Marijuana Regulatory Frameworks in Four US States: An Analysis Against a Public Health Standard

Abstract

The movement to legalize and regulate retail marijuana is growing. We examined legislation and regulations in the first 4 states to legalize recreational marijuana (Colorado, Washington, Oregon, and Alaska) to analyze whether public health best practices from tobacco and alcohol control to reduce population-level demand were being followed.

Only between 34% and 51% of policies followed best practices. Marijuana regulations generally followed US alcohol policy regarding conflict of interest, taxation, education (youth-based and problematic users), warning labels, and research that does not seek to minimize consumption and the associated health effects.

Application of US alcohol policies to marijuana has been challenged by some policy actors, notably those advocating public health policies modeled on tobacco control. Reversing past decisions to regulate marijuana modeled on alcohol policies will likely become increasingly difficult once these processes are set in motion and a dominant policy framework and trajectory becomes established. Designing future marijuana legislation to prioritize public health over business would make it easier to implement legalization of recreational marijuana in a way that protects health.

State policies to legalize and regulate recreational marijuana are being developed and implemented despite the fact that marijuana remains illegal under federal law, with marijuana listed as a Schedule I drug under the Controlled Substances Act. Nevertheless, since 1996, states have been legalizing marijuana for medicinal use.^1,2 The first 4 US states legalized recreational marijuana use through the initiative process (Colorado, 2012; Washington, 2012; Alaska, 2014; and Oregon, 2014). Policymakers have had to develop regulatory systems for the new retail marijuana industry^2–6 with only limited models and empirical evidence on the health impact of possible regulations.⁷

Considering health is important because legalization will likely increase consumption and associated health impacts^8,9—including cancer,¹⁰ respiratory problems,⁹ and cardiovascular diseases¹¹—as well as mental health impacts—including the development of schizophrenia or other psychoses, symptoms of mania and hypomania in individuals with bipolar disorders, and suicide.⁹ In the short term, marijuana use has an adverse impact on short-term memory, motor control, judgment, and, for some, triggers paranoia and psychoses at high doses.¹²

State laws to legalize recreational marijuana are diffusing rapidly, with 4 more states (California, Nevada, Maine, and Massachusetts) doing so in 2016. By 2017, 29 states and the District of Columbia, representing 63% of the US population, had legalized medical marijuana use and 8 states and the District of Columbia, representing 21% of the US population, had legalized recreational marijuana use.² This article takes a normative approach to examining implementation of recreational marijuana in the first 4 US states by comparing their implementation to public health best practices from tobacco and alcohol with the policy objective of regulating commercially legalized marijuana “as a public health priority and develop, adopt, monitor, and evaluate regulatory controls for commercially legalized marijuana that reduce and prevent the drug’s use, misuse, and abuse.”¹³

METHODS

We developed the “Public Health Protection Framework” (Table A, available as a supplement to the online version of this article at http://www.ajph.org) based on our previous work.¹⁴ This framework includes general policies (advisory committees and regulatory boards, voluntary agreements), supply-side policies (market structure and licensing, prevention of sales to youths, restrictions on retail marijuana stores, dram shop liability, illicit trade, unitary market), and demand-reduction policies (advertising and marketing, price and tax measures, prevention and control programs [media campaign, community-based education], monitoring and surveillance, smoke-free laws, local control, product regulation, packaging and labeling requirements). To be included in the framework, a best practice had to be identified by at least 2 international or US national authorities for tobacco^13,15–28 or alcohol.^29–41 This analysis yielded 67 best practices, organized into 3 regulatory themes (general, supply-side, and demand reduction).

We determined the purpose, status, and text of marijuana legalization ballot initiatives, bills, laws, executive orders, and administrative rules in Colorado,⁴² Washington,⁴³ Oregon,⁴⁴ and Alaska⁴⁵ enacted and issued between November 6, 2012, and December 31, 2016, regarding regulation of retail marijuana sales and taxation, starting with state legislative and agency Web sites. Because this article addresses a public health approach to the commercial marijuana market, it does not explore home grow and issues around the inequities associated with criminal justice enforcement of marijuana laws.

