Marijuana, or its technical and seemingly more palatable label “cannabis,” has catapulted to favorable public opinion in the US after decades of being thought of as “the evil weed.” From the mid-1990s, marijuana has caught favor for its alleged medicinal value; thereby 36 states have legalized its use. Furthermore, eighteen states have passed laws for recreational use of the substance. Over the years, the medical profession, policy makers, and the American people have had a range of attitudes toward marijuana use. Beliefs have ranged from marijuana being an elixir, to a harmless, even recreational, mood-altering substance. 

In just a few years, marijuana has shaken what critics call “Puritanesque propaganda” and has moved unwittingly toward normalization. Paradoxically, the fact remains that marijuana is considered by U.S. federal authorities to be a Schedule I substance, given its high potential for abuse and lack of medicinal value. Therefore, marijuana still needs to be considered a “controlled substance.” Surprisingly, few healthcare and public health groups and leaders have anything to say about its risk and elusive value. One potential scenario: the country’s next public health crisis. 

Most Americans approve of the use of marijuana

A 2018 Pew Research Center survey found that two-thirds of Americans say the use of marijuana should be legal. There is a steady increase in the public’s favor for legalizing marijuana use over the past decade. The percentage of adults who oppose legalization has dropped from 52% in 2010 to 32% in 2018. Combining both recreational and medical use, an overwhelming majority of American adults would approve of some form of legalization (91%), with 32% open to just medical use. 

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As with the history of other mood altering and addictive substances, such as alcohol and tobacco, those who wish to control such substances are branded as Puritans. Some who want to liberalize the use of marijuana may base their arguments on the presumption that adults should be free to be foolish, or if there is some slight harm to its use, it can be used in moderation by adults in the right place and at the right time. Others see its use as no different from how adults use tobacco and alcohol, which are legal products. 

The liberalization of marijuana is cycling through the three policy phases as that of tobacco control, but in reverse. The tobacco control movement went from a medical rationale to stop its use, to a socio-cultural label of unacceptance, to a final moral/ethical rationale to rid us of the commercialization of public health enemy number one. Conversely, the movement to normalize marijuana began with shredding the moniker of those partaking as having a moral weakness, to some level of social acceptability in use, to the substance having some medicinal value. The latter can be seen as the camel pushing its nose under the “normal behavior” tent.

Compassionate care vs. quality patient care

Questioning the therapeutic rationale for marijuana use to help ameliorate conditions of diseases such as cancer, PTSD, Alzheimer’s, and AIDS is understandably an uncomfortable public posture. However, given that we have been lectured by public officials the last few years to “follow the science” to mitigate public health and healthcare issues, it is fair to examine “the letter” of the rationale in these state acts that legalized medical use.

One author undertook a study to review state legislative initiatives to legalize medical marijuana to determine the nature and extent of how quality patient care is explicated in these state laws by reading the rationale statements used in these legislative actions. The author wanted to see how these initial acts explained quality patient care using its five recognized domains: is the act a) safe, b) effective, c) evidence-based, d) standard practice, and e) patient-centered?

Results of this descriptive study showed that:

• There is no attempt by the 33 legislatures to clearly state that medical marijuana use is safe. 
• While described in a number of ways, one consistent phrase used by these legislatures was the notion that medical marijuana “may be effective;” thus their voice, so to speak, is tentative about health enhancing efficacy of this substance. The legislatures displayed an understandable compassion for ill patients, but little confidence that medical marijuana is effective.
• Regarding the evidence-based use of medical marijuana and standard practice domains, these 33 states explicated a tacit type approval, saying “many” doctors have prescribed medical marijuana in other states and other states have passed such laws. Therefore, this health care practice is evidence enough for them to approve the use of cannabis in treatment for select conditions. 
• Additionally, a hallmark in understanding the validity of medical opinion on a standard practice is to cite a credible health authority. Several states simply used boilerplate language passed from one state to another. They rarely noted any medical group’s endorsement that using cannabis is quality treatment of patients and is good medical practice. 

Understandably, the patient-centered rationale was quite evident in many state laws ranging from using the words “compassionate care” in the title of the law to subsequent language that explains that the least we can do for patients who are suffering is to try to help them, even though the effectiveness is not overwhelmingly evident.

Health risks of marijuana use

While there have been a sundry of surveys on public opinion toward marijuana legalization at the national and state levels (medicinal or recreational), especially when bills are floated, what is the public’s understanding of the effects of marijuana use on health (risk or benefits)? Here are just a few of some highly regarded authorities’ comments.

