Five Years After Cannabis Legalization, Is It Time to Ease Restrictions on Promotion?

In the spring of 2024, the federal government is expected to report on its legislative review of the Cannabis Act (2018). One of the most contentious issues is whether to relax restrictions on cannabis promotion. This commentary describes the tension between the public health aims of legalization and the secondary aim of displacing the illicit market. We maintain that among jurisdictions that have legalized cannabis, Canada stands out as having the stated primary objective of safeguarding public health, and its restrictions on promotion are evidence-based and innovative. These measures must be preserved, even in the face of growing industry pressure to loosen them.

United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic.

BACKGROUND: To determine if marijuana legalization was associated with reduced opioid mortality. STUDY DESIGN: The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions. METHODS: Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates. RESULTS: The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01). CONCLUSIONS: During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.

Recreational cannabis legalization and immigration enforcement: a state-level analysis of arrests and deportations in the United States, 2009-2020.

BACKGROUND: Recreational cannabis laws (RCL) in the United States (US) can have important implications for people who are non-citizens, including those with and without formal documentation, and those who are refugees or seeking asylum. For these groups, committing a cannabis-related infraction, even a misdemeanor, can constitute grounds for status ineligibility, including arrest and deportation under federal immigration policy-regardless of state law. Despite interconnections between immigration and drug policy, the potential impacts of increasing state cannabis legalization on immigration enforcement are unexplored. METHODS: In this repeated cross-sectional analysis, we tested the association between state-level RCL adoption and monthly, state-level prevalence of immigration arrests and deportations related to cannabis possession. Data were from the Transactional Records Access Clearinghouse. Immigration arrest information was available from Oct-2014 to May-2018 and immigration deportation information were available from Jan-2009 to Jun-2020 for. To test associations with RCLs, we fit Poisson fixed effects models that controlled for pre-existing differences between states, secular trends, and potential sociodemographic, sociopolitical, and setting-related confounders. Sensitivity analyses explored potential violations to assumptions and sensitivity to modeling specifications. RESULTS: Over the observation period, there were 7,739 immigration arrests and 48,015 deportations referencing cannabis possession. By 2020, 12 stated adopted recreational legalization and on average immigration enforcement was lower among RCL compared to non-RCL states. In primary adjusted models, we found no meaningful changes in arrest prevalence, either immediately following RCL adoption (Prevalence Ratio [PR]: 0.84; [95% Confidence Interval [CI]: 0.57, 1.11]), or 1-year after the law was effective (PR: 0.88 [CI: 0.56, 1.20]). For the deportation outcome, however, RCL adoption was associated with a moderate relative decrease in deportation prevalence in RCL versus non-RCL states (PR: 0.68 [CI: 0.56, 0.80]; PR 1-year lag: 0.68 [CI: 0.54, 0.82]). Additional analyses were mostly consistent by suggested some sensitivities to modeling specification. CONCLUSIONS: Our findings suggest that decreasing penalties for cannabis possession through state RCLs may reduce some aspects of immigration enforcement related to cannabis possession. Greater attention to the immigration-related consequences of current drug control policies is warranted, particularly as more states weigh the public health benefits and drawbacks of legalizing cannabis.

Paucity of intellectual property rights information in the US biologics system a decade after passage of the Biosimilars Act.

In this Policy Forum piece, Robin Feldman discusses how current legislation contributes to informational deficits around drug patents for biologic drugs in the United States.

Association between non-medical cannabis legalization and alcohol sales: Quasi-experimental evidence from Canada.

BACKGROUND: There is increasing interest in understanding the impact of non-medical cannabis legalization on use of other substances, especially alcohol. Evidence on whether cannabis is a substitute or complement for alcohol is both mixed and limited. This study provides the first quasi-experimental evidence on the impact of Canada's legalization of non-medical cannabis on beer and spirits sales. METHODS: We used the interrupted time series design and monthly data on beer sales between January 2012 and February 2020 and spirits sales between January 2016 and February 2020 across Canada to investigate changes in beer and spirits sales following Canada's cannabis legalization in October 2018. We examined changes in total sales, nationally and in individual provinces, as well as changes in sales of bottled, canned and kegged beer. RESULTS: Canada-wide beer sales fell by 96 hectoliters per 100,000 population (p=0.011) immediately after non-medical cannabis legalization and by 4 hectoliters per 100,000 population (p>0.05) each month thereafter for an average monthly reduction of 136 hectoliters per 100,000 population (p<0.001) post-legalization. However, the legalization was associated with no change in spirits sales. Beer sales reduced in all provinces except the Atlantic provinces. By beer type, the legalization was associated with declines in sales of canned and kegged beer but there was no reduction in sales of bottled beer. CONCLUSIONS: Non-medical cannabis legalization was associated with a decline in beer sales in Canada, suggesting substitution of non-medical cannabis for beer. However, there was no change in spirits sales following the legalization.