We searched state Web sites (https://www.colorado.gov; http://access.wa.gov; http://www.oregon.gov; http://alaska.gov) beginning with “marijuana initiative,” “marijuana rules,” “marijuana regulations,” “retail marijuana law,” “administrative code,” and the names of ballot initiatives (Colorado “Amendment 64,” Washington “I-502,” Oregon “Measure 91,” Alaska “Ballot Measure 2”), followed up by using standard snowball searches informed by initial results. We also used Google and NewsBank to locate advisory committee reports and minutes, budget and strategic plans, appropriation bills, legislative hearing reports, agency advisory notices to marijuana companies, and newspaper articles to assess how state officials, public health, and industry representatives influenced regulatory outcomes. Searches primarily focused on documents produced between November 2012 and December 2016.

RESULTS

The policy trajectory established in Colorado⁴⁶ in 2012 set the stage for subsequent debate and decisions to be filtered through an alcohol policy lens in the other 3 states. The idea to “regulate marijuana like alcohol” was written into the ballot initiatives of Colorado and Alaska and shaped policy development in those states.^46–48 The consistent pattern of regulating marijuana based on US alcohol policies centered on regulatory compliance and youth prevention. Between 34% and 51% of policies in state regulatory regimes were consistent with public health best practices from tobacco and alcohol control (Table A, Colorado: 40% [27/67]; Washington: 46% [31/67]; Oregon: 51% [34/67]; Alaska: 34% [23/67]).

General Policies

Regulatory agencies.

The regulatory agencies charged with developing, implementing, and enforcing new regulations and the agency’s legal charge had an impact on the resulting regulations.^4,49 Drug reform activists in Washington⁴⁷ and Oregon⁴⁸ wrote their legalization initiatives to mirror state alcohol control laws, designating state liquor control boards as the lead regulatory agency. Three of the 4 states used state liquor control boards to regulate the marijuana market, which then used existing alcohol policies to develop marijuana regulations. Colorado designated the Department of Revenue, which also oversees alcohol and gambling, as the lead agency.

Conflicts of interest in policymaking.

Legalizing marijuana sales by using a regulated for-profit private marketplace, as the 4 states did, creates a strong incentive for the marijuana industry to use its political influence to avoid regulations that would make it harder for it to maximize sales, revenue, and profit.⁷ Widespread knowledge of the tobacco industry’s aggressive behavior to undermine government polices necessitates insulating the policymaking process from the tobacco industry.¹⁹ This principle is embodied in Article 5.3 of the World Health Organization Framework Convention on Tobacco Control (FCTC), which calls for excluding the tobacco industry or other vested interests from being members of any government body, committee, or advisory group that sets or implements public health policy.¹⁹ By contrast, when designing health programs,^50,51 marijuana industry representatives have had formal policymaking roles in Colorado and Alaska, similar to government partnerships with alcohol. Colorado’s Amendment 64 Task Force, which was charged with developing recommendations to the state legislature for the state’s marijuana regulatory framework, included members from the marijuana and alcohol industries. Alaska’s 5-person Marijuana Control Board, established to design the state’s regulatory system, included 2 marijuana industry members. Only Oregon prohibited marijuana interests from membership in policymaking agencies (Table A).

Supply-Side Policies

Supply-side interventions of marijuana were broadly shaped by the 2013 US Department of Justice Cole Memorandum,⁵² which states that the federal government would only intervene in states that failed to prevent criminal involvement in the market, sales to youths, and illegal diversion to other states. The language in the individual state initiatives and the associated political campaigns signaled regulators to apply supply-side interventions to marijuana based on existing alcohol policies. In particular, all 4 states instituted market-based licensing systems to regulate private commercial activity, established a minimum legal purchase age of 21 years, and implemented track-and-trace systems to monitor distribution and minimize illegal diversion.

State monopolies over alcohol sales are associated with lower consumption.^39,49,53,54 Nevertheless, in Colorado, the Amendment 64 Implementation Task Force made the early decision to not establish a public monopoly over marijuana production and sales, because doing so would not meet the “spirit” of the initiative’s intent for the state to regulate “private commercial activity.”⁵⁵ The decision to institutionalize a market-based system for marijuana, rather than a public monopoly, was subsequently reproduced in Washington, Oregon, and Alaska.

