collection and public health research, but it is more complex. Surveillance is an ongoing system that aims to inform the decisions or actions of a public health authority (Otto et al., 2014). Surveillance should start with a plan. Crafting a surveillance plan requires careful consideration of the system’s goals, essentially answering the question, “What do you want to know?” Those goals in public health surveillance include understanding the incidence or prevalence of a specific behavior, disease, or health outcome; establishing public health priorities; conducting program evaluation; and allocating resources (Teutsch, 2010).

potential product–outcome relationships by calculating disproportionality metrics of product–outcome pairs that are observed more frequently among the anecdotal reports than would be expected by chance (Fornasier et al., 2018; Nour and Plourde, 2019).

While spontaneous reporting systems are still widely used for pharmacovigilance, their use has been supplemented by screening studies of health care data aimed at identifying potential novel associations between medical products and adverse outcomes in recent years. Signals of potential medical product–outcome associations identified through spontaneous reporting systems or screening analyses of health care data are often strengthened and confirmed (or weakened and refuted) through subsequent epidemiologic studies using health care data or systematic investigation (Bate et al., 2019).

The FDA has approved a few cannabinoid drugs—Cesamet^™ (nabilone), Marinol^® (dronabinol), and Epidiolex. These drugs are monitored for safety

in existing pharmacovigilance systems. While cannabis and cannabis-derived products are not currently FDA-approved medications, the agency leverages two electronic databases—the FDA Adverse Event Reporting System (FAERS) and the Center for Food Safety and Applied Nutrition’s Adverse Event Reporting System (CAERS)—to monitor their safety profile (FDA, 2023, 2024a).

FAERS and CAERS are passive surveillance systems that rely on voluntary reporting of adverse events and product quality concerns. These reports can originate from diverse stakeholders, including health care professionals, consumers, and law enforcement officials. The FDA facilitates reporting through established channels such as the MedWatch Program, the Safety Reporting Portal, and the Consumer Complaints process. This broad accessibility allows for the collection of data from a wide range of populations, potentially uncovering safety signals that might otherwise be missed (FDA, 2023, 2024a).

The FDA could use FAERS and CAERS data regarding cannabis products to inform regulatory decisions and guide public health education. If concerning trends were identified within the data, the FDA could take appropriate regulatory actions, such as product recalls or safety warnings, to safeguard public health. The FDA could also develop targeted public health communications highlighting specific safety concerns associated with cannabis use. For example, the FDA has warned consumers about children’s accidental ingestion of cannabis edibles that were mistaken for commonly consumed foods such as breakfast cereal, candy, and cookies (FDA, 2022).

The anecdotal nature of FAERS and CAERS data introduces inherent limitations. Passive systems such as these substantially underreport events. Reported events may not be entirely representative of the entire cannabis-consuming population, and definitively establishing causality between a product and a reported event can be challenging. Another limitation is that passive reporting systems require that people know of their existence to capture adverse events. However, increasing public awareness of the reporting system can increase the reporting of cases, making it difficult to interpret whether an increase in cases indicates increasing problems (Thacker and Berkelman, 1988).

Research

Public health assessment includes research aimed at determining the root causes of any problems identified in the surveillance system or identifying new problems or issues that should be tracked in the system. Research and surveillance have many commodities and can use the same datasets. A critical difference between research and surveillance is that research is not

an ongoing system directed toward public health action. It may uncover previously unknown risk factors, shed light on structural factors influencing health, or evaluate the effectiveness of existing prevention strategies. Unlike surveillance, which prioritizes standardized and readily deploy-able methods, research can embrace a broader range of methodologies, including qualitative studies, in-depth analyses, and pilot interventions. While research findings might or might not be immediately actionable, this exploratory phase is vital in advancing public health knowledge. Validated research methods may improve surveillance systems, allowing for more comprehensive data collection and analysis in the future. CDC policies define “research” as a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge (45 CFR § 46.102[d]). This definition underscores the emphasis on knowledge creation and discovery that distinguishes research from the more action-oriented nature of surveillance.

California, Colorado, and Connecticut are all conducting or supporting research to investigate public health challenges related to cannabis use. California funds cannabis research, including that focused on public health impacts, environmental effects, economic factors, and social justice issues. Studies are examining everything from the effects of cannabis on brain development to the impact of marketing on youth use. The research is designed to inform policy and improve understanding of the complex issues surrounding cannabis legalization (DCC, 2024). In Colorado, the Cannabis Research and Policy Project, a collaboration between the Colorado School of Public Health and the University of Colorado Anschutz Medical Campus, is leading this research. It conducts systematic reviews of existing research, recommends evidence-based policy changes, and develops public education campaigns (Colorado School of Public Health, 2024). In Connecticut, cannabis research is focused primarily on therapeutic uses (King et al., 2022).

