In the USA, an increasing number of states have legalized commercial recreational cannabis markets, despite the fact that it is illegal to use or supply cannabis at the federal level. In these markets, private companies produce, distribute, and sell cannabis products to adults aged 21 and older at retail locations known as dispensaries. Discussions around public health regulations of recreational markets have drawn parallels to alcohol and tobacco and raise concerns about the effects of the developing industry’s marketing practices (Barry and Glantz 2017). A potential consequence of creating a legitimate, licit market for cannabis is that profit-driven companies will engage in promotional activities to attract new users and encourage greater intensity of use. Promoting heavy (daily or near daily use) and problem use (meeting the criteria for cannabis use disorder (Patel 2021)) is incentivized, as it is estimated that 80% of cannabis is currently consumed by these types of users (Caulkins et al. 2016). One potential consequence of legalization is greater underage youth exposure to marketing and advertising (Barry and Glantz 2017). Attracting youth is particularly desirable for companies because these customers are likely to yield lifelong dividends (Barry and Glantz 2017; Caulkins et al. 2016). Additionally, those who start using at a younger age are more likely to become heavy or problem users (Caulkins et al. 2016; Winters and Lee 2008). For example, it is estimated that half of all heavy users in the USA started using at age 14 or younger (Caulkins et al. 2016). Another concern is that the cannabis industry may follow in the footsteps of the tobacco industry and disproportionately target racial/ethnic minorities and low-income communities in their marketing campaigns (Truth Initiative 2020). For example, studies have found greater point-of-sale tobacco marketing (e.g., price discounts, branded advertisements), including marketing of menthol cigarettes, in Black and low-income communities (Cruz et al. 2019; Lee et al. 2015).

Decades of research on tobacco and alcohol have provided strong evidence that marketing exposure is causally related to initiation of use and regular use, particularly among youth (Anderson et al. 2009; DiFranza et al. 2006; Office of the Surgeon General 2014; Office of the Surgeon General 2012; National Cancer Institute 2008). Advertising by the tobacco industry has been shown to influence youth use through multiple channels, including by raising awareness of smoking, increasing brand recognition, reducing risk perceptions of use, and creating favorable beliefs surrounding use (Office of the Surgeon General 2012). A descriptive history of tobacco advertising reveals that there was intentional and persistent targeting of children and adolescents including, for example, promotions in schools, the use of cartoons, and endorsements from professional athletes (Pollay 1995).

Minimizing youth use of cannabis is an important public health objective (Pacula et al. 2014; Kees et al. 2020); adolescents are considered an at-risk population for cannabis use for multiple reasons. First, research indicates that early and frequent adolescent use negatively impacts brain development, leading to cognitive impairment in the domains of learning, attention, and memory (The National Academies and of Sciences, Engineering, and Medicine 2017). Second, adolescent use of cannabis is associated with poor social and educational outcomes including a decline in school performance, school dropout, unemployment, and use of other illicit drugs (Silins et al. 2014; Fergusson and Boden 2008). Lastly, evidence from longitudinal and cross-sectional studies have found cannabis use is associated with increased risk of mental illness, including depression (Silins et al. 2014; Gobbi et al. 2019), suicidal behavior (Silins et al. 2014; Gobbi et al. 2019), anxiety (Paruk and Burns 2016; Crippa et al. 2009), and psychosis (Paruk and Burns 2016), and, at the same time, youth with mental illness may use cannabis to self-medicate (Bottorff et al. 2009; Khantzian 1997).

Studies have shown that exposure to cannabis advertisements is already prevalent among adolescents. A large, nationally representative survey of 8th, 10th, and 12th graders found that 53% reported exposure to cannabis advertising online, 32% from television, 24% from magazines and newspapers, 20% from radio, 19% from storefronts, and 17% from billboards (Dai 2017). One study conducted in Oregon about 2 years after legal recreational sales began found exposure to advertising among youth was exceedingly common: 72% and 78% of 8th and 11th graders, respectively, reported seeing advertisements for cannabis, most commonly in storefronts and online (Fiala et al. 2020). Adolescent exposure to cannabis advertising is also associated with cannabis use (Dai 2017; Whitehill et al. 2020; D’Amico et al. 2018; D’Amico et al. 2015). Two longitudinal studies of adolescents in Southern California found greater exposure to medical cannabis advertising was associated with increased likelihood of cannabis use and greater intention to use one and seven years later (D’Amico et al. 2018; D’Amico et al. 2015). The study that followed adolescents for seven years also found that students with greater exposure were more likely to experience negative consequences of cannabis use, including missing school and having difficulty concentrating.

