Journal of Drug Issues 2004 Khatapoush 751 70

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''Sending the Wrong Message'': Did Medical Marijuana Legalization in California Change Attitudes about and use of Marijuana?
Shereen Khatapoush and Denise Hallfors Journal of Drug Issues 2004 34: 751 DOI: 10.1177/002204260403400402 The online version of this article can be found at: http://jod.sagepub.com/content/34/4/751
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2004 BY THE JOURNAL OF DRUG ISSUES
SENDING THE WRONG MESSAGE: DID MEDICAL MARIJUANA LEGALIZATION IN CALIFORNIA CHANGE ATTITUDES ABOUT AND USE OF MARIJUANA?
SHEREEN KHATAPOUSH, DENISE HALLFORS
This study was designed to assess the affect of legalization of medical marijuana on drug-related attitudes and use among youths and young adults in selected communities in California and other states. Telephone survey data, collected as part of a study of the Robert Wood Johnson Foundations Fighting Back initiative, was utilized to examine reported attitudes about and use of drugs in California and other states before and after Californians passed Proposition 215 in 1996. Descriptive, bivariate, and logistic regression analyses were used to examine attitudes and use among 16 to 25 year olds in California and 10 other states. This study found that although some marijuana-related attitudes changed between 1995 and 1999, use did not increase. These findings suggest that recent policy changes have had little impact on marijuana-related behavior.
INTRODUCTION
Marijuana policy has been a contentious issue in the United States. Over time, federal marijuana policy has become increasingly restrictive and punitive, while state policy has been more fluid and lax. Recently, citizen-sponsored state referenda to legalize marijuana for medicinal purposes have challenged federal policy, sparking a national debate. Critics have argued that medicinal use sends the wrong message to youth. The purpose of this paper is to test this argument by examining marijuana attitudes and behaviors before and after a seminal California law was passed.
__________ Shereen Khatapoush, Ph.D., is the director of the Youth Services System for the Council on Alcoholism and Drug Abuse in Santa Barbara, CA. She has worked in substance abuse prevention for 10 years and is interested in youth, prevention, and policy. Denise Hallfors, Ph.D., is a senior research scientist at PIRE in Chapel Hill, NC. Dr. Hallfors has a background in nursing, with doctoral training from the Heller School at Brandeis University. She has done extensive research on adolescent substance abuse prevention and is currently the principal investigator on two NIDA R01 grants.
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KHATAPOUSH, HALLFORS
Current federal drug policy can be characterized as a zero tolerance approach, with primary emphasis on supply reduction, enforcement strategies, and legal sanctions. Historically, federal marijuana policy began with the Marijuana Tax Act of 1937 and became more restrictive over time with the passage of the Boggs Act and the Narcotic Control Act during the 1950s (Bonnie & Whitebread, 1974). The Boggs Act established uniform penalties and mandatory minimum sentencing (Bonnie & Whitebread, 1974), and the Narcotic Control Act escalated the penalties and fines for the possession and sale of narcotics and made other provisions and guidelines for the enforcement of narcotic laws (including marijuana).1 Despite the harsher penalties that were enacted in the mid 1950s, recreational marijuana use not only continued, but increased dramatically during the 1960s. In 1970, the Controlled Substances Act classified marijuana as a Schedule I drug (along with heroin and LSD), meaning that it had a high potential for abuse, no accepted medical utility, lack of accepted safety for use even under medical supervision, and was subject to the most stringent regulatory controls. Despite these increasingly elevated sanctions over time, recreational use and the corresponding costs associated with marijuana enforcement increased, and efforts to relax federal policies since the 1970s, such as rescheduling marijuana, have failed. Although states are subject to federal law, most have experimented with their own policy approaches. During the late 1960s and 1970s, almost all states reduced the penalties for marijuana use (Resnick, 1990). By the end of 1971, only three states maintained mandatory minimum felony penalties for possession (Bonnie & Whitebread, 1974). Oregon was the first state to decriminalize marijuana in 1973; by 1978, twelve additional states, with collectively more than a third of the total U.S. population, had done so (Model, 1993). Californians passed the Moscone Act in 1976, which decriminalized possession of marijuana and removed prison sentences. For the next 20 years, until the medical marijuana initiative was passed in 1996, Californias marijuana laws did not change substantially. In November 1996, California voters passed Proposition 215, the Compassionate Use Act, which allows patients to cultivate and use marijuana for medicinal purposes with the written or oral recommendation of a doctor. A number of other states have since passed medical marijuana initiatives. These state initiatives clearly conflict with federal policy and much of the concern and opposition has been centered around the notion that allowing medicinal use would send the wrong message to youth that is, change attitudes and perceptions about marijuana and result in greater recreational use of marijuana and other illicit drugs. Comments made by General Barry McCaffrey, former director of the White House Office of National Drug Control Policy, typify this concern.
