AJPH EDITORIALS
social determinant of health, it is
one of many that interact with each
other in complex ways. At some
point, reductions in food insecurity
will have diminishing health
returns as other social factors (e.g.,
housing insecurity, social isolation)
remain and prevent further gains.
How quickly these returns might
diminish is unclear. Also, many
health and social policies at the
community, state, and federal
levels relevant to low-income
populations can powerfully affect
each point along the cycle in
positive or negative ways. Pre-
serving, cutting, or expanding
Supplemental Nutrition Assis-
tance Program and other public
benefits—or succeeding or failing
to reduce the share of health care
costs paid for by health care con-
sumers—could work to mute or
amplify the connections in Figure
1, independently or in association
Building Evidence-Based Prevention
Mechanisms Into Cannabis
Legalization Policy and Regulations
See also Everson et al., p. 1294.
Cannabis (“marijuana”) refers to
the crude and varying cannabinoid
components of several cannabis
plant varietals, including the two
most common varietals consumed
in the United States, Cannabis indica
and Cannabis sativa. Cannabis has
gone through varying phases of le-
gality in the United States; however,
it has been illegal under federal law
since enactment of the Controlled
Substances Act of 1970 (Pub L No.
91-513), where it remains classified
as a Schedule I drug (i.e., no cur-
rently accepted medical use, high
potential for abuse, and lack of ac-
cepted safety data). Despite its federal
illegality, many states have enacted
more permissive cannabis laws.
September 2019, Vol 109, No. 9 AJPH
with increases or decreases in the
rates of health insurance coverage.
Changes in wage growth attrib-
utable to government policies, in-
dependent corporate actions, or
macroeconomic forces may also
play an outsized role.
In part because of these com-
plexities, however, efforts to
explicitly test these links are
warranted. For policymakers to
fully understand the impact of
proposed policies related to
health care systems and social
safety net programs, investigating
the mechanisms through which
these policies interrelate in po-
tentially positive or detrimental
ways will be critical. Doing so
may help target policies to
promote virtuous cycles while
avoiding vicious ones for
vulnerable populations.
Rajan A. Sonik, JD, PhD, MPH
As of June 2019, ten states and
the District of Columbia have
enacted nonmedical adult-use
cannabis laws, a heterogeneous
set of provisions effectively
allowing adults aged 21 years or
older to purchase, possess, culti-
vate, and consume cannabis for
nonmedical adult-use (“recrea-
tional”) purposes. These state-
level statutory changes have been
fervently debated and there is
concern that any permissive
change in the legality of cannabis,
including specific provisions such
as allowing retail shops, may in-
crease prevalence of cannabis use
and problematic use, as well as
related adverse consequences.
ACKNOWLEDGMENTS
This project was supported by the Agency
for Healthcare Research and Quality
(grant R03HS026317).
The author thanks Reginald Tucker-
Seeley of the University of Southern
California and Lara Bishay of Children’s
Hospital Los Angeles for their thoughtful
and constructive advice.
Note. The content of this editorial is
solely the responsibility of the author and
does not necessarily represent the official
views of the Agency for Healthcare Re-
search and Quality.
CONFLICTS OF INTEREST
The author declares no conflicts of interest.
REFERENCES
1. Coleman-Jensen A, Rabbitt MP,
Gregory CA, Singh A. Household food
insecurity in the United States in 2017.
2017. Available at: https://www.ers.usda.
gov/webdocs/publications/90023/err-
256.pdf?v=0. Accessed June 21, 2019.
2. Mayer VL, McDonough K, Seligman
H, Mitra N, Long JA. Food insecurity,
coping strategies and glucose control in
low-income patients with diabetes. Public
Health Nutr. 2016;19(6):1103–1111.
3. Tarasuk V, Cheng J, de Oliveira C,
Dachner N, Gundersen C, Kurdyak P.
Cannabis is the most commonly
used illicit substance by adults in the
United States. Current research
reports that adults’ risk perceptions
of cannabis are declining while use
is increasing.1 In 2017, 9.9% of US
adults aged 18 years or older re-
ported past-30-day (“current”)
cannabis use and 48.2% re-
ported lifetime use (https://www.
samhsa.gov/data/report/2017-
nsduh-detailed-tables). Although
cannabis use appears most harmful
to youths and emerging adults,
ABOUT THE AUTHORS
Both authors are with the Commonwealth of Massachusetts, Cannabis Control Commission,
Boston, MA.