Cannabis Assessment: Findings

The committee found that among the states, cannabis surveillance does not include all the essential components of a public health surveillance system: a surveillance plan; data collection, analysis, interpretation, and dissemination; a link to action; and regular evaluation. While most states are implementing some or most components of such a system, most state surveillance systems are underfunded, limiting the frequency of analyses and data dissemination, which in turn limits the link to action. Only Colorado has a complete system with regular analyses, research, and plans for reporting to policy makers, an important activity that may lead to public health action.

that institutionalization can be helpful but should not delay acting, and awareness that promoting equity through such policies requires dedicated resources (Hall and Jacobson, 2018).

Civic Engagement and Belonging

Systems of civic engagement and belonging are critical in public health policy development and can serve as an avenue for combating health inequities. Cultivating belonging demonstrates an understanding of the value of personal and community culture and knowledge systems and an awareness that valuing these differences is essential to achieving equity. Accordingly, policy developers must work with community members to strengthen communities’ established and self-determined assets, means of connection, and values. The Federal Plan for Equitable Long-Term Recovery and Resilience (ELTRR) articulates a whole-of-government approach established by more than 35 U.S. agencies, including the departments of Health and Human Services, Education, Transportation, and Justice. The goal is to improve health and well-being for everyone in the country, with a focus on achieving equity. The ELTRR identifies seven key factors necessary for health and well-being and places “belonging and civic muscle” as the foundation of the approach, defined by the ability to have healthy, fulfilling relationships and strong social supports, along with the ability to participate in civic life. Communities with strong civic muscle can design their pathways to resilience, gather assets so they can respond effectively and equitably in a crisis, persistently expand vital conditions while alleviating urgent needs, and use their power to ensure mutual accountability (ODPHP, 2022). The working group that created the plan formulated recommendations emphasizing the importance of involving community members in policy making (NASEM, 2023a).

Prevention of Industry Influence

Industry may disproportionately influence public health policies. It can influence specific policies in many ways, such as by participating in rulemaking or assembling scientific studies or reviews that support its desired policy decisions. Industry participation in rulemaking is often called regulatory or agency capture, denoting situations in which the regulated industry strongly influences the agency or people responsible for creating or implementing the regulations. Selectively supporting and assembling science to confuse decision makers and the public is effective because if the decision makers and the public believe the science is unclear, public support for action is undermined. Some of the many examples of industry influence on policy include the tobacco industry’s downplaying the harms of tobacco use and

the health impact of secondhand smoking, the fossil fuel industry’s denying and devaluing of its impacts on climate change, and chemical companies’ efforts to deflect concerns about the safety of chemicals (Michaels, 2020; Oreskes and Conway, 2011). Industry-developed information campaigns endanger public health by delaying regulations on harmful products and pollution of the air and water. They also erode trust in science by making it difficult to distinguish genuine uncertainty from manufactured doubt (NASEM, 2023b).

State, Tribal, Territorial, and Local Public Health Policy Development

State, tribal, territorial, and local public health officials have a substantial role in public health policy development. The 10th Amendment of the U.S. Constitution, which reserves unspecified powers to the states, creates a decentralized environment for public health policy development. As a result, a significant portion of public health policy decisions is made at the state, territorial, tribal, and local levels. The CDC and other agencies guide states on many issues, and several other collaboratives provide resources for policy development. Examples of these organizations are the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the American Public Health Association (APHA), the National Conference of State Legislatures, and the National Governors Association.

Another resource available to guide public health policy decisions at any level is the Community Guide developed by the Community Preventive Services Task Force (2023), the product of an independent panel that issues evidence-based recommendations and findings on public health interventions designed to improve health and safety. The Community Guide includes recommendations for the primary prevention of potential harms on many topics, including excessive alcohol use, mental health, alcohol-impaired driving, tobacco use, and substance use (CPSTF, 2023).

