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2004 34: 751Journal of Drug IssuesShereen Khatapoush and Denise Hallfors

California Change Attitudes about and use of Marijuana?''Sending the Wrong Message'': Did Medical Marijuana Legalization in

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© 2004 BY THE JOURNAL OF DRUG ISSUES

JOURNAL OF DRUG ISSUES 0022-0426/04/04 751-770

__________

Shereen Khatapoush, Ph.D., is the director of the Youth Services System for the Council onAlcoholism and Drug Abuse in Santa Barbara, CA. She has worked in substance abuse preventionfor 10 years and is interested in youth, prevention, and policy. Denise Hallfors, Ph.D., is a seniorresearch scientist at PIRE in Chapel Hill, NC. Dr. Hallfors has a background in nursing, with doctoraltraining from the Heller School at Brandeis University. She has done extensive research on adolescentsubstance abuse prevention and is currently the principal investigator on two NIDA R01 grants.

“SENDING THE WRONG MESSAGE”: DID MEDICAL

MARIJUANA LEGALIZATION IN CALIFORNIA CHANGE

ATTITUDES ABOUT AND USE OF MARIJUANA?

SHEREEN KHATAPOUSH, DENISE HALLFORS

This study was designed to assess the affect of legalization of medical marijuanaon drug-related attitudes and use among youths and young adults in selectedcommunities in California and other states. Telephone survey data, collected aspart of a study of the Robert Wood Johnson Foundation’s Fighting Back initiative,was utilized to examine reported attitudes about and use of drugs in Californiaand other states before and after Californians passed Proposition 215 in 1996.Descriptive, bivariate, and logistic regression analyses were used to examineattitudes and use among 16 to 25 year olds in California and 10 other states.This study found that although some marijuana-related attitudes changedbetween 1995 and 1999, use did not increase. These findings suggest thatrecent policy changes have had little impact on marijuana-related behavior.

INTRODUCTION

Marijuana policy has been a contentious issue in the United States. Over time,federal marijuana policy has become increasingly restrictive and punitive, whilestate policy has been more fluid and lax. Recently, citizen-sponsored state referendato legalize marijuana for medicinal purposes have challenged federal policy, sparkinga national debate. Critics have argued that medicinal use “sends the wrong message”to youth. The purpose of this paper is to test this argument by examining marijuanaattitudes and behaviors before and after a seminal California law was passed.



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Current federal drug policy can be characterized as a “zero tolerance” approach,with primary emphasis on supply reduction, enforcement strategies, and legalsanctions. Historically, federal marijuana policy began with the Marijuana Tax Actof 1937 and became more restrictive over time with the passage of the Boggs Actand the Narcotic Control Act during the 1950’s (Bonnie & Whitebread, 1974). TheBoggs Act established uniform penalties and mandatory minimum sentencing (Bonnie& Whitebread, 1974), and the Narcotic Control Act escalated the penalties andfines for the possession and sale of narcotics and made other provisions and guidelinesfor the enforcement of narcotic laws (including marijuana).1 Despite the harsherpenalties that were enacted in the mid 1950s, recreational marijuana use not onlycontinued, but increased dramatically during the 1960s. In 1970, the ControlledSubstances Act classified marijuana as a Schedule I drug (along with heroin andLSD), meaning that it had a high potential for abuse, no accepted medical utility,lack of accepted safety for use even under medical supervision, and was subject tothe most stringent regulatory controls. Despite these increasingly elevated sanctionsover time, recreational use and the corresponding costs associated with marijuanaenforcement increased, and efforts to relax federal policies since the 1970s, suchas rescheduling marijuana, have failed.

Although states are subject to federal law, most have experimented with theirown policy approaches. During the late 1960s and 1970s, almost all states reducedthe penalties for marijuana use (Resnick, 1990). By the end of 1971, only threestates maintained mandatory minimum felony penalties for possession (Bonnie &Whitebread, 1974). Oregon was the first state to decriminalize marijuana in 1973;by 1978, twelve additional states, with collectively more than a third of the totalU.S. population, had done so (Model, 1993). Californians passed the Moscone Actin 1976, which decriminalized possession of marijuana and removed prison sentences.For the next 20 years, until the medical marijuana initiative was passed in 1996,California’s marijuana laws did not change substantially.

