An Analysis of Marijuana Policy: Part II

The Supply of Marijuana: Comparing Prohibited and Regulated Markets

Policy implementation does not occur in an ideal world. Prohibition of supply has not, in practice, meant that no one has had access to marijuana--though this may have been the intent of those who framed that law. Similarly, regulation of supply does not mean that everyone who uses marijuana will use it moderately, minimizing its harm. Prohibition of supply does make marijuana less accessible than it might otherwise be to a large number of Americans, and thus it- almost certainly reduces the total amount of the drug used and the number of users, Such reduction is the purpose of a partial prohibition policy and to some extent it is accomplished. Argument.for a regulated, legal supply of marijuana are largely based on the social costs and incomplete effectiveness of prohibition of supply and on the belief that regulating rather than prohibiting the supply would not lead to an unacceptably large increase in use.

Under a regulatory policy, the cultivation, importation, manufacture, distribution, retailing, and, of course, use of marijuana would no longer be illegal per se. Within this broad category, specific policy option.,; range from a virtual withdrawal of the government from marijuana control (allowing the drug to be freely produced, advertised, and sold, very much as coffee is today--but protecting the consumer against harmful adulterants), to a carefully controlled system of licensing, to a government monopoly on retail sale-, wholesale distribution, or manufacture of marijuana. Thus, contro s might be placed on such factors as quality, potency, amount purchased, time and place of sales, age of buyers, etc. If marijuana were regulated as is alcohol, restrictions would derive from federal, state, or local statutes, with the majority of them not at the federal level. Regulations might also include legally fixed prices--as in state-controlled alcohol beverage retailing or as a consequence of the levying of excise taxes.

The specific form and content of any proposed regulatory system are very important for those faced with the decision as to whether and under what conditions to remove penalties for the distribution of marijuana, but ,such details are beyond the scope of this report.

The advantages of a policy of regulation include the disappearance of most illegal market activity, the savings in economic and social costs of law enforcement directed against illegal supply systems, better controls over the quality and safety of the product, and, possibly, increased credibility for warnings about risks. The major disadvantages are a consequence of increased marijuana use--increases in harm to physical health and to individual development and behavior.

Costs of Prohibition of Supply

The number of arrests for violations related to supply is much lower than for those related to use. But enforcement of prohibition of supply is far more costly per arrest. Long undercover investigations, the purchase of expensive hardware, and the major consumption of trial and correctional resources are largely attributable to the prohibition of supply.

The National Institute on Drug Abuse (1975) estimated that in 1974 costs for enforcement of marijuana laws totaled $600 million for state and local agencies. If we extrapolate from the California data (State Office of Narcotics and Drug Abuse, 1977), about three-fourths of the total is spent enforcing the law against marijuana supply. The total federal drug abuse law enforcement budget was more than $400 million in 1979, about half of which was the budget for the Drug Enforcement Administration. At the federal level, authorities do not break down their expenditures on enforcement between marijuana and other drugs; virtually all of the federal resources that are allocated to marijuana are spent in attempting to enforce the laws against supply.

The task of attempting to make the prohibition of supply effective is, of course, formidable. In 1969 Operation Intercept demonstrated the practical difficulty of sealing off the Mexican border. In the weeks the operation lasted, hundreds of thousands of vehicles and passengers were searched every day; ensuing traffic jams caused expenditures by U.S. tourists and commuters to Mexico to drop 50-70 percent below normal (Kaplan, 1971). The situation was intolerable and the program was halted. However, the federal government has continued efforts to improve border surveillance and to penetrate trafficking networks. The White House Strategy Council on Drug Abuse (1979) notes that more than 5.6 million pounds of marijuana was seized at the Mexican border over a 12-month period in 1977-1978; a large increase over tile 1.5 million pounds seized during the previous 12 months, "but a fraction of marijuana entering the country." Recently, the Council has suggested strengthening border surveillance by cooperative efforts of tile Drug Enforcement Administration, the Customs Service, the Coast Guard, and tile Department of State and by tile use of the detection capabilities of the armed forces as well.

