White Paper: Cannabis
White Paper on
CANNABIS
September 07, 2017
Revised December 15, 2019
Revised December 20, 2021
Current marijuana use among adolescents in Tennessee is reported by the Centers for Disease Control and Prevention (CDC) to be 21.4 percent, which is lower than the national rate of 23.4 percent.1 States with marijuana legalization are positively associated with increased marijuana use as access and availability to the substance increases with legalization.2 Historical research has demonstrated that illegal drug use among youth increases as perception of risk and social disapproval declines; however, national perception of harm for regular marijuana use has declined sharply since 2008, when 52 percent of high school seniors believed using marijuana regularly was dangerous, compared to only 39.5 percent in 2013. The rate of adolescents in Tennessee using marijuana in the past 30 days (21.4 percent) has surpassed those who report smoking cigarettes (15.4 percent)1
▪ Marijuana potency has nearly tripled in the past 20 years3
▪ Marijuana use negatively impacts educational achievement4
▪ More than two-thirds of treatment admissions involving those under the age of 18 cite marijuana as their primary substance of misuse, more than 15 times the rate for alcohol alone5
▪ Marijuana use negatively impacts highway safety: 19 percent of teen drivers report they have driven under the influence of marijuana—only 13 percent of teen drivers report they have driven under the influence of alcohol6
▪ According to a recent RAND study, legalization will cause the price of marijuana to fall and its use to rise, especially among youth7
A recent, long-term, study revealed that heavy marijuana use during the adolescent years that continued through adulthood resulted in a permanent drop in IQ by eight points. A loss of eight IQ points could drop a person of average intelligence into the lowest third of the intelligence range.2
Is Marijuana Medicine?
The FDA requires carefully conducted studies to accurately assess the benefits and risks of a potential medication. To date, there have not been enough clinical trials that show the benefits of the marijuana plant outweigh the risks in patients with the symptoms it is meant to treat; therefore, the FDA has not approved marijuana for medical use. Cannabinoids (a large family of chemicals related to THC, marijuana’s main psychoactive ingredient) of interest for therapeutic reasons are THC and cannabidiol. THC stimulates appetite and reduces nausea: it may also decrease pain, inflammation, and spasticity. Cannabidiol is a non-psychoactive cannabinoid that may be useful in reducing pain and inflammation, controlling epileptic seizures, and possibly even treating psychosis and addictions. The FDA has approved the drugs Dronabinol (Marinol®) and Nabilone (Cesamet®), both used to treat nausea caused by chemotherapy and wasting disease caused by AIDS. Rolapitant (Varubi®) is approved to prevent delayed phase chemotherapy-induced nausea and vomiting8 and cannabidiol (Epidolex®) is the first cannabis-derived mediation approved to treat seuzures associated with epilepsy, Lennox-Gastaut syndrome, and Dravet syndrome.25 A drug called Sativex® which contains equal parts of THC and cannabidiol is currently approved in the UK to treat spasticity caused by multiple sclerosis and is now in Phase III clinical trials in the U.S. to establish its effectiveness and safety in treating cancer pain. The FDA-approved medications lack the psychoactive ingredient which makes the user feel “high,” (THC) and are already an alternative to “medical” marijuana.8
Full list of resources available in full Marijuana White Paper.
