Public Health Issues and Concerns Regarding Recreational Marijuana Legalization
By Jass Pelland, Clinical Director, Acting Executive Director:
New Jersey is currently considering the legalization of marijuana for recreational purposes. There are many addiction/behavioral health professionals with extensive experience in prevention, intervention, treatment and recovery support in the addiction field and public health, who care about the youth of NJ and are concerned about the possible consequences and effects of that legalization.
These professionals who have dedicated our lives to helping those afflicted with the disease of addiction, believe rapid movement toward legalization of marijuana in New Jersey may not be the best course for our state. Many of these professionals recommend that additional time be spent on exploring and creating alternatives that will not promote and normalize a drug that could negatively impact our children and young adults. We believe that New Jersey has the ability to use science and best practice to address the issues that face our state.
It is most concerning that Legislative and Executive Branch proposals and discussions on legalized recreational marijuana have been moving forward on an expedited schedule, without significant input from the public health, addictions, and medical communities. Experience indicates that there are significant impacts of marijuana legalization that will affect communities and persons at risk of addiction. The lack of attention to these issues in our State, as well as the failure to provide for an adequate regulatory framework, mitigation of public health impacts, ongoing planning or input from addiction professionals, creates a risk for New Jersey’s citizens and communities.
These public health impacts of recreational marijuana legalization are separate and distinct from the potential economic benefits to the State that is currently under discussion. The approaches to addressing them also are different and will need to involve a broader group of stakeholders. This article provids specific recommendations should the State of New Jersey decide to move forward with legalization of recreational marijuana.
The following recommendations, as outlined, are in line with CDC research and public health goals and with protocols for regulating and/or restricting other addictive products, such as tobacco and alcohol. Public health research suggests that reversing inadequately framed regulatory policies that do not prioritize public health is difficult to achieve once the processes have been set in motion and codified into law.
The domains listed below are drawn from research by the RAND Institute. RAND has indicated that States and other jurisdictions should be prepared to address the following areas through statute and/or regulation when considering marijuana policies:
- Manufacturing locations should have strict regulations; internal grows only; no home grows;
- In order to maintain effective initial and on-going regulations and restrictions, businesses should not be allowed to influence these regulations. The businesses should be held responsible for any damages that are caused by their products, as well as the results of the violations of the laws and regulations in place (e.g., DRAM Shop Liability Law). Very high fines should be put in place in order to ensure compliance with regulations that have been established to minimize the damages caused by these products. A review of current alcohol and tobacco laws and regulations should be the starting point. In many cases, stricter policies are needed and should be implemented in advance of implementation.
- Promotion & Advertising: No advertising or promotion, including at point of sale, on the exterior of outlets, or through any media, including social media and traditional media, regarding product or store or outlet.
- # of Outlets: Very limited outlets; placement of outlets should be restricted so as not to be near schools (1 mile away); no mandate or targeting of outlets in disadvantaged communities; sales restricted to very limited hours.
- Staff Training: Required staff training on ID check and other techniques to ensure no sales to those under 21. Increase consequences to adults of age who may provide these products to persons under 21.
- No public consumption, including testing in lounges or consumption in stores.
- Restrictions on public use should apply to both medical and recreational marijuana use.
- Automatically add marijuana to the list of prohibited products on all smoke-free ordinances and laws. Maintaining the gains in restricting the effects of second hand smoke is imperative.
Policing & Enforcement:
- Create a statewide consistent enforcement of all regulations. Create regulations that don’t negatively affect youth and/or communities often impacted by disproportionate arrests. Similar to tobacco, adults and businesses should be held accountable for violations, sales practices and other violations, rather than youth. Divert youth and adults to interventions and treatment, as opposed to arrests and incarceration.
Business held accountable if laws are not followed, with significant penalties.
Potency & Purity:
- Product Purity and Potency: Strong regulations should be in place regarding THC levels, types of products, purity, etc.
- Product Types: Restrictions on the sale of products that are attractive to youth such as candy, bakery products, sweet flavors, etc.
- Price drives youth access; lower prices allow for greater access by adolescents. Raising tax rates has served as an effective intervention, with higher tax rates reducing youth and adult use.
- Tax revenue set asides for prevention, treatment and recovery support services are needed. Establishment of mandatory setasides will ensure that funds are not diverted to cover other needs in the general budget in future years. Legalizing marijuana will have substantial negative impacts on addiction for the portion of the population that is at risk, and funding will be needed to off-set these.
