Received: 17 August 2022 Accepted: 22 December 2022

DOI: 10.1111/add.16135

ADDICTION OPINION AND DEBATE

How should policymakers regulate the tetrahydrocannabinol

content of cannabis products in a legal market?

Wayne Hall 1 | Janni Leung 1 | Beatriz H. Carlini 2

1
The National Centre for Youth Substance Use Abstract
Research, Faculty of Health and Behavioural
Sciences, University of Queensland, St Lucia, An increased use of high-potency cannabis products since cannabis legalization in the
QLD, Australia United States, Canada and elsewhere may increase cannabis-related harm. Policymakers
2
Addictions, Drug and Alcohol Institute-ADAI,
have good reasons for regulating more potent cannabis in ways that minimize harm,
Psychiatry and Behavioral Sciences,
Department, University of Washington, using approaches similar to those used to regulate alcohol; namely, banning the sale of
Seattle, WA, USA
high-potency cannabis, setting a cap on tetrahydrocannabinol (THC) content and impos-
Correspondence ing higher rates of taxes on more potent cannabis products. Given the difficulty that US
Wayne Hall, The National Centre for Youth policymakers have had in regulating cannabis extracts and edibles, governments that are
Substance Use Research, Faculty of Health
and Behavioural Sciences, University of planning to legalize cannabis need to put policies on extracts into enabling legislation
Queensland, St Lucia, QLD, Australia. and evaluate the impact of these policies on cannabis use and cannabis-related harms.
Email: w.hall@uq.edu.au

KEYWORDS
Funding information
Cannabis, cannabis potency caps, cannabis potency taxes, legal markets, regulation,
There are no funders to report.
tetrahydrocannabinol

I N T R O D U CT I O N
Since the sale of cannabis to adults was first legalized in Colorado and
Washington State in the United States in 2012 the tetrahydrocannab-
inol (THC) content of cannabis flower has increased, and so have sales
of high-potency cannabis vapes, extracts and concentrates, with THC
levels higher than 60% [1–4]. The THC content of cannabis has also
increased in Canada since cannabis use was legalized in 2018, and
sales of high-potency cannabis products were allowed in October
2019 (with the exception of Quebec [5]).
A major public health concern is that an increased use of higher
THC cannabis products will increase cannabis-related harm [2, 4, 6]. If
users receive higher doses of THC from these products [7] they may
be at increased risk of acute harms, such as accidents, adverse psy-
chological reactions, psychotic symptoms and accidental childhood
poisonings [1, 8]. The regular use of higher THC cannabis over months
and years may increase the risks of cannabis use disorders, psychotic
disorders, depression, cognitive impairment and educational under-
achievement [1, 8].
These concerns have prompted proposals to cap the THC
content of cannabis products (as has been achieved in Uruguay [9])
and to tax cannabis products based on their THC content [2, 6, 10].
The legal cannabis industry in the United States has argued that
these proposals are unnecessary, because cannabis users titrate their
doses of THC by using smaller amounts of more potent cannabis
products [11].
DO C A N N A B I S US E R S T I T R A T E TH E I R T H C
DO S E S WH E N U S I N G H I G H E R T H C
PRODUCTS?
A recent review [7] identified only 15 studies of dose titration
among cannabis users conducted in the United States, Canada, the
Netherlands and the United Kingdom.
There were 11 experimental studies [7] in which cannabis users
were asked to smoke or vape cannabis products that differed in their
THC content (see Table 1). In the older studies the THC content ran-
ged from 0.8 to 4.0% for high THC and from 0.4 to 1.8% for low THC.
The most recent studies have compared high THC content products
[e.g. 90% (high) versus 70% (low) concentrates and 24% (high) versus
16% (low) flowers]. In these studies, cannabis users took fewer and