Compliance and Enforcement

Compliance refers to the “extent to which an individual, organization, group or population acts in accordance with a specific public policy” (APIS, n.d., para. 4). It requires determining who is responsible for enforcement and the processes used to ensure that regulations are followed. The responsible agencies need the requisite skills and experience to enforce policies fairly and successfully. Another important consideration is how regulatory compliance will be determined, such as specifying how much industry self-regulation is allowed or whether compliance is assured through inspections or more passive reporting mechanisms (APIS, n.d.). While protecting against

regulatory capture when developing policies is vital, it is also essential to consider that a regulated industry may try to influence compliance and enforcement strategies. Enforcement does not mean just law enforcement or policing but encompasses the “sum total of actions taken by public entities to increase compliance with specific public policies” (APIS, n.d., para. 4). Enforcement relies on many tools beyond policing and criminal penalties, including inspections, compliance checks, fines, recall of products, and revocation of licenses. Ideally, policy enforcement creates a system that encourages compliance across the board, from licensed businesses to consumers, with penalties graduating in severity and consequences depending on the nature of the noncompliance (APIS, n.d.).

Tobacco provides an excellent example of the complexity of regulation and enforcement. The U.S. Department of Agriculture oversees cultivation standards for tobacco (7 USC 511, 511s), while the FDA regulates manufacturing, product testing, and labeling to ensure safety and limit youth appeal (PL-102-321; PL-116-94). The Bureau of Alcohol, Tobacco, Firearms, and Explosives tackles illegal tobacco suppliers (PL-111-154 [2009]). State and local governments are crucial for enforcing minimum age for purchase and use and marketing regulations at retail locations. The FDA takes the lead with warnings and penalties for violations (21 CFR 1140). Smoke-free environments are regulated primarily by state and local authorities, with the Environmental Protection Agency (EPA) providing educational resources and the federal government enforcing a ban on smoking in its buildings (Executive Order 13058).

Compliance with alcohol policy is similarly ensured through federal, state, and local authorities. The Alcohol and Tobacco Tax and Trade Bureau oversees the production, import, distribution, labeling, and advertising of alcohol. It issues permits and enforces regulations to ensure product safety and prevent illicit sales. The Federal Alcohol Administration Act (27 USC, Chapter 8, §§ 201–212) mandates permits for producers, importers, and wholesalers, while the FDA regulates ingredient labeling. Advertising is mainly self-regulated by the alcohol industry, with federal agencies such as the Federal Trade Commission encouraging responsible practices to limit youth exposure (Mart, 2012).

Policies on alcohol retail sales and consumption are set by states and some local jurisdictions, and compliance is ensured through local enforcement. For example, each state has a licensing system for retailers, and some jurisdictions require training for servers or bartenders. States also determine where alcohol can be consumed publicly and enforce laws against underage drinking. Some federal highway funding can be withheld from states, most notably to ensure adherence to a blood alcohol (BAC) limit for driving of 0.08 percent (23 USC 163); one state (Utah) has a lower BAC limit (Utah HB155) to further reduce alcohol-related crashes.

and all five have failed (Pacula et al., 2022). In Washington state, the cannabis industry attempted to impede four different bills (HB 2546, 2020; HB 1463, 2021; HB 1641, 2023; and HB 1642, 2023) that would have placed THC concentration limits on cannabis products, adopted concentration-based taxation, and instituted age-based concentration sales (Carlini et al., 2024). Three rhetorical messages were effective at defeating additional regulation of cannabis products: (1) arguing that such regulations would threaten economic benefits and public health and go against the will of the people, (2) discrediting the science that supported the regulation of cannabis products with high THC concentration or the individuals that were advocating for these policies, and (3) distracting from the bill’s focus using tangential topics that would derail the discussion (Carlini et al., 2024). Similarly, in Vermont, the industry has pushed back on limits of 30 percent THC in flower and 60 percent THC in solid extracts (Hawks, 2023; Levine, 2024).

Conflicts of interest have been observed among cannabis regulators. In Colorado, a cannabis regulator left a government job and immediately started working for a cannabis cultivator (Harmony & Green) to advise them on following the rules despite a state law requiring a 6-month waiting period after such a switch. In Washington state, a government official who approves cannabis business licenses rented out a large piece of land (25 acres) to someone who wanted to start a cannabis business. In Massachusetts, an employee responsible for issuing medical cannabis licenses applied for one of those licenses while still employed by the agency. In Ohio, six companies that lost their bids for cannabis business licenses sued the state, claiming that the reviewers who scored the applications did so unfairly and hired biased consultants with conflicts of interest. In Arkansas, a court order stopped the state from issuing licenses to grow cannabis because of a lawsuit alleging issues similar to those found in Ohio (Bowling and Glantz, 2019b).

