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Hall  W, Lynskey  M.  Evaluating the public health impacts of legalizing recreational cannabis use in the United States.   Addiction. 2016;111(10):1764-1773. doi:10.1111/add.13428 PubMedGoogle ScholarCrossref
Lake  S, Kerr  T, Werb  D,  et al.  Guidelines for public health and safety metrics to evaluate the potential harms and benefits of cannabis regulation in Canada.   Drug Alcohol Rev. 2019;38(6):606-621. doi:10.1111/dar.12971 PubMedGoogle ScholarCrossref
Department of Health and Human Services. Part 1: overview information. PA-17-132: Public policy effects on alcohol-, marijuana-, and other substance-related behaviors and outcomes (R21). January 25, 2017. Accessed July 1, 2020. https://grants.nih.gov/grants/guide/pa-files/pa-17-132.html
Vos  T, Lim  SS, Abbafati  C,  et al; GBD 2019 Diseases and Injuries Collaborators.  Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.   Lancet. 2020;396(10258):1204-1222. doi:10.1016/S0140-6736(20)30925-9 PubMedGoogle ScholarCrossref
Mair  C, Freisthler  B, Ponicki  WR, Gaidus  A.  The impacts of marijuana dispensary density and neighborhood ecology on marijuana abuse and dependence.   Drug Alcohol Depend. 2015;154:111-116. doi:10.1016/j.drugalcdep.2015.06.019 PubMedGoogle ScholarCrossref
Freisthler  B, Gruenewald  PJ.  Examining the relationship between the physical availability of medical marijuana and marijuana use across fifty California cities.   Drug Alcohol Depend. 2014;143:244-250. doi:10.1016/j.drugalcdep.2014.07.036 PubMedGoogle ScholarCrossref
Cerdá  M, Mauro  C, Hamilton  A,  et al.  Association between recreational marijuana legalization in the United States and changes in marijuana use and cannabis use disorder from 2008 to 2016.   JAMA Psychiatry. 2020;77(2):165-171. doi:10.1001/jamapsychiatry.2019.3254 PubMedGoogle ScholarCrossref
Cerdá  M, Wall  M, Feng  T,  et al.  Association of state recreational marijuana laws with adolescent marijuana use.   JAMA Pediatr. 2017;171(2):142-149. doi:10.1001/jamapediatrics.2016.3624 PubMedGoogle ScholarCrossref
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 Psychiatry. 2017;74(6):579-588. doi:10.1001/jamapsychiatry.2017.0724 PubMedGoogle ScholarCrossref
National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: Current State of the Evidence and Recommendations for Research. The National Academies Press; 2017.
Boles  SM, Miotto  K.  Substance abuse and violence: a review of the literature.   Aggression Violent Behav. 2003;8(2):155-174. doi:10.1016/S1359-1789(01)00057-XGoogle ScholarCrossref
Mulvey  EP, Odgers  C, Skeem  J, Gardner  W, Schubert  C, Lidz  C.  Substance use and community violence: a test of the relation at the daily level.   J Consult Clin Psychol. 2006;74(4):743-754. doi:10.1037/0022-006X.74.4.743 PubMedGoogle ScholarCrossref
Cafferky  BM, Mendez  M, Anderson  JR, Stith  SM.  Substance use and intimate partner violence: a meta-analytic review.   Psychol Violence. 2018;8(1):110-131. doi:10.1037/vio0000074Google ScholarCrossref
Maniglio  R.  Association between peer victimization in adolescence and cannabis use: a systematic review.   Aggression Violent Behav. 2015;25:252-258. doi:10.1016/j.avb.2015.09.002Google ScholarCrossref
Dellazizzo  L, Potvin  S, Athanassiou  M, Dumais  A.  Violence and cannabis use: a focused review of a forgotten aspect in the era of liberalizing cannabis.   Front Psychiatry. 2020;11:567887. doi:10.3389/fpsyt.2020.567887 PubMedGoogle Scholar
Smart  R, Caulkins  JP, Kilmer  B, Davenport  S, Midgette  G.  Variation in cannabis potency and prices in a newly legal market: evidence from 30 million cannabis sales in Washington state.   Addiction. 2017;112(12):2167-2177. doi:10.1111/add.13886 PubMedGoogle ScholarCrossref
Hasin  DS.  US epidemiology of cannabis use and associated problems.   Neuropsychopharmacology. 2018;43(1):195-212. doi:10.1038/npp.2017.198 PubMedGoogle ScholarCrossref
Di Forti  M, Quattrone  D, Freeman  TP,  et al; EU-GEI WP2 Group.  The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study.   Lancet Psychiatry. 2019;6(5):427-436. doi:10.1016/S2215-0366(19)30048-3 PubMedGoogle ScholarCrossref
