Megan Resolutions

2016- Regulating Marijuana

August 25, 2016
The Arizona Public Health Association (AzPHA) supports the adoption of the following APHA Policy Statement 201410 – Regulating Commercially Legalized Marijuana as a Public Health Priority and its action step recommendations.

Policy Statement: 201410

Abstract

As of 2014 four states, Colorado, Washington, Alaska, and Oregon, and the District of Columbia have legalized the sale and use of marijuana through a commercial market, and many other states are considering the option. So far the federal government has not challenged state laws legalizing commercial marijuana as long as states maintain strict rules involving sales and distribution. This policy statement calls for a public health approach to regulating and controlling commercially legalized marijuana and urges that regulation of legalized marijuana be viewed as a public health priority. Regulation will provide oversight of a market that is currently uncontrolled and can help address the unforeseen effects of marijuana legalization. If marijuana is legalized, federal, state, and local governments should develop, adopt, monitor, and evaluate strict regulatory mechanisms to control marijuana production, sales, and use while advancing the public health goals of preventing access by minors, protecting and informing consumers of legalized marijuana, and protecting third parties from unwanted consequences of legalized marijuana use. These mechanisms may include taxes, age limits, product labeling requirements, product quality testing, potency limits, labeling requirements, motor vehicle operation restrictions, and advertising restrictions.

Relationship to Existing APHA Policy Statements
• APHA Policy Statement 8817(PP): A Public Health Response to the War on Drugs: Reducing Alcohol, Tobacco and Other Drug Problems among the Nation’s Youth
• APHA Policy Statement 7121: Substance Abuse as a Public Health Problem
• APHA Policy Statement 7014: Marijuana and the Law
• APHA Policy Statement 201312: Defining and Implementing a Public Health Response to Drug Use and Misuse

Problem Statement

Marijuana is the most widely used illegal drug in the United States. In 2012, more than 111 million Americans 12 years or older (nearly 43% of this population) admitted to having tried marijuana in their lifetime, and almost 19 million had used it in the preceding month.[1,2] More than half of US states and the District of Columbia currently provide legal protections for patients whose doctors recommend the medical use of marijuana. After voters in Colorado and Washington elected to legalize marijuana, these states began to establish regulatory schemes for its cultivation, distribution, and retail sale to those 21 years of age and older. Under these and other regulatory proposals,

marijuana would be regulated in a manner similar to alcohol, with age limits, licensing controls, and other regulatory and public health mechanisms. The federal government decided to not challenge state laws legalizing commercial marijuana as long as states maintain strict rules involving sales and distribution. The areas of regulatory emphasis for the federal government include preventing distribution to minors, preventing revenue from being directed to illegal enterprises, stopping drugged driving, ensuring that marijuana does not cross to states where it is illegal, preventing marijuana activity from being used as a cover for other illegal drug activity, and stopping marijuana from being grown on public land.[3] While the decision to not challenge state adoption of commercial marijuana was an executive branch decision, the recent change in the political control of Congress is unlikely to alter the federal government’s stance. Since Washington and Colorado became the first states to legalize marijuana, other states have considered commercial legalization of the drug, with legislative proposals in Oklahoma, Maryland, Massachusetts, New York, New Jersey, Hawaii, New Hampshire, New Mexico, Pennsylvania, and Vermont and voter initiative efforts in Alaska, California, Missouri, Rhode Island, and Oregon.[4]

With the onset of commercial legalization of marijuana, several questions arise: How will access and availability to adolescents be prevented? How will the impact on vulnerable populations be addressed? What types of quality and informational controls will protect consumers? How will unwanted exposures and driving impairment be handled?

Increased availability: The national Monitoring the Future study has consistently shown that roughly 80% of 12th graders, 70% of 10th graders, and 40% of 8th graders in the United States report that marijuana is either “fairly easy” or “very easy” to obtain.[5–7] Concern exists that commercial legalization will increase the availability of marijuana to adolescents. The density of marijuana retailers is also an issue that needs to be addressed by regulation. If retailers congregate in a few locations, the populations in those areas will be more exposed to use, misuse, and abuse of marijuana. Advertising by retailers will also need to be examined, especially in light of studies revealing that alcohol and tobacco advertising is more prevalent in communities of color and areas of lower income.[8]

Passive exposures: As with the smoking of tobacco, passive exposure to marijuana smoke among children, tenants of multiunit housing developments, and nonsmokers is a concern. Protection for workers who cultivate commercial marijuana is also a concern since they may be exposed to pesticides, fertilizers, and other unhealthy adulterants.
For example, a group of workers at a medical marijuana cultivator in Maine filed a complaint with the National Labor Relations Board because of the cultivator’s use of pesticides and the workers’ exposure to mold.[9]

Quality control and consumer protection: Because marijuana remains illicit, there are no mechanisms for its production to be monitored, its potency and quality to be

standardized and tested, or its labeling for potential health effects before being sold. Research has shown that potency can vary widely depending on the strain of marijuana and that the drug can be contaminated by fungi and bacteria, heavy metals, pesticides, growth enhancers, and substances (e.g., glass beads) that are intended to increase its weight or give the appearance of a higher potency.[10] A failure to provide accurate and credible information about marijuana’s potency and quality can lead to consumer harm.

Motor vehicle safety: The “evidence of cannabis’s culpability in on-road driving accidents and injury is far less robust, with some reviews acknowledging an association between cannabis consumption and an increased risk of motor vehicle crashes while others have not.”[11] Evidence does show that marijuana can “increase driving reaction times, impair time and distance estimation, and decrease motor coordination for up to three hours after dosage impairment.”[12] One “meta-analysis of studies examining acute cannabis consumption and motor vehicle collisions [revealed] a near doubling of risk of a driver being involved in a motor vehicle collision resulting in serious injury or death.”[13] An examination of data from the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System showed that “detection of cannabis in drugged drivers [involved in fatal motor vehicle crashes] increased from 28.8% in 1993 to 36.9% in 2010.”[12] During the same period, detection of cocaine fell from 20.6% to 9.8%, while detection of prescription drugs increased from 42.2% to 46.5%.[12] However, the researchers were unable to show causality between marijuana or other drug use and involvement in fatal vehicle crashes.[12] As with other substances and products that impair the operation of motor vehicles, the issue of commercial marijuana use and motor vehicle safety will need to be addressed through federal, state, and local regulatory schemes.