• Marijuana remains classified by federal authorities as a Schedule I substance
• A 2017 report by the National Academies of Science, Engineering, and Medicine found several harmful effects of marijuana use.
• A 2018 statement by then-FDA Commissioner Dr. Scott Gottlieb states that “Research to demonstrate that marijuana or its components could be safe and effective in the treatment of medical disorders should be held to the same standard as other drug compounds.” 
• The National Institute of Health states that marijuana use has  short-term and long-term effects on the brain. Short-term effects include altered senses, altered sense of time, changes in mood, impaired body movement, difficulty with thinking and problem-solving, impaired memory, hallucinations, delusions, and psychosis. 
• A 2019 advisory by then-U.S. Surgeon General Dr. Jerome Adams warned adolescents and pregnant women about the deleterious effects of marijuana use on the developing brain.

Surprisingly, few healthcare and public health groups and leaders have anything to say about marijuana’s risk and elusive value. One potential scenario: the country’s next public health crisis. 

Health risk communication gap for our local readers of the city’s daily newspaper

Given that the health hazards of marijuana use have been tempered by the public and some healthcare researchers and providers, it makes sense that the public be provided relevant, accurate, robust, and timely health communications about the use of this substance. Furthermore, medical marijuana legalization in Pennsylvania, New Jersey, Delaware, and New York has occurred only since 2010. For recreational use it is recent for New York and New Jersey, and it looks likely to pass in Pennsylvania and Delaware.  
We analyzed articles printed in the Sunday “Health” section of The Philadelphia Inquirer from its inception (May 5, 2013) until the end of Oct. 2022 — an eight-year, five-month period — to determine the extent of coverage given to the medical or recreational use of cannabis and the nature of health risk or benefit communicated to readers via the printed articles (negative, positive, or neutral). Furthermore, an examination was made of the impressions (positive, negative, neutral) commentators gave when asked about the use of marijuana.

We found that only nineteen issues, from a total of the 444 published during this time (4.5%), had something to say about marijuana, and a paltry less than one-half of one percent of all articles published addressed this contemporary health issue. The good news could be that when stories were run, they were more than 60% negative on marijuana use. Given the dearth of stories run in this years-long review of a specific health section, there are many gaps in the health risks of marijuana use to our local readers, such as: 

• Drivers under the influence of marijuana present a clear danger to public safety. 
• The normalizing of marijuana will exacerbate the policing and judicial system which is already under attack in this country for being too vigilant in handling criminals. It will give more fodder for the enduring concern over police officers profiling those they stop. 
• As a mood-altering substance, marijuana use in the workplace enhances the level of risk to coworkers in many scenarios. 
• Coworkers and the public are at risk of bodily harm and death when a worker under the influence is tasked with using heavy equipment, technical instruments, and a range of apparatuses. 
• As noted above, although some commentary was featured pertaining to the potential medicinal benefits of medical marijuana, particularly in the field of pain management, such commentators failed to address how medical marijuana would comply with the highly recognized components of quality patient care, i.e. it is a) safe, b) effective, c) evidence-based, d) standard practice, and e) patient-centered.
• In the wake of the opioid epidemic, providers would be prudent to evaluate the potential addictive nature of marijuana. Articles gave the topic cursory treatment. 
• With so many questions left unanswered regarding the medicinal value of marijuana, could medical legalization lead to the phenomenon of pill mill doctors, who, through profit-driven motives, sign off on medical marijuana prescriptions despite having limited knowledge of treatment benefits or long-term side effects?
• Similar to the concern above, seeing that the list of conditions for medical marijuana continues to expand, it could be that eligibility becomes almost universal, e.g. what adult does not have some “anxiety” at some time and for some reason?

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Normalization of marijuana invites yet another battle of youth access to an addictive and hazardous substance

Even groups that support legalizing (really, normalizing) cannabis believe that minors (usually defined as under 21 years of age) should not have access to the substance. They argue that it should not be used until they become adults, in which case they can make informed decisions on its use. Controlling the access of marijuana, no doubt, is similar to the rationale, awareness, education, public policies, and strategies used in the long challenge of youth access to tobacco and alcohol. In looking at the epidemiology of youth-onset smoking and drinking, it should be of grave concern that marijuana use may likely follow the substance abuse model which begins with marketing, then easy access to youth, addiction, and continuing reinforcement with more marketing — often with infractions of the rules done with impunity.  

