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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Public Health Consequences of Changes in the Cannabis Policy Landscape; Boyle EB, Hurd YL, Teutsch SM, editors. Cannabis Policy Impacts Public Health and Health Equity. Washington (DC): National Academies Press (US); 2024 Nov 14.

Cannabis Policy Impacts Public Health and Health Equity.
Show detailsEvaluation, a cornerstone of public health practice, is essential for ensuring the effectiveness of public health interventions. Evaluating cannabis policy is particularly important because these policies may have significant and sometimes opposing public health consequences. Decriminalization or legalization of cannabis may reduce the harms associated with criminal justice encounters, for example, which negatively impacts the health of individuals and their families and contributes to health inequities. On the other hand, more liberal cannabis policies may lead to social acceptance of cannabis use, lower prices, and greater product diversity, all leading in turn to increased use. Additionally, allowing medical use of cannabis may provide therapeutic benefits to some with specific conditions, but also may lead people to believe cannabis use is healthy. Thus, changes in cannabis policy may have unintended public health consequences, such as increased traffic collisions, dependence or use disorders among people who use cannabis, and adverse mental health outcomes. Understanding the health effects of cannabis use is therefore crucial for evaluating the public health impacts of cannabis policy changes. This chapter explores current research on this topic.
Previous chapters evaluated cannabis policy in the United States conceptually and provided recommended actions for limiting the harms of cannabis policy or improving research and evaluation of policy changes. In this chapter, the committee proposes a research agenda that would address the many data gaps that need to be filled to improve a public health approach to cannabis policy. The chapter highlights health effects of utmost priority to the interested parties who spoke at the committee’s open meetings, reviews datasets available for evaluating cannabis policy, and summarizes the results of systematic reviews that evaluate the public health impacts of changes in cannabis policy. The discussion in these areas informs a research agenda for the next 5 years.
HEALTH EFFECTS OF CANNABIS: RESEARCH NEEDS
Numerous research needs were identified at the committee’s public meetings, which included presentations from a broad range of interested parties related to cannabis and health—clinicians, parents, and educators who raised concerns about the health impacts of cannabis use. Every public meeting had an open sign-up, allowing anyone to provide input on the committee’s task. The committee heard from more than 20 people, all of whom expressed concerns about the increased cannabis use that follows policy changes and the health impacts of this increased use. The most common conditions discussed were mental health disorders, substance use disorders, anxiety, depression, paranoia, psychosis, schizophrenia, suicidal ideation, and suicide. Others related to mental and behavioral health, violence, impaired learning, memory, and ability to hold a job. Still others related to impaired driving and deaths resulting from motor vehicle crashes; secondhand exposure to cannabis; exacerbation of other health conditions; and cannabinoid hyperemesis syndrome, a condition whereby a patient experiences cyclical nausea, vomiting, and abdominal pain (sometimes intense) after using cannabis (Chu and Cascella, 2023). The committee also heard about the changing product landscape and the need for ongoing evaluation of the health effects of cannabis, specifically of high-concentration tetrahydrocannabinol (THC) products.
Laura Stack, founder and CEO of Johnny’s Ambassadors, shared her story of losing her son to suicide due to psychosis following cannabis use. She said her organization’s parents of children with cannabis-induced psychosis “currently [has] 1,598 parents whose children are in mental institutions across the United States with cannabis-induced psychosis.” She highlighted the alarming ease with which teens can access high-potency cannabis, using medical marijuana cards obtained without legitimate medical conditions. Stack emphasized the correlation between cannabis use and rising rates of mental health issues among youth, urging stronger regulations and education to protect young people.
Aubree Adams of Every Brain Matters described witnessing her son struggle with severe mental health issues, such as psychosis, violence, and suicide attempts, following heavy cannabis use, and the challenges of finding appropriate treatment. After she found a recovery community in Texas, her son was sober for more than 3 years. He relapsed, however, and her family did not see or hear from him for more than 2 years until he reached out for help. She said, “I did not recognize him when I saw him. He was skin and bones, he couldn’t eat, he was very weak. And he was only testing positive for THC.” She believed he was using delta-8-THC vapes available at gas stations and smoke shops in Texas as a result of the 2018 Farm Bill, which allowed the sale of hemp-derived products.