- Opt-Out Communities: Allow at least 6 months for communities to opt-out of allowing marijuana outlets in their community. Do not restrict the ability of towns that opt-out to participate in any newly created programs or benefits that might occur from tax revenue from marijuana. Opt Out should always be available to communities without business interference.
Background and Discussion
The following are some of the specific concerns related to marijuana legalization, as well as some lessons learned from research and outcomes in other states that have already legalized:
Changes in Potency:
Today’s marijuana is very different than many remember even ten years ago. Not only has the THC in traditional smokable vegetative forms increased from about 5% in 1970 up to as high as 30% THC today, but it is now also available in various concentrated forms that have THC levels as high as 99%. These concentrates are being used in electronic smoking devices, commonly known as vapes or e-cigarettes, as well as edible products such as gummy bears, lollipops, brownies and other products that are very enticing to our youth. These extreme THC levels have had significant impact on the health of users.
Changing Risks for Addiction:
According to Nora Volkow of the National Institute on Drug Abuse (NIDA):
“…the higher the content of THC, the higher the likelihood that you can actually become addicted to it. And also, interestingly, high content THC also has an associated risk of psychosis… Repeated marijuana use during adolescence may result in long-lasting changes in brain function that can jeopardize educational, professional, and social achievements. However, the effects of a drug (legal or illegal) on individual health are determined not only by its pharmacologic properties but also by its availability and social acceptability. In this respect, legal drugs (alcohol and tobacco for example) offer a sobering perspective, accounting for the greatest burden of disease associated with drugs not because they are more dangerous than illegal drugs but because their legal status allows for more widespread exposure.”
In the midst of an addiction epidemic, making a drug that often starts people’s path to addiction more available to our youth and young adults is counter to common sense and research.
Major Areas of Specific Concern:
Creation of Youth Friendly Products: Legalization of marijuana makes this drug significantly more accessible to our children and adolescents. We have learned that attempts to regulate a substance do not always effectively keep the substance from our youth. Adolescent marijuana rates in states that have legalized its use are increasing, with Colorado having the highest such use rates, double the national average.ii Pressures on the industry to grow sales are an additional risk, as is the growing availability of new marijuana products that capture the attention of young people.
These new products include various edible forms of marijuana, such as gummy bears, lollipops and other foods such as cookies and brownies. It is of some concern that 47% of the marijuana sold in Colorado is in these new child-friendly forms. These edibles have extremely high THC levels - up to 99% THC - and are being promoted as harmless, which is not an accurate representation. These food-based products allow an easy introduction to marijuana use by children, which has resulted in increased accidental poisonings showing up in Colorado emergency departments. Marijuana oils and waxes also are being used in popular vaping devices, along with, or in lieu of nicotine. This has created a popular but potentially dangerous culture of use among adolescents and young adults.
Addictive Drug: Marijuana is an addictive drug for approximately one in ten adults who use it and for one in six adolescents who have used marijuana. These percentages go up to 25% - 50% for daily users. NIDA states that the higher the THC level, the higher the addiction rate. As New Jersey is in the middle of an addiction epidemic, the PAC is especially concerned about the potential impacts of legalization on persons at risk of addiction or in early recovery. Peer-reviewed research indicates that early marijuana use more than doubles the likelihood of opioid use later in life. iii Marijuana’s impact on mental health is also of concern. There is research documenting that for certain users marijuana use may trigger psychotic symptoms as well as the onset of schizophrenia.
Negative Youth Impact: For children, teenagers and young adults, there is evidence that marijuana use (especially heavy use) can have a negative impact in their academic success. These impacts include lower high school and college graduation rates, reduced employment success, increases in car crash fatalities, and greater risk of addiction and co-occurring psychiatric symptoms. Heavy marijuana use has also been found to reduce IQ scores by up to 8 points. For those students already struggling, this impact can be devastating to their success. The PAC is concerned about some of the marketing messages that promote marijuana as harmless and, occasionally, boast of the benefits of its use. This misrepresentation of the drug’s harmlessness confuses our youth.
Normalization: Increased availability and legal status will serve to change perceptions of acceptability, risk and level of interest in marijuana use among children, adolescents and young adults. Colorado has more marijuana stores than Starbucks and McDonald’s combined. These businesses promote their products through advertising, signage, discounts and more. We may see similar impacts in New Jersey. As citizens of a state that is considering legalizing recreational marijuana use, we must be prepared to consider the effects of normalized marijuana use among adults, which will in turn normalize marijuana use among our youth. Will there be sufficient controls to mitigate the risks? Will our children be walking to school in a community that has a marijuana leaf lit up in green neon lights or a marijuana drive-through convenience store? Are we sure that we have considered such impacts in our planning?