Although all of the states have set a minimum age to purchase and possess recreational marijuana at 21 years, none have required state-of-the art age-verification systems or strong merchant-education programs needed for effective enforcement of comparable laws for tobacco. Only Washington has a program of unannounced compliance checks, which are needed to ensure compliance with minimum-age sales laws for tobacco and alcohol.

Demand-Reduction Policies

Advertising and marketing.

The alcohol⁵⁶ and tobacco^57,58 industries promote ineffective self-regulation through voluntary codes to avoid effective legal restrictions. In particular, the US alcohol industry’s voluntary advertising code commits companies not to advertise in outlets (i.e., print, television, radio, and the Internet) in which more than 30% (roughly the proportion of the population aged 2 to 20 years) of the audience is “reasonably” expected to be aged younger than 21 years.⁵⁹ In 2013, the Colorado Department of Revenue codified the alcohol industry’s voluntary code into its regulations for marijuana marketing, permitting advertising and marketing, including event sponsorship (e.g., sporting events and concerts) at which less than 30% of the audience is aged younger than 21 years.^60,61 Consistent with public health best practices, in 2016, the Oregon Retail Marijuana Scientific Advisory Committee (formed by the Oregon Public Health Division) recommended that regulators broaden marketing restrictions to include sports and other sponsorships. The Committee also recommended using an audience threshold for minors of less than 15% (the fraction of the US adolescent population⁶²) for all marketing to avoid “programming for the general population [reaching] most teens.”⁶³ Despite this recommendation, the Oregon Liquor Control Commission adopted the same marketing regulations as Colorado.⁶⁴

Price and tax policies.

Public health–oriented price strategies keep prices high to discourage consumption and cover the external costs of commercial sector activity. Although the 4 states tax retail marijuana, rates were not set at levels designed to discourage consumption or even cover the full external costs of each state’s new commercial market. Instead, the states set tax rates to compete with the illicit market and generate revenue. Legislators in Colorado,^65,66 Washington,⁶⁷ and Oregon⁶⁸ reduced marijuana taxes shortly after legal sales went into effect on the basis of the claim that legal marijuana prices needed to be competitive with the illicit market. As of December 2017, none of the 4 states had proposed increasing taxes or establishing pricing regulations to reduce marijuana demand.

Prevention and control programs.

State regulators chose marijuana education programs that prioritize preventing and reducing youth use and educating adults on marijuana laws, safe storage practices, and responsible adult use, not broad demand reduction to protect public health (Table 1). Public education messages for marijuana mirror US alcohol³³ and less-effective tobacco-control⁶⁹ programs that aim to reduce risky and abusive use in vulnerable populations (e.g., children pregnant women, or problematic users) rather than discourage all use.

TABLE 1—

Comparison Between Campaign Messages for State Marijuana Education Programs: 4 US States, January 2017

Message Theme	Colorado	Washington	Oregon	Alaska
Youth prevention
Hurts athletic performance	✓	✓	✓	X
Hurts cognitive and brain development	✓	✓	✓	✓
Addiction	✓	X	✓	✓
Increased school dropout	X	✓	X	✓
Increased mental illness	X	✓	X	✓
Consequences of marijuana-related possession charges	✓	✓	✓	X
Pregnant women
Negative effects on fetal or infant health	✓	X	✓	X
No safe level of marijuana use	✓	X	✓	X
Adult education on legal use
Legal possession and purchase age is 21 years	✓	✓	✓	✓
Harms and consequences of drugged driving	✓	X	✓	✓
Illegal use of marijuana in public	✓	X	✓	✓
Illegal diversion to other states	✓	X	✓	✓
Responsible adult use
Potency education	✓	✓	✓	✓
Storage education to prevent unintentional use	✓	X	X	✓
Health effects
Respiratory problems and impaired lung function	✓	X	X	✓
Increased risk of cardiovascular disease	✓	X	X	X
Increased risk of cancer	X	✓	X	X
Increased risk of addiction	X	✓	X	✓
Increased risk of anxiety and depression	✓	✓	X	✓
Memory loss	✓	✓	X	✓
Same chemical toxins in marijuana smoke as tobacco smoke	✓	✓	✓	✓
Motivating marijuana users to quit and providing free services	X	X	X	X
Poison control hotline information for general public	X	X	X	✓
Industry manipulation: countermarketing highlighting marijuana industry marketing tactics	X	X	X	X

Note. ✓ = included; X = not included.

