Minimizing Cannabis’s Harms to Public Health
More than half of US states have legalized cannabis for recreational or medical use. Regulations on cultivation, production, and marketing vary from state to state, and most of these policies were developed without a robust public health strategy. Because it is not federally legal, Washington has provided only limited guidance to states on how to control the variety of cannabis products on the market. What’s more, the dazzling arrays of gummies, vapes, and chocolates are available with much higher concentrations of THC (the psychoactive component of cannabis) than have been previously available.
A recent National Academies of Sciences, Engineering, and Medicine report, Cannabis Policy Impacts Public Health and Health Equity, examines the connections between public health and marijuana legalization. On this episode, host Sara Frueh talks to Yasmin Hurd, vice-chair of the report committee, Ward-Coleman Chair of Translational Neuroscience, and director of the Addiction Institute at Mount Sinai. They discuss the research on the complex landscape of modern cannabis products, what’s known about their public health impacts, and strategies policymakers could use to minimize harms.
Resources
- Read the National Academies’ report, Cannabis Policy Impacts Public Health and Health Equity.
- Visit the Hurd Lab and Addiction Institute websites to learn more about Yasmin Hurd’s work on addiction.
Transcript
Sara Frueh: Welcome to The Ongoing Transformation, a podcast from Issues in Science and Technology. Issues is a quarterly journal published by the National Academy of Sciences and by Arizona State University.
Over roughly the past decade, more than half of all US states have legalized marijuana either for medical use or recreational use, or both. This shift raises new challenges for policymakers in terms of navigating public health impacts. A recent National Academies report tackles this issue and examines what policymakers should be doing to minimize harms and protect public health in the context of newly liberalized policies.
I’m Sarah Frueh, an editor at Issues. I’m joined today by Yasmin Hurd, vice chair of the committee that conducted this study and wrote the report titled Cannabis Policy Impacts Public Health and Health Equity. Dr. Hurd is Ward-Coleman chair of translational neuroscience and director of the Addiction Institute at the Icahn School of Medicine at Mount Sinai. On this episode, we’ll discuss the public health implications of marijuana legalization and what policymakers can do to meet these challenges. Dr. Hurd, welcome.
Yasmin Hurd: Thank you, Sara, for having me.
Frueh: To start, I’m wondering if you can tell us a little bit about yourself and your own work and research in this area?
Hurd: Sure. So, I’m a neuroscientist and I study the neurobiology of substance use disorders, and I’ve been doing it for over 20, 25 years. And one of the questions that my research program actually has focused on—and even before this became a very big issue—was looking at the developmental effects of cannabis. And when we did that, it was mainly to try to understand what might increase vulnerability for substance use disorders in adulthood.
We looked at the neurobiological effects of this developmental exposure to THC and were really surprised to see these long-term effects in brain.
So, I started to look at it using animal models to start, and we were studying the main intoxicating, I should say, cannabinoid, which is delta-9 THC in the cannabis plant. And when we gave them THC, the animals, whether prenatally or during adolescence, they would, for example, be more vulnerable to self-administering heroin later in life. They showed this greater opioid sensitivity.
We looked at the neurobiological effects of this developmental exposure to THC and were really surprised to see these long-term effects in brain. And that became, for me, one of the very critical things, because we hadn’t really understood what cannabis might be doing to the brain and the brain long-term. Other research teams started to look at it and you could see that there were even differences when THC was exposed during development as compared to adulthood. In adulthood it didn’t produce the same vulnerability—or sensitivity, perhaps, is a better word—that you saw during development.
So, a lot of my research started focusing on trying to understand the developmental impact of cannabis. Cannabis is a very complicated plant. So, I talked about THC, but it has more than a hundred other cannabinoids and hundreds more of other different chemicals. And I wanted to look at another cannabinoid and that’s when we started looking at cannabidiol, CBD. Before anybody really understood what CBD was. And we saw that in contrast to what we saw with THC, CBD actually decreased heroin-seeking behavior in our animal models.
