Commentary

Recreational cannabis legalization: Potential implications for individual and community health

Taseen Alam, BA, Connor Riegal, BS, Natalie Saadeh, MD, Fernanda Gushken, MD, MS, Hannah Snyder, MD, Brenden Jenks, MD and Akhil Anand, MD
Cleveland Clinic Journal of Medicine July 2025, 92 (7) 407-413; DOI: https://doi.org/10.3949/ccjm.92a.24086

The debate about recreational cannabis legalization remains contentious both globally and within the United States. Although cannabis is still a prohibited substance under the United Nations Single Convention on Narcotic Drugs,1 it remains the most widely used illicit drug worldwide.2 Recreational cannabis has now been legalized by 24 states, 3 territories, and the District of Columbia.3,4

BRIEF HISTORY OF CANNABIS USE AND LEGALIZATION

Cannabis has been serving spiritual, recreational, and medicinal purposes for millennia, and there is paleobotanic evidence of cannabis from approximately 12,000 years ago. Early medical applications included its use as an anesthetic, antidepressant, and anti-inflammatory decoction.5

Medicinal use of cannabis in the United States gained popularity during the late 19th century, and recreational cannabis use became widespread by the 20th century. The landscape shifted in 1937 when the Marihuana Tax Act was passed, which effectively criminalized cannabis and restricted possession to individuals who paid an excise tax for authorized use.6 This trend continued with the enactment of the Boggs Act of 1951 and Narcotic Control Act of 1956, which imposed mandatory sentences for cannabis-related violations, even for first-time offenders.6

In the 1960s, cannabis became a symbol of the counterculture movement and gained wide acceptance among young adults.6 The United States federal government subsequently ramped up its drug enforcement efforts in the 1970s by establishing the Drug Enforcement Administration and initiating the “War on Drugs.” During this period, cannabis was classified as a Schedule I drug under the Controlled Substances Act, which has since subjected users to severe legal penalties. Now, nearly one-quarter of all drug-related arrests are for cannabis, with about 92% of these arrests being for possession alone.7 Moreover, Black individuals have been disproportionately affected: in states where cannabis is legal, arrest rates for cannabis are 5% higher than those of White individuals.8

In response to these disparities and other factors, ongoing efforts to deschedule and decriminalize cannabis have gained momentum, including the introduction of the Marijuana Opportunity Reinvestment and Expungement Act.4 This bill aims to remove cannabis from the Controlled Substances Act and implement various criminal and social justice reforms.4,6 A key component of the bill is the expungement of past cannabis convictions, which have disproportionately impacted low-income and minority communities.4

Although cannabis regulation has steadily moved toward broader public acceptance, cannabis legalization remains complex due to varying regulations at federal, state, and local levels. For instance, while cannabis remains classified as a Schedule I drug under the Controlled Substances Act, making it federally illegal, many states have adopted their own regulations. California legalized medicinal cannabis in 1996, and, in 2012, Washington and Colorado became the first states to approve legalized recreational cannabis.9 Ohio was the 24th state to legalize recreational cannabis in 2023.3

Cannabis policies also vary across different contexts. For example, employers may conduct random drug testing because they do not allow any cannabis use, while evidence of impairment is required to evaluate cases of driving under the influence.10,11 This patchwork of regulations creates challenges for stakeholders, including patients, clinicians, and healthcare institutions, and underscores the difficulty of navigating the ever-evolving legal landscape surrounding cannabis use.4

POTENTIAL IMPACTS OF RECREATIONAL CANNABIS LEGALIZATION

The full impact of recreational cannabis legalization in the United States remains unclear. However, emerging data from states that have legalized cannabis and countries where it is legal nationwide reveal important trends.12 To help inform future policy decisions, we evaluate the effects of legalized recreational cannabis on overall cannabis consumption, crime, traffic safety, and individual and community health in the following sections.

Consumption

Decreased perceived risk, greater access, and the marketing of cannabis products in states with legalized recreational cannabis may contribute to increased consumption, particularly in some demographic groups.