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Table of Contents
I. Marijuana Use
II. Marijuana Use and Adolescents
III. Marijuana and the FDA
IV. Other State Outcomes
V. Marijuana and Dependency
VI. Social and Economic Impacts
VII. Marijuana Use and Safety
VIII. Delta-8-tetrahydrocannabinol
IX. Glossary
X. Authors
XI. Reference
Marijuana Use
It was reported that in 2015, more than 22 out of the 27 illicit drug users in America were monthly users of marijuana, making up 8.3% of the 262 million American population aged 12 or older. A staggering finding of 48.1 percent of the American adult population with less than a high school diploma reported daily use.1 These numbers have rapidly grown from the percentages from 2002 to 2013, before marijuana was legalized for “medical” marijuana use.2 It has been seen that states that have progressed to legalizing marijuana for recreational use have seen a 155% increase in use in the three-year average since legalization. 3
Marijuana is the most commonly used illicit drug, and likewise is associated with a lower public health status as it negatively affects individual health and well-being, economic, and social circumstances.4 Marijuana use is associated with lower life satisfaction, more relationship problems, and less academic and career successes.5 It is also identified with a wide range of health problems including hallucinations and paranoia, damages to DNA, breathing problems, including inflammation of the lungs, symptoms of chronic bronchitis, rapid lung destruction – even more severe than tobacco smokers, possible harm to fetus’s neurological development, and low birth weight when used during pregnancy.3,6 Furthermore, marijuana is heavily associated with high risk of addiction, schizophrenia, psychosis, and short-term declines in memory, attention, and learning.7
Marijuana Use in Adolescents
A major concern with legalizing marijuana and lessening its restrictions is the increase of use and lower quality of life in adolescents. Adolescents, compared to any other age group, are
1
particularly prone to risks associated with marijuana use.8 Cannabis use is most prevalent in ages 18 to 25 in the United States, with 20% using it on a monthly basis.2 Seven percent of 12 to 17 year olds currently use the substance, while 3% of adolescents have a Marijuana Use Disorder.2 Unfortunately when marijuana is legalized, such as Washington’s recent legalization for marijuana recreational use, adolescents’ perceived harm decreases and use increases.9 Following Colorado’s legalization for marijuana recreational use, past month use in youth increased 20% during an average 2-year span. The passage of this law also contributed to Colorado possessing the highest ranking of adolescent marijuana users in the United States, as their rates increased 74% above the national average in 2013/2014 from the previous state of 39% above the national average in 2011/2012 during the time it was legalized for “medical” use.4
The increase of cannabis use in adolescents impairs overall well-being as it declines their progression in academics.8 Any type of cannabis use in adolescents is associated with a decrease in learning from brain impairment, problem solving, memory, math, and reading.10 Brain impairment from marijuana use has shown its inability to regain its previous state of neurological function after stopping marijuana use, while it also permanently lowers adolescents’ IQ scores by up to 8 points, bringing them to the lowest third quartile of the intelligence quotant.5,11Weekly use is directly correlated with decreased rates of high school graduation. 7 In disadvantaged neighborhoods, substance abuse may be associated with the socioeconomic status.12
Research has shown that individuals with a family or personal history of psychotic episodes are at increased risk of a psychotic episode which includes delusions, hallucinations, emotional unresponsiveness, and paranoia, which, in turn, puts a person at risk for a psychotic break, igniting mental illness and potentially causing suicide. 8, 13 Use of marijuana in adolescents is also correlated with relational harm, dating violence, disinterest in activities, isolation from family, and a lower quality of life.8 Additionally, students who use marijuana are at risk for vehicle accidents, as over 28 thousand Seniors admitted they were in at least one motor vehicle accident each year in high school after the use of marijuana.10
Marijuana and the Food & Drug Administration (FDA)
Despite that a total of 32 states and the District of Columbia have now legalized marijuana, at the federal level it still remains a federal offense and is classified as a Schedule I substance under the Controlled Substances Act, where Schedule I substances have a high potential for dependence and are not for medical use.14 Although marijuana is not FDA approved (i.e. it is not certified to be safe for prescription drug use or any indication), some states are allowing patients to purchase marijuana by using a card, recommended by a healthcare worker (marijuana cannot be legally prescribed by a healthcare provider since it is not an FDA-approved medicine).