In our view, tile prospects for major success in these ventures are not great. Nor is there much likelihood that some recently suggested measures against marijuana production outside the U.S. would make future prohibition of supply more effective. For example, the White House Strategy Council on Drug Abuse has supported crop eradication programs, provided that tile proposed method of eradication is evaluated for possible health and environmental consequences and that a readily distinguishable marker is added to any chemical herbicides that are used, but the political obstacles to this course would be significant. Entirely apart from tile views of producer nations, which are likely to be quite negative, the public is unlikely to support the use of chemicals of unknown toxicity on an import product, legal or not, that may be used by large numbers of Americans. And irrespective of the degree of success of controlling imports, the problem of domestic production under a policy of partial prohibition remains. Although the illegal domestic industry is thought to account for only about 15 percent of American marijuana consumption, marijuana grows easily in many parts of tile United States. The National Commission on Marijuana and Drug Abuse cited a Department of Agriculture estimate that in 1972 there were 5 million acres containing wild marijuana in the United States and an undetermined but obviously growing number of acres under cultivation.

Law enforcement costs are by no means the only costs of prohibition of supply. There are large amounts of money being made in marijuana--which, like any illegal business, carries with it the likelihood of corruption of public officials and tile loss of tax dollars. Violence is also a cost of attempting to prohibit marijuana supply; this problem is not confined to illegal marijuana production abroad. There has been violence in marijuanagrowing regions in the United States. The extent of such violence is not known with any precision, but there have been popular press reports of kidnappings, assaults, burglaries, and homicides known to be connected with the marijuana business in northern California and elsewhere.

Another major cost of attempts to prohibit tile supply of marijuana is related to the. fact that many illegal sellers of marijuana also sell other illegal drugs, e.g., PCP, amphetamine, and barbiturates (Blum, 1971). It is likely, therefore, that prohibition of the supply of marijuana increases access to and use of other illegal drugs through the creation of an illegal marketing system for all drugs. Little is known about the structures and activities of illicit drug markets. it is clear, however, that there are many small-scale marijuana dealers, that many sellers service only their friends and acquaintances, and that those who sell marijuana are thereby more likely to come into contact with users and sellers of more dangerous drugs, to use such drugs, and to make them available to their clientele (Blum, 1971). Moreover, there Is reason to believe that marijuana sellers may become socialized Into other Illegal activities.

Costs of Regulating Supply

The wide availability and use of marijuana are not only major factors in the cost of attempts to prohibit the supply of the drug, they also have implications for the likely magnitude of increases in use that could be expected under a regulatory policy. Greater use of marijuana under a regulatory policy is regarded as the most significant cost of such a policy. In an analysis of this potential cost, however, it is important to note that under the present policy of prohibition, prevalence and frequency of marijuana use are substantial and have increased In recent years.*

*The data indicating rates of use are based on self reports, as such, their reliability and validity may be questioned. Nevertheless, as Radosevich et al. (1979) indicate, studies of questions on drug use have consistently demonstrated reliable responses within the same instrument and over time. Furthermore, there are indications that most drug surveys do not have serious validity problems (see Whitehead and Smart and Abelson and Atkinson, both cited In Radosevich et al., 1979; Johnston et al., 1982).

A National Institute on Drug Abuse general household survey (Fishburne et al., 1980) shows that 35.4 percent of the 18-25-year-olds In the United States report having used marijuana in the month preceding the survey. Yearly surveys show a steady increase from 1971 to 1979 in the percentage of people who report having ever used marijuana as well as in the percentage of people who report being current users (see Table 1). These survey results (Fishburne et al., 1980) also Indicate that between 1976 and 1977, the percentage of current users among 12-17-year-olds increased from 12.3 to 16.6 percent; this trend had leveled off by 1979 and has since shown a decline. In an annual survey of national samples of some 17,000 high school seniors, Johnston et al. (1982) found that 7.0 percent of the class of 1981 reported daily marijuana use, compared with 6.0 percent in 1975 and 10.7 percent in 1978, the peak year (see Table 2). There has been a similar trend in initial use at younger ages.