Addressing Youth Arrests: There is a misperception that legalization will eliminate legal consequences for marijuana use by children and teens and will avoid penalizing them for poor judgement in having marijuana in their possession. The legalization legislation currently proposed actually only addresses use by those over the age of 21. It will still be illegal for anyone under 21 to possess marijuana. Some data is beginning to emerge from Colorado, where full legalization was found not to have addressed the arrest rates among minority youth. Instead, arrests among minority youth have increased since legalization started, with a 58% increase for black youth and 29% increase for Hispanic youthiv.
Decriminalization Alternatives: Decriminalization options may be a more effective approach to addressing marijuana related arrests among our diverse populations, by changing the response to marijuana use to a more supportive approach and one that will not result in an arrest. The PAC supports efforts to address the social justice issues that are negatively impacting our most vulnerable communities, but we are not convinced that legalization will be the solution. Legalization elsewhere has actually followed a pattern similar to tobacco marketing, by specifically targeting minority communities. In Colorado, a higher density of marijuana outlets can be found among such areas of the state.v
Expected Increase in NJ Youth Rates: New Jersey’s current adolescent marijuana use is below the national average. The PAC believes this is due in part to the quality of our State’s prevention efforts, as well as the current status of marijuana as an illegal product. 5.7 % of New Jersey’s adolescents were found to have used marijuana in the past 30 days, which is below the national average of 8.6%.vi Colorado’s youth use rate is over 12%. Research has found that increased availability of legal substances, such as alcohol or tobacco, results in increased use among adolescents. Such increases are starting to be observed in states that have legalized marijuana.
Financial considerations: Often legalizing recreational marijuana is looked at as a windfall of much needed tax revenue. Less consideration has been given to the related additional costs that states have experienced. There are costs in establishing the government structure to support regulations, increased law enforcement costs at both the local and State levels for enforcing the new industry, and additional health care costs to State and private payers, including increased treatment needs. Studies related to alcohol and tobacco have revealed that the hidden costs associated with those legal drugs are significant and show up across diverse areas of state budgets. For every dollar received in tax from alcohol and tobacco, it costs the US approximately $10 (Alcohol = $14 billion in revenue vs. $185 billion in costs, and Tobacco = $25 billion in venue to $200 billion in costs)vii.
The experience with alcohol and tobacco tax revenue in New Jersey illustrates the challenges related to maintaining a consistent funding set aside to address on-going needs for prevention and treatment services. These allocations have historically not been increased or in some cases have been eliminated all together to cover other costs in the state budget. It is likely that there will be increases in marijuana use rates among adolescents and adults, especially in at risk populations, so establishing and maintaining adequate prevention and treatment set asides will be of key importance. These financial costs and considerations are important elements of marijuana legalization that should be considered prior to moving forward with new policies.
Need for Input from Addiction Professionals, Medical and Mental Health Professional Community: We hope that legislators and policy makers will consider the concerns noted in this White Paper with respect to the impacts and unresolved issues related to legalized use of recreational marijuana. It is critical that the Addiction, Medical and Mental Health Professionals have a voice at the table, which is not the case currently. If legalization of marijuana does come to NJ, we strongly recommend the active involvement of public health and medical professionals, including prevention and addiction professionals, in the development of regulations and restrictions for this drug product.
i Nora Volkow, Director of National Insititute of Drug Abuse from New England Journal of Medicine
ii National Survey on Health and Drug Use, 2015
iii Secades-Villa, Garcia-Rodríguez, Jin, Wang, & Blanco, 2015; Olfson, Wall, Liu, & Blanco, 2017
iv Colorado Department of Public Safety, 2016
v Rocky Mountain HIDTA Report & Colorado Department of Revenue, 2011 -2015 American Community Survey 5-Year Estimates
vi National Survey on Drug Use and Health, 2016
vii State estimates found at http://www.nytimes.com/2008/08/31/weekinreview/31saul.html?em; Federal estimates found at https://www.policyarchive.org/bitstream/handle/10207/3314/RS20343_20020110.pdf; Also see http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf; Campaign for Tobacco Free Kids, see “Smoking-caused costs,” on p.2.