Youth prevention messages on health risks included impaired memory, developmental delays,^70–73 and increased risk of addiction.^71–73 Except for Alaska, messages included ineligibility for receiving college financial aid and how marijuana-related legal charges may lead to school suspensions and expulsions.^73–75 Washington and Alaska included messaging on increased risks of dropping out of school and increased risk of depression, anxiety, psychosis, or other mental illnesses.^72,73 Colorado,⁷⁶ Oregon,⁷⁷ and Alaska⁷⁸ educated pregnant women on the risks of marijuana use on neonatal development.

Rather than discouraging population-level use on the basis of public health best practices, messages cautioned adults, particularly new users, to “be safe and sensible” when using new or highly potent products.⁷⁹ Colorado⁸⁰ and Washington⁸¹ collaborated with the marijuana industry to develop these messages. Without funding to develop its own education campaign, the Alaska Health Department reproduced messages from Colorado marijuana education campaigns online.⁸²

Colorado, Washington, and Alaska included limited information on health risks of marijuana use for adult consumers related to risk of cancer, addiction, and mental health issues. Colorado, Washington, and Oregon also included messaging on preventing secondhand marijuana smoke exposure because marijuana smoke contains the same chemical toxins as tobacco, but targeted these messages to children and pregnant women rather than the general population.^73,76,78

In 2016, the Oregon Public Health Division recommended that the legislature implement a comprehensive marijuana prevention and control program aimed at the general population by using the Centers for Disease Control and Prevention best practices for tobacco control.⁶³ As of December 2017, the Oregon legislature had not acted on this recommendation.

Monitoring, surveillance, and research.

Only Washington earmarked tax revenue to fund a continuous marijuana research program. Despite funding limitations, state health departments in Colorado⁸³ and Oregon⁸⁴ used existing behavioral surveillance systems (Healthy Kids Survey and Behavioral Risk Factor Surveillance System) to collect baseline data on youth and adult risk perceptions, use, and marijuana-related harms to measure the impact of legal marijuana sales on public health. In 2016, the Oregon Public Health Division recommended that the legislature create an independent Oregon Institute for Cannabis Research, with dedicated funding to support ongoing research efforts overseen by a scientific advisory committee.⁸⁵ As of December 2017 the legislature had not acted on this recommendation.

Smoke-free laws.

Modeled on public use of alcohol laws, the ballot initiatives prohibit marijuana consumption in view of the general public, requiring state legislatures, agencies, and local governments to define what “public use” means (aside from Alaska state ballot initiatives that prohibited marijuana consumption in licensed businesses, including retail stores). Marijuana advocates began to push the envelope on the definitions of “public” and “private” places by arguing that venues that required a fee to enter were “private events.” For example, in Oregon, marijuana advocates argued that venues that required a fee to enter were private events and venues staffed by volunteers were not workplaces.⁸⁶ In this case, health agencies used the opportunity to define “public use” as a mechanism to protect nonsmokers from exposure to secondhand marijuana smoke, resulting in a prohibition of marijuana social clubs in Washington⁴³ and inclusion of marijuana in Oregon’s smoke-free air law.

Local control.

Except for Oregon, localities are permitted to enact stricter regulations of the marijuana market than provided by state law.

Product regulation.

The limited scientific base and lack of national standards has forced the states to develop their own product standards.^2,7 In 2013, the Colorado Amendment 64 Task Force (which included industry representatives) recommended that potency limits not exceed 10 milligrams of tetrahydrocannabinol (THC) per serving size and 200 milligrams of THC per package.⁵⁵ The legislature adopted part of the Task Force’s recommendation, requiring that marijuana products contain no more than 10 milligrams of THC per serving and marijuana packages contain no more than ten 10-milligram servings (or 100 mg) of THC per package. Washington subsequently copied Colorado’s regulations.

In Alaska, the Marijuana Control Board (part of the Department of Commerce, Community, and Economic Development) that determines product regulations, including potency limits, generally followed Colorado and Washington. Through the public comment process, however, the health department recommended a serving size of 5 milligrams of THC and a limit of 10 servings per package for edibles, which the Board adopted.

