Cannabis Policy Impacts Public Health and Health Equity (2024)
Chapter: Front Matter
Consensus Study Report
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This activity was supported by contracts between the National Academy of Sciences and Centers for Disease Control and Prevention [through the National Council for Behavioral Health and the National Council for Mental Wellbeing (#27170005)], the National Institutes of Health (Contract no. HHSN263201800029I, Task Order no. 75N98023F00007), and the National Academy of Sciences Cecil and Ida Green Fund. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Cannabis policy impacts public health and health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/27766.
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COMMITTEE ON THE PUBLIC HEALTH CONSEQUENCES OF CHANGES IN THE CANNABIS POLICY LANDSCAPE
STEVEN M. TEUTSCH (Chair), University of Southern California
YASMIN L. HURD (Vice Chair), Icahn School of Medicine at Mount Sinai
DOUGLAS A. BERMAN, The Ohio State University
ASHLEY BROOKS-RUSSELL, Colorado School of Public Health
MAGDALENA CERDÁ, New York University, Grossman School of Medicine
ZIVA D. COOPER, University of California, Los Angeles School of Medicine
DUSTIN T. DUNCAN, Columbia University
DEBRA M. FURR-HOLDEN, New York University, School of Global Public Health
SEAN HENNESSY, University of Pennsylvania, Perelman School of Medicine
BEAU G. KILMER, RAND
ELLEN T. KURTZMAN, Rutgers University
ROSALIE L. PACULA, University of Southern California
JOSEPH F. SPILLANE, University of Florida
DONALD R. VEREEN, University of Michigan
LARRY WOLK, Wonderful Health and Wellness
KELLY C. YOUNG-WOLFF, Kaiser Permanente, Division of Research
NICKOLAS ZALLER, University of Arkansas for Medical Sciences
Study Staff
ELIZABETH BARKSDALE BOYLE, Study Director
KHALA HURST-BEATTY, Associate Program Officer
ALEXANDRA MCKAY, Research Associate
MIA SALTRELLI, Senior Program Assistant
ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice
Y. CRYSTI PARK, Program Coordinator
National Academy of Medicine Fellow
RUCHI FITZGERALD, Service Chief, Inpatient Addiction Medicine at PCC Community Wellness (until February 2024)
Christine Mirzyan Fellow
MATTHEW BOEHM (April–May 2024)
Consultants
EITAN AGAI, Pico Portal, Inc.
ALON AGAI, Pico Portal, Inc.
ALLIE BOMAN, Briere Associates, Inc.
ANNE E. BOUSTEAD, University of Arizona
RONA BRIERE, Briere Associates, Inc.
MYFANWY GRAHAM, University of Newcastle
DAVID HAMMOND, University of Waterloo
DANIELLE NASENBENY, Briere Associates, Inc.
SEEMA CHOSKY PESSAR, University of Southern California
POOJA SHAH, New York University Langone Health
LAUREN TOBIAS, Maven Messaging
CAROLINE MARSHALL TRIOLO, New York University, School of Global Public Health
RENÉE WILSON, Johns Hopkins University
JOY ZHU, University of Southern California Schaeffer Center
Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by LINDA C. DEGUTIS, Yale School of Public Health, and ERIC B. LARSON, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Acknowledgments
Many people were critical in helping the committee accomplish its charge. The committee gratefully acknowledges the speakers at its public meetings. This engagement ensured that our public meetings would include a range of relevant perspectives, which allowed us to learn about the context for the changes in cannabis policy central to our charge. In addition, we found the information and perspectives provided by the presentations and discussions at our public meetings immensely helpful in informing our deliberations (see Appendix B).
The committee’s work was enhanced by the technical expertise, writing contributions, data analysis, evaluations, visualization, and other support provided by Eitan Agai, Alon Agai, David Hammond, Seema Chosky Pessar, Renée Wilson, Lauren Tobias, Anne E. Boustead, Myfanwy Graham, Joy Zhu, Pooja Shah, and Caroline Marshall Triolo, who served as consultants.
The committee thanks the staff of the National Academies of Sciences, Engineering, and Medicine who contributed to producing this report, especially the extraordinary, creative, and tireless study staff: Elizabeth Boyle, Khala Hurst Beatty, Alexandra McKay, Mia Saltrelli, Y. Crysti Park, and Rose Marie Martinez. Thanks go as well to other staff in the Health and Medicine Division who provided additional support, including Monica Feit, Samantha Chao, Taryn Young, Leslie Sim, Amber McLaughlin, Marguerite Romatelli, Ben Hubbert, and Lori Brenig. This project also received important assistance from Megan Lowry (Office of News and Public Information) and Misrak Dabi (Office of Financial Administration). Valuable research assistance was provided by Anne Marie Houppert and Rebecca Morgan, senior research librarians at the National Academies Research Center. Finally, a thank you is
extended to Rona Briere, Allie Boman, and Danielle Nasenbeny, who assisted the committee with editing the report.
