Legalization of cannabis in Washington State: how is it going?

This is the authors' abstract. We don't add key points for this paper.

The world is watching with interest how things are working out with the legalization of cannabis in US states such as Washington. It is early days, but a mixed picture is already emerging with dramatically reduced criminalization of users and little evidence of increased usage, but continuing discrimination against African Americans in criminal sanctions, some evidence of increasing traffic safety risk and delays in establishing effective educational and public health services. The key lesson for other jurisdictions considering a similar move is to build in effective systems for continuous monitoring and adaption in the light of experience. The licensed production and sale of recreational cannabis were made lawful when Washington voters passed Initiative 502 (I-502) on 6 November 2012 1. Adult possession of up to 1 ounce of cannabis became legal 1 month later. Then, after a period of rule-making and the processing of license applications, the first recreational store opened on 8 July 2014. Independent evaluation of the law's impact has been a unique feature of the Washington model 2. A proportion of cannabis excise tax revenues is funding a cost–benefit evaluation of the reform's effects by the Washington State Institute for Public Policy (WSIPP). The Institute first published a roadmap for its methodology in 2015 3, and will subsequently issue reports to the Legislature in 2017, 2022 and 2032. The impact of legalization will be assessed, notably in contrast with the impact of prohibition, in a number of outcome domains: public health; public safety; rates of youth and adult use, maladaptive use and use disorders; economic impacts; criminal justice impacts; and state and local agency administrative costs and revenues. Determining outcomes specific to recreational cannabis legalization will be difficult, in part because this policy reform did not occur in a vacuum. A quasi-legal cannabis supply chain had been in place for 14 years. Initiative 692, approved in 1998, permitted authorized patients and designated care-givers an affirmative defense if prosecuted for violating cannabis possession laws 4. Beginning in 2009, largely unregulated storefront collective gardens and dispensaries proliferated in the state. In addition to serving legitimate patients, some became a source of supply for non-medical cannabis consumers who obtained illicit authorizations. In 2014, purchases through licensed retail outlets were estimated to account for only 30% of all cannabis sales in the state, with the remaining 70% occurring through the black market or medical cannabis providers 5. To complicate things further, many of the effects of the legalization will probably emerge only over a period of years. Some negative impacts, for example a possible increased demand for cannabis dependence treatment, may not become evident for 5 or 10 years. The same is true for positive impacts, such as a possible reduction in alcohol-related morbidity and mortality from substituted cannabis consumption 6. Having said this, some trends are already emerging. With regard to social justice outcomes, prosecutions for low-level misdemeanor possession offences have decreased dramatically from more than 5000 in 2012 to 120 in 2013. However, while the numbers are small, in the first year of implementation of the new law African American adults continued to be three times more likely than whites to be charged with low-level cannabis offenses, despite comparable use rates 7. In terms of youth uptake, a state-wide survey of more than 25 000 6th, 8th, 10th and 12th grade students found that use in the past 30 days had not increased from 2012 to 2014 8. A national survey of high school students reported similar results to 2013 9. However, because beliefs will probably influence use behaviors, the increasing percentage of young people in the Washington state sample who perceive regular cannabis use as not risky or only slightly risky will need to be monitored closely 10. With regard to public health, cannabis-related calls to the Washington Poison Center increased from an annual average of 155 calls (2011–13) to 246 in 2014 11. Another major health indicator is impaired driving. Forty-nine per cent of Washington current users aged 18–25 years report driving within 3 hours of consuming cannabis on the previous 30 days 8. From the last half of 2013 to the first half of 2015, the percentage of drivers suspected of driving under the influence (DUI) and testing positive for active tetrahydrocannabinol (THC) increased from 22.2 to 32.7% 12. The frequency of drivers in fatal crashes who tested positive for THC, alone or in combination with alcohol and/or other drugs, increased 111% in 2014 from the previous 4-year average. Of course, this does not necessarily imply a causal association between THC ingestion and crash risk, but the trend is not reassuring. With regard to implementation, several challenges were faced in achieving the initiative's objectives. One was that of replacing illicit sources of supply with a state-wide regulated market. The Washington attorney general has taken the view (although this is currently being challenged in the courts) that local jurisdictions could choose to ban I-502-related businesses 13. As of September 2015, 98 cities or towns and nine counties had done so, with the probable effect that the black market would continue to exist in those areas 14. In addition, hundreds of unregulated medical cannabis dispensaries and collective gardens in the state continue to be a source of supply. More recent legislation requires that all such entities either qualify to become retail licensed outlets or close by 1 July 2016. A key intention of the initiative was to replace prohibition with a public health approach involving cannabis-specific, science-based public education, youth-focused prevention, treatment of cannabis use disorders and research 15. Cannabis excise tax revenues would fund these activities. Although cannabis excise tax revenues began to accumulate in July 2014, implementation of the bulk of these provisions is just beginning. One initiative provision, based on promising findings in Australia 16, was that a cannabis public health hotline would be created to educate consumers, offer treatment referrals and deliver evidence-based telephone advice to individuals seeking help with quitting or reducing their use. Unfortunately, it seems that the hotline provision has been modified to such an extent by the state agency charged with this responsibility that its impact will probably be minimal. Therefore, the picture thus far is a curate's egg—good in parts. No policy change of this magnitude will go precisely according to plan. The key point is to monitor closely, learn the lessons and have systems in place to evaluate outcomes and make changes in the light of these. Perhaps that is the main thing that other jurisdictions thinking of following Washington's example can take from this experiment. R.R. was a co-sponsor of the Washington initiative discussed in this paper.