Gabriel Mondragon described his personal experience with schizophrenia following cannabis use. He believes his cannabis use, which began around age 10, may have activated his predisposition to schizophrenia, which he has in part as a result of his family history, and which led to homelessness and drug use for much of his life. Following a psychotic event, he experienced electrocution, which caused the loss of three limbs. In his opinion, it is not just the high-concentration cannabis products that are causing severe psychotic effects but also lower-concentration products and even exposure to secondhand cannabis smoke. Mondragon also noted the negative consequences of cannabis legalization on employment, health care, and overall societal well-being. Mondragon said, “The whole point of cannabis is self-induced psychosis. The high is psychosis.”
As noted in Chapter 3, the concentration of delta-9-THC in cannabis flower has been increasing over time. In addition, concentrates such as dabs, wax, and shatter contain very high concentrations of delta-9-THC, usually in the range of 60 percent but sometimes more than 90 percent. The high concentration allows the administration of a high dose in a short amount of time. Many public health professionals are concerned about the potential additional harm related to these higher concentrations. The committee identified two reviews that evaluate the impacts of delta-9-THC concentration on health (Bero et al., 2023; Petrilli et al., 2022).
Petrilli and colleagues (2022) evaluated the health impacts of high-concentration delta-9-THC products by conducting a systematic review of the association of delta-9-THC concentration with mental health and addiction. The review included observational studies of humans that compared the association of products with a higher concentration of delta-9-THC with those with a lower concentration, and evaluated mental health impacts such as depression, anxiety, psychosis, and cannabis use disorder. Of 4,171 articles screened, 20 met the review’s eligibility criteria: 8 studies focused on psychosis, 8 on anxiety, 7 on depression, and 6 on cannabis use disorder. The identified studies had fair to poor quality, as assessed with the Newcastle Ottawa Scale, and used different definitions of higher and lower concentration. Yet despite the fair to poor quality of the evidence, the authors determined that the use of products with a higher concentration of delta-9-THC relative to those with a lower concentration was associated with an increased risk of psychosis and cannabis use disorder. The evidence varied for depression and anxiety (Petrilli et al., 2022).
More recently, Colorado HB 21-1317 charged the Colorado School of Public Health with conducting a scoping review of the evidence for the health effects of high-THC-concentration cannabis. A scoping review completed in 2023 identified 452 studies meeting the inclusion criteria (human studies of any epidemiological design with no restrictions by age, sex, health status, country, or outcome measured that reported THC concentration or included a known high-concentration cannabis product). The characteristics of these studies and key findings were summarized and made available to the public via a dashboard and publication (Bero et al., 2021, 2023; Cannabis Research and Policy Project Team, 2023). This scoping review found significant limitations in the quality of studies and an absence of conclusive evidence for the health effects of high-concentration cannabis products. Problems with the literature were severe, including deficiencies in study methods and minimal coverage of products relevant to today’s marketplace.
The associated report from the scoping review used a scale for the amount of available evidence based on the number of statistically significant studies. The numbers of studies are classified as none, limited (1–4), moderate (5–9), and substantial (10+). There was moderate evidence for only two policy questions; all others had no or limited evidence. The two policy questions with moderate evidence were (1) whether high-concentration THC cannabis products have been associated with beneficial outcomes in those with preexisting mental health conditions (6 statistically significant studies of 15 total studies) and (2) whether high-concentration products pose a greater risk for mental and behavioral health outcomes (8 statistically significant studies of 19 total studies) (Cannabis Research and Policy Project Team, 2023).
Schlienz and colleagues (2020) found harms associated with increasing doses of THC. They administered oral THC brownie edibles that contained 0, 10, 25, and 50 mg of THC to 17 healthy adults. Peak effects were noted at 1.5–3.0 hours postingestion. The study findings indicated a dose-dependent association of increasing questionnaire subscales relating to adverse mental health effects. In the 50 mg THC group, there were statistically significant associations with paranoia, restlessness, and anxiousness or nervousness (Schlienz et al., 2020).
