OK, marijuana is now legal. So where’s the public health approach?
Strictly speaking, marijuana use isn’t fully legal across the U.S. yet. But when Montana and Missouri have legalized recreational use and the Senate is debating legal banking for cannabis companies, you know it’s all over but the shouting.
For years health experts have argued that criminalizing marijuana use was a mistake, and that rather than handling the drug as a law enforcement problem, with cops, lawyers, and jails, we should manage it as a public health problem, with prevention, treatment, and harm reduction. I have served as health commissioner for both New York City and Philadelphia, and at one time I had hopes of moving to a public health approach to illegal drugs. But instead, to my horror, the legalization freight train rolling across the nation is replacing law enforcement with corporate marketing reminiscent of the tactics of Big Tobacco in the 20th century. It’s time for us to respond to marijuana now as we belatedly responded to tobacco.
Doctors’ opinions about marijuana vary. Some believe it’s valuable for people suffering from chronic pain, like that from cancer. Many others (including me) worry a lot about its risk of addiction, strong link to schizophrenia, intoxicated-driver car crashes, and harms not yet proven. (Remember, the lag between starting smoking cigarettes and lung cancer is about 25 years.) But I hope we can all agree at least on this: As a society we should not be actively encouraging people to use this drug. Yet encouraging recreational marijuana use is exactly what is happening.
In the first half of the 20th century, the tobacco industry’s clever, ubiquitous marketing of an addictive drug transformed smoking from a niche hobby into a daily habit for nearly half of American adults. Today’s cannabis industry is using the same manipulative methods — and then some.
The tobacco companies, for all of their marketing savvy, offered just a few products to deliver nicotine: cigarettes, cigars, loose tobacco, pipe tobacco, and chewing tobacco. But today’s marijuana stores are pushing a jaw-dropping array of products to deliver tetrahydrocannabinol (THC) — well beyond leaf and vape oils. There are THC tablets, tinctures, dried concentrate, gummies, mints, lollipops, fizzy drinks, salves, patches, lip balms, massage oils, “personal lubricants,” and even bath bombs. Retailers sell these products in cheery, brightly colored packages that are attractive to kids.
A century ago, Big Tobacco calmed people’s health fears with outrageous claims that smoking was actually good for you. Camel “promote[s] good digestion” and gives you “healthy nerves,” it touted. “A famous New York research laboratory,” R.J. Reynolds told Americans in 1934, had “confirmed” that Camel has “a positive ‘energizing effect’ … a healthful and delightful release of natural, vibrant energy.” Today, cannabis companies grease sales with their own health claims — among them that marijuana helps you lose weight, prevent diabetes, and “protect[s] your brain.”
The tobacco companies advertised in the media channels of the day: newspapers, magazines, radio, and, from its very early days, television. They used scores of what we would today call “influencers.” Lucille Ball and her husband, Desi Arnaz, were there to tell you that “[y]ou’ll be glad tomorrow that you smoked Philip Morris today!” (Desi probably wasn’t glad when he died of lung cancer in 1986.) Today’s marijuana corporations are advertising on radio, billboards, and digital channels. The industry’s influencers — from Wiz Khalifa to Seth Rogen — count followers in the millions and are as likely to own their brands as be owned by them.
In the 1990s, Americans were scandalized by the news that for decades Philip Morris had secretly manipulated “freebase” nicotine levels in Marlboro to hook more smokers. Today’s marijuana manufacturers aren’t bothering with secrecy. They are in a public arms race to raise THC levels in their products to make them more addictive. Fifty years ago, weed sold on the street had a THC concentration of about 2%. Now retailers routinely offer buds with THC levels more than 10 times that, alongside concentrates that are nearly 80% THC.
All of this marketing, of course, is about “getting new customers,” as one expert admits. And sure enough, this marketing has — a lot. The number of Americans who use marijuana daily or almost daily nearly quadrupled from 2002 to 2021, to 17.4 million from 4.7 million. The states that legalized early, like Colorado, Oregon, and Washington are seeing the highest marijuana use, with roughly a third of 18- to 25-year-olds now using the drug at least once a month. Those states have seen increases not only in legal marijuana use, but also illegal marijuana use and marijuana addiction.
Marijuana marketing originates from increasingly large and increasingly multinational corporations. Wall Street itself is becoming hooked on marijuana. “Global marijuana markets are growing like a weed,” an investment website reads. “It’s no wonder that many investors are interested in owning cannabis stocks.” It’s reminiscent of something Warren Buffett is quoted as saying in the 1989 book “Barbarians at the Gate: The Fall of RJR Nabisco”: “I’ll tell you why I like the cigarette business. It costs a penny to make. Sell it for a dollar. It’s addictive.” The global cannabis market is now estimated to be more than $50 billion per year. Twenty-four cannabis companies have market capitalizations of more than $100 million, of which five are worth more than $1 billion. Curaleaf boasts that it operates more than 150 dispensaries in 18 states and has 21 cultivation sites. Tilray sells THC products under more than 10 different brand names and has operations on five continents.
To the federal Food and Drug Administration and Drug Enforcement Administration, marijuana is still illegal, so we have to look to states to rein in this marketing. And so far, state governments have done little to prevent the harms of legal marijuana use. The model they tend to use is the one for alcohol — issue licenses, grab the tax dollars, but otherwise let the industry do what it wants.
Alcohol is the wrong model. To find a better model, we don’t have to look far: It’s tobacco. Since World War II, alcohol use has been roughly level in this country, but thanks to a public health approach, smoking has fallen by about 75%.
A true public health approach to legal marijuana based on the tobacco model would first regulate the product to reduce its risk: putting safer limits on potency and prohibiting new THC delivery forms until they were evaluated for safety. That includes prohibiting, for example, gummies, lollipops, sodas, and other THC-containing edibles that are attractive to toddlers.
It would, as with packs of cigarettes, regulate the packaging. That would include requiring child-proof containers (while some states have requirements on the books, there is little enforcement, and accidental poisonings are skyrocketing), limiting the total THC amount in a package, requiring generic text and prohibiting graphics, and including traffic light-style labeling of THC content.
It would put strict limits on the number, density, and location of retail operations and prohibit home delivery that can be used by teens. That could include state control of retail sales, as some other countries and U.S. states do with liquor.
It would prohibit advertising, promotion, and sponsorship (do you really want the local weed store sponsoring your kid’s soccer team?), and ban any unproven health claims. (The FDA has occasionally warned companies about unproven health claims related to CBD and delta-8 THC, but states need to crack down much more than they are now.)
It would tax the product heavily enough to discourage use and base the tax on THC content to counterbalance the drive to higher potency products.
And it would use some of those tax revenues to fund not just treatment for marijuana addiction but also strong anti-marijuana education campaigns, like those Centers for Disease Control and Prevention antismoking ads that are effective in prompting smokers to quit.
Locking people up for selling or possessing small amounts of marijuana never worked. Now that our nation is revising its approach to this drug, we have an opportunity to do better. But we can prevent the damage from marijuana only if we set firm limits now on a ravenous industry that cares only about profit.
Thomas Farley, M.D., MPH, was commissioner of health for New York City from 2009 to 2014 and for Philadelphia from 2016 to 2021. He is currently writing a textbook on public health strategies.