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¹ “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.

21 in Colorado and Washington state, and the establishment of a regulatory structure for retail sales. As of April 24, 2023, 38 states, three territories, and the District of Columbia allowed the medical use of cannabis products (Figure 1-1). As of November 8, 2023, 24 states had passed legislation legalizing cannabis sales and use by adults over 21 years of age.² Approved measures in 9 additional states allow the sale of products with low delta-9-tetrahydrocannabinol (THC) high cannabidiol (CBD) products in limited medical situations (NCSL, 2024a, 2024b). Although not all states have voted to legalize cannabis, cannabis is sold throughout the United States and online, mainly as a result of the definition of “hemp” in the 2018 Agriculture Improvement Act (PL-115-334).

Cannabis policy changes have been influenced by political campaigns that are often financed by wealthy donors (Gunther, 2024; NFIA, 2017). Initially, state medical programs were implemented out of compassion for patients seriously ill with AIDS or cancer for whom cannabis was thought to ease suffering (Goldberg, 1996). This process was furthered by proponents who exaggerated the medical or therapeutic benefits of cannabis and minimized its harms (Jernigan et al., 2021). Greater social acceptance of cannabis use and growing skepticism about the effort and expense involved in enforcing cannabis penalties also contributed (Felson et al., 2019). National survey data suggest a near-total reversal of public

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² Some state medical cannabis laws allow use among those under 21 years of age.

opinion on cannabis legalization over the last 50 years, with the proportion of survey respondents who support legalization increasing from 12 percent in 1969 to 70 percent in 2023 (Saad, 2023). Ballot initiatives in Colorado and Washington were supported by a broad swath of policy perspectives, including those of civil liberties organizations and drug policy reform groups (Martin, 2012).

More recently, cannabis policy reforms have been associated with strategies designed to adjust for the large racial inequalities in arrests for violations of cannabis prohibition. Although national arrest statistics have gaps in race and ethnicity data, it appears that White people are less likely to be arrested for cannabis use than are members of communities of color (Bunting et al., 2013; Resing, 2019). Cannabis policy reforms are supported by 85 percent of Black people (Edwards, 2022), as well as civil rights groups such as the National Chapter of the National Association for the Advancement of Colored People (NAACP, 2019), which have supported cannabis decriminalization and regulation of adult cannabis use.

Legalization has led to the widespread availability of cannabis. At least 79 percent of Americans now live in a county with a medical or adult-use cannabis retail outlet; this figure is an underestimate because of the availability of hemp products (Chapekis and Shah, 2024) (Figure 1-2). In many states, cannabis retailers are more concentrated in neighborhoods characterized by historical disadvantage (Amiri et al., 2019; Matthay et al., 2022; Shi et al., 2016). Retail access to cannabis is associated with calls to poison control, cannabis use in pregnancy, cannabis use–related hospitalizations during pregnancy, and increased cannabis use by adults (Cantor et al., 2024). Many people now worry that changes in cannabis policy, which in part have been touted as improving social justice, may be contributing to health inequities (Cantor et al., 2024).

CANNABIS USE AND HEALTH

People use cannabis for many reasons, both recreational and medicinal. Its intoxicating effects can be relaxing, invoke euphoria, and improve sociability and sensory perception. However, it is common for cannabis to impair short-term memory, worsen anxiety, and impair perception and motor skills (Agrawal et al., 2014). Acute outcomes, such as poisoning due to accidental overconsumption or cannabinoid hyperemesis,³ are also associated with cannabis use. Harms from cannabis use may come from the impacts of the drug itself or other constituents. For example, cannabis is often consumed

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³ “Cannabinoid hyperemesis syndrome” is a condition where a patient experiences cyclical nausea, vomiting, and abdominal pain after using cannabis, and it can cause intense pain (Chu and Cascella, 2023).

by smoking, and cannabis smoke has a strikingly similar profile to tobacco smoke in terms of its physical and chemical properties (Graves et al., 2020). Much as with tobacco, there are growing public health concerns about

exposure to secondhand cannabis smoke. Toxicological studies have shown that even brief exposure to secondhand cannabis smoke may impact blood vessel linings (Wang et al., 2016). One study in New York City found biomarkers of cannabis exposure in 20 percent of children enrolled in the study (Sangmo et al., 2021).