CANNABIS REGULATORY REGIMES ACROSS THE WORLD
CANNABIS REGULATION IN THE UNITED STATES
CANNABIS LEGALIZATION IN CANADA AND URUGUAY
CONCLUSIONS AND RECOMMENDATIONS
3 Cannabis Consumption and Markets in the United States
TRENDS IN PERCEIVED AVAILABILITY OF CANNABIS AND CANNABIS USE PATTERNS
TRENDS IN CANNABIS CONCENTRATION AND PRICES
WHAT IS HAPPENING WITH THE ILLEGAL CANNABIS MARKET?
4 Applying the Core Public Health Functions to Cannabis Policy
CONCLUSIONS AND RECOMMENDATIONS
5 How Cannabis Policy Influences Social and Health Equity
IMPACTS ON HEALTH EQUITY RELATED TO CRIMINAL JUSTICE
STATE- AND LOCAL-LEVEL CANNABIS EQUITY PROGRAMS
CONCLUSIONS AND RECOMMENDATIONS
6 Available and Needed Research on Cannabis Policy
HEALTH EFFECTS OF CANNABIS RESEARCH NEEDS
LITERATURE REVIEW ON PUBLIC HEALTH IMPACTS OF CANNABIS POLICY
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Boxes, Figures, and Tables
BOXES
S-1 Public Health Challenge Due to the Definition of “Hemp” in the 2018 Agricultural Improvement Act
S-2 Public Health Approach to Cannabis Policy
S-3 Cannabis Policy Research Agenda
1-1 Cannabis and Cannabinoids: A Primer
1-2 Pharmacological Terms Important to Understanding Cannabis Intoxication
1-4 Public Health Approach to Cannabis Policy
1-5 Schedules of Drugs in the Controlled Substances Act
1-6 Decriminalization and Legalization
1-7 Lessons of Prohibition and Its Repeal
FIGURES
S-1 Map of state-level cannabis legalization
S-2 Organization of the report
1-1 Map of state-level cannabis legalization
1-3 Self-reported past-year cannabis use by age, 2002–2022
1-4 Self-reported past-year cannabis use, comparing 2002 with 2019
1-5 Examples of cannabis products
1-9 Organization of the report
1-10 Drug Arrests in the United States, 1995–2019
2-1 Twelve alternatives to status quo prohibition of cannabis supply
2-4 Outlet density in legal nonmedical cannabis states as of January 2023
2-5 State taxation of cannabis
3-1 Perception of availability of cannabis by age group, NSDUH, 2002–2022
3-2 Perception of availability of cannabis by race or ethnicity, NSDUH, 2002–2022
3-5 Past-year cannabis use by race or ethnicity, NSDUH, 2002–2022
3-6 Past-year cannabis use by sex, NSDUH, 2002–2022
3-7 Past-year cannabis use among pregnant persons, NSDUH, 2002–2022
3-8 Past-year cannabis use among veterans, NSDUH, 2002–2022
3-9 Past-year cannabis use by family poverty status, NSDUH, 2002–2022
3-10 Past-year cannabis use by education level (ages 18 and older), NSDUH, 2002–2022
3-11 Past-month cannabis use by age group, NSDUH, 2002–2022
3-13 In 2022, more people reported using cannabis than alcohol on a daily or near-daily (DND) basis
3-15 Estimated cannabis use days in the past year by age group (in billions), NSDUH, 2002–2022
3-16 Daily/near-daily cannabis use by race or ethnicity, NSDUH, 2002–2022
3-17 Daily/near-daily cannabis use by education level (ages 18 and older), NSDUH, 2002–2022
3-18 Daily/near-daily cannabis use among pregnant persons, NSDUH, 2002–2022
3-22 Past-month cannabis use by mode of administration for those aged 12 and over, NSDUH, 2022
3-23 Past-month cannabis use: Smoking, NSDUH, 2022
3-24 Past-month cannabis use: Eating/drinking, NSDUH, 2022
3-25 Past-month cannabis use: Vaping, NSDUH, 2022
3-26 Past-month cannabis use: Dabbing, NSDUH, 2022
3-27 Past-year cannabis abuse or dependence by age group, NSDUH, 2002–2020
3-28 Past-year cannabis use disorder among pregnant persons, NSDUH, 2021-2022
3-30 Median market price for a pound of “bud” in Colorado’s state-legal market
3-31 Median wholesale price per pound for “usable marijuana” in Oregon’s state legal market
3-32 Retail price per 10-mg THC in Washington state’s legal market through 2017, by type for product
3-33 Marijuana seizures at the U.S. southwest border, 2013–2023
4-2 The phases of the public health surveillance
4-3 Examples of Centers for Disease Control and Prevention (CDC) to implement its cannabis strategy
4-4 Histograms showing the number of listed cannabis contaminants regulated as of May 18, 2022
5-1 Cannabis arrests over time, stratified by race, from two articles
5-2 Conceptual model for how policies impact the social determinants of health and health equity
6-1 Risk-of-bias heat map for the identified systematic reviews
TABLES
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Preface
The landscape of cannabis legalization in the United States has been changing dramatically. Cannabis is now available throughout the United States, with policies that vary significantly in terms of public health protection. In most states, legalization occurred through ballot initiatives and public ad campaigns often financed by wealthy donors. Voters acknowledged cannabis’s widespread use, its large illegal market, the criminalization of seemingly minor infractions, and discrimination in enforcement. Today, changes in the classification of cannabis under the federal Controlled Substances Act are pending, as is a possible change in the definition of “hemp.” These sweeping changes are occurring when many of the health consequences of cannabinoids remain quite uncertain. And those changes are coupled with a disturbing legacy of discrimination during the “war on drugs,” with associated devastating consequences for individuals and communities of color in particular. The legalization of an increasingly powerful intoxicating drug has necessitated a greater fusion of public health and drug policy in the states.