Although there have been some studies conducted that associate benefits with cannabis use and certain ailments, the FDA cannot approve marijuana for drug use because it has been linked to harmful health outcomes and has not been proven for effective medication.14 In states that have legalized marijuana, healthcare workers have the freedom to give patients access to a marijuana medication card for purchasing marijuana; however, proper dosages cannot be prescribed due to the limitations of not being FDA certified, allowing patients to consume potentially harmful amounts of the substance for their ailments.15 Another concern that the FDA found with marijuana being a certified drug is the unmonitored and varying levels of THC in the cannabis sativa plant.15 THC concentrations are continuing to increase to harmful levels, but this varies based upon the dispensary.8 Thus, it has been too difficult to produce a consistent dosage of marijuana to consumers.15
There has been considerable interest in the effects of marijuana for certain conditions, such as the attempt to decrease symptoms in glaucoma, AIDS, neuropathic pain, cancer, multiple sclerosis, nausea, and certain seizure disorders; however, there is no current scientific evidence that marijuana is effective for these treatments due to the harm that may occur with testing human subjects.10, 15 The FDA has realized this interest in treatment, and thus approved two other drugs that contain a synthetic variation of a substance present in marijuana known for its medicinal effects, while they do not contain any of the harmful compounds found in marijuana, making them safe for medical use.14
Cannabinoid (CBD) oil is a substance derived from separating the resin, i.e., the sticky substance, from the flower of the cannabis sativa plant, and its purposes are typically used topically for localized pain and differ than that of marijuana use. CBD oil has been legalized in Tennessee and can be purchased for medicinal purposes, but has been known to be used in other ways, such as smoked and orally ingested for the effects of THC found in marijuana.16
Other State Outcomes
Out of the 29 states that have legalized marijuana, the most documented health outcomes have been seen in Colorado, one of the first states to legalize marijuana.7 There has been a trend found in the legalization process in states—marijuana use starts from a more restrictive law of medical marijuana use, to voting in lesser restrictive laws, and then finally being voted in for retail use. 3
Since legalizing marijuana in Colorado in 2012, significant health concerns have been found.3 Marijuana’s increase of use in Colorado following the legalization of recreational use was associated with a 49% increase in Emergency Department visits, an 87% increase in vehicle crashes whose drivers tested positive for marijuana, and a 5% increase in alcohol consumption, making alcohol consumption 6% above the national average. A large concern has been found in
supporting evidence for the increased burden of homelessness—there has been a 50% increase in homeless shelter utilization and higher incident rates for employer troubles, such as more employee drug test failures, absenteeism, injuries, and disciplinary problems.3,17 Other findings include a 471% increase of seizures in Colorado marijuana in the United States mail in the 3-year average following legalization of recreational use. Also, when Colorado had legalized marijuana in 2009, the average number of seizures of Colorado marijuana increased 357% in a 3-year span, showing that legalizing marijuana increases illegal and harmful habits among users.3
The state of Washington was the second to legalize marijuana in 2012 and although it has not documented the health effects to the extent of Colorado, also legalized recreational marijuana. It was recorded that vehicle accidents related to a positive THC test in 2014 were doubled in 2 years.3 According to the Washington State Traffic Safety Commission, there was a 460% increase in marijuana-only DUI’s since 2012.3 In the state of Oregon, which legalized retail marijuana in
2014, currently has 16.3% of its population regularly using marijuana, twice the national average.17
Knowing the detrimental health effects marijuana has on adolescents, the increasing rates of their illegal use is a great concern. Furthermore, states that have legalized marijuana, also show increased adolescent use due to the decrease in perception of harm.18 Out of 11th grade students that drove in Oregon, half of the students that smoked marijuana admitted to driving within 3 hours of use, and over 62% of students reported having easy access to the substance, despite over half of students realizing that moderate consumption increased their risk for injury and decreased their state of health.18
Marijuana and Addiction
Addiction to marijuana is becoming an increasing problem, as clinical dependence has been found to affect roughly 10% of marijuana users, most being adolescents and young adults.4 Marijuana production has had a steady increase in THC levels over the past decades, producing a more potent plant, which has been linked to higher addiction rates. Part of this complication could be linked to the unmonitored dispensaries of marijuana, in which concentration of THC levels varies by producers.8
Marijuana Use Disorder in 2015 was found among 4 million Americans, which is a precursor for addiction.17 It has been recorded that up to 30% of individuals who use marijuana are likely to develop Marijuana Use Disorder to some degree.8 In a study conducted in 2009, individuals between the ages of 12 and 25 comprised 66% of treatment admissions for Marijuana Use Disorder.17 It has been shown that users below the age of 18 are 4 to 7 times more likely than adults to develop this disorder leading to addiction.19 Colorado reported that their drug
