As of January 2020, 33 states, the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands had legalized medical use of cannabis/marijuana, and 11 of those jurisdictions had legalized nonmedical adult use, typically in commercial and retail marketplaces. The federal government has not challenged laws legalizing commercial cannabis as long as states maintain strict rules regarding sales and distribution. Given the dearth of national cannabis policy research, this policy statement calls for an evidence-based public health approach to regulating and controlling the legal commerce of cannabis products that is similar in some aspects to the long established and validated framework used for tobacco and alcohol control focused on such strategies as taxation on products and regulation of advertising and marketing. Health equity and social justice are critical components of cannabis legalization. Historically, rates of cannabis-related arrests and incarcerations have been higher among Black and Latino individuals than White individuals, despite cannabis use rates being similar by race/ethnicity. Encounters with the criminal justice system negatively affect health outcomes among individuals and within communities. Racial disparities in cannabis-related criminal justice encounters are rooted in public policy. A public policy approach to ameliorating these harms is warranted. Decriminalization and implementation of public health regulatory and enforcement structures must be supported by current evidence and best practices and must keep health equity and social justice at the forefront of public health policy and enforcement efforts. This policy statement is primarily focused on regulation of “commercial adult use markets” at the state level.
Relationship to Existing APHA Policy Statements
- APHA Policy Statement 201410: Regulating Commercially Legalized Marijuana as a Public Health Priority
- 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
- Policy Statement 201312: Defining and Implementing a Public Health Response to Drug Use and Misuse
The previous policy statement regarding legalized marijuana (201410) addressed several public health issues, including prevention of access to adolescents, impacts on vulnerable and marginalized populations, consumer protection, unwanted exposure, and driving while impaired. These issues remain relevant today. Since the earlier policy, there has been improvement in the scientific evidence, and additional states have legalized and/or implemented commercial regulated adult use. However, regulations have been implemented inconsistently across states. Colorado, Washington, Alaska, Oregon, California, Nevada, Massachusetts, Maine, Vermont, Michigan, and Illinois, along with the District of Columbia, have legalized adult use of cannabis. Additional states have introduced legislation and/or proposed voter initiatives to legalize nonmedical cannabis use, making it likely that state cannabis legalization will continue to expand. Despite a rapidly changing policy climate related to cannabis legalization, the potential harms and benefits of cannabis and its constituents remain largely unknown. Cannabis remains the most widely used illegal drug in the United States, including use among adolescents. In 2019, daily marijuana use increased significantly among 8th and 10th graders. Also, past-month marijuana vaping also nearly doubled among 8th, 10th, and 12th graders in 1 year. The highest annual marijuana use prevalence (15.9%) among Americans 12 years and older was in 2018, with the most significant increases observed among young adults 18 to 25 years of age and adults 26 years and older.
The heterogeneity of states’ policies and the increasing use of cannabis within vulnerable and marginalized populations have contributed to many urgent public health concerns. Black, Native American, and mixed-race adults are more likely than Whites to report a cannabis use disorder (abuse or dependence). Black and Latino individuals are arrested for possession at four times the rate of White individuals, despite having similar rates of cannabis use. Racial disparities in cannabis-related arrest rates persist in states that have legalized the drug for adult use. Arrest rates in the legalized adult use states of Colorado, Oregon, and Washington have remained racially disparate even after legalization.[7–9]
Other notable cannabis use harms include lower birth weights when used during pregnancy, exacerbation of chronic bronchitis, increased risk of impairment while operating a motor vehicle, and exacerbation of episodes of psychosis and schizophrenia, cognitive impairment, and cannabis use disorder. These cannabis-related effects are more prevalent when use is initiated at an early age and/or the drug is used frequently.[2,10] Additional public health concerns include the lack of consistency in regulations and data monitoring across legal cannabis states. The commercial cannabis industry has developed policies and practices that are generally inadequate to protect and safeguard public health. Many states are adapting and applying their medical cannabis regulations to commercial cannabis legalization. Although understandable, this approach fails to account for the broader public health implications of widespread cannabis availability across communities. Finally, the current evidence suggests that some current and future harms could be similar to those seen with alcohol or tobacco, especially within vulnerable or marginalized populations.