Health effects: The health effects of smoking marijuana are not fully understood. A recent study published in the Journal of the American Medical Association investigated the association between marijuana use and lung function in a cohort of more than 5,000 US adults over a period of 20 years; the study’s results suggested that “occasional use of marijuana…may not be associated with adverse consequences on pulmonary function.”[14] However, marijuana, like tobacco, contains toxic gases and other substances that can cause harm to the pulmonary system.[15] A recent review published in the New England Journal of Medicine documented the effects of long-term or heavy marijuana use, including addiction for about 9% of all regular users, altered brain development and cognitive impairment among adolescent users, chronic bronchitis symptoms, and an increased risk of chronic psychosis disorders among those who are predisposed to such orders. Short-term effects include short-term memory impairment, impaired motor control, altered judgment, and, for some, paranoia and psychosis with high doses.[16]

Strategies to Address the Problem
Jurisdictions that legalize or consider the legalization of commercial marijuana should

develop, adopt, monitor, and evaluate regulatory schemes for marijuana production, sale, and use that protect and promote public health. Regulation of commercial marijuana can have positive effects on public health. For example, evidence from the Netherlands—which has adopted a de facto legalization policy regarding retail sales and regulatory guidelines that include limits on the amount a person can buy in a day, a ban on advertisements, and a prohibition on sales to individuals under 18 years of age—indicates that the Dutch use marijuana at lower rates than some other European countries, do not escalate early use relative to other countries in Europe and the United States, and do not use marijuana as a gateway drug.[17]

A strict, rigorous regulatory response to commercial sales of marijuana should focus on access to and availability of the drug among adolescents, informing and protecting consumers, and protecting third parties and vulnerable populations from the potential consequences of marijuana use (e.g., passive exposure and impaired driving).
Regulatory interventions might include but should not be limited to age restrictions; taxation; time and date limitations for sales; potency and quality standardization, testing, and monitoring; advertising and packaging restrictions; place of use restrictions; extension of liability for injury to retailers; labor protections; and continued monitoring and evaluation of regulatory interventions. Many of these interventions are used to control alcohol and tobacco use and could also be used to control the use, misuse, and abuse of commercial marijuana.

Age restrictions: Age restrictions and enhanced enforcement of age restrictions can be used to limit the use of marijuana by adolescents, just as they are used to control tobacco use and alcohol use among adolescents, which have declined significantly over the past several years. According to the Monitoring the Future study, daily use of cigarettes by 12th graders decreased from 26.9% in 1975 to 8.5% in 2013, while the 30- day prevalence of use of alcohol by 12th graders decreased from 54% in 1991 to 39.2% in 2013.[18,19] Studies and estimates show the impact of minimum legal drinking ages (MLDAs) for alcohol and minimum legal purchase ages (MLPAs) for tobacco on alcohol- related motor vehicle crashes and the prevalence of adolescent smoking. According to estimates from a 2001 systematic review of interventions designed to reduce alcohol- impaired driving, fatal and nonfatal vehicle crashes increase by 10% with lower MLDAs and decrease by 16% with higher MLDAs (i.e., age 21).[20] In another study, the researchers concluded that raising the MLPA in the United States from 18 to 21 years would reduce the prevalence of smoking among 15- to 17-year-olds to 7.5% after 75 years as a result of delayed smoking initiation, removal of social sources of cigarettes (i.e., friends who are 18 to 20 years old), and better recognition by retailers of adolescent purchasers (i.e., it would be easier for retailers to distinguish between a 16- year-old and a 21-year-old than a 16-year-old and an 18-year-old).[21] Maintaining retailer compliance with MLDA laws through enhanced enforcement of these laws against retailers and underage purchasers also reduces access to alcohol among minors.[22]

Taxation: Taxing commercial marijuana to price adolescents out of the market may also prevent many adolescents from using marijuana. Increasing the price of cigarettes through taxes can cause adolescents to stop smoking.[23] One study of state tobacco taxes showed that every $1.00 in increased state tax could potentially result in a 5.9% decrease in past-month smoking and a 4.1% decrease in frequent smoking among US high school youth.[24] Also, according to a meta-analysis of 112 studies on alcohol, higher taxes tend to reduce alcohol consumption among adult and teenage social drinkers as well as problem drinkers.[25]

Time and date restrictions: Marijuana use, misuse, and abuse can also be addressed by instituting time and place restrictions on commercial sales and imposing liability risks on commercial marijuana retailers. For example, alcohol control measures that limit the number of days and hours that alcohol can be sold as well as restricting the location and density of alcohol outlets can help decrease alcohol consumption and consumption- related harms.[26–29]

Retailer liability: Dram shop liability laws are effective in reducing and preventing harms associated with alcohol consumption by deterring overservice of alcohol to customers.[30] These laws allow licensed establishments such as restaurants, bars, and liquor stores that sell or serve alcohol to individuals to be held liable for any injuries or deaths that result from a customer’s intoxication. Although litigation involving dram shops can be expensive and inefficient,[31] extending dram shop liability to marijuana retailers may serve as a way to reduce marijuana use, misuse, and abuse.

Standardizing, testing, and monitoring potency and quality: Regulatory frameworks can also be developed to standardize and determine the quality of commercial marijuana to protect consumers from adulterants (e.g., pesticides, mold, mildew, toxins) and inform them of the product’s potency. Similar requirements are in already in place for alcohol sales. For example, federal law and agency rules require alcohol beverage labels to include the brand name, the class and type of alcohol, the alcoholic content, the name and address of the bottler or packer, the country of origin, and a disclosure of additives and sulfites.[30,32,33] Also, the Family Smoking Prevention and Tobacco Control Act allows the US Food and Drug Administration to set standards for nicotine levels in tobacco products.[34]

Warning labels: Marijuana products could also be labeled to warn consumers of health risks. Tobacco products in the United States must display the surgeon general’s warning about the risk of tobacco use. Labels on alcohol must also contain a specific warning about health risks.[35,36] While research has shown little effect on drinking behavior from alcohol labels, tobacco labeling’s impact on consumer attitudes and behaviors is more apparent.[37]

Advertising restrictions: Advertising restrictions can also be used to control marijuana use and protect consumers, just as they are used for alcohol and tobacco. Restricting advertisements can have profound health effects. For example, according to one study, a complete ban on alcohol advertising would result in 7,609 fewer deaths and a 16.4% drop in alcohol-related life-years lost.[38] Current First Amendment protections for corporate speech would likely prevent advertising regulations aimed at adult consumers but would allow restrictions on advertising aimed at adolescents and children.[39] Consideration should also be given to the impact advertising may have on communities of color and/or groups of low socioeconomic status.

Impaired driving: Concerns about driving while impaired by marijuana can be addressed with current laws against driving under the influence or by amending those laws to include marijuana impairment. One option may be to increase “penalties for drugged driving in localities with greater accessibility to [marijuana].”[12] Some states have adopted per se drugged driving laws, meaning that any trace of illicit drugs in a driver is considered a drugged driving violation. While such a standard may be useful when prosecuting a drugged driving case, a recent study questions the effectiveness of per se drugged driving laws in lowering traffic fatality rates.[40] Research should be conducted on reliable and valid methods of determining marijuana impairment. Also, similar to the case with alcohol, education on marijuana use and driving should be available.

Passive exposure: Regulatory policies should be developed to limit passive exposures to marijuana. Passive exposures can also be addressed through prohibiting use of the drug in public locations and in the presence of minor children, as well as through restricting its use in multi-unit housing to avoid smoke drifting to neighboring units. In addition, states and localities can amend existing smoke-free laws to include marijuana smoke. Also, federal and state laws regulating the use of pesticides and fertilizers and the passive exposure of workers to such chemicals and other unsafe working conditions need to be extended to individuals working for marijuana cultivators.

Monitoring and evaluating regulatory schemes: Since the regulatory scheme for commercially legal marijuana is untested and involves many unknown elements, a final strategy is to monitor and evaluate the public health impact of regulations. Regulations can then be modified according to evidence regarding their effects on public health.