A prior report of the National Academies of Sciences, Engineering, and Medicine (2017) comprehensively reviews the literature on the health impacts of cannabis use. It categorizes the evidence reviewed into one of five categories: conclusive, substantial, moderate, limited, and no or insufficient. The report offers more than 100 conclusions on both the harms and the therapeutic effects of cannabis consumption (NASEM, 2017).

The 2017 report cites evidence of therapeutic benefit for a handful of conditions, despite many more purported medical benefits. There was conclusive evidence of therapeutic benefit for the use of oral THC-like cannabinoids (such as nabilone and dronabinol) in treating chemotherapy-induced nausea and vomiting. Substantial evidence supported the use of cannabis for managing chronic pain in adults and the effectiveness of oral cannabinoids (nabiximols and nabilone) in improving patient-reported spasticity symptoms in multiple sclerosis (NASEM, 2017).

NASEM (2017) also cites evidence for many harms associated with cannabis use. Substantial evidence linked cannabis use with an increased risk of motor vehicle collisions and the development of schizophrenia or psychosis, with the highest risk seen among frequent users. Furthermore, substantial evidence linked long-term cannabis smoking with respiratory issues, including increased chronic bronchitis, as well as lower birthweight in offspring exposed prenatally (NASEM, 2017). Evidence for many more potential harms was classified as moderate or limited (Annex Table 1-1). The 2017 report also notes many data gaps, although given that the literature searches for that study were completed in June 2016, some of those data gaps may now have been filled.

CHANGES IN CANNABIS PRODUCTS AND USE

At the same time that cannabis legalization has been occurring within the states, patterns of cannabis use have changed and new cannabis products have emerged, generating public health concerns. New cannabis products include those with high concentrations of delta-9-THC and those with cannabinoids that are less well studied (Box 1-1). According to the National Survey on Drug Use and Health (NSDUH), in 2002, 11 percent of the noninstitutionalized U.S. population aged 12 years or older reported past-year cannabis use. In 2019, that figure had risen to over 17 percent. The NSDUH began using new methods in 2020 and again in 2021, making comparisons with prior years difficult, but an

increase in past-year cannabis use for the same population appears to have continued from 2021 (19.1 percent) to 2022 (21.9 percent) (Figure 1-3). One important change is the increased prevalence of use among adults over age 65. In 2002, only 0.6 percent of adults over age 65 reported using cannabis in the past year; by 2019, that figure had risen to 5 percent, although this increase could be due to the aging of the population that uses cannabis. On the other hand, NSDUH estimates of past-year use are relatively constant across time for 12- to-17-year-olds. The percentage of 12- to 17-year-olds who used cannabis in the past year decreased

slightly from 2002 to 2019 (Figure 1-4) and remained consistent in 2021 (10.8 percent) and 2022 (11.4 percent). It is also important to note that cannabis use is socially stratified. Those with a college education have the lowest prevalence of use; additionally, those at or below the poverty line have a higher prevalence of use than those with two times the federal poverty level (see Chapter 3). It is important to note as well that national estimates of the prevalence of cannabis use may not represent what is occurring within states where cannabis has been legalized.

There are many types of cannabis products, which can be consumed through many routes of administration. The most common approach to using cannabis is by inhalation following either combustion (e.g., smoking cannabis flower or hashish, commonly rolled together with tobacco in European countries) or vaporization (e.g., heating oils, waxes, or plant material) (Figure 1-5).⁴ Cannabis can also be consumed orally (e.g., pills, capsules, edibles, beverages), while other products are manufactured to be absorbed through the skin (e.g., lotions, oils) or other membranes (e.g., suppositories). Cannabis products differ based on the concentration of delta-9-THC or the other cannabinoids that they contain.

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⁴ While flower products are typically consumed via smoking, it is also possible to vaporize them.

1990; Pomahacova et al., 2009), whereas vaping cannabis yields significantly higher delta-9-THC concentrations absorbed into the bloodstream (Budney et al., 2024; Pomahacova et al., 2009; Van der Kooy et al., 2008). These differences result in higher delta-9-THC blood levels and more pronounced intoxicating effects after vaping compared with smoking for the same sample of cannabis (i.e., sample weight and delta-9-THC concentration) (Spindle et al., 2018). Differences in metabolism can also influence the differences in effects of delta-9-THC between inhaled and oral modes of administration.

