TECHNICAL REPORT

The Impact of Marijuana Policies onYouth: Clinical, Research, and LegalUpdateSeth Ammerman, MD, FAAP, Sheryl Ryan, MD, FAAP, William P. Adelman, MD, FAAP,THE COMMITTEE ON SUBSTANCE ABUSE, THE COMMITTEE ON ADOLESCENCE

abstractThis technical report updates the 2004 American Academy of Pediatricstechnical report on the legalization of marijuana. Current epidemiology ofmarijuana use is presented, as are definitions and biology of marijuanacompounds, side effects of marijuana use, and effects of use on adolescentbrain development. Issues concerning medical marijuana specifically are alsoaddressed. Concerning legalization of marijuana, 4 different approaches in theUnited States are discussed: legalization of marijuana solely for medicalpurposes, decriminalization of recreational use of marijuana, legalization ofrecreational use of marijuana, and criminal prosecution of recreational (andmedical) use of marijuana. These approaches are compared, and the latestavailable data are presented to aid in forming public policy. The effects onyouth of criminal penalties for marijuana use and possession are alsoaddressed, as are the effects or potential effects of the other 3 policyapproaches on adolescent marijuana use. Recommendations are included inthe accompanying policy statement.

EPIDEMIOLOGY OF MARIJUANA USE AMONG YOUTH

Three major US national databases track substance use over time,including use of marijuana: Monitoring the Future (MTF),1 sponsored bythe University of Michigan and the National Institute of Drug Abuse; theYouth Risk Behavior Survey (YRBS),2 sponsored by the Centers for DiseaseControl and Prevention; and the National Survey on Drug Use and Health(NSDUH),3 sponsored by the Substance Abuse and Mental Health ServicesAdministration. Although each database uses different methods, all trackand analyze substance use trends. MTF annually surveys approximately50 000 middle and high school students (12th graders since 1975, and 8thand 10th graders since 1991). Data from MTF 2014 revealed that 6.5% of8th graders, 16.6% of 10th graders, and 21.2% of 12th graders usedmarijuana at least once in the past 30 days (“current use”). Current userates peaked in 1996 for 8th graders at 11.3% and in 1997 for 10th and

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-4147

DOI: 10.1542/peds.2014-4147

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

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12th graders at 20.5% and 23.7%,respectively. Current use ratesdecreased for all grades from 2013 to2014, although not in a statisticallysignificant manner. All rates remainlower than the peak rates in the1990s. Daily use rates for 8th, 10th,and 12th graders in 2014 were 1.0%of 8th graders, 3.4% of 10th graders,and 5.8% of 12th graders; previouspeak rates were 1.3% (2002), 3.9%(2002), and 6.6% (2011) for 8th,10th, and 12th graders, respectively.Daily use rates decreased for allgrades in 2014, with the decrease in10th graders’ use statistically signifi-cant. Rates of current marijuana usein the YRBS 2011 data were notsignificantly changed in 2013: 23.1%and 23.4%, respectively. In addition,the Partnership Attitude TrackingStudy, sponsored by the MetLifeFoundation and the Partnership atDrugFree.org, found in their mostrecent survey, in 2012, that ina school-based sample of teenagers ingrades 9 through 12, 8% reportedsmoking marijuana heavily (at least20 times) in the past month. Althoughthis rate decreased from 9% in 2011,there has been a significant increasefrom 5% in 2008.4 NSDUH 2012 datarevealed current use rates were 8.2%in 2002, 6.7% in 2006 and 2007,7.3% in 2009, and 7.9% in 2011 for12- through 17-year-olds. Marijuanacurrent use rates increased for 18-through 25-year-olds each year from2008 through 2011, from 16.5%,18.1%, 18.5%, and 19.0%, respec-tively; 2012 rates remained at 19.0%.Approximately 100 million adultAmericans have ever used marijuana,with a current use rate of 17.4million.5

As noted, MTF and NSDUH arenational databases. State-specific dataare available for many states throughtheir use of the YRBS or equivalent.Using this YRBS data, it is possiblenow to compare use rates for stateswith medical marijuana laws tonational levels. Since legislationallowing medical marijuana tookeffect across a number of states, there

have been no significant increases ordecreases in youth use rates, with theexceptions of Alaska and New Mexico(see Appendix). Whereas Alaska hasreported a significant decrease(8.5%) in current youth use ratessince legislation took effect in 1998,New Mexico has reporteda significant increase between 2011and 2013 in 12th graders only.Additionally, 2 recently publishedstudies have similarly found nosignificant differences in current userates after legislation6 or onlydifferences in 2 states (Montanadecreased, Delaware increased) thatcan be explained equally by chance.7

A number of factors may affect youthuse rates in the future, includingperceived harm of marijuana use,pertinent norms endorsed by youth,and parenting behaviors related toyouth marijuana use. Youth rates mayalso be influenced by specificcomponents of marijuana policies(eg, locations and numbers of medicalmarijuana dispensaries in a givenlocale, regulations of their operation,and how legalization of marijuana fornonmedical purposes isoperationalized).

DEFINITIONS

Cannabinoids

Cannabinoids are biologically activemolecules that bind to receptors inthe human body. Humans produceendocannabinoids, includinganandamide and 2-arachidonoylglycerol, which bind thereceptors known as CB1 and CB2.Both naturally occurring andsynthetic cannabinoid molecules canbind these human endocannabinoidreceptors and have biologic activity.Currently, cannabinoid biology ispoorly understood. Research hasidentified areas of therapeuticpotential for these molecules,including analgesia in chronicneuropathic pain, appetitestimulation in debilitating disease,and spasticity in multiple sclerosis.However, adverse effects can also

occur, ranging from benign(eg, tachycardia and palpitations)to serious (eg, mood, anxiety, andthought disorders). There are 2cannabinoid pharmaceutical productsapproved by the US Food and DrugAdministration. Controlled studiessuggest that pharmaceuticalpreparations that combinecannabinoids with varying affinitiesfor the CB1 and CB2 receptors appearto be able to deliver therapeuticeffects while protecting againstadverse effects.

Marijuana

Marijuana refers to the dried leavesand flowers of the cannabis plant,which contains a large number ofbiologically active cannabinoids.There are numerous species andsubspecies of cannabis. Leaves of theplant are smoked, vaporized, orcooked to extract cannabinoids,which can then be ingested for theirpleasurable psychoactive effects.Cannabinoids from marijuana mayalso produce therapeutic benefits,which has led to the use of marijuanaas a medication. However, marijuanais a complex mixture of cannabinoids(more than 200 have been identified)and other molecules, and therisk–benefit ratio of this mixture hasnot been well defined. Over the pastseveral decades, selective breeding ofmarijuana species has resulted inhigher concentrations ofcannabinoids in the plant, resulting ina more potent psychotropic effect andpossible increased risk of adverseeffects. Any product that requiressmoking to release the desired effectscannot be recommended byphysicians, because smoke containstar and other harmful chemicals.Alternative methods ofadministration of cannabis withoutcombustion have been developed.

Tetrahydrocannabinol

Tetrahydrocannabinol (THC) is theprimary psychoactive cannabinoid inthe marijuana plant. The amount ofTHC in a given plant varies widely,

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depending on the species andsubspecies of marijuana used inbreeding the plant.