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MEDICAL MARIJUANA: SENDING THE WRONG MESSAGE?
These measures threaten to undermine our efforts to protect our children from dangerous psychoactive drugs. They make drug abuse more likely. Marijuana is a gateway drug. Children who have used marijuana are more than 85 times likelier to use cocaine than children who have never used marijuana. They send the wrong message to our children. Coming at a time when marijuana use has doubled among our youth, these initiatives threaten to undermine our efforts to prevent drug use by our children. We cannot afford to further erode youth attitudes towards drugs by allowing marijuana to be falsely depicted as a safe drug and as effective medicine. Labeling marijuana as medicine sends the wrong message to children that it is a safe substance. What is at risk is the well-being of our nations youth (McCaffrey, Senate Judiciary Committee, 1996). In response to these and other concerns about the medical use of marijuana, the federal government commissioned a study by the Institute of Medicine (IOM). In its final report, the commission noted, Almost everyone who spoke or wrote to the IOM study team about the potential harms posed by the medical use of marijuana felt that it would send the wrong message to children and teenagers. They stated that information about the harms caused by marijuana is undermined by claims that marijuana might have medical value. Yet many of our powerful medicines are also dangerous medicines . . . The question here is not whether marijuana can be both harmful and helpful, but whether the perception of its benefits will increase its abuse. For now any answer to the question remains conjecture. (IOM, 1999, p.101) The IOM report went on to suggest, however, that reasonable inferences could be drawn from the medical use and abuse of opiates, the effects of marijuana decriminalization2 and the short-term consequences of the medical marijuana campaign in California (the NHSDA oversampled California residents to assess marijuana use in 1997 and 1998 and found no increase in use). After highlighting the findings in these areas, they concluded, no convincing data support . . . the broad social concern that sanctioning the medical use of marijuana might lead to an increase in its use among the general population (IOM, 1999, p.126). The purpose of this study is to empirically assess whether enacting more liberal state policies: (1) changes
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attitudes, decreasing beliefs that marijuana is harmful, increasing perceived availability and increasing approval for use; (2) changes behavior, increasing marijuana use; and, based on gateway theory, (3) changes other hard drug use behavior. The theoretical and empirical literature suggests that, as with most complex human behavior and social problems, substance abuse is best explained in terms of the interaction of numerous personal and environmental factors. Research indicates that personal attitudes are correlated and interact with other variables to help predict behavior (Eagly & Chaiken, 1993). There also appears to be a general sequence in drug use, and progression to a particular drug is influenced not only by age of initiation and previous softer drug use, but also by a number of other personal and environmental factors (Yamaguchi & Kandel, 1984; Kandel, 1985; Kandel & Andrews, 1987; Yu, 1992; Ellickson, Hays, & Bell, 1992; Werch & Anzalone, 1995). Taking this literature into consideration, we might not expect marijuana policy change to have a significant effect on youth. It is important, however, given the social concern and lack of studies in this area, to examine the impact of policy change and to assess whether it produced negative outcomes.
METHODS
Telephone survey data was collected as part of the evaluation of the Robert Wood Johnson Foundations Fighting Back (FB) initiative, a community based collaborative effort to reduce the demand for illegal drugs and alcohol (Saxe et al., 1997). These data were used to compare drug attitudes and use in California versus the other 10 demonstration states before and after California passed Proposition 215 in 1996. The FB evaluation conducted three telephone surveys of residents aged 16 to 44 in 12 FB intervention and 29 demographically matched comparison communities. The surveys were administered in the spring of 1995, 1997, and 1999. The questions used for the survey were previously validated and drawn from other national surveys. The response rates were similar across all three waves, approximately 50%.3 The formula used to calculate the response rate represents the most conservative estimate. For example, if calls that did not result in contact with a potential respondent are not taken into account, the overall response rate is 78.2%. This is the rate usually reported by polling agencies, and is comparable to, for example, the rate of completed interviews in the National Household Survey on Drug Abuse, which is 78% (Office of Applied Studies [OAS], 1998). For the present study, survey data were limited to respondents aged 16 to 25. The total number of respondents aged 16 to 25 in FB and comparison communities, across all three waves of the survey, is as follows: California N = 2,651; comparison states N = 12,916; Total N = 15,567.
