Recent elections brought resurgent national interest in the legalization of marijuana. This was partly fueled by the need for new tax revenue given the looming effects of COVID-19 on state budgets.
Legalization also serves racial justice concerns as drug arrests disproportionately affect minorities. Colorado and Washington were the first two states that legalized marijuana for recreational use in 2012. Since then, the District of Columbia and 11 other states have also fully legalized marijuana, including for recreational use. New Jersey, Arizona, Montana and South Dakota just voted on ballot initiatives to legalize recreational marijuana. South Dakota also voted in favor of a medical-cannabis program, as did Mississippi.
Policymakers and — in the case of ballot initiatives, voters — assessed the risks and benefits of legalizing both medical and recreational use of marijuana. They concluded that the benefits of decriminalization and legalization outweighed potential public health concerns. Decriminalization can go a long way in reducing incarceration and disproportionate incarceration of minority individuals.
However, decriminalization and legalization yield different results — good criminal justice policy may well not equate to good public health policy. Observers in our state wonder if legalization might come to North Carolina. That seems unlikely with the conservative tilt of the General Assembly and a ballot initiative is equally unlikely since legislators would have to approve putting it on the ballot in North Carolina.
As more states adopt full legalization, we have a real opportunity to gain more insights about both the intended and unintended consequences of marijuana legalization. Unfortunately, the lure of new tax revenues from legalization is enticing states to rush toward legalization — even when there is no clear plan to invest these revenues in health care or to develop systems of surveillance of the health effects of legalization before it is enacted. As these states plan for implementing recreational use, what are the tangible steps they should take toward critical public health surveillance?
The National Academies of Sciences, Engineering and Medicine in 2017 reported on the current scientific knowledge about the potential health benefits and harms associated with marijuana use. They found evidence that cannabis can have significant medical benefits in reducing pain associated with some medical conditions and pain and nausea associated with cancer chemotherapies.
Conversely, they found that cannabis use is associated with increased risk for being involved in a motor vehicle accident, unintentional overdoses in children, and developing chronic bronchitis among heavy users. They also found a serious but modest increased risk of schizophrenia or other psychotic disorders, and impairments in learning, memory and attention among youth. Most worrisome, they found that much remains unknown about potential negative health effects of recreational cannabis — alarming, in light of markedly increased potency of marijuana products.
If states legalize marijuana, they should invest their new marijuana tax revenue in collecting data on cannabis-related benefits and adverse outcomes — including tracking hospitalizations, emergency department visits, DUIs, motor vehicle accidents, incidents of mold contamination or overdoses — to be able to accurately measures rates of change in these incidents post-legalization.
Colorado offers a good example. They devised a public health framework for legalized cannabis that highlights three primary responsibilities for public health — assessment, policy development and assurance. Assessment includes, among other things, measuring cannabis use in its various forms and relevant effects; collecting administrative records for cannabis-involved hospitalizations and emergency department visits; and improving data collection on cannabis involvement in DUIs. Policy and regulation includes considerations around taxation, hours of sale, retailer licensing requirements, packaging requirements, limits on marketing that could be directed to children and prevention education campaigns. Finally, assurance involves enforcement of all policies, regulations and inspection of cannabis production, as well as potency and contamination testing.
With much still unknown about the short- and long-term health effects of cannabis, states contemplating legalization should plan for these rigorous forms of policy surveillance and avoid the temptation to direct these substantial new tax revenues into non-health or non-human welfare purposes.
Allison Robertson, Ph.D., M.P.H.; and Marvin Swartz, M.D., are faculty at the Wilson Center for Science and Justice in the Duke University School of Law.