In contrast to the other 3 states, the Oregon legislature granted the Oregon Public Health Division rulemaking and enforcement authority over serving size and THC concentration, marijuana testing, and labeling content and design. Concern that inadequate product regulations and labeling may have contributed to increased marijuana-related calls to the poison control center in Colorado (from 44 in 2006 to 227 in 2015⁸⁷) and in Washington (from 111 in 2010 to 199 in 2014⁸⁸) allowed Oregon policymakers to alter policy trajectories to prevent health harms. Based on recommendations by the Oregon Scientific Advisory Committee to take a precautionary approach, the Public Health Division adopted regulations limiting maximum THC levels to 5 milligrams per serving and 50 milligrams per package for retail marijuana products.^89,90 The Public Health Division also limited THC levels in concentrates, extracts, tinctures (250 mg/container), and topicals (6% THC concentration per container).⁹¹

Packaging and warning labels.

Health agencies in Colorado and Oregon used concern about accidental ingestion of marijuana edibles by youths and uninformed adults to insert the precautionary principle into regulatory debates on warning labels for marijuana edibles. In 2016, Colorado, Washington, and Oregon passed laws requiring marijuana companies to include a THC warning symbol on the principal display area of a marijuana product package to indicate that the product contained marijuana (Table 2). As of December 2017, none of the states required pictorial warnings or standardized packaging based on international tobacco health warning label best practice to deter use.⁹⁷

TABLE 2—

Comparison of Warning Label Statements and General Characteristics of Marijuana Sales: 4 US States, January 2017

	Colorado	Washington	Oregon	Alaska
Thematic content
Unidentified health risks	There may be health risks associated with the consumption of this product.	Warning: This product has intoxicating effects. Smoking is hazardous to your health. There may be health risks associated with consumption of this product.	X	There are health risks associated with consumption of marijuana. Marijuana has intoxicating effects.
Risk of addiction or dependence	X	May be habit forming.	X	May be habit forming and addictive.
Age requirement	This product is intended for use by adults aged 21 years and older. Keep out of the reach of children.	For use only by adults aged 21 years and older. Keep out of reach of children.	For use by adults aged 21 years and older. Keep out of reach of children.	For use only by adults aged 21 years and older. Keep out of the reach of children.
Risk to vulnerable populations	There may be additional health risks associated with the consumption of this product for women who are pregnant, breastfeeding, or planning on becoming pregnant.	Should not be used by women that are pregnant or breastfeeding.	X	Marijuana should not be used by women who are pregnant or breastfeeding.
Risks to driving under the influence	Do not drive or operate heavy machinery while using marijuana.	Marijuana can impair concentration, coordination, and judgment. Do not operate a vehicle or machinery under the influence of this drug.	It is illegal to drive a motor vehicle while under the influence of marijuana.	Marijuana impairs concentration, coordination, and judgment. Do not operate a vehicle or machinery under its influence.
Activation time for edibles	This product is infused with marijuana. The intoxicating effects of this product may be delayed by 2 or more hours.	Caution: When eaten or swallowed, the intoxicating effects of this drug may be delayed by 2 or more hours.	Be cautious: Cannabinoid edibles can take up to 2 hours or more to take effect.	X
Health and safety	This product was produced without regulatory oversight for health, safety, or efficacy.	X	This product is not approved by the FDA to treat, cure, or prevent any disease.	X
Law and order	This product is unlawful outside the State of Colorado.	This product may be unlawful outside the state of Washington.	X	X
Warning label characteristics
Warning statement required on advertising and marketing	X	X	X	X
Content required on principal display area	Contains marijuana. Keep out of the reach of children.	X	Keep out of reach of children.	X
Text size	No smaller than 9-point Arial or 10-point Times New Roman font	No smaller than 9-point Arial or 10-point Times New Roman font	No smaller than 8-point Arial, Times New Roman, or Helvetica font	X
Graphics or symbols required in principal display area (Figure 1)	“! THC”92	“Not for Kids”93	Universal symbol for marijuana94
Universal symbol size	No smaller than 1/2 of an inch by 1/2 of an inch	No specific requirements	No smaller than 0.48″ wide by 0.35″ high	X
Comparison of warning statements to recommendations of the NIH95 based on grade-level and readability scores96
Word count (NIH recommends health information contain no more than 10–15 words)	74	74	27	63
Average reading level (NIH recommends health information be at a 6th- to 7th-grade level)	8	9.5	6	12
Readability score (0–100; with higher scores being easier to read)	59	56	80	43

Note. FDA = US Food and Drug Administration; NIH = National Institutes of Health; X = a provision was not included in the regulatory framework for health warning content or design.