Correspondence should be sent to Julie K. Johnson, Director of Research, Cannabis Control
Commission, 101 Federal St, 13th Floor, Boston, MA 02110 (e-mail: julie.johnson@
mass.gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This editorial was accepted June 14, 2019.
doi: 10.2105/AJPH.2019.305249
Association between household food in-
security and annual health care costs.
CAMJ. 2015;187(14):E429–E436.
4. Nord M, Golla AM. Does SNAP de-
crease food insecurity: untangling the
self-selection effect. 2009. Available at:
https://www.ers.usda.gov/webdocs/
publications/46295/10977_err85_1_.
pdf?v=42317. Accessed June 21, 2019.
5. Huang J, Guo B, Kim Y. Food in-
security and disability: do economic re-
sources matter? Soc Sci Res. 2010;39(1):
111–124.
6. Coleman-Jensen A, Nord M. Food
Insecurity Among Households With
Working-Age Adults With Disabilities.
Washington, DC: US Department of
Agriculture; 2013. Economic Research
Report 144.
7. Kayes HS. Disability-related disparities
in access to health care before (2008–2010)
and after (2015–2017) the Affordable Care
Act. Am J Public Health. 2019;109(7):
1015–1021.
adult use is not without risk. Hasin
et al. found that approximately 30%
of cannabis users met criteria for a
cannabis use disorder.2 In addition,
cannabis use risks include impaired
driving, accidents and injury, cog-
nitive impairment, psychiatric symp-
toms, and unknown long-term
effects.1,3
Research assessing the impacts
of cannabis legalization (i.e.,
medical or nonmedical adult
use) laws on adult cannabis use is
still developing and is further
complicated by law, regulatory,
and other state-level differences. In
a small study of Washington State
parents, Kosterman et al. found that
cannabis use frequency and disor-
ders increased after nonmedical
adult-use legalization.4 To date,
Johnson and Doonan Editorial 1165
AJPH EDITORIALS
most studies have assessed medical
cannabis legalization enactment
or implementation. Hasin et al.
examined early, late, and non-
adopting medical cannabis legali-
zation states and found that
cannabis use prevalence and dis-
orders among adults increased
in states that enacted medical
legalization while decreasing in
nonenacting states.3 Similarly,
Williams et al. found that cannabis
use increased among adults aged 26
years or older in permissive medical
cannabis states but did not change
in less permissive states.5 In contrast
to Hasin et al., authors found that
medical cannabis legalization did
not have an impact on rates of
cannabis use disorders, a more
harmful potential effect of legali-
zation.3,5 Major knowledge and
methodological gaps remain, in-
cluding assessment of and adjust-
ment for the heterogeneity
inherent in state-led design, reg-
ulation, and enforcement of these
cannabis legalization laws—as well
as their effects, which may include
changing social norms; patterns of
use; modes of consumption; po-
tency; substance use and mental
health disorders; hospitalizations,
accidents, and injury; and long-
term health outcomes.
In a novel study presented in
this issue of AJPH, Everson et al.
(p. 1294) assess adult cannabis use
outcomes by using a sophisticated
Prescription Opioids: A Continuing
Contributor to the Epidemic
See also Griesler et al., p. 1258.
The opioid crisis is frequently
conceptualized as occurring in
three waves, beginning with
prescription opioids in 1999, fol-
lowed by heroin in 2010, and
then by illicitly manufactured syn-
thetic opioids, primarily fentanyl,
1166 Editorial Heins
methodological approach to isolate
changes following implementation
of a specific provision, retail cannabis
market (“access”). The study’s
novelty lies in its detailed account
of state-specific heterogeneity, in-
cluding regulation (e.g., number of
permitted retail stores, seed-to-sale
tracking), implementation (e.g.,
number and dates of active retail
stores at varying locations), and
community-level indicators (i.e.,
proximity, geospatial density,
and per-capita density) for a local-
ized assessment of access to retail
cannabis on adult cannabis use be-
haviors. Authors report that current
and frequent cannabis use grew
significantly between 2009 and
2016 in Washington State, but
changes were not significant until
there was greater access to cannabis
retailers. Specifically, cannabis use
rates significantly increased for adults
residing in proximity to a retail
cannabis store (£ 18.4 miles), and
frequent use significantly increased
for adults living very close to a store
(£ 0.8 miles). On the basis of these
findings, authors suggest that poli-
cymakers consider density limits as a
strategy to prevent heavy cannabis
use in adults, an important proactive
public health consideration for states
enacting cannabis legalization.