And so, we started doing human clinical studies with CBD in individuals with opioid use disorder, to see if that might be indeed a treatment. And the interesting thing is that even my fellow researchers in the beginning when we were studying the developmental effects of cannabis, they were like, “Yasmin, why are you studying that? Cannabis is not a problem. People smoked in college. You should be studying more cocaine, and so on.” And it was tough for us to even get published. And the same thing when we showed that CBD might have potential benefits. It was, “There is no way that cannabis can be beneficial.”
So, to me, it really emphasizes what we were charged to in the committee, the complexity of cannabis from even the science of it, the complexity of the plant, but the complexity of even the policies that are associated with cannabis in our country. It’s very complex.
Frueh: It sounds like it. And I want to shift in a moment to asking you more about your recent study that you did with the committee. You recently vice-chaired this study by the National Academies that looked at cannabis policy and public health impacts and what policymakers should be thinking about. Can you tell us a little bit about the background of that study? What was the motivation for it? What issues were you asked to look at? And why do you think it’s an important study to have done now?
Hurd: I will be very honest, when I saw the charge that we were tasked with, I thought, “There is no way.” It was very daunting because there are a number of issues that we were asked to address.
Today, more people use cannabis daily or near daily than alcohol.
But I’ll just step back and the first part of your question, why now? So, you mentioned that more than half the states have legalized cannabis in some way, shape or form, whether for medicinal purposes or for adult use in terms of recreational purposes. And now, today, more people use cannabis daily or near daily than alcohol. So, the increased use of cannabis and also these hemp-derived products that have really blossomed into this huge commercial market that are not really regulated. Then this really caused, I think rightly so, the CDC and the NIH and others to ask questions as to what are the public health issues regarding such a high increase in cannabis use in our society.
Also, that the concentrations of THC, the most intoxicating cannabinoid in the plant, has increased, and is increasing because there’s now a plethora of cannabis-related products that have no federal oversight. So, we don’t really even know what people are using. And so, that’s why we were charged with looking at the public health aspects and also the aspects about social equity of cannabis laws and policies in the US.
People forget that the legalization actually started more from a medicinal use in terms of for compassionate care for patients who had AIDS or cancer. People, also, they started to have issues with the fact that many Black and brown people were targeted, for the most part, for the criminality of being arrested for cannabis use. And that, they thought, was indeed a part of social justice in terms of the racial inequities that were there.
So, we were asked to really consider aspects of the public health approach to cannabis policies, looking, like I said, at social and health equities in this regard in terms of the policies. And those things are definitely challenging. We were not asked to really look into the specific health effects of cannabis, because that was actually already assessed in the 2017 report from the National Academies. So, it was mainly the widespread use of cannabis, the fact that legalization is so mixed across the states, the widespread products that are out there today, and the increasing concentrations of the THC products, that there was this growing concern about the public health, and public health had not actually been evaluated in the policies that had been made.
Frueh: When you talk about public health impacts, what kinds of impacts are you referring to? Are they different than the sort of individual health impacts that were looked at in the 2017 report? What are the kinds of things in your new report that you’re saying policymakers and society need to be more alert to?
This loophole really unleashed all these semi-synthetic cannabinoids that have no oversight.
Hurd: For example, if we take the 2018 Farm Bill and that bill is what changed products derived from hemp to now be legal. The cannabinoids in hemp are the same cannabinoids that are in cannabis. It’s just the concentrations that may differ. So, hemp plants usually have very low THC and have a higher percentage of CBD, cannabidiol, and cannabidiol is a non-intoxicating cannabinoid.
But one of the things about CBD is that you can chemically change it to THC. And so, the Farm Bill had no regulation of limiting how people took these hemp products and then made them intoxicating. So, this just caused this huge balloon of this very largely unregulated commercial cannabis market that have all of these hemp-derived products. And these hemp-derived products are very potent, and these products, as I said, are made with chemicals and a lot of the chemicals can be harmful, and there’s no legislation that really looks into that.