Oral ingestion results in slower absorption and more delayed peak concentrations. Ingestion can take roughly 30 minutes to 2 hours to induce intoxicating effects, which can be felt for 5–8 hours (Huestis, 2007;

Jernigan et al., 2021; NASEM, 2017). Oral delta-9-THC administration undergoes first-pass metabolism in the liver, leading to slower absorption of delta-9-THC and its active metabolites (see Figure 1-6). Effects after oral delta-9-THC administration are delayed and prolonged compared with inhalation, with peak effects occurring about 60 minutes after ingestion and lasting 4–12 hours, depending on a variety of factors, including dose and drug preparation (Karschner et al., 2009; Newmeyer et al., 2016, 2017; Sholler et al., 2021).

combustion of plant material (smoking) versus inhalation of concentrates. Nonetheless, the highly concentrated nature of dabs, wax, and shatter makes it possible to consume a higher dose of delta-9-THC because more of the intoxicating compound is delivered in a much smaller volume of product relative to plant material (Loflin and Earleywine, 2014; Raber et al., 2015), although the dose can be titrated. Concentrates are also heated to a very high temperature (Raber et al., 2015), producing highly concentrated vapor or aerosols that can be administered in few inhalations, whereas smoked cannabis requires the combustion of a relatively larger volume of material (Loflin and Earleywine, 2014; Raber et al., 2015).

FEDERAL ROLE IN CANNABIS POLICY

The federal role in cannabis policy is complex. As noted earlier, although now widely available in most states, cannabis has been classified as Schedule I under the CSA (PL-91-513), the primary policy in the United States for control of illicit drugs, from 1970, when the act was first passed, through the time of this writing (June 2024), although the Biden administration has recommended that it be rescheduled to Schedule III. Since cannabis is a Schedule I drug under the CSA, its manufacture, distribution, or possession remains a criminal violation under federal law, enforceable by the Drug Enforcement Administration (DEA) and other law enforcement agencies. The ability of states to implement cannabis policies stems from the concept of federalism, or “the division and sharing of power between the national and state governments” (CRS, n.d., para. 1). Other countries where cannabis is legal, such as Canada and Uruguay, have had much more involvement from their federal governments (see Chapter 2 for comparisons with other countries). The end of this chapter provides a more detailed history of cannabis policy in the United States.

Department of Justice Actions Toward State Cannabis Policy

The Ogden Memo was written in 2009 to address uncertainty regarding the federal role in enforcing cannabis policy in states that were early to legalize cannabis for medical use. It emphasized that because federal criminal enforcement typically is concerned with large-scale illicit drug trafficking, federal prosecutors generally should not focus on “individuals whose actions are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana” (Ogden, 2009, p. 2). The Ogden Memo also noted, however, that federal prosecutors should be concerned with cannabis activity connected to unlawful firearm possession, violence, sales to minors, illegal possession of other drugs, and ties to other criminal activity.

state regulatory authority unclear. A recent example is a preliminary injunction issued by a federal judge in Arkansas, which halted the implementation of a state law banning intoxicating hemp products (Demko, 2024). As of November 2023, 17 states had successfully banned delta-8-THC, and 7 had severely restricted its sale (Johnson and Willner, 2023). Recently, a bipartisan group of state attorneys general wrote to Congress asking it to act regarding what they term intoxicating hemp products and expressing concern that a public health crisis is looming (Demko, 2024; Elbein, 2024). Although the 2025 Agricultural Improvement Act may include an updated definition of “hemp” to encompass only nonintoxicating products, which would help address this confusion, that new Farm Bill had not passed as of July 2024 (Johnson, 2024).