Issues with conflicts of interest may be more commonly associated with medical than with adult-use cannabis programs. Surveys found that only 20 percent (6 out of 30) of the states that legalized medical cannabis had conflict-of-interest provisions in their medical cannabis codes, and the remaining 80 percent relied on general provisions relating to all areas of regulation. In contrast, 88 percent (seven out of eight) of the first states to legalize adult cannabis use included conflict-of-interest provisions directly in their cannabis codes or regulations (Bowling and Glantz, 2019b).

Guidance for Cannabis Policy Development

Neither the CDC nor the White House Office of National Drug Control Policy (ONDCP) has crafted guidance for cannabis policy development. In fact, under 21 USC 1703, ONDCP is prohibited from using federal funds

to study anything related to the medical or nonmedical legalization of cannabis and other Schedule I drugs.¹ However, other organizations, such as ASTHO, NACCHO, and APHA, provide resources for policy development (Jernigan et al., 2021). The Community Guide includes no recommendations for cannabis policy development, but the recommendations related to tobacco and alcohol can be applied (Ghosh et al., 2016). Chapter 2 describes how these public health levers have been implemented in various ways across the states with legal cannabis for adult use.

Compliance with and Enforcement of Cannabis Policy

Cannabis regulatory compliance can be burdensome to implement. Currently, each state with a legal cannabis market must bear the administrative burdens associated with establishing and maintaining systems to ensure compliance with state policies on cannabis cultivation, product development, packaging restrictions, marketing restrictions, sales, and youth access.

An audit of 700 California outlets during summer 2019 found that while nearly all retail outlets were compliant with age identification checks before any purchase, the vast majority (85.1 percent) did so after entry into the building, where child-appealing marketing and materials promoting the health benefits of cannabis were visible to anyone allowed in the waiting room. The audit found that violations of rules regarding free samples (21.6 percent), on-site consumption (16.1 percent), and materials promoting health benefits (38.9 percent) were all common (Shi and Pacula, 2021).

Another audit of the retail sales of 30 randomly selected cannabis retailers in each of five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; and Los Angeles, California) in summer 2022 likewise found that age verification rates were high (>90 percent) (Berg et al., 2023). Most retailers also complied with regulations on signage, such as restricted access for those under the legal age (87.3 percent), no on-site consumption (73.3 percent), and no distribution to people below the legal age (53.3 percent). Retailers were likely to post warnings regarding use during pregnancy or breastfeeding

___________________

¹ The law states: “no Federal funds appropriated to the Office of National Drug Control Policy shall be expended for any study or contract relating to the legalization (for medical use or any other use) of a substance listed in schedule 1 of section 812 of this title and take such actions as necessary to oppose any attempt to legalize the use of a substance (in any form) that –

• is listed in schedule I of section 812 of this title; and
• has not been approved for medical purposes by the Food and Drug Administration” (21 USC 1703 § (b)12).

(72.0 percent), followed by health risks (38.0 percent), impacts on youth (18.7 percent), and driving under the influence (14.0 percent). However, there were other signs of noncompliance with policies, as 28.7 percent of these stores posted health claims, 20.7 percent posted signage appealing to youth, and 18.0 percent sold products with youth-oriented packaging (Berg et al., 2023).

Retail audit studies provide evidence of the states’ challenges in encouraging compliance and enforcement. A study conducted in summer 2017 sought to understand the extent to which retail employees at either medical or adult-use cannabis outlets would recommend cannabis to pregnant women (Dickson et al., 2018). Female researchers from the study team made calls to 400 retailers throughout Colorado, claiming to be 8 weeks pregnant and experiencing severe nausea and inquiring whether the person working at the retailer could recommend any products for them. The study found that most retailers (67 percent) recommended cannabis products for “morning sickness,” with medical stores doing so more frequently than adult-use-only stores (83.1 percent versus 60.4 percent). A more recent study that in 2022 conducted a mystery shoppers audit of 140 licensed cannabis stores in five cities with well-established state markets (Denver, Colorado; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California; and Seattle, Washington) also found that it was common for retail employees to recommend cannabis for therapeutic uses (90 percent), regardless of whether state laws existed to prohibit the practice (Romm et al., 2023). While retailers endorsed cannabis primarily for common conditions such as anxiety, insomnia, and pain, endorsements for pregnancy-related nausea and warnings against use during pregnancy and driving varied by city (Romm et al., 2023).