So, this has been one of the biggest issues, this federal policy that then made these state-by-state regulations but allowed a big loophole in this 2018 Farm Bill. This loophole really unleashed all these semi-synthetic cannabinoids that have no oversight. So, that was one of the things that our report, really one recommendation was that Congress should really redefine the definition of hemp to really be clear that no form of THC or semi-synthetic cannabinoids that derive from hemp is exempt from this Controlled Substances Act, which it was the Farm Bill of 2018. So, that’s one aspect about policy.
Another aspect about policy, ironically, there’s very little federal oversight even though one of the biggest federal policies, like I just said, the Controlled Substances Act, the Farm Bill of 2018, has caused such challenges to many states and many people. But the fact that the federal government, they’ve been absent from regulating a very important product.
The federal government, they’ve been absent from regulating a very important product.
And so, the question is, can some of those policies that have been developed in consideration of alcohol and tobacco, why are those not used on a federal level rather than having these state by state patchwork of cannabis policies throughout the country? So, for example, marketing, limiting the access truly to youth and those surveillance of those systems, the tax strategies, the restrictions. A lot of these things, that’s a federal oversights that are done, that the federal government, I should say, play a really strong role in those public health policies because the goal is to create safer products. So, like I said, how are they advertised? How are the products labeled? How are the restrictions on the sales? You definitely have statewide laws in a number of for alcohol and tobacco, but you do still have federal oversight for many of them. And that’s really not done at all for cannabis.
I will say for cannabis, it is actually a little bit more challenging to regulate when you compare to alcohol and tobacco, because again, I realize I’ve said it a number of times, is that the cannabis plant does contain hundreds of cannabinoids, and you have all these hybrid strains out there and they have different chemical profiles and different health impacts that we really don’t know. It’s very different than tobacco and alcohol. And you have that the extracts from these cannabis plants, they’re even put in many different products and there are different routes of administration. So, they have many different intoxicating profiles than what we’re used to in policies that are there for tobacco and alcohol.
So, these concentrated products that are out there for THC, for example, you have products that are 60 to 90% THC. That’s not the concentrations in the original plant. Again, there’s no regulation of those, and those are some aspects that could definitely play a big role.
Frueh: You talked about the federal government being sort of absent in these dialogues, and I’m wondering why do you think that is? Is it because it’s illegal at a federal level, and so, they don’t want to wade into it? Or what’s holding them back from taking a more, I guess, assertive public health approach?
Hurd: It’s a mixture, I think. I do think that this is the only drug that the public has voted on whether or not it’s, quote-unquote, “medicine.” And the politicians don’t really want to touch it because they still want to get elected. But what they didn’t really do was to even ask the questions, “Let’s do the research. Does cannabis have health impact that if it goes unchecked can lead to major public health implications?” And that’s one of the things that I think government needs to do. That’s what government’s role should be. But as I said, they instead allowed the public to decide that that substance is medicine. When normally in the US we have a pipeline of the FDA making that judgment through clinical trials, structured. And so, we can see what are the benefits of a particular medicine and what are maybe the side effects, and which individuals or groups may benefit from that medicine and which groups may be harmed by that medicine.
You can’t have state-by-state decisions or policies when it relates to health like this.
There’s nothing that we’ve ever seen that is purely positive and don’t have side effects of some sort, but at least physicians and clinicians know what to recommend and what kind of guidance to tell their patients. But here it’s the public. So, we are now doing one of the biggest experiments ever, because we are now telling the public that, “You decide. You tell your clinicians how does this affect you on a negative or positive way, rather than your clinician giving you guidance even about dose, dosing regimen.” A lot of things that we see as the THC concentrations have gone up are not good. And so, the policies are really essential and having federal oversights. You can’t have state-by-state decisions or policies when it relates to health like this.
