By: Steven Teutsch, Yasmin Hurd, and Elizabeth Boyle

The landscape of cannabis legalization in the United States has been changing dramatically. Cannabis is now available throughout the United States, with policies that vary significantly in terms of public health protection. In most states, legalization occurred through ballot initiatives and public ad campaigns often financed by wealthy donors. Voters acknowledged cannabis’s widespread use, its large illegal market, the criminalization of seemingly minor infractions, and discrimination in enforcement. Today, changes in the classification of cannabis under the federal Controlled Substances Act are pending, as is a possible change in the definition of “hemp.” These sweeping changes are occurring when many of the health consequences of cannabinoids remain quite uncertain. And those changes are coupled with a disturbing legacy of discrimination during the “war on drugs,” with associated devastating consequences for individuals and communities of color in particular. The legalization of an increasingly powerful intoxicating drug has necessitated a greater fusion of public health and drug policy in the states.

In the face of this complexity, how, then, is one to assess the consequences of the changes in cannabis policy for public health and social equity? This was the charge to the Committee on the Public Health Consequences of Changes in the Cannabis Landscape. The 2017 report of the National Academies of Sciences, Engineering, and Medicine, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, focuses on the health effects and potential therapeutic benefits of cannabis, noting the paucity of high-quality studies on its health effects. Regrettably, little has changed in this regard since that report was published, and scant to no research exists on the explosion of new cannabis and cannabinoid products. The present report focuses on the public health consequences of cannabis policies that have not been examined by the National Academies.

States have received little federal guidance on how to proceed regarding the health impact of cannabis on the public and communities. Other than two memoranda deferring to states, the federal government has been noticeably missing from this dialogue. Yet cannabis can cause real harms, as multiple investigators, families, and various groups attested to our committee. The tools of public health—assessment, policy development, and assurance—can provide the critical health information decision-makers need to protect the public health and make amends for past cannabis-related inequities, but those tools are only slowly being applied.

With legalization by states now widespread, it is time to ask about its impact, especially given the large variation in state policies. These natural experiments provide a rich but very complex set of experiences for analysis, but these policies are all of relatively recent vintage. Consequently, available products, use patterns, and markets have not yet stabilized. Facing these challenges, the committee reviewed what is known about these policies, formulated recommendations where possible, and delineated a path forward. With a strong commitment to policy research and the application of traditional public health tools, we fully anticipate that better and more consistent policies will unfold.

This report would not have been possible without the deep expertise, wide range of perspectives, and strong commitment of all the committee members. Elizabeth Boyle, study director, and her National Academies colleagues, Khala Hurst-Beatty, Alexandra McKay, and Mia Saltrelli, labored long and hard to tie together all the disparate pieces of this report. We are deeply grateful to all of them. Lastly, we want to express our appreciation to our sponsors, the Centers for Disease Control and Prevention and the National Institutes of Health, without whose vision this study would not have been possible.

The National Academies Press 2024

By Anine Kriegler

Cannabis legalization has the potential to weaken organized crime, but it can just as easily strengthen it unless a balance is found between restriction and liberalization, coordinated across both the supply and demand sides of the market. South Africa’s current cannabis policy lacks coherence, with reforms driven more by legal challenges than by strategic policymaking, posing challenges in effectively countering organized crime.

This paper summarizes the history and status of cannabis decriminalization in South Africa and draws on a review of literature to identify a key set of variables that determine the impact of legalization on organized crime: the type and degree of restrictiveness of the new regulations; various cultural, socio-economic, and political factors; features of the criminal justice system; and the structure and nature of criminal organization in the illegal cannabis market.

Reflections are provided on what these suggest about the likely impact of South African cannabis legalization on organized crime, and potential lessons and recommendations are proposed for effective policy reform in South Africa, as well as guidance for similar decision-making in other contexts.

Effective reform requires integrating marginalized communities and black-market participants into the legal market, along with considerations for managing legal supply, strategic enforcement against criminal gangs, and public health education to ensure a comprehensive approach to reducing organized crime. A phased implementation of regulatory frameworks, ongoing monitoring, and investment in data collection are essential to assess and optimize the impact of legalization on organized crime. Geneva: SWIT: Global Initiative Against Transnational Organized Crime , 2024. 29p.

