The evolution of cannabis policy in the U.S. is deeply influenced by the country's federal system, which grants states significant authority over public health and safety regulations. As cannabis remains illegal at the federal level, states have taken the lead in legalizing and regulating its use, resulting in a diverse and often complex landscape of cannabis policies across the country.

Federalism and State Authority

In the U.S., states play a crucial role in shaping cannabis policy due to the principle of federalism. While cannabis remains prohibited federally, states have independently chosen to legalize it for medical and/or recreational purposes. This dynamic has allowed states to experiment with various models of regulation, creating both opportunities and challenges in the absence of consistent federal guidance.

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A Patchwork of State Laws

The state-led nature of cannabis legalization has produced a patchwork of laws across the country. States differ widely in how they approach licensing, regulation, taxation, and social equity provisions. This inconsistency complicates research on cannabis policy impacts and poses challenges for businesses operating in multiple states. The lack of uniformity makes it difficult to assess the broader public health, economic, and social effects of cannabis legalization across jurisdictions.

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State-Level Policy Innovation

Despite the challenges presented by federal prohibition, states have emerged as laboratories of democracy, testing different approaches to cannabis regulation. Innovations have been seen in areas such as social equity programs designed to address historical injustices, harm reduction strategies, and public health campaigns aimed at educating the public on safe cannabis use. These state-level experiments are shaping the future of cannabis policy both regionally and nationally.

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Tensions Between State and Federal Law

The ongoing conflict between state legalization efforts and federal prohibition continues to create legal uncertainty. For instance, while state laws may permit cannabis businesses, these businesses often face challenges with banking, taxation, and other federal regulations. Financial institutions remain wary of engaging with the cannabis industry, and federal restrictions on cannabis research hinder comprehensive understanding of its public health impacts.

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Impact on State and Local Revenues

One clear outcome of cannabis legalization is the generation of substantial tax revenue for state and local governments. Many states earmark these funds for critical public services such as education, substance use treatment, and public health programs. However, questions remain about the long-term economic effects of legalization, including its impact on the illicit cannabis market.

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State-Level Public Health Responses

States with legalized cannabis have taken various steps to address public health concerns. These include:

• Surveillance Systems: States have established systems to track cannabis use, health outcomes, and market trends. However, the scope and effectiveness of these systems vary, highlighting the need for standardized data collection practices.
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• Public Education Campaigns: Many states have launched educational initiatives focused on the risks and benefits of cannabis, particularly targeting youth prevention and impaired driving.
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• Harm Reduction Efforts: Some states have embraced harm reduction strategies, such as offering naloxone—an opioid overdose reversal medication—at cannabis dispensaries to address potential public health risks indirectly related to cannabis use.
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• Product Safety Regulations: All states with legal cannabis mandate safety testing to protect consumers, but differences in testing standards raise concerns about the quality and accuracy of cannabis products across state lines.

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Equity and Social Justice

States have been addressing the long-standing racial disparities associated with cannabis prohibition by implementing social equity programs. These programs aim to promote business ownership and employment opportunities for those disproportionately impacted by past enforcement practices. However, the effectiveness of these programs in achieving true equity remains under ongoing review.

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Key Challenges for States

States face several significant challenges as they continue to refine cannabis policies:

• Unregulated Hemp Market: The 2018 Farm Bill legalized hemp, but also opened the door to the production of intoxicating hemp-derived products, such as delta-8-THC. States struggle to regulate these products due to limited federal oversight, leading to confusion and gaps in public safety protections.
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• Adapting to a Rapidly Evolving Market: As the cannabis industry evolves with new products and higher-potency THC items, states must continuously update their regulatory frameworks and public health strategies to mitigate risks.
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• Youth Access and Prevention: Preventing youth from accessing cannabis remains a major concern. States must work diligently to enforce age restrictions, control exposure to cannabis marketing, and develop effective prevention campaigns.

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Recommendations for State Policymakers

To navigate the evolving cannabis landscape effectively, policymakers should consider the following recommendations:

• Prioritize Public Health: Policymakers should ensure that public health remains central to cannabis policy decisions, adopting a comprehensive approach that emphasizes continuous assessment, policy development, and monitoring of outcomes.
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• Strengthen Data Collection and Surveillance: Investment in data systems is essential to track usage trends, product potency, health outcomes, and the impact of policy interventions.
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• Implement Evidence-Based Regulations: Drawing from the lessons of alcohol and tobacco control, states should develop robust regulations governing the production, testing, labeling, marketing, and sale of cannabis to protect consumers and reduce risks.
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• Promote Social Equity: States should continue addressing the harms of cannabis prohibition by implementing and refining social equity programs, ensuring marginalized communities have access to the legal cannabis market, and reinvesting cannabis tax revenues into these communities.
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• Address the Unregulated Hemp Market: States should push for federal clarification on the legal status of intoxicating hemp-derived products and seek greater authority to regulate them.
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• Support Research: Investment in research is crucial to understanding the long-term health impacts of cannabis, developing effective prevention and treatment programs, and evaluating current policies.

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Conclusion

As cannabis legalization spreads across the U.S., states hold the responsibility of crafting policies that balance public health priorities with economic opportunity. By focusing on data-driven decision-making, social equity, and comprehensive regulation, states can harness the benefits of legalization while minimizing its potential harms.

Citation: National Academies of Sciences, Engineering, and Medicine. 2024. Cannabis policy impacts on public health and health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/27766.

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