Factors driving the diffusion of medical marijuana legalisation in the United States

Abstract

In the past 20 years, the drive to legalise medical marijuana (cannabis) has gained national attention with the public and policy makers. Beginning in 1996 states started implementing MMLs (medical marijuana laws), and by the end of 2015, 23 states and the District of Columbia had adopted laws legalizing marijuana use for medical purposes. We find that measures of policy diffusion and political culture are important drivers of adoption. However, the relative effects of positive pressure from neighbouring states and negative pressure from the ideological distance between adopting and non-adopting states is such that complete diffusion is unlikely.     

Associations between state-level policy liberalism,cannabis use,and cannabis use disorder from 2004 to 2012: Looking beyond medical cannabis law status

BackgroundMedical cannabis laws (MCL) have received increased attention as potential drivers of cannabis use (CU), but little work has explored how the broader policy climate, independent of MCL, may impact CU outcomes. We explored the association between state-level policy liberalism and past-year cannabis use (CU) and cannabis use disorder (CUD).MethodsWe obtained state-level prevalence of past-year CU and CUD among past year cannabis users for ages 12–17, 18–25, and 26+ from the 2004–2006 and 2010–2012 National Surveys on Drug Use and Health. States were categorized as liberal, moderate, or conservative based on state-level policy liberalism rankings in 2005 and 2011. Linear models with random state effects examined the association between policy liberalism and past-year CU and CUD, adjusting for state-level social and economic covariates and medical cannabis laws.ResultsIn adjusted models, liberal states had higher average past-year CU than conservative states for ages 12–17 (+1.58 percentage points; p = 0.03) and 18–25 (+2.96 percentage points; p = 0.01) but not for 26+ (p = 0.19). CUD prevalence among past year users was significantly lower in liberal compared to conservative states for ages 12–17 (−2.87 percentage points; p = 0.045) and marginally lower for ages 26+ (-2.45 percentage points; p = 0.05).ConclusionLiberal states had higher past-year CU, but lower CUD prevalence among users, compared to conservative states. Researchers and policy makers should consider how the broader policy environment, independent of MCL, may contribute to CU outcomes.     

Factors contributing to changes in frequency of cannabis consumption by cannabis users in England: A structured interview study

Structured interviews were conducted to identify factors that contribute to changes in frequency of personal cannabis use (increases, decreases or abstinences). Sixty cannabis users were recruited from locations throughout England (mean duration of use: 14.1 years). Among those who gave reasons for escalating their cannabis use, a large majority (79%) cited the importance of increased use by others. Approximately one-third cited the importance of a change in circumstances that provided more opportunities to use the drug, and a similar proportion claimed a role for the perceived beneficial effects of the drug. The reasons given for reducing or abstaining were more diverse, but changed circumstances were again highlighted (by 55% and 73% respectively). Reductions primarily followed changes to living arrangements, peer relations or employment; in contrast, changes precipitating abstention were more transient. Negative health effects were considered relevant by 31% of reducers and by the same proportion of those who had ever abstained. The results suggest that perceived external constraints play important roles in both upward and downward changes in cannabis use; that perceived functional effects influence escalation; and that concerns about addiction and health are salient to reduced use.     

Routes of cannabis administration among adolescents during criminal prohibition of cannabis in Canada