Hemp

A low-THC strain of Cannabis sativa,hemp, is not used for psychoactiveeffects. Rather, hemp is used to makea variety of consumer products,including paper, textiles, clothing,health food, and biofuel.Commercially available hempproducts (eg, hemp milk) are devoidof cannabinoids. Hemp is legallygrown in a number of countries,including Spain, China, Japan, Korea,France, and Ireland.

MARIJUANA BIOLOGY

There are various species of marijuana,but the 2 most common species usedfor “medical marijuana” are Cannabissativa and Cannabis indica.Psychotropically, Cannabis sativatypically causes increased alertness andan energetic sense, whereas Cannabisindica is reported to cause more ofa sense of relaxation and, in somecases, lethargy. However, both specieshave been hybridized repeatedly, anda typical plant will have varyingamounts of both sativa and indica.8

Regardless of the species, the mainknown active ingredients responsiblefor the desired medicinal effects areTHC; cannabidiol (CBD),a nonpsychoactive cannabinoid; andarachidonoyl ethanolamide(anandamide), an endogenous ligandthat is involved in binding THC andCBD to endocannabinoid receptors.8

These and other cannabinoids forma complex mix that bind to CB1 andCB2 with varying affinity. These activecompounds bind to the body’sendocannabinoid receptors, which arefound throughout the body. There are 2major endocannabinoid receptors: CB1,found in the brain and nervous system,and CB2, found in the immune system.8

Side Effects of Marijuana Use

The most consistent physical sideeffects are an increase in heart rateand systolic blood pressure. Other

side effects include conjunctivalinjection, dry mouth, orthostatichypotension, increased appetite,increased thirst, drowsiness,insomnia, anxiety symptoms, panicattacks, short-term memory loss,hallucinations, and ataxia.9 There isno specific antidote for marijuanaintoxication, but in cases of severeanxiety symptoms or a panic attack,treatment with a benzodiazepine mayhelp,9 and supportive treatment isused for oversedation.10 Ischemicstroke in young people has also beenreported.11 No fatalities have everbeen reported as solely attributableto a marijuana overdose; however,ingestion of marijuana by childrencan result in a variety of symptoms,including drowsiness, ataxia,nystagmus, hypothermia, andhypotonia. Respiratory depression orcoma has rarely been reported.12

Since the legalization of medicalmarijuana in Colorado, a number ofreports of children with toxicingestions have occurred.10

Treatment with activated charcoal toprevent absorption of the marijuanamay be helpful in specific severesituations if there is no concern aboutlevel of consciousness and iftreatment is initiated well within 2hours of onset of the ingestion. Aswith any other prescribed medicationfor adults, children should not haveaccess to medical marijuana, with theexception of unique circumstancesdiscussed later.

Impact of Marijuana Use onAdolescent Brain Development

New research on adolescent braindevelopment has found that brainmaturation, particularly that of theprefrontal cortex, proceeds into themid-20s. This maturation includessubstantial changes in specializationand efficiency, which occur throughmyelination and synaptic pruning.Synaptic pruning or refining consistsof a reduction in gray matter,primarily in the prefrontal andtemporal cortex areas and insubcortical structures through the

elimination of neuralconnections.13–15 Increasedmyelination also occurs, which allowsincreased neural connectivity andefficiency and better integrity ofwhite matter fiber tracts.16,17 Theprefrontal lobes are the last areas ofthe adolescent brain to undergo theseneuromaturational changes, which,when complete, allow more efficientcommunication between the higher-order areas of the brain and thelower-order sensorimotor areas.18,19

It has been postulated that thedeveloping adolescent brain isparticularly at risk for thedevelopment of substance usedisorders, although a number offactors are involved, including geneticpredisposition, environment, andmental health disorders. The earlierthe adolescent initiates substanceuse, the more likely a substance usedisorder, such as dependence oraddiction, is to occur.20–25 Now, withnewer techniques to study brainstructure and function, data areemerging to suggest that the use ofmarijuana may alter the developingbrain, paralleling what has beenfound in studies on adolescentneurocognitive functioning. Forexample, studies have shown thatadolescents who report regularmarijuana use perform more poorlyon tests of working memory, visualscanning, cognitive flexibility, andlearning.26 Furthermore, the numberof episodes of lifetime marijuana usereported by subjects correlated withoverall lower cognitive functioning.27

Recently, studies evaluating brainstructure have found effects ofmarijuana use on hippocampal,prefrontal cortex, and white mattervolume. Specifically, heavy marijuanausers have been found to havegreater gray matter volume,particularly in the left hippocampalarea, suggesting an interference withsynaptic pruning.28–30 Furthermore,heavy marijuana use was alsocorrelated with poorer verbal andattention performance.31 Functional

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MRI studies examining neural activityin abstinent marijuana users havefound abnormalities in activationduring cognitive tasks, which arepostulated to be correlated withmarijuana-related changes seen incognition and attention, such asdeficits in spatial working memory,verbal encoding, and inhibition.31

Additionally, use of substances mayalter the developing brain itself inways that are not yet fully understoodbut are different from usual braindevelopment, and additional studiesusing multimodal neuroimagingapproaches are needed.32 It is also notclear whether there are criticalperiods during adolescence whenthere is heightened vulnerability tosubstances and whether these changescan be reversed with abstinence orreduced use.32 However, thedocumented effects on cognition andthe emerging data that correlate theseeffects with detrimental effects onbrain structure and function33,34

should serve as cautionary evidence todiscourage recreational marijuana usein adolescents.

CANNABINOID THERAPEUTICS

Pharmaceutical Cannabinoids

Two legal synthetic forms ofcannabinoids are available in theUnited States and approved by theFood and Drug Administration (FDA);a third is available in the UnitedKingdom and Canada. The first,dronabinol (Marinol), is a schedule IIIoral medication approved by the FDAfor the treatment of AIDS-relatedwasting and chemotherapy-inducednausea and vomiting.35 Dronabinol isa capsule that must be taken wholeorally, which may prove problematicin the face of nausea or vomiting.Additionally, the onset of symptomrelief with dronabinol is significantlylonger than that of smoked orvaporized marijuana. The second,nabilone (Cesamet), is an oral capsulewith properties similar to dronabinolbut is a schedule II medicationbecause of a possibly higher abuse

potential. Nabilone is also prescribedfor spasticity secondary to spinal cordinjury.36

A third cannabinoid pharmaceutical isknown as Sativex, a fast-actingnonsynthetic oral-mucosal spray.37

Sativex is currently approved inCanada and the United Kingdom forsymptomatic relief of neuropathicpain in multiple sclerosis. In Canada,it is also approved as an adjunctiveanalgesic treatment in patients withcancer pain. Sativex is undergoinglate-stage clinical testing in Europeand the United States for similarindications. Sativex contains equalamounts of THC and CBD. Sativex israpidly absorbed and easy to titrate,which may make it a more effectiveand easy-to-use medication thandronabinol. Onset of desired effectstypically occurs within minutes.