Although the present policy of prohibition of supply is preventing preventiiig the current levels of marijuana use, including use among the very young, it is probable that most strategies under a regulatory policy would result. In an overall increase in use. Even more important than overall use rates, however, are likely changes In consumption patterns; such patterns are the most difficult changes to predict. The smallest increases in numbers of users can be expected to occur among those to whom marijuana is now most readily available--the young. Johnston et al. (1982) found that close to 90 percent of the high school seniors in their national sample survey report that marijuana Is "fairly easy" or "very easy" for them to get. This percentage remained relatively stable over the seven years, 1975-1981. At the same time, the reported availability of most other illegal drugs (except cocaine) declined considerably. For example, while 46.2 percent of the 1975 high school seniors said that LSD would be "fairly easy" or "very easy" to get, only 32.2 percent of the class of 1978 gave those responses. It would appear, therefore, that the reports of easy availability are not due to a tendency of adolescents to report any illegal drug as easy to get, but reflect their actual access to the drug. It might also be noted that only 13.9 percent of the class of 1978 reported having no friends who smoke marijuana; thus it is reasonable to expect that at least 86 percent have a factual basis for estimating the availability of the drug.

Other survey data corroborate these findings. Radosevich et al. (1979) report that a 1975 national survey by the Drug Abuse Council found that at least 70 percent of the high school students in their sample reported marijuana "easy to get," and O'Donnell et al. (1976) found similar results. There are no contrary reports for recent years. In sum, one can be reasonably confident that, at least with respect to older adolescents, the prohibition against supply does not succeed in suppressing access to marijuana. (The effect on price discussed below.)

Regulation could be expected to provide the greatest increase in availability to those to whom the drug is now least available, i.e., older adults who are not in contact with marijuana sellers or a drug-using subculture and who are most likely to avoid illegal "connections."

It has been argued that a serious cost of the adoption of a regulatory policy for marijuana is the likelihood that such a change might delude many people into believing that the drug is safe. As noted above, there is no indication that the elimination of penalties for marijuana use has caused the drug to be regarded as any less dangerous. Moreover, alcohol and tobacco are almost universally regarded as involving risks to health, and these drugs are already made available under regulatory systems.

To the extent that marijuana use causes harm, one is necessarily concerned about policy changes that will lead to increases in use. As we have noted, however, it is a fact that marijuana is already widely available despite the legal prohibition of supply and that, despite the best efforts of government under any foreseeable set of conditions, it will continue to be. Though a regulatory policy would increase the availability of the drug, estimates of the size of these increases, and associated increases in harm, must be weighed against estimates of the costs and weaknesses of continuing prohibitions of supply. in pragmatic terms, the issue is whether more harm would be done, overall, by retaining the partly effective, costly prohibition of supply or by moving to a system of legalized regulated sales--wherein presumably more people would use more marijuana, but some of the costs imposed by prohibition of supply would be removed.

Regulatory Systems: Some Concrete Aspects

To this point, a policy of regulation has been discussed rather abstractly in contrast with the more concrete discussion of prohibition policies. Experimentation with varying systems of regulation followed by adjustment and readjustment based on experience would be necessary before those most appropriate for particular circumstances could be developed. This can be a complex matter. For instance, U.S. alcohol policy, developed with the repeal of Prohibition, consists of an umbrella of national policy and a wide variety of supporting state and local regulation. The national policy umbrella includes controls on importation, taxation, potency, packaging, labeling, advertising, use in federal jurisdictions (e.g., parks, military installations), and use in systems regulated by the federal government (e.g., air transportation); it also provides funds and guidelines for the treatment of casualties of excessive use. Under the umbrella policy, states and local jurisdictions regulate taxes, retail sales, hours of availability, age limits, and the like, where supply is legal, or prohibit sales entirely. Some states have monopoly systems for package sales, others use licensed private stores. Historically, under this system, the strictness of controls has reflected local sentiment about the consumption of alcohol. Although few "dry" jurisdictions exist today, various degrees of local "dryness" were quite widespread until very recently (National Research Council, 1981).

Controlling Use

A regulated system of marijuana sale might attempt to moderate use by inhibiting the frequency of use and the amounts used as well as by prescribing conditions of purchase and use. However, it is likely that under a regulatory system consumption would in great part be controlled by informal social norms--as it is today.