Therefore, APHA calls for the following policy actions:
- Provide protection to children and youth and other vulnerable and marginalized populations through careful regulation of (1) the availability of and access to cannabis products; (2) advertising and marketing; (3) product potency, form, and characteristics; and (4) packaging and labeling
- Minimize harm to the public through (1) effective prevention education, (2) protection of clean indoor air, (3) prevention of impaired driving, (4) adoption of policies to promote and protect health equity, and (5) investment in public health and safety programs
- Monitor patterns of cannabis use and related public health and safety outcomes through (1) population-based surveys, (2) syndromic surveillance, and (3) other data sources
Evidence-Based Strategies to Address the Problem
Strategies for addressing the problems associated with the use of cannabis and other cannabis products are still evolving. As noted, evidence suggests that some current and future harms could be similar to those experienced with alcohol or tobacco. Strategies previously used and proven effective to reduce demand for and use of traditional tobacco products and alcohol can serve as a reference point to address public health priorities related to commercial cannabis. While there are important nuanced differences among these substances, cannabis policy could draw on some important lessons from tobacco control and alcohol prevention. Such strategies include those described below.
Protecting children, youth, and other vulnerable and marginalized populations: Despite efforts to curtail availability of and access to cannabis products through regulation, there is concern that cannabis remains highly accessible to youth and other vulnerable populations, particularly through illicit markets or through informal or unreliable sources. Age restrictions and enhanced enforcement must be used to limit access to commercial cannabis among adolescents. States with legal commercial marketplaces that have policies requiring adult-only, cannabis-only stores, with mandatory ID checks upon entry (i.e., minimum legal age of 21 years), have generally reported high compliance with age restrictions (above 90%), suggesting this as a promising strategy to reduce youth access. However, there is a dearth of evidence regarding access to and availability of cannabis among youth through informal means such as family members and friends of legal age. Examining outcomes from evidence related to proximity of alcohol and tobacco retail establishments may further assist in regulating the availability of cannabis products to prevent use among youth and other vulnerable populations.[13–16] While information is still emerging with regard to the association between mental health and cannabis use, data suggest that cannabis has an association with schizophrenia and psychosis, and individuals with existing psychotic illness are at greater risk of relapse and hospitalization when they are using cannabis (and especially when they are engaging in heavy use). There may be continued success in reducing access and availability further through approaches similar to current tobacco and alcohol product controls, some of which are enumerated in other sections of this policy.
Protecting pregnant and breastfeeding women and their offspring from the potential harms of cannabis is also important. Data suggest that cannabis use during pregnancy (which ranges from 2% to 5% among pregnant women) is associated with lower birth weights and may affect the longer-term development of offspring. Pregnant women should be counseled on the potential implications of cannabis use during pregnancy, including the potential for mandatory reporting requirements in the case of a positive screen. Patients should be informed that the purpose of screening is to treat their substance use, not to punish or prosecute them. For medicinal use, they should be encouraged to discontinue marijuana in favor of alternative therapies for which there are better pregnancy-specific safety data. THC (tetrahydrocannabinol) is fat soluble and passes through breast milk; however, data are insufficient to evaluate the effects of cannabis use on infants during lactation. In the absence of such data, breastfeeding women should be advised not to use cannabis.
Cannabis advertising must be restricted to the maximum extent allowable under U.S. and state law, incorporating lessons from U.S. and global tobacco and alcohol control. Restricting advertisements can have a profound effect on health. 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. Historically, the alcohol and tobacco industries have focused marketing efforts on targeted populations, including communities of color, economically disadvantaged groups, women, and LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) individuals. Beyond broad marketing regulations, attention must be given to mitigating harm from targeted population campaigns.
As measured by concentration of THC, cannabis potency has increased significantly from 3% to 4% in the products previously sold to 15% to 30% in current products (with certain concentrates as high as 90%).[20,21] The impacts of high concentrations of THC in cannabis are still being explored, but earlier initiation of cannabis use and heavier use patterns have been associated with increased negative health effects. While there is limited evidence for including product potency information, messages about poisoning and potential overconsumption could potentially be incorporated as an early warning strategy to reduce such harms as overdose or poisoning.