Opposing Arguments/Evidence
Arguments opposing public health regulations often center on personal autonomy, the freedom to do business, and economic costs to consumers and businesses. Those who oppose regulating passive exposure to marijuana smoke and marijuana-impaired driving will focus on the lost autonomy of people who use marijuana in the presence of children, use the drug in multi-unit housing complexes, and drive after becoming impaired. Rates of alcohol-related motor vehicle fatalities have decreased since 1982, with some of the credit being given to laws aimed at deterring intoxicated driving.[41]

Laws aimed at deterring marijuana-impaired driving could lead to similar trends. Also, smoke-free laws are associated with lower risks of smoking-related cardiac, cerebrovascular, and respiratory diseases.[42]

Advertising and information restrictions along with required disclosures such as warning labels may be viewed as government interference with the protected right to free speech. However, these restrictions are designed to counter statements and messages that encourage harmful behavior, and, as noted above, a ban on alcohol advertising would result in fewer deaths and alcohol-related life-years lost.[38]

Age restrictions limit the accessibility of marijuana to adolescents, and opponents view these restrictions as an infringement upon the autonomy of youth. Restrictions that are set at 21 years of age may also be opposed because they limit access among adults (i.e., people 18 to 20 years of age). As noted, however, age restrictions could reduce health risks associated with alcohol and tobacco use among adolescents. For example, age restrictions on the use of alcohol and tobacco have been shown to decrease the prevalence of alcohol-related motor vehicle crashes and the prevalence of adolescent smoking.[21,22] These same regulatory measures could apply to marijuana.

Regulation of commercial marijuana’s quality and potency and limitations on times and dates of marijuana sales could be perceived as impairing business interests and leading to increased consumer costs. However, these actions could provide protections to consumers and limit the accessibility of marijuana among adolescents. Today, many types of commercial products are subject to content and disclosure requirements to protect consumers and allow them to make informed decisions. For example, the Family Smoking Prevention and Tobacco Control Act requires tobacco companies to disclose the contents of cigarettes and allows the Food and Drug Administration to determine nicotine levels.[34]

Regulatory opponents will argue that protecting marijuana cultivation workers from dangerous working conditions by regulating pesticide exposures interferes with business activities and interests and increases consumer costs. However, popular organophosphate pesticides are associated with “nausea, dizziness, vomiting, headaches, abdominal pain, and skin and eye problems [as well as] chronic health problems or health symptoms such as respiratory problems, memory disorders, dermatologic conditions, cancer, depression, neurologic deficits, miscarriages, and birth defects.” It is clear that limiting workers’ exposure to harmful pesticides would create safer and healthier work environments.[43]

Finally, those who oppose regulating commercial marijuana through taxation may contend that taxation adds to consumer costs and interferes with business interests. Evidence in the realm of alcohol control demonstrates that taxation reduces the use of alcohol. For example, a systematic review of 112 studies examining the association

between taxes on and prices of alcohol and alcohol sales and use revealed significant relationships between taxes or prices and overall consumption and heavy drinking.[25]

Despite any opposition to the regulation of legalized marijuana, there is strong evidence from the areas of tobacco control and alcohol control that a regulatory scheme for commercial marijuana would have an impact on marijuana accessibility and use.

Action Steps

APHA believes that, in jurisdictions that legalize the commercial sale of marijuana, the preponderance of evidence supports regulating marijuana as an important public health policy.

Therefore, APHA
• Urges federal, state, and local governments to:
o Regulate commercially legalized marijuana as a public health priority and develop, adopt, monitor, and evaluate regulatory controls for commercially legalized marijuana that reduce and prevent the drug’s use, misuse, and abuse.
o Support and fund research into the health effects of marijuana use, misuse, and abuse.
o Coordinate their efforts to effectively regulate commercial marijuana in an effort to reduce and prevent its use, misuse, and abuse.
o Regulate commercially legalized marijuana in partnership with state and local health departments, including the provision of resources to local and state public health agencies for the purpose of reducing and preventing marijuana’s use, misuse, and abuse.
o Tax commercial marijuana and dedicate the revenue to funding prevention, treatment, research, and regulatory frameworks to offset the costs and effects incurred through the increased availability of marijuana and other products containing tetrahydrocannabinol (THC).
o Develop and fund standards for the quality and potency of commercial marijuana and ensure safe working conditions for those cultivate marijuana.
o Exercise their authority to limit and restrict the advertising of commercial marijuana and develop required written disclosures to protect commercial marijuana consumers.
o Develop standards for determining impaired operation of motor vehicles.
o Ensure the development and availability of linguistically competent educational and informational materials for individuals with limited English proficiency.
• Calls on the federal and state governments and all federal and state agencies involved in research, policies, and programs related to marijuana to develop an evidence base regarding the public health benefits of regulating commercial marijuana.
• Calls for states that may consider legalizing commercial marijuana to refer to evidence-based regulatory controls for legalized marijuana and review and assess the regulatory frameworks of those states that have already legalized the drug.

References
1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Table 1.24A: Marijuana use in lifetime, past year, and past month among persons aged 12 or older, by demographic characteristics: numbers in thousands, 2011 and 2012. Available at: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH- DetTabsSect1peTabs1to46-2012.htm#Tab1.24A. Accessed January 16, 2015.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Table 1.24B: Marijuana use in lifetime, past year, and past month among persons aged 12 or older, by demographic characteristics: percentages, 2011 and 2012. Available at: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH- DetTabsSect1peTabs1to46-2012.htm#Tab1.24B. Accessed January 16, 2015.
3. US Department of Justice. Guidance regarding marijuana enforcement. Available at: http://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf. Accessed January 16, 2015.
4. Mother Jones. Will your state be next to legalize pot? Available at: http://www.motherjones.com/politics/2014/02/pot-marijuana-legalization-map-states. Accessed January 16, 2015.
5. Monitoring the Future. Trends in availability of drugs as perceived by 12th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl14.pdf. Accessed January 16, 2015.
6. Monitoring the Future. Trends in availability of drugs as perceived by 10th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl13.pdf. Accessed January 16, 2015.
7. Monitoring the Future. Trends in availability of drugs as perceived by 8th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl12.pdf. Accessed January 16, 2015.
8. Barbeau EM, Wolin KY, Naumova EN, Balbach E. Tobacco advertising in communities: associations with race and class. Prev Med. 2005;40:16–22.
9. Quimby B. Pot dispensary workers rally in Portland. Available at: http://www.pressherald.com/2013/04/06/medical-pot-workers-protest-in-portland/. Accessed January 16, 2015.
10. McLaren J, Swift W, Dillon P, Allsop S. Cannabis potency and contamination: a review of the literature. Addiction. 2008;103:1100–1109.
11. Armentano P. Cannabis and psychomotor performance: a rational review of the evidence and implications for public policy. Drug Test Anal. 2013;5:52–56.
12. Wilson FA, Stimpson JP, Pagan JA. Fatal crashes from drivers testing positive for drugs in the U.S., 1993–2010. Public Health Rep. 2014;129:342–350.
13. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536.
14. Pletcher MJ, Vittinghoff E, Kalhan R, Richman J, Safford M, Sidney S, Lin F,

Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012;307:173–181.
15. Tashkin DP. Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med. 2001;7:43–61.
16. Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. New Engl J Med. 2014;370:2219–2227.
17. MacCoun RJ. What can we learn from the Dutch cannabis coffeeshop system? Addiction. 2011;106:1899–1910.
18. Monitoring the Future. Trends in prevalence of use of cigarettes in grades 8, 10, and
12. Available at: http://www.monitoringthefuture.org/data/13data/13tobtbl1.pdf. Accessed January 16, 2015.
19. Monitoring the Future. Trends in 30-day prevalence of use of various drugs in grades 8, 10, and 12. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl3.pdf. Accessed January 16, 2015.
20. Shults RA, Elder RW, Sleet DA, et al. Reviews of evidence regarding interventions to reduce alcohol-impaired driving. Am J Prev Med. 2001;21:66–88.
21. Ahmad S, Billimek J. Limiting youth access to tobacco: comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the United States. Health Policy. 2007;80:378–391.
22. Elder RW, Lawrence B, Janes G, et al. Enhanced enforcement of laws prohibiting sale of alcohol to minors: systematic review of effectiveness for reducing sales and underage drinking. Transp Res E-Circular. 2007;E-C123:181–188.
23. Ding A. Youth are more sensitive to price changes in cigarettes than adults. Yale J Biol Med. 2003;76:115–124.
24. Carpenter C, Cook P. Cigarette taxes and youth smoking: new evidence from national, state, and local youth risk behavior surveys. J Health Econ. 2008;27:287–299.
25. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction. 2009;104:179–190.
26. Middleton JC, Hahn RA, Kuzara JL, et al. Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms. Am J Prev Med. 2010;39:575–589.
27. Hahn RA, Kuzara JL, Elder R, et al. Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. Am J Prev Med. 2010;39:590–604.
28. Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003;93:1404–1408.
29. Campbell CA, Hahn RA, Elder R, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. Am J Prev Med. 2009;37:556–569.
30. Federal Alcohol Administration Act, 27 USC §§ 201 et seq.
31. Rammohan V, Hahn RA, Elder R, et al. Effects of dram shop liability and enhanced

overservice law enforcement initiatives on excessive alcohol consumption and related harms: two Community Guide systematic reviews. Am J Prev Med. 2011;41:334–343.
32. Labeling and Advertising of Malt Beverages, 27 CFR Part 7.
33. Labeling and Advertising of Distilled Spirits, 27 CFR Part 5.
34. US Food and Drug Administration. Overview of the Family Smoking Prevention and Tobacco Control Act. Available at: http://www.fda.gov/downloads/TobaccoProducts/GuidanceComplianceRegulatoryInform ation/UCM336940.pdf. Accessed January 16, 2015.
35. Alcoholic Beverage Labeling Act of 1988, 27 USC §§ 213 et seq.
36. Alcoholic Beverage Health Warning Statement, 27 CFR Part 16.
37. Wilkinson C, Room R. Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug Alcohol Rev. 2009;28:426–435.
38. Hollingworth W, Ebel BE, McCarty CA, et al. Prevention of deaths from harmful drinking in the United States: the potential effects of tax increases and advertising bans on young drinkers. J Stud Alcohol. 2006;67:300–308.
39. Lorillard v. Reilly, 533 US 525 (2001).
40. Anderson DM, Rees DI. Per se drugged driving laws and traffic fatalities. Available at: http://ssrn.com/abstract=2189786. Accessed January 16, 2015.
41. US Department of Transportation, National Highway Traffic Safety Administration. Statistical analysis of alcohol-related driving trends, 1982–2005. Available at: http://www-nrd.nhtsa.dot.gov/Pubs/810942.pdf. Accessed January 16, 2015.
42. Tan CE, Glantz SA. Association between smokefree legislation and hospitalizations for cardiac, cerebrovascular and respiratory diseases: a meta-analysis. Circulation. 2012;126:2177–2183.
43. McCauley LA, Anger WK, Keifer M, Langley R, Robson MG, Rohlman D. Studying health outcomes in farmworker populations exposed to pesticides. Environ Health Perspect. 2006;116:953–960.

164~2016_(1)APHA Regulating Marijuana(public safety, marijuana)

Megan Resolutions

2017- Restrict Tobacco Sales to Persons 21 and Over in Arizona

Resolution to Restrict Tobacco Sales to Persons 21 and Over in Arizona

Background and Summary

Tobacco use poses serious public health problems. Over the past 50 years, tobacco control in the United States has led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, and more than 40 million Americans still smoke.
Nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age. The parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices (electronic cigarettes).

In 2009, the Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration broad authorities over tobacco products but prohibited the FDA from establishing a nationwide minimum age to buy tobacco above 18. The law directed the FDA to convene a panel of experts to conduct a study on the public health implications of raising the minimum age to purchase tobacco products and electronic nicotine delivery devices.
At FDA’s request, the Institute of Medicine published a report entitled Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. The report literature on tobacco use initiation, developmental biology and psychology, and tobacco policy and predicted the likely public health outcomes of raising the minimum legal age for tobacco products.
The report concluded that: “… Increasing the minimum age of legal access to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan”. The report also quantifies the immediate and long term accompanying public health outcome improvements. The report concludes that there would be a 12% decrease in the prevalence of smoking among the cohort if the minimum age of purchase were moved to 21 years old from the current 18.

The analysis concluded that raising the minimum age to 21 will “… likely immediately improve the health of adolescents and young adults by reducing the number of those with adverse physiological effects such as increased inflammation and impaired immune functioning caused by smoking, as these could potentially lead to negative health consequences, including increased hospitalizations and lessened capacity to heal wounds. Adverse maternal, fetal, and infant outcomes—including preterm births, low birth weight, and sudden infant death—will also probably decrease due to reduced tobacco exposure in mothers and infants. Raising the minimum legal age will also lessen the population’s exposure to secondhand smoke and its associated health effects, both now and in the future.”

Over time, the report concludes that raising the minimum legal age for buying tobacco will likely lead to substantial reductions in smoking-­‐related mortality observed for 30 years. If the minimum legal age to purchase tobacco were raised to 21 nationally, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Several jurisdictions have already raised the minimum legal age to buy tobacco. New York City raised the age to 21, in 2013. Hawaii did it in 2015, becoming the first state to go to the 21 (the Hawaii Public Health Association was instrumental in that effort). California followed suit in 2016, and New Jersey and Oregon did so in 2017. In Arizona, Douglas and Cottonwood have passed local ordinances restricting the sale of tobacco to people 21 and older.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that tobacco use poses serious public health problems; and
Whereas, nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age; and

Whereas, the parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices; and

Whereas, increasing the minimum age of legal access to tobacco products and electronic nicotine delivery devices will prevent or delay initiation of tobacco use by adolescents and young adults and improve the health of Americans across the lifespan; and

Whereas, if the minimum legal age were raised to 21 in Arizona, there would be approximately 4,460 fewer premature deaths, 1,000 fewer deaths from lung cancer, and 840,000 fewer years of life lost for those born between 2000 and 2019;

Therefore, be it resolved that the Arizona Public Health Association supports raising the minimum legal age to purchase tobacco and electronic nicotine delivery devices in Arizona to 21 years old.