If any cannabis business has integrity, it will support and abide by any laws and regulations that restrict the marketing, advertising, and promotion of the substance and guard against any way youth gain access to the product, whether by direct sales or otherwise. While those supporting normalizing marijuana use ostensibly don’t want minors to use the substance, the history of tobacco and alcohol advertising and control is a cat-and-mouse game of regulation and compliance. Creative advertising teams behind tobacco companies were able to keep Americans smoking in the face of mounting medical reports that delineated the health hazards of tobacco. Whenever health groups or government entities proved “something was not right about the advertising,” tobacco companies successfully reformulated their focus. Parents and regulators are no match for Madison Avenue. The history of cigarette advertising demonstrates the power of advertising in creating the perception of a new human need. 

Supporters of legalizing marijuana assure critics that the commercialization of cannabis will be “controlled.” That’s odd! Why does something so harmless, victimless, peaceful, soothing, and generally misunderstood need to be controlled? As with most consumer products, the marketing minds are way ahead of us in telling us what we need, what we want, or what we must have.

For example, one medical marijuana dispensary in Pennsylvania is named “CURE” and claims “to support a proactive approach to using cannabis as a health management tool and help patients ‘Discover Their Cure Today.’” Similarly, another dispensary is called “Curaleaf.” How did we make the leap from a palliative remedy for those suffering to a cure? What medical evidence is there that cannabis cures a disease or condition? Another dispensary setting up in Philadelphia is called “Restore” and uses a tag line in print ads that it is “Dispensing Happiness” in your neighborhood. Other dispensaries are marketed as taking a “holistic” approach to your maladies and some are sporting a “health-spa look.” One Center City dispensary promotes the message “Sleep Well. Wake Well. Stay Well.” Entrepreneurs have opened shops to destigmatize the use of cannabis. Similar to book clubs, you can come in and relax, learn how to use the products, and discuss your experience in a “nonjudgmental environment.”

A review of all states’ marijuana marketing rules and regulations can be organized into six major areas:

• To whom the product is marketed
• The channel used for marketing 
• Where the product is marketed 
• The nature or the manner of marketing 
• Explicit wording 
• Sponsorship 

On the surface this looks swell, but as noted above, the history of trying to temper the marketing of products to youth — from cereal to video games to alcohol — is a continual battle. In a short amount of time, there will be strategies that essentially tell us that “when used as intended,” ingesting cannabis is society’s new elixir for a variety of conditions and moods. For example, in late 2019, after just a few years of vaping products targeted to youth, a few began to mix vaping with other street substances. This became deadly. Cannabis investors, sales reps, lobbyists and a growing list of apologists will claim that the substance should only be used by informed adults. As its use becomes normalized, we should be prepared for the recruitment of non-medical or recreational markets via some type of aggressive marketing. A PA Spotlight investigation found that “some Pennsylvania cannabis companies are using incomplete or misleading claims to promote marijuana as a treatment for opioid addiction, potentially putting patients’ lives at greater risk.”

As normalization of marijuana for expanding medicinal and recreational use continues to accelerate nationwide, it is reasonable to question why robust public health and healthcare communication campaigns are not evident when evidence for health risks and benefits of use is elusive.

Why is there scant healthcare and public health leadership concern for what portends to be a next public health crisis?

It is curious that no major public health or healthcare coalitions are forming to fight against the normalization of marijuana when the clarion call in public discourse lately is for public policy and programs to be “driven by the science.” Changing sociocultural attitudes toward marijuana does not obviate the need to see credible scientific evidence that the use of marijuana has a sundry of risks (acute, short term, and long term), and by normalizing pot could be inviting the next public health threat in the US. Why has marijuana been given a “get out of jail free” card? The proliferation of marijuana-friendly public policies and little pushback from health care professionals is stunning given that our country is burdened with enduring alcohol and tobacco abuse problems, the opioid overdose carnage, and the “mysterious” ills of teen vaping. 

The marijuana industry’s break happened with the confluence of changes in: socio-cultural norms, legislators’ race to be seen as the most liberal, attraction to the newest consumer cash cow that brings in state taxes, and the vicarious exemption to use cannabis for medicinal purposes. As normalization of marijuana for expanding medicinal and recreational use continues to accelerate nationwide, it is reasonable to question why robust public health and healthcare communication campaigns are not evident when evidence for health risks and benefits of use is elusive. Hanging in the balance is the potential for the next major public health problem in the United States.

Stephen F. Gambescia is professor of health services administration at Drexel University and co-editor of the book “The Healthcare Nonprofit: Keys to Effective Management.”

Thomas Morris is a Master of Public Health student in Drexel University’s Dornsife School of Public Health.