treatment facilities were at full capacity, the majority of patients being young in age, and almost half were admitted for their high dependence to marijuana versus other illicit drugs.10
Societal and Economic Impacts
Lessening the restrictions on marijuana is becoming a perpetual theme in the polls in all states, which is also associated with poorer societal and economic outcomes.10 Many new cannabis use laws were elected during 2016 throughout the United States, which not only allowed over 28 states and Washington D.C. access to marijuana, but also lessened the restrictions associated with its use in other states, making marijuana more easily acceptable to the public.20
There are many adverse side effects associated with increased marijuana use at the societal level. According to one study, the negative impacts of expanding marijuana laws will have such a severe impact on public health from a social and economic standpoint, there will be no turning back.3 The costs presently cannot be determined; however, they are noted to be cruel.10 One argument for marijuana use is that it will yield more profit to the government through increased tax revenues. Nonetheless, this rationale is mistaken for various reasons. First, tax revenue assessments cannot be determined because the impact of the black-market’s supply to users is not known, although it has been documented that Colorado’s black market has increased significantly since marijuana has been legalized.3 Furthermore, it has been observed that Colorado’s tax revenue from marijuana is only 0.5% of total tax income. This amount may seem somewhat of a worthy amount; however, according to the National Drug Intelligence Center, in 2011 there were over $193 billion annual losses due to negative side effects of illicit drug use, such as sickness, accidents, loss of productivity, and crimes. Over 66% of the losses were from poor productivity, which is heavily associated with marijuana use.3 In another study by the National Center on Addiction and Substance Abuse at Columbia University, it was found that much of governmental spending is towards attempting to decrease the negative effects of our continued failure to treat the substance misuse, rather than preventing it before the damage occurs.3 Only 3% of governmental funds is spent towards preventative care, while 60% was spent towards healthcare costs, including alcohol and drug abuse.3
Other economic impacts of the legalization of marijuana include negative environmental side effects, such as an increase in air pollution from production. It was found that for every pound of marijuana grown indoors, there is almost 5,000 pounds of carbon dioxide released into the environment.3
A 2019 study completed by the National Institute on Drug revealed marijuana use is at an all time high among high school students. According to the Monitoring the Future (MTF) survey, 14% of seniors vaped marijuana in the past 30-days. This number represents the second largest jump
in the 45-year history of the MTF survey. In the previous survey, it was reported that 7.5% of seniors had vaped marijuana in the last 30-days.23
Marijuana Use and Safety
A major concern with the use of marijuana is its negative effects on traffic accidents and correlated deaths. It was reported in that marijuana-related traffic accidents, deaths increased almost 50% in the three-year average after legalization of recreational marijuana, which was 40% more than the national average.3 The use of marijuana prior to driving has been shown to double the chances of collisions, due to slower cognitive function, reaction speed, and lane-weaving.3
Other safety issues have been found among employees at work that are marijuana users, who are at increased risks to accidents and injuries to themselves and others, due to inability to safely multitask, lessened sensorimotor skills, and attentional deficits. 3 There are also studies that highlight marijuana’s impacts on public safety. Short and long-term uses have been shown to delay cognitive function, affecting sensorimotor abilities, attention span, memory, self-control, learning, and educational attainment, which have detrimental effects on many aspects of daily life. There has also been moderate evidence that marijuana use has been linked to suicidal attempts and completions.5
Vaping THC
Since the popularity of vaping has risen, there have been problems identified by the Center for Disease Control and Prevention (CDC). On November 8, 2019, the CDC conducted a laboratory experiment analyzing bronchoalveolar lavage (BAL) fluid samples. The CDC reported the BAL samples from 29 participants from 10 states measuring the presence of vitamin E acetate, which is linked to the ever-growing illnesses and deaths associated with vape products. As of December 10, 2019, a total of 2,409 cases of hospitalization due to complications to vaping, or e-cigarette products have been reported to the CDC. With this information, fifty-two deaths have been confirmed due to the use of vape products. Currently, more deaths are under investigation.21 In Tennessee, 78 vaping-related lung injury cases have been reported to the Tennessee Department of Health: 69 of the 78-required hospitalization and two deaths have been reported.24
In the past few years, vaping marijuana has become mainstream. Vaping marijuana has nearly tripled in two years from 2017-2019 from 5 percent to 14 percent, respectively. From 2018-2019, prevalence of vaping marijuana doubled from 7.5 percent to 14 percent, which isthe largest one year jump of any drug to-date.22
Delta-8-tetrahydrocannabinol
Delta-8 THC (Delta-8-tetrahydrocannabinol) is a psychoactive substance found in the Cannabis sativa plant (of which marijuana and hemp are varieties). Delta-8 is one of over 100 cannabinoids produced naturally by the cannabis plant and is estimated to be about 50-75% as psychoactive as Delta-9-THC. Concentrated amounts of Delta-8 THC are typically manufactured from hemp derived cannabidiol (CBD). This practice may occur in uncontrolled settings.
