air can come in through the screen door. He is home all the time too and his pot smoke, which smells like a skunk, fills my kitchen and bedroom windows. I have politely asked him to please switch over to medical cannabis pills or edibles and he said that the Corte Madera law currently allows him to smoke pot anytime he wants to in his unit. I checked online and saw that he is correct. I don't want to sell my condo just to get away from this rude and inconsiderate neighbor who is destroying my indoor air quality and my health. Most of us in Corte Madera don't even smoke dope because we have to make a living to pay for our condos. Many of us can't afford to buy a house where we would have more space from these types of neighbors.

I have not been able to use my patio since he got addicted to cannabis. A friend of mine told me that you will have a meeting about this on Tuesday. I won't be able to make it but would you please have compassion for residents like me and close any loopholes in the ordinance?

Thank you for any help you provide those of us who don't want to suffer another warm-weather season under the nauseating influence of unwanted weed smoke.

Victor Greenfield

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/5/2021 Mail - [email protected] [EXTERNAL] Request to the Corte Madera Council from the Smoke-Free Marin Coalition

Smoke-Free Marin Coalition

Fri 4/2/2021 3:45 PM

To:Eli Beckman ; Public Comment ;

Dear Mayor Beckman and Corte Madera Councilmembers,

The Smoke-Free Marin Coalition has enjoyed a 31-year collaboration with the Corte Madera to publicize and implement all of Corte Madera's tobacco control ordinances to contribute to high compliance rates to protect public health. We are sincerely grateful for your progressive Flavor Ban ordinance that protects youth from candy-flavored addiction. We were also pleased with the proposed 100% smoke-free housing ordinance that passed on First Reading, until we realized it included an unsupportable exemption for smoking or vaping any type of marijuana. We work hard (and also volunteer our time) to help residents protect themselves and their families from unwanted smoke and vape toxins and fire safety dangers that come with these habits, especially with poly-use such as pot and tobacco smoking and vaping while using alcohol.

Having served as Chair of the Smoke-Free Marin Coalition for many years, I am pleased to see the progress in Corte Madera Council having such high regard for its residents that you are willing to protect them from the health-damaging effects of chronic drifting smoke. We and the County's Tobacco-Related Disease Control Program have tried to help residents over the years deal with drifting smoke, which used to be mostly tobacco smoke. However, now that marijuana is becoming so readily available, there are more people suffering from forced exposure to their neighbor's weed smoke than ever before. Frequent complaints are that this has a skunk-like odor, although some people have been coached by the cannabis industry to call it their "incense" or their "medicine." Whatever people call it, there is a tremendous injustice to those who are forced to inhale weed fumes for hours against their will. During the warm weather months, residents want to open their balconies and windows and enjoy fresh air without the odors and toxins that come from tobacco and pot smoking and vaping.

Many people living in multi-unit housing cannot afford to move in order to get away from their neighbor's smoke, and with so many people staying at home during the covid lockdowns, there has been an increase in marijuana smoking as well as involuntary exposure for those who choose to not to use any of these addictive substances. An exemption for any type of pot smoking will remove protection for the majority of non-smoking, non-vaping residents who desire to protect themselves and their families from toxic air quality in their homes, where these days, folks spend most of their time.

During the March Council meeting on this proposed ordinance, there was mention of a telephone survey conducted of property managers and homeowner's associations of large multi-housing complexes. Every one of the property managers and/or owners and HOA boards wanted 100% of units to be protected by an ordinance, with zero exemptions including no marijuana or tobacco smoking. They said that an ordinance like this would cut down on maintenance, fires, and time-consuming disputes between smoking and nonsmoking neighbors.

Since the property managers have to enforce the new smoke-free leases on site, and the Smoke-Free Marin Coalition volunteers and the County Health Department's Tobacco-Related Disease Control Program give the residents and property managers technical support to maintain smoke-free environments, it would help everyone to have an effective, enforceable 100 percent zero exemption ordinance behind them. Otherwise, there is not much that anyone can do to help those forced to inhale toxins against their free will.

Recent scientific reports show that both tobacco and marijuana smoke have similar chemical composition and suggests that they may have harmful cardiovascular health effects, such as atherosclerosis (partially blocked arteries), heart attack, and stroke. Recent studies have shown that tobacco and marijuana smoke have both been shown to increase the risk for COVID, making it harder to survive the disease.

There was a fatality in one of our local jurisdictions when a nonsmoker died in a condo fire started by a smoker. We also received a complaint in which an infant was born in a cloud of smoke drifting from the neighbor. Secondhand smoke is one of the leading causes of SIDS, Sudden Infant Death Syndrome. These types of tragedies are preventable by smoke-free housing ordinances only when there are no exemptions. The seven jurisdictions in Marin (including San Anselmo) which have passed 100% smoke-free MUH ordinances, similar to your proposed ordinance, did not exempt medical marijuana. For the sake of enforcement, it would be far easier for enforcement agencies and property managers to have uniform ordinances. When smoke-free marin ordinances are uniform all throughout the 12 jurisdictions in the county, they are easier for the public to understand, and this awareness translates into high compliance rates, making them self-enforcing.

https://west.exch090.serverdata.net/owa/#path=/mail 1/2 4/5/2021 Mail - [email protected] The cannabis industry tries to convince its customers that the only way that they can get medical marijuana is via smoking and vaping, but there are hundreds of products that provide safer and healthier alternatives. Examples include Marinol (prescription) tablets, lozenges, edibles such as candy, cookies, lotions, and creams. A mother recently asked why anyone would expect their relief to come at the expense of sending her child to the hospital with a violent asthma attack triggered by their secondhand marijuana smoke?” We had no answer.

State laws support local jurisdictions in protecting their residents. California’s Health and Safety Code prohibits marijuana smoking or vaping wherever tobacco smoking is restricted and it does not exempt medical marijuana. When local governments reflect this in their smoke-free multi-unit housing ordinances, public compliance is much higher due to the increase in awareness that comes with the implementation. The Smoke-Free Marin Coalition provides public education campaigns about these ordinances after enactment. We learned through the years that effective language is needed to make them fulfill their purpose.

Studies have shown that there are as many dangers from drifting marijuana smoke as there are in tobacco products. We have posted these on this page: https://www.smokefreemarin.org/marijuana-smoking-information/

Regarding enforcement the Smoke-free Marin Coalition learned over the last 30 years: the more uniform tobacco control ordinances are (in the 12 jurisdictions county-wide), the higher the public compliance rate. Uniformity helps make these laws cost-effective and self-enforcing after the Smoke-Free Marin Coalition has launched its public education campaigns. Our public education campaigns actually leave very little work for municipalities. In the rare cases when local enforcement does get involved, it is easier when all the ordinances are identical, especially for the Central Marin Police Authority which as you know, enforces laws for three jurisdictions.

The Smoke-Free Marin Coalition and the County Tobacco-Related Disease Control Program look forward to continuing our 31-year collaboration on the successful implementation of these public health ordinances.

Link to the California State Health and Safety Code: https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml? lawCode=HSC§ionNum=11362.3

Link to marijuana smoke science: https://www.smokefreemarin.org/marijuana-smoking-information/

Thank you for your commitment to the public health and safety of Corte Madera residents!

Pam Granger, Chair, Smokefree Marin Coalition

Email: [email protected]

Web: www.smokefreemarin.org

https://west.exch090.serverdata.net/owa/#path=/mail 2/2 4/5/2021 Mail - [email protected] [EXTERNAL] Request to remove Ordinance No. 1006 Prohibiting Smoking In Multiunit Housing

Jeremiah Mock

Fri 4/2/2021 6:45 PM

To:Eli Beckman ; Fred Casissa ; Charles Lee ; Bob Ravasio ; Public Comment ; Leila Mongan ;

 2 attachments (768 KB)

Wayne 2021 Measuring indoor fine particle concentrations, emission rates, and decay rates from cannabis use in a residence.pdf; Sangmo 2021 Reported Marijuana and Tobacco Smoke IncursionsAmong Families Living in Multiunit Housingin New York City.pdf;

Dear Mayor Beckman and Corte Madera Councilmembers,

I am writing to respectfully request that you remove from the Consent Calendar Ordinance No. 1006 Prohibiting Smoking In Public Places, Places Of Employment, Other Areas, And Multi-Unit Housing.

The exemption allowing smoking and vaping of "medical marijuana” is unacceptable and will significantly undermine the purpose of the ordinance. Please strike this exemption from the ordinance language.

My wife, sons and I have our own exasperating and toxic personal experience of having our condominium unit air contaminated with infiltrating cannabis smoke and vape aerosol from adjacent units, including drifting from with private patios and balconies.

Secondhand cannabis smoke and vape aerosol emissions have been shown to be substantial sources of air pollution, reported in the new peer- reviewed study "Measuring indoor fine particle concentrations, emission rates, and decay rates from cannabis use in a residence” published in Atmospheric Environment (attached).

https://www.sciencedirect.com/science/article/pii/S259016212100006X?via%3Dihub#!

This study was based on 60 real-world experiments in homes comparing indoor PM2.5 (measure of harmful particulate air pollution) from secondhand marijuana & tobacco smoke. The study found that:

- A marijuana joint's PM2.5 emission rate was 3.5 times that of smoke from a Marlboro cigarette.

- All the cannabis sources had PM2.5 emission rates greater than tobacco cigarettes.

- Cannabis vape emissions from exhaled vape aerosol polluted air as much as a cigarette, and lingered longer than cigarette smoke emissions.

Cannabis smoke has been shown to travel through multiunit housing and is a risk to children, as reported in the recent peer-reviewed study "Reported Marijuana and Tobacco Smoke Incursions Among Families Living in Multiunit Housing in New York City” published in Academic Pediatrics (attached). https://www.sciencedirect.com/science/article/pii/S1876285921000061

This study found that "about one third of the families enrolled in the study reported smelling secondhand marijuana smoke while at home with their child." https://west.exch090.serverdata.net/owa/#path=/mail 1/2 4/5/2021 Mail - [email protected]

In practice, in Marin County almost anyone ages 18 and older can get a medical marijuana card regardless of whether there is any medical evidence that using marijuana might improve their condition, as shown by this page at Nice Guys Delivery in San Rafael: "Don’t have your Doctor’s recommendation? Get it today at our partner platform, Heally. Heally provides an on-demand online connection between fully licensed medical marijuana doctors and patients via HIPAA compliant and encrypted live video, audio, and messaging. It’s fast, easy, and always private. Get your evaluation and recommendation for $39 in less than 10 minutes!" https://www.niceguysdelivery.com/get-a-card

ANYONE CAN SAY, “I’m using for medical purposes” putting the uncomfortable burden on the exposed neighbor to ask the smoker/vaper for “proof.” We have faced this situation, and it was IMPOSSIBLE to make such a request because we felt THREATENED by our AGGRESSIVE pot- smoking and vaping neighbor.

Those who wish to use marijuana for “medical" purposes, they may do so by consuming candies, drops, tinctures and sodas. https://www.niceguysdelivery.com/menu?

The FDA has approved these cannabis products for medical use (all of which are NOT combustible/vaporized):

CBD product is Epidiolex. Indication: Dravet Syndrome or Lennox-Gastaut syndrome

Dronabinol (Marinol) – FDA approved synthetic THC comes in capsules. It is used to treat chemotherapy-induced nausea and vomiting in patients that don’t respond to other therapies, as well as anorexia related to weight loss in patients with AIDS

Nabilone (Cesamet) is also man-made medication similar to cannabis used to treat nausea caused by chemotherapy and boost appetite in patients with AIDS wasting syndrome

Nabiximols (Sativex) Nasal spray. Approved in UK and Canada and there are trials in the US. Used for treatment of multiple sclerosis

Please remove this large unnecessary loophole in the current ordinance.