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Random Digit Dialing (RDD) sampling was used, as were weights (by household size and number of phones) in order to adjust for bias introduced by probability of selection. All analyses were performed in SUDAAN because the data were weighted and had to be adjusted for design effects. It is not known whether the sample is biased, and to what extent, by lack of participation due to phone numbers that were not in service or disconnected or by exclusion due to refusal to provide zip code or to answer substance use questions. However, cooperation rates, the proportion of all eligible respondents who qualified by screening questions have been high across all three waves of the survey (approximately 75% of eligible respondents). Furthermore, termination rates, the percent of respondents who terminate the interview before completion, and item nonresponse rates (excluding demographics) were low for all waves of the survey (less than 1% and less than 2% of respondents, respectively). Multilevel modeling, usually used to account for effects at different levels, such as the individual and community levels, was not used for two reasons. First, the overall FB program effect has not been significantly different from zero. That is, there was little to no variance in outcome measures in contrast to comparison sites; therefore, for most of the analyses, FB and comparison sites could be and were grouped together. Secondly, in some analyses, potential differences between FB and comparison communities within California were examined. There are, however, only two FB sites in California; thus, FB could not be considered a random effect as would be necessary in multilevel modeling. Descriptive, bivariate and logistic regression techniques were used to examine attitudes and use among 16 to 25 year olds in California and other states. Analyses were guided by the following research questions: 1. Have marijuana-related attitudes and use changed over time in California? 2. How do attitudes and use compare between California and other states, before and after Proposition 215? The primary outcomes in the present study address respondents use of marijuana and their marijuana-related attitudes. Marijuana use was assessed by questions about use in the past month (1-month) and past year (12-month), and marijuanarelated attitudes were primarily assessed by questions regarding perceived availability (availability), perceived harm (lowharm), and approval (approval) of marijuana use. Attitude towards marijuana legalization (legal) and medical use (Rx) were also examined, but these two questions were not asked in wave 1 of the survey. Because there was also a concern that changing attitudes and use of
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marijuana would lead to increases in other drug use, the secondary outcome is use of other drugs in the past year (other drugs: 12-month); past month other drug use was not asked. If more pro-drug attitudes and more drug use behavior were found in waves 2 and 3 in California but not in comparison states, then we could conclude that the policy causes untoward outcomes.
MEASURES
Measures were as follows:
Marijuana, 1-month: used past month (1) versus no use (0). Marijuana, 12-month: used past year (1) versus no use (0). Other Drugs, 12-month: used any drug illegally or an illegal
drug, last 12 months (1) versus no use (0) (includes cocaine/ crack, LSD, heroin, inhalants, tranquilizers, barbiturates, amphetamines, and analgesics). Availability: fairly to very easy to get (1) versus fairly difficult to impossible (0). Lowharm: risk/harm from marijuana once or twice a week; slight to no risk of harm (1) versus moderate to great risk of harm (0). Approval : approve of occasional use; approve (1) versus disapprove or strongly disapprove (0). Legal: should marijuana be made legal;4 yes (1) versus no (0). Rx: should marijuana be a prescription drug; somewhat or strongly favor (1) versus somewhat or strongly oppose (0).
We also selected other variables and conducted analyses to identify the composition of the sample and to compare California to comparison states. We selected many of the variables because of their associations in the literature with substance use. Furthermore, since the survey represents a repeated measures design at the community and not the individual level, it was important to assess the threat of differential selection to internal validity. Other variables included: age, sex, race, partner (married/living with partner), college (level of educational attainment), unemployed, religious services (attend religious services), income, student (current student) and children (live with children or stepchildren).