Pregnant women are a key population for studying the impact of recreational cannabis legalization. Recent retrospective cohort studies showed an increase in perinatal cannabis use after cannabis was legalized in California and Colorado.13,14 This trend may be driven by cannabis retailers advertising the use of cannabis to alleviate morning sickness—in one study, 69% of surveyed dispensaries recommended cannabis to treat first-trimester nausea.15

While cannabis may have potential antiemetic effects for morning sickness, multiple specialty organizations, including the American College of Obstetricians and Gynecologists, strongly advise against its use during pregnancy.15 This recommendation is based on numerous associated risks, such as the development of cannabis use disorder in the mother, cannabinoid hyperemesis syndrome, premature delivery, lower birth weight, neonatal abstinence syndrome, and potential negative neurodevelopmental outcomes in the child, including increased aggressive behavior, attention deficits, and poorer adolescent and early adult achievement.14,16,17 In fact, a study in Colorado found that the incidence of growth restriction was significantly higher after recreational cannabis legalization (2.9% vs 5.1% incidence rate, P = .0084).13

A study in Ontario reported that recreational cannabis legalization led to an increase in acute care visits for cannabis use during pregnancy, from 11 to 20 cases per 100,000 pregnancies.18 A subsequent study in Nova Scotia with a cohort of more than 100,000 pregnant women found that infants of mothers who reported cannabis use during pregnancy were more likely to be small for their gestational age (16% vs 7.6% incidence, weighted relative risk 1.52, 95% confidence interval [CI] 1.34–1.71) and have major anomalies (3.5% vs 2.0% incidence rate, weighted relative risk 1.82, 95% CI 1.47–2.23).16 These adverse effects may be affected by dose or method of ingestion; however, further research is needed to account for potential confounders.14,17

Adolescents are another key demographic affected by recreational cannabis legalization. One study showed a statistically significant association between legalized recreational cannabis and greater likelihood of transitioning to using cannabis when compared with both nonlegalized states (odds ratio [OR] 2.18, 95% CI 1.37–3.45) and nonlegalized states combined with medical legalization states (OR 1.73, 95% CI 1.23–2.42). However, the study was limited by the timing between data collection and the addition of new states legalizing recreational cannabis.19

In addition, adolescents in states where recreational cannabis is legal perceive cannabis as less risky and report greater ease of access.20

Survey limitations. It is important to recognize that most epidemiologic studies on substance use rely on self-reported data, which can underestimate actual rates of use.14 Survey data are prone to recall and social desirability biases, leading to underreporting or misrepresentation of substance use. Some national surveys, such as the National Survey on Drug Use and Health, exclude certain groups, including individuals without fixed household addresses (eg, unhoused), active-duty military personnel, and those who live in institutional settings.9 This exclusion limits the ability to generalize findings to the wider population. However, research has also shown that self-reporting can be reliable in specific contexts, such as in clinics that treat patients with a history of substance use.21

Self-reported cannabis use may increase in the context of recreational cannabis legalization due to a lower perceived risk, social desirability bias, and a diminished fear of criminal penalties. This may influence studies comparing states with and without legalized recreational cannabis because the increase in reported use may skew results. The dynamic of skewed data after any reported increase in use due to recreational cannabis legalization, as well as the aforementioned database exclusions, highlight the need for more rigorous future studies to address knowledge gaps.

Crime

The impact of recreational cannabis legalization on crime rates is a pressing challenge to policymakers, given the complexity of interpreting recent laws that vary significantly from state to state. Regardless, several studies have provided some insight into the effects of recreational cannabis legalization on crime. Using US Uniform Crime Reporting data from Washington and Oregon, Dragone et al22 found a small decrease in rape (by 4.2 occurrences per 100,000 inhabitants), theft (by 105.6 occurrences per 100,000 inhabitants), other drug use (by 0.5 points off a base level of about 4%), and alcohol consumption (2 points off a base level of approximately 50%). Another analysis of the same database showed that legalizing recreational cannabis did not lead to a significant increase in property crimes.20

These findings show the nuanced effects of cannabis legalization on crime, but do not support an associated increase, emphasizing the need for continued, state-specific research.