Another example of evidence supporting harms of increasing dose is the crossover trial conducted by Sainz-Cort and colleagues (2021). It included four exposure groups: THC extract (65 mg), cannabidiol (CBD) extract (130 mg), THC (65 mg) + CBD (130 mg) extract, and placebo (<0.05 mg THC, <0.05 CBD). The THC-only condition scores were higher than those for the THC + CBD condition for all subscales on the Psychotomimetic States Inventory. Subjective effects subscales (hearing voices and having suspicious ideas or beliefs) were also highest with the high-THC group. The outcomes for the high-THC group were the most elevated at all time points up to 75 minutes (Sainz-Cort et al., 2021).
While the research on the health effects of high-concentration THC products is in its early stages, there is reason for concern. The increasing availability of products with THC concentrations exceeding 60 percent is coupled with evidence, albeit of fair to poor quality, suggesting a link between higher doses and a higher risk of psychosis and cannabis use disorder (Petrilli et al., 2022). The Colorado scoping review identified some evidence for both potential benefits and risks associated with high-THC products; it also found moderate evidence for a dose-dependent association between high-THC products and adverse mental health effects, with studies showing increased paranoia, anxiety, and even psychotic symptoms following THC administration (Bero et al., 2023). The THC concentration is less of a concern if the dose administered is low. The prescription drug dronabinol is more than 90 percent THC but is prescribed in small doses (2.5 mg). Some people may titrate their use of high-concentration products and limit the dose they receive; the research on titration behavior is mixed and limited. Future epidemiologic research on titrating behavior may inform harm reduction policies related to high-THC cannabis products (Leung et al., 2021).
LITERATURE REVIEW ON PUBLIC HEALTH IMPACTS OF CANNABIS POLICY
To evaluate whether health outcomes have changed as a result of changes in cannabis policy, the committee conducted a review of systematic reviews. Unlike traditional reviews that synthesize primary research, overviews of systematic reviews employ rigorous methods to identify and analyze existing systematic reviews on a specific topic. Rather than summarizing individual studies, overviews assemble evidence and compare results across multiple reviews to paint a broader picture of the evidence landscape (Becker and Oxman, 2019). The committee’s review consisted of the following steps: a literature search, screening of abstracts, a full-text review of studies identified in the abstract screening, and evaluation of a final set of 14 relevant systematic reviews (Appendix D).
The committee used the Risk Of Bias In Systematic Reviews (ROBIS) tool to evaluate the systematic reviews (Whiting et al., 2016). It has been shown to have adequate internal consistency and strong evidence for measuring the intended construct (Bühn et al., 2017). The ROBIS tool helps identify potential biases within the systematic review process. Its use consists of three phases: phase 1 assesses relevance; phase 2 identifies concerns with the review process; and phase 3 judges the risk of bias in the review. Concerns with the systematic review process are captured by considering four key domains: study eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings. Signaling questions are used to guide the judgments in each domain, and they are each answered “Yes,” “Probably Yes,” “Probably No,” “No,” and “No Information.” “Yes” indicated low concerns about the domain’s contributing to the risk of bias. The subsequent level of concern about bias associated with each domain is then judged as “low,” “high,” or “unclear” (Whiting et al., n.d.).
This approach has its limitations. Primary among these is that many harms associated with changes in cannabis policy will be difficult to observe at the population level. Most outcomes of concern associated with cannabis have many potential component causes, meaning there are many factors that would influence the prevalence of these outcomes at the population level. Another common issue is that relative to experimental designs, observational studies typically have lower internal validity, which refers to the confidence that the observed association is, in fact, true (Rosenbaum, 2017). Another flaw of the review-of-reviews approach is that some review papers include overlapping studies. To avoid double-counting studies, the committee judged the most recently published review to be the most up-to-date assessment of the evidence and relied less on the older reviews (Appendix D).
The identified systematic reviews evaluated cannabis policies with respect to decriminalization (7 reviews), medical use (8 reviews), and adult use (4 reviews). Outcomes covered include those related to perceptions and attitudes (3 reviews), use (10 reviews), other substance use (5 reviews), traffic safety (7 reviews), health care (2 reviews), and mental health (3 reviews). Annex Table 6-1 provides a high-level overview of the systematic reviews included in the committee’s review.

ANNEX TABLE 6-1
Systematic Reviews of Cannabis Policy Identified by the Committee.