165~2017_(1) Tobacco 21 (tobacco)

Megan Resolutions

2017- Texting and Driving

Resolution to Restrict Texting While Driving in Arizona

Background and Summary

Texting has become a social norm in recent years because of the popularity of smart phones. The scientific literature on the dangers of driving while sending a text message from a mobile phone, or driving while texting is growing. A study at the Accident Research Center1 provided strong evidence that retrieving and sending text messages has a detrimental effect on a number of safety-­‐critical driving measures including detecting and responding correctly to road signs, detecting hazards, time spent with eyes off the road.
Several studies have linked texting while driving to be the cause of life-­‐threatening accidents due to driver distraction. A recent National Traffic Highway Safety Administration NHTSA report found that teens have the highest prevalence of cell phone use while driving and rank at the top of the list for being distracted at the time of a fatal crash.

For many years, Arizona has been one of only 3 states that did not restrict the use of smart phones while driving. During the 2017 Arizona Legislative Session SB 1080 was passed and signed which restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18). Using the phone in an emergency is still allowed and citations can only be issued if the driver committed another violation. Prior to this, the only other limitation in AZ to this kind of distraction applied to school bus drivers.

A study of US crash data called Driver distraction and crashes: An assessment of crash databases and review of the literature found that driver distraction (among all ages) is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%.

Arizona’s new law only restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18), yet evidence suggests that texting while driving creates unnecessary and dangerous driver distractions that cause motor vehicle accidents that result in injuries and deaths.

1. Hosking, S.G., Young, K.L., & Regan, M.A. (2006). “The effects of text messaging on young novice driver performance” (PDF). Retrieved 16 August 2014.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that texting has become a social norm in recent years because of the popularity of smart phones and studies have linked texting while driving to be the cause of life-­‐threatening accidents due to driver distraction; and

Whereas, a recent National Traffic Highway Safety Administration NHTSA report found that smart phone use while driving is linked with distracted at the time of a fatal crash; and

Whereas, a study of US crash data found that driver distraction is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would prohibit texting and other smart phone use among all drivers.

166~2017_(1) Texting and Driving(public safety)

Megan Resolutions

2017- Physical Activity in Schools

Resolution to Require 50 Minutes of Unstructured Recess in Arizona Elementary Schools (K-­‐5)

Background and Summary

The percentage of children with obesity in the United States has more than tripled since the 1970s. Today, about one in five school-­‐aged children is obese. Childhood obesity has immediate and long-­‐term impacts on physical, social, and emotional health. For example:
• Children with obesity are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease.
• Children with obesity are bullied and teased more than their normal weight peers, and are more likely to suffer from social isolation, depression, and lower self-­‐esteem.
• Childhood obesity also is associated with having obesity as an adult, which is linked to serious conditions and diseases such as heart disease, type 2 diabetes, metabolic syndrome, and several types of cancer.

Children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese. Schools provide a unique venue for youth to meet the activity recommendations. However, schools have been facing increasing challenges in allocating time for physical education and physical activity.
There is a growing body of research focused on the association between school-­‐based physical activity, and academic performance among school-­‐aged youth. A recent report from the CDC’s entitled The Association Between School-­‐based Physical Activity, Including Physical Education, and Academic Performance examined the association between school-­‐based physical activity, including physical education, and academic performance, including indicators of cognitive skills and attitudes, academic behaviors.
The CDC found that “… across all 50 studies that they examined there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Measures of cognitive skills and attitudes were used most frequently.”

During the 2017 Arizona Legislative Session, House Bill 2082 was introduced which would have required all schools to have 50 minutes of recess per day from K through 5th grade. The Bill was passed by the House of Representatives but stalled in the State Senate.

Data from the CDC report provides evidence that such a bill, should it become law, would have a positive impact on academic achievement as well as physical activity. The report found that time spent in recess appears to have a positive relationship with children’s attention, concentration, and/or on-­‐task classroom behavior. All eight studies found one or more positive associations between recess and indicators of cognitive skills, attitudes, and academic behavior; none of the studies found negative associations between recess time and academic achievement.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that childhood obesity continues to pose an increasing public health threat; and

Whereas, children that are obese are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease; and

Whereas, children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese; and

Whereas, schools provide a unique venue for youth to meet the activity recommendations; and

Whereas, there is a growing body of research focused on the association between school-­‐based physical activity, and academic performance among school-­‐aged youth; and

Whereas, recess has a positive relationship with children’s attention, concentration, and on-­‐task classroom behavior;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would require all schools to have 50 minutes of recess per day from K through 5th grade and prohibit the withholding of recess for academic or behavioral reasons.

167~2017_(1) Conference Resolution Physical Activity in School(preventative health, education)

Megan Resolutions, Uncategorized

2018- Prevent Firearm Violence in Schools

Arizona Public Health Association (AzPHA) Resolution: Preventing Firearm Violence in Schools

Effective Date: October 3, 2018

Background and Summary
Since the 1999 massacre at Columbine High School, some 208,000 children at 212 schools have experienced gun violence on school campuses. School-based rampage shootings took 13 lives at Columbine High School, 26 lives at Sandy Hook Elementary School, 17 lives at Marjory Stoneman Douglas High School, and most recently 10 lives at the Santa Fe High School.
Aside from the loss of life and the pain these events inflict on survivors and the community, there are monetary costs to the community and to schools. Those costs include funerals, trauma counseling, reconstructing or refurbishing buildings, and investing in new security measures. To the broader
community, there’s a growing concern about the safety of children and what steps can be taken to reduce the risk and prevent violence. The toxic stress of exposure to gun violence affects the developing brain, causing damaging effects for these children across the lifespan.
While these events captured the attention of the media, public, and politicians, they occur in a larger context of gun violence. Gun violence is a leading cause of premature death in the United States. Guns kill more than 38,000 people and cause nearly 85,000 injuries every year. In 2016, 36 children under the age of 18 in Arizona died from firearms. Twenty-nine of the 36 were between the ages of 15-17.

The causes of gun violence are complex and deeply rooted in our culture, which is why we must take a public health approach to keeping our schools and communities safe. This effort should begin with supporting the social and emotional development of children from early childhood. We must place a renewed emphasis on improving research into firearm injuries and violence. Ongoing work must increase to ensure that firearms do not fall into the wrong hands, including preventing access by children. Mental health services must be available to help those who need it most. We need a change in mindset and policy from reaction to prevention.
AzPHA Resolution October 2018
Whereas, the Arizona Public Health Association recognizes growing public concern over issues around gun violence and public safety, especially at schools; and
Whereas, some of the deadliest incidents have happened in the past six years resulting in loss of life and trauma for the surviving victims;
Therefore, be it resolved that the Arizona Public Health Association supports:
Efforts to improve the safety of students in the school environment:
● The creation and evaluation of community- and school-based programs (including coalitions) targeting the prevention of firearm injuries including homicides and suicides.

● A national requirement for all schools to assess school climate and maintain physically and emotionally safe conditions that protect all students and adults from bullying, discrimination, harassment, and assault.
● Ongoing training and support for school-based, multi-disciplinary threat management teams that utilize behavior and facts to determine the credibility of threats of violence and evidence- based strategies to manage situations of potential violence.
● Reform of school discipline to reduce exclusionary practices and foster positive social, behavioral, emotional, and academic success for students.
● Funding for Mental Health First Aid and Youth Mental Health First Aid training in Arizona schools and communities. The funding for this program needs to be ongoing to reach new teachers and administrators every year.
● Adequate staffing for school-based counseling services for the early identification of student behavioral health concerns with referral for treatment as necessary .
● Provision of Suicide Prevention Training in schools because, as the American Foundation for Suicide Prevention reports, suicide is the leading cause of death for children ages 10-14 and the second leading cause of death for those aged 15-34.