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REGULATING THC IN LEGAL CANNABIS
TABLE 1 Summary of research on cannabis dose titration and associations with mental disorders.
First author (year): method
Evidence on whether or not people who used more potent cannabis titrate their dose of THC
Leung (2021): systematic review of
experimental laboratory studies,
observational studies and surveys on
titration behaviours and effects [7]
Cuttler (2021): randomized control trial, 80
people (aged 21+) who used cannabis
they purchased were assigned to potency
conditions. Outcomes were assessed
over Zoom [12]
van der Pol (2014): cross-sectional and
1.5 years’ follow-up observational study
of 98 heavy cannabis users who used
their own cannabis in a naturalistic
setting. Measures included the content
of the joint, dosing and smoking
behaviour [13]
Freeman (2014): cross-sectional naturalistic
observation study. Participants reported
the potency of their own cannabis and
smoked it in front of the researcher.
Measures included the amount of
cannabis used and sample potency [14]
Reinarman (2009): cross-sectional study of
216 experienced cannabis users in
Amsterdam and San Francisco with self-
reports of cannabis use [15]
Korf (2007): cross-sectional field study of
388 respondents interviewed in 28
cannabis coffeeshops in 5 Dutch cities,
self-reports of titration behaviours [16]
Evidence on whether or not the use of more potent cannabis was associated with mental disorders
Craft (2019): cross-sectional study of 55 240
people aged 16+ who use different
cannabis products, latent class analysis to
identify patterns associated with mental
health disorders [17]
Chan (2017): cross-sectional survey in more
than 20 countries in 2014 and 2015,
181 870 people aged ≥ 16 years,
including non-users and users of high-
potency herbal cannabis and more potent
cannabis extracts [18]
Freeman (2015): cross-sectional study of
adults in United Kingdom who had used
skunk (high-potency) and low-potency
cannabis preparations in the last year
[19]
Key findings
Mixed and incomplete: cannabis users took
fewer and shallower puffs of more potent
cannabis, but higher blood THC levels were
still observed in some studies. In some
studies, users reported more pronounced
psychological effects after using more
potent cannabis
People who used concentrates reported
comparable levels of intoxication and
impairment levels as those who used
cannabis flower
Cannabis users adjusted their intake by inhaling
lower volumes of smoke when smoking
strong joints, but the THC concentration in
the cannabis was positively correlated with a
higher dose of THC received
People used lower amounts of higher-potency
cannabis products and higher THC cannabis
was not associated with higher levels of
intoxication. Daily users made good
estimates of the potency of their cannabis
but non-daily users’ estimates of cannabis
potency were not correlated with sample
THC concentration levels
Most respondents reported that they self-
titrated when using more potent strains
Three groups of users: (1) a small group who
preferred lower-dose cannabis reported self-
titration; (2) a group with longer histories of
regular cannabis use did not; (3) a group of
younger users with more dependence
symptoms reported inhaling more deeply
when using more potent cannabis
Classes of cannabis users who used more potent
concentrates reported higher rates of life-
time mental disorders, compared to classes
of users who used less potent cannabis
products, e.g. herbal or hashish
The use of butane hash oil (highly potent) was
associated with greater risk of life-time
diagnoses of depression, anxiety and
substance use
The frequency of high-potency cannabis use
was associated with an increased severity of
cannabis dependence
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999
Limitations
Lack of rigorous studies on whether people who
use cannabis can effectively titrate their
doses of higher-potency cannabis, some
evidence to support the titration hypothesis
but limited evidence from use outside
laboratories
The THC and CBD concentrations in the
products used could not be verified,
participants were assigned to the potency
conditions instead of using their preferred
products
It investigated between-subject correlations
rather than within-subject adaptations and
relied upon self-report for the preferred type
of cannabis and for the estimated monthly
total THC dose
People who were not daily users had low levels
of knowledge of the potency of their
cannabis. The study did not use a within-
subject design so we do not know if
individuals would use less when using more
potent products. Subjective intoxication was
measured by self-report
Based on self-reported behaviours only, no
validation of doses consumed, and only data
regarding experienced users
Based on self-reported behaviours only, no
validation of doses consumed, no data
regarding non-experienced users
Study was cross-sectional, findings cannot be
used to infer causality
Based on a non-probability sample of a cross
sectional self-reported survey
Study was a cross-sectional survey of a self-
selected sample; dependence was measured
using the severity of dependence scale
rather than a structured clinical interview
(Continues)