Figure 6-1 presents the committee’s assessment of the quality of the systematic reviews using ROBIS. Almost half of the identified systematic reviews had an overall low risk of bias. Study appraisal and synthesis were common domains likely to be judged as having a high risk of bias. Formal risk-of-bias tools and evidence-to-decision frameworks such as GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) are applied only sometimes in policy analysis and likely need to be adapted to the types of study designs included in these systematic reviews; this is an area for methodology development for systematic reviews. The findings of the committee’s review are summarized below.

FIGURE 6-1
Risk-of-bias heat map for the identified systematic reviews.
Attitudes and Risk
Research on the impact of changes in cannabis policy changes on attitudes and risk perceptions presents a complex picture. Some systematic reviews, such as French et al. (2022), suggest decreased perceived harmfulness, particularly among youth and young adults. This finding aligns with the conclusion in Smart and Pacula (2019) that broader access through retail stores can influence perceptions. Sarvet et al. (2018) presents mixed results, with some studies reporting a moderate- to high-risk perception for occasional use, and others showing no significant perception of harm. All the systematic reviews evaluating the impact of cannabis policy changes on attitudes and risk perceptions had a high risk of bias. However, French et al. (2022) includes the most updated information, which shows decreasing risk perceptions with changes in legalization. This finding was corroborated by the committee’s analysis of the National Survey on Drug Use and Health Data (NSDUH). Thus, the committee determined that there is limited or suggestive evidence that cannabis legalization leads to decreased risk perception of cannabis use.
Use-Related Outcomes
Systematic reviews investigating the link between cannabis policy changes and consumption patterns reveal mixed findings across age groups. Multiple reviews suggest an increase in adult cannabis use following legalization (Athanassiou et al., 2023; Blanchette et al., 2022; French et al., 2022; Lachance et al., 2022), but one found no significant changes after legalization of medical cannabis (Sarvet et al., 2018). Data on young adults were similarly inconclusive, with two systematic reviews finding an increase in cannabis use (Athanassiou et al., 2023; French et al., 2022) and others highlighting a mixed picture, with studies showing increases, decreases, and no change (O’Grady et al., 2022). All the systematic reviews identified a high risk of bias in evaluations of changes in adult use. Athanassiou et al. (2023) includes the most updated information, which is corroborated by the committee’s analysis data from the NSDUH, which shows increasing use among adults (online Appendix E). The committee determined that there is limited or suggestive evidence that cannabis legalization leads to increased use among adults.
Adolescent use (ages 12–17 in most systematic reviews) presents the most inconsistent results. While some systematic reviews suggest potential increases after legalization (French et al., 2022; Melchior et al., 2019), others present a mix of findings (O’Grady et al., 2022) or report no changes with legalization (Sarvet et al., 2018; Smart and Pacula, 2019). Melchior et al. (2019) is the only review with a low risk of bias, but it is more than 5 years old. French et al. (2022) and O’Grady et al. (2022) contain many of the same studies yet arrive at different conclusions. Given that the NSDUH also shows that adolescent use has been stable as cannabis policies have changed, the committee judges the evidence as insufficient to determine an association between cannabis policy changes and adolescent use.
Other Substance Use
Some systematic reviews evaluated the impact of cannabis policy changes on changes in the use of other substances, such as opioids, alcohol, tobacco, and other illicit substances (Athanassiou et al., 2023; Chihuri and Li, 2019; French et al., 2022; Scheim et al., 2020; Smart and Pacula, 2019). Of these, the impact of cannabis legalization on opioid use was the most well studied in the systematic reviews. Specific opioid-related outcomes include opioid prescriptions, hospitalizations, mortality, nonmedical opioid use, and opioid misuse. While some evidence suggests a decrease in opioid prescriptions and hospitalizations, with cannabis legalization, the impact on mortality and nonmedical use remains inconclusive. Two systematic reviews suggest a decrease in opioid prescriptions and hospitalizations for opioid-related issues following cannabis legalization for medical use (Athanassiou et al., 2023; Chihuri and Li, 2019). However, the literature basis for this conclusion is somewhat old. The evidence for opioid mortality was mixed among the reviews that evaluated it (Athanassiou et al., 2023; Chihuri and Li, 2019; French et al., 2022). The evidence for nonmedical opioid use and opioid misuse was also mixed, with two reviews finding mixed results among the included studies (Chihuri and Li, 2019; French et al., 2022). Given the mixed evidence and high risk of bias of the systematic reviews, the committee determined there was insufficient evidence for an association between cannabis legalization and opioid use.
