As marijuana decriminalization spreads, public health prepares: Health effects, regulations examined
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* Natalie McGill

More than a dozen U.S. states have decriminalized the possession of marijuana, meaning it is no longer a criminal offense for someone to have small amounts of the drug, such as an ounce or less. States such as Colorado and Washington have gone even further — legalizing recreational use for adults 21 and older in 2012.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/44/7/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/44/7/1.3/F1)

Customers shop for marijuana at Top Shelf Cannabis in Bellingham, Washington, in July. As more states decriminalize marijuana, state and local health workers are preparing for the health and regulatory ramifications of its use.

Photo by David Ryder, courtesy Getty Images

The public health implications that come with widespread decriminalization or legalization are beginning to surface as state health departments and scientific research attempt to stay in step with the trend.

Decriminalization has been supported by many health equity advocates because of disparities in law enforcement and imprisonment for marijuana possession among U.S. populations. Unequal arrests “force people into the criminal justice system and those with convictions have a difficult time getting jobs and the related access to health insurance,” said Kathleen Hoke, JD, director of the eastern region for the Network for Public Health Law.

“Others say, ‘We’ve worked for decades to fight against the scourge of cigarette smoking. Why are we embracing this substance?’ Yet we don’t have the same type of evidence we have with smoking. We never studied it this closely because it’s an illegal product.”

But emerging research already shows the potential short- and long-term effects of marijuana use on public health, with young adults a high-risk group. Young adults who use marijuana heavily as teens are more likely to become addicted, have altered brain development and perform poorly in school, according to a National Institute on Drug Abuse review published in June in the *New England Journal of Medicine.* Marijuana impairs driving skills and is often associated with motor vehicle accidents, particularly when combined with alcohol, said the review, which analyzed multiple studies on marijuana and its effects on health.

“It is important to alert the public that using marijuana in the teen years brings health, social and academic risk,” said Nora Volkow, MD, a review author and director of the National Institute on Drug Abuse, in a June 4 news release. “Physicians in particular can play a role in conveying to families that early marijuana use can interfere with crucial social and developmental milestones and can impair cognitive development.”

The risk to child health is of particular concern, especially with edible products containing marijuana that are not regulated on the same levels as the food and prescription drugs Americans use. Between 2005 and 2011, states that decriminalized marijuana saw a 30 percent increase per year in calls to poison control centers for children ages 9 and younger who consumed marijuana products, according to a June study in the *Annals of Emergency Medicine.*

Child poisoning is just one of the health concerns in Colorado, where safety of edible or infused-marijuana products is also a concern. There is no regulatory agency similar to the Food and Drug Administration to enforce edible manufacturing safety, as marijuana is still considered an illegal substance federally. Therefore, the burden falls on state and local agencies, said Tista Ghosh, MD, MPH, deputy chief medical officer and director of the Disease Control and Environmental Epidemiology Division for the Colorado Department of Public Health and Environment.

“You have people making these edible products, but are they using appropriate food safety practices?” Ghosh told *The Nation’s Health.* “Then there’s the maternal and child health issues. We’ve heard anecdotally that pregnant women are using marijuana products, so what is the effect on the fetus? From pediatricians, we’re hearing anecdotally about breastfeeding moms using marijuana to help treat colic or calm fussy babies. And from geriatricians, we are hearing about older adult falls related to use. There’s a variety of issues we never thought of.”

With the new health concerns comes a need for adequate public health laws that address them.

APHA’s Alcohol Tobacco and Other Drugs Section has proposed an Association policy statement on the issue, which calls for a public health approach to regulating marijuana products.

One way to tackle regulation is to develop policies modeled after strategies to address alcohol and tobacco use, according to a June article in APHA’s *American Journal of Public Health.* To address public health concerns such as access by children and the risk of addiction, the article recommends keeping prices high, measuring and preventing impaired driving, and limiting marketing and the types of product sold.

Marijuana needs to catch up to the way alcohol is taxed based on its level of potency, said Rosalie Liccardo Pacula, PhD, an article author and co-director of the Rand Drug Policy Research Center. She said marijuana is not the same across the board, and other research has shown that the average potency of marijuana has been rising in states that allow marijuana dispensaries.

“Those that legally permit dispensaries, including their commercialization and marketing, experience higher average potencies,” Pacula told *The Nation’s Health.* “Can we expect that in a legalized environment? Yes, unless policy considers restrictions on the type of strains of marijuana.”

Whether FDA will regulate edible marijuana products as the agency does with food is unknown, but the lesson for states to pull from tobacco and alcohol is to ban products such as lollipops and candy that are attractive to kids, she said.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/44/7/1.3/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/44/7/1.3/F2)

Deb Greene, right, is the first customer at the Cannabis City store in Seattle in July after Washington became one of the first states to legalize marijuana for recreational use.

Photo by Elaine Thompson, courtesy AP/Getty Images

Hoke said public health laws in states that decriminalize marijuana may also need to address how people are examined for driving under the influence. The number of Colorado drivers in fatal motor vehicle crashes who tested positive for marijuana increased after medical marijuana was available commercially in mid-2009, according to a study in July’s *Drug and Alcohol Dependence.* A total of 4.5 percent of fatal crashes in the first six months of 1994 involved a driver using marijuana, compared with 10 percent of crashes in the last six months of 2011, the study said.

“It’s not like you can have a driver blow into a breathalyzer and know if they’re intoxicated by marijuana,” Hoke said. “The process for determining if a driver is intoxicated from marijuana is far more complex and costly than the roadside breathalyzer. How can the law be changed to address this concern?”

Another focus is on whether state indoor air laws need to be amended to include marijuana to avoid the risk of secondhand smoke exposure, especially to children and their developing brains, Hoke said.

Colorado already has indoor air laws covered. Ghosh said her department from the beginning included marijuana in the state’s Clean Indoor Air Act, so, like tobacco, users are not allowed to smoke indoors in public areas such as restaurants. As far as other regulations, the health department is providing consultation to the state’s Department of Revenue, which is in charge of creating marijuana regulations, such as those for child-proof packaging on marijuana products. Ghosh said the health department is also working on developing surveillance systems to track marijuana-related data, as well as using existing data — such as poison control data for unintentional poisonings and emergency room visit data — to monitor health outcomes. The health department is also adding questions to foodborne illness surveillance systems to track illnesses possibly linked to contaminated edible products, Ghosh said.

Colorado’s health department created a website, [www.colorado.gov/marijuana](http://www.colorado.gov/marijuana), this year with fact sheets that answer questions about the health effects of marijuana, marijuana laws and methods of use such as eating, smoking and vaporizing. The website consolidates information from across state agencies, such as the Department of Education and Department of Transportation.

Ghosh said one of the things she has learned is that addressing the public health implications of decriminalization is a multidisciplinary effort. The issue involves a range of public and environmental health disciplines, such as food safety, injury prevention and infectious disease surveillance — not just tobacco or substance use.

For more information, visit [www.networkforphl.org](http://www.networkforphl.org) or [www.drugabuse.gov](http://www.drugabuse.gov).

*   Copyright The Nation’s Health, American Public Health Association