Furthermore, product characteristics that may attract youth, including flavors such as fruit and flavored-sounding brand names (e.g., “Girl Scout Cookie”), certain shapes and forms that imitate existing products marketed to children or youth (e.g., flavored gummies), and products with images of people, animals, or cartoons, are emergent public health concerns. Addressing these issues is critical for consumer protection as well as minimizing harm to youth and vulnerable and marginalized populations.
Cannabis packaging regulations must include plain and opaque packaging, preferably with small, approved, and limited brand elements. Packaging must disclose all ingredients, including flavoring agents (and sources, for example, cannabis derived, botanically derived, or synthetic) and diluents, as well as the percentage and milligrams of THC and CBD (cannabidiol). Tobacco products have long displayed the surgeon general’s warning about the risk of tobacco use and will soon be required to display graphic pack warnings. Labels on alcohol also contain specific warnings about health risks.[23,24] Similarly, cannabis products must include requirements for prominent, clear, rotating pictorial health warnings on all cannabis product packages and prominently posted health warnings in stores and on advertisements. Required warnings must address all key conditions with substantial evidence of associated harm, at a minimum those identified in the National Academies of Sciences 2017 report, and be updated periodically to reflect the best available science. Warnings must also incorporate the best available science on textual and visual features that enhance message effectiveness. Rotating warnings must be required on any cannabis advertising allowed, whether print, Internet, radio, or other. Labeling should also include a universal symbol on the product packaging (layer closest to the product) denoting that the product contains cannabis. In addition, child-resistant packaging must be required given the rapid increase in emergency room visits and accidental poisonings. On the basis of the extensive evidence for health warnings in tobacco, the government must consistently require that lessons from tobacco control on informing consumers of health risks be incorporated within cannabis regulation.
Minimizing harm to the public: Dedicated funding is required to support evidence-based alcohol, tobacco, and other drug prevention education. Alcohol, tobacco, and other drug (ATOD) education programs rarely focus on just one category of drugs. The Substance Abuse and Mental Health Services Administration has identified a number of scientifically vetted prevention and education programs (e.g., Family Checkup). While cannabis is not the only targeted substance in prevention education evidence-based programming, it is often included in programs related to ATOD prevention and intervention education. Dedicated funding of cannabis-related prevention education programming could reduce harm to youth and adolescents much in the same way that has been effective in tobacco and alcohol prevention education. This includes school and community evidence-based education programs that have proven effective in improving knowledge of risks and delaying initiation (e.g., Project Alert).[29,30] Dedicated funding from taxation of cannabis products must be set aside for designing, implementing, and evaluating these programs and supporting community efforts. As indicated above, daily marijuana use increased significantly among 8th and 10th graders in 2019, and past-month marijuana vaping nearly doubled among 8th, 10th, and 12th graders in 1 year. This policy statement supports funding school and community evidence-based programming that begins before 8th grade, as such programs would likely reduce the incidence and prevalence of early initiation.
Advances in smoke-free air have been a major public health achievement of the 20th and 21st centuries, contributing to denormalizing smoking, protecting workers, and protecting children and adult nonsmokers from secondhand smoke. These public health gains are now threatened by public cannabis smoking and vaping, licensing of outdoor cannabis events, and licensing of on-site cannabis consumption in dispensaries and consumption lounges, as well as renormalizing smoking among youth and the public.[31,32] Furthermore, emerging evidence suggests that exposure to secondhand cannabis smoke/aerosols is not safe, as it has been linked to increased risk of myocardial infarction and stroke. These products contain many of the same carcinogenic compounds and fine inhalable particulates found in tobacco smoke. Outcomes from tobacco control smoke-free laws, such as lower risks of smoking-related cardiac, cerebrovascular, and respiratory diseases, can serve to inform the establishment of similar regulatory frameworks to reduce negative effects from secondhand/aerosol cannabis exposure.
