Received: 7 September 2021 Accepted: 10 January 2022

DOI: 10.1111/add.15840

SHORT REPORT

Cannabis legalization and traffic injuries: exploring the role of

supply mechanisms

Beau Kilmer1 | Ariadne Rivera-Aguirre2 | Rosario Queirolo3 |

Jessica Ramirez4 | Magdalena Cerdá2

1
RAND Drug Policy Research Center, Santa Abstract
Monica, CA, USA
2
Background and aim: In Uruguay, residents age 18 and older seeking legal cannabis must
Department of Population Health, New York
University Grossman School of Medicine, New register with the government and choose one of three supply mechanisms:
York, NY, USA
self-cultivation, non-profit cannabis clubs or pharmacies. This is the first paper to mea-
3
Department of Social Sciences, Universidad
lica del Uruguay, Montevideo, CP,
Cato
sure the association between type of legal cannabis supply mechanism and traffic
Uruguay crashes involving injuries.
4
Observatorio Uruguayo de Drogas, Design: Ecological study using ordinary least squares regression to examine how
Montevideo, Uruguay
department-level variation in registrations (overall and by type) is associated with traffic
Correspondence crashes involving injuries.
Beau Kilmer, RAND Drug Policy Research
Center, 1776 Main St., Santa Monica, CA
Setting: Uruguay.
90407, USA. Cases: 532 department-quarters.
Email: kilmer@rand.org
Measurements: Quarterly cannabis registration counts at the department level and
Funding information incident-level traffic crash data were obtained from government agencies. The analyses
National Institute on Drug Abuse, Grant/
controlled for department-level economic and demographic characteristics and, as a
Award Number: R01DA040924
robustness check, we included traffic violations involving alcohol for departments
reporting this information. Department-level data on crashes, registrations and alcohol
violations were denominated by the number of residents ages 18 and older.
Findings: From 2013 to 2019, the average number of registrations at the department-
quarter level per 10 000 residents age 18 and older for self-cultivation, club membership
and pharmacy purchasing were 17.7 (SD = 16.8), 3.6 (SD = 8.6), and 25.1 (SD = 50.4),
respectively. In our multivariate regression analyses, we did not find a statistically signifi-
cant association between the total number of registrations and traffic crashes with inju-
ries (β = −0.007; P = 0.398; 95% CI = −0.023, 0.01). Analyses focused on the specific
supply mechanisms found a consistent, positive and statistically significant association
between the number of individuals registered as self-cultivators and the number of
traffic crashes with injuries (β = 0.194; P = 0.008; 95% CI = 0.058, 0.329). Associations
for other supply mechanisms were inconsistent across the various model specifications.
Conclusions: In Uruguay, the number of people allowed to self-cultivate cannabis is
positively associated with traffic crashes involving injuries. Individual-level analyses are
needed to assess better the factors underlying this association.

KEYWORDS
Cannabis, impaired driving, legalization, marijuana, traffic injuries, Uruguay

Addiction. 2022;117:2325–2330. wileyonlinelibrary.com/journal/add © 2022 Society for the Study of Addiction 2325