Contreras  C.  A block-level analysis of medical marijuana dispensaries and crime in the city of Los Angeles.   Justice Q. 2017;34(6):1069-1095. doi:10.1080/07418825.2016.1270346Google ScholarCrossref
Hughes  LA, Schaible  LM, Jimmerson  K.  Marijuana dispensaries and neighborhood crime and disorder in Denver, Colorado.   Justice Q. 2020;37(3):461-485. doi:10.1080/07418825.2019.1567807Google ScholarCrossref
Caulkins  JP, Kilmer  B, Kleiman  MAR.  Marijuana Legalization: What Everyone Needs to Know. 2nd ed. Oxford University Press; 2016. doi:10.1093/wentk/9780190262419.001.0001
Chang  T, Jacobson  M.  Going to pot? the impact of dispensary closures on crime.   J Urban Econ. 2017;100:120-136. doi:10.1016/j.jue.2017.04.001 PubMedGoogle ScholarCrossref
Anderson  DM, Rees  DI, Sabia  JJ.  Medical marijuana laws and suicides by gender and age.   Am J Public Health. 2014;104(12):2369-2376. doi:10.2105/AJPH.2013.301612 PubMedGoogle ScholarCrossref
Freisthler  B, Ponicki  WR, Gaidus  A, Gruenewald  PJ.  A micro-temporal geospatial analysis of medical marijuana dispensaries and crime in Long Beach, California.   Addiction. 2016;111(6):1027-1035. doi:10.1111/add.13301 PubMedGoogle ScholarCrossref
Grucza  RA, Hur  M, Agrawal  A,  et al.  A reexamination of medical marijuana policies in relation to suicide risk.   Drug Alcohol Depend. 2015;152:68-72. doi:10.1016/j.drugalcdep.2015.04.014 PubMedGoogle ScholarCrossref
Freisthler  B, Gaidus  A, Tam  C, Ponicki  WR, Gruenewald  PJ.  From medical to recreational marijuana sales: marijuana outlets and crime in an era of changing marijuana legislation.   J Prim Prev. 2017;38(3):249-263. doi:10.1007/s10935-017-0472-9 PubMedGoogle ScholarCrossref
Rylander  M, Valdez  C, Nussbaum  AM.  Does the legalization of medical marijuana increase completed suicide?   Am J Drug Alcohol Abuse. 2014;40(4):269-273. doi:10.3109/00952990.2014.910520 PubMedGoogle ScholarCrossref
Bartos  BJ, Kubrin  CE, Newark  C, McCleary  R.  Medical marijuana laws and suicide.   Arch Suicide Res. 2020;24(2):204-217. doi:10.1080/13811118.2019.1612803 PubMedGoogle ScholarCrossref
Chu  YWL, Townsend  W.  Joint culpability: the effects of medical marijuana laws on crime.   J Econ Behavior Org. 2019;159:502-525. doi:10.1016/j.jebo.2018.07.003Google ScholarCrossref
Shepard  EM, Blackley  PR.  Medical marijuana and crime: further evidence from the western states.   J Drug Issues. 2016;46(2):122-134. doi:10.1177/0022042615623983Google ScholarCrossref
Morris  RG, TenEyck  M, Barnes  JC, Kovandzic  TV.  The effect of medical marijuana laws on crime: evidence from state panel data, 1990-2006.   PLoS One. 2014;9(3):e92816. doi:10.1371/journal.pone.0092816 PubMedGoogle Scholar
Dragone  D, Prarolo  G, Vanin  P, Zanella  G.  Crime and the legalization of recreational marijuana.   J Econ Behavior Org. 2019;159:488-501. doi:10.1016/j.jebo.2018.02.005Google ScholarCrossref
Wu  G, Boateng  FD, Lang  X.  The spillover effect of recreational marijuana legalization on crime: evidence from neighboring states of Colorado and Washington State.   J Drug Issues. 2020;50(4):392-409. doi:10.1177/0022042620921359Google Scholar
Lu  R, Willits  D, Stohr  MK,  et al.  The cannabis effect on crime: time-series analysis of crime in Colorado and Washington State.   Justice Q. Published online October 8, 2019. https://doi.org/10.1080/07418825.2019.1666903Google Scholar
Pacula  RL, Powell  D, Heaton  P, Sevigny  EL.  Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details.   J Policy Anal Manage. 2015;34(1):7-31. doi:10.1002/pam.21804 PubMedGoogle ScholarCrossref
Chapman  SA, Spetz  J, Lin  J, Chan  K, Schmidt  LA.  Capturing heterogeneity in medical marijuana policies: a taxonomy of regulatory regimes across the United States.   Subst Use Misuse. 2016;51(9):1174-1184. doi:10.3109/10826084.2016.1160932 PubMedGoogle ScholarCrossref