Abstract

This report assesses sociodemographic correlates of cannabis routes of administration (ROAs) among adolescents in 2017, one year prior to legalization of cannabis in Canada. We analyze a subsample of 809 students (Grades 9–12) from the Ontario Student Drug Use and Health Survey (OSDUHS) who used cannabis in the previous year. Pipes/bongs/waterpipes (81.8%) are the most prevalent ROA, followed by joints (73.8%) and edibles (42%). Approximately 70% of students report 2+ ROAs. Alcohol use in the previous year is associated with 2.28 (1.3–5.58 OR; 95% CI) times the odds of food/drink ROA and 2.91 (1.10–3.89; 95% CI) times the odds of joint ROA. Tobacco use is associated with 1.60 (1.07–2.41 OR; 95% CI) times the odds of blunt ROA, 2.07 (1.10–3.89; 95% CI) times the odds of pipe/bong/waterpipe ROA, and 1.75 (1.03–2.95 OR; 95% CI) times the odds of e-cigarette/vape pen/vaporizer ROA. Students who used alcohol have a rate 1.59 (1.08–2.36 IRR; 95% CI) times greater for total ROA count, and students who used tobacco have a rate 1.24 (1.09–1.40 IRR; 95% CI) times greater. Given young people’s vulnerability to adverse outcomes associated with cannabis use, it is important to track ROA trends to inform harm reduction and educational programing and to evaluate impacts of policy changes.     

Mapping Australian public opinion on alcohol policies in the new millennium

Introduction and Aims. Drawing on 16 items in the 2004 National Drug Strategy Household Survey (NDSHS), the paper explores the degree to which Australian public opinion towards different alcohol policies cohere or diverge, and the social location of support for and resistance to more restrictive alcohol controls. Variations in support for particular policies by demographic groups, across states and territories and among those with difference drinking patterns are explored. The extent and direction in which attitudes have changed over time was determined. Design and Methods. Sixteen items from the 2004 NDSHS were subjected to factor analysis. Both a single factor and a four‐factor solution were derived and became the dependent variables for state/territory comparisons and multiple regression analyses determining the predictive power of respondents demographics and drinking behaviour. Trends over time in alcohol policy attitudes used the 1993, 1995, 1998, 2001 and 2004 NDSHS. Results. More severe penalties against drink driving and stricter laws against serving customers who were drunk had the strongest support while policies that controlled accessibility to alcohol such as reducing trading hours received the least support. For all policies support was greater among females, older respondents and those drinking less. The individual's drinking pattern was as strong, and in some cases a stronger predictor of support than gender and age. Discussion and Conclusions. While support for the majority of the alcohol policies decreased over the 11‐year period since 1993, attitudes may be influenced and changed over a shorter period of time.[Wilkinson C, Room R, Livingston M. Mapping Australian public opinion on alcohol policies in the new millennium. Drug Alcohol Rev 2009]     

Community attitudes towards cannabis law and the proposed Cannabis Infringement Notice scheme in Western Australia

Western Australia (WA) became the fourth Australian jurisdiction to adopt a prohibition with civil penalties scheme for minor cannabis offences when its Cannabis Infringement Notice (CIN) scheme became law on 22 March 2004. Previous criminological research has demonstrated the importance of public attitudes towards the law in determining the effectiveness of legislation. This survey represents the first phase of a pre-post study that attempted to gauge public attitudes towards the legal status of cannabis, the proposed legislative reforms surrounding the drug and their likely effects. A random telephone survey of 809 members of the WA population was conducted prior to the implementation of the new laws with a view to exploring contemporary views of the existing legal status of cannabis, attitudes to the proposed legislative model and respondent perceptions of its likely effects. Despite cannabis being viewed negatively by large numbers of the sample, criminal penalties for minor cannabis offences were viewed as inappropriate and ineffective. Once explained, the proposed civil penalty scheme was viewed as 'a good idea' by 79% of the sample, despite significant differences due to personal experience of cannabis use, political affiliation, religiosity and age of offspring. Most believed that the legislative change would not result in changes to levels of cannabis use (70%) or ease of obtaining cannabis (59%). These data suggest that prior to its implementation the new legislation was highly acceptable to the majority of the community. These baseline data will be compared with data to be collected at the post-change phase of the study to allow empirical observations of attitudinal and behavioural changes occurring in the community. [Fetherston J, Lenton S. Community attitudes towards cannabis law and the proposed Cannabis Infringement Notice scheme in Western Australia. Drug Alcohol Rev 2005;24:301-309]     

Regulating Cannabis Social Clubs: A comparative analysis of legal and self-regulatory practices in Spain,Belgium and Uruguay