Efforts to improve the safety of students in the community environment:
● Funding to upgrade the Criminal Background Check Database to ensure that information is
current and require its use for sales including those at “gun shows”.
● Implement a process such as a Domestic Violence Order of Protection (including judicial review) in Arizona wherein a gun would be removed from individuals identified as dangerous and a potential threat to individuals or the community. As with the Order of Protection, these determinations should be based on the behavior of the individual, not on a diagnosis of mental health or substance use disorder.
● Raising the age for purchasing a firearm to 21.
● Banning the purchase of semi-automatic firearms with large magazines of ammunition designed and configured for rapid fire and use in combat.

Efforts to improve the body of evidence to improve overall student safety:
● The creation and evaluation of comprehensive national, state, and local data collection systems to facilitate research on the prevention of firearm fatalities and injuries and the movement of firearms within the population, particularly youth.
● Urging schools of public health to offer curricula in violence prevention that includes the epidemiology of firearm-related violence, intervention design and evaluation.
● Urging schools of medicine and nursing and other health care professions to educate future health care providers about interpersonal violence, the role of firearms in violence, and how to intervene with patients to recognize risk factors and prevent the effects of v

168~2018_(1)Prevent Firearm Violence in Schools(education, violence)

Megan Resolutions

2018- Continuing Support of Title X – the Nation’s Family Planning Program

Arizona Public Health Association (AzPHA) Resolution: Continuing Support of Title X – the Nation’s Family Planning Program

Effective Date: October 3, 2018

Background and Summary
The Title X program is the nation’s only federal grant program dedicated solely to providing low-income, uninsured or underinsured individuals with comprehensive, medically accurate, reproductive healthcare and related preventive healthcare services. Title X healthcare services include contraception, cancer screening, and STD testing and treatment, annual health exams, counseling, education and more. Often times it is the only regular health care many women receive.

In Arizona a 40-year old private not for profit, the Arizona Family Health Partnership (AFHP), has been awarded the Title X grant since 1983 and continues to provide high quality, medically accurate, and non- judgmental care through a network of delegate agencies.

● In 2017, AFHP served more than 36,000 women, men and teens who received high quality family planning care and information including healthcare services, including contraception, STI testing, cancer screenings, and education, among other services;
● Additionally, Title X-funded family planning healthcare services prevented an estimated 6,070 unintended pregnancies;
● Saving the state $50 million in related healthcare expenses;
● Those 6,070 unintended pregnancies would have resulted in an estimated 2,860 unplanned births, 2,050 abortions, and 1,160 miscarriages, according to the Guttmacher Institute’s Health Benefits and Cost Savings Tool; and
● STD services prevented an estimated 570 cases of chlamydia and gonorrhea, which could have resulted in 60 cases of pelvic inflammatory disease, which can cause infertility.

AzPHA Resolution July 2018

Whereas, Family Planning is one of the 10 greatest public health achievements of the 20th century1; and
Whereas, medically accurate information and comprehensive care is imperative for a strong, trusted provider patient relationship; and

1 CDC: Ten Great Public Health Achievements — United States, 1900-1999

Whereas, Title X has contributed to a 30-year low in unintended pregnancies, a historic low in teen pregnancies and an absolute reduction in abortions by providing access to reproductive health care; and

Whereas, a full range of FDA approved birth control methods should be available to all women and men; and

Whereas, non-directive pregnancy options counseling and referral is essential for informed consent and is the standard of care endorsed by American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics and American Academy of Physician Assistants2; and

Whereas, comprehensive, confidential and medically accurate information is the national standard of care; and

Whereas, high-quality medical care relies on honest, unfiltered conversations between patients and their physicians3; and

Whereas, Policy decisions about women’s health must be firmly rooted in science, and increase access to safe, effective and timely care4; and

Whereas abstinence-only-until-marriage message – especially (but not only) directed at adolescents is a marked shift from evidenced-informed and patient-centered approach5; and

Whereas STD cases of chlamydia, gonorrhea and syphilis are on the rise in Arizona; and Whereas, federal law specifically prohibits Title X dollars from being used for abortions; and
Whereas, eight in 10 (80%) of the public say federal funding for family planning and other reproductive health services to low-income women is “very important” or “somewhat important” to them6; and

Therefore, be it resolved that the Arizona Public Health Association supports the Title X program and rules as they are currently enacted, will advocate for the continuation of the Title X program as it is currently enacted and will educate its members and the public regarding the importance and comprehensive nature of the Title X services provided for the health of Arizonans.

2 Guttmacher: Unbiased Information on and Referral for All Pregnancy Options Are Essential to Informed Consent in Reproductive Health Care
3 AMA Objects to attack on family planning services
4 ACOG: America’s Women’s Health Providers Oppose Efforts to Exclude Qualified Providers from Federally-Funded Programs
5 Guttmacher: The Trump Administration’s Irresponsible Use of Research in Pushing Its Abstinence-Only Agenda into Title X

6 Kaiser Family Foundation Poll: Two-thirds of Americans Don’t Want the Supreme Court to Overturn Roe

169~2018_(1) AzPHA Title X Resolution(reproduceive health, education)

Megan Resolutions, Uncategorized

2018- Universal Access to Contraceptive

Arizona Public Health Association (AzPHA)
Resolution: Universal Access to Contraception

Effective Date: October 3, 2018
Based on APHA Approved Policy Number: 20153 on November 3, 2015

Abstract
This resolution supports the universal right to contraception access in Arizona (AZ) and the United States. Contraceptive use confers significant health benefits through reductions in unwanted and high- risk pregnancies, maternal and infant morbidity and mortality, unsafe abortions, and medical therapy. These benefits are so significant that universal access to contraception is accepted internationally as an essential human right.

Frequent barriers to access include financial, geographical, and sociocultural factors. Considering these barriers, as well as contraceptive failure rates, this policy supports the universal human right to voluntary, informed, affordable access to the full range of modern contraceptive methods, including emergency contraception. In addition, it urges health providers and health funding systems to ensure the right to contraception through services including comprehensive evidence-based counseling, language translation, and referrals as needed. Finally, it urges governments and donor agencies to support contraceptive technology research as well as strategies to facilitate use and acceptability.

Relationship to Existing AzPHA Resolutions
Through its resolutions, policies and advocacy, AzPHA has long supported the right to contraception access. However, AzPHA has no up-to-date comprehensive resolution addressing the necessity and public health benefits of universal, informed, and voluntary access to the full range of contraceptive methods. Previous resolutions provide basic foundations for this proposed contraception resolution and many are outdated.

The intent of this resolution is to update AzPHA’s long standing position on access to contraception and
when adopted, will replace previously approved topic-related resolutions and serve as the basis for
AzPHA’s education and advocacy efforts on this topic. The following resolutions are being recommended for updating and replacement by this new universal access to contraception resolution.

