Introduction

There is much disagreement in society today into what type of regulations should be applied to the plant Cannabis sativa, also known as marijuana.  Many individuals and groups involved with this discussion are looking to the other legalized substances of tobacco and alcohol as a reason for both pro-legalization and anti-legalization arguments.  Although marijuana can be ingested and not just inhaled to produce the desired effect, tobacco will be the main comparison substance for this discussion as both products most common form of intake is inhalation through the burning of the substance.  Marijuana and tobacco are commonly associated as co-use substances. In a report in 2012, almost three-fourths of those who reported marijuana use also reported cigarette use within the same month (Peters et al., 2017). Although the focus of this study is on legalization issues for marijuana use and comparative consequences of tobacco cigarette use, alcohol will be touched on briefly as prohibition in the 1920-1930 gives some guidance as to the effectiveness or ineffectiveness of legalization of an intoxicating substance.

What is Marijuana?    

Marijuana is a plant in the Cannabis genus that has intoxicating elements that, through various means of ingestion or inhalation, can produce euphoric-type pain relief with varying degrees of consciousness and even a hypnotic state in some users.  All parts of the plant tend to have these properties except the stalk. The main substance that induces the altered psychological effect is the chemical Tetrahydrocannabinol (THC) (Rich, 2017). Marijuana became quite popular in the early 1970’s as a recreational drug for younger citizens, and in 1972 it was estimated that 25 million Americans had tried marijuana.  It is also interesting to note that a survey was performed in 1977 reporting that only a slightly smaller number of young adults have tried marijuana as opposed to tobacco (Rich, 2017). Because of marijuana’s success among the younger generation and it subsequent illegality, marijuana has developed various names and phrases associated with its use, mainly as an attempt to hide it from adults and authorities.  Those names include, but are certainly not limited to, MJ, Mary Jane, Weed, Grass, 4:20, Hashish, Hash, Hemp, Joint, Reefer, and Pot.

Effects of Marijuana Use

One of the biggest concerns in the legislation battle of marijuana for recreational use is the propensity for younger people to use the drug.  According to a recent survey in 2014, it was discovered that an astonishing 35 percent of high school seniors nationwide reported using marijuana in the past year (Miech et al., 2015).  It is the fear of many on the anti-legalization side of the argument that legalizing marijuana will only give credibility for the youth to continue its use or for new users to try the drug.  As has been seen in the legalization of alcohol, far too many minors are still able to obtain it rather readily.

Kathleen E. Feeney and Kyle M. Kampman (2016) from the University of Pennsylvania Perelman School of Medicine have documented a list of adverse effects from most frequent to least frequent from the continued use of marijuana as adapted in Table 1. 

There seems to be no debate in the literature as to the legitimacy of this list in regard to the negative consequences of the continued use of marijuana.  The combined use of marijuana and tobacco has been documented in several resources illustrating that co-use exacerbates the listed adverse effects and the addictive potential tends to increase the difficulty of stopping either one separately (Agrawal, Budney, & Lynskey, 2012).

The argument holds that continued and excessive use of legalized alcohol could produce the same list of undesirable outcomes.  It was the fear of these very consequences from the use of alcohol that produced the federal policy that has since been known as Prohibition from 1920 to 1933.  The action of limiting the production and acquisition of alcohol was intended to protect the public from its harmful effects but instead created organized crime operations and an actual increase in the consumption of alcohol.  In some cases, more toxic and even dangerous products of alcohol were produced due to Prohibition (Rich, 2017).

Each item on the list in Table 1 can be debated and argued but there appears to be some of the effects that may become more harmful than others.  Impairment of driving ability has yet to be really determined or experienced to the degree that alcohol consumption has presented to driving impairment.  Just because a substance is legal does not give an individual the right to operate a machine or vehicle that can become, if used inappropriately or carelessly, a deadly weapon.  With more individuals using marijuana, if such becomes legal, what will be the limit of usage for operating a vehicle and how will that be determined? This and many other questions must be answered ethically and effectively prior to any legalization efforts and will explored more fully in the discussion section of this paper.   

Another legitimate concern is item number 9 in Table 1; increased chances for using other illicit drugs.  Hall (2006) reports that marijuana is often referred to as the “gateway drug.” There is evidence in the literature that individuals who have become addicted to cocaine, methamphetamines, and heroine began their drug journey with marijuana, however, the propensity for such in not within the scope of this report.  It is of interest to note that in the 70’s and 80’s, the gateway drug to marijuana was tobacco, but since 2005 this trend has changed to marijuana being the gateway to cigarettes (Barry, Hiilamo, & Glantz, 2014).

