The CTCRE submitted the following public comment on July 22, 2024. The Regulations.gov Comment Tracking Number is lyx-e7ky-82yn. A PDF of the comment can be downloaded here.
Because perceived harms of cannabis affect youth use, regulators must consider the impact of rescheduling cannabis from Schedule I to Schedule III on youth perceptions and use and design appropriate communications describing health risks
Docket Number DEA-1362
Nhung Nguyen, PhD, PharmD; Vira Pravosud, PhD; Bonnie Halpern-Felsher, PhD*;
Lauren Kass Lempert, JD, MPH; Stella Aguinaga Bialous, DrPH, FAAN;
Pamela M. Ling, MD, MPH
University of California San Francisco
*UCSF and Stanford University
July 22, 2024
The Department of Justice has proposed to transfer “marijuana” (we prefer to use the term “cannabis”) from Schedule I to Schedule III of the Controlled Substances Act, based on the view that cannabis has a currently accepted medical use and has a low to moderate abuse potential and level of physical or psychological dependence. However, DOJ and DEA must recognize that perceived harm is associated with substance use and abuse, and changes in product and policy landscapes may impact perceived harms of cannabis use. Therefore, DOJ’s rescheduling of cannabis could lead adolescents and young adults to having decreased perception of the health harms related to cannabis and therefore result in increased use of cannabis.
- Research has shown that changes in perceived harms of cannabis is associated with increased use.
We conducted a representative panel survey of young adults in California’s Bay Area in 2014 and 2019-2020, before and after cannabis legalization. In that study, we found a significant increase in the prevalence of cannabis use among young adults following legalization. In addition, while perceptions of harm from cannabis did not change over time, increased perceived harm of cannabis was associated with lower odds of cannabis use, and decreased perceived harm toward cannabis was associated with a higher likelihood of cannabis use.[1] Consistent with our research, other published literature shows that perceiving lower risks of harm is associated with cannabis use among adolescents and young adults.[2], [3], [4]
In addition to published research, preliminary analysis of our own study of California adolescents and young adults surveyed in 2023 (n=103, age range 14-21) showed that more than half of respondents perceived cannabis vaporizer use safer than nicotine e-cigarette use (53.4%). The perception did not differ significantly by type of products used in the past month: 68% of adolescents who used cannabis and nicotine vapor products perceived cannabis vaporizer use safer than nicotine e-cigarette use, compared to 53% of those who used cannabis vaporizers only, 42% of those who used nicotine e-cigarettes only, and 53% of those who did not use any vapor products in the past month.”[5] Another study recently accepted for publication showed that among adolescents, young adults, and adults ages 13-40, 38.4% reported use of both tobacco and cannabis in the past 30 days. Even when young people (under age 21) started using tobacco products first, they moved to also using cannabis within 1-2 years.[6]
Other studies also show that adolescents’ attitudes towards cannabis use are changing, with adolescents’ perceived risk of cannabis use steadily declining, permissive attitudes increasing, and disapproval decreasing.[7], [8], [9]Adolescents often lack a comprehensive understanding of addiction, and fail to recognize the negative outcomes associated with such use.[10], [11], [12] These attitudes and perceptions are attributable in part to increased positive marketing and social media presence of cannabis products, increased social acceptability,[13], [14] availability of a wide range of flavored cannabis products,[15], [16] and legalization of adult use of medical and recreational cannabis in the US.
Although much remains unknown about the negative outcomes of cannabis use, past and emerging research has revealed the harmful effects of cannabis use on youth’s health. More studies are showing the harmful effects of e-cigarette use with cannabis on the respiratory system.[17] In addition to recreational use, youth report using cannabis as self-medication to cope with mental health issues. Our research found that youth perceived cannabis use as beneficial to their mental health.[18] This perception is concerning given that recent national data report an increasing trend in poor mental health in this age group.[19] Furthermore, our recent research using a national sample of US adolescents found that those who use cannabis are at risk for mental health issues, and that adolescents and young adults who were depressed were more likely to use marijuana and co-use marijuana and tobacco.[20], [21] Likewise, recent reviews indicate that youth’s cannabis use is associated with poorer outcomes among those with mood and anxiety disorders[22] and increased risk for developing major depression and suicidality[23] Other research indicated the link between cannabis use on brain development long-lasting neuropsychiatric disorders in youth.[24] Studies show that cannabis use negatively impacts brain structure and function, especially with early age of onset and prolonged use, and can lead to adverse cognitive outcomes such as poor attention span, impaired learning and problem-solving, and interference with educational and economic outcomes.[25],[26]
- DEA and DOJ should design its communications around the rescheduling of cannabis to ensure that youth understand the health harms associated with its use.
Among U.S. adults, youth cannabis smoking has become more socially acceptable compared to tobacco smoking.[27],[28] Perceived parental acceptance and approval of cannabis use following cannabis legalization may be associated with the increased cannabis use among adolescents.[29] Evidence from past and emerging research demonstrates negative health impacts of cannabis.[30], [31], [32], [33], [34], [35], [36]
Early cannabis use[37] also has been linked to increased risk of cannabis use disorder. Another concerning trend is the increasing cannabis and tobacco co-use among adolescents[38] and potentially higher health risks associated with it.[39],[40], [41] A 2022-2023 prospective study of adolescents found that cannabis use as associated with increased odds of persistent use of e-cigarettes or any nicotine product at follow up, and the authors call for cannabis use prevention to help inhibit persistent nicotine use and its public health burdens.[42] Given these findings, it is urgent for DEA and DOJ to design communications to increase perceived harms of cannabis use among youth as well as among their parents and guardians.
Prevention and intervention efforts should focus on communicating the negative impacts of cannabis use. Our research highlights a need for correcting youth’s misperceptions regarding the benefits of cannabis use and educating adults and young adults on mental health risks related to the use of cannabis. In addition, including screening for mental health problems into routine clinical care and integrating resilience training (e.g., family or school support) in prevention programs may offer youth better ways to cope with their mental health issues,[43] which in turn may prevent their cannabis use. Well-designed communications that increase youth and adult awareness about health risks (e.g., brain impairment, mental health disorders), social risks (e.g., losing friends or impacting family relationships), and the addictive nature of cannabis use may help deter youth cannabis use.[44], [45]
Conclusions:
Current research demonstrates:
- Youth’s perceptions of cannabis are a major driver of use, with low perceived harms associated with initiation and continued use of cannabis.
- Concurrent with the rise in use, youth’s perceived harms of cannabis have declined over the past decade.
- The expanding legalization of cannabis nationwide may increase acceptability and ease of access among youth.
- Cannabis use among youth poses concerns of negative health effects on brain development and mental function
- Communication targeting preventing cannabis use among this developmental age group is of public health importance.
Based on this scientific evidence, DEA and DOJ should not discount the risk of the potential negative physical, mental, and social consequences of federal changes in cannabis laws, policies, and regulations on youth, and policy changes such as the rescheduling of cannabis from Schedule I to Schedule III “should apply a public health framework and consider the possible downstream effects of marijuana policy change on pediatric health.”[46]
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