In November 1996, California voters passed Proposition 215, the CompassionateUse Act, which allows patients to cultivate and use marijuana for medicinal purposeswith the written or oral recommendation of a doctor. A number of other states havesince passed medical marijuana initiatives. These state initiatives clearly conflictwith federal policy and much of the concern and opposition has been centeredaround the notion that allowing medicinal use would “send the wrong message” toyouth – that is, change attitudes and perceptions about marijuana and result ingreater recreational use of marijuana and other illicit drugs. Comments made byGeneral Barry McCaffrey, former director of the White House Office of NationalDrug Control Policy, typify this concern.



MEDICAL MARIJUANA: “SENDING THE WRONG MESSAGE”?

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These measures threaten to undermine our efforts to protect ourchildren from dangerous psychoactive drugs. They make drug abusemore likely. Marijuana is a “gateway” drug. Children who haveused marijuana are more than 85 times likelier to use cocaine thanchildren who have never used marijuana. They send the wrongmessage to our children. Coming at a time when marijuana use hasdoubled among our youth, these initiatives threaten to undermineour efforts to prevent drug use by our children. We cannot affordto further erode youth attitudes towards drugs by allowing marijuanato be falsely depicted as a safe drug and as effective medicine.Labeling marijuana as “medicine” sends the wrong message tochildren that it is a safe substance. What is at risk is the well-beingof our nation’s youth” (McCaffrey, Senate Judiciary Committee,1996).

In response to these and other concerns about the medical use of marijuana, thefederal government commissioned a study by the Institute of Medicine (IOM). Inits final report, the commission noted,

Almost everyone who spoke or wrote to the IOM study team aboutthe potential harms posed by the medical use of marijuana felt thatit would send the wrong message to children and teenagers. Theystated that information about the harms caused by marijuana isundermined by claims that marijuana might have medical value.Yet many of our powerful medicines are also dangerous medicines. . . The question here is not whether marijuana can be both harmfuland helpful, but whether the perception of its benefits will increaseits abuse. For now any answer to the question remains conjecture.(IOM, 1999, p.101)

The IOM report went on to suggest, however, that “reasonable inferences” couldbe drawn from the medical use and abuse of opiates, the effects of marijuanadecriminalization2 and the short-term consequences of the medical marijuanacampaign in California (the NHSDA oversampled California residents to assessmarijuana use in 1997 and 1998 and found no increase in use). After highlighting thefindings in these areas, they concluded, “no convincing data support . . . the broadsocial concern that sanctioning the medical use of marijuana might lead to an increasein its use among the general population” (IOM, 1999, p.126). The purpose of thisstudy is to empirically assess whether enacting more liberal state policies: (1) changes





attitudes, decreasing beliefs that marijuana is harmful, increasing perceivedavailability and increasing approval for use; (2) changes behavior, increasingmarijuana use; and, based on gateway theory, (3) changes other “hard” drug usebehavior.

The theoretical and empirical literature suggests that, as with most complexhuman behavior and social problems, substance abuse is best explained in terms ofthe interaction of numerous personal and environmental factors. Research indicatesthat personal attitudes are correlated and interact with other variables to help predictbehavior (Eagly & Chaiken, 1993). There also appears to be a general sequence indrug use, and progression to a particular drug is influenced not only by age ofinitiation and previous “softer” drug use, but also by a number of other personal andenvironmental factors (Yamaguchi & Kandel, 1984; Kandel, 1985; Kandel &Andrews, 1987; Yu, 1992; Ellickson, Hays, & Bell, 1992; Werch & Anzalone, 1995).Taking this literature into consideration, we might not expect marijuana policy changeto have a significant effect on youth. It is important, however, given the socialconcern and lack of studies in this area, to examine the impact of policy change andto assess whether it produced negative outcomes.