2326
I N T R O D U CT I O N
There are many outcomes to consider when evaluating and discussing
cannabis legalization. Its effect on traffic safety is prominently
featured in these debates, but most of the research is focused on the
United States (US). Although US studies do not find an association
between the legal change and traffic fatalities [1, 2], subsequent
research focused on the opening of retail stores finds a positive and
possibly temporary increase in traffic fatalities [3, 4]. Another study
reports mixed results depending on the states considered [5].
Outside the United States, we are only aware of one study
examining the relationship between nonmedical legalization and
traffic safety. Focusing on five jurisdictions in Uruguay and using an
interrupted times series approach focused on when the law was
enacted in December 2013, the study finds that enactment ‘may have
been associated with an increase in fatal motor vehicle crashes …’ [6]
Our article contributes to this literature by looking beyond enact-
ment in Uruguay and using a novel dataset that reports the number of
people in Uruguay who registered with the government to obtain legal
cannabis through one of three supply mechanisms: (i) self-cultivation
(“growers”); (ii) becoming a member of a non-profit cannabis club and
paying a monthly fee that in some instances would be offset by in
kind labour (“members”) [7]; or (iii) purchasing at a pharmacy
(“purchasers”). We examine how variation in registrations for legal
cannabis—in total and by mechanism—is associated with traffic
crashes involving injuries.
B A CKG R OUND ON CANNABI S
LEGALIZATION IN URUGUAY
In December 2013, Uruguay became the first country to legalize the
supply of cannabis for nonmedical purposes. Unlike jurisdictions in
the United States and Canada, Uruguay limits legal supply to residents
and requires them to register with the government and choose a sup-
ply mechanism [8]. Regardless of mechanism, each registrant is limited
to obtaining no more than 480 grams of dried cannabis per year. In
the pharmacies, this is tracked by biometric sensors and buyers
cannot purchase more than 10 grams per week [9]. Cannabis clubs
and self-cultivators are subject to inspections by the Instituto de
Regulacion y Control del Cannabis (IRCCA) [10], but the probability of
a self-cultivator being inspected is low and inspections have been
decreasing [11].
Little research has been published on the public health conse-
quences of legalization in Uruguay outside the aforementioned traffic
study and an analysis finding that legalization is neither associated
with adolescent prevalence nor perceived risk of use [12]. Neither of
these studies explore the effects of different supply mechanisms. This
is an important gap considering that these mechanisms could be
associated with different levels of potency and intoxication, which
may influence public health and safety outcomes. Although the
government initially limited the tetrahydrocannabinol (THC) content
of cannabis sold at dispensaries to 2% THC, it eventually expanded
13600443, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.15840 by Univ of Sao Paulo - Brazil, Wiley Online Library on [05/04/2024]. 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
KILMER ET AL.
the product line to include cannabis flowers that were up to 9% THC
[13]. The legislation did not impose potency limits for the cannabis
produced by self-cultivators or cannabis clubs, and there is some
evidence that the cannabis grown in these environments exceeds the
caps imposed on pharmacies [14]. There is also the possibility that
self-grown cannabis may be more likely to be supplied to others,
especially given the low probability of inspection [15].
DA T A A N D M E T H O D S
Quarterly registration counts for growers, members and purchasers
were obtained from data provided by the IRCCA [16]. Licenses for
growers and members expire after 3 years and individuals must renew
them to remain within the legal market; the registrations for
purchasers do not expire. Individuals can only be registered for one
supply mechanism at a time; therefore, if they want to change how
their cannabis is supplied, they need to cancel their current registra-
tion or let it expire. We confirmed that those who switch are not
double counted in the quarterly counts.
Traffic crash data were obtained from Uruguay’s National Unit of
Road Safety and includes information on date, time, location and
injury severity of every reported crash [17]. Annual department-level
data for population, percent of the population 18 or older, percent
male, and unemployment rate were obtained from the Continuous
Household Survey of the National Statistics Institute (we linearly
interpolate these figures to generate quarterly values) [18]. Quarterly
information on traffic violation fines involving alcohol were obtained
from the Vehicle Revenue Collection System and are unavailable for
) [19]. Given the
three departments (Flores, Paysandú and Tacuarembo
missing data and our inability to distribute violations made by the
national transit police to departments, we use this variable in the
sensitivity analyses instead of the main specifications.
Our analysis leverages the variation in registrations across time
and Uruguay’s 19 departments to examine the association with traffic
injuries. We estimate an ordinary least squares (OLS) model using the
following specification:
Idt = β0 + β1 Registrationsdt + β2 Xdt + αd + αt + εdt, ð1Þ
where the number of per capita traffic crashes (I) in department d at
year-quarter t is a function of the number of per capita registrations
(Registrationsdt) as well time-varying department-level variables (Xdt).
The models also include department-level (αd) and year-quarter level
fixed effects (αt). Given the potential differences that supply mecha-
nisms may have on products consumed and diverted, we also estimate
models that focus on the number of per capita registrations for each
mechanism, separately and in the same model.
We also present the results from six sensitivity analyses. First, we
present the results from a model without time-varying demographic
and economic control variables. Second, we limit the sample to the
period before the pharmacies started selling cannabis (July 2017). This
helps us better isolate the association with growers and club members
 13600443, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.15840 by Univ of Sao Paulo - Brazil, Wiley Online Library on [05/04/2024]. 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
CANNABIS LEGALIZATION AND TRAFFIC INJURIES 2327