Murray  RM, Hall  W.  Will legalization and commercialization of cannabis use increase the incidence and prevalence of psychosis?   JAMA Psychiatry. 2020;77(8):777-778. doi:10.1001/jamapsychiatry.2020.0339 PubMedGoogle ScholarCrossref
Shi  Y, Liang  D.  The association between recreational cannabis commercialization and cannabis exposures reported to the US National Poison Data System.   Addiction. 2020;115(10):1890-1899. doi:10.1111/add.15019 PubMedGoogle ScholarCrossref
Angrist  JD, Pischke  JS.  Mostly Harmless Econometrics: An Empiricist’s Companion. Princeton University Press; 2008. doi:10.2307/j.ctvcm4j72
Lin  TC, Lin  R.  Domestic violence and marijuana: evidence from retail marijuana law.  Published January 15, 2020. Accessed July 1, 2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3509989 doi:10.2139/ssrn.3509989
Gunaseelan  V, Kenney  B, Lee  JSJ, Hu  HM.  Databases for surgical health services research: Clinformatics Data Mart.   Surgery. 2019;165(4):669-671. doi:10.1016/j.surg.2018.02.002 PubMedGoogle ScholarCrossref
Lipska  KJ, Ross  JS, Van Houten  HK, Beran  D, Yudkin  JS, Shah  ND.  Use and out-of-pocket costs of insulin for type 2 diabetes mellitus from 2000 through 2010.   JAMA. 2014;311(22):2331-2333. doi:10.1001/jama.2014.6316 PubMedGoogle ScholarCrossref
Kiang  MV, Humphreys  K, Cullen  MR, Basu  S.  Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study.   BMJ. 2020;368:l6968. doi:10.1136/bmj.l6968 PubMedGoogle ScholarCrossref
Li  G, Fife  D, Wang  G,  et al.  All-cause mortality in patients with treatment-resistant depression: a cohort study in the US population.   Ann Gen Psychiatry. 2019;18(1):23. doi:10.1186/s12991-019-0248-0 PubMedGoogle ScholarCrossref
Burn  E, Weaver  J, Morales  D,  et al.  Opioid use, postoperative complications, and implant survival after unicompartmental versus total knee replacement: a population-based network study.   Lancet Rheumatol. 2019;1(4):e229-e236. doi:10.1016/S2665-9913(19)30075-XGoogle ScholarCrossref
Alcohol Policy Information System. Recreational use of cannabis: volume 1: data on a specific date. Accessed December 4, 2019. https://alcoholpolicy.niaaa.nih.gov/cannabis-policy-topics/recreational-use-of-cannabis-volume-1/104
Alcohol Policy Information System. Recreational use of cannabis: volume 2: data on a specific date. Accessed December 4, 2019. https://alcoholpolicy.niaaa.nih.gov/cannabis-policy-topics/recreational-use-of-cannabis-volume-2/105
Williams  J, Pacula  RL, Smart  R.  De Facto or De Jure? Ethnic Differences in Quit Responses to Legal Protections of Medical Marijuana Dispensaries. National Bureau of Economic Research; 2019. Working paper 25555. doi:10.3386/w25555
Powell  D, Pacula  RL, Jacobson  M.  Do medical marijuana laws reduce addictions and deaths related to pain killers?   J Health Econ. 2018;58:29-42. doi:10.1016/j.jhealeco.2017.12.007 PubMedGoogle ScholarCrossref
Blanchette  JG, Lira  MC, Heeren  TC, Naimi  TS.  Alcohol policies in US states, 1999-2018.   J Stud Alcohol Drugs. 2020;81(1):58-67. doi:10.15288/jsad.2020.81.58 PubMedGoogle ScholarCrossref
National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WISQARS injury data. Updated July 1, 2020. Accessed July 1, 2020. https://www.cdc.gov/injury/wisqars
Hemenway  D, Kennedy  BP, Kawachi  I, Putnam  RD.  Firearm prevalence and social capital.   Ann Epidemiol. 2001;11(7):484-490. doi:10.1016/S1047-2797(01)00235-6 PubMedGoogle ScholarCrossref
Siegel  M, Ross  CS, King  C  III.  A new proxy measure for state-level gun ownership in studies of firearm injury prevention.   Inj Prev. 2014;20(3):204-207. doi:10.1136/injuryprev-2013-040853 PubMedGoogle ScholarCrossref
Caulkins  JP, Kilmer  B, Kleiman  MAR,  et al. Considering marijuana legalization: insights for Vermont and other jurisdictions. Published January 16, 2015. Accessed January 13, 2021. https://www.rand.org/pubs/research_reports/RR864.html
Dellazizzo  L, Potvin  S, Dou  BY,  et al.  Association between the use of cannabis and physical violence in youths: a meta-analytical investigation.   Am J Psychiatry. 2020;177(7):619-626. doi:10.1176/appi.ajp.2020.19101008 PubMedGoogle ScholarCrossref