In the face of this complexity, how, then, is one to assess the consequences of the changes in cannabis policy for public health and social equity? This was the charge to the Committee on the Public Health Consequences of Changes in the Cannabis Landscape. The 2017 report of the National Academies of Sciences, Engineering, and Medicine, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, focuses on the health effects and potential therapeutic benefits of cannabis, noting the paucity of high-quality studies on its health effects. Regrettably, little has changed in this regard since that
report was published, and scant to no research exists on the explosion of new cannabis and cannabinoid products. The present report focuses on the public health consequences of cannabis policies that have not been examined by the National Academies.
States have received little federal guidance on how to proceed regarding the health impact of cannabis on the public and communities. Other than two memoranda deferring to states, the federal government has been noticeably missing from this dialogue. Yet cannabis can cause real harms, as multiple investigators, families, and various groups attested to our committee. The tools of public health—assessment, policy development, and assurance—can provide the critical health information decision makers need to protect the public health and make amends for past cannabis-related inequities, but those tools are only slowly being applied.
With legalization by states now widespread, it is time to ask about its impact, especially given the large variation in state policies. These natural experiments provide a rich but very complex set of experiences for analysis, but these policies are all of relatively recent vintage. Consequently, available products, use patterns, and markets have not yet stabilized. Facing these challenges, the committee reviewed what is known about these policies, formulated recommendations where possible, and delineated a path forward. With a strong commitment to policy research and the application of traditional public health tools, we fully anticipate that better and more consistent policies will unfold.
This report would not have been possible without the deep expertise, wide range of perspectives, and strong commitment of all the committee members. Elizabeth Boyle, study director, and her National Academies colleagues, Khala Hurst-Beatty, Alexandra McKay, and Mia Saltrelli, labored long and hard to tie together all the disparate pieces of this report. We are deeply grateful to all of them. Lastly, we want to express our appreciation to our sponsors, the Centers for Disease Control and Prevention and the National Institutes of Health, without whose vision this study would not have been possible.
Steven M. Teutsch, Chair
Yasmin L. Hurd, Vice Chair
Committee on the Public Health Consequences of Changes in the Cannabis Landscape
Acronyms and Abbreviations
| ACOG | American College of Obstetricians and Gynecologists |
| APHA | American Public Health Association |
| ASTHO | Association of State and Territorial Health Officials |
| BAC | blood alcohol content |
| CAERS | Adverse Event Reporting System |
| CBD | cannabidiol |
| CDC | Centers for Disease Control and Prevention |
| CSA | Controlled Substances Act |
| CSTE | Council of State and Territorial Epidemiologists |
| DEA | Drug Enforcement Administration |
| DFC | Drug-Free Communities |
| DND | daily/near-daily |
| DSM | Diagnostic and Statistical Manual of Mental Disorders |
| ED | emergency department |
| ELTRR | Federal Plan for Equitable Long-Term Recovery and Resilience |
| EPA | Environmental Protection Agency |
| EVALI | e-cigarette or vaping product use–associated lung injury |
| FAERS | FDA Adverse Event Reporting System |
| FBI | Federal Bureau of Investigation |
| FBN | Federal Bureau of Narcotics |
| FDA | Food and Drug Administration |
| HHS | U.S. Department of Health and Human Services |
| ICPS | International Cannabis Policy Study |
| IRCCA | Institute for the Regulation and Control of Cannabis |
| JJ-TRIALS | Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System |
| LST | Life Skills Training (program) |
| MLPA | minimum legal purchase age |
| NACCHO | National Association of County and City Health Officials |
| NCSL | National Conference of State Legislatures |
| NGA | National Governors Association |
| ng/mL | nanograms per milliliter |
| NIH | National Institutes of Health |
| NIOSH | National Institute for Occupational Safety and Health |
| NSDUH | National Survey on Drug Use and Health |
| OLCC | Oregon Liquor and Cannabis Commission |
| OMB | Office of Management and Budget |
| ONDCP | Office of National Drug Control Policy |
| ROBIS | Risk Of Bias In Systematic Reviews |
| SAMHSA | Substance Abuse and Mental Health Services Administration |
| THC | tetrahydrocannabinol |
| THCA | tetrahydrocannabinolic acid |