Medical Marijuana

As of December 2014, medicalmarijuana (cannabis) was legal understate law for adults 21 years and olderin 23 states and the District ofColumbia (for the list of medicalmarijuana states and related updates,see the AAP Web site www.aap.org/marijuana). Cannabis is illegal byfederal law and is a schedule I drugunder the federal ControlledSubstances Act (no legitimate medicaluse). California was the first state tolegalize medical marijuana in 1996.Efforts are under way in a number ofadditional states to legalize the use ofmedical marijuana. Specifics of themedical marijuana laws vary by state,38

but all allow adults to use marijuanafor medical purposes, usually forcertain specified conditions, ifrecommended by a physician, althoughgeneral categories also often include“pain.” Minors are able to obtainmedical marijuana with parents’written permission (and, in some cases,other restrictions) in most states thathave legalized medical marijuana.

Marijuana Delivery

Medical marijuana dispensariesprovide marijuana in forms that can

be either smoked throughcombustion or vaporization oringested to produce the desiredmedical effects. Smoking orvaporizing marijuana results in rapidonset (minutes) of desired effects,whereas ingestion results in a moregradual and delayed onset (half hourto several hours). Vaporization isconsidered less harmful to the lungs,because the marijuana is slowlyheated to its vaporization point,releasing THC and water vapor, ratherthan being burned to its combustionpoint to release THC (as well as tarand other potentially harmfulproducts in smoke). The dose of THCis the same whether the marijuana isvaporized or burned.39–41 It shouldbe noted that use of a water pipe tosmoke marijuana does not eliminateany of the harmful products in thesmoke.

Medical Marijuana and PotentialImpact on Adolescent Use ofRecreational Marijuana

One concern of parents andpediatricians is whether thelegalization of medical marijuanaresults in increased use ofrecreational marijuana byadolescents. This concern ismultipronged: that legitimizingmarijuana as a medication may leadadolescents to believe that marijuanais a safe drug, whether prescribed ornot; that access to marijuana will bemore widespread; and that there willbe efforts to target youth throughmarketing not only for medicalmarijuana but also for decriminalizedand possibly legal use as well. As anexample, the abuse of prescriptiondrugs such as pain relievers,sedatives, tranquilizers, andstimulants for nonmedical purposesis increasing among adolescents andyoung adults, given increasedprescribing practices with thesesubstances.42

When all high school data arecombined for each state in whichmedical marijuana is legalized and forwhich data for current use before and

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after medical marijuana legalizationare available (14 states to date),6,7

no state with legalized medicalmarijuana has shown a statisticallysignificant increase in adolescentrecreational marijuana use exceptDelaware; 2 states (Alaska andMontana) have shown statisticallysignificant decreases. One recentstudy found that states with medicalmarijuana laws, on average, reportedhigher rates of marijuana use in 12-to 17-year-olds over the time periodof 2002 to 2008 (8.68%; 95%confidence interval [CI], 7.95–9.42),compared with the average ratereported by 12- to 17-year-olds in allstates without such laws—(6.94%;95% CI, 6.60–7.28).42 States withlegalized medical marijuana alsoreported lower rates of perception ofriskiness of marijuana than stateswithout. However, this study was notable to determine the changes withineach individual state with legalizedmedical marijuana before the passageof the laws compared with afterpassage of the laws; in fact, in 8 statesthat passed medical marijuana lawswithin the time period studied (since2004), these states already hada baseline rate that was higher thanin states without legalized medicalmarijuana, but no data were providedcomparing marijuana use rates forteenagers in those states before andafter passage of medical marijuanalaws.43 To date, data have shown thatstate-specific legalization of medicalmarijuana has not led to an increasein recreational use of marijuana byadolescents. This relationship iscomplex, and research andepidemiologic surveillance mustcontinue.

Adolescent Use of Medical Marijuana

There are numerous reports in thepopular media by parents regardingthe successful use of medicalmarijuana by adolescents for thetreatment of a variety of healthconditions, includingattention–deficit/hyperactivitydisorder, anxiety, depression, and

autism, as well as anorexia, chronicpain, and postchemotherapy nauseaand vomiting. There are no dataconcerning rates of adolescent use ofmedical marijuana obtained throughlicensed dispensaries. There are alsono published studies on the use ofmarijuana in the pediatric oradolescent patient populations, withthe exception of 1 study evaluatingthe source of marijuana used byadolescents receiving care ina substance abuse treatment facility.This study found that diverted“medical marijuana” had been usedby 74% of the adolescents in thetreatment facility.44

The American College of Physiciansissued a position paper in 2008emphasizing the importance of soundscientific study to evaluate the role ofmarijuana in modern medicaltherapy.45 Although directlyaddressing the adult population, theposition paper stressed thatmarijuana was neither devoid ofpotentially harmful effects noruniversally effective.

In 2010, the California Society forAddiction Medicine issueda statement on the medical aspects ofmarijuana legalization,46 whichaddressed the following 7 points:

1. Effective restrictions created tominimize access to marijuana foranyone younger than 21 years

2. Treatment of adolescent marijuanaabusers, rather than punishment,made universally available

3. Revenue streams for treatmentfunded by fees and taxes frommarijuana sales

4. Warning labels placed on smok-able products

5. Regulation of marketing (adver-tising), distribution, and salesimplemented

6. Evaluation components to docu-ment the impact of legalization

7. Technical difficulties documentingdriving under the influence to beaddressed and clarified

Based on consideration of thesepoints, the California Society forAddiction Medicine concluded that“medical marijuana” is a flawedconcept for the following 3 reasons:administering any medication viadrawing hot smoke into the lungs isinherently unhealthy; although use ofvaporizers, sprays, and tincturessolves problems inherent in smoking,treatment of illness withoutstandardized dose or content of themedication remains a safety issue;and if the public wants to legalizemarijuana, there is no reason to forcephysicians to be gatekeepers ina manner that enables liberal accessto marijuana but generally fails touphold accepted standards of practicefor recommending a potentiallyaddicting medication or drug.

Research Findings onPharmaceutical Cannabinoids andMedical Marijuana

Cannabinoids in all forms andmarijuana have been used for a widevariety of pathologic states anddiseases, including chronic pain,nausea, anorexia, cancer, autoimmuneand rheumatic diseases, inflammatorybowel disease, attention–deficit/hyperactivity disorder, multiplesclerosis and spasticity, depression,anxiety, and posttraumatic stressdisorder. There are no FDA safety orefficacy data about marijuana formedical use. The FDA has approvedsynthetic THC (dronabinol) andnabilone for chemotherapy-inducednausea and vomiting as well asanorexia associated with AIDS, aspreviously discussed. Two recentarticles have reviewed, respectively,current and emerging research on thephysiologic mechanisms ofcannabinoids and their applicationsin managing chronic pain, musclespasticity, cachexia, and otherdebilitating problems as well as theefficacy of marijuana for treatment ofchemotherapy-induced nausea andvomiting.47,48 Research hasdemonstrated that cannabinoids areuseful in treating anorexia associated

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with cancer, nausea and vomitingassociated with chemotherapy,chronic pain, and multiplesclerosis.49–52 A recently publishedstudy also demonstrated that currentmarijuana use was associated withlower levels of fasting insulin, lowerhomeostasis model assessment-estimated insulin resistance, andsmaller waist circumference.53 Tworecently published review articles onmedical marijuana for digestivedisorders and select neurologicdisorders generally noted smallnumbers of studies and mixedresults.54,55 There are no publishedstudies on the use of cannabinoids ormarijuana to treat health conditionsin children or adolescents.