METHODS

Telephone survey data was collected as part of the evaluation of the RobertWood Johnson Foundation’s Fighting Back (FB) initiative, a community basedcollaborative effort to reduce the demand for illegal drugs and alcohol (Saxe et al.,1997). These data were used to compare drug attitudes and use in California versusthe other 10 demonstration states before and after California passed Proposition215 in 1996. The FB evaluation conducted three telephone surveys of residentsaged 16 to 44 in 12 FB intervention and 29 demographically matched comparisoncommunities. The surveys were administered in the spring of 1995, 1997, and 1999.The questions used for the survey were previously validated and drawn from othernational surveys. The response rates were similar across all three waves,approximately 50%.3 The formula used to calculate the response rate representsthe most conservative estimate. For example, if calls that did not result in contactwith a potential respondent are not taken into account, the overall response rate is78.2%. This is the rate usually reported by polling agencies, and is comparable to,for example, the rate of completed interviews in the National Household Survey onDrug Abuse, which is 78% (Office of Applied Studies [OAS], 1998). For the presentstudy, survey data were limited to respondents aged 16 to 25. The total number ofrespondents aged 16 to 25 in FB and comparison communities, across all threewaves of the survey, is as follows: California N = 2,651; comparison states N =12,916; Total N = 15,567.




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Random Digit Dialing (RDD) sampling was used, as were weights (by householdsize and number of phones) in order to adjust for bias introduced by probability ofselection. All analyses were performed in SUDAAN because the data were weightedand had to be adjusted for design effects. It is not known whether the sample isbiased, and to what extent, by lack of participation due to phone numbers that werenot in service or disconnected or by exclusion due to refusal to provide zip code orto answer substance use questions. However, cooperation rates, the proportion ofall eligible respondents who qualified by screening questions – have been high acrossall three waves of the survey (approximately 75% of eligible respondents).Furthermore, termination rates, the percent of respondents who terminate theinterview before completion, and item nonresponse rates (excluding demographics)were low for all waves of the survey (less than 1% and less than 2% of respondents,respectively).

Multilevel modeling, usually used to account for effects at different levels, suchas the individual and community levels, was not used for two reasons. First, theoverall FB program effect has not been significantly different from zero. That is,there was little to no variance in outcome measures in contrast to comparison sites;therefore, for most of the analyses, FB and comparison sites could be and weregrouped together. Secondly, in some analyses, potential differences between FBand comparison communities within California were examined. There are, however,only two FB sites in California; thus, FB could not be considered a random effect aswould be necessary in multilevel modeling.

Descriptive, bivariate and logistic regression techniques were used to examineattitudes and use among 16 to 25 year olds in California and other states. Analyseswere guided by the following research questions:

1. Have marijuana-related attitudes and use changed over time inCalifornia?

2. How do attitudes and use compare between California and otherstates, before and after Proposition 215?

The primary outcomes in the present study address respondents’ use of marijuanaand their marijuana-related attitudes. Marijuana use was assessed by questionsabout use in the past month (1-month) and past year (12-month), and marijuana-related attitudes were primarily assessed by questions regarding perceivedavailability (availability), perceived harm (lowharm), and approval (approval) ofmarijuana use. Attitude towards marijuana legalization (legal) and medical use (Rx)were also examined, but these two questions were not asked in wave 1 of thesurvey. Because there was also a concern that changing attitudes and use of





marijuana would lead to increases in other drug use, the secondary outcome is useof other drugs in the past year (other drugs: 12-month); past month other drug usewas not asked. If more pro-drug attitudes and more drug use behavior were foundin waves 2 and 3 in California but not in comparison states, then we could concludethat the policy causes untoward outcomes.

MEASURES

Measures were as follows:

• Marijuana, 1-month: used past month (1) versus no use (0).• Marijuana, 12-month: used past year (1) versus no use (0).• Other Drugs, 12-month: used any drug illegally or an illegal

drug, last 12 months (1) versus no use (0) (includes cocaine/crack, LSD, heroin, inhalants, tranquilizers, barbiturates,amphetamines, and analgesics).

• Availability: fairly to very easy to get (1) versus fairly difficultto impossible (0).

• Lowharm: risk/harm from marijuana once or twice a week; slightto no risk of harm (1) versus moderate to great risk of harm (0).

• Approval: approve of occasional use; approve (1) versusdisapprove or strongly disapprove (0).

• Legal: should marijuana be made legal;4 yes (1) versus no (0).• Rx: should marijuana be a prescription drug; somewhat or strongly

favor (1) versus somewhat or strongly oppose (0).

We also selected other variables and conducted analyses to identify thecomposition of the sample and to compare California to comparison states. Weselected many of the variables because of their associations in the literature withsubstance use. Furthermore, since the survey represents a repeated measures designat the community and not the individual level, it was important to assess the threatof differential selection to internal validity. Other variables included: age, sex, race,partner (married/living with partner), college (level of educational attainment),unemployed, religious services (attend religious services), income, student (currentstudent) and children (live with children or stepchildren).

