EXAMINING the POLITICS and POLICY IMPACTS Yuna C. Kim A
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HARM REDUCTION AND SUBSTANCE USE: EXAMINING THE POLITICS AND POLICY IMPACTS Yuna C. Kim A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements of the degree of Doctor of Philosophy in the Department of Public Policy. Chapel Hill 2016 Approved by: Krista M. Perreira Christine P. Durrance Daniel P. Gitterman Jeremy G. Moulton Jonathan Oberlander © 2016 Yuna C. Kim ALL RIGHTS RESERVED ii ABSTRACT Yuna C. Kim: Harm Reduction and Substance Use: Examining the Politics and Policy Impacts (Under the direction of Krista M. Perreira) This dissertation evaluates the impacts and political dynamics of harm reduction policies concerning substance use in North America. In doing so, this three-essay dissertation focuses on two substance use policies: medical marijuana laws (MMLs) and supervised injection services (SISs). The first two essays evaluate the unintended impacts that result from the implementation of MMLs in the U.S. The first essay evaluates the impact of state-level MML implementation and specific policy dimensions (i.e., dispensaries, patient registries, and in-home cultivation) in the U.S. on non-drug related arrest rates and crime rates for violent and property crimes. The second essay analyzes the effect of each MML policy dimension on the probability of cigarette smoking among U.S. adults. Considered together, these two essays highlight various unintended downstream impacts that need to be taken into consideration as policymakers adopt and implement MMLs. The third essay is a political evaluation of the barriers to adopting SISs in North America. The dearth of SISs in North America is puzzling considering the wealth of evidence suggesting their effectiveness in preventing overdoses and connecting injection drug users with treatment resources. Using the Canadian province of Ontario as a case study, this essay identifies the political barriers to adopting SISs and considers the limits and possibilities of establishing SISs in the North American context. iii Taken as a whole, this three-essay dissertation provides valuable information to policymakers considering the implementation of MMLs or SISs. Policymakers considering marijuana legalization should be cognizant of the impact of particular policy dimensions on arrest rates and tobacco use to mitigate additional costs that may outweigh benefits. Moreover, this research underscores the importance of understanding the political environment in which harm reduction policies are made. iv To my mom, Grace Soon-Ok Kim. Thank you for reminding me about juice. v ACKNOWLEDGEMENTS I consider myself to have the “dream team” of dissertation committees. I would like to thank my dissertation committee chair, Krista Perreira, for sharing her wisdom and expertise to help me develop as a researcher. From day one, your feedback on my work has always been incredibly insightful and I thank you for your willingness to guide me through each milestone of this program. I am also thankful to my committee members, Christine Durrance, Dan Gitterman, Jeremy Moulton, and Jon Oberlander. Thank you for challenging me intellectually and providing the supports to help me overcome each challenge. My committee’s mentorship and support throughout the ups and downs of this program is something I treasure; I will never be able to thank each of you enough. Thank you also to all of the new friends I made during my time in North Carolina. Thank you to Adria Molotsky, Nicole Ross, and Paige Clayton, for keeping me sane and giving me a safe space to be vulnerable. Thank you to my School of Public Health counterparts, Megan Roberts, Sarah Lewis, Emily Gillen, Kristen Brugh, Larissa Calancie, and Lisa Selker for always being there and making this academic journey that much more fun. Thank you to my Canadian friend, Saleema Karim, for your mentorship; I promise we will be writing our Harold and Kumar series of papers soon! Thank you also to Ashley Richards for letting me join her work softball team; I hope you know how much joy that brought me. Lastly, but most certainly not least, thank you to my dear friends Evan Johnson and Lisa Spees. I think the universe must have had some plan to bring us all together in Chapel Hill. How wonderful it was that we were able to share the vi joys and frustrations of this program together. I also feel so fortunate that I met such loving people during one of the most painful periods of my life. Thank you, quite literally, for everything. I also want to thank the faculty, instructors, graduate, and undergraduate students in the Department of Public Policy. I cannot think of a better place to call my academic home and I am honoured I was able to learn from each of you. Thank you to Kim Jeffs, Patrick Jeffs, and Maureen Dunn for your patience, kindness, and guidance, and for helping me to see clearly. Thank you to Krystie and Jason Green, for being amazing roommates and friends. I look up to you both and admire how you face each obstacle life throws at you with spirituality and grace. I look forward to many more Super Bowl parties to come. Thank you to Harry MacNeill, Lenna Panou, Rhea Jankowski, and Charlsie Searle for keeping me grounded and for texting me during the 2015 Toronto Blue Jays playoff run. I am not entirely sure how to thank adequately one very special individual in my life. Ross Keatley, I do not know how you did it, but you carried me through my lowest lows. You managed to support me even when you were not quite sure of what to say. Despite living over 1,200 kilometres away, you made sure I never felt alone. I hope you know how much I cherish you. Lastly, thank you to my family. Dad, thank you for spending hours with me when I was young going over math problems, editing my essays, reading Dr. Seuss to me, and playing softball with me. Like mom used to say, I am just like you, and I believe that makes me very lucky, even if a little stubborn. Thank you for supporting me unconditionally. I can act fearlessly knowing you will catch me if I fall. Danny, you are the coolest big brother. When we were kids, you once told me never to use a word if I did not know its meaning; I still remember this and vii stick by this rule the best I can. Thank you for always keeping me humble and sticking up for me. Thank you to my aunt, Olivia Yoon, for checking in on me and providing sports updates. Thank you to my aunt, Susie Whang, for giving me a home during American Thanksgiving. My mom is my hero. Thank you for showing me what it means to be strong. You took some big risks in your life and sacrificed so much just so I could have the opportunity to be anything I wanted to be. Thank you for your love. I owe this dissertation to each of you. Thank you for believing in me and supporting me. viii TABLE OF CONTENTS LIST OF TABLES ......................................................................................................................... xi LIST OF ABBREVIATIONS ...................................................................................................... xiii CHAPTER 1: EXECUTIVE SUMMARY ..................................................................................... 1 Essay One.................................................................................................................................... 3 Essay Two ................................................................................................................................... 4 Essay Three ................................................................................................................................. 5 References ................................................................................................................................... 6 CHAPTER 2: MEDICAL MARIJUANA LAWS, ARREST RATES, AND CRIME ................... 7 I. Introduction ............................................................................................................................. 7 II. Background ............................................................................................................................ 9 III. Data and Empirical Specification ....................................................................................... 19 IV. Results................................................................................................................................. 28 V. Sensitivity Analysis.............................................................................................................. 33 VI. Conclusion .......................................................................................................................... 36 REFERENCES ......................................................................................................................... 40 APPENDIX TABLE 1: DEFINITIONS OF VIOLENT AND PROPERTY CRIMES ............... 62 CHAPTER 3: EXAMINING THE JOINT USE OF MARIJUANA AND TOBACCO: THE EFFECT OF MEDICAL MARIJUANA LAWS AND CIGARETTE SMOKING AMONG U.S. ADULTS .............................................. 63 I. Introduction ........................................................................................................................... 63 II. Background .......................................................................................................................... 65 ix III. Data and Empirical Specification ....................................................................................... 68 IV. Results................................................................................................................................