Executive Summary of This Case Study Report
This report explores the experiences of several states as they regulated nonmedical adult cannabis use through the lens of a public health perspective. The report includes four state case studies developed through research and process participant interviews, including those considered early adopters of nonmedical cannabis use as well as more recently adopting states. Challenges and lessons learned include issues surrounding the role and protection of public health, data collection and monitoring, industry and public engagement, education and social equity.
Current State of Cannabis Legalization
Cannabis contains more than 100 compounds or cannabinoids, some of which produce a psychoactive effect or “high,” like tetrahydrocannabinols (THC). Other compounds include cannabidiol (CBD), which is not intoxicating. Cannabis containing over 0.3% delta-9 THC and products derived from it remain categorized as Schedule I under the federal Controlled Substances Act, with “no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.”
States began regulating cannabis for medical use in 1996 and for nonmedical adult use in 2012. During the expansion of states regulating medical cannabis from 2014 to 2017, over a dozen states without medical cannabis allowed for low-THC or CBD-only products for people with specific health conditions.
As of July 2022, 37 states, three territories and the District of Columbia have approved cannabis for medical use. Nineteen states, two territories and the District of Columbia allow for the nonmedical use of cannabis by adults over age 21. Thirteen states enacted via ballot measure and five state legislatures took nonmedical measures into their own hands.
From the beginning
The path to a well-regulated and operating cannabis industry has potential challenges and lessons learned for public health, according to experts interviewed for this report. These challenges and lessons include collecting and monitoring data, engaging and educating interested parties, regulating consumer products and businesses, and ensuring equitable opportunities for people who would like to participate in the industry.
Dozens of the initial decisions required to regulate cannabis at the state level relate to public health including licensing requirements and fees, taxes, revenue designation, business structures, product testing, packaging and labeling, public education and prevention campaigns.
“Gather as much information as possible from stakeholders and be inclusive. Consider starting strict and loosen up, or start the system slowly. It may be easier to stand up a system that way because you can’t put the genie back in the bottle.”
Rick Garza, director of Washington Liquor and Cannabis Control Board
Collect and direct revenue
Policymakers in many states have collected and directed taxes and revenue toward public health purposes to balance potential public health impacts of cannabis use.
Roles of and need for public health
Public health departments may play a variety of roles in the cannabis legalization landscape, such as continuous data monitoring, and creation of evidence-based rules and regulations. However, the cannabis science and policy worlds would benefit from additional rigorous scientific studies and reviews of reliable and existing data to create a trusted reference library of knowledge, according to interviews. Cannabis policies are evolving much faster than the science needed to give policymakers and regulators confidence in their decisions.
Although systems are in place in several states and nationwide, a need still exists for more cohesive and up-to-date surveillance data. Commonly collected cannabis-related data include the prevalence and trends of nonmedical adult use, prevalence and trends of youth cannabis use, types of products used and health-related outcomes.
Examples of public health research and reports identified as useful to policymakers and the public include general use patterns and trends, economic and fiscal impacts including social equity efforts, illicit market analysis, impact on educational systems, use of science and technology staff to access issues around testing and vaping devices and related contaminants, and public education about cannabis product testing.
“Even if they [public health community] didn’t get everything they wanted, they thought it was an overall balanced and pretty fair process and that they were able to influence the regulations and have their voice heard,” says former Colorado Marijuana Enforcement Division director Lewis Koski.
Social equity opportunities
Creating opportunities for people commonly affected by cannabis prohibition was among the most discussed issues of the cannabis legalization process. Intentionally including people from disproportionately impacted communities in the industry provides them opportunities to benefit economically from cannabis legalization. Social equity programs (SEPs) are intended to create pathways for people from communities historically negatively affected by cannabis prohibition to become licensees. SEPs may provide business guidance, financial assistance or mentorships to applicants entering the market. As of June 2022, at least 15 states and some localities have SEPs.
What’s old is new again
At least 40 states, territories and the District of Columbia regulate cannabis for medical or nonmedical adult use. Early-adopting states have made changes over time that reflect new information or lessons learned from their experiences. More recently adopting states have looked to those experiences to inform their policymaking processes, in addition to designing novel ideas. In turn, those novel ideas may be considered by early-adopting states.
The policymaking process often provides opportunities to craft rules and regulations addressing common public health and safety concerns and measure data over time. The early involvement of state and local health officials brings a range of perspectives and expertise into the policymaking process, according to interviews. Early and more recently adopting states have looked to each other for examples of evolving policies and new ideas, creating an ever-changing policy landscape.
Karmen Hanson is a senior fellow in NCSL's Health Program.
This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $563,000 with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.