The effects of cannabis legalization on alcohol consumption are complex. Athanassiou et al. (2023) suggests an increase in adult alcohol consumption following legalization, while French et al. (2022), which reviews some of the same studies, reports no changes. Findings were mixed as well for the impacts of cannabis legalization on adolescent alcohol use. French et al. (2022) includes two studies suggesting that medical legalization might be associated with decreased binge drinking and past-month alcohol use among 8th and 9th–12th graders. In three studies, legalization was not found to be associated with a change in underage drinking among those aged 12–20, 10th- and 12th-grade students, or high school seniors. Overall, the committee judged the evidence for the impact of cannabis legalization on alcohol consumption–related outcomes to be insufficient for an association.
Evidence regarding the association between cannabis legalization and tobacco use is similarly mixed. One systematic review found that some studies suggest a higher prevalence of co-use of cannabis and tobacco in states with legalized cannabis (French et al., 2022). However, other systematic reviews found no significant changes in cigarette sales following legalization, making the overall impact on tobacco use unclear (Smart and Pacula, 2019). Overall, the committee judged the evidence for the impact of cannabis legalization on tobacco consumption–related outcomes to be insufficient for an association.
Findings of systematic reviews evaluating the impact of cannabis legalization on the use of other illicit drugs are also mixed and likely highly context dependent (French et al., 2022). Studies on adult illicit drug use following cannabis legalization show mixed results, and the literature on adolescent illicit drug use post legalization is similarly inconclusive. Overall, the committee judged the evidence for the impact of cannabis legalization on the consumption of illicit drugs to be insufficient for an association.
Traffic-Related Outcomes
Some systematic reviews evaluated the impact of cannabis policy changes on traffic-related outcomes, such as impaired driving and traffic collisions (Athanassiou et al., 2023; Chihuri and Li, 2019; French et al., 2021; González-Sala et al., 2023; Scheim et al., 2020; Vingilis et al., 2021; Windle et al., 2022). One systematic review found the literature on cannabis use and impaired driving performance to be inconclusive (French et al., 2021). Another identified a study with a higher prevalence of cannabis-impaired drivers in countries with more liberal cannabis policies (González-Sala et al., 2023), although this study was limited by recall bias (Wadsworth and Hammond, 2019).
Evidence regarding the impact of cannabis policy changes on traffic collisions was mixed (Athanassiou et al., 2023; Chihuri and Li, 2019; French et al., 2021; González-Sala et al., 2023; Scheim et al., 2020; Vingilis et al., 2021; Windle et al., 2022). The committee noted that studies evaluating the opening of retail outlets, not just legalization, were more likely to observe an association (Scheim et al., 2020). Three systematic reviews that evaluated traffic-related outcomes had a low risk of bias (González-Sala et al., 2023; Scheim et al., 2020; Vingilis et al., 2021; Windle et al., 2022). González-Sala et al. (2023) includes the most up-to-date literature and identifies 15 studies showing a relationship between cannabis legalization and increased traffic collisions; 5 studies did not show this relationship. Thus, the committee believes there is limited or suggestive evidence of an association between cannabis legalization and traffic collisions.
Health Care–Related Outcomes
Two systematic reviews evaluated the impact of changes in cannabis policy on health care–related measures, such as cannabis-related hospitalizations and emergency department visits. Athanassiou et al. (2023) identifies four studies that assessed the impact of cannabis legalization on cannabis-related hospitalizations and emergency department visits. Three of the four studies noted an increase in hospital-related outcomes following cannabis legalization. Scheim et al. (2020) found that nine studies evaluating health-related outcomes related to cannabis policy changes identified increased cannabis-related hospitalizations and emergency department visits. One of those two systematic reviews (Scheim et al., 2020) had a low risk of bias; that review was somewhat old but updated by Athanassiou et al. (2023), which includes the same findings. Thus, the committee believes there is limited or suggestive evidence of an association between cannabis legalization and hospital visits related to cannabis use.