By The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

This report is based on information provided to the EMCDDA by the EU Member States, the candidate country Türkiye, and Norway, in an annual reporting process.

The purpose of the current report is to provide an overview and summary of the European drug situation up to the end of 2022. All grouping, aggregates and labels therefore reflect the situation based on the available data in 2022 in respect to the composition of the European Union and the countries participating in EMCDDA reporting exercises. However, not all data will cover the full period. Due to the time needed to compile and submit data, many of the annual national data sets included here are from the reference year January to December 2021. Analysis of trends is based only on those countries providing sufficient data to describe changes over the period specified. The reader should also be aware that monitoring patterns and trends in a hidden and stigmatised behaviour like drug use is both practically and methodologically challenging. For this reason, multiple sources of data are used for the purposes of analysis in this report. Although considerable improvements can be noted, both nationally and in respect to what is possible to achieve in a European level analysis, the methodological difficulties in this area must be acknowledged. Caution is therefore required in interpretation, in particular when countries are compared on any single measure. Caveats relating to the data are to be found in the online Statistical Bulletin, which contains detailed information on methodology, qualifications on analysis and comments on the limitations in the information set available. Information is also available there on the methods and data used for European level estimates, where interpolation may be used.

Lisbon: EMCDDA, 2023.

By The United Nations General Assembly. Office of the High Commissioner for Human Rights

The present report outlines human rights challenges in addressing and countering key aspects of the world drug problem. It also offers an overview of recent positive developments to shift towards more human rights-centred drug policies, and provides recommendations on the way forward in view of the upcoming midterm review of the 2019 Ministerial Declaration and to contribute to the implementation of the 2030 Agenda for Sustainable Development.

United Nations, 2023. 19p.

By The International Drug Policy Consortium (IDPC)

In September 2023, the UN High Commissioner for Human Rights released a landmark report on human rights in drug policy. Prepared at the request of the Human Rights Council as a contribution to the mid-term review of the 2019 Ministerial Declaration on drugs, this report constitutes the most ambitious and comprehensive UN document to date on the alignment of drug policies with human rights. The report consolidates existing human rights standards, develops new recommendations, and proposes a blueprint for transformative change, from a global punitive paradigm to drug policies based on health and human rights.

This IDPC advocacy note focuses on three key issues. First, the new standards and recommendations developed in the OHCHR report, which update our understanding of the human rights dimension of drug policies. Secondly, the consolidation of prior human rights standards developed by other UN bodies. Lastly, we lay down our recommendations for an effective implementation of the vision proposed by the report.

London: IDPC, 2023. 7p.

By UK Parliament, House of Commons, Home Affairs Committee

Drugs can have a significant and negative impact on people who use drugs, their loved ones and society. Trends in drugs may vary over time but this consequence is constant. Concerningly, drug misuse deaths across the UK continue to increase with opiates playing a significant role in this, and ‘street’ benzodiazepines and polydrug use also playing an increasing role. There were 250 drug misuse deaths per million population in Scotland in 2022—significantly higher than in England, Wales and Northern Ireland. In her Independent Review of Drugs, Professor Dame Carol Black estimated the total cost of drugs to society to be more than £19 billion per year—more than twice the value of the illicit drugs market (an estimated £9.4 billion).

In recent years, the response by the international community and devolved nations to drugs has increasingly focused on responding to drugs through a public health lens. UK policy should ensure that an approach originally and primarily based on criminal justice principles continues to adapt to achieve a proper balance of public health interventions that may reduce illicit drug use in the longer term rather than aiming simply to disrupt demand. We believe that this approach would be best supported by making drug policy the joint responsibility of the Home Office and the Department of Health and Social Care, with a minister sitting across both departments.

The main piece of legislation controlling drugs in the UK—the Misuse of Drugs Act 1971—is more than 50 years old. It is in need of review. Further, a full review by the Advisory Council is required on whether the most commonly controlled drugs in the UK are correctly classified and scheduled (under the Misuse of Drugs Regulations 2001), based on the evidence of their harms.

The Government’s latest drugs strategy, ‘From Harm to Hope: A 10-Year drugs plan to cut crime and save lives’ (the 10-Year Drugs Strategy) signals a shift towards recognising the need for a holistic response to drugs that not only aims to tackle the illicit drug market but also supports people who use drugs, their loved ones and society. However, the Government’s response could go further by adopting a broader range of public health-based harm reduction methods in tandem with its support of law enforcement efforts to tackle the illicit drugs market.

