Web Box 14.1 Of Special Interest: Cannabis Legalization: What are the Issues, and What are the Consequences

Decriminalization if not outright legalization of cannabis (marijuana) has been a topic of social policy for many years in the United States. Nationwide organizations like NORML (National Organization for the Reform of Marijuana Laws; https://norml.org/) and the Drug Policy Alliance (https://drugpolicy.org/) have led the charge for marijuana legalization. Even though cannabis remains a Schedule I substance under federal law, federal officials have rarely enforced this categorization in recent years. Consequently, cannabis use has become a matter of state regulation, with each state enacting legislation as to whether or not marijuana or marijuana-based products can be procured for medical or recreational use and, if so, additionally specifying the minimum age of such use, the legally permitted forms and doses of the various products, the means of production and distribution, and the imposition of taxes on cannabis sales. Figure 1 shows the legal status of medical or recreational marijuana use in each state as of February 2021. Of the 50 U.S. states, 36 permit sales of marijuana at least for medical use, and at the time of this writing 13 states plus the District of Columbia have additionally legalized marijuana and other cannabis products for recreational use.

Advocates of marijuana decriminalization or legalization have raised numerous arguments to support their position; among them are the following: (1) the original laws making marijuana illegal were racially motivated and these laws continue to disproportionately affect African American and Latinx communities (https://drugpolicy.org/issues/reforming-marijuana-laws); (2) regular marijuana use is generally less harmful to one’s health than regular use of alcohol or tobacco; (3) people should have the liberty to use marijuana if they wish since others are not harmed by this practice; (4) patients should have access to marijuana and other cannabis-based products for medicinal use; (5) government-regulated sale of marijuana and related products ensures purity and dose accuracy for the user; (6) enforcement of anti-marijuana laws and incarceration of offenders waste law enforcement resources (both funds and personnel) that could be put to better uses; (7) legalization of marijuana would reduce black-market sales and profits for criminal enterprises; and (8) taxation of marijuana sales would bring additional government revenues that could be used for drug awareness education and treatment of substance use disorders.

Arguments against marijuana legalization include (1) marijuana use would increase, leading to adverse health outcomes and greater prevalence of CUD, particularly in light of the high THC concentrations in contemporary strains of cannabis and in cannabis-based vape products and edibles; (2) greater marijuana use would result in increased use of tobacco and other substances like cocaine or heroin (the “gateway effect”); (3) the number of moving vehicle and workplace accidents would increase because of people driving or working “under the influence” of marijuana; (4) legalization would fail to eliminate the black market, since underage users would have to find sources of marijuana outside of the legal system; and (5) marijuana shouldn’t be legalized by individual states as long as it remains illegal at the federal level.

U.S. public opinion polls have revealed an enormous increase since the 1960s in the percentage of the population favoring marijuana legalization (Pew Research Center, 2015). This change is likely related to multiple factors, including not only growing acceptance of the arguments supporting legalization but also generational differences in attitudes. In the 2015 Pew Research Center poll, 68% of the Millennial Generation (born 1981–1997) favored legalization, in contrast to just 29% of the Silent Generation (born 1928–1945). Additional factors that influence attitudes toward marijuana legalization include gender (men more than women) and political affiliation (Democrats and independents more than Republicans) (Elder and Greene, 2019).

The first medical marijuana law was enacted in 1996 in California, followed over the next several years by Oregon, Alaska, Washington State, Maine, Hawaii, Nevada, and Colorado. In contrast, recreational cannabis use wasn’t first legalized until 2012 by Colorado and Washington State. Ample time has elapsed for researchers to ascertain the impact of medical marijuana laws on overall cannabis use, and studies have even begun to emerge that address the effects of cannabis legalization within the early adopter states. We will first consider the impact of medical marijuana and then address the more contentious issue of legalized cannabis.