Sincerely,

Jeremiah Mock Corte Madera resident

https://west.exch090.serverdata.net/owa/#path=/mail 2/2 ATMOSPHERIC ENVIRONMENT: X 10 (2021) 100106

Contents lists available at ScienceDirect

Atmospheric Environment: X

journal homepage: http://www.journals.elsevier.com/atmospheric-environment-x

Measuring indoor fine particle concentrations, emission rates, and decay rates from cannabis use in a residence

Wayne R. Ott *, Tongke Zhao, Kai-Chung Cheng, Lance A. Wallace, Lynn M. Hildemann

Civil and Environmental Engineering, Stanford University, Stanford, CA, 94305, USA

ARTICLE INFO ABSTRACT

Keywords: Fifteen states have legalized the sales of recreational marijuana, and California has the largest sales of any state. Indoor air Cannabis is most often smoked indoors, but few measurements have been made of fine particle mass concen­ Cannabis trations produced by secondhand cannabis smoke in indoor settings. We conducted 60 controlled experiments in Marijuana 3 a 43 m room of a residence, measuring PM2.5 concentrations, emission rates, and decay rates using real-time PM2.5 monitors designed to measure PM mass concentrations. We also measured the room’s air exchange rate. Fine particles 2.5 Aerosol During each experiment, an experienced smoker followed an identical puffing protocol on one of four different Bong methods of consuming marijuana: the pre-rolled marijuana joint (24 experiments), the bong with its bowl Glass pipe containing marijuana buds (9 experiments), the glass pipe containing marijuana buds (9 experiments), and the Vaping commercially available electronic vaping pen with a cartridge attached containing cannabis vape liquid (9 ex­ Smoking periments). For comparison, we used the same puffing protocol to measure the PM2.5 emissions from Marlboro Cigarette cigarettes (9 experiments). The results indicated that cannabis joints produced the highest indoor PM2.5 con­ centrations and had the largest emission rates, compared with the other cannabis sources. The average PM2.5 emission rate of the 24 cannabis joints (7.8 mg/min) was 3.5 times the average emission rate of the Marlboro cigarettes (2.2 mg/min). The average emission rate of the cannabis bong was 67% that of the joint; the glass pipe’s emission rate was 54% that of the joint, and the vaping pen’s emission rate was 44% that of the joint. The differences compared to the joint were statistically significant.

1. Introduction For example, Moore et al. (2011) asked 10 healthy volunteers who were not marijuana smokers to spend up to 3 h in a Dutch coffee shop with The District of Columbia and 15 US states – Alaska, Arizona, Cali­ heavy marijuana smoking. THC exceeding 4 ng/ml was detected in the fornia, Colorado, Illinois, Maine, Massachusetts, Michigan, Montana, oral fluidof half the volunteers but not the metabolite 11-nor-9-carbox­ Nevada, New Jersey, Oregon, South Dakota, Vermont, and Washington – y-THC (THC-COOH), so the authors recommended measuring this have legalized recreational marijuana sales, but few research studies metabolite as an indicator to avoid falsely concluding a person was an have measured exposure to secondhand marijuana smoke in everyday active cannabis smoker. We reviewed 729 papers on exposure to mari­ settings. On January 1, 2018, California legalized the sale of recreational juana in the scientific literature, and we found almost no published cannabis to adults, and the state currently has 358 state-licensed stores papers measuring fine particle mass concentrations from secondhand selling recreational cannabis products (Marijuana Business Daily, 2020). cannabis smoke in homes. Both marijuana and tobacco cigarettes pro­ Many studies have measured the psychoactive compound delta-9- duce fine particle mass concentrations (PM2.5) consisting of airborne tetrahydrocannabinol (THC) and other related cannabinoids produced particles less than 2.5 μm in diameter. by marijuana use (Tashkin et al., 1991; Hiller et al., 1984; Cone et al., Klepeis et al. (2017) and Posis et al. (2019) reported results from one 1987; Sheehan et al., 2018). Berthet et al. (2016) identified958 papers of the few studies that measured indoor particles, a randomized clinical on passive exposure to cannabis, and they selected 21 papers for review. survey in San Diego of 298 predominantly low-income homes with an These passive exposure studies generally employed biomarkers of adult smoker and a child less than 14 years old. In each participating exposure such as urine, blood, oral fluid,hair, and sebum to determine residence, a Dylos™ DC1700 monitor (Dylos Corporation, Riverside, for forensic purposes whether an individual had recently used cannabis. CA, USA) was set up for a week to measure indoor particle counts.

* Corresponding author. 1008 Cardiff Lane, Redwood City, CA 94061, USA E-mail address: [email protected] (W.R. Ott). https://doi.org/10.1016/j.aeaoa.2021.100106 Received 28 May 2020; Received in revised form 2 December 2020; Accepted 25 February 2021 Available online 9 March 2021 2590-1621/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). W.R. Ott et al. Atmospheric Environment: X 10 (2021) 100106

Homes without indoor smoking had 7-day average particle levels lower tobacco smoke and 2575 different compounds in marijuana smoke, with than homes with only cannabis smoking or homes with both cigarette 231 compounds common to both tobacco and marijuana smoke. Of and cannabis smoking, and 33 homes reported that marijuana smoking these, 173 different tobacco smoke compounds and 110 marijuana took place from 1 to 7 times per week. Hughes et al. (2018) present smoke compounds (69 in common) were known to cause adverse health details of the San Diego study and its selection of participating families. effects through carcinogenic, mutagenic, teratogenic, or other toxic The Dylos monitor provides an indication of particle levels, but it does mechanisms. not measure particle mass concentrations with the same accuracy as the Ni et al. (2020) reviewed dozens of health studies on PM2.5 related to gravimetric filter-and-pump “gold standard,” or a research-grade air tobacco smoking, concluding that indoor PM2.5 from cigarette smoking monitor with its calibration factor based on gravimetric filter is closely correlated with chronic lung disease. Due to the small size of measurements. these particles, they can go deep to the distal airways and deposit in The common methods of smoking marijuana include a pre-rolled alveolar regions, doing serious harm to the human respiratory system. joint, which is similar to a cigarette or a cigar, a pipe or bong contain­ They carry with them PAHs and many other toxic compounds. Although ing marijuana buds, and a vaping pen that vaporizes cannabis liquid there are few studies of the health effects of marijuana aerosols, Wang from a commercially available cartridge. A nationwide survey of 4269 et al. (2016) reported that 1-min of exposure to secondhand cannabis adults in 2014 found that 7.2% had used marijuana over the past 30 days smoke can impair vascular endothelial function in rats. (Schauer et al., 2016). Among current users, 10.5% reported medicinal In the US, marijuana is most often smoked indoors in homes (Berg use only, 53.4% reported recreational use only, and 36.1% reported et al., 2015, 2018), but relatively few measurements have been made of both. More than half of current users reported only one method of use indoor air pollution from cannabis use in residences. Californians are (58.8%); 22.4% reported two methods; and 18.8% reported three prohibited from consuming legal cannabis in “any public place or area” methods. For these users, the two most popular methods of smoking or in “any location where tobacco smoking is prohibited,” although legal marijuana were the joint (49.2%) and the pipe (49.5%), with less pop­ cannabis can be consumed in private residences or in structures located ular use of the bong, water pipe, and hookah (21.7%). In 2014, 7.6% of on the grounds of a private residence (California Department of Public the respondents reported using marijuana vaporizers, but more recently Health, 2020). Other residents of a home may find the odor from battery-powered pens using liquid cannabis cartridges have become marijuana smoking objectionable, so the smoker may confinehis or her increasingly popular for cannabis vaping. In 2015, 5.3–8.0 million smoking activity to a room with a closed door. children in the US lived with a parent who was a cannabis user, and both To provide data on the concentrations and emissions produced by current cannabis use and daily cannabis use have been increasing among cannabis use indoors in a home, we conducted 60 controlled experi­ parents (Goodwin et al., 2018). National surveys showed the prevalence ments in the spare bedroom of an occupied residence. Twenty-four ex­ of marijuana vaping among US adolescents increased from 2017 to 2019 periments were conducted on pre-rolled cannabis joints, and 9 (Miech et al., 2019). Vaping among Grade 12 students in the last 30 days experiments each were conducted on bongs, glass pipes, vaping pens, increased from 4.9% in 2017 to 7.5% in 2018, reaching 14% in 2019 and tobacco cigarettes. These measurements of PM2.5 from secondhand (Johnston et al., 2019). cannabis smoke were compared with PM2.5 from secondhand tobacco Cecinato et al. (2014a, 2014b) measured THC in four homes in smoke from Marlboro cigarettes (Philip Morris, Inc.), the most popular Rome, Italy, reporting that the indoor THC concentration in two homes cigarette brand in the US (Cigarette brands most smoked in the US, was 6.6 ng/m3 indoors and 1.1 ng/m3 outdoors. Indoor concentrations 2019). Zhao et al. (2020) conducted cannabis experiments in a car using of THC and cannabidiol (CBD) often exceeded those measured at out­ joints, bongs, glass pipes, and vaping pens as sources, developing door fixedair monitoring stations, indicating the sources were indoors. gravimetric calibration factors for four different methods of smoking Chu et al. (2019) conducted a two-stage probability telephone survey of marijuana. These calibration factors were used for the same sources in 2,812 respondents living in multiunit housing in Ontario, Canada, the present study. Wallace et al. (2020) measured secondhand exposure reporting that 7.5% reported being exposed involuntarily to secondhand to PM2.5 from vaping marijuana in two different homes. To our knowl­ cannabis smoke. The prevalence of involuntary exposure to cannabis edge, these efforts are the firstsystematic studies measuring PM2.5 mass smoke in multiunit buildings was similar to that from secondhand to­ concentrations, source strengths, emission rates, and decay rates from bacco smoke. secondhand cannabis smoke indoors in residences. Moir et al. (2008) compared a large number of toxic air pollutants produced by mainstream and sidestream marijuana and tobacco smoke, 2. Methods and materials using a smoking machine to produce the smoke. For both marijuana and tobacco cigarettes, the mass of the pollutants measured in sidestream 2.1. Participant smoke was much greater than the mass of the pollutants measured in mainstream smoke for the majority of air pollutants. The amount of A habitual user of cannabis and tobacco, who consumes cannabis in benzene, a known human carcinogen, measured in secondhand mari­ multiple ways, was recruited to help generate secondhand cannabis juana smoke was about the same as that measured in secondhand to­ smoke. The study protocol was accepted by the participant, and a signed bacco smoke (399 μg for a marijuana cigarette and 352 μg for a tobacco consent form was obtained before the experiments. The same participant cigarette). These investigators also compared 30 polycyclic aromatic who smoked and vaped the marijuana sources also smoked the tobacco hydrocarbons (PAHs) measured in marijuana and tobacco smoke. They cigarettes. No individual other than the participant was involved in the found that sidestream marijuana smoke contained about the same smoking or vaping activities, and no persons were present in the room amount of the human carcinogen benzo(a)pyrene as sidestream tobacco during the air pollutant decay periods. The main focus of this research smoke (101 ng compared to 91.7 ng). They also found that marijuana was on comparing the emission rates produced by different methods of sidestream smoke contained about 1.5 times the amount of benzo(a) smoking or vaping cannabis sources, not on the health impact on human anthracene, another probable human carcinogen, as did tobacco smoke. subjects. The study protocol was approved by the Institutional Review In both mainstream and sidestream marijuana smoke, they reported the Board at Stanford University. This study was supported by a grant presence of many similar known carcinogens and other chemicals awarded to Stanford University to study secondhand exposure to mari­ implicated in respiratory diseases. juana: Agreement #28IR-0062 sponsored by the University of California Graves et al. (2020) compared tobacco and marijuana smoke parti­ Office of the President; Tobacco Related-Disease Research Program cles and found them quantitatively similar in volatility, shape, density, (TRDRP). The cannabis materials used in this study were provided by and number concentration, with differences in particle size and chemi­ the participant. cal composition. Their study detected 4350 different compounds in