Monitoring of online marketing is highly challenging for states. One study conducted in 2022 collected and analyzed data regarding retailer characteristics, age verification, and marketing strategies (e.g., product availability, health-related content, promotions, website imagery) among 195 cannabis retail websites in five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; and Los Angeles, California). The analysis reveals concerning trends, such as the prevalence of unsubstantiated health claims despite regulations prohibiting them in some states (59 percent). Discounts, samples, or promotions were on 90.8 percent of websites, and 63.6 percent had subscription/membership programs. Subpopulations represented in website content included 27.2 percent teens/young adults, 26.2 percent veterans, 7.2 percent sexual/gender minorities, and 5.6 percent racial/ethnic minorities. Imagery also targeted young people (e.g., 29.7 percent party/cool/popularity; 18.5 percent celebrity/influencer endorsement) (Duan et al., 2023).

of services and actions than just health care. Assurance processes address factors that create barriers to public health interventions or directly improve health outcomes for the population. Examples include ensuring fair housing policies; protecting voting rights; and promoting equitable access to education, particularly within the public health workforce itself (Churchwell et al., 2020; Jain et al., 2022; NASEM, 2017; Perry, 2024).

Ensuring occupational health and safety is also important in cannabis policy. Certain safety and security professions in the United States require employee drug testing, with the goal of deterring drug use among these critical roles, identifying potentially impaired workers, and minimizing health and safety risks associated with compromised performance. The U.S. Department of Transportation requires testing for employees in transportation sectors such as aviation and trucking. The Department of Defense enforces similar regulations for contractors accessing classified information. And the Nuclear Regulatory Commission mandates “fitness-for-duty” programs at certain nuclear facilities, which include drug testing to ensure that workers’ impairment from the use of cannabis does not compromise safety (SAMHSA, 2023).

Ensuring occupational health for those who work in the cannabis industry requires establishing occupational health and safety standards and procedures that ensure compliance with and enforcement of those standards. The Occupational Safety and Health Administration is responsible for setting occupational standards in the United States. The National Institute for Occupational Safety and Health (NIOSH) focuses on research, recommendations, and education, offering free health hazard evaluations, investigating potential health risks in workplaces, promoting research, and safeguarding worker well-being. The Health Hazard Evaluation program helps employees, unions, and employers learn whether health hazards exist at their workplace and recommends ways to reduce hazards and prevent work-related illness (Lybrand and Coughanour, 2021).

Status of Cannabis Policy Assurance

Public health assurance completes the cycle of ten essential public health services. Assurance leverages existing organizational structures to safeguard public health in the context of cannabis legalization, seeking to advance four key priorities. First, assurance prioritizes harm reduction by minimizing the potential risks associated with cannabis production and use. At the same time, it ensures access to appropriate treatment for individuals who may require interventions. Second, assurance recognizes the vital role of a skilled and diverse public health workforce equipped specifically to address the complexities of cannabis legalization. Third, it fosters a culture of continuous improvement in cannabis public health functions through ongoing evaluation, research, and a commitment

to evidence-based practice. Finally, assurance emphasizes the need for a robust organizational infrastructure that effectively supports cannabis-specific and broader public health initiatives.

Protecting Those Who Use Cannabis from Potential Harm

States with legal adult use of cannabis are using several strategies to mitigate the risks of consuming cannabis products and limiting certain types of products that might be deemed unsafe, limiting serving sizes, banning certain harmful ingredients, and testing products to ensure that they do not contain harmful contaminants (Schauer, 2021).

A review of cannabis policies in 2021 found that all adult-use states allow a broad array of products (e.g., flower, vape, concentrates). Three states (California, Michigan, and Washington) limit edibles to shelf-stable forms to minimize food safety risks. Most states prohibit adulterated prepackaged products with added THC. Colorado implements a unique level of oversight by requiring specific audits for products designed to mimic existing noncannabis medications (e.g., inhalers, suppositories) (Schauer, 2021).

As of 2021, all adult-use cannabis states had implemented THC serving-size limits for edibles and other consumable products (Schauer, 2021). While these limits were developed in response to high-profile incidents of edible overconsumption (Barrus et al., 2016; Nicks, 2014; Schauer, 2021), they differ among states. Most states allow a 10-mg THC serving, generally capped at 100 mg per package. Washington requires individual wrapping for edible and infused product servings within a package. However, highly concentrated THC products exceeding these serving sizes remain widely available. Vermont planned to implement limits on THC concentration in flower (30 percent) and oils (60 percent) and to restrict oils and concentrates to vape pen cartridges (Schauer, 2021).