Using publicly available data to predict recreational cannabis legalization at the county-level: A machine learning approach.

BACKGROUND: There is substantial geographic variability in local cannabis policies within states that have legalized recreational cannabis. This study develops an interpretable machine learning model that uses county-level population demographics, sociopolitical factors, and estimates of substance use and mental illness prevalences to predict the legality of recreational cannabis sales within each U.S. county. METHODS: We merged data and selected 14 model inputs from the 2010 Census, 2012 County Presidential Data from the MIT Elections Lab, and Small Area Estimates from the National Surveys on Drug Use and Health (NSDUH) from 2010 to 2012 at the county level. County policies were labeled as having recreational cannabis legal (RCL) if the sale of recreational cannabis was allowed anywhere in the county in 2014, resulting in 92 RCL and 3002 non-RCL counties. We used synthetic data augmentation and minority oversampling techniques to build an ensemble of 1000 logistic regressions on random sub-samples of the data, withholding one state at a time and building models from all remaining states. Performance was evaluated by comparing the predicted policy conditions with the actual outcomes in 2014. RESULTS: When compared to the actual RCL policies in 2014, the ensemble estimated predictions of counties transitioning to RCL had a macro f1 average score of 0.61. The main factors associated with legalizing county-level recreational cannabis sales were the prevalences of past-month cannabis use and past-year cocaine use. CONCLUSION: By leveraging publicly available data from 2010 to 2012, our model was able to achieve appreciable discrimination in predicting counties with legal recreational cannabis sales in 2014, however, there is room for improvement. Having demonstrated model performance in the first handful of states to legalize cannabis, additional testing with more recent data using time to event models is warranted.

Public opinion on the expenditure of adult-use cannabis tax revenue: Evidence from New Jersey.

OBJECTIVES: To describe New Jersey residents' relative priorities for the allocation of tax revenue generated by recreational cannabis sales. We aim to assess preferences for public health initiatives, including drug treatment, compared to a range of alternatives, including traditional policing, especially within the social and demographic groupings of people generally most impacted by punitive drug enforcement policies. METHODS: We collected population-representative survey data four months post-implementation of recreational cannabis sales in New Jersey (N = 1,006). We gauge respondents' top preferences for the allocation of new revenue generated by the legal cannabis market. Using multinomial logistic regression, we assess how various demographic and political factors shape public support for devoting revenue toward public health initiatives. RESULTS: While priorities are mixed within the sample, we find more general support for funding community-based initiatives in public health, housing, and education than for funding police, courts, and prisons. Among Black residents, the largest proportion chose investments in affordable housing. Regression analysis reveals political orientation as having the most consistent association with expressed preferences, with Republicans favoring investments in traditional law enforcement priorities over other potential funding domains. CONCLUSIONS: Recreational cannabis legalization is occurring at a rapid pace, yet important context, including how the tax revenue could be invested in communities, remains unclear. Insight into current public opinion on funding priorities suggests a desire for investment in fundamental societal institutions, including education and public health, rather than the punitive enforcement mechanisms that have defined cannabis policy for many decades.

Why Are Adolescent Cannabis Use Disorder Treatment Admissions Declining in the US? The Mediated Pathway of State Treatment Admissions Rates before and after Recreational Cannabis Legalization.