Revised Cannabis Scheduling under the Controlled Substances Act

In 2022, the executive branch announced that the U.S. Department of Health and Human Services (HHS) and the Department of Justice would review the scheduling of botanical cannabis⁵ under the CSA (White House, 2022). Drug scheduling is a complex science policy process. HHS conducts an evaluation and makes a scheduling recommendation to the DEA in the form of an “eight-factor analysis” in accordance with the CSA (21 USC §§ 811[a–c], 812[b]). The eight-factor analysis weighs a drug’s potential for abuse, scientific backing, public health risks, dependence potential, and history of use. The analysis results inform decisions required for a drug scheduling recommendation, which reflects the drug’s potential for abuse, whether it has a federally accepted medical use in the United States, and its relative safety or ability to produce physical dependence compared with other drugs, as provided under 21 USC § 812(b). The process used by HHS to determine whether cannabis has a currently accepted medical use differed from that used in prior attempts to reschedule cannabis. Typically, currently accepted medical uses are determined using criteria that are most applicable to a drug with ample evidence from clinical trials. The usual approach to evaluation of a currently accepted medical use “left no room for an evaluation of (1) whether there is widespread medical use of a drug under the supervision of licensed health care practitioners under State-authorized programs and, (2) if so, whether there is credible scientific evidence supporting such medical use” (21 CFR Part 1308.2). As a result, HHS used a two-factor analysis to take into account the current widespread medical use of cannabis under

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⁵ Cannabinoid drugs fall within different areas of the CSA. Cesamet^™ (nabilone), synthetically derived delta-9-THC in a powder form, is Schedule II, and Marinol^® (dronabinol), synthetically derived delta-9-THC in liquid form, is Schedule III. Epidiolex, highly purified naturally derived cannabidiol, is Schedule V (DOJ/DEA, 2020).

the supervision of clinicians under state-authorized programs (21 CFR Part 1308.2; Budney et al., 2024).

Following its review, in August 2023, HHS recommended that the DEA change the scheduling of cannabis from Schedule I to Schedule III, and on April 30, 2024, the DEA announced that it accepted HHS’s proposal (HHS, 2023; Lampe, 2024; Miller et al., 2024). The change would have significant consequences should the White House Office of Management and Budget (OMB) approve that recommendation. Businesses in the legal cannabis industry cannot deduct many business expenses from their federal taxes. Rescheduling could change that situation because the limitations on federal tax deductions apply only to Schedule I and II substances. Moreover, cannabis is currently banned from interstate commerce, and a change to federal scheduling could make federal authorities less inclined to target cannabis businesses that transact cross-border sales (Sacirbey, 2023).

The most significant benefit of rescheduling cannabis from Schedule I to Schedule III would be in the reduction of, but not elimination of, the barriers to medical research on the therapeutic impacts of the plant (Wallack and Hudak, 2016). Schedule III drugs do not require separate researcher registration and have less stringent laboratory controls and more limited reporting requirements; therefore, more researchers may be willing to conduct research on the drug (Wallack and Hudak, 2016).

Rescheduling cannabis would create additional policy confusion. First, changing the schedule of cannabis would not make botanical cannabis a Food and Drug Administration (FDA)–approved prescription drug; FDA drug approval entails a different application process. Second, the state medical programs would still operate in violation of the CSA. Schedule III substances have accepted medical uses but have federal requirements for prescription and sale that differ significantly from the methods used in most state medical cannabis programs (Lampe, 2024). Schedule III substances require FDA approval before they can be prescribed by a physician and marketed as a medication. Moreover, if one or more cannabis products obtained FDA approval, manufacturers and distributors would need to register with the DEA and comply with regulatory requirements that apply to Schedule III substances. Cannabis users would need to obtain valid prescriptions for the substance from clinicians and obtain cannabis from a pharmacist (Lampe, 2024).

Exactly how the rescheduling of cannabis to Schedule III would impact state medical programs is unknown and would depend on how the FDA managed the rescheduling and how the courts interpreted the law. Assuming there was no further act by Congress to legalize cannabis, its supply and adult use would remain illegal under federal law, penalties would decrease, and medical access might increase across the states (since the federal government would have determined that cannabis has a currently accepted medical use).

Although the committee was asked to develop recommendations related to “strengthening a harm reduction approach, which would minimize harms, of various regulatory models, including but not limited to social, employment, education, and health impacts” the committee interpreted that task more broadly. It identified “harm reduction” as a series of approaches that reduce health and safety consequences for individuals and society associated with drug use or other behaviors (Vakharia, 2024). Additionally, while harm reduction services and approaches can have important implications for public health, the committee believed a broader set of recommendations, or a public health approach, was needed to respond to its statement of task.