| UCR | Uniform Crime Reporting |
| USDA | U.S. Department of Agriculture |
| USP | U.S. Pharmacopeia |
| USPSTF | U.S. Preventive Services Task Force |
| WHO | World Health Organization |
Key Terms
| Cannabis | “Cannabis” is a broad term that can be used to describe products (e.g., cannabinoids, marijuana, hemp) derived from the Cannabis sativa plant. These products exist in various forms and are used for various purposes (e.g., medical, industrial, social). The all-encompassing word “cannabis” has been adopted as the standard terminology within scientific and scholarly communities. The committee uses the term “cannabis” rather than “marijuana” throughout this report. |
| Cannabis abuse and dependence | Cannabis “abuse” and “dependence” are terms that are derived from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). DSM-IV was based on seven criteria related to symptoms, duration, and impact on daily functioning. A diagnosis of cannabis abuse required meeting one or more of four criteria, and cannabis dependence required meeting three or more of the seven total criteria. |
| Cannabis club or cannabis social club | Cannabis clubs are typically formal, nonprofit associations of adult cannabis users who produce and distribute that substance close to or at cost among themselves.1 |
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1 Pardal, M. (Ed.). 2022. The cannabis social club. London: Routledge.
| Cannabinoid hyperemesis syndrome | Cannabinoid hyperemesis syndrome is a condition in which a patient experiences cyclical nausea, vomiting, and abdominal pain after using cannabis. This disorder is characterized by (1) several years of preceding cannabis use, predating the onset of illness; (2) a cyclical pattern of hyperemesis every few weeks to months, at which time the patient is still using cannabis; and (3) resolution of the symptoms after cessation of cannabis use, confirmed by a negative urine drug screen.2 |
| Cannabis industry | The legal cannabis industry includes companies involved with the cultivation, processing, manufacturing, distribution, sale, and marketing of cannabis or cannabinoids for medical or adult use. Pharmaceutical manufacturers of Food and Drug Administration (FDA)–approved cannabis products are not typically considered part of the cannabis industry. |
| Cannabis use | “Cannabis use” refers to any use of cannabis for medical or other purposes. |
| Cannabis use disorder | Cannabis use disorder is a clinical diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). DSM-V combines elements of DSM-IV and dependence into a single category of “cannabis use disorder” with varying degrees of severity—mild (presence of 2–3 criteria), moderate (4–5 criteria), and severe (6+ criteria). |
| Collateral consequences | Penalties occurring because of a criminal encounter, which include loss of certain civil rights, such as voting, have long been a part of the experience of punishment in the United States and may play a role in perpetuating health disparities in marginalized groups.3 |
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2 Chu, F., and M. Cascella. 2023. Cannabinoid hyperemesis syndrome. Treasure Island, FL: StatPearls Publishing.
3 Adapted from: Lhamon, C., P. Timmons-Goodson, D. P. Adegbile, G. L. Heriot, P. N. Kirsanow, D. Kladney, K. Narasaki, and M. Yaki. 2019. Collateral consequences: The crossroads of punishment, redemption, and the effects on communities. Washington, DC: United States Commission on Civil Rights.
| Decriminalization | Decriminalization describes policies that remove the criminal status and criminal penalties associated with simple cannabis possession (typically small amounts) and use.4 |
| Harm reduction | A series of approaches that reduce health and safety consequences for individuals and society associated with drug use or other behaviors. |
| Health equity | Health equity refers to everyone having the opportunity to attain their full health potential, and no one being disadvantaged from achieving this potential because of any socially defined circumstance. |
| Legalization | Legalization removes criminal and monetary penalties for the supply of cannabis for adult use purposes, in addition to removing these penalties for possession and use.4 |
| Public health | Public health describes what society does collectively to ensure conditions in which people can be healthy.5 |
| Social equity | Social equity requires valuing everyone equally through focused and ongoing societal efforts to address avoidable inequalities and historical and contemporary injustices. |
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4 Adapted from: Pacula, R. L., and R. Smart. 2017. Medical marijuana and marijuana legalization. Annual Review of Clinical Psychology 13:397-419.
5 Institute of Medicine. 1988. The future of public health. Washington, DC: The National Academies Press.