Frueh: So, you mentioned that you look at this as sort of this big experiment that’s been happening so far. States legalize it, maybe not always aware of all of the complexity of regulating it, which then has to catch up with it. Do we have any, I guess, results from this experiment so far in terms of knowing more about the public health benefits, the public health harms of legalizing cannabis?
Hurd: We have some data, and that’s one of the things, that’s why we need more research on this, and the National Institutes of Health, they’re supporting more research. The CDC needs to do more research, and so on. And I think that that will help. As I mentioned earlier, that there’s increased daily and near daily use of cannabis, and the cannabis products today have much higher THC than ever. And you do see greater mental health, for example, issues, cannabis impaired driving issues. And so, that’s one of the problems.
And also, perhaps not every group may be impacted in the same manner. So, for example, pregnant women, as I said about the developing brain, teens, even, we see that there’s a greater use among individuals that are 65 and older. We still don’t know what that means for their health outcomes, but we see that more, dose may matter. So, perhaps there may be reduction in agitation and anxiety with perhaps low-THC products in older individuals, but they also have greater falls, and so on.
There’s still not a lot of data on the new cannabis products that are out there, but what we do see so far, it still should be of concern that you see more, for example, suicidal ideation, and you’ll see more emergency room visits related to cannabis than you ever saw before. For example, cannabis hyperemesis, a lot of vomiting and so on, are showing up in record numbers, that was not there before.
We do know that as THC concentration increases, as those doses increases, you do get more adverse cannabis-related harms.
So, whether or not there may be benefits, as I said, when we’re talking about cannabis, people use cannabis for talking about cannabidiol, CBD. And I think that’s one thing in our society, we should start being very specific when we’re talking about cannabis. CBD, and CBD that is again, still needs to be regulated in terms of making sure that the product is safe, not having chemicals that are harmful, and that the product concentrations are accurate to what’s said on the label. I mean, so much research has shown that CBD for the large part can have beneficial effects on, for example, mental health issues, but a lot of research is still needed to be done to really finalize if that is true. But THC and delta-9 THC and delta-8 THC, and those at these high concentrations have been shown to have greater risk of psychosis and cannabis use disorder.
So, we should be very clear when we talk about cannabis versus the cannabinoids and make sure that we’re talking about the cannabinoids, because it’s the cannabinoids and the concentrations in these products that are the issue. But we do know that as THC concentration increases, as those doses increases, you do get more adverse cannabis-related harms. And that’s one of the things that we really must bring awareness to.
I’m going to tell you, I get emails from parents all the time, all the time about their child, their teen and young adults who are suffering from severe psychosis, suicidality, cannabis use disorder, huge, huge issues that is only due to their cannabis use. And we can’t ignore that. Even if you can say the majority of people may use cannabis and not develop a problem, but we don’t know what cannabis they’re using versus some of, as I said before, the cornucopia of the products and the concentrations of the products. The cannabis today is much more potent, much more concentrated THC products are being used.
Frueh: How much do we know about how legalization has impacted use of cannabis by kids and teens? Do we know how much that’s changed?
Hurd: Well, this is the problem, again, getting data. So, when you look at different groups, teens in large part, they’re using now daily and near daily. They also use in different patterns in terms of they wake up and immediately are smoking… and not only smoking, also vaping these concentrated dabs much more than ever before. So, the pattern of cannabis use of there is different. And that also has implications for mental health risk.
We don’t have enough data as yet to understand the full health impact on teens and young adults.
So, again, it’s not even if you say, “Oh, the number of people may be using may be the same, they’re using very differently.” They’re using different products that are much more potent, much more concentrated THC, and some of these products have other chemicals. They’re still very potent, and they are these semi-synthetic products that have these other chemicals that they use to convert them that, indeed, can impact on the brain and on other organs.