FIGURE 1—

Graphics or Symbols Required in Principal Display Area on Marijuana Products in (a) Colorado, (b) Washington, and (c) Oregon

Source. State of Colorado,⁹² Washington State Liquor and Cannabis Control Board,⁹³, and Oregon Public Health Division.⁹⁴

The Oregon Public Health Division developed rules for marijuana labeling and warning labels, providing an opportunity to propose alternative policies to those adopted in Colorado and Washington, where state liquor control boards developed labeling rules.

Although all 4 states prohibit marijuana companies from making false or misleading claims on marijuana packages, only Oregon requires health claims to be

. . . supported by the totality of publicly available scientific evidence (including evidence from well-designed studies conducted in a manner which is consistent with generally recognized scientific procedures and principles), and for which there is significant scientific agreement, among experts qualified by scientific training and experience to evaluate such claims.⁹⁸

In addition to false or misleading health claims, the Oregon labeling law specifically prohibits labels that are “attractive to minors,” including

. . . cartoons, designs, brands, or names resembling non-cannabis products typically marketed to minors, symbols or celebrities used to market products to minors, images of minors, and words that refer to products commonly associate with or marketed by minors.⁹⁸

Colorado, Washington, and Alaska use vague health risk statements, age restriction (i.e., legal for those aged 21 years and older), risks to pregnant women, risks of driving under the influence, and activation time for marijuana edibles (Table 2). These warnings are modeled on the alcohol industry’s voluntary code, which current research suggests is not effective in preventing problematic alcohol use.^99,100

The National Institutes of Health recommends health warnings be no more than 10 to 15 words long and use language at a sixth-grade reading level or lower to ensure readability across a wide array of socioeconomic backgrounds.⁹⁵ Only Oregon designed warning statements suitable for low-literacy children and adults⁹⁶ (Table 2). None of the states require health message content to rotate or be regularly updated as new scientific evidence becomes available to prevent “burn out” of outdated warning labels.

DISCUSSION

These findings are broadly consistent with less systematic studies of state marijuana regulations, which found that the dominant policy framework in the 4 states is to “regulate marijuana like alcohol”^101–103 and an analysis of Colorado and Washington that, while favoring public health, favors the practical over the ideal.² By contrast, this analysis is a normative analysis of the policies in the 4 states against public health best practices without regard for the politics that led to these laws.

The dominant policy framework in the 4 states, established through the language of ballot initiatives and legalization campaigns, does not follow public health best practices for tobacco and alcohol control from international and national authorities (Table A). Rather, despite the many other models available for legalization,⁷ it is assumes a private for-profit model, which may make some public health policies “impractical.”^2,7 The decision to model marijuana regulations on US alcohol policies (which generally do not follow public health best practices) resulted in several similarities across both policy regimes:

• A focus on preventing youth access and use, illustrated through the same minimum legal age of purchase for marijuana and alcohol with limited and ineffective controls on advertising and promotion;

• The same thematic content for education campaigns and warning labels, which provide factual information on harms of use yet promote consumption as an adult activity (a “forbidden fruit” message that may inadvertently encourage use among youths);

• Promotion of “responsible use” by adults;

• Consideration of the marijuana industry as a partner, as illustrated by industry participation in forming systems designed to regulate their activities;

• Lack of attention to demand-reduction policies, particularly taxation, as mechanisms to counter the external costs of corporate activities such as increased consumption.

In a few cases, health agencies were able to insert public health best practices into regulatory debates, which allowed health departments and medical experts on regulatory advisory committees to incorporate the more public health–oriented tobacco framework into public usage, some warning labels, and approaches for potency limits in ways favorable to public health.