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2.2. Measurement methods 3 s of the correct time. Each experiment used a pair of SidePak monitors for redundancy and sometimes a third SidePak monitor as a backup. The 60 controlled experiments measuring fine particle mass con­ Each SidePak’s internal calibration factor was set to 1.0, and the proper centrations were carried out in an occupied residence in Redwood City, calibration factors for the monitors and source type, based on the CA, on 24 dates between April 16 and November 25, 2019. All the ex­ gravimetric measurements of Zhao et al. (Table S1), were applied sub­ periments were conducted in a 43 m3 spare bedroom that was set off sequently in the data analysis phase. A comparison of the two main from the rest of the house. This room had one window and one door, SidePak monitors, each using a calibration factor for cannabis vaping both of which were closed prior to the start of each experiment. The 60 based on gravimetric filter measurements, showed good agreement (R2 experiments were conducted on 23 different dates, with one experiment = 0.9993 for n =179 pairs of observations with an intercept of 0.1 μg/m3 conducted on each of three dates, two experiments conducted on five and a slope of 1.015). In these experiments, we also used a pair of TSI dates, three experiments on 13 dates, and four experiments on two dates. 3007 condensation particle counters (CPC’s) to measure ultrafine par­ On dates with more than one experiment, the room’s window and door ticles (UFP) greater than 10 nm in diameter at 1-min time intervals. were opened before each experiment to air out the room, and the home’s The monitors were placed near the midpoint of the room at a height front door, backdoor, and a kitchen window also were temporarily above the floorof 0.6 m, and a small battery-powered fan with an 11 cm opened. diameter blade was run for the duration of each experiment to assist All experiments took place during the daytime hours, each lasting with air mixing. Immediately after the smoking or vaping ended, the about 2–1/2 h. This provided sufficienttime for mixing in the room and participant exited the room, carefully closing the door behind him. Thus, allowed for estimation of the PM2.5 decay rate. Prior to starting each no one was exposed to secondhand smoke in the room during the decay experiment, the monitors were operated for at least 10 min to measure period of about 100–130 min. A video camera was set up in the room the background PM2.5 concentrations in the room. The background with its lens pointed toward a SidePak monitor’s display screen, sending concentrations were relatively small and were subtracted prior to readings of the measured PM2.5 concentrations to computer screens analyzing the PM2.5 concentration data. The heating and air condi­ outside the room. tioning system of the home was turned off before and during all ex­ We used a pair of Model T15n electrochemical Carbon Monoxide periments, and the home’s exterior doors and windows were closed. Measurers™ (Langan Products Co., San Francisco, CA, USA) to measure We compared the PM2.5 emissions produced by four different the CO concentrations in the room produced by releasing CO from a 105 methods of consuming cannabis – joint, bong, glass pipe, and vaping pen L cylinder containing 10% CO gas in nitrogen (Ecosmart™, gasco.com). – with the emissions from Marlboro tobacco cigarettes purchased in The CO gas was emitted into the room for approximately 6 min prior to California in 2019. The first three cannabis consumption methods use the start of each experiment using an adjustable flowrate regulator set to combustion to produce PM2.5, while the vaping pen uses a heated coil to 1 L/min. The resulting CO decay rate was used to estimate the room’s air vaporize cannabis liquid without combustion. We used TSI AM510 exchange rate, based on the negative slope of the logarithm of the SidePak™ laser photometers (TSI, Shoreview, MN, USA) with the indi­ background-corrected CO concentration. Ferro et al. (2009) used Brüel vidual calibration factors of each monitor based on gravimetric mea­ and Kjær Type 1302 photoacoustic sulfur hexafluoride(SF 6) monitors to surements (Zhao et al., 2020). The calibrated SidePak mass measure the volume of this same room and its air exchange rate, and our measurements were found to agree well with measurements by the air exchange rate measurements were consistent with their published piezoelectric microbalance (Model 8510 Piezobalance, TSI, Shoreview, measurements. MN, USA), an instrument that measures real-time mass concentrations directly. 2.3. 3-Puff protocol All the cannabis joints, bongs, buds, and vaping supplies used in this study were commercially available and were purchased from four state- Our main objective was to compare the concentrations and emission licensed stores in three California towns in 2019: San Jose, Palm Desert, rates produced by different methods of cannabis smoking and vaping, so and Cathedral City. The 24 pre-rolled marijuana joints used in this study it was important to apply the same procedure to each source in these consisted of 9 different name brands that are widely available in Cali­ experiments. All the smoking or vaping methods in these experiments fornia. A factory label that came with each joint listed its CBD and THC followed the 3-Puff Protocol, which consisted of a starting puff at time t content. The CBD content of the 24 joints ranged from 0% to 1.5%, and = 0, followed by a 2nd puff at t = 60 s, followed by a 3rd puff at t = 120 s the listed THC content ranged from 8.55% to 27.6%, with a mean of (Fig. 1). When a joint or a cigarette reached 3.0 min, the participant put 17.7%. We used a laboratory scale to measure 0.3 g of cannabis buds it out by dipping the tip in water. This protocol is well-suited to com­ into the bowls of the bong and the glass pipe, and the two types of bustion sources, which produce both mainstream and sidestream smoke. cannabis buds used were “Mirage” (CBD 0% and THC 10.48%) and Sidestream smoke, which is emitted directly from the source between “Blueberry Muffin” (CBD 0.0% and THC 15.01%). The electronic vaping puffs and not exhaled by the smoker, has been shown to produce greater pen was manufactured by AbsoluteXtracts (ABX), and we attached two emissions than mainstream smoke (Moir et al., 2008; Schick and Glantz, different vaping cartridges to the pen: a Care by Design 18:1 cartridge 2005). Based on observations of the participant, the inhalation time of (CBD 69.8% and THC 3.51%) and a Care by Design 2:1 cartridge (CBD the puff was about 2 s, and the exhalation time was ~2–4 s, making the 46.1% and THC 21.9%; https://www.cbd.org/). total puff time about 6 s. We applied the same 3-puff protocol to the In each experiment, we used at least 2 AM510 SidePak monitors with AbsoluteXtracts vaping pen, which carried out an internal 15-s pre-heat their individual calibration factors based on the gravimetric filter mode prior to the start of puffing and produced little sidestream emis­ measurements obtained by Zhao et al. (2020). Each SidePak was sions between puffs. equipped with a physical 2.5 μm size impactor supplied by the manu­ An important advantage of the 3-puff protocol in our experiments is facturer, and the data logging times were set to 1.0 min. Before starting that it avoided the extremely high PM2.5 concentrations expected to each set of experiments, the grease on the monitor’s particle size occur in the 43 m3 room if a marijuana joint had been smoked impactor was replaced, and the monitor was zeroed using a precision completely in the room, thus allowing the participant to avoid exposure zero filter supplied by the manufacturer. Periodically we measured the to unacceptably high concentrations. Based on our interviews with flow rate of each monitor using a Gillibrator Primary Flow Calibrator experienced cannabis smokers and information available on the (Sensidyne, St. Petersburg, FL, USA), verifying that it was within 5% of Internet, we concluded that marijuana smoking often differed from to­ the 1.7 L/min flow rate specified by the manufacturer. We also used bacco cigarette smoking in several respects. Smoking a marijuana joint precision digital clocks synchronized with the atomic clock in Boulder, often takes place in a group setting, where more than one person CO, to verify that the data logging times of each monitor were within ± smokes, following the rule, “take two puffs and pass it to the left.” We

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Fig. 1. Conceptual representation of 3-puff protocol timing for smoking a marijuana joint. The participant started the first puff at t = 0 by inhaling on the joint for about 2 s (green), followed by exhalation of the mainstream smoke for an additional ~2–4 s (yellow). Between puffs, the burning joint produced sidestream emissions (light grey). At time t = 180 s, the joint was put out. (For interpretation of the references to colour in this figurelegend, the reader is referred to the Web version of this article.) also learned that a marijuana smoker, when smoking alone, often takes Ott, 1996; Ott, 2007; Ott et al., 2003; Dacunto et al., 2013): just 2 or 3 puffs, then puts the joint out so it can be smoked later in the φt y(t) = ymaxe for t ≥ 0 (1) day. The 3-puff protocol in Fig. 1 includes nearly a minute between puffs for the burning joint to emit sidestream smoke, thus producing both Fig. 2 shows both the observed mass PM2.5 concentration (black 3 mainstream and sidestream smoke in a realistic manner. This protocol dots) and this exponential decay model (red line) with ymax = 568 μg/m also has a mathematical advantage for calculating emission source and decay rate φ = 0.00722 min 1 = 0.433 h 1 from our experiment strengths, since the 3-min emission time is much shorter than the resi­ with a sativa pre-rolled joint. For illustrative purposes, the graph of the dence time of the room, which averaged 115 min for the 60 pre-rolled model begins 16 min prior to time t = 0. The firstpuff started at time t = joints, bongs, glass pipes, vaping pens, and cigarettes. An objective of 0, and the overall experiment ended at t = 390 min. The exponential this study was to compare emission rates from different sources smoked decay model fit to the decay curve (red line) enables the analyst to in the same manner by a human participant. Although a smoking ma­ extend the decay curve “backward” to estimate the true maximum. The chine may reduce experimental variability, we focused on determining false maximum shown in Fig. 2 resulted from poor mixing very early in whether the differences between the mean emission rate of the pre- the experimental period. If the false maximum of 697 μg/m3 had been rolled marijuana joints and the mean emission rates of the other sour­ used instead of the true maximum of 568 μg/m3, the estimated source ces, including the tobacco cigarettes, were statistically significant. strength would have had an error of 23%. The same methodology for calculating the decay rate illustrated in 2.4. Data analysis and modeling Figure S1 and Fig. 2 was applied to all 60 experiments in this study, but the decay time period was generally less than the 390 min shown in the – The source strength is the total emissions produced by a given source, example in Fig. 2. Usually, we found 100 130 min was sufficient for and the emission rate is the emissions per minute. We used the peak- calculating the PM2.5 decay rate and estimating the true maximum estimation approach described in Ott et al. (2007) to estimate the source concentration. The PM2.5 time series response can be accurately strength and the emission rate. Fig. 2 shows an example of one of our modeled by piecewise continuous equations that intersect at a coincident = experiments with a sativa “Doobie” pre-rolled joint. The firststep in the point (Ott, 2007). The concentration predicted at t 3.0 min can be used analysis was to graph the natural logarithm of the background-corrected by the exponential decay model to estimate the maximum concentration ymax. An alternative method is to estimate ymax using the intersection of PM2.5 concentrations versus time during the decay period (Figure S1). Applying linear regression (SigmaPlot 11, Systat Software, San Jose, CA, the exponential decay model and the observed rise of the PM2.5 1 concentration. USA), the PM2.5 decay rate was found to be φ = 0.00722 min = 0.433 h 1 with a coefficient of determination of R2 = 0.995 (Figure S1). The In Fig. 2, the intersection of the measured concentration rise and the residence time τ, which is the reciprocal of φ, was τ =139 min. The decay model (red line) yielded a true maximum concentration of 568 μg/m3 (green dot), and the source strength G was calculated as the background-corrected PM2.5 concentration in the room y(t) was modeled by piecewise continuous exponential solutions to the mass product of the peak concentration and the volume of the room v: balance equation for short-term sources in a reasonably well-mixed room with a small fan and naturally-occurring turbulence (Mage and

Fig. 2. PM2.5 concentration time series produced by a sativa “Doobie” pre-rolled joint smoked with the 3- puff protocol. This figure shows the measured con­ centrations (black dots) for 390 min and an expo­ nential decay model fit to the data (red line). The coincident point (green dot) is the true maximum concentration used to estimate the source strength. A false maximum also can be seen early in the experi­ ment, before the room has had time to become suffi­ ciently well-mixed. In this experiment, a 3.9 μg/m3 background concentration was subtracted from the observed PM2.5 concentration. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

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μg 1 mg = = = × 3 × Table 1 G Source Strength ymaxv 568 3 43 m m 1000 μg PM2.5 maximum concentrations and background concentrations. a = 24.4 mg (2) Source Type Measured Maximum PM2.5 Concentration Background PM2.5 3 3 ymax μg/m Concentration μg/m Once the maximum concentration ymax had been estimated, it was n Mean SD Min. Max. Mean SD used to calculate the source strength and the emission rate. The emission rate g was obtained by dividing the source strength G Joint 24 540 162 143 809 3.2 1.4 Bong 9 361 261 65 762 2.7 1.3 by the emission time ts: Glass Pipe 9 294 187 73 606 3.6 1.2 / G 24.4 mg Vaping 9 225 141 32 415 3.8 1.6 g = Emission ​ Rate = = = 8.13 mg min(3) Cigarette 9 154 64 22 209 3.4 2.2 ts 3.0 min a Background-corrected. Here, g represents the average of the time-varying emissions over 3.0 min with discrete puffing. room for all fivesources. The background-corrected ymax concentrations In Fig. 2, the true maximum concentration was 568 μg/m3 at time t of PM observed in the 24 experiments with pre-rolled joints had a = μ 3 = 2.5 0, and the PM2.5 concentration decayed to 34 g/m at time t 390 μ 3 μ 3 1 1 mean of 540 g/m and ranged from 143 to 809 g/m . By comparison, min. With a decay rate of φ = 0.00722 min = 0.433 h , the PM2.5 3 3 the PM2.5 ymax concentrations in the 9 Marlboro tobacco cigarette ex­ concentration will reach 3.14 μg/m in 12 h and 0.02 μg/m in 24 h as it 3 3 periments had a mean of 154 μg/m and ranged from 22 to 209 μg/m . asymptotically approaches zero. Equation 4 provides a general expres­ Each marijuana source produced a larger mean maximum concentration sion for calculating the mean concentration ymean(T) for any averaging ymax than the tobacco cigarettes. time T: Table 2 shows the summary statistics for the 60 experiments with ∫T five different sources. The 24 joints had a mean PM emission rate of y y ) 2.5 y (T) = max e φtdt = max 1 e Tφ (4) 7.8 mg/min, which was greater than all the other cannabis emission mean T Tφ 0 rates and was 3.5 times the mean PM2.5 emission rate of the Marlboro