With the development of a recreational commercial market, there are also considerations for health claims in cannabis advertising. While cannabis meets the definition of a drug under the Food and Drug Administration’s (FDA) Food Drug and Cosmetic Act, it is not an FDA-approved drug, and the FDA does not allow companies to make health claims for drugs that are not FDA-approved (Caulkins 2017). However, in practice, the FDA does not punish companies for making health claims about cannabis products with tetrahydrocannabinol (THC) because cannabis is listed as a Schedule I drug under the Controlled Substance Act (Caulkins 2017). Therefore, the responsibility of regulating health claims in advertising falls on the states that legalized recreational markets.

Cannabis is distinct from tobacco and alcohol, the only two legal recreational drugs, in that it has been shown to have medical benefits. For example, according to the National Academy of Sciences, there is conclusive evidence that cannabis is effective at treating chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis (MS) spasticity symptoms (The National Academies and of Sciences, Engineering, and Medicine 2017). Many states with comprehensive medical cannabis programs also allow medical access for many conditions that are supported by low-quality evidence. For example, several states list opioid use disorder as an indication for medical cannabis access based on an ecological study that found medical cannabis legalization was correlated with a reduction in opioid overdoses (Shover et al. 2020). There are two concerns related to health claims in advertising of cannabis. First, without regulations and enforcement, dispensaries may make false or misleading health claims. Second, cannabis companies may promote the medical benefits of cannabis to create a “health halo effect,” which leads to positive perceptions of recreational use (Kees et al. 2020). For example, one major multi-state cannabis brand, MedMen, regularly touts the medical benefits of cannabis despite the fact that most of its stores sell only recreational cannabis (Ayers et al. 2019).

At the federal level, it is illegal to advertise cannabis because Section 843 of the Controlled Substance Act prohibits advertising of Schedule I drugs. Cannabis advertising regulations and enforcement, however, are set by states with legal markets because the Department of Justice allows state-sanctioned cannabis-related activities if states have “strong and effective regulatory and enforcement systems” that are consistent with federal enforcement priorities (Caulkins et al. 2015). All states with commercial recreational markets have regulations related to advertising and promotional activities, including restrictions on child-appealing marketing (Kees et al. 2020; Cao et al. 2020). However, the degree of systematic monitoring and enforcement of these regulations, as well as cannabis industry compliance, is unclear.

Currently, there is limited research on marketing practices of recreational dispensaries, including assessments of adherence to state regulations. Studies on this topic have been conducted in a variety of settings. A study examining point-of-sale marketing in recreational dispensaries in California found 35% had child-appealing marketing items in the interior of the store, 39% had signs, posters, or advertisements that promoted health benefits, and 22% violated regulations by providing free samples of cannabis products for customers to take away (Shi and Pacula 2021). Another study using the same audit tool in a subset of dispensaries located near schools found 74% had child-appealing marketing items in the interior of the dispensary. Furthermore, a qualitative content analysis of cannabis advertisements from freely distributed tabloids and magazines in Western Washington concluded that most advertisements contained themes that could be appealing to youth and focused on purported personal and social rewards from use (Carlini et al. 2020).