Summary

Cannabinoids may be helpful in adultsfor certain medical conditions.However, for pediatricians therecommendation of medical marijuanais problematic for the followingreasons: It is not regulated by the FDA,its purity and THC content are notconsistently verified, and becausethere are only small case studiesavailable, the risk–benefit relationshipcannot be determined. Available datahave shown that legalization ofmedical marijuana has not led toa significant increase in the currentuse of recreational marijuana byadolescents. Pediatricians may legallyrecommend the use of medicalmarijuana in some states, althoughthere are no consistent datasupporting the effectiveness of its usein pediatric medical conditions. It isalso recognized that in certain uniquesituations, such as with a seriousdisease not amenable to usualtreatment, or a terminal illness,a pediatrician may recommendmarijuana for compassionate medicalpurposes, on a case-by-case basis,using anecdotal information. Thus,without peer-reviewed studiesproviding scientific evidence favorablefor the use of medical marijuana inpediatric populations, recommendingits use would have to be based on an

individual provider’s experience,weighing the needs and potential risksfor an individual patient.

LEGALIZATION OF MARIJUANA: US ANDINTERNATIONAL EXPERIENCES

In contrast with marijuanadecriminalization (ie, no criminalpenalties and either no or reducedcivil penalties for possession orpersonal use), legalization refers topermitting the growing, sale, andpossession of marijuana.Decriminalization and legalization ofmarijuana have been the focus ofglobal debate and controversy forseveral decades and continue to be anactive concern, particularly as theypertain to the adolescent population.It is still illegal to possess andconsume, cultivate, and sell cannabisin almost all countries throughout theworld, although a number ofcountries have adopted actual or defacto policies of decriminalization ofpossession. In many cases, thereluctance of nations globally tochange the illegal status of drug-related activities results in part frominternational commitments andtreaties, which oblige them to adhereto drug prohibition policies.56

The 3 nations that can provide themost information and insight intoexperiences with and consequencesof liberal marijuana laws are Uruguay,Portugal, and the Netherlands. In2013, Uruguay became the firstcountry in the world to legalize thecultivation, sale, and use of marijuanafor both recreational and medicinalpurposes, in response in part to thelarge illegal and crime-associateddrug trafficking occurring in thatcountry.57 At this point, it is too earlyto determine the effect of such a lawon the use of marijuana and theanticipated decrease in drug-associated violent crime in Uruguayand its neighboring countries, butthere is keen interest in how this lawwill play out.

In 2000, Portugal officially abolishedall criminal penalties for the personal

use and possession of all illicit drugs,including marijuana, cocaine, heroin,and amphetamines.58 Although fallingshort of outright legalization, thiscountry has opted to pursue a publichealth approach to the problem ofsubstance use, moving those usingdrugs from the criminal justicesystem to the public health andmedical system. For example, inexchange for jail time, any personcaught using or possessing drugs isrequired to appear before a provincial“dissuasion committee” made up ofan attorney and 2 healthprofessionals, including a socialworker. The committee’s task is todetermine whether the person’s useis limited to recreational use or meetscriteria for addiction. Each committeecan take an individualized approachto each case and has the ability todetermine which sanctions to apply,such as warnings, fines, licensesuspension, or, in the case of drugaddiction, the requirement for drugtreatment. In the latter case, theperson is offered drug treatment asan alternative to a fine or suspensionof his or her driver’s license; failure tocomply with treatment can result inreferral to criminal court.59 Studiessuggest that it has been difficult forjurisdictions to enforce therequirement for treatment and toenlist the assistance of localphysicians in using these committeesfor their patients with substance usedisorders.58 However, proponents ofthis legislation have cited severalstatistics demonstrating that in thefirst 5 years after passage of thislegislation, reduced levels of drug useby teenagers, decreased rates of HIVinfection through injection drug use,and a doubling in the rates of peopleseeking treatment for substance usedisorders were observed.60

The Netherlands has also takena liberal view toward criminalprosecution of cannabis users,although it is still officially illegal topossess, use, sell, and cultivatemarijuana in that country. Assignatory to a number of

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international anti–drug use treaties,the Netherlands is obliged tomaintain the illegality of the use andpossession as well as trafficking andmanufacture of all illicit substances(prohibition), including all thoserelated to the cannabis plant.However, through the Opium Act of1976, the Netherlands attempted tomake a clearer distinction in theirview between drugs such as cocaine,heroin, lysergic acid diethylamide,ecstasy, and mushrooms, which werefelt to have an unacceptable publichealth risk, and hashish andmarijuana, which were thought toentail less overall risk.61 Thus, strictcriminal penalties are maintained forpossessing, dealing in, and selling forlarge-scale drug trade in these drugs.In contrast, the sale of marijuana in“coffeehouses” throughout thecountry is tolerated, as long as theyadhere to a number of restrictions.For example, they cannot advertise,be located near international borders,sell amounts greater than 5 g to anyperson, sell any illicit substancesother than marijuana, and sell toanyone younger than 18 years old.62

The public smoking of marijuana isalso discouraged, although it is notviewed or treated as a criminaloffense.

Of note, the rate of marijuana use didincrease among adolescents after thepassage of these acts but was notthought to be sufficient to repeal orchange the laws regarding youthaccess.63 Recently, however, becauseof increases in what has beendetermined to be international “drugtourism,” the Dutch governmentrefined the laws such that“coffeehouses” are run more asprivate clubs, and only Dutch citizensare allowed to purchase marijuanathrough them.64 In 2012, a judgeupheld a government plan to banforeign tourists from buyingmarijuana by introducing a “weedpass” available only to Dutch citizensand permanent residents. Worriedthat tourism will take a hit,Amsterdam’s mayor, Eberhard van

der Laan, worked out a compromisewith the national government, whichrelies on municipalities and localpolice to enforce its drug policies.65

The Dutch government has recentlydecided to reclassify high-strengthcannabis (.15% THC containing)into the same category as cocaine orheroin, meaning that the“coffeehouses” will not be able to sellthis product, and only the lower-strength cannabis will be available.66

DECRIMINALIZATION OF MARIJUANA:US AND INTERNATIONAL EXPERIENCES

Decriminalization of marijuanatypically is defined as the reduction ofcriminal offenses for the possessionof small amounts of the marijuanaplant to a misdemeanor, infraction, orcivil penalty (eg, similar to a parkingor speeding ticket) rather thana felony charge. In addition toPortugal and the Netherlands,a number of other countries haveopted to decriminalize the use andpossession of marijuana forindividual use, although the specificpolicies vary widely across nations.For example, several South Americancountries (ie, Venezuela, Argentina,Columbia, and Peru) have toleratedthe use and possession of “smallamounts” (,1 g) of marijuana (notthe sale or trafficking) or haveeffectively abolished requirements forjail time or fines for possession.67