Tφ cigarettes of 2.2 mg/min. The mean emission rates of the bong and the Since the quantity e often turns out to be very small, the compact glass pipe were 67% and 54% of the joint’s mean emission rate, approximation shown in Equation 5 often provides a reasonably accu­ respectively, and the mean emission rate of the vaping pen was 44% that rate result. In the experiment shown in Fig. 2, for of the mean emission rate of the joints. μ 3 example, Equation 4 gives an exact 24-h mean of 54.66 g/m , while The box plots shown in Fig. 3 illustrate the frequency distributions of Equation 5 gives a close 24-h mean of 54.67 μg/m3. the PM2.5 emission rates, allowing them to be compared graphically. ymax Only the pre-rolled cannabis joints had enough observations (n = 24) to ymean(24) ≅ (5) 24φ show the 5th and 95th percentiles of the emission rates (large black dots), while all the box plots showed the 10th and 90th percentiles (whiskers). The box boundaries themselves represent the 25th and 75th 2.5. Statistical methods percentiles, and the bong had the largest spread between these two percentiles. This result was consistent with Table 2, which shows the The statistical methods used in this study are designed to test bong also had the greatest coefficientof variation (SD-to-mean ratio) of whether there is a statistically significantdifference between the means 0.71 for the five sources. The mean emission rate in Fig. 3 (red dashed of two unpaired groups. The unpaired t-test is a parametric test based on line) was higher for the joint than for the cigarette, which also is evident estimates of the mean and standard deviation of normally distributed in the emission rate column of Table 2. The median in Fig. 3 showed a populations from which the samples were drawn. It tests whether the pattern similar to that of the mean. difference between two groups is greater than that caused by random Table 3 shows the results of applying standard statistical tests to 10 sampling variation. The p value is the probability of being wrong in comparisons of the different methods of smoking marijuana, vaping concluding that there is a true difference between the two groups. The marijuana, and smoking tobacco cigarettes. In five of the comparisons, smaller the p value, the greater the probability that the samples are the t-test met the requirement that the data were normally distributed drawn from different populations. We chose the probability p < 0.05 as but did not meet the requirement of equal variances. In these fivecases, our criterion for statistical significance. Sigma-Plot substituted the nonparametric Mann-Whitney Rank Sum The statistical analyses were performed using SigmaPlot 11 (Sigma- Test for the t-test. With both tests, the criterion for statistical significance Plot User’s Guide, Part 2, Statistics, Systat Software, San Jose, CA, USA), was the probability p < 0.05. The difference between the mean emission which employs the Kolmogorov-Smirnov test for a normally distributed rate of the joint and the mean emission rate of the bong was statistically population. This program also tests for equal variances. If these condi­ significant (p < 0.05), and the differences between the mean emission tions are met, it performs the unpaired t-test. If either of these conditions rate of the joint and the mean emission rates of the glass pipe, vaping is not met, it informs the user that the data are unsuitable for the un­ pen, and cigarette were highly statistically significant (p < 0.001). The paired t-test, and it recommends using the nonparametric Mann- Whitney Rank Sum Test instead, which performs comparisons based on the ranks of the observations. Table 2 PM2.5 decay rates, air exchange rates, source strengths, and emission rates. 3. Results Source Type Decay Ratea Air Exchange Source Emission h 1 Ratea h 1 Strengtha mg Ratea mg/ 3.1. Decay rates, source strengths, and emission rates min Mean SD Mean SD Mean SD Mean SD

Table 1 provides summary statistics for the 60 experiments in this Joint 0.461 0.10 0.368 0.09 23.2 7.0 7.8 2.2 study with the various cannabis and tobacco sources, based on the 3-puff Bong 0.509 0.13 0.375 0.10 15.5 11.2 5.2 3.7 protocol. The background concentrations were subtracted from the Glass Pipe 0.563 0.22 0.407 0.13 12.6 8.1 4.2 2.7 measured PM2.5 concentrations in Table 1, and the last two columns Vaping 0.690 0.23 0.369 0.09 9.7 6.1 3.4 1.8 Cigarette 0.501 0.26 0.290 0.06 6.6 2.8 2.2 0.9 show the background PM2.5 concentrations were much smaller than the a background-corrected maximum PM2.5 concentrations measured in the Background-corrected.

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Fig. 3. Box plots comparing emission rates for 3 puffs from fivedifferent smoking sources based on 60 experiments. The boxes are the 25th and 75th percentiles; the whiskers are the 10th and 90th percentiles; the dots are the 5th and 95th percentiles, which appear only for n = 24. The probabilities listed above the box plots show the statistical significance of the differences between groups.

difference between the mean decay rate of the marijuana joints and the Table 3 mean decay rate of the vaping pens was highly statistically significant( p Statistical significance tests comparing emission rates of five different sources. < 0.001). This appears likely due to the volatility of the aerosol from the Comparison Statistical Test p value Statistically Significant? cannabis vaping pen. Joint vs. Bong Mann-Whitney p < 0.05 Yes The measured decay rate φ for the SidePak monitor is the sum of the Joint vs. Glass Pipe t-Test p <0.001 Yes air exchange rate a and the deposition rate k, as well as the other Joint vs. Vaping t-Test p <0.001 Yes possible particle losses or gains due to evaporation, condensation, and Joint vs. Cigarette Mann-Whitney p <0.001 Yes φ = + + Bong vs. Glass Pipe t-Test p = 0.541 No coagulation. That is, the decay rate a k other. If we subtract the Bong vs. Vaping Mann-Whitney p = 0.377 No observed air exchange rate from the observed decay rate, we are left Bong vs. Cigarette Mann-Whitney p = 0.377 No with a term called the “removal rate” due to aerosol dynamics, which is Glass Pipe vs. Vaping t-Test p = 0.474 No the sum of the deposition rate k and all the other gain or loss mecha­ Glass Pipe vs. Cigarette t-Test p <0.05 Yes nisms, excluding the effect of air exchange. For the 24 cannabis joints, Cigarette vs. Vaping Mann-Whitney p = 0.251 No the mean removal rate was 0.085 h 1. For the bong, the glass pipe, and the cigarette, the mean removal rates were 0.111 h 1, 0.096 h 1, and probabilities listed above the box plots in Fig. 3 show the statistical 0.103 h 1, respectively. The average removal rate of the four marijuana significance of the differences between the groups. combustion sources was 0.10 h 1, which was smaller than deposition Although there were n = 24 experiments with joints, there were only rates listed by Thatcher et al. (2002) for a furnished room with a small n = 9 experiments each with bongs, glass pipes, vaping pens, and fan or no fan. In contrast, the mean removal rate of the 9 vaping pen Marlboro cigarettes. Comparisons of the bong vs. the glass pipe, the experiments was 0.321 h 1, which was the largest removal rate of the bong vs. vaping, the bong vs. the cigarette, the glass pipe vs. vaping, and five sources and was 3.2 times the average removal rate of the four the cigarette vs. vaping did not show a statistically significantdifference combustion sources (joint, bong, pipe, and cigarette). It is likely that this in mean emission rates, which is partly due to the small sample sizes. An larger removal rate of the vaping pen was due to volatility of the vaping exception was the mean emission rate of the glass pipe compared to the aerosol and its greater evaporative losses. Evaporation of particles from mean emission rate of the cigarette, which was statistically significant cannabis vaping is not expected to be as great as evaporation from (p < 0.05). In general, groups that did not include the joint were less e-cigarette vaping (Zhao et al., 2017; Zhao et al., 2020). We believe this likely to show a statistically significant difference when compared to is an important topic for future research. groups that included the joint with its high emission rate and larger Since each new marijuana joint included a factory label showing the sample size. The difference between the mean emission rate of the joint’s percent THC content, we also compared the THC listed for each marijuana joints and the mean emission rate of the tobacco cigarettes joint with our measurements of the joint’s PM2.5 source strength. was highly statistically significant (p < 0.001). Applying the t-test, we found the relationship between the THC per­ The largest mean decay rate in Table 2 of 0.690 h 1 occurred with centage and the source strength was statistically significant (p < 0.01). the cannabis vaping pen, while the other four mean decay rates were However, this result may occur mainly because the larger joints in our fairly close together, averaging 0.509 h 1. When we compared the dif­ study happen to have higher THC percentages, and their larger size may ferences between the five mean decay rates, we found that only one cause their greater source strength. A more detailed study that controls difference was statistically significant: comparison of the mean decay for the size of the joint would be useful. rate of the 24 marijuana joints with the mean decay rate of the 9 vaping Our measurements of ultrafineparticles (UFP) > 10 nm used a pair of pen experiments. Based on the Mann-Whitney Rank Sum Test, the TSI 3007 condensation particle counters that were collocated with the