Purpose: State-level prevalence data are used to investigate whether recreational cannabis legalization moderates the mediated pathway from the perception of low risk of harm, to cannabis use, to cannabis use disorder (CUD) treatment admissions, among adolescents (age 12-17) in the US. Methods: Annual state prevalence measures of perception of low risk, cannabis use, and CUD treatment admissions between 2008 and 2019 (N = 542 state-year observations) were collected from the National Survey on Drug Use and Health (NSDUH) and the Treatment Episode Dataset - Admissions (TEDS-A). A two-way fixed effects (state and year) moderated mediation model was used to test whether recreational legalization moderated the indirect effect of perception of low risk on treatment admissions via cannabis use. Results: A positive indirect effect of perceiving cannabis as low risk on CUD treatment admissions via cannabis use was observed prior to legalization but not afterwards. After legalization, the positive association of perceiving cannabis as low risk with cannabis use was strengthened, and the positive association of cannabis use with treatment admissions was suppressed, as compared to before legalization. Discussion: Recreational legalization may alter the social acceptability and medical self-administration of cannabis, potentially leading to CUD treatment utilization decline among adolescents even as risk factors for CUD increase. Linking recreational cannabis legalization to advancing awareness of the health risks associated with adolescent cannabis use and promoting adolescent CUD treatment engagement through mHealth approaches and primary care providers are key to addressing potential adolescent health challenges brought about by expanding cannabis legalization.

Youth Exposure to Recreational Cannabis Legalization: Moderation of Effects by Sex and Parental Cannabis Use during Adolescence.

OBJECTIVE: Few studies of recreational cannabis legalization (RCL) have assessed adolescents both before and after RCL or considered moderators of RCL effects. The present study tested whether RCL was more strongly associated with cannabis use for girls and among youth whose parents had a history of cannabis use during adolescence. METHOD: Data were pooled from 940 adolescents from three intergenerational studies that began in Washington (where RCL was enacted in 2012), Oregon (RCL year = 2015), and New York (RCL year = 2021). Youth were assessed repeatedly from ages 13 to 18 years (k = 3,650 person-years) from 1999 to 2020 (prior to RCL in New York). Parent cannabis use at or before age 18 years (yes/no) was assessed prospectively during the parent's adolescence. Multilevel models focused on the between-subjects effects of years of youth exposure to RCL on adolescents' mean cannabis use likelihood, and interactions with child sex and parent use history. RESULTS: Child exposure to RCL was associated with a higher likelihood of cannabis use if their parents had a history of adolescent use, (Estimate [SE] = 0.67 [0.25], p = 0.008), versus no such history (Estimate [SE] = -0.05 [0.28], p = 0.855). RCL effects were not moderated by child sex. CONCLUSIONS: The effects of RCL on adolescents' cannabis use may depend on their parents' history of using the drug. Identifying other moderators of RCL effects, and understanding the mechanisms of these risks and the ways that parents and communities can offset them, are prevention priorities.

(1) Adolescents' use of cannabis may have intergenerational consequences, making it more likely their future offspring will use cannabis. (2) Whether or not recreational cannabis legalization influences adolescents' cannabis use may depend on their parents' cannabis use history. (3) Parenting in a state with liberalized cannabis policies may present new challenges and require that novel prevention resources be developed.

Medicinal cannabis use among young adults during California's transition from legalized medical use to adult-use: a longitudinal analysis.

Background: In 2016, California transitioned from legalized medical cannabis use to adult-use. Little is known about how this policy change affected medicinal cannabis use among young adults.Objectives: To identify longitudinal groups of medicinal cannabis users and concurrent changes in health- and cannabis use-related characteristics among young adults in Los Angeles between 2014 and 2021.Methods: Cannabis users (210 patients and 156 non-patients; 34% female; ages 18-26 at baseline) were surveyed annually across six waves. Longitudinal latent class analysis derived groups from two factors - cannabis patient status and self-reported medicinal use. Trajectories of health symptoms, cannabis use motives, and cannabis use (daily/near daily use, concentrate use, and problematic use) were estimated across groups.Results: Three longitudinal latent classes emerged: Recreational Users (39.3%) - low self-reported medicinal use and low-to-decreasing patient status; Recreational Patients (40.4%) - low self-reported medicinal use and high-to-decreasing patient status; Medicinal Patients (20.3%) - high self-reported medicinal use and high-to-decreasing patient status. At baseline, Medicinal Patients had higher levels of physical health symptoms and motives than recreational groups (p < .05); both patient groups reported higher level of daily/near daily and concentrate use (p < .01). Over time, mental health symptoms increased in recreational groups (p < .05) and problematic cannabis use increased among Recreational Patients (p < .01).Conclusions: During the transition to legalized adult-use, patterns of medicinal cannabis use varied among young adults. Clinicians should monitor increases in mental health symptoms and cannabis-related problems among young adults who report recreational - but not medicinal - cannabis use.

What impact could the legalisation of recreational cannabis have on the health of the UK? Lessons from the rest of the world.