In some cases, countries requiremandatory drug treatment andrehabilitation for any use(eg, Venezuela, Argentina, andBrazil).67,68 In Brazil, Bolivia, Ecuador,and Paraguay, recreational use isillegal.67,68 Chile specifically allowsprivate growing and possession forrecreational use or medical conditionsbut specifically prohibits group use,buying, and trafficking.69

Canada, along with several Europeancountries, likewise tolerates the useor possession of small amounts ofmarijuana by individuals and has alsolegalized medical marijuana use.70

The definition of “a small amount”

varies between 3 and 30 g dependingon the country. Furthermore, in somecases use is designated asa misdemeanor without prison terms(eg, Hungary).70 Czechoslovakiarecently passed laws decriminalizingthe use of all drugs, in much the sameway as Portugal did in 2000.71 MostAsian nations still do not makea distinction between use orpossession of small amounts and theselling of or trafficking in largerquantities—all of which can carrystiff penalties including fines orsignificant prison sentences. In rarecases (eg, China and Saudi Arabia),executions have taken place.72,73

Since 1937, the US federalgovernment’s approach has remainedthat of prohibition, meaning that itslaws and its participation ininternational treaties have upheld theillegal status of use, possession,cultivation, and sale of marijuana.These laws also provide the basis forefforts to deter individual use, as wellas interdiction efforts aimed at large-scale selling, smuggling, andtrafficking of all illicit drugs.74

Despite the fact that there are nosignificant plans of the current USadministration to change thisposition, 18 states currently (2014)have laws that have decriminalizedthe individual use and possession ofmarijuana,75 and 4 states and theDistrict of Columbia, have legalizednonmedical use, marketing, and salesof marijuana for adults.

In 2009, the Justice Departmentannounced that the federalgovernment would not prosecutemedical marijuana providers andconsumers who were in compliancewith state laws. Subsequently, in2013 the Justice Department alsoannounced that it would not interferewith the legalization laws inWashington State and Colorado.Eighteen states have decriminalizedthe use and possession of smallamounts (usually #1 ounce, althoughamounts vary by state) of marijuanafor personal use; see www.aap.org/

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marijuana for the list of states andlatest updates. The specifics of thelaws vary across states, as does thedegree to which these laws areenforced at the local level. Althougharrests still occur, penalties are minorand range from first offensesresulting in no penalty to fines thatmay increase with subsequentoffenses, and, in some cases,requirement for treatment orrehabilitation. In other cases, offenseshave been reduced to civil violations,resulting in fines or requirements foreducational programs.75 The keyaspect from the standpoint ofdecriminalization is that althoughthese offenses are considered“criminal,” the level of offense hasbeen reduced to a misdemeanor or aninfraction rather than a felony charge,which carries higher immediatecriminal consequences, such as prisontime. Felonies also carry significantlong-term collateral consequences,such as the inability to obtain studentloans, stigma related to employment,and the inability to vote.

ARGUMENTS FOR AND AGAINSTLEGALIZATION OR DECRIMINALIZATIONOF MARIJUANA

Legalization

Because Uruguay is the only countrythat has officially legalized the saleand possession of marijuana, thereare no available studies evaluatingthe effect of this action on use byadolescents and young adults. Inresponse to the ongoing debate aboutthis issue, however, arguments havebeen put forth both for and againstlegalization. Proponents oflegalization sometimes claim thatmarijuana is a benign substance, withlow rates of dependence and physicalor behavioral effects, and thatlegalization would reduce illegal tradeand the crime associated with it byinstituting regulations.76

Furthermore, proponents argue thatthese regulations would providesignificant and needed monetaryresources, through taxation, and

would reduce the use of resources forinterdiction.76 In terms of effects onadolescents, proponents oflegalization also argue that therequirement for selling only throughlicensed stores, as with tobacco andalcohol, with penalties for thoseselling to minors, would limit theamount of marijuana available toyouth.76

Proponents of legalization also citereports from the United NationsOffice on Drugs and Crime that haveconcluded that efforts to control thelarge-scale production and traffickingof illegal drugs not only have beenfutile but have not taken into accountthe human and economic toll thatincarceration for drug-related crimeshas had on individuals, families, andsocieties.77 And because the primaryapproach to resolving illicit drugproblems has emphasized lawenforcement, it has been difficult forthe public health community torespond appropriately to the medicalproblems of dependence andaddiction and their role in drug-related offenses, such as intoxicateddriving by minors.77

Opponents of legalization citea number of concerns specificallyabout youth and young adults. Forexample, there is significant concernthat the legalization of marijuana willopen the floodgates of marketing,with much of that being subtlemarketing toward youth, even thoughany such legalization laws would beexpected to apply only to adults olderthan either 18 or 21 years. Theexperience with the alcohol andtobacco industries, which use subtleand creative messaging directed atyouth, has been cited as one of thereasons that alcohol and tobacco areused at such high rates byadolescents and young adults, and itis feared that similar marketingstrategies would contribute toincreased rates of use anddependence by adolescents.78 Moreimportantly, opponents argue thatdespite earlier reports claiming that

marijuana has fewer long-term effectsthan either tobacco or alcohol, thereare newer data on the medical andpsychological effects of cannabis onadolescents, particularly youngerteens. Research continues toaccumulate on its potential negativeeffects on brain development andcognitive effects on short-termmemory and learning.79,80 Physicaleffects on coordination and reactiontime raise serious concerns about thecontribution of marijuanaintoxication to motor vehicle injuriesand deaths.81,82 Medicalconsequences include respiratoryeffects83 and the long-term effects ofexposure to carcinogenic componentsof marijuana smoke, with a recentstudy from New Zealand findingelevated rates of lung cancer in adultswith histories of long-term marijuanasmoking.84 Studies have also shownconnections between chronicmarijuana use and mental healthdisorders such as anxiety andschizophrenia.85

Ultimately, marijuana’s health andbehavioral risks when used by eitheryouth or adults may be irrelevant interms of the criteria with whichmarijuana policy should be evaluated.Rather, the most salient criterion forevaluating these policies should bethe determination of which policy(criminalization, decriminalization, orlegalization) is most effective inminimizing harm.86 One mainargument against legalization but insupport of decriminalization is thatillicit substance use, includingmarijuana use, should be considereda public health problem, notsomething that should be given the“green light,” as would be the case ifwidespread legalization of marijuanaand other substances occurred. Thisis an acknowledgment of theseriousness of issues related tosubstance use disorders forindividuals and society, recognizingthat problems related to use andsmall-scale possession, in contrast tothose associated with large-scaleproduction and trafficking, are best

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dealt with in the public health andmedical system, not the criminaljustice system. This argumentrepresents the commonly observedtension between a public healthsystem’s role in prevention,rehabilitation, and treatmentcompared with the criminal justicesystem’s primary role of removingcriminals from society (incarceration)and punishing them.

The amount of resources used by thecriminal justice system to arrest,process, adjudicate through courts,and imprison people for minor drug-related charges (separate from moresevere crimes, such as selling andtrafficking) are significant, and manyhave cited potential cost savings asa reason for changing policies onindividual use and possession.