The 2021 review of cannabis policy found that states also have limits on ingredients that can be contained in cannabis products. Many states have banned or are testing for vitamin E acetate because of the 2019 outbreak of e-cigarette or vaping product–associated lung injury (EVALI) (Schauer, 2021). Colorado has banned medium-chain triglycerides oil and polyethylene glycol oil entirely. Similarly, Oregon has prohibited squalane, propylene glycol, and all triglycerides, substances that lack established safety data for aerosols. Nevada limits the added terpene content in vape oils to 10 percent, which aligns with the upper range of naturally occurring terpenes in the cannabis plant. Vermont takes the strictest approach, permitting only natural cannabis-derived flavors in its upcoming adult-use market. States that regulate cannabis and cannabis-derived products do not have uniform testing procedures or regulatory approaches to ensure product integrity, safety, and labeling (Schauer, 2021).

to primary prevention are peer association, family involvement, community-based programs, and media campaigns. These interventions target individuals (through skills development), families (through communication), schools (through educational programs), and communities (through environmental changes and policy). By addressing cannabis use at its roots, primary prevention strategies aim to prevent initiation and promote healthy choices.

Although many different programs can be implemented across jurisdictions to discourage cannabis use, the effectiveness of such programs is mixed. A systematic review found low to moderate evidence for the effectiveness of primary prevention programs in deterring substance use among adolescents. Results indicated that adolescents who received a brief intervention generally reduced their alcohol and cannabis use more compared with adolescents who received no intervention at all. However, adolescents who received a brief intervention did not reduce their alcohol and cannabis use more than adolescents who received information-only interventions (Carney et al., 2016).

A systematic review found the most robust evidence for universal school-based interventions that target multiple risk behaviors, demonstrating that such programs may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use (which included cannabis), and antisocial behavior and in improving physical activity among young people, but not in preventing other risk behaviors. The results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviors studied (MacArthur et al., 2018).

Another systematic review of primary prevention programs for substance use among children and youth found the most substantial evidence of effectiveness for the Life Skills Training Program (LST). LST targets elementary to high school settings and is delivered by teachers or trained moderators, addressing such topics as misunderstandings about drugs, decision making, problem solving, and stress and anxiety management. Across the 17 LST evaluations reviewed, 10 found a reduction in use of substances, including alcohol and drugs, among adolescents (Tremblay et al., 2020). However, poor reporting and concerns about variation in the quality of evidence highlight the need for greater investment in rigorous evaluations of universal primary prevention interventions directed at children and adolescents (MacArthur et al., 2018). Blueprints for Healthy Youth Development provides information on primary prevention programs for children and adolescents with a demonstrated effectiveness for substance use prevention (Mihalic and Elliott, 2015).

Community-level prevention programs, such as the Drug-Free Communities (DFC) Support Program, may be effective. Participants in this program had lower cannabis use relative to participants in the Youth Risk Behavior Survey, which was used for comparison purposes (ONDCP,

2023). The DFC Support Program is a national initiative funded by the federal government and led by ONDCP in collaboration with the CDC; the program is aimed at preventing and reducing youth substance use by empowering local communities. DFC grants are awarded to coalitions comprising representatives from various sectors, such as schools, parents, law enforcement, and youth organizations. These coalitions develop and implement evidence-based strategies for addressing local substance use risk factors and promoting protective factors that encourage healthy choices among youth (CDC, 2023).

Mass media campaigns to prevent illicit use of drugs, including cannabis, are widespread. A systematic review of media campaigns to prevent illicit drug use identified 23 studies of designs involving 188,934 young people conducted in the United States, Canada, and Australia. The studies tested very different interventions and used several questionnaires to interview the young people about the effects of the interventions. Because of the variability in interventions studied and methods used, the authors could not reach substantive conclusions (Ferri et al., 2013).

Building a Strong Cannabis Workforce

Building a strong cannabis workforce will require collaborations among public health authorities within each state and across states and among cannabis regulators, clinical providers, and the cannabis industry. Colorado has established a network with a point of contact for cannabis in each county or city health department. The state health department also learns about emerging issues from the local public health officials. The health department, in conjunction with the Colorado Department of Revenue’s Marijuana Enforcement Division, holds science policy forums and educational conferences for local and state public health officials to learn about and discuss cannabis-related public health topics. The health department is creating educational materials for health care providers to inform them about cannabis-related topics (Ghosh et al., 2016).