Manipulating the price of the drug is an obvious means of inhibiting use. It has been argued that most adults would be willing to pay a higher price for legal marijuana than they currently pay for illegal supplies in return for not having to seek out "connections" and being relieved of the feeling that they may be supporting organized crime. A high price would be comparatively more restrictive for young people--precisely those whom one would most want to discourage from use--since, though they seem affluent compared with young people in previous times, their budgets are in fact more constrained than those of adults. The possibility of illegal markets selling to young people remains, but today's kind of illegal market for marijuana would probably, shrink greatly under a regulatory system in the same way that illegal alcohol distribution systems have become so scarce. Young users would be much more likely to gain access to marijuana by diversion from the legal market-as they do today for alcohol--or from homegrown plants than from a wholly illegal chain of distributors. Such a development would make marijuana selling a less profitable and status-producing occupation among the young.

It has been suggested that if legal limits were imposed on the potency of legally available marijuana, a substantial illegal market for high-potency forms of the drug, including hashish, would still exist. Since it is likely that there would continue to be some users who prefer high-potency forms of cannabis, this is a reasonable concern. But there is no compelling a priori reason to believe that a legal structure for retail marijuana sales, which includes limits on potency, would result in any increase in the availability and use of high-potency products.

Home Cultivation

Cultivation of marijuana by users is another issue that would have to be confronted in devising a regulatory system. Growing marijuana without payment of a tax might be treated as a revenue offense. Without criminal penalties or vigorous enforcement, however, deterrent effects would be minimal since marijuana can be grown indoors anywhere in the United States using artificial light--and at comparatively little expense. A recent British study of options for marijuana control (Logan, 1979) suggests that, from a law enforcement perspective, it is not feasible to attempt to control home cultivation. Whether users would take the trouble to grow their own marijuana would depend in part on the legal price. The relatively high prices that might be charged in order to discourage use and to increase revenues would also tend to encourage home cultivation. Whatever its disadvantages, however, the use of homegrown marijuana at least would not bring users into contact with those who illegally sell the drug. With respect to young people, moreover, marijuana under cultivation is much harder for children to hide from parents than is the purchased prepared drug, and cultivation by juveniles could remain illegal if age limits on use were imposed. Nonetheless, the treatment of home cultivation represents a major issue for the design of a regulatory system.

Public Education

Excessive use may be discouraged by policies aimed at public education and at the use of the media, including a ban on commercial advertising. Although information on how to use drugs, on drug hazards, and on the attributes of drugs is passed along most effectively through informal channels (see, e.g., Hanneman, 1972), media and education programs can make such information far more readily available.

Research on the communication of messages to the public has identified source credibility as a major factor contributing to the persuasive power of a message (McGuire, 1969). It appears that the public is now extremely wary of some government information programs that attempt to influence health behaviors. The credibility of the federal government may be especially suspect when it issues health warnings about an illegal substance that it is clearly trying to prohibit. Rosenthal (1979) asserts that distrust of the government and the medical establishment has grown because of past exaggerations and distortions of the effects of some mind-altering drugs.

Informal Social Controls

In an assessment of possibilities for governmental controls under a regulatory system, the operation of informal norms for controlling substance use practices must be taken into account (Maloff et al., 1980). National experience with alcohol use, for example, provides evidence that there are informal rituals and sanctions that generally encourage moderation in the use of recreational drugs. Moreover, moderation is encouraged when a drug is introduced gradually, that is, to a growing population like marijuana in the 1960s and early 1970s. of users, One might expect that when a new drug is introduced into a society, governmental control would be particularly important since no informal controls for teaching people appropriate rules for use would have developed. if a potent drug is made widely available precipitously and very cheaply to a novice population, severe societal disruptions may occur: for example, the gin epidemics of early eighteenth-century England (see Clark, 1976). Because in the past two decades informal norms for controlling marijuana use have spread in the United States under conditions of greatly increased availability of marijuana, there is reason to believe that widespread uncontrolled use would not occur under regulation. In deed, regulation might facilitate patterns of controlled use by diminishing the "forbidden fruit" aspect of the drug and perhaps increasing the likelihood that an adolescent would be introduced to the drug through families and friends who practice moderate use, rather than through their heaviest-using, most drug-involved peers.