• Delta-8 is derived from the Hemp plant which can be grown legally in most states • Through synthesis, Delta-8 is extracted from the Hemp plant
• Delta-8 contains THC
• Delta-8 products are marketed for “therapeutic or medical purposes” but have not been substantiated by the Food and Drug Administration (FDA)
The FDA has received adverse event reports (consumption of edibles, ie: brownies, gummies) from consumers and law enforcement agencies with a 63.6% hospitalization rate between December 2020 to July 2021. Adverse events included lethargy, decreased psychomotor activity, slurred speech, increased heart rate progressing to slower heart rate, low blood pressure, difficulty breathing, sedation, vomiting, hallucinations, trouble standing, and coma.
National poison control centers also received exposure cases (661 between January 2018 and July 2021; 660 of which occurred between January 1, 2021, and July 31, 2021) which included:
• 41% involved unintentional exposure to Delta-8 THC and 77% of these unintentional exposures affected pediatric patients less than 18 years of age.
• 18% required hospitalizations, including children who required intensive care unit (ICU) admission following exposure to these products.
What does it do:
Delta-8 THC has psychoactive and intoxicating effects, similar to Delta-9 THC (i.e., the component responsible for the “high” people may experience from using cannabis).
Is it legal?
A plant that contains a higher Delta-9 concentration is defined as marijuana, which is a federally illegal drug, subject to enforcement by the Drug Enforcement Administration (DEA). Since Delta 8 is manufactured from hemp-derived CBD, not extracted directly from the hemp plant, it is
considered to be a controlled substance under law, according to the DEA. Since the restriction on THC content set out in the 2018 Farm Bill applies only to Delta-9 THC, producers can still legally sell Delta-8 THC products in states with no legal marijuana market.
The Farm Bill limit for Delta-9 THC is 0.3%
• Hemp is defined as a Cannabis sativa plant that contains 0.3% Delta-9 THC or less. • A plant that contains a higher Delta-9 THC concentration is defined as marijuana, which is a federally illegal drug, subject to enforcement by the Drug Enforcement Administration (DEA).
Because Delta-8 THC is manufactured from hemp-derived CBD, not extracted directly from the hemp plant, it is considered to be a controlled substance under law, according to the DEA.26
States that have restricted or banned Delta-8 include Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Kentucky, Idaho, Iowa, Michigan, Mississippi, Montana, New York, North Dakota, Rhode Island, Utah, Vermont, and Washington. Other states are reviewing Delta-8’s legal status, as of November 4, 2021, including Alabama, Illinois, Oklahoma, Oregon, and Texas.27
Why should we be concerned?