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 minimum legal drinking ages (MLDAs) and decrease by 16% with higher MLDAs (i.e., 21 years). Maintaining retailer compliance with MLDA laws through enhanced enforcement of these laws against retailers and underage purchasers also reduces access to alcohol among minors. Six systematic reviews examined in 2017 by the National Academies concluded that there is substantial evidence of a positive association between cannabis use and increased risk of motor vehicle crashes. In addition to increasing the risk of vehicle crashes (especially when combined with alcohol use), recent cannabis use has been associated with significant driving impairment.[2,38] A number of states and Canada have found deploying drug recognition officers combined with biological detection methods to be an effective roadside intervention strategy.[39,40] Similar to alcohol and driving, education on cannabis use, impairment, and driving is needed to mitigate incidence rates. The initial emphasis must be with young adults and early drivers, as this approach has been shown to have limited but still some impact. This policy statement supports maintaining retailer compliance along with continued review and monitoring of enforcement of age restriction policies to prevent motor vehicle crashes related to impaired driving. Greater research on determining driving functional status and cannabis impairment is still needed.
The driving force behind cannabis legalization includes the economic and health effects of cannabis prohibition that have fallen heavily on the individual, family, and community. Such effects also include encounters with the criminal justice system, which negatively affect long-term health outcomes among individuals and within communities. People who have been incarcerated, or even arrested without being charged, can suffer lasting repercussions on their ability to find work and housing or access social services. Historically, rates of cannabis-related arrests and incarcerations have been higher among Black and Latino individuals than among White individuals, despite cannabis use rates being similar according to race and ethnicity. Studies link incarceration to homelessness and/or loss of access to subsidized housing. Housing restrictions are linked to increased recidivism. Research also shows a strong relationship between housing instability and health outcomes for individuals and families. Individuals living in federally funded public housing may risk their housing if they are using medical or nonmedical cannabis because the drug is illegal at the national/federal level. Jurisdictions must develop public policies and social equity programs as part of a public health approach to prevent and ameliorate the harm caused by cannabis law enforcement. In addition, policies must not permit cannabis commerce to concentrate in low-income neighborhoods, as alcohol retailers have traditionally done. Decriminalization and implementation of public health regulatory and enforcement structures not only must be supported by current evidence and best practices but must keep health equity and social justice at the forefront of all components of public health policy and enforcement efforts.
The challenge is regulating adult commercial markets in such a way as to eliminate racial disparities in arrest and incarceration rates and to support the inclusion of Black and Latino individuals in the emerging cannabis economy. Systemizing expungement of records for cannabis convictions is an important component of legalization and can be far reaching. Failing to allocate resources and systemize an expungement process places an unfair burden on people who do not have the resources and time to navigate this complex process but who would benefit the most from expungement.
Raising cannabis prices by taxing commercial cannabis can help price adolescents out of the market as is consistently demonstrated in tobacco control taxation measures.[45,46] Linking taxes to a number of standard THC doses or THC content may discourage market trends toward higher potency. 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 U.S. high school youth. 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. Importantly, these taxes should be primarily reinvested in public health and safety programs, especially those that seek to protect the public from the harmful effects of cannabis.
Monitoring public use and public health harms: Cannabis surveillance is conducted at a macro level through national surveys such as Monitoring the Future, the Behavioral Risk Factor Surveillance System, the Youth Risk Behavior Surveillance System, and the National Survey on Drug Use and Health. According to a recent case series review, no state or national surveys monitor all eight key indicators of cannabis use behaviors and perceptions. This policy statement supports more consistent and micro-level surveillance on cannabis use to address these gaps in monitoring. Surveillance data are critically important, both at the federal level and in states, territories, and communities, to assess changes in patterns of cannabis use as policies change. Furthermore, assessing possible adverse health effects of cannabis and its constituents, understanding the impacts cannabis policy changes have on health and safety outcomes, and informing the development of public health programs and policies remain significant priorities. More extensive data monitoring and surveillance must, at a minimum, encompass data collection through the following avenues.