Decriminalization

Specific arguments fordecriminalization are similar to thosefor legalization but also focus on thecosts (both human and monetary)that are involved in the enforcementof criminal laws for what areconsidered either minor infractionsor offenses that indicate a person’sneed for drug treatment. Data areabundant on the costs involved in thearrest, detention, court proceedings,and the imprisonment of youth andadults who have committed theoffense of possessing small amountsof marijuana, which in 2006 cost stateand local governments $10.3billion.87 What is often not discussedare the long-term effects thatadjudication or imprisonment fora marijuana offense can have for anindividual and the subsequent effectthat this can have on an individual’sfamily and on society.88

POSSIBLE EFFECTS OF LEGALIZATIONAND DECRIMINALIZATION OFMARIJUANA ON ADOLESCENTS

US Experience With Decriminalization

Since a number of states havedecriminalized marijuana, there hasbeen close scrutiny to determine

whether this change would result inhigher use rates among adolescents,in particular. Several studies havecompared the rates in the initial 11states that decriminalized marijuanain the 1970s before and after criminallaws were changed. None of thesestudies have supported the concernthat rates would increase sharply instates with decriminalization. In fact,these studies, published in the early1980s, found that the overall nationaldeclines in rates of use of alcohol andillicit substances, includingmarijuana, seen since the 1970s weresimilar in states with and withoutdecriminalization laws.89–91 Single,89

one of the authors of these initialstudies, provided an update of thisissue in 1989 and found that althoughstates with penalties for possessionlimited to fines experienced increasedrates of marijuana use, theseincreases were similar to or lowerthan those observed in states thatretained stiff penalties. They alsoconcluded that states withdecriminalization laws experiencedsignificant savings in criminal justicecosts and resources.

International Experiences WithDecriminalization

In calling for a more humaneapproach to the problems of drug useand to address the concerns ofopponents who believe thatdecriminalization will result inwidespread increases in marijuanaand other illicit substance use, peoplehave also looked to the internationalexperience of drug policy reform. Inthe case of Portugal, it has beendemonstrated that in the 5 to 10years since their laws were passeddecriminalizing all drug use andpossession, twice as many peoplehave sought treatment for addictionthan did so before thedecriminalization of all illicit drugs in2001. And although marijuana userates were not higher than incountries that have stiff penalties,such as Norway and the UnitedStates, it is important to note that

reported rates of use among youth inPortugal did increase during thattime.92 Since 2001, Portugal has alsoexperienced decreased rates of HIVinfection from injection drug use,although rates of heroin use andsome drug-related crimes haveincreased in some locales throughoutthe country.58

Although it is difficult to make cross-national comparisons, givendifferences in culture, legal statutes,and methods of data collection, in theNetherlands there has been an overalldecline in the rates of current usesince the 1970s, paralleling what hasbeen observed across the EuropeanUnion. Specifically, the current userate among Dutch youth ages 15 to 24is currently around 11%; this ishigher than the 8.4% average use rateof other European Union nations,perhaps because of the liberalapproach to marijuana selling and usein the Netherlands.93 Both of theserates are significantly lower thanrates reported in the United States.42

COMPARISONS BETWEEN MARIJUANA,ALCOHOL, AND TOBACCO

One argument in support ofmarijuana legalization is that alcoholand tobacco cause more harm tosociety, in terms of financial andhealth costs, than marijuana.94 Thisargument is based on their belief thattight controls on the use, possession,and sale of what some considera benign substance, such asmarijuana, are inconsistent withpolicies that permit the legal use ofsubstances such as alcohol andtobacco, which cause far more harmto individuals and society. Few wouldargue that the use of tobacco andunderage or excessive use of alcoholare not harmful. However, theharmful effects of marijuana arerarely included in discussions aboutlegalization of recreational andmedical marijuana use, despite theemerging and convincing data on theneurodevelopmental consequences ofmarijuana and its potential for

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addiction. Proponents of legalizationalso claim that legalization wouldfacilitate tighter control of its usethrough regulation, such as requiringa license for selling, restricting sale tothose 21 years of age or older, andtaxation, similar to what is done foralcohol and tobacco.94 However, thelax enforcement of such laws foralcohol and tobacco and the push ofadvertisers to market these productsto adolescents, despite legalsanctions, both suggest that it will bedifficult to enforce similar limits oflegal sale and advertising ofmarijuana to youth.78 Rather thanlegalizing marijuana, given datasupporting a causal relationshipbetween tobacco advertising andpromotional activities, andsubsequent initiation and use oftobacco by youth, it has beensuggested that tighter regulations andstricter enforcement of lawsregulating advertisement and sales oftobacco and alcohol to minors areneeded.95

The high current use rates ofunderage alcohol and tobacco among12- to 17-year-olds (12.9% and 8.6%,respectively),42 despite state lawsbarring the sale of alcohol to thoseyounger than 21 years and tobaccousually to those younger than 18years, support this concern. Anadditional concern is that over thepast decade, adolescents’ perceptionof the risks of heavy drinking, tobaccouse, and marijuana use have declined,with significantly fewer youth nowreporting that there is “great risk”associated with routine or heavy useof these substances.1 Researchers citethese changes in perception of risk ascontributors to this reversal of ratesamong youth. These perceptions havechanged despite the emergence ofsocietal norms opposing tobacco usein public and media coverage aboutexcessive alcohol use and driving.96

SOCIETY AND SOCIAL JUSTICE

The majority of arrests for marijuanapossession occur among adolescents

and young adults; these arrestsdisproportionately affect young menand boys, particularly young blackmen and boys. Ongoing criminalprosecution for marijuana possessionhas led to serious and oftenpermanent legal problems for theseyouth. Since 1991, marijuana arrestshave nearly doubled,87 but levels ofmarijuana use have not declined toa similar extent.1 In 2009, there were858 408 arrests for marijuana, ofwhich 755 399 were for possession(88% of the total). Fifty-two percentof all marijuana possession arrestswere in adolescents and youngadults: Male adolescents ages 15 to19 years accounted for 28% of allpossession arrests, and young menages 20 to 24 years accounted foranother 24%. Thus approximately392 807 adolescents and youngadults were arrested for marijuanapossession in 2009.97 Although blackpeople account for 13% of thepopulation and only 15% of currentmarijuana users, since 2007 theyhave also consistently accounted forbetween 31% and 34% of marijuanapossession arrests, reflecting thedisparities in enforcement ofprevailing laws across racial andethnic groups throughout the UnitedStates.97–99 Although no national dataare available about the amount ofmarijuana that adolescents have intheir possession at the time of arrest,the Federal Bureau of InvestigationUniform Crime Reports databaserevealed that, for example, inMassachusetts beforedecriminalization, 90% of arrestswere for 1 ounce or less, and inConnecticut, 75% of arrests in thoseolder than 18 years were for a halfounce or less.100,101 Afterdecriminalization of marijuanapossession went into effect inMassachusetts in 2008, the number ofminors arrested for marijuanapossession dropped by 89%–90%—to 189 in 2009 and 170 in 2010.