Several jurisdictions across the globe have introduced legislation to legally permit the sale and consumption of recreational cannabis. This editorial considers current evidence from the rest of the world and asks how this might inform the possible consequences of 'legalisation' models in the UK.

Threaten, Distract, and Discredit: Cannabis Industry Rhetoric to Defeat Regulation of High-THC Cannabis Products in Washington State.

OBJECTIVE: Washington State legislators have attempted to regulate high delta-9-tetrahydrocannabinol (THC) cannabis to reduce cannabis-related harms. Historically, industry actors of other health-compromising products have influenced governments' adoption of evidence-based regulation policies. A better understanding of the industry rhetoric can be used by public health advocates to develop counterarguments and disseminate alternative narratives that protect the public's health. We analyzed the arguments used by cannabis industry actors opposing regulations to de-incentivize the availability and use of high-THC products in Washington State. METHOD: We analyzed 41 testimonies transcribed from 33 cannabis industry actors in 3 public bill hearings and one legislative work session that occurred between 2020 and 2023. Using a deductive thematic analysis, informed by industry actors' arguments opposing regulation of alcohol, tobacco, and high-sugar beverages, we developed a codebook to analyze and identify themes within cannabis industry rhetorical strategies. RESULTS: We identified three main rhetorical strategies used by cannabis industry actors to oppose THC content regulation: threaten, distract, discredit. The most frequently used rhetorical strategy was threats to economic benefits, public health, and the will of the people. The other two most apparent strategies were distracting from the bill's focus by introducing a tangential topic and discrediting the science that supported regulation of cannabis products with high THC concentration or its advocates. CONCLUSIONS: Cannabis industry actors have leveraged several arguments used by industry actors of other health-compromising products to undermine initiatives to advance public health. They have also adapted rhetoric from other industries to the unique conditions of the cannabis regulatory landscape.

Cannabis legalization and driving under the influence of cannabis and driving under the influence of alcohol among adult and adolescent drivers in Ontario, Canada (2001-2019).

BACKGROUND: The impacts of cannabis legalization on driving under the influence of cannabis and driving under the influence of alcohol among adults and adolescents were examined in Ontario, Canada. METHODS: Data were sourced from adult (N=38,479) and adolescent (N=23,216) populations-based surveys (2001-2019). The associations between cannabis legalization and driving within an hour of using cannabis and driving within an hour of drinking two or more drinks of alcohol were quantified using logistic regression, with testing of multiplicative interactions between cannabis legalization and age and sex. All analyses were conducted separately for adults and adolescents and restricted to participants with a valid driver's license. RESULTS: Cannabis legalization was not associated with driving within an hour of using cannabis among adults (OR, 95% CI: 1.21, 0.69-2.11). However, a multiplicative interaction indicated that there was an increased likelihood of driving within an hour of using cannabis among adults ≥55 years of age (4.23, 1.85-9.71) pre-post cannabis legalization. Cannabis legalization was not associated with driving within an hour of using cannabis among adolescents (0.92, 0.72-1.16), or with driving within an hour of consuming two or more drinks of alcohol among adults (0.78, 0.51-1.20) or adolescents (0.87, 0.42-1.82). CONCLUSIONS: An increased likelihood of driving under the influence of cannabis among adults ≥55 years of age was detected in the year following cannabis legalization, suggesting the need for greater public awareness and education and police monitoring and enforcement concerning driving under the influence of cannabis, particularly among older adults.

Recreational and Medical Cannabis Legalization and Opioid Prescriptions and Mortality.