RESULTS

Demographic characteristics of the sample are reported in Table 1. The averageage of respondents was 20.46 years (mode=16) and slightly more than half the




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sample was male. Almost three fourths were White or Black, with the remainingquarter mostly Latino (7% identify as another race/ethnicity; this includes Asian/Pacific Islander, American Indian, Alaska Native, or other race). Nearly three fourthswere students, less than a quarter lived with a partner or children, and averageannual household income was approximately $21,250 dollars (5 = $20-25,000; mean = 5.25). Finally, about 40% of respondents were unemployedand about half never or rarely attended religious services.

Each of the demographic variables was examined over time. Because the sampleincludes more than 15,000 respondents, some changes, while statistically significant(p<.05), are not likely to be very important but are reported here nonetheless. Theaverage age of respondents decreased slightly and the samples included fewerWhite and more Latino and other respondents over time. The percentage ofrespondents who lived with a partner also fluctuated, first decreasing and thenincreasing (though 1999 rates were not substantially different from 1995 rates).Finally, unemployment was decreasing and household income increasing (by about$4,000 between 1995 and 1999). While the changes in age and racial compositionare small (less than 3% changes each year), changes in employment and incomeare more substantial and likely reflect the improving economy between 1995 and1999.

Though not all differences are of a large magnitude, almost every demographicvariable differed (p<.05) between California and other states. As indicated Table 1,the California sample was slightly younger and included more males. Differenceswere also found by race/ethnicity; the California sample included more White, Latinoand other respondents and fewer Black respondents than other states. The Californiasample also reported less church attendance and fewer children living in thehousehold. Finally, even though unemployment was higher in California, householdincome was higher than in other states. Although not all differences betweenCalifornia and other states nor changes over time were necessarily problematic(for example, we would expect more Latinos in California), they were controlledfor in all multivariate analyses.

In all subsequent analyses, the percent reported and/or value modeled is theaffirmative (1 or yes) category. Thus, for example, for all use variables, the percentreported from cross-tabulations and value modeled in regression equations is ofrespondents who used the substance.

CHANGE IN MARIJUANA-RELATED ATTITUTDES AND USE OVER TIME IN CALIFORNIA

We calculated cross tabulations and used logistic regressions to model probabilitiesassociated with attitudes towards availability, harm and approval, and use (pastmonth and year marijuana use and past year other drug use) among California





TABLE 1DEMOGRAPHIC CHARACTERISTICS




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respondents, controlling for demographic variables that changed over time. Theonly attitude that changed significantly over time in California was the decline inperceived harm from marijuana use (Tables 2 and 3). Substance use, as measured

TABLE 2PERCEIVED HARM BY YEAR (CALIFORNIA)

TABLE 3HARM: MODELING PROBABILITY OF SLIGHT TO NO RISK OF HARM (CALIFORNIA)





for medicinal purposes, but were less approving of marijuana use. Past month andyear use of marijuana, and other drug use, were higher in California than otherstates.We also analyzed changes over time. There were actually fewer significant (p<.05)changes in California than in other states (Table 5). Within California, perceptionsof slight to no harm in marijuana use increased. In other states, as in California,slight to no harm increased, but in contrast, approval for legalization and legalizationfor medical use also increased.

DISCUSSION

We found that while perceptions of harm from marijuana use have decreasedover time in California and in other states, marijuana and other drug use has remainedstable. Though support for medical use and general legalization of marijuana has

by marijuana use during the past month and year and other drug use during the pastyear, did not change significantly over time in California (data not shown).

COMPARABILITY OF ATTITUDES AND USE IN CALIFORNIA AND OTHER STATES, BEFORE AND AFTER

PROPOSITION 215We compared attitudes and use between California and other states by year

(Table 4). Californians differed significantly (p<.05) on all attitudes and use, exceptperceived availability. Specifically, Californians perceived less risk of harm inoccasional marijuana use, were more approving of marijuana legalization and use

TABLE 4ATTITUDES AND USE: CALIFORNIA AND OTHER STATES BY YEAR




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TABLE 5SUMMARY, DIFFERENCES, AND CHANGES IN MARIJUANA-RELATED ATTITUDES AND USE

increased over time in other states, personal approval for recreational use hasdecreased and use has not changed.