Babor  T, Caetano  R, Casswell  S,  et al.  Alcohol: No Ordinary Commodity: Research and Public Policy. Oxford University Press; 2003.
Tomlinson  MF, Brown  M, Hoaken  PNS.  Recreational drug use and human aggressive behavior: a comprehensive review since 2003.   Aggression Violent Behav. 2016;27:9-29. doi:10.1016/j.avb.2016.02.004Google ScholarCrossref
Freisthler  B, Gruenewald  PJ, Wolf  JP.  Examining the relationship between marijuana use, medical marijuana dispensaries, and abusive and neglectful parenting.   Child Abuse Negl. 2015;48:170-178. doi:10.1016/j.chiabu.2015.07.008 PubMedGoogle ScholarCrossref
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. HHS Publication No. PEP19-5068, NSDUH Series H-54. Published August 2019. Accessed September 24, 2020. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
Mauro  CM, Newswanger  P, Santaella-Tenorio  J, Mauro  PM, Carliner  H, Martins  SS.  Impact of medical marijuana laws on state-level marijuana use by age and gender, 2004-2013.   Prev Sci. 2019;20(2):205-214. doi:10.1007/s11121-017-0848-3 PubMedGoogle ScholarCrossref
Zammit  S, Allebeck  P, Andreasson  S, Lundberg  I, Lewis  G.  Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study.   BMJ. 2002;325(7374):1199. doi:10.1136/bmj.325.7374.1199 PubMedGoogle ScholarCrossref
Annest  JL, Fingerhut  LA, Gallagher  SS,  et al; Centers for Disease Control and Prevention (CDC).  Strategies to improve external cause-of-injury coding in state-based hospital discharge and emergency department data systems: recommendations of the CDC Workgroup for Improvement of External Cause-of-Injury Coding.   MMWR Recomm Rep. 2008;57(RR-1):1-15.PubMedGoogle Scholar
Caveney  AF, Smith  MA, Morgenstern  LB, Lisabeth  LD.  Use of death certificates to study ethnic-specific mortality.   Public Health Rep. 2006;121(3):275-281. doi:10.1177/003335490612100309 PubMedGoogle ScholarCrossref
Mohler  B, Earls  F.  Trends in adolescent suicide: misclassification bias?   Am J Public Health. 2001;91(1):150-153. doi:10.2105/AJPH.91.1.150 PubMedGoogle ScholarCrossref
Subbaraman  MS, Kerr  WC.  Simultaneous versus concurrent use of alcohol and cannabis in the National Alcohol Survey.   Alcohol Clin Exp Res. 2015;39(5):872-879. doi:10.1111/acer.12698 PubMedGoogle ScholarCrossref
Guttmannova  K, Lee  CM, Kilmer  JR,  et al.  Impacts of changing marijuana policies on alcohol use in the United States.   Alcohol Clin Exp Res. 2016;40(1):33-46. doi:10.1111/acer.12942 PubMedGoogle ScholarCrossref
Subbaraman  MS.  Substitution and complementarity of alcohol and cannabis: a review of the literature.   Subst Use Misuse. 2016;51(11):1399-1414. doi:10.3109/10826084.2016.1170145 PubMedGoogle ScholarCrossref
Subbaraman  MS, Kerr  WC.  Subgroup trends in alcohol and cannabis co-use and related harms during the rollout of recreational cannabis legalization in Washington state.   Int J Drug Policy. 2020;75:102508. doi:10.1016/j.drugpo.2019.07.003 PubMedGoogle Scholar
Silver  LD, Naprawa  AZ, Padon  AA.  Assessment of incorporation of lessons from tobacco control in city and county laws regulating legal marijuana in California.   JAMA Netw Open. 2020;3(6):e208393. doi:10.1001/jamanetworkopen.2020.8393 PubMedGoogle Scholar
Humphreys  K, Shover  CL.  Recreational cannabis legalization presents an opportunity to reduce the harms of the US medical cannabis industry.   World Psychiatry. 2020;19(2):191-192. doi:10.1002/wps.20739 PubMedGoogle ScholarCrossref
Shover  CL, Vest  NA, Chen  D,  et al.  Association of state policies allowing medical cannabis for opioid use disorder with dispensary marketing for this indication.   JAMA Netw Open. 2020;3(7):e2010001. doi:10.1001/jamanetworkopen.2020.10001 PubMedGoogle Scholar
Shover  CL, Humphreys  K.  Debunking cannabidiol as a treatment for COVID-19: time for the FDA to adopt a focused deterrence model?   Cureus. 2020;12(6):e8671. doi:10.7759/cureus.8671PubMedGoogle Scholar
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    Original Investigation
    Substance Use and Addiction
    March 18, 2021