1000
TABLE 1 (Continued)
First author (year): method Key findings
Petrilli (2022): systematic review of The use of higher-potency cannabis was
observational human studies on associated with an increased risk of
associations between cannabis potency and psychosis and cannabis use disorder (CUD).
mental health [20] Evidence was mixed for depression and
anxiety
Note: The studies included in the table are presented in the same order as discussed and expanded upon in the text.
Abbreviations: CBD, cannabidiol; THC, tetrahydrocannabinol.
shallower puffs on joints that contained more potent cannabis, but
higher blood THC levels were still observed in some studies and some
users reported more pronounced psychological effects after using
more potent cannabis [7]. A more recent study by Cuttler et al. has
found that regular cannabis users titrated their THC doses of more
potent cannabis products (≥ 60% THC concentrates versus ≥ 20%
THC flowers) to produce comparable intoxication levels [12]. In these
studies, dose titration is usually defined as a reduction in the quantity
of cannabis consumed but the reductions have not been proportional
to the THC content, so these studies do not exclude the possibility
that users of higher-potency cannabis products receive higher doses
of THC.
Two studies observed patterns of cannabis use in regular users
who used products that varied in potency in their usual surroundings
[13, 14]. In these studies, users also varied the frequency and depth
of inhalations when using more potent cannabis and the self-reported
effects of cannabis did not differ, but higher THC blood levels were
found in those who used more potent forms of cannabis.
In two surveys, cannabis users were asked whether they titrated
their doses if they were using more potent cannabis. Two-thirds of
users surveyed in San Francisco reported using smaller amounts of
more potent cannabis [15]. In a survey of cannabis users in coffee-
shops in the Netherlands a small group of users preferred to use
lower-strength cannabis, and reported inhaling less deeply and smok-
ing less of the more potent cannabis. Older users, with longer histories
of regular cannabis use, did not adjust their use, and younger users,
with cannabis dependence symptoms, reported inhaling more deeply
when using more potent cannabis [16].
Fewer studies have assessed whether cannabis users titrate their
THC doses in real-life settings when using more potent cannabis.
More critically, there is an absence of studies of the THC doses that
are received by people who use highly potent cannabis products via
vaping cannabis oils or dabbing; that is, inhaling the fumes produced
when very high THC cannabis extracts are heated.
In a number of surveys, people who report using more
potent cannabis products also report more affective symptoms and
help-seeking than those who use less potent products [17–19]. A
systematic review of these studies found that the use of more potent
cannabis was associated with an increased risk of psychotic symptoms
and symptoms of cannabis use disorder [20], but the authors cau-
tioned that there were major limitations in the measures of cannabis
exposure and mental health outcomes in these studies.
13600443, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.16135 by Cochrane Poland, Wiley Online Library on [22/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HALL ET AL.
Limitations
The number of available studies to inform each
disorder type was low: 8 on psychosis, 8 on
anxiety, 7 on depression and 6 on CUD, and
measures of cannabis exposure were often
poor
W H A T S O R T O F RE S E A R C H I S NE E D E D ?
We need better research to inform the design of public health policies
on the regulation of cannabis products. These studies should obtain
the informed consent of larger, more representative samples of
cannabis users [21] and include naturalistic observations of the
effectiveness with which users titrate their THC doses when they use
the cannabis flower, oils, edibles and concentrates available in legal
markets in Canada and the United States. Some existing large surveys
in Canada and the United States can provide good cross-sectional
data on the characteristics of people who use more potent cannabis
products and assess associations between the use of these products
and various adverse health outcomes (e.g. [22]).
We also need longitudinal studies of the effects of the regular
use of higher-potency cannabis products over sustained periods of
time, such as months or years of use, to assess whether or not the
regular use of higher-potency cannabis increases the risk of develop-
ing cannabis dependence, psychotic symptoms and adverse psychoso-
cial effects. Ideally, these studies should: measure THC in blood,
assess the characteristics of cannabis users; describe how different
cannabis products are used (e.g. frequency and quantity of use);
assess symptoms of cannabis dependence and degrees of cognitive
impairment; and inquire about psychological symptoms such as
depression and anxiety. Given the public health importance of these
research questions, a portion of cannabis tax revenues should be
earmarked to fund this research.
Cannabis potency may not be the only issue of public health
concern. Research on the health effects of cannabis products should
also assess the effects of new routes of administering novel cannabis
products, such as edibles and beverages, vaping and dabbing. If legal
cannabis markets are further liberalized in future, we may also need
studies of the effects of cannabis products that include alcohol and
nicotine.
POLICY QUESTIONS
Should policymakers in jurisdictions that plan to legalize cannabis wait
for better research before deciding whether they only legalize herbal
cannabis and, if not, whether they ban or regulate the sale of high
THC cannabis products? The answers to these questions will critically
depend upon who is assumed to bear the burden of proof. Does the