Several states and Canada require or encourage responsible vendor training of cannabis retail sales staff. The Massachusetts program, for example, teaches compliance with regulations; licensing requirements; product labeling; acceptable payment methods; tracking systems; methods for verifying customer age, identifying valid ID, and determining whether a sale is legal based on the customer’s age; and techniques for handling a suspected underage purchase. The training also covers the physiological and cognitive effects of cannabis, including its effects as a stimulant, depressant, and hallucinogen, as well as ways to discuss the legal and safety aspects of cannabis use, such as how cannabis impairs driving and the legal limitations on consumption locations (CCCM, n.d.).

and best practices for trimming machines, pesticide management, allergen control, wildfire preparedness, and psychosocial support (Schenker and Beckman, 2023).

Improving and Innovating with Ongoing Cannabis Evaluation

Evaluation is essential to ensuring effective cannabis policy. It can determine whether the right questions are being asked of the cannabis surveillance system, whether the cannabis policies are appropriate, and whether the prevention education and workforce campaigns are working. Policies have changed when problems have been identified, as in the example previously described of vitamin E acetate being banned from cannabis inhalation products following the 2019 EVALI outbreak. Several states partner with universities to support continuous evaluation and research aimed at monitoring essential outcomes (Ghosh et al., 2016).

Cannabis Assurance: Findings

The committee found that states have adopted many measures for public health assurance related to cannabis policy. The efforts at consumer protection regarding product safety testing are commendable, but there are inconsistencies across the state programs and issues with laboratory quality. Guidelines related to lowering the risk of use have been implemented in some localities, as have primary prevention media campaigns, which appear to improve consumer knowledge of the risks of cannabis. The Drug-Free Communities Support Program, the Life Skills Training Program, and other programs identified by Blueprints for Healthy Youth Development can all be leveraged to inform primary prevention for substance use. Encouraging a robust public health workforce for cannabis is critical, as are communication and information sharing within and between states with legalized cannabis. Training of retail sales staff is also needed, as they are routinely asked for advice on cannabis use, and audits have found that best practices for public health protection are not followed consistently. Clinician training is important as well because providers are not confident in discussing cannabis use with patients.

CONCLUSIONS AND RECOMMENDATIONS

This analysis of the application of the core public health functions to cannabis policy underscores the need for a more comprehensive public health approach to cannabis in the United States. Prioritizing public health alongside economic considerations, ensuring balanced stakeholder involvement, implementing consistent consumer protection measures, and fostering a well-trained workforce are critical steps in promoting responsible

cannabis use. The policy landscape is complex, marked by an initial focus on economic outcomes in early legalization efforts. Public health considerations, such as reducing dependence and underage use, were often lower priorities. Similarly, consumer awareness of cannabis-related health risks received minimal attention.

Conclusion 4-1: Cannabis policy discussions need to consider impacts on public health. Inadequate inclusion of public health in cannabis policy decisions has limited the application of the core public health functions in states that have legalized cannabis for adult or medical use. Further development of the core public health functions as related to cannabis is therefore needed.

Currently, cannabis surveillance data are collected and analyzed by various entities with limited coordination. While most states are completing some components of a surveillance system, many systems are incomplete. State surveillance systems are underfunded, limiting the frequency of analyses and data dissemination, which in turn limits their link to action. Only Colorado has a complete system with regular analyses, research, and plans for reporting to policy makers, an important activity that may lead to public health action. Despite their limitations, diverse data sources, such as surveys, health records, and mortality statistics, are available, related mainly to the products used. Consistent use and application of the essential components of a public health surveillance system—data collection, analysis, and dissemination—would create a more comprehensive picture of cannabis use and its health impacts, ultimately informing practical public health actions. The CDC has a cannabis surveillance plan that is missing such elements as approaches to data dissemination, a link to action, and regular evaluation. Collaboration with federal partners, such as the departments of Agriculture and Commerce, is also needed to gain an understanding of cannabis production. The FDA has passive reporting systems to monitor product safety (FAERS and CAERS). However, it is difficult to interpret the data from these systems because increased reporting may be a function of increased knowledge that the system exists.