Finally, although the statement of task refers explicitly to “adults,” the committee determined that any public health approach to cannabis policy would need a significant focus on youth. It is well known that for other substances, experimentation in adolescence may lead to lifelong use, which increases the potential for impacts on health and well-being.

Study Approach

The committee developed its public health approach to cannabis policy based on the published literature and the presentations and discussions during its large public meetings in fall 2023 and winter 2023–2024. In these public sessions, the committee heard from various stakeholders, including the CDC, NIH, and FDA; state cannabis regulators; public health officials; people impacted by adverse outcomes of cannabis use; those who grow cannabis and make cannabis products; and academic researchers studying cannabis policy, health effects, harm reduction, treatment, and primary prevention.

Social equity is central to the committee’s statement of task. This area often focuses on addressing racism and other forms of discrimination, but it is highly intertwined with health equity. Systems of power (which are influenced by social equity), individual factors, and physiological pathways all influence health equity. “Systems of power” are policies, processes,

and practices that determine who gets resources and better opportunities for health. These systems can promote health equity or perpetuate inequities in such areas as access to basic needs, humane housing, meaningful work, and reliable transportation. “Individual factors” concern people’s responses to social, economic, and environmental conditions through their attitudes, skills, and behaviors and the interaction of those factors with biological predisposition. “Physiological pathways” refers to a person’s biological, physical, cognitive, and psychological abilities (Peterson et al., 2021). The committee considers these issues throughout this report.

In carrying out this study, the committee considered the core public health functions (Box 1-4). A public health approach to cannabis policy

differs from other public policy–making approaches. Public health policy aims to improve the health of entire communities, not just individuals, which requires considering factors that influence health outcomes for large groups, such as access to healthy food or safe environments (Castrucci, 2021; Jernigan et al., 2021). Ideally, public health decisions are based on scientific research and data on the most effective interventions for preventing disease and promoting health within communities. Public health policy must often balance individual freedoms with promotion of the greater good. For example, smoking restrictions limit the personal choice of the smoker but reduce unhealthy exposures for everyone. Public health issues often are complex, requiring collaboration among government sectors such as education, transportation, and housing. Public health policy development also requires understanding community needs and wants and considering the economic impact, feasibility, and acceptability of implementing policies and programs. Public health policy is meant to be more preventive than reactive, aiming to prevent health problems before they occur.

Public health can inform many aspects of cannabis policy, such as policies on how cannabis is cultivated, processed, marketed, or sold, in addition to where it is sold and marketed, to whom, in what type of packaging, and under what circumstances. Public health policies can similarly target consumers, directly regulating how and where products can be consumed and under what circumstances. In intervening in these areas, the goals of public health policy are to mitigate the harms of legal markets while promoting the benefits of cannabis (Figure 1-8).

The committee found it difficult to delineate the differences between medical and adult-use policies and their public health consequences; therefore, this report focuses primarily on policies that legalize possession and some forms of supply to adults. Additionally, the two categories of use overlap across different policy regimes. Some people living in states with legal adult use will purchase cannabis without a recommendation from a medical provider to self-medicate for trouble sleeping or to unwind. On the other hand, some states with medical programs have such relaxed policies for obtaining cannabis for medical use that they do not differ significantly from adult-use states

(Pacula et al., 2014). Another source of confusion in any policy analysis is that the legal uncertainties posed by the 2018 Farm Bill have led to the availability of cannabis in most states (CANNRA, 2023; Elbein, 2024; Gottron et al., 2019; Johnson, 2023; Johnson and Willner, 2023; Rossheim et al., 2024).

ORGANIZATION OF THE REPORT

Figure 1-9 provides an overview of the steps taken by the committee to address its charge. The report is organized around this framework. Following the overview of the study’s public health and social context in this chapter, Chapter 2 reviews the U.S. approach to cannabis policy making compared with those of other countries. Chapter 3 examines cannabis use and markets in the United States. Chapter 4 applies core public health concepts to cannabis policy and considers how the harms associated with that policy can be mitigated. Chapter 5 describes the impacts of cannabis policy on social and health equity. Finally, Chapter 6 reviews the literature evaluating the public health impacts of cannabis policy and provides research recommendations.