- Population-based surveys: Data ideally would be collected not only in the general adult population but particularly in vulnerable population groups such as youth, pregnant women, and other marginalized and underserved populations. Survey questions must extend beyond ever use and past-month use and seek to characterize mode of use, type of products being used, frequency of use, reasons for use, dependence, and related risk behaviors and exposures (e.g., impaired driving). Where possible, questions must be cognitively tested before use, and an attempt must be made to use the same question wording to allow for cross-state comparison.
- Syndromic surveillance: Syndromic data are near-real-time data used to detect, monitor, and characterize unusual activity for further public health investigation or response. Syndromic surveillance of cannabis would ideally include patient encounter data from emergency department, urgent care, ambulatory care, and inpatient health care settings as well as pharmacy, laboratory, and poison control data. States and other jurisdictions are encouraged to develop syndromic and sentinel surveillance plans and contribute data to the Centers for Disease Control and Prevention’s BioSense Platform through the National Syndromic Surveillance Program.
- Other data sources: Other data sources that provide a context and must be considered may include school and business absentee data, data related to motor vehicle crashes or fatalities, and market and sales data. Public health programs are encouraged to collaborate with other state agencies in accessing and analyzing these data sources. Furthermore, these data can be coupled with information from other sources, including population-based data and syndromic data, to provide a broader sense of potential public health and safety issues.
Additional data monitoring and evaluation approaches may also be warranted to inform public health and prevention work, including specific surveys of cannabis users and qualitative studies or evaluations seeking to better understand certain trends.
Arguments opposing public health regulations often center on personal autonomy, the freedom to do business, and economic costs to consumers and businesses. Arguments opposing the strategies described here are addressed below.
Protecting children, youth, and other vulnerable and marginalized populations: Opposing arguments for protecting vulnerable and marginalized populations are often associated with restrictions and infringements upon certain rights of individuals such as free speech, the autonomy to make health-related decisions, and the ability to conduct business without interference. 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. Age restrictions limit the accessibility of cannabis 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). Furthermore, there is still a dearth of evidence related to negative health effects among other vulnerable and marginalized populations, such as pregnant and breastfeeding women as well as military veterans. There simply is not enough evidence of harm to warrant these restrictions, or the evidence is contradictory. Regulation of the quality and potency of commercial cannabis and limitations on times and dates of sales could be perceived as impairing business interests and leading to increased consumer costs.
Minimizing harm to the public: This policy statement supports the adaptation of tobacco and alcohol control measures to address potential harms to the public from cannabis use. However, data on cannabis use and harms are still emerging and do not, in fact, support that the degree of harm to the public is equal to or greater than that of alcohol or tobacco use. Costs and resources related to enacting and enforcing control measures similar to those used for tobacco and alcohol are not yet supported by data or evidence. There are many who support and promote the therapeutic and medical benefits of cannabis,[1,11] and yet the evidence supporting the medical value of cannabis is still emerging. Similarly, much of the scientific evidence is contradictory. As previously stated, it can be argued that restrictions limit cannabis use autonomy. Moreover, there is evidence that restrictions may not completely protect the public from harm. For example, most prescribed medications have some level of regulation and control, and yet many medications still cause public harms (e.g., opioids). Those who oppose regulating passive (secondhand) exposure to cannabis smoke will focus on the lost autonomy of people who use cannabis in the presence of children and other vulnerable and marginalized populations, as well as those who use cannabis in public spaces and multi-unit housing complexes.