Mental and Behavioral Health
Few of the systematic reviews evaluated mental and behavioral health outcomes. Smart and Pacula (2019) evaluates the impact of cannabis legalization on cannabis use disorder and finds mixed evidence of an association between medical cannabis legalization and cannabis use disorder. French et al. (2022) identifies one study on the association between medical cannabis policies and suicide, which had no significant findings. One review (Scheim et al., 2020) notes that 5 percent of the identified studies included mental health outcomes but drew no conclusions about the association with cannabis policy changes. Given the null findings, the committee determined there is insufficient evidence of an association between cannabis policy changes and mental and behavioral health.
CONCLUSIONS AND RECOMMENDATION
The committee’s review of systematic reviews underscores the complexities of evaluating the public health impacts of changes in cannabis policy. Evaluation is a cornerstone of public health practice and is even more crucial when policies may have both positive and negative consequences. The committee found 14 systematic reviews that evaluate the public health impacts of cannabis policy. The differences in how policies are implemented among the states are not well captured, making interpretation difficult. Improvements in policy analysis databases and surveillance systems are needed to allow assessments of policy changes. The committee found limited or suggestive evidence that the perceived risk of cannabis declines after legalization, use among adults increases, traffic collisions increase, and hospital visits related to cannabis use increase. For all other outcomes, the committee judged the evidence to be insufficient.
One of the most prominent public health concerns related to cannabis policy is the rise of high-concentration THC products. The committee reviewed a systematic review and a scoping review that aimed to evaluate this question. Both reviews found that studies comparing high- and low-concentration THC products often have methodological issues and may not reflect the types of high-THC products available today. However, associations have been found between high-concentration THC products and a higher risk of psychosis and cannabis use disorder.
Conclusion 6-1: The risks associated with THC consumption (including psychosis, suicidal ideation, and cannabis use disorder) increase as the dose increases. Legalizing products with a high concentration of THC allows users to administer high doses in a short time and may increase cannabis-related harms. Research is urgently needed to describe the relationship between high-concentration THC products and adverse effects to better inform public policy.
During the committee’s public meetings concerns were raised about many outcomes not evaluated in the systematic reviews, including mental health outcomes; cognitive function; and physical health outcomes, such as cannabinoid hyperemesis syndrome. Further research is critically needed to explore the impacts of changes in cannabis policy on these outcomes and improve public health practices. The committee developed a research agenda (Box 6-1) designed to improve the ongoing evaluation of the public health impacts of cannabis policy.

BOX 6-1
Cannabis Policy Research Agenda.
Recommendation 6-1: The National Institutes of Health; the Centers for Disease Control and Prevention; state, local, and tribal health authorities; and private entities should support a research agenda focused on:
public health outcomes of different approaches to cannabis regulation, efficacy of tests used to determine cannabis impairment, health effects of cannabis use (by product, amount, and frequency) by specific populations, health effects of emerging cannabis products, and mitigation of the risks of cannabis use.
CONCLUSION
The rapidly evolving landscape of cannabis legalization presents a formidable public health challenge. State-by-state variations, potential federal policy shifts, and high-concentration products raise concerns about potential health risks (e.g., mental health disorders, impaired driving, cognitive decline). This complexity is compounded by the legacy of discrimination from the war on drugs and limited research on the long-term health effects of these new products, especially for vulnerable populations.
This report offers a roadmap to a more comprehensive public health approach to cannabis policy. Implementation of the committee’s recommendations to increase federal involvement, revise the unclear definition of hemp in the 2018 Farm Bill, improve cannabis product quality and safety standards, and evaluate the impacts of cannabis policies on health and social equity would address public health concerns. It is the committee’s view, based on the evidence presented in this report, that federal leadership in cannabis policy, the promotion of research on the health effects of cannabis, and assurance of equitable access to safer cannabis products would improve the public health response to cannabis policy in the United States.
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- Available and Needed Research on Cannabis Policy - Cannabis Policy Impacts Publi...Available and Needed Research on Cannabis Policy - Cannabis Policy Impacts Public Health and Health Equity
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