Recommendation 4-1: The Centers for Disease Control and Prevention, in conjunction with its federal, state, tribal, and territorial partners, should create an adaptable public health surveillance system for cannabis. This surveillance system should include, at a minimum, cannabis cultivation and product sales, use patterns, and health impacts. It should also include all the essential components of a public health surveillance system: a surveillance plan, data collection, data analysis, data interpretation, data dissemination, a link to action, and regular evaluation.

has also developed reference standards to ensure accurate identification and measurement of constituents and sampling considerations to improve representative analysis, labeling, and packaging resources. And it is developing a cannabis inflorescence (flower) monograph for the Herbal Medicines Compendium, scientifically valid methods, information on physical reference standards, and acceptance criteria for establishing the identity of cannabis chemotypes, content of cannabinoids and terpenes, and limits on contaminants (Sarma et al., 2020). Although the standards are in development for primarily medical cannabis products, the reference materials and laboratory methods could be used to improve the quality of laboratory safety for cannabis products consumed for any reason.

Recommendation 4-2: The U.S. Pharmacopeia has established product quality and analytical standards for cannabis inflorescence (flower) and is developing standards for cannabis extracts incorporated into pills and edibles. As these standards are completed, state cannabis regulators should adopt and enforce them to ensure the safety and quality of all legal cannabis products.

As the cannabis industry expands, fostering a well-trained workforce across both the industry and public health sectors is critical. Colorado’s collaborative approach, whereby public health authorities, regulators, and the cannabis industry share resources, facilitates communication and knowledge exchange. However, a significant gap exists. Clinicians often report discomfort with discussing cannabis use with patients, highlighting the need for improved training and resources. Providing this training is especially important considering the potential interactions between cannabis and prescription medications, as well as the link between cannabis use and chronic disease risk factors. As recommended by the U.S. Preventive Services Task Force, conducting routine screening for substance use by asking questions would allow for early identification of cannabis use and potential interventions.

Conclusion 4-3: The U.S. Preventive Services Task Force has guidelines for screening adult patients for substance use. Education and training of clinicians related to the effects of cannabis use, as well as the management of patients using cannabis, could improve clinical care.

Several states require training for retail cannabis sales staff on regulations, product knowledge, and responsible sales practices. Despite limited evidence in the literature for the effectiveness of this training in preventing underage sales, training for retail staff on many different aspects of cannabis and its implications for public health remains vital. Since many people who use cannabis trust cannabis retail staff (Young-Wolff et al., 2022), staff

need to be trained on the health effects and harms associated with cannabis use. The CDC or another public health authority could create an online training model that could be updated regularly.

Recommendation 4-3: State cannabis regulators should require training and certification for all staff at cannabis retail outlets who interact with customers. The training should address the effects of cannabis on humans, prevention of sales to minors, warnings about cannabis-impaired driving, cannabis use in pregnancy, high-concentration or high-potency products, and how to identify signs of impairment. The effectiveness of the training should be assessed and the content updated as new scientific information about the positive and negative impacts of cannabis emerges.

Colorado and other states have developed targeted public health campaigns, which are essential for improving knowledge about cannabis and its potential harms. Developing and evaluating education campaigns is time- and resource-intensive. Leadership from the CDC could help guide the states toward developing campaigns that are more likely to improve knowledge.

Recommendation 4-4: The Centers for Disease Control and Prevention (CDC), in coordination with other relevant agencies, should develop and evaluate targeted public health campaigns directed mainly toward parents and vulnerable populations (e.g., youth, those who are or are likely to become pregnant, adults over age 65) about the potential risks of cannabis; how to identify risky behavior, such as the use of cannabis in combination with alcohol or prescription drugs; and risk mitigation strategies, such as lower-risk use guidelines and safe storage. These public health campaigns should include discouraging unhealthy use, such as the use of cannabis in combination with other substances (alcohol, tobacco, or drugs), and the increased risk associated with the use of high-concentration or high-potency products.

Continued evaluation of the public health and societal impacts of changes in cannabis policy is critical as the policy landscape rapidly evolves. Currently, the ONDCP is prohibited from studying the impacts of cannabis legalization because as of July 2024, cannabis is classified as a Schedule I substance under the Controlled Substance Act, and botanical cannabis has no FDA-approved medical use.

Recommendation 4-5. Congress should remove restrictions on the Office of National Drug Control Policy (ONDCP) from studying the impacts of cannabis legalization. The ONDCP should be allowed to support research on the impacts of changes in cannabis policy.