A major concern was that legalizing medical marijuana would “send the wrongmessage to youth” and lead to greater drug use. Since use did not increase, thesearguments are not supported. Respondents in this study increasingly believed thatmarijuana was not terribly harmful. However, this was not coupled with increaseduse, and approval for personal recreational use decreased, even while support formedical use increased. One might argue that policy changes did in fact “send thewrong message,” since perceived harm decreased, and youth and young adults inother states’ policy attitudes became more liberal. However, there is a conceptual,and this research suggests an empirical, distinction between attitudes that mayrelate to recreational use verses those that relate to medical use/policy. Even whileperceived harm decreased and support for medical legalization increased, approvalfor use decreased and actual use did not change. Therefore, it may be that changesin perceived harm have more to do with policy attitudes, and changes in approvalhave more to do with recreational use, since use remained stable across the country.Moreover, since six states passed medical marijuana initiatives between 1997 and2000, we would expect, and indeed found, in all but California, attitudes about policybecame more liberal over time. That is, on the whole, attitudes were not changing





over time in California but were changing in other states. Therefore, one implicationof our results may be that policy changes reflect attitude changes, rather thanpolicy causing attitude changes.

Another implication is that other states may be converging with California.Attitudes are typically more liberal (and use higher) in the West, and in California inparticular, compared to the rest of the country (Office of Applied Studies [GallupPoll], 2000). The majority of Americans still oppose the idea of legalized marijuana.Americans see drugs as a serious problem nationally, but not in their local area.Liberal attitudes may have led to policy changes in California; although attitudeshave since been stable in California, they have been changing in other states, whilepolicy was also changing. Thus, California can be viewed as a bellwether state.However, in order to fully test the direction and association of attitudes and policychange, longitudinal data with representative state samples are needed, with datacollection both before and after policy change.

The results of this study indicate that marijuana and other illicit drug use remainedstable in the latter part of the 1990s; these results are validated by other recentfindings. The most recent Monitoring the Future (MTF) data indicate that adolescentuse has remained stable or decreased in the last few years (Department of Healthand Human Services [DHHS], 2000). Similarly, National Household Survey onDrug Abuse (NHSDA) data indicate little change in marijuana use among 12 to 26year olds between 1997 and 1999 (OAS, 1999). Moreover, as in the present study,the NHSDA data indicate a decline in perceived risk of harm from marijuana use(OAS, 2001). Finally, the Harvard College Alcohol Study found that past monthmarijuana use among college students increased from 1993 to 1999 but that nearlyall of the change had occurred by 1997 (Gledhill-Hoyt, Lee, Strote, & Wechsler,2000). Thus, the results of this study are consistent with other recent research onyouth and young adult marijuana use.

How do these findings compare to other studies about the relationship betweenmarijuana attitudes and use? Previous analyses of MTF data suggested that changesin marijuana use are closely correlated with perceived harm and approval (Bachman,Johnston, & O’Malley, 1998). However, in the present study, although harm andapproval were significantly associated with use, they were moving in differentdirections. It is possible that although Proposition 215 and the ongoing debate didnot change attitudes and thus affect use, the policy change and debate may havealtered the relationship between attitudes and use. Examination of correlationsbetween attitudes and use over time suggest that the relationship between attitudesand use has in fact changed.5 Correlations between use, availability, harm, andapproval became weaker over time. This suggests that attitudes about availability,harm, and approval may be becoming somewhat less salient to actual use of marijuana.




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One perplexing finding here was that Californians indicated less approval foroccasional marijuana use, but higher use rates. Likewise, respondents in other statesindicated higher approval for use, but less actual use of marijuana. It may be thatthis finding is an artifact of our data, or it may be another indication that the relationshipbetween attitudes and use is complex and changing. The results further suggestthat people distinguish between recreational and medical use: they can believemarijuana is not greatly harmful and approve of legalization for medical use but stilldisapprove of personal use. Further research is clearly needed to explore and explainthe relationship between attitudes and use, the impact of policy changes on thisrelationship, and the impact of policy changes on use.