Research on adult-use cannabis
legalization is in a nascent stage
and is only beginning to examine
the heterogeneity in cannabis
in 2013.1 However, the term
“wave” is somewhat misleading,
as it implies that the threats from
prescription opioids and heroin
have crested and then receded.
In reality, overdoses from these
sources have remained stubbornly
legalization efforts and potential
differential impacts of varying
provisions.6 These findings are
important in light of the methods
often used in the current litera-
ture assessing varying legalization
change(s), which use a homoge-
nous binary (yes or no) indicator for
legalization enactment or imple-
mentation, potentially masking if
varying statutes, regulation, pro-
visions, and enforcement affect
outcomes or cohorts differently.
This study elucidates both the
methodological limitation of bi-
nary coding of legalization and the
need for more complex constructs
of legalization in future studies.
Furthermore, the full effects of le-
galization may be lagged; thus,
assessing both time and variation
are also key to a more compre-
hensive understanding. The lack of
federal direction combined with
state policy preceding what is
collectively known scientifically
necessitates innovative methods
to establish a baseline and mea-
surement of the variations in-
herent in state laws in a constantly
evolving cannabis law landscape.
As we have learned from the to-
bacco and alcohol industries and
regulation, once science discerns
differential effects of laws and
specific provisions, evidence-
based prevention mechanism(s)
can be built into legalization
policy and regulations.
high despite a variety of policy
efforts. Perhaps a more apt met-
aphor would be that of three
ABOUT THE AUTHOR
Sara E. Heins is with the RAND Corporation, Pittsburgh, PA.
Correspondence should be sent to Sara E. Heins, Associate Policy Researcher, RAND
Corporation, 4570 Fifth Ave, Pittsburgh, PA 15219 (e-mail: sheins@rand.org). Reprints can
be ordered at http://www.ajph.org by clicking the “Reprints” link.
This editorial was accepted June 14, 2019.
doi: 10.2105/AJPH.2019.305253
AJPH
Julie K. Johnson, PhD
Samantha M. Doonan, BA
CONTRIBUTORS
Both authors contributed equally to this
article.
CONFLICTS OF INTEREST
There are no conflicts of interest to report.
REFERENCES
1. Hasin DS. US epidemiology of can-
nabis use and associated problems.
Neuropsychopharmacology. 2018;43(1):
195–212.
2. Hasin DS, Saha TD, Kerridge BT, et al.
Prevalence of marijuana use disorders in
the United States between 2001–2002
and 2012–2013. JAMA Psychiatry. 2015;
72(12):1235–1242.
3. Hasin DS, Sarvet AL, Cerdá M, et al. US
adult illicit cannabis use, cannabis use
disorder, and medical marijuana laws:
1991–1992 to 2012–2013. JAMA Psy-
chiatry. 2017;74(6):579–588.
4. Kosterman R, Bailey JA, Guttmannova
K, et al. Marijuana legalization and par-
ents’ attitudes, use, and parenting in
Washington state. J Adolesc Health. 2016;
59(4):450–456.
5. Williams AR, Santaella-Tenorio J,
Mauro CM, Levin FR, Martins SS. Loose
regulation of medical marijuana programs
associated with higher rates of adult
marijuana use but not cannabis use
disorder. Addiction. 2017;112(11):
1985–1991.
6. Pacula RL, Smart R. Medical marijuana
and marijuana legalization. Annu Rev Clin
Psychol. 2017;13(1):397–419.
successive dams breaking, with
each increasingly contributing to
the rising water level. Notably,
prescription opioid mortality hit a
record high in 2017 with 17 029
deaths.2 The annual number of
deaths from prescription opioids
has remained fairly consistent since
September 2019, Vol 109, No. 9
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