RESULTS
Demographic characteristics of the sample are reported in Table 1. The average age of respondents was 20.46 years (mode=16) and slightly more than half the
sample was male. Almost three fourths were White or Black, with the remaining quarter mostly Latino (7% identify as another race/ethnicity; this includes Asian/ Pacific Islander, American Indian, Alaska Native, or other race). Nearly three fourths were students, less than a quarter lived with a partner or children, and average annual household income was approximately $21,250 dollars (5 = $2025,000; mean = 5.25). Finally, about 40% of respondents were unemployed and about half never or rarely attended religious services. Each of the demographic variables was examined over time. Because the sample includes more than 15,000 respondents, some changes, while statistically significant (p<.05), are not likely to be very important but are reported here nonetheless. The average age of respondents decreased slightly and the samples included fewer White and more Latino and other respondents over time. The percentage of respondents who lived with a partner also fluctuated, first decreasing and then increasing (though 1999 rates were not substantially different from 1995 rates). Finally, unemployment was decreasing and household income increasing (by about $4,000 between 1995 and 1999). While the changes in age and racial composition are small (less than 3% changes each year), changes in employment and income are more substantial and likely reflect the improving economy between 1995 and 1999. Though not all differences are of a large magnitude, almost every demographic variable differed (p<.05) between California and other states. As indicated Table 1, the California sample was slightly younger and included more males. Differences were also found by race/ethnicity; the California sample included more White, Latino and other respondents and fewer Black respondents than other states. The California sample also reported less church attendance and fewer children living in the household. Finally, even though unemployment was higher in California, household income was higher than in other states. Although not all differences between California and other states nor changes over time were necessarily problematic (for example, we would expect more Latinos in California), they were controlled for in all multivariate analyses. In all subsequent analyses, the percent reported and/or value modeled is the affirmative (1 or yes) category. Thus, for example, for all use variables, the percent reported from cross-tabulations and value modeled in regression equations is of respondents who used the substance.
CHANGE IN MARIJUANA-RELATED ATTITUTDES AND USE OVER TIME IN CALIFORNIA
We calculated cross tabulations and used logistic regressions to model probabilities associated with attitudes towards availability, harm and approval, and use (past month and year marijuana use and past year other drug use) among California
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TABLE 1
DEMOGRAPHIC CHARACTERISTICS
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respondents, controlling for demographic variables that changed over time. The only attitude that changed significantly over time in California was the decline in perceived harm from marijuana use (Tables 2 and 3). Substance use, as measured
TABLE 2
PERCEIVED HARM BY YEAR (CALIFORNIA)
TABLE 3
HARM: MODELING PROBABILITY OF SLIGHT TO NO RISK OF HARM (CALIFORNIA)
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by marijuana use during the past month and year and other drug use during the past year, did not change significantly over time in California (data not shown).
COMPARABILITY OF ATTITUDES AND USE IN CALIFORNIA AND OTHER STATES, BEFORE AND AFTER PROPOSITION 215
We compared attitudes and use between California and other states by year (Table 4). Californians differed significantly (p<.05) on all attitudes and use, except perceived availability. Specifically, Californians perceived less risk of harm in occasional marijuana use, were more approving of marijuana legalization and use
TABLE 4
ATTITUDES AND USE: CALIFORNIA AND OTHER STATES BY YEAR
for medicinal purposes, but were less approving of marijuana use. Past month and year use of marijuana, and other drug use, were higher in California than other states. We also analyzed changes over time. There were actually fewer significant (p<.05) changes in California than in other states (Table 5). Within California, perceptions of slight to no harm in marijuana use increased. In other states, as in California, slight to no harm increased, but in contrast, approval for legalization and legalization for medical use also increased.