Relations Among States

As has historically been the case with respect to alcohol, state governments differ in their approaches to marijuana. So long as present federal law continues to prohibit cultivation and distribution of marijuana, states cannot adopt a regulatory system, although they are legally free to reduce or eliminate their own penalties for sale and are not compelled to enforce federal laws. If federal law were changed, however, the institution of a regulatory system in one state would have reverberations in other states. Residents of states that continued to prohibit marijuana could be expected to cross state lines to purchase the drug in a state with a regulated system, thus further compromising the ability of states to enforce prohibition of supply among its residents. Furthermore, states that attempted to curtail consumption by raising prices might find their populations turning to lower-cost marijuana from neighboring states with lower prices. This is a familiar situation. Large numbers of both cigarettes and guns are smuggled illegally into New York from other states. Moreover, New Yorkers may travel to New Jersey to gamble in a casino, or Virginians to the District of Columbia to buy cheaper liquor. It is difficult to see how state prohibitions could remain effective if the number of states with regulatory systems grew very large unless the changes occurred in only one region of the country. However, there may be advantages in permitting a stateby-state approach. Conditions governing the costs and benefits both of partial prohibition and of regulation vary among the states. in this area of uncertainty, we may learn from experiment. if one regulatory system proved successful, other states would be more likely to adopt similar systems; similarly, if it worked poorly in one state, other states would be less inclined to adopt a regulatory policy.

Effects on Foreign Relations

The 1961 Single Convention on Narcotic Drugs, which now obligates the U.S. government to prevent the importation of marijuana and to prohibit the adoption of a licensing system by any state, is a serious (although not an insurmountable) obstacle to the adoption of a federal regulatory policy and the development of state licensing. The treaty allows a signatory to terminate its adherence to the agreement at any time after two years from the date of the convention. Of course the general impact of any move to withdraw from the convention includes a broad foreign policy context, which is beyond the expertise of this Committee to judge.

Conclusions

For the last decade, concern with health hazards attributable to marijuana has been rising. The hearts, lungs, reproductive functions, and mental abilities of children have been reported to be threatened by marijuana, and such threats are not to be taken lightly. Heavy use by anyone or any use by growing children should be discouraged. Although conclusive evidence is lacking of major, long-term public health problems caused by marijuana, they are worrisome possibilities, and both the reports and the a priori likelihood of developmental damage to some young users makes marijuana use a cause for extreme concern.

At the same time, the effectiveness of the present federal policy of complete prohibition falls far short of its goal--preventing use. An estimated 55 million Americans have tried marijuana, federal enforcement of prohibition of use is virtually nonexistent, and 11 state.have repealed criminal penalties for private possession of small amounts and for private use. It can no longer be argued that use would be much more widespread and the problematic effects greater today if the policy of complete prohibition did not exist: The existing evidence on policies of partial prohibition indicates that partial prohibition has been as effective in controlling consumption as complete prohibition and has entailed considerably smaller social, legal, and economic costs. On balance, therefore, we believe that a policy of partial prohibition is clearly preferable to a policy of complete prohibition of supply and use.

We believe, further, that current policies directed at controlling the supply of marijuana should be seriously reconsidered. The demonstrated ineffectiveness of control of use through prohibition of supply and the high costs of implementing such a policy make it very unlikely that any kind of partial prohibition policy will be effective in reducing marijuana use significantly below present levels. Moreover, it seems likely to us that removal of criminal sanctions will be given serious consideration by the federal government and by the states in the foreseeable future. Hence, a variety of alternative policies should be considered.

At this time, the form of specific alternatives to current policies and their probable effect on patterns of use cannot be determined with confidence. It is possible that, after careful study, all alternatives will turn out to have so many disadvantages that none could command public consensus. To maximize the likelihood of sound policy for the long run, however, further research should be conducted on the biological, behavioral, developmental, and social consequences of marijuana use, on the structure and operation of drug markets, and on the relations of various conditions of availability to patterns of use.

Recommendations for Research

Health and Behavior

The persistent concern about the health-related effects of marijuana requires both an immediate and a continuing response. First, as the report of the Institute of Medicine (1982:5) recommends, there should be "a greatly intensified and more comprehensive program of research into the effects of marijuana on the health of the American people." An important goal of this research program should be the identification of subgroups at high risk for physiological and psychological damage in relation to patterns of use and doses of marijuana. The report presents a detailed agenda of needed research. Second, to the extent that potential health hazards are identified, policy research should address possible safeguards and precautions to protect the user.

If marijuana use can be scientifically shown to entail grave risks--to the brain, the cardiovascular and respiratory systems, or to reproductive functions, for example--that are currently not known, it can be argued that, as was the case with cigarette smoking, knowledge of those effects will be more effective than criminal enforcement as a deterrent to use.