Data are not available on thepercentages of youth who arearrested for marijuana possession

who then have their chargesdismissed, are charged withmisdemeanors and petty offenses,have some kind of felony drugconviction, or are imprisoned. Thesenumbers vary from state to state.Many people are held at least forsome time in jail before they arecharged with a crime. This can bea very traumatic and dangerousexperience and could result in lostjobs and derailed education. Beingreleased from jail can also bedangerous, because many jails releasenonminors in the middle of the night,often without theirpossessions.102,103 Currently, criminalprosecution for marijuana possessionby teenagers and young adultsadversely affects almost 400 000youth a year in the United States.87

Imprisonment represents directremoval of a person from neededroles in society: adults away fromjobs, parents from young children,and adolescents from school and theirfamilies. Furthermore, these peopleare placed in environments wherethey are likely to have close contactwith people who have committedserious violent offenses or are repeatoffenders.

Advocates of decriminalization citethe importance, particularly foryouth, of ensuring that criminaloffenses are limited to misdemeanorsor petty offenses or noncriminal civilviolations. These reduced violationsdo not carry the requirement forshort-term prison time or probationor the longer-term stigma of a felonydrug conviction, which may result inthe inability to obtain student loansor attend school, ineligibility forcertain housing, and difficulties withfuture employment.104 For example,students applying to college may bedenied federal financial aid becauseof a drug conviction, includingmarijuana possession (part of theHigher Education Act Aid EliminationPenalty passed by Congress in 1998).Penalties for marijuana possession of1 ounce or less range widely fromstate to state, with maximum

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penalties ranging from a fine of only$100 to $5000 and 5 years in prison.Possession of greater than 1 ounce ofmarijuana usually results in largermaximum fines and jail time. As withany other law, penalties for marijuanapossession should not be targeted ator applied disproportionately tominority populations.

Detention facilities are also ill-equipped to deal with issues that mayrelate to an inmate’s substance usedisorder, and many adolescents donot receive any treatment.105 Fewtreatment programs are available asan alternative to incarceration.Treatment and diversion programsfor drug use are not a usual focus ofthe criminal justice system, althoughsome jurisdictions require drugeducation or community service forminors convicted of drug possession.Juvenile drug courts have also beenused for drug education andtreatment of minors convicted of drugpossession.105

The main argument againstdecriminalization is that it will lead toincreased rates of marijuana use andillicit substances in general, which inturn would lead to increases incriminal activity related to sales anddistribution. It has also been arguedthat adolescents are frequent buyersof small amounts of marijuana, whichleads to higher numbers of local drugdealers and more frequentinteractions with them. Nearly 16%of 12- to 17-year-olds who boughtmarijuana did so from someone theyhad just met or did not know.106

Anecdotally, some illicit drug dealerspromote and sell numerous drugssimultaneously, such as cocaine andmethamphetamine. Thus, adolescentbuyers using the black market arepotentially exposed to andencouraged to buy and try otherpsychoactive substances. Opponentsalso argue that it sends the “wrongmessage” to young people when thepenalties for use are reduced tominor infractions that may carry littleincentive to change behaviors.

Driving while intoxicated bymarijuana may need a different policyapproach. Cannabis is the mostprevalent illicit drug detected infatally injured drivers and motorvehicle crash victims.107 However,currently there are no accepted lowerlevels of blood concentration forcarboxy-THC, the active metabolitemeasured in serum, or standardsregarding serum thresholdsindicating intoxication.81 Becausecarboxy-THC is lipid soluble,a positive serum level can be detectedseveral weeks after abstinence in thechronic user.81 Individual drivers canvary widely in their sensitivity forTHC-induced impairment, as evincedby weak correlations between THC inserum and magnitude of performanceimpairment.81 Plasma of driversshowing substantial impairmentcontained both high and low THCconcentrations, and different driverswith high plasma concentrationsshowed substantial impairment, noimpairment, and even someimprovement.108,109 Other THCmetabolites are being investigated tohelp distinguish between acute andmore chronic or heavy use.110

Although blood alcohol content canbe accurately measured andcorrelated with behavioralimpairment, this may not be the casewith cannabis, in part because alcoholis water soluble, whereas cannabis isstored in the fat and is metabolizeddifferently, making a directcorrelation with behavior difficult tomeasure.109 Because marijuana usedoes cause impaired driving,pediatricians should explicitlycounsel adolescents to never driveunder the influence of marijuana.

SUMMARY

Marijuana use in pediatricpopulations remains an ongoingconcern, and marijuana use byadolescents has known medical,psychological, and cognitive sideeffects. Marijuana alters braindevelopment, with detrimental effectson brain structure and function, in

ways that are incompletelyunderstood. Furthermore, marijuanasmoke contains tar and other harmfulchemicals, so it cannot berecommended by physicians. At thistime, there is no published researchto suggest benefit of marijuana use bychildren and adolescents. In thecontext of limited but clear evidenceshowing harm or potential harm frommarijuana use by adolescents, formalrecommendations for “medicalmarijuana” use by adolescents arecontrary to current evidence.Exceptions may be those that pertainto emerging anecdotal informationconcerning the medical potential ofcannabinoid medications, which maybe an option for children who havelife-limiting or severely debilitatingconditions and for whom currenttherapies are inadequate. Criminalprosecution for marijuana possessionadversely affects hundreds ofthousands of youth yearly in theUnited States, particularly minorityyouth. Current evidence does notsupport a focus on punishment foryouth who use marijuana. Rather,drug education and treatmentprograms should be encouraged tobetter help youth who areexperimenting with or dependent onmarijuana. Decriminalization ofrecreational use of marijuana byadults has also not led to an increasein youth use rates of recreationalmarijuana. Thus, decriminalizingsimple possession of marijuana forboth minors and young adults may bea reasonable alternative to outrightcriminal prosecution, as long as it iscoupled with drug education andtreatment programs. The impact ofoutright legalization of adultrecreational use of marijuana onyouth use is unknown, and it cannotbe recommended.

At this time, evaluative data on theimpact of recently enacted lawsregulating and taxing marijuana foradults in Washington State andColorado may inform the issue of howyouth are affected. At a minimum,marijuana should be regulated

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closely, similar to what has beenattempted for tobacco products andalcohol, in terms of restrictions onmarketing and sale to those youngerthan 21 years old, continued penaltiesfor the wholesale distribution ofmarijuana, clean indoor air acts toprotect against passive marijuanasmoke, and bans on marijuana use oncollege campuses, schools, and childcare centers. However, the AAPrecognizes that despite ongoingregulation of the tobacco and alcoholindustries, youth remain commontargets and ultimately consumers ofthese products. Thus, more effectiveregulation of the medical marijuanaand legal marijuana industries iscrucial to truly protect children andadolescents from potential harm.

APPENDIX. STATISTICAL SIGNIFICANCEOF THE INCREASE OR DECREASE OFCURRENT TEEN USE OF MARIJUANABEFORE AND AFTER PASSAGE OFA MEDICAL MARIJUANA LAW

The Youth Risk Behavior Survey(YRBS) provides an online tool toaccess the statistical significance ofchanges in the variable data theycollect. Below is specific informationdetailing the P value of the increaseor decrease in current marijuana userates for 12th graders in the yearsimmediately preceding passage ofa state medical marijuana lawcompared with the most recent yearfor which there are data. To accessthe full information with tables on theYRBS Web site, visit http://nccd.cdc.gov/YouthOnline/App/QuestionsOrLocations.aspx?CategoryId=C3.