Arguments for and against legalization of marijuana seem never ending with data driven “facts” by both sides.  However, a look back into the history, development, advertisement, sale, and legalization of tobacco with its evident ill effects on public health and subsequent litigation, may give some insight and guidance into in an appropriate course of action.  In 1984, Leonard Zahn, who was an assigned public relations specialist from the Council for Tobacco Research (CTR) attended a meeting of the American Lung Association (ALA). In his memorandum of the meeting, Zahn reports, “There’s no conclusive evidence as yet that marijuana smoking causes chronic, debilitating lung disease in humans.  With cigarette smoking, these diseases appear only after 10-20 years; most marijuana smokers in the US haven’t yet smoked that long” (Barry, Hiilamo, & Glantz, 2014). Although marijuana use has been practiced for many years, commercialization and marketing of its use on a large scale with large numbers of potential new users, with its addictive qualities, can very well create a public health crisis similar to the one faced throughout the world with tobacco.  As to what that public health crisis would be; that is up to much speculation. But uncontrolled, illicit, inappropriate, and/or excessive use of marijuana and how or whether it is legalized, will determine much of what that health crisis becomes. Thus, the question must be asked, “If marijuana is legalized and commercialized, how long will it be before we need an anti-marijuana campaign?”

What is Tobacco?

According to the Health and Human Services website, Betobaccofree.gov, tobacco is a plant grown throughout the world and is currently grown in 16 of the 50 states in the US.  Companies that produce cigarettes take the dried tobacco leaves and combined them with different compounds for increases in taste, smoke, flavor, and burn quality. The key stimulating substance that is responsible for addiction is nicotine.  It is reported that within 10 seconds of nicotine entering a human being, the brain is affected with a surge of adrenaline, among other neurotransmitters creating a feeling of pleasure and energy (HHS, 2017). Tobacco has become a multi-billion dollar a year business.  Along with the feeling of pleasure, nicotine also increases heart rate, blood pressure, and constricts blood vessels as a stimulant (Brown, 2013).

Effects of Tobacco Use

Nicotine comes in many forms: snuff, chew, cigarettes, cigars, pipes, to e-cigarettes, and now many readily available new sub-products.  The money generated by the selling of tobacco containing products is a major driver of new innovations of nicotine uptake. Within the past few decades, lung cancer rates have been greatly and directly attributed to cigarette use.  According to Health and Human Services in 2001, Tobacco was the leading cause of morbidity and mortality among ailments that can be considered preventable diseases (Berg et al., 2015). The Centers for Disease Control report that in 2005, tobacco accounted for 438,000 deaths per year (CDC, 2005).  These statistics are considered part of the “winnable battles” within the public health realm that can be obtained, however; fatalities from controlled substances including alcohol and tobacco may be greatly increased should marijuana become another legal but potentially lethal substance.

Ethics of Legalizing Recreational Marijuana Use

According to Bernheim et al. (2015) several ethical issues must be considered when creating public health policy and/or laws.  The following questions are proposed to guide the decision-making process:

• What public health problems, needs, concerns are at issue?
• What are appropriate public health goals in this context?
• What is the source and scope of legal authority, if any, and which laws and regulations are relevant?
• What are the relevant norms and claims of stakeholders in the situation and how strong or weighty are they?
• Are there relevant precedent legal and ethical cases?
• Which features of the social-cultural-historical context are relevant?
• Do professional codes of ethics provide guidance? (p.13)

Additional considerations for the legalization of marijuana must include moral issues as also outlined in Bernheim et al. (2015).  These include:

1. Producing benefits
2. Avoiding, preventing, and removing harms
3. Producing the maximal balance of benefits over other costs (utility)
4. Distributing burdens and benefits fairly (distributive justice)
5. Respecting autonomous choices
6. Ensuring public participation (procedural justice)
7. Protecting privacy and confidentiality
8. Disclosing information and speaking truthfully and honestly (transparency)
9. Building and maintaining trust (p.21)

Discussion

Although a comparison of the legalization of tobacco to marijuana is proposed during this work, it is of utmost importance to note that in a report by Barry, Hiilamo, & Glantz (2014) it is suggested that there is a very clear difference between drugs like nicotine that act on stimulating levels of brain activity versus drugs that act on the state of consciousness such as marijuana.  Therefore, marijuana and tobacco are not analogous and treating them as such legally can be a great peril to public health.

Public opinion of legalizing marijuana for recreational use has increased over the recent years and such represents a moral issue of procedural justice.  The public attitudes, norms, and wishes must be included in the discussion. One study, in particular, notes that US policy and attitudes toward marijuana are swiftly changing with the evidence of acceptance rates of marijuana by the public.  In 1969, according to the Pew Research Center (2015), 12 percent of the population in the United States approved of marijuana use; contrast that to 2016 in which the approval rate was reported at 54 percent (Quinnipiac University, 2016). This same study reports that 28 states have legalized marijuana for medical use and eight states and the District of Columbia have legalized marijuana for recreational use for adults (McGinty et al., 2017).