Resolution Title Date
Support for Local Birth Control Clinics 1938
Proper Medical Supervision in Birth Control Clinics 1938
Proposed Resolution by APHA on Male Involvement in Family
Planning 1981
Adolescent Access to Comprehensive, Confidential Reproductive
Health Care 2005

At the center of this proposed AzPHA resolution is the fundamental belief in an individual’s right to informed and voluntary choice of contraceptive methods during her or his life cycle for pregnancy prevention, delay of a pregnancy, disease prevention, or medical treatment. This right to contraception includes the right to information on the effectiveness of all methods, as well as their side effects,

reversibility, and other related issues, to enable voluntary and informed contraception choice.[1–4]
Ideally, a person’s literacy or income level or place of residence would not limit informed contraceptive choice.[1,4,5] This comprehensive resolution on universal access to contraception contributes to
AzPHA’s mission to improve public health and achieve equity in health status; it is an essential
component of AzPHA’s priority to ensure rights to health and health care.

Problem Statement
The development of safe, effective contraception is widely considered to be one of the greatest public health achievements of the 20th century.[6] Contraception allows individuals to safely space and limit their pregnancies and reduces unintended pregnancies, unsafe abortions,[7] and maternal morbidity and mortality.[8] Contraception also improves birth outcomes, slows population growth, and improves socioeconomic status.[9–12] Contraception plays a pivotal role in the well-being and health of women and gives individuals control over their sexuality, fertility, and reproduction.

Many contraceptive methods reduce the risk of endometrial and ovarian cancers, are therapeutic agents for menstrual-related disorders, and have other proven health benefits.[12] Evidence has shown definitively that the relative risk associated with use of any tested method of contraception is significantly lower than the risks from pregnancy, childbirth, and unsafe abortion.[13]

Evidence-Based Strategies to Address the Problem
With universal access to contraception, individuals make choices resulting in positive public health outcomes. There is extensive historical and evolving evidence over the past 60 years, both domestically and internationally, supporting many strategies to improve contraception access and use. Studies [14– 17] have shown the success of the following strategies:

● Comprehensive, evidence-based sexuality and contraception education and counseling without bias, discrimination, or coercion;
● A focus on antenatal, childbirth, and postpartum visits as key opportunities to reach clients for family planning services;
● Advocacy and community outreach projects engaging multiple disciplines and including social media, social and community gathering locations, peer-to-peer engagement, behavioral modification programs, condom negotiation training, and group engagement;
● Voluntary and client-centered choices of contraceptive methods;
● Availability of community-based reproductive health services;
● Low- or no-cost provision of contraception and reproductive health services;
● Adequate and accessible referral systems in the case of conscientious objection; and
● Safe and affordable access to emergency contraception and legal abortion.

These strategies have demonstrated higher rates of effective contraception use, lower unintended pregnancy rates, and improved birth spacing. Use of these findings to drive health policies has demonstrated the same results on a larger scale.

Whereas AzPHA Supports Universal Rights to Contraception Access;

The AzPHA urges protection and fulfillment of rights to safe, voluntary, confidential access to the full range of contraceptive methods without barriers, regardless of age, marital status, gender identity, ethnicity, sexual orientation, religious background, socioeconomic status, geography, health status (including chronic disease, especially HIV/AIDS), nationality, immigration status or other demographic characteristics.

Whereas AzPHA Strives to Ensure Universal Access to Evidence-Based Contraceptive Information and Services;

The AzPHA supports comprehensive and evidence-based reproductive health education curricula for doctors, nurses, clinicians, and non-clinicians providing primary health care so that relevant content on all currently available contraceptive methods is routinely integrated into the education of all individuals involved in the delivery of contraceptive services.

The AzPHA urges health systems to address the main barriers to access to contraception in their local/national context, such as legal, financial, and geographical factors; gender-based violence; and sociocultural factors. Also, measures should be taken to ensure implementation of referral systems for contraceptive or abortion services in cases of conscientious objection.

The AzPHA supports the right of all individuals to evidence-based, comprehensive contraceptive counseling and education free from personal bias, including information on risks, benefits, effectiveness, proper usage, alternatives, and adverse effects, accompanied by a comprehensible, culturally/linguistically appropriate informed consent process.

The AzPHA urges that health policies and regulations guarantee universal access to emergency contraception in cases of sexual violence, rape, contraception failure, and other instances of unprotected sexual intercourse.

The AzPHA supports the principle of voluntary and informed choice under all circumstances and opposes practices that coerce or exert undue pressure to use contraception or to use methods unacceptable to the user.

The AzPHA urges governments and organizations to respect, protect, and fulfill sexual and reproductive health and rights, including actions to make modern contraception and safe legal abortion available, accessible, and affordable for all Arizonans.

Whereas AzPHA Advocates to Ensure Adequate Funding of Universal Contraception;

The AzPHA urges that health funders and payers, public and private, cover the cost of all contraceptives that have been shown to be effective in preventing pregnancy or are medically indicated.

The AzPHA advocates adequate government and private funded programs and services aimed at prevention and management of unintended pregnancies (for all women and men, regardless of citizenship status) that include contraceptive methods, access to emergency contraception and legal and safe abortion.

Whereas AzPHA Supports Contraceptive Access through Research and Development;

The AzPHA urges the continued development of contraceptive technology to improve the safety, effectiveness, and acceptability of methods for both men and women. AzPHA further urges new, ongoing, and increased funding (from both public and private sources) to support research designed to address factors enhancing or limiting voluntary and informed contraceptive use in diverse cultural and social settings.

Therefore, be it resolved that the AzPHA supports and advocates for the rights to universal access and delivery of contraception services throughout Arizona, including ongoing comprehensive education, funding, use of evidenced-based information and services, and research efforts for such services.

References

1. United Nations Population Fund and Center for Reproductive Rights. Briefing paper: the right to contraceptive information and services for women and adolescents. Available at: http://www.unfpa.org/resources/rights- contraceptive-information-and-services-women-and-adolescents. Accessed December 15, 2015.

2. Cook RJ, Dickens BM, Fatahalla MF. Reproductive Health and Human Rights: Integrating Medicine, Ethics and Law. Oxford, England: Oxford University Press; 2003.

3. Population Reference Bureau. Contraceptive evidence: questions and answers. Available at: http://www.prb.org/pdf13/contraceptive-evidence-2013.pdf. Accessed December 15, 2015.

4. Hardee K, Kumar J, Newman K, et al. Voluntary, human rights–based family planning: a conceptual framework. Stud Fam Plann. 2014; 45:1–18.

5. Singh S, Darroch JE. Adding it up: the costs and benefits of investing in sexual and reproductive health. Available at: http://www.unfpa.org/adding-it-up. Accessed December 15, 2015.

6. Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: family planning. MMWR Morb Mortal Wkly Rep. 1999;48:1073–1080.

7. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120:1291–1297.

8. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet. 2012;380:149–156.

9. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta A. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295:1809–1823.

10. Zhu B. Effect of inter-pregnancy interval on birth outcomes: findings from three recent US studies. Int J Gynaecol Obstet. 2005;89(suppl 1):S25–S33.

11. Wendt A, Gibbs CM, Peters S, Hogue CJ. Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatr Perinat Epidemiol. 2012;26(suppl 1):239–258.