ASSUMPTIONS ABOUT THE GATEWAY: OTHER DRUG USE

In light of gateway theory and the historically greater risk of progression toother illicit drug use among marijuana users, how do we understand the apparentlyshort lived but marked increase in marijuana but not other drug use in the 1990s?Should we be concerned that higher rates of initiation and use of marijuana in themid 1990s may yet lead to greater other illicit drug use? Two recent and relatedstudies by Golub and Johnson help clarify these issues. In the first of these studies,they examine probabilities of drug use progression and their covariates and conclude,“The recent increase in youthful marijuana use has been offset by lower rates ofprogression to hard drug use among youths born in the 1970s. Dire predictions offuture hard drug abuse by youths who came of age in the 1990s may be greatlyoverstated” (Golub & Johnson, 2001a, p.225). In a study for the National Instituteof Justice, which included both the criminal and general populations, they conclude:

A standing argument for controlling marijuana use, based on thegateway theory, is that it can lead to the use of more dangerousdrugs. As determined in this study, however, the drug of choice forpersons born in the 1970’s and coming of age in the 1990’s hasbeen marijuana. These youths have been much less prone to progressto other drugs than their predecessors. This suggests that thegateway theory may be less relevant to their experience. (Golub &Johnson, 2001b, p.14)

Furthermore, although the number of new marijuana initiates aged 12-17 wasincreasing in the early 1990’s, this trend peaked in 1995 and the number of newmarijuana initiates declined each year thereafter (OAS, 2002).

The available data suggest that the changes in marijuana policy did not “sendthe wrong message” and lead to greater drug use. Why might this is be so? Consider





the content of the message – imbedded in the debates, the controversy – thatmarijuana is an illegal substance. The very fact that there was a debate highlightedthe tension between possible medical benefit while reminding the public that marijuanais illegal, to say nothing of the message sent by actions of federal agencies, such asraids on distribution centers, threatening doctors with revocation of their DEAprescription authority, criminal prosecution, and exclusion from participation inMedicare and Medicaid programs, and prosecution of anyone involved with medicalmarijuana under federal law (JoinTogether,1998; Bouford,1997; JoinTogether, 2003).

Moreover, the policy change and associated debate may have sent some“message” but not one we would expect to dramatically change marijuana-relatedattitudes and use because the relationship between attitudes and behaviors iscomplex, as is drug use behavior. Various attitudes have a differing relationship touse, and attitudes are not the only influences on drug use. Moreover, researchsuggests that attitudes are helpful in predicting behavior to the extent that they areaggregated, well matched to the behavior in question, and when they are based onpersonal experience and substantial information (Eagly & Chaiken, 1993). Policy-related attitudes about medical legalization likely have not had an impact on druguse behavior because, these variables, together or separately, are not well matchedor explicitly linked to youth recreational marijuana use, and therefore did not alterrecreational use norms and behavior. Finally, what we know about the etiology ofdrug use suggests that drug use is complex and is influenced by numerous factors,some more proximal and personal, and others more distal, contextual, orenvironmental. Medical marijuana policy is a relatively distal factor, compared toother variables that are important in predicting marijuana use, such as individual riskfactors and social influence. Thus, despite the considerable media attention andpublic discussion and debate about legalizing medical marijuana, the policy changeand associated issues may have been sufficiently irrelevant and/or ambivalent toproduce changes in youth and young adult marijuana-related attitudes and use.

LIMITATIONS

The principal limitations of the study are related to the data, the survey sample,the content of the instruments, and mode of administration. The findings andconclusions drawn here are based on reports of respondents in FB anddemographically matched comparison communities and therefore are notgeneralizable to all communities across the U.S. The California sample, likewise,may not be generalizable to persons living in that state; however, our results aresimilar to the NHSDA study. Because legalization of medical marijuana was notanticipated when the wave 1 instrument was administered, baseline attitudes towardsmedical use were not gathered until after Proposition 215 passed. Therefore, it wasnot possible to examine differences both before and after the policy change. However,




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other marijuana-related attitudes were examined over time in California and werecontrasted with comparison states in the sample. Also, the survey sample did notinclude anyone who was younger than 16. Attitudes and use vary with age, and thedistributions were therefore somewhat truncated. There is also a possibility of acohort effect since our samples included 16 to 25 year olds in each year. However,marijuana use is typically initiated around age 16 and is most prevalent amongyoung adults; our sample therefore included the most relevant, potentially using,population and the age group of most concern. Also, all modes of administration,whether telephone, face-to-face, self-administered paper and pencil, or computerizedinterview, have particular strengths and limitations. Data collected through telephonesurvey methods tend to bias estimates due to underreporting (McAuliffe, Geller,LaBrie, Paletz, & Fournier, 1998), and we found this to be true for the most sensitivequestions in the FB survey6 (Livert et al., 2000). Finally, results may be somewhatbiased since attitudes and use may affect each other and a nonrecursive model wasnot employed. Limitations notwithstanding, only one other study has examinedchanges in attitudes and use (NHSDA) after legalization of medical marijuana;these findings therefore add to our rather limited existing knowledge.