One of Public Health’s overreaching goals is to protect the public from unhealthy practices.  Although there are many of which to choose from, legalizing a practice due to popular opinion rather than sound scientific evidence of safety can greatly compromise that goal.  McGinty et al. (2017) makes a sobering statement, “Americans are being asked to decide whether they support or oppose legalization policies in the absence of clear scientific evidence on their public health consequences” (p. 80). The report also suggests that the best research thus far in legalization of marijuana and its possible adverse effects on public health could lead to increased usage which in turn could delay or decrease brain development, create a decrease in education practices and learning, and increase injury from careless acts or intoxicated driving (McGinty, 2017).  Other unknown factors that would influence public health upon the legalization of marijuana can be plentiful and unpredictable. Being truthful and honest with available information regarding recreational use of marijuana must be available to the public for an honest debate and consideration. Transparency of benefits and risks must be honestly discussed. A complete and unbiased release of available information will also serve to establish trust with the public and allow the public to be informed from all sides of the issue. With marijuana use mostly being illicit, any “real” human continuous exposures and research from different users within different demographics, especially youth, are severely lacking.  Research should be performed from an unbiased, non-stakeholder if possible.

It appears that social acceptance has been the leading driver to the legalization of marijuana.  Health behavior decision making can be influenced from sharing experiences with marijuana usage on social media web sites.  The internet can be a great influencer of public opinion regarding the safety of the drug (Roditis et al., 2016). Often, positive imagery and experiences are relayed on social platforms regarding the use of marijuana.  Such has become part of human culture and social acceptability and ignorance of associated risks of marijuana use can quickly be propagated by the internet. This is a huge challenge for the safe and regulated use of marijuana legislation.  Alcohol and tobacco went through magazine, movie, billboard, and television commercial influences, but nowhere close to the influence of the social media storms of today’s constant electronic medium - the smart phone. With no real monitor of content or editor of fact on the World Wide Web, misinformation and possible harmful advice can reach more people more quickly than cigarette campaigns or beer commercials could have ever dreamed possible.  In today’s world, it appears that more influence can be exerted by an electronic post than by any postal coupon or television advertisement.

Correct usage guidelines and warnings must be put into place far before any legislation is drafted.  Warning labels and efforts to educate the public on the dangers of cigarette and tobacco usage have been somewhat effective but proven to be far too late to negate many of the adverse effects.  Social attitudes, potential costs, and ethics of advertisement and usage must be studied in depth to limit a repeat of the litigation of the tobacco companies marketing practices and misinformation campaigns.  

The public’s perception of harm caused by marijuana use has been investigated with some disturbing results.  One study from Pedersen et al. (2016) examined the interpreted perceptions of harm from substance abuse in the United Kingdom and found that alcohol was ranked the most dangerous while marijuana was ranked the least dangerous.  This type of perception should be alarming to anyone who is serious about the debate for legalizing marijuana. With marijuana’s seemingly casual upbringing and relationship to the hippie and peace movement of the 1960’s and 70’s, the concern arises that many users of the drug, should it become legal, will see it as simply an after-work evening drink or a cigarette break to relieve the stress of the day.  However, it should be stressed again that marijuana has a sedative effect on the consciousness of the brain and much like alcohol, it can alter perceptions of reality if overused or misused. To date, from casual observation, it is apparent that alcohol consumption at work is not tolerated in the United States and legalization of marijuana would have to follow that restriction rather than the acceptable roll of cigarette smoking as an approved activity if performed in the designated smoking areas of work and public places.

Proposed Course of Action

Distributive justice must be considered.   The “who” and “why” of those who will share a disproportionate burden must be identified.  Will the legalization of marijuana cause an undue burden upon lower socioeconomic classes that have less resources to accurate information?  Will lower socioeconomic groups have a voice in the distribution of the drug as to the who and where, or will those with more resources and power control the distribution and market it to a class of their choosing?  As with the lack of transparency and honesty in smoking campaigns, will the youth be unduly targeted and even exploited? Will the benefit of increased tax revenue for the sale of the drug be distributed equitably? These are questions that must be addressed and answered satisfactorily for all stakeholders which include, but certainly not limited to, the public at large, businesses (both those that will be selling the product and those that will not), locations and methods of distributions and proximity of schools, producers of the products, youth programs and church organization, hospitals and law enforcement, and families who support or reject recreational marijuana use.  These stakeholders must be consulted and considered, therefore, multiple entities and regulations must be put into place prior to legalization of marijuana. Much like the development of a new pharmaceutical, quality, quantity, effective dose, overdose limits, and human trials should be performed. Regulation of potency must be addressed and measured against body mass, age, and possibly gender or ethnicity sensitivity differences. Uptake of the active ingredient THC must be established with a half-life determined and route of elimination thoroughly understood and defined. Risks of concomitant use must be established with other drugs, and warnings put in place for those who desire to use marijuana who have compromised or ill health.  With the current routes of administration of marijuana, namely via ingestion in combination with another substance and/or inhalation, standardization of an effect and appropriate dose may be difficult to establish and even more problematic to enforce.