Driving ability

Cannabis is known to impair driving skills, such as reaction time, decision-making, and motor coordination, in a dose-dependent fashion, raising concern that recreational cannabis legalization could potentially increase cannabis-related vehicular accidents.23 However, current evidence has been mixed. One study found no statistically significant differences in motor-vehicle crash fatality rates between states with and without legalized recreational cannabis (adjusted difference-in-differences coefficient +0.2 fatalities per billion vehicle miles traveled, 95% CI −0.4 to 0.9).24 Conversely, another study by Adhikari et al25 that evaluated data from 50 states and the District of Columbia between 2007 and 2020 suggested that recreational cannabis legalization could contribute to as many as 1,400 excess traffic fatalities per year nationally. These discrepancies may be due to variations in dependent variables, sample sizes, and policy implementation delays.25

Some authors argue that it is difficult to attribute changes in motor-vehicle injuries to legalization when comparing states because policies and contexts differ widely. Adhikari et al25 noted that studies conducted shortly after legalization often include fewer states and years in their datasets, which may result in misleading conclusions about the effects of legalization over time. However, another study found that urban drivers in fatal crashes were more likely to test positive for cannabis compared with rural drivers (adjusted OR 1.21, 95% CI 1.14–1.28), suggesting that cannabis may have a greater impact on urban driving.23

While cannabis use may influence driving abilities, the seemingly contradictory study findings suggest that the overall impact of cannabis legalization on traffic safety requires further investigation to clarify the association between patterns of cannabis use and traffic safety outcomes.

Drug testing

Policies on workplace drug testing for cannabis in the context of cannabis legalization vary among states. For example, New York prohibits using results of a cannabis drug test to make employment decisions, while Georgia enforces strict zero-tolerance policies.26,27 Of note, Black workers report a much greater frequency of workplace drug testing compared with White workers (15%–20% increase), and Black and Hispanic workers report they are more likely to be fired due to a positive test (relative risk 1.56, 95% CI 1.45–1.69 for Black workers; relative risk 1.37, 95% CI 1.26–1.5 for Hispanic workers).10 The policy variations for cannabis drug testing among states may lead to inequities in enforcement and downstream outcomes, such as risks of unemployment or furthering racial disparities.

Similarly, evaluating drivers for cannabis impairment is difficult. Whereas blood alcohol concentration can be used to determine acute alcohol intoxication, cannabis presents difficulties due to its high lipophilicity and pharmacokinetic properties.28 For instance, urine drug screens commonly used in emergency departments may report positive tetrahydrocannabinol results up to 30 days after consumption.29 Although negative effects on coordination and reflexes can be observed at the roadside, there is currently a lack of standardized measurement tools to accurately assess acute cannabis impairment. Without a set of standardized tools, there is concern about the potential for racial discrimination and wrongful arrests. To address these issues, initiatives like the Drug Evaluation and Classification Program have been established, which aim to standardize field sobriety assessments for cannabis impairment and reduce drug-related vehicular crashes.11

Physical health

Cannabis use can cause numerous physical symptoms and health problems. Acute clinical effects of cannabis poisoning include vomiting, headache, chest pain, and hypertension or hypotension.30 More severe vascular complications, such as heart attacks, transient ischemic attacks, and strokes, have also been reported with cannabis use.31 The type of symptoms and their severity can vary depending on factors such as age, preexisting psychiatric conditions, and co-occurring substance use, including alcohol.30,32

Chronic and heavy users of cannabis—defined as daily or near-daily use—may also experience cannabinoid hyperemesis syndrome.33 This condition is characterized by recurrent episodes of nausea, vomiting, and abdominal pain, which often improve with hot baths or showers. The persistent vomiting and dehydration caused by cannabinoid hyperemesis syndrome can lead to severe complications like renal failure.33