BackgroundCannabis Social Clubs (CSCs) are a model of non-profit production and distribution of cannabis among a closed circuit of adult cannabis users. CSCs are now operating in several countries around the world, albeit under very different legal regimes and in different socio-political contexts.AimIn this paper we describe and compare the legal framework and the self-regulatory practices of Cannabis Social Clubs in three countries (Spain, Belgium, and Uruguay). The objective of our comparative analysis is to investigate how CSCs operate in each of these countries. To foster discussions about how one might regulate CSCs to promote public health objectives, we conclude this paper with a discussion on the balance between adequate governmental control and self-regulatory competences of CSCs.MethodsThe data used for this analysis stem from independently conducted local studies by the authors in their countries. Although the particular designs of the studies differ, the data in all three countries was collected through similar data collection methods: analysis of (legal and other documents), field visits to the clubs, interviews with staff members, media content analysis.FindingsWe identified a number of similarities and differences among the CSCs’ practices in the three countries. Formal registration as non-profit association seems to be a common standard among CSCs. We found nevertheless great variation in terms of the size of these organisations. Generally, only adult nationals and/or residents are able to join the CSCs, upon the payment of a membership fee. While production seems to be guided by consumption estimates of the members (Spain and Belgium) or by the legal framework (Uruguay), the thresholds applied by the clubs vary significantly across countries. Quality control practices remain an issue in the three settings studied here. The CSCs have developed different arrangements with regards to the distribution of cannabis to their members.ConclusionsBy uncovering the current practices of CSCs in three key settings, this paper contributes to the understanding of the model, which has to some extent been shaped by the self-regulatory efforts of those involved on the ground. We suggest that some of these self-regulatory practices could be accommodated in future regulation in this area, while other aspects of the functioning of the CSCs may require more formal regulation and monitoring. Decisions on this model should also take into account the local context where the clubs have emerged. Finally, the integration of medical supply within this model warrants further attention.     

Understanding Public Attitudes Toward Cannabis Legalization: Qualitative Findings From a Statewide Survey

Background: Cannabis policy is rapidly evolving in the United States as more states legalize medical and non-medical marijuana. Public opinion has shifted dramatically in favor of marijuana legalization. Objectives: This study examines the reasons that people support, oppose, or are unsure about marijuana legalization, focusing on the participants’ own words. Methods: A statewide sample of adults (N?=?2,608) in Michigan completed an online survey about marijuana legalization (August and September 2016). Participants indicated whether they supported, opposed, or were unsure about marijuana legalization, and were then prompted to complete an open-ended response explaining the main reasons for their view. Thematic analysis was then used to code the open-ended responses (n?=?2,054) and analytic induction was used to evaluate the coding. Results: 48.1% of the sample supported cannabis legalization, 41.9% were opposed to legalization, and 10% were unsure. Harms associated with marijuana use were the most commonly given reasons for opposing legalization. Those who supported legalization were most likely to state that marijuana is less dangerous than other substances and has medical benefits. They also cited criminal justice reform and the potential for tax revenue as potential benefits of legalization. Reasons for supporting and opposing legalization differed based on gender, age, and recent marijuana use. Conclusions/Importance: Findings highlight nuances in public attitudes toward cannabis legalization. Many who support cannabis legalization recognize some potential negative consequences of these policy changes. Understanding views of cannabis is important as policies for marijuana use and sales become less restrictive.     