In cases of uncertainty, policymakers seek knowledge from communities of experts for solutions to highly technical issues.^104,105 This appears to be the case with marijuana dosage, labeling, and pesticide regulations, in which policymakers, without federal guidance on how to develop highly technical aspects of regulation, relied on knowledge from the marijuana industry. It is uncertain what the long-term consequences of such interactions will be given the adverse outcomes that could result from recommendations by these vested interests. Best practices from tobacco control indicate that those with a financial interest should not be considered authorities for forming or evaluating marijuana policy. Health authorities could use FCTC Article 5.3¹⁹ to challenge marijuana industry involvement in the policy process while also pursuing conflict-of-interest management policies.

Limited Federal Engagement

Because the federal government continues to list marijuana as a Schedule I drug under the Controlled Substances Act, the federal government has played only a limited role in research, consensus discussions, or administrative approaches to a regulated marijuana market framework. Thus, local action at the state and community levels will determine both the legislative and regulatory agendas. However, at least in the first 4 states that have legalized recreational marijuana, neither state governors nor legislators have developed the legalization legislation. The limited federal engagement also makes it more difficult to include marijuana in the existing monitoring and surveillance data systems. This situation leaves the surveillance burden largely on the states with limited resources, which further hinders effective regulation.

Implications of a Corporate Market

Economic interest to grow the market has been important in shaping marijuana policy change⁷ in the 4 states analyzed in this article. However, from a public health perspective, lessons from tobacco, alcohol, ultra-processed foods, and pharmaceutical companies illustrate the risks of corporate domination of the market, whereby corporate interests actively weaken and prevent public policies that would erode sales and profits.¹⁰⁶ A noncommercial approach to marijuana could include a government monopoly over production and sales^{7,39,49,53,54} with an emphasis on reducing demand at the population level, a prohibition on marketing and promotional activity, and the use of taxes to reduce consumption and cover the external costs of the marijuana industry.

Health advocates can challenge the idea to “regulate marijuana like alcohol” in future marijuana legalization campaigns by providing the historical context of alcohol policy formation, the alcohol industry’s participation in shaping regulatory outcomes, and associated adverse effects on public health. Health advocates could also use literature on tobacco^107–109 and alcohol^62,110 industry marketing strategies and their impact on youth use to explain the inadequacy of marijuana advertising regulations in terms of protecting public health. Reversing past decisions to regulate marijuana like alcohol will become increasingly difficult once these processes are set in motion and a dominant policy narrative and trajectory become established.

There were several key areas in which health departments failed to challenge the applicability, in terms of protecting health, of alcohol policies to marijuana, allowing for the institution of alcohol industry voluntary codes for marijuana regulations, including public–private partnerships, marketing restrictions, campaign messaging themes aimed at youths, and inadequate health warning labels.

Probably the most difficult area in which to apply global best practices from tobacco control to marijuana is in the area of advertising restrictions. The 2014 American Public Health Association Policy statement on marijuana observed the following:

Current First Amendment protections for corporate speech would likely prevent advertising regulations aimed at adult consumers but would allow restrictions on advertising aimed at adolescents and children. The other two criteria should be demonstrated to exist for the marijuana market in order for the states to be marked down as failing to have them in place.¹³

The fact that marijuana remains illegal under federal law, however, may provide states with more latitude to restrict advertising.

The failure of nongovernmental health organizations to play an active role in marijuana policy discussions has undermined the ability of health departments to respond to potential health threats and possibly ceded debate to expertise from marijuana advocacy groups and commercial interests.

Conclusion

The lessons from the US experience in implementing legalized recreational marijuana, despite their shortcomings from a public health perspective, are valuable in that they demonstrate how early ideas and policy decisions can provide both advantages and challenges in future marijuana policy debates. The idea to “regulate marijuana like alcohol” embodied in legalization legislation permeated the regulatory design, aims, and strategies of marijuana policy regimes in 4 US states. For health advocates and researchers interested in policy change both within and outside the United States, the processes of problem identification, agenda setting, policy formation, and implementation may provide opportunities through consistent and active participation in policy debates to reorient policy toward noncommercial approaches to marijuana. In particular, designing marijuana legislation that prioritizes public health over business interests would make it easier to implement legalization of recreational marijuana in a way that prioritizes public health.