We support the use of diamorphine assisted treatment supported by psychosocial support as a second-line treatment for people with a chronic heroin dependency. We visited a centre in Middlesbrough and saw the dramatic and positive effect this treatment had on the lives of a small group of people who had used drugs and, albeit on a small scale, to local crime reduction. Disappointingly, such treatment programmes are few and controversial, and the Middlesbrough programme lost its funding. The Government should provide centralised funding for such programmes.

Safe consumption facilities, where people who use drugs may do so in safe, secure surroundings, may also reduce harm and deaths, but the status of such facilities is uncertain because of the restrictive regime in place under the 1971 Act. We recommend that the Government support a pilot facility in Glasgow and create a legislative pathway to enable more.

A national drug checking service in England could enable people to anonymously test samples of drugs, again preventing harm and potentially death. We recommend the Government establish a drug checking service, taking into account the experience of Wales. We also recommend the expansion of on-site drug checking services at temporary events such as music festivals and in the night-time economy through the creation of a dedicated licensing scheme. The power to issue such licences could include the devolution of power to grant licences to local authorities.

These public health and harm reduction interventions must be balanced with the role of police in applying the law. The police can also have a role in aiding prevention of drug use and treatment of harms. Scotland’s pioneering programme of having all police officers carry naloxone (a nasal spray or injection that can be administered immediately to reverse the effects of an opioid overdose) should be rolled out elsewhere in the UK as a straightforward means of saving lives. The police can also play an important role in diverting young people who have committed low-level drug-related offences away from the criminal justice system. We support greater standardisation of police-led diversion across England and Wales, to avoid a ‘postcode lottery’ in the treatment of such offenders.

London: House of Commons, 2023. 98p.

By Amanda Doggett, ; Kyla Belisario,; André J. McDonald,; et al

Importance A key concern about recreational cannabis legalization is increases in use and adverse consequences, particularly among young adults (aged 18-29 years) who have the highest prevalence of cannabis use, and especially in higher-risk, more vulnerable young adults. However, few longitudinal studies have examined patterns of cannabis consumption in high-risk young adults over the course of legalization.

Objective To examine changes in cannabis use frequency and cannabis-related consequences over recreational cannabis legalization in Canada in a longitudinal sample of high-risk young adults.

Design, Setting, and Participants Longitudinal observational cohort study following young adults in Ontario, Canada, aged 19.5 to 23.0 years who reported regular heavy episodic drinking (65% past-month cannabis use) at enrollment. Participants were surveyed every 4 months for 3 years between February 2017 and February 2020 (3 prelegalization waves, 4 postlegalization waves). Data were analyzed from March to May 2023.

Exposures Recreational cannabis legalization in Canada and 4 potential moderators of change: sex, income, education, and prelegalization cannabis use frequency.

Main Outcomes and Measures Cannabis use frequency and cannabis-related adverse consequences.

Results In a cohort of 619 high-risk young adults (baseline mean [SD] age, 21.0 [1.2] years; 346 female participants [55.9%]), omnibus model testing revealed significant overall decreases in both cannabis use frequency (F = 2.276, 3000.96; P = .03) and cannabis-related consequences (F = 10.436, 3002.21; P < .001) over time, but these changes were substantially moderated by prelegalization frequency (frequency: F = 7.5224, 3021.88; P < .001; consequences: F = 7.2424, 2986.98; P < .001). Follow-up tests showed individuals who used cannabis more frequently prelegalization significantly decreased their use and cannabis-related consequences postlegalization. In contrast, individuals who did not use cannabis prelegalization exhibited a small magnitude increase in frequency over time but nonsignificant changes in cannabis-related consequences. Sex, income, and education did not moderate changes over time.

Conclusions and Relevance In this cohort study of high-risk young adults, individuals using cannabis frequently prelegalization showed significant reductions in use and consequences over time, reflecting an aging out pattern. Small increases in use among participants with no prelegalization use were observed over time, but without parallel changes in cannabis-related consequences. The results did not reveal substantive adverse near-term outcomes across the legalization period, although a within-participants design cannot rule out the possibility of alternative trajectories in the absence of legalization.

JAMA Netw 5 September 2023Open; 6(9); 2023