Importance: While some have argued that cannabis legalization has helped to reduce opioid-related morbidity and mortality in the US, evidence has been mixed. Moreover, existing studies did not account for biases that could arise when policy effects vary over time or across states or when multiple policies are assessed at the same time, as in the case of recreational and medical cannabis legalization. Objective: To quantify changes in opioid prescriptions and opioid overdose deaths associated with recreational and medical cannabis legalization in the US. Design, Setting, and Participants: This quasiexperimental, generalized difference-in-differences analysis used annual state-level data between January 2006 and December 2020 to compare states that legalized recreational or medical cannabis vs those that did not. Intervention: Recreational and medical cannabis law implementation (proxied by recreational and medical cannabis dispensary openings) between 2006 and 2020 across US states. Main Outcomes and Measures: Opioid prescription rates per 100 persons and opioid overdose deaths per 100 000 population based on data from the US Centers for Disease Control and Prevention. Results: Between 2006 and 2020, 13 states legalized recreational cannabis and 23 states legalized medical cannabis. There was no statistically significant association of recreational or medical cannabis laws with opioid prescriptions or overall opioid overdose mortality across the 15-year study period, although the results also suggested a potential reduction in synthetic opioid deaths associated with recreational cannabis laws (4.9 fewer deaths per 100 000 population; 95% CI, -9.49 to -0.30; P = .04). Sensitivity analyses excluding state economic indicators, accounting for additional opioid laws and using alternative ways to code treatment dates yielded substantively similar results, suggesting the absence of statistically significant associations between cannabis laws and the outcomes of interest during the full study period. Conclusions and Relevance: The results of this study suggest that, after accounting for biases due to possible heterogeneous effects and simultaneous assessment of recreational and medical cannabis legalization, the implementation of recreational or medical cannabis laws was not associated with opioid prescriptions or opioid mortality, with the exception of a possible reduction in synthetic opioid deaths associated with recreational cannabis law implementation.

Impact of non-medical cannabis legalization with market restrictions on health service use and incident cases of psychotic disorder in Ontario, Canada.

BACKGROUND: Cannabis is a risk factor in the onset and persistence of psychotic disorders. There is concern that non-medical cannabis legalization in Canada may have population-level impacts on psychotic disorders. We sought to examine changes in health service use and incident cases of psychotic disorder following cannabis legalization, during a period of tight restrictions on retail stores and product types. METHODS: We conducted a cross-sectional interrupted time-series analysis using linked population-based health administrative data from Ontario (Canada) from January 2014 to March 2020. We identified psychosis-related outpatient visits, emergency department visits, hospitalizations, and inpatient length of stay, as well as incident cases of psychotic disorders, among people aged 14 to 60 years. RESULTS: We did not find evidence of increases in health service use or incident cases of psychotic disorders over the short-term (17 month) period following cannabis legalization. However, we found clear increasing trends in health service use and incident cases of substance-induced psychotic disorders over the entire observation window (2014-2020). CONCLUSION: Our findings suggest that the initial period of tight market restriction following legalization of non-medical cannabis was not associated with an increase in health service use or frequency of psychotic disorders. A longer post-legalization observation period, which includes expansion of the commercial cannabis market, is needed to fully understand the population-level impacts of non-medical cannabis legalization; thus, it would be premature to conclude that the legalization of non-medical cannabis did not lead to increases in health service use and incident cases of psychotic disorder.

Association Between Marijuana Laws and Suicide Among 12- to 25-Year-Olds in the United States From 2000 to 2019.

OBJECTIVE: Cannabis use is associated with suicide-related outcomes in both adolescents and adults, and may be increasing amid shifting cannabis policies. However, little is known about the impact of medical marijuana legalization (MML) and recreational marijuana legalization (RML) policies on youth suicide. Using 20 years of national data, we examined associations between MML, RML, and suicide-related mortality among US individuals aged 12 to 25 years, and assessed whether they varied based on age and sex. METHOD: Suicide deaths (N = 113,512) from the 2000-2019 National Vital Statistics System Multiple Cause of Death files for age groups 12 to 13, 14 to 16, 17 to 19, 20 to 22, and 23 to 25 years were examined in relation to time-varying cannabis law status using a staggered adoption difference-in-difference (DiD) approach with a negative binomial regression to determine associations between MML, RML, and suicide rates, controlling for individual- and state-level covariates and accounting for the varying effective dates of MML and RML by state. RESULTS: The overall unadjusted annual suicide rate was 10.93/100,000, varying from 9.76 (states without marijuana laws (ML)) to 12.78 (MML states) to 16.68 (RML states). In multivariable analysis, both MML (incidence rate ratio [IRR] = 1.10, 95% CI: 1.05-1.15) and RML (IRR = 1.16, 95% CI: 1.06-1.27) were associated with higher suicide rates among female youth compared to those in states without ML. Youth aged 14 to 16 years had higher rates of suicide in states with RML compared to states with MML (IRR = 1.14, 95% CI: 1.00-1.30) and states without ML (IRR = 1.09, 95% CI: 1.00-1.20). Findings were consistent across sensitivity analyses. CONCLUSION: MML and RML were associated with increased suicide-related mortality in female youth and 14- to- 16-year-old individuals of both sexes. Mechanisms through which cannabis policies are related to increased youth suicide warrant further study and should inform legislative reform.