6 W.R. Ott et al. Atmospheric Environment: X 10 (2021) 100106 other monitors in the room during these experiments. The UFP results the present study and found they have a uniform manufactured length of are summarized in Table S2. Of the five sources, the pre-rolled mari­ 79 mm, which includes a 24 mm mouthpiece that acts as a filter. As a juana joints had the greatest average UFP source strength (2.0 x 1012 result, the length of the tobacco-containing portion of the cigarette is particles), while the Marlboro cigarettes had an almost equal UFP source 79–24 mm = 55 mm. By measuring the cigarette length before and after strength (1.8 x 1012 particles). The mean UFP source strengths of the each cigarette was smoked, we found the 3-puff protocol used up 31.7 three other methods of consuming marijuana were 1.3 x 1012 particles mm of the tobacco-containing portion of the cigarette on average, pro­ for bongs, 6.4 x. 1011 particles for glass pipes, and 3.3 x 1011 particles for ducing the 6.6 mg average source strength listed in Table 2. Therefore, the vaping pens. Overall, the UFP source strengths of bongs, glass pipes, the Marlboro cigarettes emitted (6.5 mg)/31.76 mm) = 0.2082 mg/mm and vaping pens were smaller than the UFP source strengths of either the on average as they were being smoked, and smoking the remaining pre-rolled marijuana joints or the Marlboro cigarettes. 55–31.7 mm = 23.3 mm would add 4.9 mg to the total, bringing the estimated total source strength for a fully smoked tobacco cigarette to + = 3.2. Estimating secondhand PM2.5 emissions from fully-smoked 6.6 4.9 mg 11.5 mg. Marijuana cigarettes Repace (2007) presented a histogram of fine particle mass source strengths of 50 brands of tobacco cigarettes, representing 65.3% of the McClure et al. (2012) studied 20 heavy users of marijuana, reporting US market. The average source strength for a fully-smoked cigarette was that heavy users smoked an average of 11–12 marijuana cigarettes per 13.8 mg (SD 3.1 mg), which is close to the 11.5 mg source strength we day, averaging 13–14 puffs per joint. Since our study compared the estimated for a fully smoked Marlboro tobacco cigarette in the present PM2.5 emission rates based on 3.0 min of smoking or vaping, we also study. Dacunto et al. (2013) reported a 19.9 mg source strength for a attempted to estimate the emissions produced by a fully-smoked mari­ fully smoked Marlboro cigarette, and Chen et al. (2018) reported a mean juana joint. source strength of 17.3 mg (SD 1.6 mg) per cigarette for 10 Chinese We used a precision laboratory scale to measure the weights of the 24 cigarettes smoked by two volunteer smokers. marijuana joints before they were smoked, which ranged from 0.56 to 1.35 g with a mean of 1.024 g (SD 0.24 g). By comparison, the pre- 4. Discussion smoking weights of the 9 Marlboro cigarettes ranged from 0.83 to 0.89 g with a mean of 0.863 g (SD 0.022 g). We found that measuring the In the 60 experiments, the mean PM2.5 decay rate for the 9 vaping difference in the weight of a joint before and after it was smoked was pen experiments of 0.690 h 1 was greater than the mean decay rates of challenging, because the water used to put out the joint affected its the four other sources, which ranged from 0.461 h 1 to 0.563 h 1, and tightly rolled cannabis leaves, causing the post-smoking weight some­ this difference was statistically significant (p < 0.001). In comparison, times to be larger than the original weight. In addition, it was difficultto the differences between the decay rates of the joint, bong, glass pipe, and account for the smoking ashes lost in the water. Therefore, we concluded cigarette were not statistically significant.The larger decay rate for the that comparing the weights before and after smoking a joint would need vaping pen appears likely due to the greater volatility of its aerosol. to use a different method of putting out the joint. As an alternative The 24 experiments with 9 different brands of pre-rolled joints pro­ approach, we explored using the average length to estimate the source duced extremely high PM2.5 concentrations. With just 3 puffs, the strength of a fully-smoked joint. maximum PM2.5 concentrations in the room ranged from 143 to 809 μg/ 3 3 The 24 marijuana joints used in the present study consisted of 9 m and averaged 540 μg/m . By comparison, the maximum PM2.5 con­ different name brands that ranged in length from 59 to 91 mm. The centrations for the 9 experiments with tobacco cigarettes smoked in the mean length was 79 mm, which was the same as the mean length of the same manner ranged from 22 to 209 μg/m3 and averaged 154 μg/m3. As Marlboro cigarettes. Four of the name-brand joints were shorter than the a result, the mean secondhand smoke PM2.5 emissions from Marijuana Marlboro cigarette, one was the same length, and four were longer. Like joints was 3.5 times greater than from the tobacco cigarettes. The PM2.5 the tobacco cigarettes, each joint had a mouthpiece that acted as a filter. emissions from the three alternative methods of smoking or vaping Before and after each joint was smoked in our 24 joint experiments, we marijuana – the bong, glass pipe, and vaping pen – were lower than the measured the length of the portion of the joint that contains the cannabis emissions of the joint, but all three methods produced greater PM2.5 leaf. Before smoking, the mean length of the cannabis portion was 52.1 emissions than the tobacco cigarettes. mm. After smoking, the mean length of the cannabis portion was Zhao et al. (2020) conducted a similar set of experiments with an reduced to 38.6 mm, indicating that the 3.0-min smoking period used up experienced smoker and the same fivesources used in the present study. 52.1–38.6 mm = 13.5 mm of the marijuana-containing portion of the A car parked in a garage to reduce the effect of winds was used as a 6.5 joint. Since this smoking period produced a mean source strength of m3 mixing chamber. Like the present study, the marijuana joints had the 23.2 mg (Table 2), we estimated the average PM2.5 emission per unit greatest emission rates, while the tobacco cigarettes had the lowest smoking length as (23.2 mg)/(13.5 mm) = 1.72 mg/mm. Thus, smoking emission rates. The emission rates of the vaping pen, bong, and glass the remaining 38.6 mm was estimated to add the mass emissions of pipe were in between the marijuana joints and the tobacco cigarettes. (1.72 mg/min) × (38.6 mm) = 66.4 mg, bringing the estimated mean Graves et al. (2020) measured several thousand different compounds source strength of the fully smoked joint to 23.2 + 66.4 mg = 89.6 mg. present in mainstream marijuana and mainstream tobacco smoke, as We estimated this large source strength would produce a maximum well as Total Particulate Matter (TPM) mass concentrations. They 3 PM2.5 concentration in the room of 2080 μg/m , and we estimated the collected the TPM on 47 mm quartz filters that were weighed on a smoking time would be 11.6 min. It would be useful to evaluate the laboratory microbalance. They report that the average TPM concentra­ accuracy of these estimates in a future experimental study. tion in marijuana mainstream smoke was 3.4 times greater than the TPM It also is instructive to compare our tobacco cigarette results with concentration in mainstream tobacco smoke. Their 95% confidence in­ other studies of fully smoked tobacco cigarettes. Chen et al. (2018) terval around this ratio was ±0.6, and thus our ratio of 3.5 for the recruited 2 volunteers to each smoke 5 Chinese tobacco cigarettes in a marijuana joint emission rate relative to the tobacco cigarette emission stainless steel mixing chamber. Their study used mass balance equations rate was within their 95% confidenceinterval. However, their result was like those in the present study to calculate emission rates for each of the for mainstream smoke, while our result was for secondhand smoke, 10 fully-smoked cigarettes. Their observed mean PM2.5 emission rate for which is a combination of mainstream and sidestream smoke. the 10 cigarettes was 2.25 mg/min (SD 0.9 mg/min), which was Moir et al. (2008) reported the mainstream TPM mass concentrations extremely close to our mean emission rate of 2.2 mg/min (SD 0.9 in marijuana smoke was about the same as in tobacco smoke. They also mg/min) shown in Table 2. measured the mass concentrations of 30 PAH compounds in both We measured the lengths of the Marlboro tobacco cigarettes used in marijuana and tobacco smoke. Their study indicated that 89.8% of the

7 W.R. Ott et al. Atmospheric Environment: X 10 (2021) 100106

PAHs in secondhand marijuana smoke were from sidestream emissions This study shows that smoking a marijuana joint indoors can produce while 10.2% were from mainstream emissions. extremely high indoor PM2.5 concentrations. Based on the results of 24 McClure et al. (2012) reported that the volume of the puffs from an experiments, smoking cannabis joints for 3.0 min in a 43 m3 room 3 adult smoker decreases steadily over the course of smoking a cigarette. produced maximum PM2.5 concentrations averaging 540 μg/m that Wu et al. (1988) studied 15 habitual marijuana smokers and reported ranged from 143 to 809 μg/m3. By comparison, the Marlboro tobacco the puff volume was smaller for the second half than for the firsthalf of cigarettes smoked in the same manner in the same room produced 3 marijuana cigarettes, while Tashkin et al. (1991) reported mainstream maximum PM2.5 concentrations averaging 154 μg/m that ranged from CO, tar, and THC emissions were greater for the second half than for the 22 to 209 μg/m3. first half of a marijuana cigarette. For estimating secondhand smoke The emissions from marijuana and tobacco cigarettes have been emissions from a fully-smoked tobacco or marijuana cigarette, we feel found to contain many of the same toxic chemicals and carcinogens our assumed linear relationship between secondhand smoke emissions (Moir et al., 2008; Sheehan et al., 2018; Graves et al., 2020). In view of and length smoked is reasonable and would be a good topic for future the large emission rates from marijuana smoking measured in the pre­ research. sent study and the many similar toxic air pollutants found in both marijuana and tobacco smoke in previous studies, we conclude that 5. Limitations of study additional research is needed on the health effects of secondhand smoke from cannabis smoking and vaping. More research also is needed on Since the marijuana joint has a long history of use and is one of the personal exposure to secondhand marijuana smoke. To the best of our most popular methods of consuming cannabis, we chose the largest knowledge, this is the first systematic study measuring PM2.5 concen­ sample size, n = 24 experiments, for the pre-rolled joint. The bong, glass trations, mass emission rates, and decay rates from secondhand smoke pipe, vaping pen, and cigarette all had smaller sample sizes of n = 9 produced by using different cannabis sources indoors in a residence. experiments. Except for one case, the differences in the PM2.5 emission This study plan was approved by the Institutional Review Board at rates between these four common methods of consuming marijuana or Stanford University. The authors declare this paper raises no ethical tobacco based on 9 experiments did not reach statistical significance at concerns. the p < 0.05 level. The 24 marijuana joints used in the present study were obtained CRediT authorship contribution statement from four state-licensed stores in three California towns, and the joints included 9 different name brands that are popular in California. Only Wayne R. Ott: Methodology, Formal analysis, Writing – original two different kinds of marijuana buds were used in the bong and glass draft. Tongke Zhao: Conceptualization, Methodology, Writing – review pipe experiments, however, and the results should show greater varia­ & editing. Kai-Chung Cheng: Conceptualization, Experimental Design, tion if more types of cannabis buds were included and if sample sizes Investigation. Lance A. Wallace: Conceptualization, Methodology, were larger. The AbsoluteXtracts (ABX) vaping pen used in the present Writing – review & editing. Lynn M. Hildemann: Conceptualization, study is battery-powered and uses an electronic microprocessor that Project administration. controls the temperature of the vaping fluid.This vaping pen has several settings that a user can select by pressing a button on the side of the pen. In our vaping pen experiments, we chose the “pre-heat” mode recom­ Declaration of competing interest mended in the ABX instructions, and we selected the highest of three power levels. This approach pre-heats the vaping liquid for 15 s, fol­ The authors declare that they have no known competing financial lowed by the 3-puff protocol that started within 1-1/2 min after pre- interests or personal relationships that could have appeared to influence heating ended. A user might choose different settings of this vaping the work reported in this paper. pen that could result in greater or lesser emissions. Using an identical ABX vaping pen, Wallace et al. (2020) reported that two different vaping Acknowledgements protocols produced two different temperatures, resulting in about 3 times greater source strength for the high-heat protocol than for the This research was supported by funds from the California Tobacco- low-heat protocol. In the present study, the 9 cannabis vaping experi­ Related Disease Research Program of the University of California, grant ments were limited to two different commercial vaping cartridges. Many number 28IR-0062. The authors wish to thank the journal referees and other vaping cartridges are available with different levels of THC and our six research advisors Casey Langfelder, Ed Connolly, David and Sam CBD that could be compared in a future study with a larger sample size. McClure, and Colin and Jane McAteer for their thoughtful comments on To compare different source types with each other, the 60 experiments this study. in this study used the same smoker, while future studies may choose to explore differences among smokers. Appendix A. Supplementary data 6. Conclusions Supplementary data to this article can be found online at https://doi. The methodology in this paper applied a standardized smoking org/10.1016/j.aeaoa.2021.100106. protocol to compare PM2.5 concentrations, source strengths, emission rates, and decay rates from different types of cannabis smoking and References vaping methods in a 43 m3 room of an occupied residence. The average PM emission rate of the pre-rolled marijuana joints was found to be Berg, C.J., Buller, D.B., Schauer, G.L., Windle, M., Stratton, E., Kegler, M.C., 2015. Rules 2.5 regarding marijuana and its use in personal residences: findings from marijuana 3.5 times the average emission rate of Marlboro tobacco cigarettes, the users and nonusers recruited through social media. J. Eviron. Public Health, 476017. most popular US cigarette brand. The average emission rate of the Accessed 3/10/21. https://doi.org/10.1155/2015/476017. ¨ cannabis bong was 67% that of the joint; the glass pipe was 54% that of Berg, C.J., Haardorfer, R., Wagener, T.L., Kegler, M.C., Windle, M., 2018. Correlates of allowing tobacco product or marijuana use in the homes of young adults. Pediatrics the joint, and the vaping pen was 44% that of the joint. These differences 141, 2018. https://doi/10.1542/peds.2017-1026E. in emission rates compared to the marijuana joints were statistically Berthet, A., De Cesare, M., Favrat, B., Sporkert, F., Augsburger, M., Thomas, A., significant,and the difference between the average emission rates of the Giroud, C., 2016. A systematic review of passive exposure to cannabis. Forensic Sci. Int. 269, 97–112. https://doi.org/10.1016/j.forsciint.2016.11.017. marijuana joints and the tobacco cigarettes was highly statistically sig­ Business Daily, Marijuana, 2020. Accessed 8/1/2020. https://mjbizdaily.com/chart-num nificant (p < 0.001). ber-california-licensed-recreational-marijuana-stores-falls-short/.