Making marijuana available for medicinal use has had little or no effect on use by adolescents but has led to an increase in adult use (Smart and Pacula, 2019). Because medical marijuana prescribing is often poorly regulated, increased adult use after the passage of medical marijuana legislation could be related not only to recognized therapeutic applications of the drug (see Box 14.1) but also to use that is more “recreational” than medicinal. Indeed, most medical marijuana users also take cannabis recreationally (Shover and Humphreys, 2019). Additional evidence suggests that availability of medical marijuana may increase the rate of CUD among adults, particularly in states that allow cannabis dispensaries (Smart and Pacula, 2019).

In general, it is too soon to fully appreciate the effects of marijuana legalization for recreational use. Initial findings from states permitting recreational marijuana suggest a possible increase in CUD among both adolescents and adults, although follow-up studies confirming this conclusion are necessary (Cerdá et al., 2020). A more in-depth approach to assessing the impact of marijuana legalization is to examine some of the consequences that have occurred in Colorado. In late 2012, Colorado voters approved an amendment to the state constitution legalizing cannabis for recreational purposes for anyone over the age of 21. The following year was spent setting up the mechanisms to regulate cannabis sales, and the first retail shops opened at the beginning of 2014. The local cannabis industry subsequently grew so explosively that by 2019, the state had more cannabis sales outlets than the combined total of McDonald’s and Starbucks locations (Sabet, 2021). Other data from Colorado showed that between 2013 and 2017, the number of hospital emergency department visits related to marijuana use increased by 54%, and the number of marijuana-related hospital admissions increased by 101% (Rocky Mountain High Intensity Drug Trafficking Area, 2019). As discussed by Sabet (2021), marijuana legalization may have additional adverse outcomes related to socioeconomic variables such as homelessness and crime.

Despite these early findings, there currently is no obvious national sentiment to reverse the trend toward marijuana legalization, particularly for medical use. It also seems likely that in the coming years, more states will enact legislation permitting cannabis sales for recreational use. If so, what is the best course of action for states and local communities to take? Considering all of the pros and cons of marijuana legalization, some authors suggest that overall harm to individuals and society as a whole is minimized when marijuana is legalized but with the appropriate strict regulations in place (Adinoff and Cooper, 2019). Hopefully, continuing studies of states like Colorado that have had legalized recreational marijuana for some time will help us determine what those regulations should be.

References

Adinoff, B., and Cooper, Z. D. (2019). Cannabis legalization: Progress in harm reduction approaches to substance use and misuse. Am. J. Drug Alcohol Abuse, 45, 707–712.

Cerdá, M., Mauro, C., Hamilton, A., Levy, N. S., Santaella-Tenorio, J., Hasin, D., Wall, M. M., et al. (2020). Association between recreational marijuana legalization in the United States and changes in marijuana use and cannabis use disorder from 2008 to 2016. JAMA Psychiatry, 77, 165–171.

Elder, L., and Greene, S. (2019). Gender and the politics of marijuana. Soc. Sci. Q., 100, 109–122.

Pew Research Center. (2015). In Debate Over Legalizing Marijuana, Disagreement Over Drug’s Dangers. Available at https://www.pewresearch.org/politics/2015/04/14/in-debate-over-legalizing-marijuana-disagreement-over-drugs-dangers/. Accessed 3/13/21.

Rocky Mountain High Intensity Drug Trafficking Area. (2019). The Legalization of Marijuana in Colorado: The Impact, Vol. 6. Available at https://www.rmhidta.org/strategic/. Accessed 3/15/21.

Sabet, K. (2021). Lessons learned in several states eight years after states legalized marijuana. Curr. Opin. Psychol., 38, 25–30.

Shover, C. L., and Humphreys, K. (2019). Six policy lessons relevant to cannabis legalization. Am. J. Drug Alcohol Abuse, 45, 698–706.

Smart, R., and Pacula, R. L. (2019). Early evidence of the impact of cannabis legalization on cannabis use, cannabis use disorder, and the use of other substances: Findings from state policy evaluations. Am. J. Drug Alcohol Abuse, 45, 644–663.