Drug Markets

Research on the price elasticity of demand in legal and illegal markets is a clear priority. The result of such research will be important in determining the likelihood of controlling heavy use through price mechanisms and in computing the amount of money--if any--that could be realized in taxation of marijuana.

Present knowledge of the structure and activities of drug markets and networks is insufficient to allow prediction of the effects of policy changes on them. Research in this area is difficult but the questions are important. If many dealers who sell cocaine, PCP, amphetamines, and barbiturates as well as marijuana would be put out of business if marijuana were available through legal channels, it might result in a curtailed market for a variety of other drugs. On the other hand, it is also possible that the market structure is so loosely organized, and dealers so transiently involved, that removing marijuana from the illegal markets would have little effect. To be sure, much research on some of these questions could not be conducted unless a regulatory system were in place in some state. Nonetheless, some research, particularly ethnographic and economic studies, should be undertaken now to discover the importance of marijuana profits to drug-dealing networks; the transiency, size, and nature of such networks; etc. it is essential for research in this area to be supported by appropriate government agencies.

Effects on Use

Although many questions remain to be answered before the most informed choices can be made between prohibiting and regulating supply, there are many things that cannot be known unless some jurisdiction tries a regulatory policy. Although adoption of a regulatory policy is likely to result in increased use, little is known about changes in patterns of use that are likely to result. If federal laws prohibiting supply are changed to allow states: to license marijuana sales, epidemiological research programs must be ready to monitor any changes in use and their consequences. To do so, research should be organized and operating well in advance of any such policy changes in order to determine rates of use before the change. Although the shift in the law from complete to partial, prohibition in 11 states has apparently had little effect on consumption patterns there, we do not know the degree to which legally available marijuana would attract a larger market. The impact on use of educational campaigns, health warnings, and informal social controls under a regulatory system should be investigated.

In the absence of the opportunity for states to adopt regulatory policies, there can only be educated guesses about which age groups are likely to increase use or whether individuals who now use marijuana will use more, etc. Meanwhile, every bit of analysis to predict the answers to these questions, by surveying public attitudes, assessing past experiences with the spread of drug use in society (e.g. , alcohol use following the repeal of Prohibition), and critically reviewing the experience vi other societies in which marijuana is more readily available, will be valuable.

Marijuana regulation would permit systematic provision of comprehensive, clearly communicated health warnings on package inserts or covers, in public health education, by medical practitioners, and by public health interest groups as well as by the government. The extent to which such warnings would have more credibility for users than current health warnings, generated in an atmosphere of prohibition, is an important subject for research. Despite widespread pessimism about the failures of drug education campaigns, there are encouraging results in educational approaches based on the Stanford Heart Disease Prevention Program experience. With appropriate, research-based models and techniques, public health education may be an attractive means for limiting excessive use (see, e.g., Maccoby, 1979).

References

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Appendix: Summary of Marijuana and Health

The Institute of Medicine (IOM) of the National Academy of Sciences has conducted a 15-month study of the health-related effects of marijuana, at the request of the Secretary of Health and Human Services and the Director of the National Institutes of Health. The IOM appointed a 22-member committee to:

• analyze existing scientific evidence bearing and the possible hazards to the health and safety of users of marijuana;
• analyze data concerning the possible therapeutic value and health benefits of marijuana;
• assess federal research programs in marijuana;
• identify promising new research directions, and make suggestions to improve the quality and usefulness of future research; and
• draw conclusions from this review that would accurately assess the limits of present knowledge and thereby provide a factual, scientific basis for the development of future government policy.

This assessment of knowledge of the health-related effects of marijuana is important and timely because marijuana is now the most widely used of all the illicit drugs available in the United States. In 1979, more than 50 million persons had tried it at least once. There has been a steep rise in its use during the past decade, particularly among adolescents and young adults, although there has been a leveling-off in its overall use among high school seniors in the past 2 or 3 years and a small decline in the percentage of seniors who use it frequently. Although substantially more high school students have used alcohol than have ever used marijuana, more high school seniors use marijuana on a daily or near-daily basis (9 percent) than alcohol (6 percent). Much of the heavy use of marijuana, unlike alcohol, takes place in school, where effects on behavior, cognition, and psychomotor performance can be particularly disturbing. Unlike alcohol, which is rapidly metabolized and eliminated from the body, the Psychoactive components of marijuana persist in the body for a long time. Similar to alcohol, continued use of marijuana may cause tolerance and dependence. For all these reasons, it is imperative that we have reliable and detailed information about the effects of marijuana use on health, both in the long and short term.