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California Department of Public Health, 2020. Let’s talk cannabis: what’s legal for adult Moir, D., Rickert, W.S., Levasseur, G., Larose, Y., Maertens, R., White, P., Desjardins, S., use. Accessed 11/1/20. https://www.cdph.ca.gov/Programs/DO/letstalkcannabis/ 2008. A comparison of mainstream and sidestream marijuana and tobacco cigarette CDPH%20Document%20Library/October%202017%20Update/CDPH-Legal.pdf. smoke produced under two machine smoking conditions. Chem. Res. Toxicol. 21, Cecinato, A., Romagnoli, P., Perilli, M., Patriarca, C., Balducci, C., 2014a. Psychotropic 494–502. substances in indoor environments. Environ. Int. 71, 88–93. https://doi.org/ Moore, C., Coulter, C., Uges, D., Tuyay, J., van der Linde, S., van Leeuwen, A., 10.1016/j.envint.2014.06.008. Accessed 11/19/20). Garnier, M., Orbita, J., 2011. Cannabinoids in oral fluid following passive exposure Cecinato, A., Balducci, C., Romagnoli, P., Perilli, M., 2014b. Behaviours of psychotropic to marijuana smoke. Forensic Sci. 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Health 16, 3332. https://doi.org/10.3390/ijerph16183332. Ott, W.R., Klepeis, N.E., Switzer, P., 2003. Analytical solutions to compartmental indoor Cone, E.J., Johnson, R.E., Darwin, W.D., Yousefnejad, D., Mell, L.D., Paul, B.D., air quality models with application to environmental tobacco smoke concentrations Mitchell, J., 1987. Passive inhalation of marijuana smoke: urinalysis and room air measured in a house. J. Air Waste Manag. Assoc. 53, 918–936. levels of delta-9-tetrahydrocannabinol. J. Anal. Toxicol. 11, 89–96. Posis, A., Bellettiere, J., Liles, S., Alcaraz, J., Nguyen, B., Berardi, V., Klepeis, N.E., Dacunto, P.J., Cheng, K.-C., Acevedo-Bolton, V., Jiang, R.-T., Klepeis, N.E., Repace, J.L., Hughes, S.C., Wu, T., Hovell, M.F., 2019. Indoor cannabis smoke and children’s Ott, W.R., Hildemann, L.M., 2013. Real-time particle monitor calibration factors and health. Prev. Med. Rep. 14, 100853. https://doi.org/10.1016/j.pmedr.2019.100853. 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9 ARTICLE IN PRESS

Reported Marijuana and Tobacco Smoke Incursions Among Families Living in Multiunit Housing in New York City

Lodoe Sangmo, BS; Bian Liu, PhD; Cordelia Elaiho, MPH; Lisa Boguski, MD; Michael Yaker, MD; Micah Resnick, MD; Alefiyah Malbari, MD; Karen M. Wilson, MD, MPH From the Icahn School of Medicine at Mount Sinai (L Sangmo), New York City, NY; Department of Population Health Science and Policy, Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai (B Liu), New York City, NY; and Department of Pediatrics, Kravis Children’s Hospital, Icahn School of Medicine at Mount Sinai (C Elaiho, L Boguski, M Yaker, M Resnick, A Malbari, and KM Wilson), New York City, NY The authors have indicated they have no potential conflicts of interest to disclose. Address correspondence to Karen M. Wilson, MD, MPH, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1198, New York City, NY 10029 (e-mail: [email protected]). Received for publication September 25, 2020; accepted January 5, 2021.

TAGEDPBSTRACT

BACKGROUND: While public knowledge on the prevalence .0043); and by housing types (P < .0001). Participants in New and adverse health effects of secondhand tobacco smoke expo- York City Housing Authority (NYCHA) developments were sure is well established, information on the prevalence of sec- more likely to report smelling SHMS (adjusted odds ratio = ondhand marijuana smoke (SHMS) exposure is limited. 3.45, 95% confidence interval = 1.18, 10.10], P = .02). Those METHODS: A convenience sample of parents of children in Section 8 housing were also more likely to report smelling attending 1 of 4 pediatric practices in the Mount Sinai Health SHMS, but the association was not significant (adjusted odds System completed an anonymous questionnaire assessing ratio = 3.29, 95% confidence interval = 0.94, 11.55, P =.06). demographics, housing characteristics, and the child’s health Approximately two thirds of the participants reported viewing status, as well as smoke incursions and household smoking marijuana smoke as being harmful to their child. behaviors. CONCLUSIONS: About one third of the families enrolled in the RESULTS: About 450 parents completed the survey between study reported smelling SHMS while at home with their child. 2018 and 2019; those with incomplete data were excluded, and Reported marijuana smoke exposure was associated with 382 surveys were included in the analysis. Approximately living in NYCHA housing. Policies that limit all smoke in 40% of the children were white; the median age was 15 months multiunit housing should be supported. (interquartile range: 5−40 months). About 30.9% (n = 118) of participants reported marijuana incursions in their home while TAGEDPKEYWORDS: housing; marijuana; smoke exposure; tobacco with their child, while 33.5% (n = 122) reported tobacco smoke incursions. SHMS exposure differed by race (P = ACADEMIC PEDIATRICS 2021;XXX:1−7

TAGEDPWHAT’S NEW medical marijuana.2 States do not have laws or restrictions on smoking marijuana around children.3 We found that 30.9% of the families enrolled from In the United States, smoking remains the most com- pediatric clinics in New York City reported smelling mon method of using marijuana among adults.4 Marijuana secondhand marijuana smoke in their home while with smoke contains carcinogens and respiratory irritants simi- their child even though combusted marijuana remains lar to tobacco smoke.5 Marijuana smoke pollutants can illegal in New York State. extend to children through secondhand marijuana smoke (SHMS)6 or thirdhand marijuana smoke, which consists of pollutants that deposit in the air, dust, and surfaces.7,8 MTAGEDPARIJUANA USE HAS become increasingly common and Studies on the prevalence of marijuana smoke exposure socially acceptable in the United States. A 2018 national and its effects on health and developmental outcomes in survey conducted by the Substance Abuse and Mental children are limited. A study conducted in Colorado after Health Services Administration found that 15.9% of recreational marijuana was legalized found detectable Americans reported past-year marijuana use.1 As of April marijuana smoke metabolites in 16% of the children 2020, 11 states and the District of Columbia allow for enrolled.9 Previous research also demonstrates that chil- recreational marijuana use while 33 states, the District dren with exposure to tobacco smoke are more like to of Columbia, Guam, and Puerto Rico, have legalized have exposure to marijuana smoke,9 raising concerns of

ACADEMIC PEDIATRICS Volume 000 Copyright © 2021 by Academic Pediatric Association 1 XX 2021 ARTICLE IN PRESS

2TAGEDN SANGMO ET AL ACADEMIC PEDIATRICS the effects of dual exposure to tobacco and marijuana As this was a convenience sample, we do not know how smoke. There is emerging evidence that exposure to mari- many parents were offered participation and declined. juana smoke may have negative effects on the children’s The study was approved by the Mount Sinai Institutional health. For example, a cross-sectional study found that Review Board. At the time of the survey, New York State children in households with indoor marijuana smoking had legalized marijuana only for medical use, and only in were more likely to have a higher frequency of adverse noncombusted forms.23 A total of 450 surveys were health outcomes after controlling for exposure to tobacco returned. The analysis was restricted to 382 participants smoke and other confounding variables.3 who had no missing items on incursion or any of the covari- Marijuana is most commonly smoked indoors and smoke ates used in logistic regression models. In the excluded can transfer between different units in multiunit housing group, the proportion of non-Hispanic white, non-Hispanic (MUH) developments, putting nonsmoking residents at black, Hispanic, and other race/ethnicity was 31.15%, increased risk of SHMS exposure,10,11 as has been demon- 11.48%, 36.07%, and 21.31%, respectively, compared to strated with tobacco smoke incursions.12,13 In particular, 40.31%, 11.26%, 29.84%, and 18.59% in the included low-income and minority populations in urban areas are at group. increased risk as studies demonstrate poor enforcement of 14−16 smoking policies within MUH in these populations. AGEDH2MTEASURESTAGEDN Despite variations in state laws, marijuana is currently Exposure to SHMS was defined as positive answers to illegal per federal law and therefore prohibited in federal 17 either the question “Do you ever smell marijuana smoke subsidized buildings. in your room/apartment/ condominium coming from Furthermore, the Department of Housing and Urban another apartment, when you are with your child?” or the Development has issued guidelines mandating smoke-free question “Do you ever smell marijuana smoke in common housing policies as of July 30, 2018, prohibiting tobacco areas such as the hallway or stairwell, when you are with use indoors and within 25 feet of public housing build- 18 your child?” A positive answer to the first question was ings. Marijuana smoke is not targeted as marijuana defined as marijuana smoke incursionwithinthehome. remains illegal according to federal law and is Exposure to secondhand tobacco smoke (SHTS) within the ... 18 “grounds to deny housing or terminate a tenancy.” homeandincommonareaswasalsoassessedsimilarly. These policies do not apply to Section 8-funded housing, which are privately managed. A study conducted among AGEDH2STELF-REPORTED MARIJUANA USE AND OTHER COVARIATESTAGEDN New York City residents who were Section 8 subsidy recipients or living in housing developments operated by Marijuana exposure in the home was assessed with the New York City Housing Authority (NYCHA) found that questions “Is there anyone who lives in your home or who up to two thirds of residents reported smelling SHMS in cares for your child who smokes marijuana?” Caretaker their home over the past year.19 The purpose of this study beliefs around SHMS exposure were assessed with the was to determine the prevalence of reported SHMS incur- question “Do you think that smelling marijuana smoke sions among participants while with their child, and to could be harmful for your child?” Housing policies assess demographic and housing characteristics associated around tobacco smoking were assessed with the question with marijuana smoke incursions. “If you chose apartment/condominium or house attached to one or more houses, which of the best describes your housing policies about tobacco smoking?” Participants TAGEDH1METHODSTAGEDN were defined as living in housing with comprehensive TAGEDH2STUDY DESIGNTAGEDN smoke-free policies if they reported that tobacco smoking This is a cross-sectional study designed to examine the is not allowed in apartments or units, or in shared areas. prevalence of marijuana smoke incursions in the home We collected demographic information, such as age, sex, through self-report questionnaire. Families of children and race/ethnicity of the participating children and their presenting for well-child or sick visits to four pediatrics parents, and the highest education level attained by the clinics in New York City were offered the opportunity to reporting parents. participate and verbal consent was obtained by clinic staff. The clinics included 2 private practices and 2 Article AGEDH2STTATISTICAL ANALYSISTAGEDN 28-certified clinics,20 which serve a higher proportion of Comparisons of SHMS and SHTS, respectively, by Medicaid recipients.21 Questions were piloted with 20 sur- covariates were done using chi-square tests. The associa- veys in September 2018 using cognitive interviewing tions between housing type and SHMS and SHTS, respec- techniques to assess parent understanding of the survey tively, were investigated in 2 separate logistic regression questions.22 Each site was instructed to offer the survey models, while adjusting for age group, race/ethnicity, edu- to all parents; we collected distributed surveys between cation, and clinic site. We also explored the co-occurrence September 2018 and December 2019. All information of SHMS and SHTS in 2 ways. First, SHTS was treated as was collected anonymously, with no means of linking a covariate in the model for studying the association questionnaire data or sample results to the patient or par- between SHMS and housing type. Second, we created a ent; after completing the survey, parents placed it into a 3-level variable to indicate the incursion of both SHMS sealed envelope that was then returned to the study team. and SHTS, either only SHMS or only SHTS, and the ARTICLE IN PRESS

ATGEDN CADEMIC PEDIATRICS MARIJUANA AND TOBACCO SMOKE INCURSIONS IN NYC 3 reference level of neither SHMS nor SHTS; and used a SHMS than non-Hispanic white participants (>50% vs multinomial logistic regression to study the association <37%, Table 1). Participants who had not completed high between incursion and housing type, while adjusting school or only completed some college were also more for covariates. Analyses were done using SAS software likely to report smelling SHMS than participants who had (V 9.4) (SAS Institute, Cary, NC). completed college (53.8%, 42.9%, and 32.2%, respec- tively, Table 1).