HISTORY OF CANNABIS POLICY IN THE UNITED STATES

Discussion of public policies related to cannabis use depends on a comprehensive understanding of the drug’s chemistry and physiological effects. As mentioned previously, the plant itself and the products derived from it have evolved over the past few decades. However, because public policy is influenced by historical context as well, a review of the history of cannabis policy is essential for understanding the current U.S. policy landscape.

Early State Cannabis Control Policies, ~1860s to ~1940s

For much of U.S. history, state governments have led the way in cannabis regulatory activity, building on traditions of local control of public health and safety and given constitutional authority under the 10th Amendment. State legislative activity has generally preceded corresponding federal policies.

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⁶ An early version of scheduling, the United Nations Single Convention on Narcotic Drugs (1961), had also controlled cannabis in the most stringent schedules, reserved for substances with serious risk of abuse and extremely limited medical or therapeutic value.

encouraged the NIH and Food and Drug Administration (FDA) to consider supporting cannabis research. In the same year, the National Organization for the Reform of Marijuana Laws filed a petition with the Bureau of Narcotics and Dangerous Drugs (now the DEA) to reschedule cannabis to Schedule II, enabling legal physician prescription. That petition ultimately failed, as did subsequent petitions to do the same in 1995, 2002, and 2011.

Interest in the therapeutic utility of cannabis reemerged in the 1960s and 1970s, spurred on the laboratory front by the isolation of THC in 1964 and the synthesis of THC in 1967, and more popularly by advocacy from patient groups and a renewed appreciation of plant-based medicine (Dufton, 2017; Taylor, 2008, 2022). In 1978, the Compassionate Investigational New Drug (IND) program allowed access to medical cannabis for a limited number of patients (Clark et al., 2011). Nevertheless, federal policy on medical cannabis saw only modest changes in the later 1970s.

Federal Approvals of Cannabinoid Drugs, 1980 to the Present

Federal approval of synthetic cannabinoids for medical use represented the next policy evolution in the remedicalization of cannabis. In 1980, the National Cancer Institute supported the use of dronabinol as an investigational antinausea drug for chemotherapy patients (Sawtelle and Holle, 2021). In 1985, the FDA approved dronabinol to treat nausea and vomiting associated with cancer chemotherapy (IOM, 1999). FDA approvals since then include other indications and formulations for dronabinol, the THC analog nabilone, and cannabidiol (FDA, 2023; Todaro, 2012).

Cannabis for Research

Research supporting the process of cannabis remedicalization has long been hindered by significant problems in obtaining reliable supplies of raw material for study (Taylor, 2022). In 2020, a change in DEA rulemaking allowed for multiple sources of cannabis supply for researchers, who for more than a half-century had relied solely on a single federally approved source at the University of Mississippi (DEA, 2020). Now, several other cultivation facilities have DEA licenses,⁷ but they may not yet meet federal research requirements imposed by the FDA. Federal support of medical cannabis research received further attention with the passage of the Medical Marijuana and Cannabidiol Research Expansion Act of 2022, which aims to encourage medical research on cannabis (Purcell et al., 2022).

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⁷ https://www.deadiversion.usdoj.gov/drugreg/marihuana.html (accessed August 10, 2024)

New Mexico’s Controlled Substances Therapeutic Research Act was intended to protect scientific research. The New Mexico model deferred to, rather than challenged, federal policy dominance by essentially creating a state-level version of the federal research program described above. More than 20 states followed New Mexico’s lead, although most never created research programs. In practice, the administrative burden of such programs limited their scope (Randall and O’Leary, 1999). In 1979, Illinois took an alternative approach, passing legislation that gave physicians with a controlled substances license the authority to prescribe cannabis for patients with debilitating conditions (Public Act 098-0122, 2014). A few other states⁸ adopted similar legislation between 1981 and 1996.

State medical cannabis programs tended to be bureaucratically complicated and costly to run (Randall and O’Leary, 1999). The 1985 FDA approval of dronabinol described above may have dampened enthusiasm for further medical cannabis programs. There was also a growing antidrug sentiment in the 1980s, along with momentum for increased prosecutorial action from the government (Chaiken and McDonald, 1988; Mold, 2021; Pascual, 2021, p. 1760). Taken together, these factors contributed to reducing state interest in medical cannabis programs.