from the rapid increase in pharmacy registrations. Third, there are five
departments (Canelones, Colonia, Maldonado, Montevideo and
Rocha) that typically see a large increase in tourism in the summer
months (which is largely captured by quarter 1, January–March).
Because this could lead to an increase in traffic crashes, we estimate a
model that includes an interaction term that equals 1 for these five
departments in quarter 1 (0 otherwise). Fourth, to see if our results
change if we use an alternative specification, we present the results
from a Poisson model, which includes counts of traffic crashes with
injuries as the dependent variable and the population age 18 and older
as the exposure variable.
We also attempt to rule out alternative explanations by control-
ling for the number of per capita traffic violation fines involving alco-
hol. Including these alcohol violations serves two purposes: (i) it helps
control for the role that alcohol may have played in traffic crashes,
and (ii) it helps control for the intensity of traffic enforcement in each
department quarter. As noted, this information is not available for
three departments, so it reduces our sample size from 532 to 448.
Therefore, the fifth sensitivity analysis replicates our main specifica-
tion, but excludes these three departments so we can see what the
results look like before controlling for alcohol violations. The sixth
analysis includes an additional control for the alcohol violations.
RESULTS
members did not start until quarter 4 of 2014 and quarter 1 of 2015,
respectively. Pharmacies selling cannabis did not open until July 2017,
but registrations to acquire cannabis from them started being issued
in quarter 2 of 2017.
Main results
Table 2 presents the results from our main OLS models. Model 1 of
Table 2 includes the total number of individuals who were registered
to obtain legal cannabis and we do not observe a statistically signifi-
cant relationship between this value and the number of traffic crashes
involving injuries (β = −0.007, P = 0.398).
Models 2 to 4 of Table 2 report the results separately for the
number of registrations for each supply mechanism. We find a posi-
tive and statistically significant association (P < =0.05) for growers
(β = 0.153, P = 0.015) and no statistically significant association for
members (β = 0.031, P = 0.588) or pharmacy registrations (β = −0.016,
P = 0.088). When we include each of these variables in model 5, the
positive association with growers becomes somewhat larger and more
precise (β = 0.194, P = 0.008). This result suggests that, on average
and holding everything else constant, a 1 unit increase in the number
of registered self-cultivators per 10 000 population in a department-
quarter is associated with a 0.194 unit increase in the number of traf-
fic crashes with injuries per 10 000 population.

Descriptive statistics
Table 1 presents the descriptive statistics for our dependent and inde-
pendent variables for the 532 department-quarters (19 departments ×
7 years × 4 quarters). At the department-quarter level, the median
(mean) number of traffic crashes involving injuries per 10 000 popula-
tion from 2013 to 2019 is 23.8 (24.1), with minimum and maximum
values of 6.1 and 47.1, respectively.
Figure 1 displays the reported traffic crashes involving injuries
and number of registrations for the entire country over time by supply
mechanism. Registrations for growers and cannabis social club
Sensitivity analyses
Table 3 presents the results from a series of robustness checks. To
make comparisons easier, model 1 reproduces the results from the
main specification from Table 2. Model 2 excludes time-varying
demographic and economic control variables and the results remain
similar for growers (β = 0.209, P = 0.011).
Model 3 limits the sample to the period before the pharmacies
started selling cannabis. This specification reduces our sample size by
roughly one-third and, not surprisingly, reduces the precision of our

TABLE 1 Descriptive statistics

Variable n Mean Median 25th Percentile 75th Percentile Min Max

Crashes w/injuries per 10 000 pop 532 24.1 23.8 19.4 27.6 6.1 47.1
Total registrations per 10 000 pop 532 47.4 19.4 0.51 71.6 0.0 378.7
Grower registrations per 10 000 pop 532 17.7 16.3 0.51 26.8 0.0 86.6
Member registrations per 10 000 pop 532 3.6 0.0 0.0 3.9 0.0 56.6
Pharmacy registrations per 10 000 pop 532 26.1 0.0 0.0 27.1 0.0 290.0
Unemployment rate 532 4.2 4.0 3.4 4.7 1.8 10.5
Log (population) 532 11.6 11.4 11.0 11.8 10.2 14.1
% of population 18+ 532 72.8 72.6 71.2 74.3 66.8 77.6
% male 532 48.9 49.0 48.5 49.3 47.0 51.6
Alcohol violations per 10 000 pop 448 7.9 5.2 3.0 9.6 0.3 77.3

All per capita measures are for department residents ages 18 and older pop = population.
 13600443, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.15840 by Univ of Sao Paulo - Brazil, Wiley Online Library on [05/04/2024]. 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
2328 KILMER ET AL.