DISCUSSION
We found that while perceptions of harm from marijuana use have decreased over time in California and in other states, marijuana and other drug use has remained stable. Though support for medical use and general legalization of marijuana has
TABLE 5
SUMMARY, DIFFERENCES, AND CHANGES IN MARIJUANA-RELATED ATTITUDES AND USE
increased over time in other states, personal approval for recreational use has decreased and use has not changed. A major concern was that legalizing medical marijuana would send the wrong message to youth and lead to greater drug use. Since use did not increase, these arguments are not supported. Respondents in this study increasingly believed that marijuana was not terribly harmful. However, this was not coupled with increased use, and approval for personal recreational use decreased, even while support for medical use increased. One might argue that policy changes did in fact send the wrong message, since perceived harm decreased, and youth and young adults in other states policy attitudes became more liberal. However, there is a conceptual, and this research suggests an empirical, distinction between attitudes that may relate to recreational use verses those that relate to medical use/policy. Even while perceived harm decreased and support for medical legalization increased, approval for use decreased and actual use did not change. Therefore, it may be that changes in perceived harm have more to do with policy attitudes, and changes in approval have more to do with recreational use, since use remained stable across the country. Moreover, since six states passed medical marijuana initiatives between 1997 and 2000, we would expect, and indeed found, in all but California, attitudes about policy became more liberal over time. That is, on the whole, attitudes were not changing
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over time in California but were changing in other states. Therefore, one implication of our results may be that policy changes reflect attitude changes, rather than policy causing attitude changes. Another implication is that other states may be converging with California. Attitudes are typically more liberal (and use higher) in the West, and in California in particular, compared to the rest of the country (Office of Applied Studies [Gallup Poll], 2000). The majority of Americans still oppose the idea of legalized marijuana. Americans see drugs as a serious problem nationally, but not in their local area. Liberal attitudes may have led to policy changes in California; although attitudes have since been stable in California, they have been changing in other states, while policy was also changing. Thus, California can be viewed as a bellwether state. However, in order to fully test the direction and association of attitudes and policy change, longitudinal data with representative state samples are needed, with data collection both before and after policy change. The results of this study indicate that marijuana and other illicit drug use remained stable in the latter part of the 1990s; these results are validated by other recent findings. The most recent Monitoring the Future (MTF) data indicate that adolescent use has remained stable or decreased in the last few years (Department of Health and Human Services [DHHS], 2000). Similarly, National Household Survey on Drug Abuse (NHSDA) data indicate little change in marijuana use among 12 to 26 year olds between 1997 and 1999 (OAS, 1999). Moreover, as in the present study, the NHSDA data indicate a decline in perceived risk of harm from marijuana use (OAS, 2001). Finally, the Harvard College Alcohol Study found that past month marijuana use among college students increased from 1993 to 1999 but that nearly all of the change had occurred by 1997 (Gledhill-Hoyt, Lee, Strote, & Wechsler, 2000). Thus, the results of this study are consistent with other recent research on youth and young adult marijuana use. How do these findings compare to other studies about the relationship between marijuana attitudes and use? Previous analyses of MTF data suggested that changes in marijuana use are closely correlated with perceived harm and approval (Bachman, Johnston, & OMalley, 1998). However, in the present study, although harm and approval were significantly associated with use, they were moving in different directions. It is possible that although Proposition 215 and the ongoing debate did not change attitudes and thus affect use, the policy change and debate may have altered the relationship between attitudes and use. Examination of correlations between attitudes and use over time suggest that the relationship between attitudes and use has in fact changed.5 Correlations between use, availability, harm, and approval became weaker over time. This suggests that attitudes about availability, harm, and approval may be becoming somewhat less salient to actual use of marijuana.
One perplexing finding here was that Californians indicated less approval for occasional marijuana use, but higher use rates. Likewise, respondents in other states indicated higher approval for use, but less actual use of marijuana. It may be that this finding is an artifact of our data, or it may be another indication that the relationship between attitudes and use is complex and changing. The results further suggest that people distinguish between recreational and medical use: they can believe marijuana is not greatly harmful and approve of legalization for medical use but still disapprove of personal use. Further research is clearly needed to explore and explain the relationship between attitudes and use, the impact of policy changes on this relationship, and the impact of policy changes on use.