State-Level Medical Cannabis, 1996 to the Present

In 1996, by ballot initiative, California voters passed Proposition 215, the Compassionate Use Act, allowing for medical cannabis use outside of FDA-approved indications and formulations (Uniform Controlled Substances Act, 2017). The ideas behind Proposition 215 were not new. However, the successful use of the ballot initiative broke a political logjam around medical cannabis. Initiative supporters enjoyed a substantial fund-raising advantage and deployed their resources in a politically savvy public campaign. By activating popular support for patients’ rights and creating an exemption from prosecution for patients and caregivers, Proposition 215 challenged federal policy dominance in ways no previous state policy had done. Clinical providers were allowed to recommend cannabis for any illness where it could provide relief, thus access was widely available.

Proposition 215 ushered in the “ballot initiative era” of medical cannabis policy. While the federal government remained explicitly opposed to such actions, voters expressed a different view. Of the states that have authorized medical cannabis use, most did so through a ballot initiative (Orenstein and Glantz, 2020). The resulting medical cannabis policies varied widely. Some were thinly veiled legal adult-use programs, while others had more complex requirements (Pacula and Smart, 2017; Pacula et al., 2015).

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⁸ Connecticut, New Hampshire, Vermont, Virginia, and Wisconsin.

political pressure, cultural attitudes, and public opinion (DeFleur, 1975; Reiss, 1971; Skolnick, 1966).

Patterns of bias in cannabis law enforcement have evolved over time. Cannabis policing in the 1920s and 1930s was highly localized and episodic, reflecting patterns of generally low law enforcement interest, with occasional moments of higher priority. During this period, cannabis arrests appear to have constituted a small proportion of overall drug law enforcement activity. The policing of opiates and cocaine had the highest priority, and cannabis arrests were often incidental to enforcement activity directed at these substances. Moreover, racial disproportion in these early years is not particularly apparent (Campos, 2018; Rathge, 2018).

During the 1940s and 1950s, while cannabis remained a secondary concern for law enforcement, racial disproportion in drug enforcement took on far more significance (Frydl, 2013). Many states classed cannabis as a “narcotic,” and simple possession could be a felony offense. Mandatory minimum drug sentencing laws, adopted in the 1950s by the federal government and many individual states, generally included cannabis (Frydl, 2013). Consequently, while overall levels of cannabis arrests remained low, legal sanctions increased, and racial disproportion emerged as a significant problem.

The first significant prioritization of cannabis law enforcement emerged with the general rise of cannabis use among college- and high school–age populations in the 1960s. Public concern over youth consumption led law enforcement to take a specific interest in cannabis, and the result was a substantial increase in arrests and convictions in that decade. California led the way, with a startling 20-fold increase in the number of cannabis arrests from 1962 to 1972, 95 percent of which were for felony charges and most for possession (Lassiter, 2023; Polson, 2021). In Chicago, officers reported pressure from their superiors to focus arrest activities on white youth and marijuana (DeFleur, 1975). As enforcement priorities shifted toward cannabis, the proportion of drug arrests involving cannabis increased—accounting for more than half of all drug arrests by 1967 (DOJ, 1968; Dufton, 2017; Lassiter, 2023).

This surge of cannabis enforcement activity, with its focus on younger White people from suburban areas, is largely forgotten today but yielded substantial numbers of felony arrests and convictions for simple possession. Drug enforcement was overwhelmingly biased toward racial minorities in this period, but cannabis enforcement represented an interesting exception. Cannabis arrests were a mechanism for targeting “hippie” groups and political activists, and school grounds and college campuses were a convenient enforcement target in the cultural battle over the drug (Dufton, 2017; Lassiter, 2023; Sanders, 1975; Smith, 1969).