F I G U R E 1 Registrations for legal cannabis and traffic

crashes involving injuries in Uruguay. Notes: The drop in
registrations for growers after mid-2018 reflects a decision by
IRCCA to extend these registrations until 20 July, 2018. Those
who did not renew were terminated from the registry [20]

TABLE 2 Main analyses

Independent variable Model 1 Model 2 Model 3 Model 4 Model 5

Total registrations per 10 000 pop −0.007

(0.398)
[−0.023, 0.01]
Grower registrations per 10 000 pop 0.153 0.194
(0.015) (0.008)
[0.034, 271] [0.058, 0.329]
Member registrations per 10 000 pop 0.031 −0.070
(0.588) (0.130)
[−0.087, 0.148] [−0.163, 0.023]
Pharmacy registrations per 10 000 pop −0.016 −0.007
(0.088) (0.221)
[−0.035,0.003] [−0.019, 0.005]
R2a 0.6779 0.6516 0.6776 0.6819 0.7059

n = 532. The dependent variable is the number of traffic crashes with injuries per 10 000 population(pop) ages 18 and older. For each model, the OLS
coefficient, P value (in parentheses), and 95% CI [in brackets] are presented for the key independent variables. All models control for the unemployment
rate, log (population), % of population 18+, % male and department and year-quarter fixed effects (i.e. 1 = Q1 2013 … 28 = Q4 2019). The standard errors
are clustered at the department level. aModel 5 reports the adjusted R-squared.

estimates; however, the coefficient on growers remains statistically
significant (β = 0.168, P = 0.034).
In the summer months, five departments typically see a large
increase in tourism, which could lead to an increase in traffic
accidents. Model 4 includes an interaction term that equals 1 for
these five departments in quarter 1 and the coefficient on growers
remains statistically significant (β = 0.160, P = 0.038).
Model 5 presents an alternative to the OLS results presented in
model 1. Using a Poisson regression with the count of traffic crashes
with injuries as the dependent variable and population ages 18 and
older as the exposure, the coefficient on growers remains positive and
statistically significant (β = 0.009, P = 0.005).
Model 6 replicates our main specification (model 1) but excludes
the three departments without information about alcohol violations.
Once again, the coefficient on growers is positive and statistically sig-
nificant (β = 0.204, P = 0.006). However, the coefficient on members
is negative and now statistically significant (β = −0.114, P = 0.007). It
is unclear what is driving the negative association between members
and traffic crashes, as the coefficient on members is not statistically
significant at the 5-percent level in all other models discussed to this
point. When we control for alcohol violations in model 7, the results
are similar to model 6. This suggests that the unusual finding on mem-
bers is likely being driven by a change in the composition of sample,
not the inclusion of the alcohol violation variable.
 13600443, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.15840 by Univ of Sao Paulo - Brazil, Wiley Online Library on [05/04/2024]. 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
CANNABIS LEGALIZATION AND TRAFFIC INJURIES 2329

TABLE 3 Sensitivity analyses

Model n Growers per 10 K Members per 10 K Purchasers per 10 K

[1] Main specification (from Table 2, model 5) 532 0.194 −0.070 −0.008
(0.008) (0.130) (0.221)
[0.058, 0.329] [−0.163, 0.023] [−0.020, 0.005]
[2] No time-varying covariates 532 0.209 −0.092 −0.002
(0.011) (0.122) (0.739)
[0.054, 0.363] [−0.210, 0.027] [−0.014, 0.01]
[3] Limit analysis to period before pharmacies started selling 342 0.168 −0.093 −0.220
cannabisa (0.034) (0.327) (0.327)
[0.014, 0.321] [−0.287, 0.101] [−0.678, 0.238]
[4] Include interaction term for 5 departments most affected 532 0.160 −0.075 −0.008
by tourism and quarter 1 (0.038) (0.104) (0.181)
[0.01, 0.31] [−0.167, 0.017] [−0.021, 0.004]
[5] Poisson regression: dependent variable = count of 532 0.009 −0.004 0.00005
crashes with injuries; exposure = total population age 18 (0.005) (0.09) (0.813)
+
[0.003, 0.015] [−0.008, 0.0005] [−0.0004, 0.001]
[6] Drop 3 departments missing data on traffic violations 448 0.204 −0.114 −0.007
involving alcohol (0.006) (0.007) (0.258)
[0.069, 0.338] [−0.192, −0.037] [−0.02, 0.006]
[7] Control for traffic violations involving alcohol 448 0.200 −0.101 −0.005
(0.015) (0.014) (0.444)
[0.045, 0.354] [−0.179, −0.023] [−0.019, 0.01]

The dependent variable is the number of traffic injuries per 10 000 population age 18 and over, except for model 4. Each row represents a different model.
For each model, the OLS coefficient, P value (in parentheses), and 95% CI [in brackets]. Except for model 2, all models control for the unemployment rate,
log (population), % of population 18+, % male and department and year-quarter fixed effects (i.e., 1 = Q1 2013 … 28 = Q4 2019). The standard errors are
clustered at the department level.
a
The number of pharmacy registrations is included because some registrations were approved in the quarter before the pharmacies opened.