Mitigation of Marijuana-Related Legal Harms to Youth in California

ABSTRACT

If recreational marijuana is legalized for adults in California, a rational implementation of public policy would neither criminalize youth possession, nor medically pathologize it by conflating possession with addiction. The harms of a criminal justice approach to juveniles should not exceed the harms of the drug itself. Juvenile arrests and probation have consequences: (1) arrest records, probation, and juvenile hall; (2) an incarceration subculture, “crime school,” psychological and re-entry costs; (3) school “zero-tolerance” expulsions and suspensions; (4) ineligibility for federal school loans; (5) employment screening problems; (6) racial disparities in arrests; (7) fines and attorney’s fees; and (8) immigration/naturalization problems. Marijuana-related arrest rates in California dropped after a 2011 law making possession under 1 oz. an infraction for all, but juvenile marijuana arrests continue to outnumber arrests for hard drugs. Recommendations for prudent implementation policy include: stable marijuana tax funding for Student Assistance Programs (SAPs) in high schools; elimination of “zero-tolerance” suspension/expulsion policies in favor of school retention and academic remediation programs; juvenile justice transparency discriminating among infractions, misdemeanors, and felonies. Criminal sanctions and durations must be proportional to the offense. Probation-based interventions should be reserved for larger possession amounts and recidivist offenders, and outcomes should be independently evaluated.     

Public health messages about perinatal marijuana use in an evolving policy context

Background: Marijuana is a commonly used substance in pregnancy in the United States. It is unknown what public health messages about perinatal marijuana use are being disseminated in the changing policy landscape. Methods: The authors systematically searched 51 state and 5 federal public health agencies' Web sites in February 2016 for information about perinatal marijuana use. Of these, 1 federal agency and 10 state agencies had published information about perinatal marijuana use. Content analysis was performed by 2 investigators, with excellent interrater reliability (mean κ = 0.87). Results: Most content was targeted to the public, although 3 agencies had content targeted to health care providers. Common messages about health effects included adverse outcomes in infants and children exposed in utero and that marijuana can be passed via breast milk to infants. Eight sites mentioned health effects of marijuana use during breastfeeding, 5 included resources to stop using marijuana, 5 mentioned implications of marijuana use for infant safety, and 3 mentioned potential legal consequences. Conclusions: The volume of public health messages about perinatal marijuana use is low, content of messages differs across state agencies, and perinatal marijuana is seldom addressed in content published by federal agencies.     

Normalization and denormalization in different legal contexts: Comparing cannabis and tobacco

Aims: This study provides an examination of normalization trends associated with the use of cannabis and tobacco, and whether and to what extent health concerns and legal contexts appear to modify the tolerance displayed to users. Methods: Data for this paper are drawn from a mixed methods interview study involving 202 respondents who reported being regular users of cannabis (alone n?=?100 or in conjunction with tobacco n?=?67) or tobacco only users (n?=?35), in four Canadian cities (Halifax, Montreal, Toronto and Vancouver). Findings: While participants commonly attributed serious health risks to the use of tobacco, cannabis was viewed as relatively low risk. All groups described cannabis laws as too punitive, while most agreed with the regulatory controls for tobacco. Drawing on norms around appropriate context for use, cannabis users illustrate the expansion of normalization, with varying degrees of acceptability in different spaces. In contrast, tobacco users’ heightened awareness of the dangers of smoking leads them to engage in a reflexive process-limiting appropriate venues and contexts for use. Conclusions: These findings suggest that perceptions of health risk shape users’ experience of normalization (and denormalization) and help to contextualize the larger societal processes where both drugs are in a stage of societal re-evaluation. Much can be learned about the cannabis future from the tobacco past.     

An Examination of Beliefs and Opinions about Drug Use in Relation to Personal Stigmatization towards Drug Users

Abstract

Stigma can be harmful to drug users, particularly those in need of treatment. Beliefs and opinions about drug use may influence how individuals view or treat drug users, so research was needed to examine whether specific beliefs and opinions are related to stigma towards users. A sample of 531 adults was assessed to examine how stigmatization relates to specific beliefs and opinions about drug use. Eighty percent of the sample reported lifetime use of an illicit drug. While controlling for demographic characteristics, lifetime drug use and exposure to users, stigmatization towards users more than doubled the odds of reporting that addiction is a choice, and more than tripled the odds for reporting that marijuana and heroin are equally dangerous. Stigmatization, however, lowered the odds of reporting that drugs would be okay to use if legal. Individuals who stigmatize drug users may be under-educated about drug use; however, such individuals appear to be at low risk for use. Beliefs and opinions guided by misinformation may negatively affect users, so public health efforts are needed to educate individuals about drug use and addiction in an objective manner, and treat use as more of a health behavior and less of a moral behavior.     