    Evaluation of State Cannabis Laws and Rates of Self-harm and Assault

    Author Affiliations
    • 1Center for Health and Community, University of California, San Francisco
    • 2Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California
    • 3Medical student, Stanford University School of Medicine, Palo Alto, California
    • 4Philip R. Lee Institute for Health Policy Studies and Department of Humanities and Social Sciences, University of California, San Francisco
    • 5Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
    • 6Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
    JAMA Netw Open. 2021;4(3):e211955. doi:10.1001/jamanetworkopen.2021.1955
    Key Points

    Question  Are state cannabis legalization laws with varying degrees of commercialization associated with rates of self-harm or assault injuries?

    Findings  In this cohort study based on health insurance claims data from 75 395 344 beneficiaries between 2003 and 2017, rates of self-harm injuries among males younger than 40 years increased more in states legalizing recreational cannabis dispensaries compared with states without cannabis legalization laws. For other age and sex groups and for more restrictive legalization approaches, no association with self-harm and assault was found.

    Meaning  States with recreational cannabis may benefit from monitoring levels of self-harm as a potential consequence of legalization.


    Importance  State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.

    Objective  To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.

    Design, Setting, and Participants  Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.

    Exposures  Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).

    Main Outcomes and Measures  Claims for self-harm and assault injuries based on International Classification of Diseases codes.

    Results  The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.

    Conclusions and Relevance  Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.