12. Maguire K, Westhoff C. The state of hormonal contraception today: established and emerging non-contraceptive health benefits. Am J Obstet Gynecol. 2011;205(suppl 4):S4–S8.

13. Hatcher RA, Cates W, Trussel J, Nelson A, Kowal D, Policar M. Contraceptive Technology. 20th ed. New York, NY: Ardent Media; 2011.

14. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371:1316–1323.

15. Harper CC, Rocca C, Thompson K, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomized trial. Lancet. 2015;386:562–568.

16. Canning D, Schultz PT. The economic consequences of reproductive health and family planning. Lancet. 2012;380:165–171.

17. Tavernise S. Colorado’s effort against teenage pregnancies is a startling success. Available at: http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling- success.html. Accessed December 15, 2015.

170~2018_(1) AzPHA Resolution Universal Access to Contraception (medication, reproductive health)

Megan Resolutions, Uncategorized

1971- Arizona Laws Regarding Abortion

ARIZONA PUBLIC HEALTH ASSOCIATION
41st Annual Meeting – Tucson, Arizona – October 6,7,8, 1971

RESOLUTION CONCERNING ARIZONA LAWS REGARDING ABORTION

WHEREAS, the Arizona Public HeaJ.th Association recog­nizes the right of the individual to secure quality medical care, and

WHEREAS, the existing legislation is prejudicial to the rights of women in a free society; and

WHEREAS, the decision of having an abortion be the judgment of the woman and a qualified doctor

THEREFORE, BE IT RESOLVED THAT as a professional organiza­tion we will actively promote liberalization or abolishment of the current Arizona Laws concerned with abortion.

1971-arizona laws regarding abortion

Shelby Disease Control, Early Childhood, Public Health

Ducey’s Ban on School Mask Requirements is Unconstitutional

THE NEW LAW VIOLATES THE CONSTITUTION’S ‘SINGLE SUBJECT’ RULE

While Governor Ducey and Director Christ have made dozens of damaging and head-scratching decisions throughout the pandemic, few are as profoundly puzzling as their support of the new law that prevents K-12 school districts from being able to protect their students by requiring masks in the classroom.

The state legislature prohibited school districts from requiring students to wear masks inside classrooms (or anywhere for that matter) in the K-12 budget bill. Governor Ducey enthusiastically signed the bill and Director Christ expressed no concern whatsoever about preventing districts from requiring masks (despite CDC guidance and tons of evidence for this important protective measure).

The restriction even includes kids in grades K-5 who won’t have access to a vaccine until November. Masking, symptom checks, distancing, increased ventilation, and excluding kids sick with COVID-19 and their unvaccinated close contacts are the only tools that elementary schools have right now to keep kids safe. Now, masking is off the table.

Governor Ducey signed the K-12 budget bill banning schools from requiring masking indoors even though it’s the highest ROI intervention that they have until the kids have access to a vaccine. Astonishingly, Director Christ expressed no concern whatsoever about the Governor’s prohibition of this effective infection control practice. Not only did she not speak up during the legislative session, she didn’t urge the governor to veto the law.

Now that this harmful ban is law are school districts hands really tied?

There may be a pathway to overturn this harmful restriction that will threaten the health of kids, but it will take going to court.

Arizona’s Constitution requires every bill to have a ‘single subject’. The Constitution protects us from legislators passing bills that are about multiple unrelated topics. This new law obviously violates the AZ Constitution’s ‘single subject’ rule AZ Const. Article 4, Part 2, § 13. Here’s what the Constitution says:

13. Subject and title of bills

Section 13. Every act shall embrace but one subject and matters properly connected therewith, which subject shall be expressed in the title; but if any subject shall be embraced in an act which shall not be expressed in the title, such act shall be void only as to so much thereof as shall not be embraced in the title.

 The K-12 Budget Reconciliation Bill that Ducey signed and that Christ supports stopping districts from requiring masks (15-342.05. Face coverings; requirement prohibition: A school district governing board may not require the use of face coverings by students or staff…) has NOTHING to do with the funding of schools and is therefore in clear violation of the constitution.

However, the courts can’t intervene and stop this damaging micromanagement of schools unless somebody challenges the language in ARS § 15-342.05, arguing that the provision is in violation of the state constitution.

We need a courageous school district to take the Governor and Director Christ to court and challenge ARS § 15-342.05.

If a judge looks at the language in the constitution and the K-12 Budget Reconciliation Bill objectively, I expect her or him to issue a Preliminary Injunction or Restraining Order and allow districts to make their own decisions about whether, when, and where students need to wear masks while on campus this fall.

Shelby Disease Control

COVID-19 Exponential Growth Accelerating

Dr. Gerald just published his weekly epidemiology and hospital capacity report – and it’s not good news. Take a look at the epi curves among persons of all age groups in today’s report. Very steep epi curves in all populations below age 65. This week, he breaks down the cases among kids in 5 categories this week (less than 5, 6-10, 11-14 and 15-20 years old). All are increasing at a steep clip. Percent positivity is up to 20%! Not good. His summary is below- but as always I encourage you to read the full report:

This past week saw another marked increase in viral transmission. Arizona is now experiencing high levels of transmission that could be sustained for weeks to come. Unlike my previous assumption – roughly counterbalanced forces – it appears that total immunity is still insufficient to avert another surge in the presence of the more transmissible Delta variant.

As of July 21st, new cases were being diagnosed at a rate of 108 cases per 100,000 residents per week. The rate is increasing at 27 cases per 100,000 residents per week. Another wave of cases and hospitalizations, most likely caused by the increasing prevalence of the Delta variant, seems almost certain. The Delta variant now accounts for about 75% of all cases. Vaccination remains the most important public health priority to reduce viral transmission and severe illness.

With this marked acceleration in transmission, mandating masks in indoor spaces and limiting large gatherings is warranted to reduce transmission in public settings.

Unfortunately, it seems unlikely that state policymakers will take action to protect public safety, either by allowing vaccination mandates (e.g., school attendance), indoor mask mandates (e.g., schools), or targeted business restrictions. Individual action alone is unlikely to stem the tide unless those most resistant to vaccination and mask-wearing voluntarily change their behaviors.

Hospital COVID-19 occupancy is increasing in the ward and ICU. COVID-19 occupancy is likely to exceed 10% of all beds for at least several weeks, if not considerably longer. Access to care remains somewhat restricted as overall occupancy remains unseasonably high at 85%.

Arizona Covid-19 fatality counts are now about 50 deaths per week but the number of deaths should increase over the coming weeks as case counts increase. The number of deaths could exceed 100 per week by the middle-to-end of August.

According to the CDC, 55% of Arizona adults have received at least 2-doses of vaccine while another 9% have received 1-dose. Arizona passed peak vaccination rates in early April and these rates continue to erode. Despite evidence of limited immune escape to the Delta variant, especially before completion of the full vaccination sequence, vaccination continues to provide extraordinarily high levels of protection from infection and severe illness.

With inadequate vaccination uptake, eliminating COVID-19 is no longer a plausible public health policy goal. COVID-19 is almost certain to become an endemic disease with varying temporal and geographic implications. Fortunately, vaccination will remain a viable disease control strategy offering a high degree of protection to those willing to accept them.

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