What, then, did we learn from our review of the published scientific literature? Numerous acute effects have been described in animals, in isolated cells and tissues, and in studies of human volunteers; clinical and epidemiological observations also have been reported. This information is briefly summarized in the following paragraphs.

Effects on the Nervous System and on Behavior

We can say with confidence that marijuana produces acute effects on the brain, including chemical and electrophysiological changes. Its most clearly established acute effects are on mental functions and behavior. With a severity directly related to dose, marijuana impairs motor coordination and affects tracking ability and sensory and perceptual functions important for safe driving and the operation of other machines; it also impairs short-term memory and slowlearning. other acute effects include feelings of euphoria and other mood changes, but there also art disturbing mental phenomena, such as brief periods anxiety, confusion, or psychosis.

There is not yet any conclusive evidence as to whether prolonged use of marijuana causes permanent changes in the nervous system or sustained impairment of brain function and behavior in human beings. In a few unconfirmed studies in experimental animals, impairment of learning and changes in electrical brain-wave recordings have been observed several months after the cessation of chronic administration of marijuana. In the judgment of the committee, widely cited studies purporting to demonstrate that marijuana affects the gross and microscopic structure of the human or monkey brain are not convincing; much more work is needed to settle this important point.

Chronic relatively heavy use of marijuana is associated with behavioral dysfunction and mental disorders in human beings, but available evidence does not establish -it marijuana use under these circumstances is a cause or 4 result of the mental condition. There are similar problems in interpreting the evidence linking the use of marijuana to subsequent use of other illicit drugs, such as heroin or cocaine. Association does not prove a causal relation, and the use of marijuana may merely be symptomatic of an underlying disposition to use psychoactive drugs rather than a "stepping stone" to involvement with more dangerous substances. It is also difficult to sort out the relationship between use of marijuana and the complex symptoms known as the amotivational syndrome. Self-selection and effects of the drug are probably both contributing to the motivational problems seen in some chronic users of marijuana.

Thus, the long-term effects of marijuana on the human brain and on human behavior remain to be defined. Although we have no convincing evidence thus far of any effects persisting in human beings after cessation of drug use, there may well be subtle but important physical and psychological consequences that have not been recognized.

Effects on the Cardiovascular and Respiratory Systems

There is good evidence that the smoking of marijuana usually causes acute changes in the heart and circulation that are characteristic of stress, but there is no evidence to indicate that a permanently deleterious effect on the normal cardiovascular system occurs. There is good evidence to show that marijuana increases the work of the heart, usually by raising heart rate and, in some persons, by raising blood pressure. This rise in workload poses a threat to patients with hypertension, cerebrovascular disease, and coronary atherosclerosis.

Acute exposure to marijuana smoke generally elicits broncho-dilation; chronic heavy smoking of marijuana causes inflammation and pre-neoplastic changes in the airways, similar to those produced by smoking of tobacco. Marijuana smoke is a complex mixture that not only has many chemical components (including carbon monoxide and "tar") and biological effects similar to those of tobacco smoke, but also some unique ingredients. This suggests the strong possibility that prolonged heavy smoking of marijuana, like tobacco, will lead to cancer of the respiratory tract and to serious impair-ment of lung function. Although there is evidence of impaired lung function in chronic smokers, no direct confirmation of the likelihood of cancer has yet been provided, possibly because marijuana has been widely smoked in this country for only about 20 years, and data have not been collected systematically in other countries with a much longer history of heavy marijuana use.