TAGEDH1RESULTSTAGEDN TAGEDH2SSOCIATIONS BETWEEN SHMS AND HOUSING TYPETAGEDN TAGEDH2SHMS IN THE STUDY POPULATIONTAGEDN After adjusting for covariates, participants in NYCHA Table 1 lists the general characteristics of the 382 housing were more likely to report smelling SHMS participants in the study population and by their SHMS (adjusted odds ratio [OR] = 3.45, 95% confidence interval status. About 40.3% (n = 154) of participants were white; the [CI] =1.18, 10.10, P = .02; Table 3). Those in Section median age of the children of participants was 15 months. 8 housing were also more likely to report smelling Overall, 39.0% (n = 149) of the participants reported SHMS, but the association was not significant (adjusted smelling SHMS in their homes or common areas while OR = 3.29, 95% CI = 0.94, 11.55, P = .06; Table 3). with their child. About 30.9% (n = 118) of the participants reported smelling SHMS in their home while with their AGEDH2SHTST IN THE STUDY POPULATIONTAGEDN child. Of those who reported smelling SHMS at home, Of the participants, 33.5% (n = 122) reported tobacco 43.6% (n = 48) reported smelling SHMS rarely, 12.7% smoke incursions in their home while 31.3% (n = 114) (n = 14) reported smelling it monthly, 28.2% (n = 31) reported smelling SHTS in common areas. Reported reported smelling it weekly, and 15.5% (n = 17) reported tobacco smoke incursions were associated with housing smelling it daily. About 30.4% (n = 116) of the partici- type (P < .001), self-reported race/ethnicity (P= .021) and pants reported smelling SHMS in common areas while educational level (P < .001; Table 2). Participants living with their child. Of those who reported smelling SHMS in in NYCHA (adjusted OR = 2.17, 95% CI = 0.74, 6.35, common areas, 42.1% (n = 45) reported smelling in rarely, P = .16) and Section 8 housing (adjusted OR = 2.13, 95% 15.9% (n = 17) reported smelling it monthly, 23.4% CI = 0.61, 7.47, P = .24) were more likely to report (n = 25) reported smelling it weekly, and 18.7% (n = 20) tobacco smoke incursions than participants living in other reported smelling it daily. multihousing units, though these associations were not Reported SHMS exposure differed by housing type (P significant (Table 3). < .001) and covariates such as self-reported race/ethnicity (P = .004), educational level (P = .014) and reported SHTS (P < .001; Table 1). The prevalence of SHMS TAGEDH2SSOCIATIONS BETWEEN SHMS AND/OR SHTS AND among participants living in NYCHA (73.9%) or Section HOUSING TYPETAGEDN 8 (73.3%) housing nearly doubled those in other housing About 30.6% (n = 117) participants reported both type (36.6%). Participants who identified as non-Hispanic SHMS and SHTS, while 47.9% (n = 183) had neither black or Hispanic were more likely to report smelling incursion, with the remaining 21.0 % (n = 82) reported

Table 1. Reported Marijuana Incursions by Housing Type, Race/Ethnicity, Education, and Tobacco Smoke Incursion

Overall ÀSHMS +SHMS n = 382 (Column %) n = 228 (Row%) n = 154 (Row%) P Value Housing type P < .001 NYCHA 23, 6.0% 6, 26.1% 17, 73.9% Section 8 15, 3.9% 4, 26.7% 11, 73.3% Other 344, 90.1% 218, 63.4% 126, 36.6% Race/ethnicity P = .004 Non-Hispanic White 154, 40.3% 106, 68.8% 48, 31.2% Non-Hispanic Black 43, 11.3% 21, 48.8% 22, 51.2% Hispanic 114, 29.8% 56, 49.1% 58, 50.9% Non-Hispanic other 71, 18.6% 45, 63.4% 26, 36.6% Education P = .014

4TAGEDN SANGMO ET AL ACADEMIC PEDIATRICS

Table 2. Reported Tobacco Smoke Incursions by Housing Type, Race/Ethnicity, Education, and Age

Overall ÀSHTS +SHTS n = 382 (Column %) n = 220 (Row%) n = 162 (Row%) P Value Housing type P < .001 NYCHA 23, 6.0% 6, 26.1% 17, 73.9% Section 8 15, 3.9% 4, 26.7% 11, 73.3% Other 344, 90.1% 210, 61.1% 134, 38.9% Race/ethnicity P = .021 Non-Hispanic White 154, 40.3% 96, 62.3% 58, 37.7% Non-Hispanic Black 43, 11.3% 21, 48.8% 22, 51.2% Hispanic 114, 29.8% 55, 48.3% 59, 51.7% Non-Hispanic other 71, 18.6% 48, 67.6% 23, 32.4% Education P < .001

ATGEDN CADEMIC PEDIATRICS MARIJUANA AND TOBACCO SMOKE INCURSIONS IN NYC 5

Table 4. Results of Logistic Regression Assessing for Association Between SHMS and/or SHTS Exposure and Housing Type (SHMS + SHTS, SHMS only or SHTS only, neither SHMS or SHTS

Marijuana Smoke and Tobacco Smoke Exposure Marijuana Smoke or Tobacco Smoke Incursion Housing Type OR (95% CI)* P Value OR (95% CI)* P Value NYCHA 4.50 (1.12−18.1) .03 3.11 (0.75−12.84) .12 Section 8 3.35 (0.68−16.54) .14 0.74 (0.1−5.26) .76 Other Reference NYCHA indicates New York City Housing Authority; SHMS, secondhand marijuana smoke; SHTS, secondhand tobacco smoke; CI, confi- dence interval; and OR, odds ratio. *OR adjusted for covariates including age group, race/ethnicity, education, clinic site.

Table 5. Reported Marijuana and Tobacco Smoke Incursions by Smoke-Free Housing (SFH) Policy

SHMS Overall ÀSHMS + SHMS n = 382 (Column %) n = 228 (Row%) n = 154 (Row%) P Value SFH* 159, 41.6% 106, 66.7% 53, 33.3% P = .019 Other 223, 58.4% 122, 54.7% 101, 45.3%

SHTS Overall ÀSHTS + SHTS n = 382 n = 220 (Row%) n = 162 (Row%) P Value SFH 159, 41.6% 108, 67.9% 51, 32.1% P < .001 Other 223, 58.4% 112, 50.2% 111, 49.8% SHMS indicates secondhand marijuana smoke; SHTS, secondhand tobacco smoke. *SFH = Tobacco smoking is not allowed in apartments or units, or in shared areas. and SHTS. As marijuana smoke contains carcinogens and SHMS incursion was also more likely in participants who respiratory irritants similar to tobacco smoke,5 children self-identified as non-Hispanic black or Hispanic. This is with dual exposure may face increased risk. Reported consistent with disparities in SHTS exposure,29 caused in part by unequal access and enforcement of comprehensive 30 Table 6. Views on Marijuana Smoke Incursions Among Caretaker smoke-free policies within MUH. In addition, residents Reporting SHMS Incursions in the Home or in Common Areas who reported comprehensive tobacco smoke-free housing policies prohibiting tobacco smoking in both individual How much does smelling marijuana smoke in your room/apartment/condominium/common apartments and common areas were less likely to report areas bother you? (n = 144) both SHTS and SHMS exposure. Not at all 24, 16.7% Approximately three fourths of NYCHA and Section A little 46, 31.9% 8 housing residents reported smelling SHMS and SHTS. Some 27, 18.8% This demonstrates that despite implementation of smoke- A great deal 47, 32.6% Have you ever complained to your landlord or free housing policies targeting tobacco smoke in NYCHA building manager about smelling marijuana housing as of July 2018, the prevalence of second-hand smoke in your room/apartment/condominium/ tobacco and marijuana smoke remains widespread.19,28 common areas? (n = 146) More research is necessary to study the effects of smoke- Yes 57, 39.0% free housing policies in NYCHA housing in order to opti- No 89, 61.0% Don’t know 0, 0.00% mally implement and enforce such policies. This study If yes, did this result in any change in demonstrates that vulnerable populations, including racial the amount of smell? (n = 26) groups disproportionally burdened by SHTS exposure and Yes 6, 23.1% children in subsidized housing, are more likely to be No 17, 65.4% exposed to SHMS within their homes. Given this, current Don’t know 3, 11.5% Do you think that smelling marijuana smoke policies that solely restrict tobacco smoke should be could be harmful for your child? (n = 359) expanded to include restrictions on marijuana smoke in Yes 248, 69.1% order to mitigate disparities in the compounded effects of No 43, 12.0% dual smoke exposure.29 Based on historical disparities in Don’t know 68, 18.9% marijuana-related convictions,31 collaborative approaches Is there anyone who lives in your home or who cares for your child who smokes involving access to cessation services and resident educa- marijuana? (n = 367) tion could prove more efficacious than punitive measures Yes 20, 5.5% such as terminating tenancy.16 No 340, 92.6% A majority of participants reported that they thought Don’t know 7, 1.9% smelling marijuana smoke could be harmful to their child ARTICLE IN PRESS

6TAGEDN SANGMO ET AL ACADEMIC PEDIATRICS

(Table 6). Despite the increasing prevalence and social 8. Sempio C, Lindley E, Klawitter J, et al. Surface detection of THC acceptability of smoking marijuana, families remain con- attributable to vaporizer use in the indoor environment. Sci Rep. cerned about their child’s exposure to SHMS.32 Approxi- 2019;9:18587. 9. Wilson KM, Torok MR, Wei B, et al. Detecting biomarkers of second- mately one third of the participants who experienced hand marijuana smoke in young children. Pediatr Res. 2017;81:589– marijuana incursions reported complaining to their land- 592. lord about smelling marijuana smoke and noted that 10. King BA, Travers MJ, Cummings KM, et al. Secondhand smoke smelling marijuana smoke bothered them “a great deal.” transfer in multiunit housing. Nicotine Tob Res. 2010;12:1133– As states consider marijuana legalization, laws and poli- 1141. 11. Rendon AD, Unger JB, Cruz T, et al. Perceptions of secondhand and cies that limit SHMS exposure in children living in MUH thirdhand smoke among Hispanic residents of multiunit housing. should be considered. J Immigr Minor Health. 2017;19:162–169. Our study has several limitations. There is a possibility for 12. Wilson KM, Klein JD, Blumkin AK, et al. Tobacco-smoke exposure selection bias as participants were recruited by administra- in children who live in multiunit housing. Pediatrics. 2011;127:85–92. tive staff who informed patients that the survey was on sec- 13. Kraev TA, Adamkiewicz G, Hammond SK, et al. Indoor concentra- tions of nicotine in low-income, multi-unit housing: associations ondhand smoke exposure. It is possible the families who use with smoking behaviours and housing characteristics. Tob Control. tobacco and/or marijuana were less likely to participate. 2009;18:438–444. There is also a possibility for information bias as data were 14. Delgado-Rendon A, Cruz TB, Soto D, et al. Second and thirdhand gathered through parent report and parents may not disclose smoke exposure, attitudes and protective practices: results from a the SHMS and SHTS accurately. In addition, SHMS may be survey of Hispanic residents in multi-unit housing. J Immigr Minor Health. 2017;19:1148–1155. present even though parents do not smell it. Future studies 15. Delgado Rendon A, Cruz TB, Baezconde-Garbanati L, et al. can include tests for marijuana smoke biomarkers to assess Managers’ practices of tobacco and marijuana smoking policies the accuracy of reported incursions. In future studies, bio- in Hispanic-occupied multiunit housing. Health Equity. 2019;3: markers for tobacco and marijuana exposure could be 304–311. included to verify self-reported incursion status. Finally, our 16. Jiang N, Thorpe L, Kaplan S, et al. Perceptions about the federally mandated smoke-free housing policy among residents living in pub- results may not be generalizable outside of this convenience lic housing in New York City. Int J Environ Res Public Health. sample of children in New York City. 2018;15:2062. https://doi.org/10.3390/ijerph15102062. This study represents an important step in understand- 17. U.S. Drug Enforcement Administration. Drug Scheduling. U.S. ing the extent of marijuana smoke incursions in a large Drug Enforcement Administration. Available at: https://www.dea. urban area without legal combusted marijuana use. As gov/druginfo/ds.shtml. Accessed January 29, 2021. 18. The U.S. Department of Housing and Urban Development. Imple- states continue to legalize marijuana use, further research menting HUD’s Smoke-Free Policy in Public Housing: HUD Guide- must be done to understand the consequences of SHMS book 2017. U.S. Department of Housing and Development; 2017. exposure on children. Available at: https://www.hud.gov/sites/documents/SMOKEFREE_ GUIDEBK.PDF. Accessed January 29, 2021. 19. Anastasiou E, Chennareddy S, Wyka K, et al. Self-reported second- TAGEDH1CKNOWLEDGMENTTAGEDN hand marijuana smoke (SHMS) exposure in two New York City (NYC) subsidized housing settings, 2018: NYC housing authority Financial statement: Children’s Foundation Board of the Kravis and lower-income private sector buildings. J Community Health. Children’s Hospital at the Icahn School of Medicine at Mount Sinai. The 2019;45:635–639. funder/sponsor did not participate in the work. 20. New York State Department of Health. Hospitals and diagnostic and treatment centers (clinics) in New York State. 2019. Available at: TAGEDH1REFERENCESTAGEDN https://www.health.ny.gov/facilities/hospital/. Accessed September 25, 2020. 1. Bose J, Hedden SL, Lipari RN, et al. Key substance use and mental 21. New York State Department of Health, New York State Office of health indicators in the United States: results from the 2017 National Mental Health, New York State Office of Alcoholism and Substance Survey on Drug Use and Health (HHS Publication No. SMA 18- Abuse Services. Medicaid collaborative care program billing guid- 5068, NSDUH Series H-53). Administration SAMHSA. Rockville, ance for article 28 outpatient clinic claims 2018. Available at: Md: Center for Behavioral Health Statistics and Quality, Substance https://aims.uw.edu/nyscc/sites/default/files/Article%2028%20Col Abuse and Mental Health Services Administration; 2017. laborative%20Care%20Billing%20Guidance%20-%20FINAL.pdf. 2. DISA Global Solutions. Map of Marijuana Legality by State. 2020. Accessed September 25, 2020. 3. Posis A, Bellettiere J, Liles S, et al. Indoor cannabis smoke and 22. Willis G, Lessler JT, Caspar RA. Cognitive Interviewing: A “How children’s health. Prev Med Rep. 2019;14:100853. To” Guide. University of Iowa; 1999. 4. Pepin D, Hoss A, Schauer GL, et al. Public use of recreational mari- 23. New York State Department of Health. The New York State medical juana: a legal landscape of state law. Seton Hall Legis J. marijuana program. Available at: https://www.health.ny.gov/regula 2016;41:283–303. tions/medical_marijuana/. Accessed September 25, 2020. 5. Moir D, Rickert WS, Levasseur G, et al. A comparison of main- 24. Tortoriello G, Morris CV, Alpar A, et al. Miswiring the brain: stream and sidestream marijuana and tobacco cigarette smoke pro- Delta9-tetrahydrocannabinol disrupts cortical development by duced under two machine smoking conditions. Chem Res Toxicol. inducing an SCG10/stathmin-2 degradation pathway. EMBO J. 2008;21:494–502. 2014;33:668–685. 6. Cone EJ, Bigelow GE, Herrmann ES, et al. Non-smoker exposure to 25. Tetrault JM, Crothers K, Moore BA, et al. Effects of marijuana secondhand cannabis smoke. I. Urine screening and confirmation smoking on pulmonary function and respiratory complications: a results. J Anal Toxicol. 2015;39:1–12. systematic review. Arch Intern Med. 2007;167:221–228. 7. Jacob 3rd P, Benowitz NL, Destaillats H, et al. Thirdhand smoke: 26. Holitzki H, Dowsett LE, Spackman E, et al. Health effects of expo- new evidence, challenges, and future directions. Chem Res Toxicol. sure to second- and third-hand marijuana smoke: a systematic 2017;30:270–294. review. CMAJ Open. 2017;5:E814–E822. ARTICLE IN PRESS