REGULATING THC IN LEGAL CANNABIS
cannabis industry bear the burden of showing that more potent
cannabis products do not increase harm to users—or does the burden
of proof fall upon regulators and policymakers to show that the use of
more potent cannabis products increases harm to users?
There are three reasons why the burden of proof should fall upon
producers and retailers to make a case against bans or greater regula-
tion of higher-potency cannabis products [23]. The first reason is that
advocates for cannabis legalization in the United States and other
countries have most often argued for legalizing herbal cannabis and
cannabis resin with much lower THC levels than the extremely high
THC cannabis extracts now being sold. When this has been the case
the cannabis industry arguably does not have the same social license
to sell cannabis extracts, as it has to sell herbal cannabis and lower
THC resin [24].
A second reason is that a popular argument for cannabis
legalization—that cannabis should be regulated like alcohol—does not
preclude tighter regulation of high THC cannabis products [25, 26].
This argument appeals to governments because of their experience in
regulating alcohol. It was the regulatory approach adopted in the first
US states to legalize cannabis, Washington and Oregon, and later in
the US states of Illinois, Colorado and New York, whose cannabis laws
and regulations resemble those in place for alcohol [27]. Canada has
also broadly used provincial approaches to alcohol regulation to regu-
late cannabis while adding greater restrictions on packaging, labelling
and promotion modelled on tobacco control policies to minimize
cannabis uptake among adolescents [28].
Alcohol regulation provides precedents for the stricter regulation
of higher-potency cannabis than herbal cannabis [6, 10]. For example,
most countries do not allow the sale of 90% ethanol in bars and liquor
stores, and they usually ban the sale of pure ethanol as beverage
alcohol. Russian experience with the consumption of very high alcohol
beverages in the 1990s exemplifies the greater health risks of high
alcohol beverages [29]. Some US states and Canadian provinces
restrict the sale of alcoholic spirits to tightly regulated liquor outlets.
Governments also impose higher rates of tax on higher alcohol
beverages [30]. These policies provide strong precedents for similar
approaches to regulating high-potency cannabis products.
P OL I C Y O P TI O NS
One policy option would be to ban the sale of high THC cannabis
extracts [10]. Its major advantages would be its simplicity and ease of
enforcement and its similarity to bans on the sale of pure ethanol.
Another option would be to place a cap on the THC level in
cannabis products that can be legally sold [10]. The cap could vary for
cannabis flower, extracts and edibles. A major challenge with this
option is specifying what the THC cap should be, as shown by Van
Laar and Van De Pol’s analysis of a proposal to set a 15% THC limit
on cannabis flower sold in coffee-shops in the Netherlands [31].
A ban on the sale of cannabis extracts or a THC cap could create
incentives for users to make their own extracts, or for the illicit
production and supply of cannabis extracts. The use of butane for
13600443, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.16135 by Cochrane Poland, Wiley Online Library on [22/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1001
extracting THC from cannabis plants could ignite fires [32]. Illicit pro-
duction could result in the addition of untested ingredients to THC
extracts, as occurred in the US outbreak of ‘e-cigarette vaping
associated acute lung injury’ (EVALI) [33], caused by the adulteration
of illegal cannabis vaping products with vitamin E acetate [34]. Policy-
makers would need to monitor the scale of illicit extract production if
they chose this policy.
Another approach would be to increase cannabis taxes in propor-
tion to the THC content [35], as is the case with alcohol in many
countries [30]. The costs of this policy for producers, retailers and reg-
ulators would arguably be similar to the costs of testing required to
label the THC and cannabidiol (CBD) content of legal cannabis
products.
US states that have legalized cannabis have introduced or
considered a range of policies that regulate or inform cannabis users
of the potency of cannabis products [36]. A number of these state
governments have attempted to introduce THC caps and THC-based
taxes after initially allowing the sale of cannabis extracts. None has
succeeded in the face of strong opposition from the cannabis industry
[2]. This suggests that other jurisdictions considering cannabis legali-
zation should set their policies on THC limits and potency taxes
before these products are allowed to be sold [2].
Accurate labelling of cannabis should be a minimum policy for
ensuring consumer sovereignty that also provides legal cannabis prod-
ucts with a marketing advantage over illicit cannabis [37]. The addition
of health warnings may increase consumers’ awareness of the risks of
using high-potency products. In this case, it would be imperative to
impose clear standards of font size, colours and placement of such
warnings to cannabis manufacturers [38].
The impacts of different approaches to regulating cannabis
potency and novel cannabis products should be priorities for public
health research on cannabis legalization. This should include research
on how the legal cannabis industry responds to different types of
cannabis regulations.
CONC LU SION
An increase in the use of higher-potency cannabis products after their
legalization has the potential to increase cannabis-related harm. There
is some evidence that cannabis users can partially titrate their doses
of THC when using higher-potency products, but regular consumers
may not want to do so or may still receive higher-than-intended doses
of THC. Regulators have good reasons for regulating more potent
cannabis in ways that minimize harm. This can be adapting approaches
used to regulate alcohol; namely, banning the sale of extremely high
cannabis extracts, setting a cap on THC content and imposing higher
rates of taxes on more potent cannabis products. Given the difficulty
that US policymakers have had in regulating cannabis extracts and
edibles after their sale has been allowed, national and state govern-
ments that are planning to legalize adult cannabis use need to include
policies on the regulation of different cannabis products in the
enabling legislation.

1002
ACKNOWLEDGEMEN TS
Open access publishing facilitated by The University of Queensland,
as part of the Wiley - The University of Queensland agreement via
the Council of Australian University Librarians.
AUTHOR CONTRIBUTIONS
Wayne Hall drafted the article. Beatriz Carlini and Janni Leung con-
tributed content, revised and approved the final version.
DECLARATION OF INTERES TS
None.
ORCID
Wayne Hall https://orcid.org/0000-0003-1984-0096
Janni Leung https://orcid.org/0000-0001-5816-2959
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should policymakers regulate the tetrahydrocannabinol
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