Effects on the Reproductive System and on Chromosomes

Although studies in animals have shown that delta-9-THC (the major psychoactive constituent of marijuana) lowers the concentration in blood serum of pituitary hormones (gonadotropins) that control reproductive functions, it is not known if there is a direct effect on reproductive tissues. Delta-9-THC appears to have a modest reversible suppressive effect on sperm production in men, but there is no proof that it has a deleterious effect on male fertility. Effects on human female hormonal function have been reported, but the evidence is not convincing. However, there is convincing evidence that marijuana interferes with ovulation in female monkeys. No satisfactory studies of the relation between use of marijuana and female fertility and child-bearing have been carried out. Although delta-9-THC is known to cross the placenta readily and to cause birth defects when administered in large doses to experimental animals, no adequate clinical studies have been carried out to determine if marijuana use can harm the human fetus. There is no conclusive evidence of teratogenicity in human offspring, but a slowly developing or low-level effect might be undetected by the studies done so far. The effects of marijuana on reproductive function and on the fetus are unclear; they may prove to be negligible, but further research to establish or rule out such effects would be of great importance.

Extracts from marijuana smoke particulates ("tar") have been found to produce dose-related mutations in bacteria; however, delta-9-THC, by itself, is not mutagenic. Marijuana and delta-9-THC do not appear to break chromosomes, but marijuana may affect chromosome segregation during cell division, resulting in an abnormal number of chromosomes in daughter cells. Although these results are of concern, their clinical significance is unknown.

The Immune System

Similar limitations exist in our understanding of the effects of marijuana on other body systems. For example, some studies of the immune system demonstrate a mild, immunosuppressant effect on human beings, but other studies show no effect.

Therapeutic Potential

The committee also has examined the evidence on the therapeutic effects of marijuana in a variety of medical disorders. Preliminary studies suggest that marijuana and its derivatives or analogues might be useful in the treatment of the raised intraocular pressure of glaucoma, in the control of the severe nausea and vomiting caused by cancer chemotherapy, and in the treatment of asthma. There also is some preliminary evidence that a marijuana constituent (cannabidiol) might be helpful in the treatment of certain types of epileptic seizures, as well as for spastic disorders and other nervous system diseases. But, in these and all other conditions, much more work is needed. Because marijuana and delta-9-THC often produce troublesome psychotropic or cardiovascular side-effects that limit their therapeutic usefulness, particularly in older patients, the greatest therapeutic potential probably lies in the use of synthetic analogues of marijuana derivatives with higher ratios of therapeutic to undesirable effects.

The Need for More Research on Marijuana

The explanation for all of these unanswered questions is insufficient research. We need to know much more about the metabolism of the various marijuana chemical compounds and their biologic effects. This will require many more studies in animals, with particular emphasis on subhuman primates. Basic pharmacologic information obtained in animal experiments will ultimately have to be tested in clinical studies on human beings.

Until 10 or 15 years ago, there was virtually no systematic, rigorously controlled research on the human health-related effects of marijuana and its major constituents. Even now, when standardized marijuana and pure synthetic cannabinoids are available for experimental studies, and good qualitative methods exist for the measurement of delta-9-THC and its metabolites in body fluids, well-designed studies on human beings are relatively few. There are difficulties in studying the clinical effects of marijuana in human beings, particularly the effects of long-term use. And yet, without such studies the debate about the safety or hazard of marijuana will remain unresolved. Prospective cohort studies, as well as retrospective case-control studies, would be useful in identifying long-term behavioral and biological consequences of marijuana use.

The federal investment in research on the health-related effects of marijuana has been small, both in relation to the expenditure on other illicit drug.-; and in absolute terms. The committee considers the research particularly inadequate when viewed in light of the extent of marijuana use in this country, especially by young people. We believe there should be a greater investment in research on marijuana, and that investigator-initiated research grants should be the primary vehicle of support.

The committee considers all of the areas of research on marijuana that are supported by the National Institute on Drug Abuse to be important, but we did not judge the appropriateness of the allocation of resources among those areas, other than to conclude that there should be increased emphasis on studies in human beings and other primates. Recommendations for future research are presented at the end of Chapters 1-7 of this report.

Conclusions

The scientific evidence published to date indicates that marijuana has a broad range of psychological and biological effects, some of which, at least under certain conditions, are harmful to human health. Unfortunately, the available information does not tell us how serious this risk may be.

The major conclusion is that what little we know for certain about the effects of marijuana on human health--and all that we have reason to suspect--justifies serious national concern. of no less concern is the extent of our ignorance about many of the most basic and important questions about the drug. Our major recommendation is that there be a greatly intensified and more comprehensive program of research into the effects of marijuana on the health of the American people.