Edible vs inhalable cannabis. The relative harms of cannabis use may differ based on whether it was ingested or inhaled, and further investigation is needed. Edible products have distinct absorption, onset, and duration kinetics compared with inhaled cannabis. While inhalable cannabis leads to strong psychotropic effects and maximal plasma concentration within minutes and effects taper within 2 to 3 hours, edible products need at least 30 to 90 minutes for notable psychotropic effects to occur, peak at 2 to 3 hours, and last for 4 to 12 hours after ingestion.28 The combination of delayed onset of psychotropic effects and the longer effect duration increases the risk of unintentionally ingesting excessive amounts of tetrahydrocannabinol via edibles, leading to accidental poisonings. However, a 5-year retrospective study found that inhaled cannabis use led to more emergency department visits for cannabinoid hyperemesis syndrome, intoxication, and cardiovascular symptoms compared with edible cannabis use.34 These findings are somewhat limited, as edible cannabis use accounted for only an estimated 10.7% of cannabis-attributable visits.

Frequent cannabis smoking is also linked to a range of harmful medical effects, including chronic bronchitis, pneumonia, and increased rates of respiratory infections due to airway and lung inflammation.31

Cannabis withdrawal. Nearly half of regular users—defined as weekly or more frequent use35—experience withdrawal symptoms when cannabis is abruptly discontinued.28 These symptoms can include dysphoria, nausea, abdominal pain, tremors, sweating, fever, chills, and headaches.31,36,37

Mental health

Cannabis intoxication can lead to euphoria, anxiety, or altered time perception.28 It can also cause social withdrawal and appetite stimulation.28,37 Intoxication intensity depends on route, dose, and individual factors such as tolerance.28

Some individuals seek these psychotropic effects to cope with various psychiatric conditions. One study found that 76% of young adults who consume cannabis reported using it to self-medicate for mental health distress, including anxiety and depression.36 Interestingly, this study also found that recreational cannabis legalization correlated with diminished use of cannabis for self-medication, differing from previous studies that noted no consistent relationship between recreational cannabis legalization and self-medication.

Despite these reports of self-medication, no current evidence supports treating psychiatric disorders with cannabis. A recent systematic review and meta-analysis evaluated 83 studies on cannabinoids for mental health symptoms.38 It found cannabinoids had limited efficacy treating patients with anxiety disorders in the setting of co-occurring medical conditions. Furthermore, it found no evidence supporting the use of cannabinoids to treat other psychiatric conditions or patients with anxiety disorders alone. However, there was a lack of high-quality randomized trials and poor standardization among studies.

Other research has shown that cannabis use is associated with depression, anxiety, panic attacks, risk of self-harm, insomnia, mania, and psychosis.32 Additionally, starting cannabis use at a younger age increases the risk of developing psychosis later in life.31 However, evidence is inconsistent. In a multiple regression analysis of 34,653 respondents, Blanco et al39 found that, while cannabis use was significantly associated with substance use disorders, there was no significant association with mood disorders (OR 1.1, 95% CI 0.8–1.4) or anxiety disorder (OR 0.9, 95% CI 0.7–1.1). The strengths of these associations are unclear, and the causal link between cannabis use and these disorders has yet to be fully established, highlighting the need for more rigorous studies.

Cognitive impact

Cannabis can have both acute and chronic effects on cognition. Acute cannabis use can impair learning, short-term memory, motor coordination, and judgment, impacting executive function and decision-making.31,37 Chronic use, particularly among heavy daily or near-daily users, can lead to sustained deficits in executive function, attention, memory, and social achievement.31

Structural neuroimaging studies have shown that cannabis use may lead to morphologic brain abnormalities, particularly in chronic users during early and late adolescence.40 These effects are especially pronounced in regions of the brain with high densities of cannabinoid receptors, as well as in areas involving cognitive and executive function, although the findings are not always consistent.31,40 For instance, some research has indicated a brain volume decrease in regions such as the hippocampus, orbitofrontal cortex, amygdala, and striatum, while other studies have reported increases in cortical thickness and medial parietal cortex volume.40 Establishing a causal relationship between these morphologic changes and behavioral, cognitive, or emotional functions remains challenging.