Ease of access to purchase
• No age restriction
• Available in vape stores, convenience store, online
• Excessive advertising to community and youth
Lack of regulation
• Quality and safety inconsistencies
• Actual ingredient list is unknown in many cases
Delta-8 THC products have not been evaluated or approved by the FDA for safe use and may be marketed in ways that put the public health at risk. In addition, the natural amount of Delta-8 THC in hemp is very low, therefore, additional chemicals are required for synthetic conversion to convert other cannabinoids into hemp. Results of this chemical synthesis process include potentially harmful by-products that contaminate the final product if consumed or inhaled.26
On September 14, 2021, the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) simultaneously released health alerts regarding Delta-8 and adverse evets, notifying public health departments, healthcare professionals, first responders, poison control centers, laboratories, and the public to the increased availability of cannabis products containing delta-8 tetrahydrocannabinol (THC) and the potential for adverse events due to insufficient labeling of products containing THC and cannabidiol (CBD).27,28
Glossary
Cannabinoid: a class of diverse chemical compounds that act on receptors in the brain that repress neurotransmitter release, including endocannabinoids (produced in the body), phyto cannabinoids (found in plants) and synthetic cannabinoids (manufactured chemically). There are two types of cannabinoid receptors in the body: type one, found in the brain (basal ganglia and limbic system, including hippocampus) and type two, found in the immune system (especially in the spleen).
Current use: use of a substance within the past 30 days.
Illicit drug: use includes the non-medical use of a variety of drugs that are prohibited by international law. These drugs include: amphetamine-type stimulants, cannabis, cocaine, heroin and other opioids, and ecstasy.
Marijuana: dried leaves, flowers, stems and seeds from the hemp plant Cannabis sativa, which contains the psychoactive chemical delta-9-tetrahydrocannabinol (THC), as well as other related compounds; may also be concentrated in a resin called hashish or a sticky black liquid called hash oil.
Schedule I: classification for drugs, substances or chemicals with no currently accepted medical use and high potential for abuse; pose potentially severe psychological or physical dependence.
THC: primary psychoactive component of the Cannabis plant; delta-9-tetrahydrocannabinol; scheduled by the international Single Convention on Narcotic Drugs (Schedule I and IV) and by the United States Drug Enforcement Administration (Schedule I).
Authors
Mariel Crawford, MPH
No conflicts of interest identified.
Stephanie Strutner, MPH, CPSII
No conflicts of interest identified.
Edited: Nicholas Edwards, MPH Student
No conflicts of interest identified.
Revised: Gabrielle McConkey
No conflicts of interest identified.
References
1 Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda, Board on Population Health and Public Health Practice, Health and Medicine Division, & National Academies of Sciences, Engineering, and Medicine. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, D.C.: National Academies Press. https://doi.org/10.17226/24625
2 Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/
3 Rocky Mountain High Intensity Drug Trafficking Area. (2016). The Legalization of Marijuana in Colorado: The Impact (No. Volume 4). Retrieved from
https://www.sheriffs.org/sites/default/files/2016%20FINAL%20Legalization%20of%20Marijuana%20in%20Colorado%2 0The%20Impact.pdf
4 Hasin, D. S., Saha, T. D., Kerridge, B. T., Goldstein, R. B., Chou, S. P., Zhang, H., … Grant, B. F. (2015). Prevalence of Marijuana Use Disorders in the United States Between 2001-2002 and 2012-2013. JAMA Psychiatry, 72(12), 1235. https://doi.org/10.1001/jamapsychiatry.2015.1858
5 Meier, M. H., Caspi, A., Ambler, A., Harrington, H., Houts, R., Keefe, R. S. E., … Moffitt, T. E. (2012). Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences, 109(40), E2657–E2664. https://doi.org/10.1073/pnas.1206820109
6 Panlilio, L. V., Zanettini, C., Barnes, C., Solinas, M., & Goldberg, S. R. (2013). Prior Exposure to THC Increases the Addictive Effects of Nicotine in Rats. Neuropsychopharmacology, 38(7), 1198–1208. https://doi.org/10.1038/npp.2013.16 7 Teigen, A., & McInnes, K. (2019, November 17). Marijuana Overview. Retrieved from http://www.ncsl.org/research/civil-and criminal-justice/marijuana-overview.aspx.