DISCUSSION
This is the first paper to explore the association between how legal
cannabis is supplied and traffic crashes involving injuries. Using a
novel dataset of registrations for different supply mechanisms in
Uruguay and detailed information on traffic crashes, our analyses sug-
gest that increasing the number of people allowed to self-cultivate
cannabis is positively associated with traffic crashes involving injuries.
The external validity of these findings may be limited. To date,
Uruguay is the only country that requires individuals to register and
choose a supply mechanism. In most places that have legalized
cannabis, adults can purchase and grow cannabis if they wish without
registering. Further, Uruguay is unique in that it does not allow con-
centrates or edibles and imposes a potency cap on flower products
sold in pharmacies.
Another limitation of our analysis is the small number of
department-level variables we could incorporate. For example, we
would have preferred to denominate injuries by vehicle miles
travelled instead of population, but we were unable to locate a
source with this information at the department level. Although we
were able to obtain some department-level information on other
traffic enforcement variables such as tickets for not wearing a seat
belt, there were noteworthy data quality issues that prevented us
from including them. Still, the inclusion of standard socioeconomic
characteristics and department and year-quarter fixed effects as well
as alcohol violations for most departments helps us rule out some
alternative explanations.
Finally, because the analysis was not pre-registered and it is an
ecological study, the results should be considered exploratory. More
could be learned about this association by merging individual-level
registration data with traffic records and/or analysing self-report
survey data that include information about cannabis use/acquisition,
alcohol use and traffic outcomes.
Despite these limitations, the robust finding on self-cultivation is
not only generally consistent with an earlier study (which largely
focused on the period before pharmacies started selling) [6], it also
raises questions that may be of interest outside of Uruguay.
Although our data preclude us from assessing the factors underlying
this association, we wonder if the differential potencies of cannabis
flower associated with different supply mechanisms may help
explain the results. As noted, available data suggest that the flower
grown by self-cultivators tended to be stronger than the 9% THC

2330
flower sold in the pharmacies [14]. Although the effects of THC can
vary by individual [21]—and it may be the case that some of those
using stronger cannabis are titrating—if self-cultivation, on average,
is leading to more intoxication, this may partially explain the increase
in traffic injuries. Because this argument could also be applied to
those supplied by cannabis clubs, more research is needed to test
this hypothesis.
Another avenue of future research should focus on diversion.
Although those registered for self-cultivation are not permitted to sell
or gift cannabis, there are reports of this is occurring [22]. If those reg-
istered for self-cultivation are more likely to supply cannabis to others
(especially if it is a relatively strong product), this may also help explain
the differential findings by supply mechanism.
This paper provides new insights and raises important questions
about the possible mechanisms underlying the observed associations.
We hope this exploratory analysis with novel data motivates other
researchers to not only use these data to extend our analysis, but to
also address other questions related to cannabis legalization.
ACKNOWLEDGEMEN TS
This work was supported by a grant from the National Institute on
Drug Abuse (R01DA040924; PI: Cerdá). We thank Héctor Suárez
 pez (National Road Safety
(Junta Nacional de Drogas) and Javier Lo
Unit) for providing data and technical assistance. We are also grateful
to Steven Davenport for his assistance with the traffic crash data. The
views presented here only reflect those of the authors.
DECLARATION OF INTERES TS
None.
AUTHOR CONTRIBUTIONS
Beau Kilmer: Conceptualization; formal analysis; methodology.
Ariadne Rivera-Aguirre: Data curation; formal analysis; funding
acquisition. Rosario Queirolo: Data curation; formal analysis; funding
acquisition; methodology. Jessica Ramírez: Data curation. Magdalena
Cerda: Conceptualization; formal analysis; funding acquisition;
methodology.
ORCID
Beau Kilmer https://orcid.org/0000-0002-9333-8080
Ariadne Rivera-Aguirre https://orcid.org/0000-0003-4860-2791
Rosario Queirolo https://orcid.org/0000-0002-4385-8045
Magdalena Cerdá https://orcid.org/0000-0001-8441-7046
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Addiction. 2022;117:2325–30. https://doi.org/10.1111/add.
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