Notably, no significant differences in brain structure have been observed between nonusers and occasional cannabis users.40

Addiction and substance use disorders

Cannabis use before the age of 21 can disrupt the development of the brain’s reward system, potentially influencing other addictive behaviors.31 A recent systematic review explored the relationship between recreational cannabis legalization and addiction, and found no significant changes in the consumption patterns of cigarettes, stimulants, or opioids after cannabis legalization.41 However, the review did suggest that recreational cannabis legalization may be correlated with an increase in alcohol use and a decrease in opioid prescriptions.

Other studies have also indicated a potential rise in concurrent alcohol and cannabis use in states with legalized recreational cannabis. Blanco et al39 found that cannabis use between 2001 and 2002 was significantly associated with substance use disorders 3 years later. Notable increases were seen in alcohol use disorder (OR 2.7, 95% CI 1.9–3.8), nicotine dependence (OR 1.7, 95% CI 1.2–2.4), and other substance use disorders (OR 2.6, 95% CI 1.6–4.4).

Cannabis use disorder. There is concern that recreational cannabis legalization could lead to an increase in cannabis use disorder. Approximately 9% of individuals who have tried cannabis will develop a substance use disorder.31 This risk increases to 17% for those who first used cannabis during childhood, and the likelihood of developing a cannabis use disorder is between 25% and 50% for regular users. However, the pathophysiology behind cannabis use disorder remains unclear, as there is insufficient evidence to support the notion that striatal dopamine receptors, which are involved in alcohol or opioid abuse disorders, also modulate cannabis use disorder.37

A 2023 systematic review of 9 studies found a general increase in the proportion of adults with cannabis use disorder after legalization (from 0.9% to 1.23%, OR 1.36, 95% CI 1.08–1.71), and a similar trend was observed among adolescents (from 2.18% to 2.72%, OR 1.25, 95% CI 1.01–1.55), although effect sizes varied across demographic groups.2 The review identified only 1 study that did not find significant differences in cannabis use disorder prevalence based on legalization status. However, it was a cross-sectional study with a small sample size. The overall findings of the review, however, may be limited by several factors, including the small number of studies, variability in the implementation of recreational cannabis legalization among states, and the absence of individual- and community-level characteristics.2

Although these studies have identified a concerning relationship between recreational cannabis legalization and cannabis use disorder, the data on the impact of cannabis use on other substance use disorders are mixed and warrant further investigation.

Drug interactions

Cannabinoids may interact with medications via the cytochrome P450 enzyme system, which plays a role in the metabolism of various drugs, including warfarin, fluoxetine, and clozapine.28,42,43 These interactions can potentially affect medication safety and efficacy. For example, a case series of 7 patients on warfarin who also used cannabis reported a hemorrhage in 1 patient, while the other 6 developed elevated international normalized ratios.42

Further research is needed to explore the impact of recreational cannabis legalization on adverse cannabis-drug interaction rates.

Healthcare utilization

Several retrospective cross-sectional studies have reported that recreational cannabis legalization greatly increases cannabis-related emergency department visits across all demographics.12 One study identified cannabis-related withdrawal and psychosis as the most common indications for emergency department visits,44 while another study found a positive association between the legalization of edible cannabis and cannabis-related poisonings.34 A study examining cannabis-related hospitalizations of pregnant patients in Colorado reported a significant increase per county, from 1.7 in 2011 to 4.7 in 2018.45 Such increases were much greater than all-cause hospitalizations or hospitalizations due to other substance use.44 Overall, these findings suggest that recreational cannabis legalization is associated with higher cannabis-related healthcare utilization.12

CONCLUSION

Issues surrounding recreational cannabis legalization are complex, with studies linking it to increased cannabis consumption, cannabis use disorder, and heightened cannabis-related healthcare utilization. Some studies suggest recreational cannabis legalization may increase traffic collisions and fatalities and anxiety rates, but their credibility is limited by self-reported data and short study periods. There is no conclusive evidence that cannabis legalization affects other substance use disorders or brain development at the population level. As more states legalize recreational cannabis, better research is needed to fully understand its health and societal outcomes, ensuring policies address public health concerns effectively and accurately.

DISCLOSURES

The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.

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