8 Abuse, National Institute on Drugs. (August, 2017). What is the Scope of Marijuana Use in the United States? Retrieved September 4, 2017, from https://www.drugabuse.gov/publications/research-reports/marijuana/what-scope-marijuana-use in-united-states
9 Cerdá, M., Wall, M., Feng, T., Keyes, K. M., Sarvet, A., Schulenberg, J., Hasin, D. S. (2017). Association of State Recreational Marijuana Laws with Adolescent Marijuana Use. JAMA Pediatrics, 171(2), 142–149.
https://doi.org/10.1001/jamapediatrics.2016.3624
10 David Evans. (2013). The Economic Impacts of Marijuana Legalization, 39
11Abuse, N. I. on D. (2013, August 13). Early-Onset, Regular Cannabis Use Is Linked to IQ Decline. Retrieved September 7, 2017, from https://www.drugabuse.gov/news-events/nida-notes/2013/08/early-onset-regular-cannabis-use-linked-to-iq decline
12 Karriker-Jaffe K. J. (2013). Neighborhood socioeconomic status and substance use by U.S. adults. Drug and alcohol dependence, 133(1), 212–221. doi:10.1016/j.drugalcdep.2013.04.033
13 U.S. Department of Justice, “DEA Position on Marijuana," Drug Enforcement Administration (DEA), Washington, DC U.S.A. July 2010, www.DEA.gov, pages 23-26 and 33-34; Speaking Out Against Drug Legalization, DEA, pages 51-53 14 State Medical Marijuana Laws. (October, 2019). Retrieved December 15, 2019, from
http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
15Commissioner, O. of the. (February, 2017). Public Health Focus - FDA and Marijuana [WebContent]. Retrieved September 2, 2017, from https://www.fda.gov/newsevents/publichealthfocus/ucm421163.htm
16Murray, R. M., Quigley, H., Quattrone, D., Englund, A., & Di Forti, M. (2016). Traditional marijuana, high-potency cannabis and synthetic cannabinoids: increasing risk for psychosis. World Psychiatry, 15(3), 195–204.
https://doi.org/10.1002/wps.20341
17 National Survey on Drug Use and Health. Conducted by Substance Abuse and Mental Health Services Administration, 2017. 18 Oregon Health Authority, Public Health Division. (2016). Marijuana Report: Marijuana use, attitudes, and health effects in Oregon. (p. 70). Retrieved from http://www.oregon.gov/oha/ph/PreventionWellness/marijuana/Documents/oha-8509- marijuana-report.pdf
19Winters, K. C., & Lee, C.-Y. S. (2008). Likelihood of developing an alcohol and cannabis use disorder during youth: Association with recent use and age. Drug and Alcohol Dependence, 92(1–3), 239–247.
https://doi.org/10.1016/j.drugalcdep.2007.08.005
20 Marijuana State Laws. (2018). 33 Legal Medical Marijuana States and DC. Retrieved December 18, 2018 from https://medicalmarijuana.procon.org/view.resource.php?resourceID=000881
21 Center for Disease Control and Prevention. (2019, December 12). Outbreak of Lung Injury Associated with the Use of E Cigarette, or Vaping, Products. Retrieved December 18, 2019, from https://www.cdc.gov/tobacco/basic_information/e cigarettes/severe-lung-disease.html#map-cases.
22 Miech, R. A., Patrick, M. E., & O'Malley, P. M. (2019, December 17). Trends in Reported Marijuana Vaping Among US Adolescents, 2017-2019. Retrieved December 18, 2019, from
https://jamanetwork.com/journals/jama/fullarticle/2757960?guestAccessKey=ed8256f1-6c66-41d8-b834-
055ab7bb1ce1&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_ term=121719.
23 NIDA. (2019, December 18). Monitoring the Future. Retrieved from https://www.drugabuse.gov/related-topics/trends statistics/monitoring-future on 2019, December 19
24Tennessee Department of Health: Vaping-Associated Pulmonary Illness report. Retrieved from
https://www.tn.gov/health/cedep/vaping-illness.html, January 27, 2020.
25Food and Drug Administration. “FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy.” News release, June 25, 2018.
26Food and Drug Administration. “5 Things to Know about Delta-8 Tetrahydrocannabinol – Delta-8 THC..” News release, September 14, 2021.
27“States Where Delta-8 THC Is Illegal As Texas Temporarily Allows Sale of Cannabis Extract.” Newsweek. November 11, 2021. 28“Increase in Availability of Cannabis Products Containing Delta-8 THC and Reported Cases of Adverse Events.” CDC Emergency Health Advisory; Health Alert Network. September 14, 2021.