Electronic media, which is cited as the number one source of cannabis advertisements by adults and adolescents (Dai 2017; Krauss et al. 2017; Rup et al. 2020), is a third medium for advertising that has been evaluated. Studies have examined cannabis company advertising on their websites (Cavazos-Rehg et al. 2019; Bierut et al. 2017), on Weedmaps (Bierut et al. 2017) (a website that markets cannabis retailers online), and on social media platforms (Moreno et al. 2018; Jenkins et al. 2021; Spillane et al. 2021; Sheikhan et al. 2021). One study of medical and recreational dispensary websites in ten states found 75% did not have a method to verify the user was of legal age before they entered the site (Cavazos-Rehg et al. 2019). The results also revealed that most dispensary websites promoted health benefits of cannabis use (67%) (Cavazos-Rehg et al. 2019). A similar study of dispensary websites and Weedmaps webpages found many were not in compliance with state regulations in Colorado and Washington (Bierut et al. 2017). A large portion of websites did not have the required age gate (41% in Colorado and 35% in Washington) and 44% of Washington dispensaries made health claims, which is prohibited (Bierut et al. 2017). Two studies have examined content on social media from cannabis companies and found marketing strategies included references to popular culture to normalize use (Jenkins et al. 2021) and posts from cannabis vaporizer companies frequently showed someone using a product (68%) and had some posts with cartoons (5%) (Spillane et al. 2021). Two studies have examined cannabis company compliance with advertising regulations on social media platforms. The first study, which evaluated adherence to advertising regulations on Facebook, Twitter, and Instagram across all Canadian cannabis firms, reported that 86% of firms had at least one violation, most commonly involving lack of age restrictions, absence of information on health risks, and brand glamorization (Sheikhan et al. 2021). Additionally, 37.8% of firms made unsubstantiated health claims (Sheikhan et al. 2021). The second study used a sample of Facebook and Twitter posts from 38 recreational dispensaries in the state of Washington to examine compliance with state advertising regulations (Moreno et al. 2018). The study results revealed that very few posts were appealing to youth (0.01%), 13% of posts made health claims, which is prohibited, and 89% of posts lacked the required warning message (Moreno et al. 2018).

Social media is an important forum for dispensaries to market to current and potential consumers. While social media platforms such as Facebook and Twitter prohibit direct advertising of illegal drugs, cannabis companies can create promotional content on their social media business pages. Individuals can engage with these business pages in several ways: they can like, share, and comment on content as well as become a “follower” of the page. Furthermore, content promoted by the dispensaries on social media can be amplified by influencers and hashtags. Marketing on social media can potentially increase adolescent exposure to cannabis advertising because nearly all adolescents use social media platforms (Anderson and Jiang 2018). Recent lessons from the e-cigarette industry have demonstrated that social media campaigns with youth-oriented advertising can lead to a surge in use among youth (Jackler et al. 2019). Preliminary evidence also suggests that exposure to cannabis advertising on social media is associated with cannabis use (Whitehill et al. 2020; Trangenstein et al. 2019). The results of a study of adolescents and adults in Canada and the USA revealed that social media was the number one source of advertising and that advertising awareness and brand recall was associated with greater frequency of use (Rup et al. 2020). Another study of adolescents living in states with commercial markets found that adolescents who “liked” or “followed” a cannabis business on one or more social media platforms had five times greater odds of cannabis use in the past year (Trangenstein et al. 2019). Social media also has the potential to broadly disseminate unsubstantiated health claims. Because cannabis companies are not regulated by the FDA, they can make claims that are not supported by rigorous research (as required by the FDA); in fact, cannabis companies are known for publicizing low-quality, small-scale medical studies on social media (Caputi 2020).

The purpose of this study is to evaluate recreational dispensary compliance on social media with advertising regulations in the state of Illinois. On May 31, 2019, the Illinois General Assembly passed the Illinois Cannabis Regulation and Tax Act, which legalized the use and sale of cannabis starting January 1, 2020 (Cannabis Regulation and Tax Act 2019). Thirty-seven dispensaries began selling cannabis for recreational use on January 1; by the end of the year, the number of recreational dispensaries increased to 75. The Illinois Cannabis Regulation and Tax Act includes several restrictions on advertising, which it defines as engaging in any promotional activities, including through internet and electronic media. Cannabis companies are prohibited from using advertisements that (1) contain content that is likely to appeal to those under the age of 21 or (2) “make any health, medical, or therapeutic claims” (Cannabis Regulartion and Tax Act 2019). The Act also prohibits a number of other types of advertising practices, for example, promoting overconsumption and using images of cannabis leaf or bud (Cannabis Regulation and Tax Act 2019). Oversight and enforcement of these regulations are not designated to a specific regulatory body in the legislation; additionally, the legislation does not outline consequences for dispensary non-compliance (Cannabis Regulation and Tax Act 2019). To our knowledge, dispensary advertising practices are not systematically monitored for compliance with advertising regulations in the state of Illinois. In this study, primary data were collected from all recreational dispensary business pages on Facebook and Twitter for the entire year of 2020, the first year of recreational sales, to measure compliance with the Act. Understanding the current state of compliance is critical for informing future public health policies that aim to prevent advertising practices that may increase use among youth and misinform consumers about the health benefits and harms of cannabis.