Capturing Heterogeneity in Medical Marijuana Policies: A Taxonomy of Regulatory Regimes Across the United States

Background: There is considerable movement in the U.S. to legalize use of cannabis for medicinal purposes. Twenty-three U.S. states and the District of Columbia have laws that decriminalize use of marijuana for medicinal purposes. Most prior studies of state medical marijuana laws and their association with overall marijuana use, adolescent use, crime rates, and alcohol traffic fatalities have used a binary coding of whether the state had a medical marijuana law or not. Mixed results from these studies raise the question of whether this method for measuring policy characteristics is adequate. Objectives: Our objective was to develop a validated taxonomy of medical marijuana laws that will allow researchers to measure variation in aspects of medical marijuana statutes as well as their overall restrictiveness. Methods/Results: We used a modified Delphi technique using detailed and validated data about each state's medical marijuana law. Three senior researchers coded elements of the state laws in initiation of use, quantity allowed, regulations around distribution, and overall restrictiveness. We used 2013 data from the U.S. National Survey on Drug Use and Health to assess validity of the taxonomy. Results indicate substantial state-level variation in medical marijuana policies. Validation analysis supported the taxonomy's validity for all four dimensions with the largest effect sizes for the quantity allowed in the state's medical marijuana policy. Conclusions/Importance: This analysis demonstrates the potential importance of nondichotomous measurement of medical marijuana laws in studies of their impact. These findings may also be useful to states that are considering medical marijuana laws, to understand the potential impact of characteristics of those laws.     

From Toques to Tokes: Two challenges facing nationwide legalization of cannabis in Canada

BackgroundIn 2015, a new Liberal Government came to power in Canada, elected on a platform that included legalization and regulation of cannabis for recreational purposes. Their legislation, based on recommendations from a Federal Task Force on Marijuana Legalization and Regulation, is due in early April 2017.MethodsThis commentary utilizes Canadian Federal policy papers, previous literature, and internal and international agreements to examine two key areas critical to the development of a nationwide regulated market for cannabis in Canada; the need to overcome restrictions to legalizing cannabis in United Nations’ drug control treaties, and the unique challenges that non-medical cannabis creates for navigating interprovincial trade policies in Canada.ResultsIrrespective of UN conventions that appear to prohibit legalization of cannabis the Government is preparing to bring forward legislation as this article goes to print. At the same time significant squabbles impede the selling of even beer and wine inter-provincially in Canada. This paper identifies the challenges facing Canadian legalization efforts, but also shows how the legalization legislation may provide opportunities to engender significant change beyond the simple legalization of a specific drug.ConclusionThis commentary does not argue for any specific course of action for Canada, but rather explores the nuance of legalization absent from the declaration in the Liberal party platform. The paper argues that Canada’s efforts may hasten the dismantling of the UN drug control structure, and provide renewed opportunities for intern-provincial trade in Canada.     

UNGASS 2016: Insights from Europe on the development of global cannabis policy and the need for reform of the global drug policy regime

This article is framed by the forthcoming United Nations General Assembly Special Session on drugs (UNGASS) debates on global drug policy. It explores European drug policy experiences to draw out important lessons and insights that could be applied to wider global drug policy regimes. European experiences with (i) diverse cannabis policies and (ii) longstanding attempts to harmonise or coordinate diverse national drug policies in general are examined and the results are extrapolated to global drug policy debates. The diversity of drug policy seen within EU borders should be viewed (i) as a strength, (ii) flexibility under the international conventions is possible, but has limitations, (iii) changes to the global drug policy regime should seek to increase flexibility, and (iv) the importance of international institutions in providing a framework and an evaluatory role should not be under emphasised. Collectively, the evidence suggests the need for the loosening of controls restricting the development of diverse drug policy innovations, and the development of international drug policy frameworks and international standards of drug-related data collection.