The same social trends that encouraged nascent decriminalization efforts in the 1970s also led several states to reclassify cannabis in their criminal statutes, separating it from the general category of “narcotics” and reducing formerly draconian penalties for cannabis possession (Dufton, 2017; Lassiter, 2023). Changes to California law, for example, now allowed

district attorneys to opt into a misdemeanor charge for cannabis; in some jurisdictions, misdemeanor charges became the norm for individuals with no prior convictions or with small amounts in possession. Concerns that cannabis law enforcement could alienate a whole generation of Americans (Hills, 1970), with a particular focus on shielding middle-class White youth from the criminal justice system, gradually led not only to a reduction in criminal penalties but also to a pause in the growth of cannabis arrests nationally (Lassiter, 2023). Arrests peaked in 1973 at 200 per 100,000 residents and stayed roughly level until the mid-1980s, then actually fell through the early 1990s, as did the relative share of cannabis arrests in total drug arrest activity (Beckett and Herbert, 2008).

The next historical chapter of cannabis law enforcement emerged in the 1990s, marked by historically unprecedented levels of arrests. Data from the Federal Bureau of Investigation’s Uniform Crime Report show that cannabis arrests began rising in 1992 and by 1994 had surpassed previous 1970s-era peaks. This pattern of increase in enforcement activity continued through 2007. A few features of the 1992–2007 enforcement era stand out. First, cannabis possession offenses were the main driver of increased arrest totals; relegated to a lower priority in the past, strict enforcement of possession laws emerged as standard enforcement practice. In New York City, this change in priority sent cannabis possession arrests soaring, from a mere 774 in 1991 to more than 50,000 in the year 2000 (Geller and Fagan, 2010). Cannabis arrests once again rose to more than half of all drug arrests nationally (Golub et al., 2007; King and Mauer, 2006) (Figure 1-10).

Second, the 1992–2007 enforcement period featured significant racial disproportion, as numerous contemporary studies confirmed (Beckett et al., 2005, 2006; Cole, 1999; Tonry, 2011)—the highest levels of racial disproportion in the history of U.S. cannabis law enforcement. Racial disproportion entered every phase of the process, including initial stop, arrest, pretrial detention, charge, and final disposition (Geller and Fagan, 2010; Golub et al., 2007). Whether this disproportion is understood as a reflection of drug markets or enforcement tactics (Coker, 2002; Tonry, 1995) or of explicit racial bias (Alexander, 2010; Beckett et al., 2005, 2006), or as a broader consequence of institutional racism (Cole, 1999; Lynch and Campbell, 2011), it remains true that because of these enforcement patterns, the impact of cannabis enforcement was not experienced evenly.⁹

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⁹ The extreme racial disproportion in cannabis arrests during this latter period reflects a historical truism that drug law enforcement has always reflected particular social control agendas, equally true whether the focus was on “hippies” on college campuses in the 1960s or urban minority youth in the 1990s. Antidrug policies have always patterned themselves around larger social and political agendas, while resting upon a foundation of sentiment opposing the drugs themselves. In the case of the 1992–2007 period, cannabis continued to be framed as a dangerously addictive drug, a gateway drug, and a source of violent behavior. In a 2002 letter to state and local prosecutors, the White House Office of National Drug Control Policy averred that no drug matches the threat posed by marijuana (Lassiter, 2023).

of the Higher Education Act¹⁰—that collectively limited or cut off access to federally funded health care programs, federal education aid, federally subsidized housing, welfare and food stamp benefits, and more (Chin, 2002; Silva, 2015).

Conclusion

This brief survey of historical patterns in cannabis law enforcement suggests that the contemporary period of adult-use cannabis legalization emerged out of a precise historical moment during which criminal justice activity, collateral consequences of drug law convictions, and racial inequity in cannabis law enforcement were all at historically high levels.

History demonstrates that cannabis policy is a complex and contested sociopolitical landscape. The following chapters delve deeper into this critical issue, exploring core public health concepts as they relate to cannabis, examining usage patterns and markets, and analyzing the impact of current and potential cannabis policies on public health outcomes. Understanding of these various dimensions of cannabis policy can allow society to move toward a more informed and equitable approach to cannabis regulation.

REFERENCES

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¹⁰ Federal student aid is now allowed among those with a drug conviction (see https://studentaid.gov/help-center/answers/article/do-drug-convictions-affect-ability-to-get-federal-student-aid [accessed August 14, 2024]), but state aid may still have restrictions.

SOURCE: Adapted from NASEM, 2017.