So, sadly, we don’t have enough data as yet to understand the full health impact on teens and young adults. But again, based on the fact that there is more mental health reports of teen use and young adult use, both in terms of the emergency room visits, in terms of psychosis, that does say that something is, indeed, happening, that we have not seen before. And that needs to be looked at in much more detail.
Frueh: You mentioned before that, and I remember this from the report text, that the committee recommends borrowing strategies and lessons learned from public health regulation of tobacco and alcohol, and that that could be useful in thinking about cannabis regulation and public health. Are there specific things that have been really effective in the way that the federal or state governments have regulated tobacco and alcohol, that you think might apply well in the context of marijuana?
Hurd: Well, one of the things as we discussed earlier was for example, the marketing. And so, the advertising and packaging, it’s really critical. And those are things that can be leveraged from the tobacco industry in terms of the legislation, the federal oversights for that. Also, the retail stores, where they operate, how they operate, those are also have federal guidelines. Taxation, and the aspect of price restriction was also, you can take from the policies of tobacco, but all of these things are really important. Even in terms of advertising, product design, can limit youth access.
When we think also in terms of the public education for tobacco, a lot of work went into that. And smoking cigarettes have definitely decreased dramatically in our society because of the national education that went into it. And so, we can learn from those and try to use those as well when we think about what can be done leveraging what was used for tobacco and alcohol. So, things like that, I think, are low-hanging fruit, but there’s still so many other things as well.
Frueh: All right. I’d like to talk a little bit about an issue you brought up earlier, which is equity, which I know your report looked at. And one of the arguments, you know this well, driving efforts to decriminalize cannabis and to legalize it were racial inequities in enforcement and arrests. And I think many people expected that decriminalizing it or legalizing it would sort of take care of that. But your report says that during this period of increased liberalization of cannabis use, racial disparities in arrests have increased. And that surprised me. Can you talk a little bit about that, why that might be happening?
Hurd: It also surprised us, and it also was really sad because it also emphasizes one thing, you can make policies, but how they’re implemented, it’s also important to monitor. So, overall, legalization of cannabis in our country did reduce arrests; however, the data suggests that it was mainly for white individuals, not for Black. And so, it shows that there is still a stigma, or I should say, still a bias in our society in terms of even though Black and brown people and white may use cannabis in the same amount, Blacks are still being arrested more, even when arrests due to the legalization in our society has decreased for the population at large, but not for Black individuals. So, it comes back to, again, racial biases.
You can make these policies, but if you’re not taking a social health equity lens to it, you may, in fact, worsen the situation that you say that you are trying to achieve.
Another aspect of health inequities, it’s not just racial inequities that we can see with arrests, which was, like I said, really sad to see that our society, we have not moved further. But the health inequities are also important because when you look at where a number of the retailers are, many of the cannabis retailers are within these lower income communities and communities of color. So, once again, they may suffer greater health issues because we know that perhaps there’s a disproportionate amount of marketing to these groups. And having, like I said, the retailers within these communities. And these communities, many of the, quote-unquote, “laws” that were made for different states that the taxes that were obtained from cannabis would be used to try to address social inequities, but most of that money does not come back to that community.
So, once again, you can make these policies, but if you’re not taking a social health equity lens to it, you may, in fact, worsen the situation that you say that you are trying to achieve. So, it’s really critical that I think looking at these social equity programs in each state, it’s really important for people to understand the huge impact that cannabis-related arrests had on these communities from future employment, housing, businesses, and even their educational opportunities. And so, now the fact that legalization of cannabis should have improved on that, and in fact, you may even get the opposite.
So, this is very painful, and I think that we’re not learning, and we really need to make this, I think, a priority of when these policies are made, that they actually look at how they’re implemented and how they’re enforced, so that we don’t hurt the individuals and the populations, I should say, that we say that these programs were meant to help.
