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California Cannabis Markets-Why Industry-Friendly Regulation Is Not Good Public Health.

The US legal cannabis market is growing rapidly, and California is leading the way. It has the largest legal cannabis market in the world, and the industry is expected to continue expanding. For better or for worse, many states have adopted practices similar to those in California; across the US, California has become a bellwether. Because of its geographic, economic, and cultural diversity, California is a laboratory for the vast natural experiment studying how state and local policies are associated with cannabis use and related harms and is able to generate valuable lessons for decision makers in other jurisdictions. On the positive side, arrests for cannabis possession offenses, a conveyor belt to widespread incarceration, have continued to decline.1 A system for legal access has been created, which has also created enormous tax revenue and new jobs for Californians.1,2 Unfortunately, however, California has failed to take seriously the public health concerns about cannabis, particularly as they pertain to vulnerable populations. Emblematic of the misalignment of state priorities with public health objectives, the California State Fair will hold its first-ever cannabis competition in July 2022. Prizes will be awarded for the cannabis flower with the highest concentration of the cannabinoids tetrahydrocannabinol (THC) and cannabidiol. Cannabis products with high concentrations of THC, cannabis's main psychoactive ingredient, are associated with psychosis and psychotic symptoms, dependency, and other health problems.3 The prize for highest THC content epitomizes the lack of governmental recognition that this cannabis characteristic drives cannabis use disorder and its negative health consequences. Meanwhile, rates of cannabis use among California’s most vulnerable populations continue to increase. Research has documented worrisome growth in cannabis use among pregnant individuals in Northern California since 2009, with relative rates of daily use increasing most rapidly and the prevalence more than doubling by 2017,4 accompanying large increases in prevalence and frequency of use among adults in general. Cannabis exposures reported to the California Poison Control System tripled between 2010 and 2020, particularly among children who ingested candies and gummies.5 And though research has so far suggested little effect of legalization on adolescent prevalence rates, studies have also shown growing persistence of youth use and progression to higher-potency products.6,7 Although cannabis has valuable therapeutic uses for certain conditions in adults and even for rare seizure disorders in children, public health implications associated with wide availability, particularly of high-potency products, need to be taken seriously when developing regulations for recreational markets. Frequent cannabis use during adolescence is associated with risk of cannabis addiction; impairments in attention, memory, and learning; and mental health issues.3 Cannabis use during pregnancy is associated with low offspring birth weight, and recent research from the National Institutes of Health’s landmark Adolescent Brain Cognitive Development study found that exposure to cannabis in utero was associated with neurodevelopmental problems in 9-year-old children.8 Highlighting growing concerns related to the effects of cannabis on the developing brain, the US Surgeon General issued an advisory in 2019 recommending that adolescents and pregnant individuals abstain from cannabis use, noting in particular the harms associated with higher-potency THC products. Author affiliations and article information are listed at the end of this article.