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27. Zarfin Y, Yefet E, Abozaid S, et al. Infant with altered conscious- 30. Hafez AY, Gonzalez M, Kulik MC, et al. Uneven access to ness after cannabis passive inhalation. Child Abuse Negl. 2012;36: smoke-free laws and policies and its effect on health equity in 81–83. the United States: 2000-2019. Am J Public Health. 2019;109: 28. Wang X, Derakhshandeh R, Liu J, et al. One minute of marijuana 1568–1575. secondhand smoke exposure substantially impairs vascular endothe- 31. Harcourt BE, Ludwig J. Reefer madness: broken windows policing lial function. J Am Heart Assoc. 2016;5:e003858. https://doi.org/ and misdemeanor marijuana arrests in New York City, 1989−2000. 10.1161/JAHA.116.003858. Criminol Public Policy. 2007;6:165–181. 29. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in non- 32. Glantz SA, Halpern-Felsher B, Springer ML. Marijuana, second- smokers’ exposure to secondhand smoke−United States, 1999- hand smoke, and social acceptability. JAMA Intern Med. 2018; 2012. MMWR Morb Mortal Wkly Rep. 2015;64:103–108. 178:13–14. 4/6/2021 Mail - [email protected] [EXTERNAL] Corte Madera Ordinance

Erica Costa

Mon 4/5/2021 4:34 PM

To:Public Comment ;

 1 attachments (49 KB)

Corte Madera Vaping and Marijuana Exemption 04.05.21.pdf;

Good afternoon,

Please see the attached letter from the American Lung Association in regards to the possible exemptions to the secondhand smoke ordinance.

Thank you, Erica Costa

Erica Costa, MPPA Advocacy Director | California American Lung Association 1531 “I” Street, Suite 201 | Sacramento, CA 95814

Lung HelpLine: 1-800-LUNGUSA Lung.org | Preferred Pronouns: She/Her/Hers

https://west.exch090.serverdata.net/owa/#path=/mail 1/1

April 5, 2021

Corte Madera City Council 300 Tamalpais Drive Corte Madera, CA 94925

Re: Secondhand Smoke Ordinance Exemption

Dear City Councilmembers:

On behalf of the American Lung Association in California, the leading public health organization fighting to reduce and prevent the harmful effects of tobacco use, I am writing to express our support our concern for exemptions being considered to the smokefree housing ordinance last month. We appreciate your support for a smokefree housing ordinance, and your willingness to protect 100% of residents living in apartments and condos. However, the exemption for marijuana smoking and vaping compromises the effectiveness of the ordinance which was designed to protect all residents of multi-unit housing from the public health hazards of drifting marijuana smoke. We can support the ordinance once the exemption is removed.

Each year in California, nearly 40,000 adults die from smoking-related causes, and over 12,000 kids become new daily smokers. According to the U.S. Surgeon General, tobacco companies have a long history of using flavored products to entice new, younger customers. Eight out of ten youth smokers report that they initiated tobacco use with a flavored tobacco product, and the younger a person is, the more likely they will be to use a flavored tobacco product.

Marijuana smoke many of the same chemicals and toxins as secondhand tobacco smoke and damages the human lung. Research shows that smoking marijuana causes chronic bronchitis and marijuana smoke has been shown to injure the cell linings of the large airways, which could explain why smoking marijuana leads to symptoms such as chronic cough, phlegm production, wheeze and acute bronchitis. A new study just published by the Science Direct Journal (as well as UCSF School of Medicine) shows that the marijuana smoke emission rate was 3.5 times that of the tobacco cigarette.

A strong policy not containing exemptions will help protect the health of Corte Madera residents. We respectfully ask for your support for these vital public health policies.

Sincerely,

Erica Costa

1531 I Street, Suite 201 | Sacramento, CA 95814 | 916-554-5864 | Lung.org

4/6/2021 Mail - [email protected] [EXTERNAL] Concern about second-hand smoke policy for multi unit housing

Jessica Mendieta

Mon 4/5/2021 5:47 PM

To:Public Comment ;

Dear City Council and staff members,

My name is Jessica Mendieta, a member of the Youth Leadership Institute’s Alcohol, Tobacco and other drugs sub-committee, writing to you today to ask that you change the current second-hand smoke ordinance so that everyone that lives in multi unit housing is protected from second-hand smoke, including smoke from medical cannabis. If the ordinance includes an exception to the second-hand smoke from medical cannabis, then that means that there is a loophole that will harm the health of individuals (including children and people with low auto- immune systems) that live in multi unit housing in Corte Madera. This is especially concerning because most people are spending time indoors this year in an effort to stay safe from the spread of coronavirus.

Thank you so much for your support in increasing the protection of multi-unit housing residents from living in 80% smoke-free housing to 100%. As a member of the community, I appreciate you taking this equity and health issue seriously.

Sincerely, Jessica Mendieta

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/6/2021 Mail - [email protected] [EXTERNAL] 4/6 City Council Meeting - Second Hand Smoke Policy

Xitlalli Pineda

Mon 4/5/2021 6:50 PM

To:Public Comment ;

Hello Corte Madera City Council and staff,

My name is Xitlalli Lechuga and I am a member of the Marin County Youth Leadership Institute (YLI). In my time in the YLI Alcohol, Tobacco, and other drugs sub-committee, I have become aware that Corte Madera is one of the remaining 5 cities (of 12) in Marin County that still allows second-hand smoke in multi-unit housing. I was happy to hear that this has been brought to your attention and that you have expressed support of increasing this protection to all multi-unit housing, however, I have also learned that medical cannabis is currently allowed in the ordinance. I have a problem with this because it will allow for residents to continue smoking inside of these shared spaces and residences, which will thus continue to allow for the exposure of second-hand smoke to impact the health of others.

I am in no way against the legal usage of cannabis-in fact, I support the decriminalization of cannabis use- however, I think that it’s important that it is used in a manner that does not harm the health of others. Please remove the exemption that allows residents of multi-unit housing to smoke or vape medical cannabis. There are many alternatives for a person to legally consume CBD and THC products that do not explicitly put the health of neighboring residents at risk.

Thank you for taking my concern into consideration. I hope that you do all that you can to protect the lungs and overall health of people in multi-unit housing in this way.

Xitlalli Lechuga

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/6/2021 Mail - [email protected] [EXTERNAL] Secondhand Cannabis Smoke in Multi-unit Housing

Annika Danne

Tue 4/6/2021 8:43 AM

To:Public Comment ;

Dear Council members and Corte Madera Town staff,

My name is Annika Danne and I am a sophomore at Redwood High School. I am reaching out to you today to ask that you please consider removing the exemption for medical cannabis/marijuana in Corte Madera’s secondhand smoke in multi-unit housing ordinance ( 6:14.110 ) as this exemption would render the current changes to the ordinance, aimed to protect more residents of multi-unit housing, practically unenforceable. I was very happy to hear that tobacco and other drugs alike have been banned from multi-unit housing. However, I am still concerned about the allowance of cannabis as second hand marijuana smoke contains many of the same cancer-causing substances and toxic chemicals as second hand tobacco smoke. This fine particulate matter of marijuana can deeply impact someone’s health when it is breathed deeply into one’s lungs. The exemption is not necessary. There are numerous forms that people can take medical marijuana without harming the health of their neighbors. Tobacco smokers living in apartments use nicotine lozenges, FDA-approved inhalers or nicotine gum to fend off cravings. Those using cannabis have far more options: oils, lotions, creams, lozenges, tablets, edibles such as cannabis candy, cookies, etc. People in multi-unit housing should not have to worry about their safety and health while in their own homes. That is why I ask you to do your part and close this loophole to smoking in multi-unit housing here in Corte Madera, so that families, like mine, do not have to worry about the air we breathe in.

Thank you, Annika Danne

https://west.exch090.serverdata.net/owa/#path=/mail 1/1 4/6/2021 Mail - [email protected] [EXTERNAL] Second Hand Smoke Policy 4/6

Naedy Mendoza

Tue 4/6/2021 10:57 AM

To:Public Comment ;

Hello, City council members and town staff,

My name is Naedy Mendoza. I am 17 years old and I have lived here in Marin my whole life. I have lived in multi- unit housing my whole life. I have learned that living in this kind of residence means that I have to deal with the issue of people smoking around my home on a regular basis. More recently, I have noticed that the majority of the time that I noticeably inhale second-hand smoke in my family’s apartment, it comes from the smoke of cannabis. Sometimes I want to open the windows so that I can get fresh air in my room in my family’s apartment but I can’t because of how bad and strong the smell of second-hand smoke from Cannabis is. Lower-income populations and communities of color have higher rates of exposure to second-hand smoke and higher rates of health issues. Lower-income residents desire smoke-free housing, but there is less availability of smoke free buildings, and fewer options to move here in Marin. Everyone, regardless of their financial situation, deserves to breathe safe, smoke-free air at home.

Our homes should be our sanctuaries where we always have the right and access to fresh air. Please prohibit smoking inside or too close (30 ft) of multi-unit housing in Corte Madera and please eliminate any exceptions to this rule.

Thank you very much, Naedy Mendoza

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