ASSUMPTIONS ABOUT THE GATEWAY: OTHER DRUG USE
In light of gateway theory and the historically greater risk of progression to other illicit drug use among marijuana users, how do we understand the apparently short lived but marked increase in marijuana but not other drug use in the 1990s? Should we be concerned that higher rates of initiation and use of marijuana in the mid 1990s may yet lead to greater other illicit drug use? Two recent and related studies by Golub and Johnson help clarify these issues. In the first of these studies, they examine probabilities of drug use progression and their covariates and conclude, The recent increase in youthful marijuana use has been offset by lower rates of progression to hard drug use among youths born in the 1970s. Dire predictions of future hard drug abuse by youths who came of age in the 1990s may be greatly overstated (Golub & Johnson, 2001a, p.225). In a study for the National Institute of Justice, which included both the criminal and general populations, they conclude: A standing argument for controlling marijuana use, based on the gateway theory, is that it can lead to the use of more dangerous drugs. As determined in this study, however, the drug of choice for persons born in the 1970s and coming of age in the 1990s has been marijuana. These youths have been much less prone to progress to other drugs than their predecessors. This suggests that the gateway theory may be less relevant to their experience. (Golub & Johnson, 2001b, p.14) Furthermore, although the number of new marijuana initiates aged 12-17 was increasing in the early 1990s, this trend peaked in 1995 and the number of new marijuana initiates declined each year thereafter (OAS, 2002). The available data suggest that the changes in marijuana policy did not send the wrong message and lead to greater drug use. Why might this is be so? Consider
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the content of the message imbedded in the debates, the controversy that marijuana is an illegal substance. The very fact that there was a debate highlighted the tension between possible medical benefit while reminding the public that marijuana is illegal, to say nothing of the message sent by actions of federal agencies, such as raids on distribution centers, threatening doctors with revocation of their DEA prescription authority, criminal prosecution, and exclusion from participation in Medicare and Medicaid programs, and prosecution of anyone involved with medical marijuana under federal law (JoinTogether,1998; Bouford,1997; JoinTogether, 2003). Moreover, the policy change and associated debate may have sent some message but not one we would expect to dramatically change marijuana-related attitudes and use because the relationship between attitudes and behaviors is complex, as is drug use behavior. Various attitudes have a differing relationship to use, and attitudes are not the only influences on drug use. Moreover, research suggests that attitudes are helpful in predicting behavior to the extent that they are aggregated, well matched to the behavior in question, and when they are based on personal experience and substantial information (Eagly & Chaiken, 1993). Policyrelated attitudes about medical legalization likely have not had an impact on drug use behavior because, these variables, together or separately, are not well matched or explicitly linked to youth recreational marijuana use, and therefore did not alter recreational use norms and behavior. Finally, what we know about the etiology of drug use suggests that drug use is complex and is influenced by numerous factors, some more proximal and personal, and others more distal, contextual, or environmental. Medical marijuana policy is a relatively distal factor, compared to other variables that are important in predicting marijuana use, such as individual risk factors and social influence. Thus, despite the considerable media attention and public discussion and debate about legalizing medical marijuana, the policy change and associated issues may have been sufficiently irrelevant and/or ambivalent to produce changes in youth and young adult marijuana-related attitudes and use.
LIMITATIONS
The principal limitations of the study are related to the data, the survey sample, the content of the instruments, and mode of administration. The findings and conclusions drawn here are based on reports of respondents in FB and demographically matched comparison communities and therefore are not generalizable to all communities across the U.S. The California sample, likewise, may not be generalizable to persons living in that state; however, our results are similar to the NHSDA study. Because legalization of medical marijuana was not anticipated when the wave 1 instrument was administered, baseline attitudes towards medical use were not gathered until after Proposition 215 passed. Therefore, it was not possible to examine differences both before and after the policy change. However,
other marijuana-related attitudes were examined over time in California and were contrasted with comparison states in the sample. Also, the survey sample did not include anyone who was younger than 16. Attitudes and use vary with age, and the distributions were therefore somewhat truncated. There is also a possibility of a cohort effect since our samples included 16 to 25 year olds in each year. However, marijuana use is typically initiated around age 16 and is most prevalent among young adults; our sample therefore included the most relevant, potentially using, population and the age group of most concern. Also, all modes of administration, whether telephone, face-to-face, self-administered paper and pencil, or computerized interview, have particular strengths and limitations. Data collected through telephone survey methods tend to bias estimates due to underreporting (McAuliffe, Geller, LaBrie, Paletz, & Fournier, 1998), and we found this to be true for the most sensitive questions in the FB survey6 (Livert et al., 2000). Finally, results may be somewhat biased since attitudes and use may affect each other and a nonrecursive model was not employed. Limitations notwithstanding, only one other study has examined changes in attitudes and use (NHSDA) after legalization of medical marijuana; these findings therefore add to our rather limited existing knowledge.