Frueh: It sounds like there are a lot of unintended consequences from this legalization, a lot of things, nuances that people didn’t necessarily know about in terms of differences between products, in terms of definitions in the federal law about hemp. That there’s just a lot, and it sounds sort of overwhelming as a problem to address. And I’m wondering if the committee would suggest one or two things that the federal government could do to start working on this problem and untangling it, and one or two priorities that state governments should be thinking about as they take a public health approach to marijuana use?
Hurd: Well, the first thing for me on a federal level, I do think is closing the loophole on hemp-derived products. That can go very far because a lot of those products are still getting into the hands of kids, young adults, pregnant people that think that these, quote-unquote, “light” THC products are healthier. And that is not the case. So, I think, if anything, that’s one thing that the federal government can do sooner than later.
There are benefits to certain cannabinoids and perhaps cannabis in lower THC concentrations for certain disorders. But the high potency products, we do need to educate, especially certain groups, about the potential negative impact.
I also think that an educational campaign is essential. And again, it is about knowledge. The public has to learn or has to know that this cannabis today is not cannabis what many people would normally think about. The cannabis today is indeed very complex, and I understand that for the public it’s maybe too much, but for them to even understand that the amount of THC or the concentration, it is very high. We’re not even talking the same drug. So, educational campaigns, I think, are really, really important.
And I remembered there was a parent who came to the committee. We had a number of people who have been negatively impacted by the cannabis policies and those who are also concerned about the cannabis policies in terms of the health outcomes. And one parent, I remembered her so well because she voted to legalize cannabis because of the social inequities that she saw. She was not a Black or a brown person, but for her, she saw that it was so wrong. And then, what happened with the legalization, as you said, the unintended consequences and what it had meant for her family and her child, she said, “I didn’t vote for this.”
And so, I do think that education will go very far. And again, education is based on the policies of, for example, tobacco, that have worked. I do think that the horses have left the barn. I don’t think that we can bring cannabis back underneath some sort of restrictive in terms of extremely draconian policy. And as I said, there are benefits to certain cannabinoids and perhaps cannabis in lower THC concentrations for certain disorders. But the high potency products, we do need to educate, especially certain groups, about the potential negative impact. And we can try to perhaps through policy, rein in some of the high concentrated products. And that can only be done really at the federal level. Companies will still make money, but we will improve public health. So, those are the two things to me that I think that could be done, and they’re not needing major, major, major overhaul in a manner that is not possible to do.
Frueh: Thank you. I mean, when you think about the future, how optimistic are you or aren’t you, that we can find a wise way through this, that states can legalize marijuana, but find a way to minimize the public health harms? Do you think that’s possible?
We can do that by having everyone come together to understand that this is not the same drug as it was 20 years ago, 30 years ago, 40 years ago. It is not.
Hurd: I do think it’s possible. I do think that we need to let data be the guide for how we do this in a responsible manner, but with that said, we can’t wait another 20 years. Perhaps I’m biased because of some of my research does deal with the developing brain. We’re going to impact a whole generation. So, for me, it’s not waiting 20 more years and say, “Let’s see what happens.” I don’t think that we should wait just like we did with tobacco or alcohol. We know. The problem for me is often that we wait too long. So, that’s my worry, that we will wait too long.
But I’m optimistic that as more people, and I hear from people all the time, as more and more people in our society realize this is not a panacea, we do not need to arrest people for cannabis use. We need to just improve health. And we can do that by having everyone come together to understand that this is not the same drug as it was 20 years ago, 30 years ago, 40 years ago. It is not. And it is about education. And I think when people get educated, they will all come together to really understand how do we put some platforms in place that protect but still does not criminalize its use? So, part of me is optimistic, but there are still some … I just don’t want time to keep going by.
Frueh: Check out our show notes to find links to the report titled Cannabis Policy Impacts Public Health and Health Equity and other resources. Please subscribe to The Ongoing Transformation, wherever you get your podcasts. Thanks to our podcast producer, Kimberly Quach, and our audio engineer, Shannon Lynch. I’m Sarah Frueh, an editor at Issues in Science and Technology. Thank you for listening.