In additions, overdose treatment must be established, and training offered for those in the health profession who may come across the misuse of the substance.  Brooks et al., (2017) asks the question if providers of health care are ready to conquer the adverse outcomes that may occur with marijuana use and concludes that most providers are uncomfortable and inconsistent in addressing health related risks, benefits, and possible outcomes or side effects from marijuana use amongst their patients or clients.  A study by Ghosh et al. (2017) reflects upon some of the issues that presented in Colorado upon the legalization of recreational marijuana use, the most notable with regards to accidental ingestion of marijuana. The report reveals that although the passage of legislation occurred in November of 2012, sales of the substance did not start until 2014. Ghosh et al. (2017) reports a corresponding 63 percent increase in calls for that first year to the Colorado poison call center regarding unintentional exposure of marijuana to children ages 0 to 8.  

Lessons learned from Alcohol and Tobacco

Regulating recreational marijuana use can be accomplished if certain lessons are taken into consideration that society has learned from the alcohol and tobacco successes and failures.  Emotional and societal pressures must be overcome and replaced with thoughtful, purposeful, and scientific evidence based research. Logic, public health inputs, and ethics of transparency, distributive and procedural justice, along with utility must shape the legislation if marijuana for recreational use is to be adopted as a safe and alternative form of self-medicated therapy or social interactive substance.  Marketing, supply, demand, price, quality, consistency, training, restrictions, and evidence for harm, to name of few aspects of recreational marijuana use, must all be accounted for and addressed with reasonable outcomes prior to legislation. Pacula et al. (2014) recommends some starting points for addressing some of these issues prior to any legalization:

1. Minimizing the access and availability of the drug, especially for minors.
2. Minimize driving under the influence of the drug
3. Minimize the dependence and addictiveness of the drug
4. Minimize edibles of the drug that have uncertain potency and other additives
5. Minimize the use of the drug in combination with other substances such as alcohol

Elimination of these five factors would be more desirable than just minimization, but most likely such action is unreasonable and unrealistic.  Serious consideration of doing the least harm to the public must be paramount in the discussion. A level of acceptable risk must be established and discussed as an ethical element in the process.  Public input must be available and considered with risks clearly identified to the public.

Conclusion: Are we doomed to repeat ourselves?

Deaths will happen, people will suffer loss, and abuse will occur with legalization of recreational marijuana use.  On the converse side, criminalization rates for small amounts of possession will decrease, the industry will be regulated, and control will be put in place to restrict use.  The rules surrounding alcohol purchasing and consumption can certainly serve as a guide. As with alcohol, the public needs to decide how much risk they are willing to tolerate to make marijuana legal.  Using alcohol as a historical perspective, driving under the influence is bound to happen. Crime rates may increase and drop out of high schools and universitys may occur. Addiction and abuse are a real problem.  The long-term effects of legalization of marijuana are impossible to completely predict, however, the past can be a good indicator of future events. One study by Barry, Hiilamo, & Glantz (2014) believes that current tobacco companies are primed and set to take full advantage of the law, should legislation pass to legalize marijuana.  Current tobacco companies already have the mechanisms in place to conquer the market with previous established practices of tobacco manufacturing and sales. This study reveals that due to access to the 80 million pages of internal documents from major tobacco manufacturer companies release from litigation, three multinational companies have recorded documentation proposing the production of cigarettes containing marijuana since the 1970’s.  How and when those companies that mass produce marijuana cigarettes and products will become liable for the ails of marijuana usage on public health will be interesting to observe. How much risk is too much and how often will those risk factors present themselves? These questions must be answered and presented to all stakeholders. Thus, the additional question arises, if marijuana becomes a legal substance available commercially to the public, will the public eventually reach an outcry and pursue litigation in a feeble attempt to stop the epidemic of marijuana similar to that of tobacco cigarettes?

References 

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Master’s in Public Health

Salt Lake City, Utah

Ronald is the Dental Director of the Fourth Street Homeless Clinic here in Salt Lake, and became involved in this research because he gets asked about the safety of dental amalgam with mercury on a constant daily basis. Ronald found a lot of misinformation about dental mercury in fillings, and thus conducted his own research. For his second paper, he became interested in the topic through an ethics class at Westminster. It is a very politically charged topic and so it was challenging for him to find unbiased information.