CONCLUSION

This research suggests that medical marijuana policy has had little impact onyouth and young adult marijuana-related attitudes and use in selected communitiesacross the country. The ultimate outcome measure in this study was marijuana use,and it remained stable from 1995 to 1999.

Medical marijuana continues to be part of public dialogue and debate nationallyand internationally. As of August 2003, nine states (with more than 20% of the U.S.population) allow medical marijuana use, and Canada recently legalized medicaluse. Nearly three out of four Americans (73%) favor legalization for medicalpurposes, less than one third (31%) support general legalization of marijuana andthe country is nearly evenly split on whether marijuana possession should be treatedas a criminal offense (Gallup Poll, 2000). Regardless of public opinion, however,marijuana is a controlled substance and recreational use, although decriminalized insome states, is still illegal.

Clearly, more research is needed on the impact of medical marijuana policy andhow this may relate to nonmedical marijuana-related attitudes and use. In a reviewof marijuana policy issues in the U.S. and Australia, Single and colleagues (2000)conclude:

Regardless of one’s position on these issues, it is clear that thepolicy debate, both in the United States and in Australia, has not





been well informed by research, and different legislative approacheshave been introduced in different locations at different times, withlittle or no planning for evaluating the impacts of the changes andmonitoring them on an ongoing basis. Both sides of the debatehave presumed that certain impacts will result from changes inpolicy, with little or no reference to empirical evidence (Single,Christie, & Ali, 2000, p. 160).

Attitudes about and use of marijuana need to be monitored as medical use becomesmore prevalent as a result of policy changes. Though the data reported here do notindicate great cause for concern, the effects of these policy changes may not beimmediate. Medical legalization could, for example, lead to increased access to andavailability of marijuana and this may have an effect on prevalence of use. Resultsfrom all such studies will be of interest to policy makers, researchers and publichealth professionals. As states legalize medical marijuana use, it will be critical tounderstand the impact of such policies on substance use and abuse.

1 The Narcotics Control Act of 1956 established the following penalties:

Possession Minimum Sale MinimumFirst offense 2 years First offense 5 yearsSecond offense 5 years Second offense 10 yearsThird and 10 years Sale to 10 yearsFine $20,000

(Bonnie & Whitebread, 1974)

2 Analyses of the Monitoring The Future data from 1975 to 1980 revealed thatstudents in decriminalized states (seven states) did not report either attitudes orrates of marijuana use that were significantly different from students in states wheremarijuana was not decriminalized (IOM, 1999, p. 102; Chaloupka & Laixuthai,1997, p. 253). For a review of several studies on decriminalization and marijuanause see Single, E.W. 1989. The impact of marijuana decriminalization: An update.Journal of Public Health Policy. Winter 1989, 456-466.3 Response Rates: wave 1 = 57.3, wave 2 = 57.8, wave 3 = 49.2.4 Only 8% of all respondents answered this dichotomous yes/no question by saying“yes, for medicinal purposes.” These responses were recoded as 1, yes, in favor oflegalization.5 Correlations not shown.




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6 Fighting Back Survey data were compared to NHSDA data and though prevalenceof alcohol was about the same, reports of other drug use were lower.

ACKNOWLEDGMENTS

This paper represents some of the research conducted for a doctoral dissertationat the Heller School, Brandeis University. It was supported by a NIAAA pre-doctoral fellowship and with funding and data from the Robert Wood JohnsonFoundation. Special thanks are extended to my dissertation chairperson andcommittee: Leonard Saxe, Helen Levine, John Capitman and Denise Hallfors.

REFERENCES

Bachman, J.G., Johnston, L.D., & O’Malley, P.M.1998 Explaining recent increases in students’ marijuana use: Impacts of perceived

risks and disapproval, 1976 through 1996. American Journal of PublicHealth, 88(6), 887-892.

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