This application allows only runningthe statistical significance for states inwhich YRBS collected data, which isnot applicable to California, Oregon,and Washington.

Alaska

In 1995, 30.9% of 12th graders inAlaska reported being currentmarijuana users (having used in thepast month) on the YRBS. In 1998, thevoters of Alaska passed their medical

marijuana law. In 2011, only 22.2% of12th graders in Alaska reported beingcurrent marijuana users on the YRBS.The difference in use rates—8.7percentage points—is statisticallysignificant, with P = .03. In 2013, 22.4%of 12th graders were current users,a nonsignificant increase from 2011.

Maine

In 1997, 33.1% of 12th graders inMaine reported being currentmarijuana users (having used in thepast month) on the YRBS. In 1999, thevoters of Maine passed their medicalmarijuana law. In 2011, 27.3% of12th graders in Maine reported beingcurrent marijuana users on the YRBS.The difference in use rates—5.8percentage points—is not statisticallysignificant, with P = .12. In 2013,29.5% of 12th graders were currentusers, a nonsignificant increase from2011.

Hawaii

In 1999, 27.2% of 12th graders inHawaii reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2000,Hawaii passed its medical marijuanalaw via the legislature. In 2011, 25.4%of 12th graders in Hawaii reportedbeing current marijuana users on theYRBS. The difference in use rates—1.8percentage points—is not statisticallysignificant, with P = .67. In 2013, 22.9%of 12th graders were current users,a nonsignificant decrease from 2011.

Nevada

In 1999, 27.5% of 12th graders inNevada reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2001,Nevada passed its medical marijuanalaw via the legislature. In 2009, only22.7% of 12th graders in Nevadareported being current marijuanausers on the YRBS. The difference inuse rates—4.8 percentage points—isnot statistically significant, P = .34.In 2013, 21.5% of 12th graders werecurrent users, a nonsignificantdecrease from 2009.

Montana

In 2003, 29.1% of 12th graders inMontana reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2004, thevoters of Montana passed theirmedical marijuana law. In 2011,27.2% of 12th graders in Montanareported being current marijuanausers on the YRBS. The difference inuse rates—1.9 percentage points—isnot statistically significant, withP = .63. In 2013, 24.0% of 12thgraders were current users, anonsignificant decrease from 2011.

Vermont

In 2003, 37.2% of 12th graders inVermont reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2004,Vermont passed its medicalmarijuana law via the legislature.In 2011, 31.5% of 12th graders inVermont reported being currentmarijuana users on the YRBS. Thedifference in use rates—5.7percentage points—is not statisticallysignificant, with P = .07. In 2013,32.8% of 12th graders were currentusers, a nonsignificant increase from2011.

Rhode Island

In 2005, 34.3% of 12th graders inRhode Island reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2006,Rhode Island passed its medicalmarijuana law via the legislature.In 2011, 34.0% of 12th graders inRhode Island reported beingcurrent marijuana users on the YRBS.The difference in use rates—0.3percentage points—is not statisticallysignificant, with P = .93. In 2013,37.0% of 12th graders were currentusers, a nonsignificant increase from2011.

New Mexico

In 2007, 25.4% of 12th graders inNew Mexico reported being currentmarijuana users (having used in thepast month) on the YRBS. In mid-

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2007, New Mexico passed its medicalmarijuana law via the legislature. In2011, 26.8% of 12th graders in NewMexico reported being currentmarijuana users on the YRBS. Thedifference in use rates—1.4 percentagepoints—is not statistically significant,with P = .66. In 2013, 32.7% of 12thgraders were current users,a significant increase from 2011.

Michigan

In 2007, 19.0% of 12th graders inMichigan reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2008,Michigan voters passed their medicalmarijuana law. In 2011, 21.1% of12th graders in Michigan reportedbeing current marijuana users on theYRBS. The difference in use rates—2.1 percentage points—is notstatistically significant, with P = .57.In 2013, 24.7% of 12th graders werecurrent users, a nonsignificantincrease from 2011.

Arizona

In 2009, 28.2% of 12th graders inArizona reported being currentmarijuana users (having used in thepast month) on the YRBS. In 2010,Arizona voters passed their medicalmarijuana law. In 2011, 27.1% of 12thgraders in Arizona reported beingcurrent marijuana users on the YRBS.The difference in use rates—1.1percentage points—is not statisticallysignificant, with P = .74. In 2013, 25.4%of 12th graders were current users,a nonsignificant decrease from 2011.

New Jersey

In 2009, 31.0% of 12th graders inNew Jersey reported being currentmarijuana users (having used in thepast month), on the YRBS. In 2010,New Jersey voters passed theirmedical marijuana law. In 2011,33.4% of 12th graders in New Jerseyreported being current marijuanausers on the YRBS. The difference inuse rates—2.4 percentage points—isnot statistically significant, with P = .74.In 2013, 29.7% of 12th graders

were current users, a nonsignificantdecrease from 2011.

LEAD AUTHORS

Seth D. Ammerman, MD, FAAPSheryl A. Ryan, MD, FAAP*William P. Adelman MD, FAAP

COMMITTEE ON SUBSTANCE ABUSE,2014–2015

Sharon Levy, MD, MPH, FAAP, ChairpersonSeth D. Ammerman, MD, FAAPPamela K. Gonzalez, MD, FAAPSheryl A. Ryan, MD, FAAPLorena M. Siqueira, MD, MSPH, FAAPVincent C. Smith, MD, MPH, FAAP

LIAISONS

Vivian B. Faden, PhD – National Institute of Alcohol

Abuse and Alcoholism

Gregory Tau, MD, PhD – American Academy of Child

and Adolescent Psychiatry

STAFF

James Baumberger, MPPKatie Crumley, MPPRenee Jarrett, MPH

COMMITTEE ON ADOLESCENCE,2014–2015

Paula K. Braverman, MD, FAAP, Chairperson*William P. Adelman, MD, FAAPElizabeth Meller Alderman, MD, FSAHM, FAAPCora C. Breuner, MD, MPH, FAAPDavid A. Levine, MD, FAAPArik V. Marcell, MD, FAAPRebecca Flynn O’Brien, MD, FAAP

LIAISONS

Margo Lane, MD, FRCPC – Canadian Pediatric Society

Benjamin Shain, MD, PhD – American Academy of

Child and Adolescent Psychiatry

Julie Strickland, MD – American College of

Obstetricians and Gynecologists

Lauren B. Zapata, MD, PhD, MSPH – Centers for

Disease Control and Prevention

STAFF

James Baumberger, MPPKaren S. Smith

*The views expressed are those of the author anddo not necessarily reflect the policy or position ofthe Department of the Army, Department ofDefense, or the US Government.

RESOURCES

American Academy of Pediatrics:www.aap.org/marijuanaNational Institute on Drug Abuse:www.drugabuse.govOffice of National Drug Control Policy:www.whitehouse.gov/ondcp

Smart Approaches to Marijuana:http://learnaboutsam.comSubstance Abuse and Mental Health ServicesAdministration:www.samhsa.govUS Department of Health & Human Services, Officeof Adolescent Health:www.hhs.gov/ash/oah/resources-and-publications/publications/substance-abuse.html

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