Monitoring public use and public health harms: Research into the long-term effects of cannabis legalization and the various state- and local-level cannabis laws on public health outcomes is still emerging, particularly with respect to the impact of cannabis policies on use among youth or among adults who may experience adverse effects after using cannabis commercially. Rigorous, ongoing scientific research is therefore needed to inform policy and regulatory leaders about the laws and policies that may best protect public health. An important aspect of monitoring use, mitigating harms, and supporting cannabis research is the existence of dedicated funding. Although designating a percentage of taxation revenue raised through the sale of commercial cannabis is a practical funding mechanism that states can utilize, this policy could be seen as a burden to consumers and an infringement on business interests. If taxation policy does involve cannabis products, states could use funding for other more emergent health and/or infrastructure issues rather than reinvesting funds for an issue that is not yet strongly supported by emergent data and evidence. Evidence in the realm of alcohol and tobacco control demonstrates that taxation reduces the use of alcohol and tobacco[45–48,53]; however, the evidence for this approach with respect to cannabis use is lacking. States with high levels of taxation may even experience further development of illegal cannabis sales. Finally, because cannabis is still federally prohibited, monitoring use through surveys presents challenges as respondents are less likely to report self-incriminating use, and thus the extent of harm will still be unclear.
If cannabis or its constituents are legalized in any state or jurisdiction, this policy statement proposes action steps to foster planned and consistent protection of health as well as governance through regulation and monitoring of the commercial legal cannabis market. This statement further supports a planned approach to the regulation of commercial cannabis from a public health policy perspective as a key component of protecting and maintaining public health and safety. Even in jurisdictions that have not legalized cannabis or any of its constituents, certain public health measures (e.g., data monitoring) remain essential.
Therefore, APHA urges:
Protection of children, youth, and other vulnerable and marginalized populations
- State, tribal, and local governments that regulate cannabis to develop and implement policies that control access and use among youth (i.e., a minimum legal age of 21 years) and other vulnerable and marginalized populations.
- State, tribal, and local governments to adopt policies that advance primary prevention efforts and reduce the demand for cannabis products.
- Federal, state, tribal, and local governments to develop youth-focused cannabis prevention strategies to denormalize cannabis use.
- State, tribal, and local governments to require packaging and labeling that clearly identify products containing cannabis (e.g., through a universal symbol), list all product ingredients, and provide prominent health warnings to consumers. Packaging that appeals to children and youth should be avoided.
- Federal, state, tribal, and local governments to develop policies and regulations that address social inequality and the harms caused by disproportionate drug-related arrests among minority, vulnerable, and marginalized populations.
- Federal, state, tribal, , and local governments to develop funding and monitoring mechanisms to expunge cannabis-related records, decrease arrests, and support reentry and community development.
Minimizing harm to the public
- State, tribal, and local governments to develop and fund standards for commercial legal cannabis products, including standards related to quality, product characteristics that may appeal to children and youth (e.g., flavors, shapes, forms, names), and product safety (e.g., additives, potential modes of consumption, THC potency).
- State, tribal, and local governments to restrict the advertising and promotion of commercial cannabis products in retail environments (e.g., at the point of sale) and in the broader community, particularly in venues and locations frequented by youth.
- Federal, state, tribal, and local agencies and governments to routinely and consistently monitor cannabis use behaviors and perceptions utilizing evidence-based key indicators.
- State, tribal, and local governments engaged in cannabis regulation efforts to collaborate with state and local health departments in these efforts as a means of preventing and treating cannabis abuse and dependence.
- Any jurisdiction regulating cannabis to tax commercial cannabis products and dedicate the majority of the revenue to funding cannabis and other substance use prevention, education, treatment, research, and regulatory efforts.
- State, tribal, and local governments to retain strong smoke-free indoor air rules by prohibiting combustible/aerosolized cannabis use in indoor public commercial settings.
Monitoring patterns of cannabis use
- Federal, state, tribal, and local governments to support and fund monitoring of cannabis use behaviors and research into the health effects of cannabis use.
- Federal, , state, tribal, and local governments to develop and enforce rigorous standards for cannabis products that prohibit contaminants such as pesticides, heavy metals, microbials, and residual solvents (in concentrates).
- Federal, state, and tribal agencies and governments to develop standards and objective technologies for determining impaired operation of motor vehicles and other heavy machinery.
- Federal, state, and tribal agencies and governments to develop and expand the evidence base regarding the health effects of cannabis as well as the public health and safety outcomes that result from regulating commercial cannabis products.
- Federal, state, tribal, and local governments to review and assess any disproportionate impact as well as the public health effectiveness of cannabis regulations in states and countries that have legalized cannabis.
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