CONCLUSION
This research suggests that medical marijuana policy has had little impact on youth and young adult marijuana-related attitudes and use in selected communities across the country. The ultimate outcome measure in this study was marijuana use, and it remained stable from 1995 to 1999. Medical marijuana continues to be part of public dialogue and debate nationally and internationally. As of August 2003, nine states (with more than 20% of the U.S. population) allow medical marijuana use, and Canada recently legalized medical use. Nearly three out of four Americans (73%) favor legalization for medical purposes, less than one third (31%) support general legalization of marijuana and the country is nearly evenly split on whether marijuana possession should be treated as a criminal offense (Gallup Poll, 2000). Regardless of public opinion, however, marijuana is a controlled substance and recreational use, although decriminalized in some states, is still illegal. Clearly, more research is needed on the impact of medical marijuana policy and how this may relate to nonmedical marijuana-related attitudes and use. In a review of marijuana policy issues in the U.S. and Australia, Single and colleagues (2000) conclude: Regardless of ones position on these issues, it is clear that the policy debate, both in the United States and in Australia, has not
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been well informed by research, and different legislative approaches have been introduced in different locations at different times, with little or no planning for evaluating the impacts of the changes and monitoring them on an ongoing basis. Both sides of the debate have presumed that certain impacts will result from changes in policy, with little or no reference to empirical evidence (Single, Christie, & Ali, 2000, p. 160). Attitudes about and use of marijuana need to be monitored as medical use becomes more prevalent as a result of policy changes. Though the data reported here do not indicate great cause for concern, the effects of these policy changes may not be immediate. Medical legalization could, for example, lead to increased access to and availability of marijuana and this may have an effect on prevalence of use. Results from all such studies will be of interest to policy makers, researchers and public health professionals. As states legalize medical marijuana use, it will be critical to understand the impact of such policies on substance use and abuse.
1
The Narcotics Control Act of 1956 established the following penalties: Minimum 2 years 5 years 10 years $20,000 Sale First offense Second offense Sale to Minimum 5 years 10 years 10 years
Possession First offense Second offense Third and Fine
(Bonnie & Whitebread, 1974)

2
Analyses of the Monitoring The Future data from 1975 to 1980 revealed that students in decriminalized states (seven states) did not report either attitudes or rates of marijuana use that were significantly different from students in states where marijuana was not decriminalized (IOM, 1999, p. 102; Chaloupka & Laixuthai, 1997, p. 253). For a review of several studies on decriminalization and marijuana use see Single, E.W. 1989. The impact of marijuana decriminalization: An update. Journal of Public Health Policy. Winter 1989, 456-466. 3 Response Rates: wave 1 = 57.3, wave 2 = 57.8, wave 3 = 49.2. 4 Only 8% of all respondents answered this dichotomous yes/no question by saying yes, for medicinal purposes. These responses were recoded as 1, yes, in favor of legalization. 5 Correlations not shown.
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6
Fighting Back Survey data were compared to NHSDA data and though prevalence of alcohol was about the same, reports of other drug use were lower.
ACKNOWLEDGMENTS
This paper represents some of the research conducted for a doctoral dissertation at the Heller School, Brandeis University. It was supported by a NIAAA predoctoral fellowship and with funding and data from the Robert Wood Johnson Foundation. Special thanks are extended to my dissertation chairperson and committee: Leonard Saxe, Helen Levine, John Capitman and Denise Hallfors.
REFERENCES
Bachman, J.G., Johnston, L.D., & OMalley, P.M. 1998 Explaining recent increases in students marijuana use: Impacts of perceived risks and disapproval, 1976 through 1996. American Journal of Public Health, 88(6), 887-892. Bonnie, R.J., & Whitebread, C.H. 1974 The marihuana conviction: A history of marihuana prohibition in the United States. Charlottesville: University Press of Virginia. Bouford, J.I. 1997 California Proposition 215 and Arizona Health Proposition 200 challenged. Journal of the Mississippi State Medical Association, 38(5), 172. Chaloupka, F.J., & Laixuthai, A. 1997 Do youths substitute alcohol and marijuana? Some econometric evidence. Eastern Economic Journal, 23(3), 253-276. Department of Health and Human Services 2000 Study released: Moderating trend among teen drug use continues. HHS News: U.S. Department of Health and Human Services. Retrieved September 15, 2004, from http://www.hhs.gov/news/press/2000pres/ 20001214.html Eagly A.H, & Chaiken S. 1993 Psychology of attitudes. Orlando, FL: Harcourt, Brace Jovanovich, Inc. Ellickson, P.L., & Hays, R.D. 1992 On becoming involved with drugs: Modeling adolescent drug use over time. Health Psychology,11(6), 337-385. Ellickson, P.L., Hays, R.D., & Bell, R.M. 1992 Stepping through the drug use sequence: Longitudinal scalogram analysis of initiation and regular use. Abnormal Psychology, 101(3), 441-451.
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