Paper: Public health orientation of Cannabis and alcohol regulators: An analysis of state-level variation in the United States

An important slogan in the campaign for legalization of cannabis for adult use was “Regulate like alcohol” (Caulkins, 2017; Caulkins & Kilborn, 2019; Caulkins, Kilmer et al., 2012; Caulkins, Lee et al., 2012; MacDonald, 2015). For many public health scholars this was an ironic banner under which to march. Alcohol regulation is regarded within the public health community as largely a failure, and sometimes even as, an example of regulatory capture by the industry it regulates (Cook, 2007; Noel et al., 2017; Room, 1984; Savell et al., 2016). Alcohol-related health consequences and mortality remain among the leading preventable causes of death in the United States (US) (Centers for Disease Control and Prevention [CDC], 2024).

Several studies have found the legalization of adult-use cannabis to be associated with increases in the prevalence of cannabis use as well as the extent of frequent and high intensity use, particularly among males and those of low-income status (Goodman et al., 2020; Goodwin & Silverman, 2024; Hasin et al., 2019; Jeffers et al., 2021; Kephart et al., 2025; Lapham et al., 2023). A burgeoning literature also suggests that increases in prevalence and high frequency use may come with notable public health consequences, including increases in the prevalence of Cannabis Use Disorder (CUD) (Smart & Pacula, 2019; Patrilli et al., 2022), neurocognitive deficits (Dellazizzo et al., 2021), hyperemesis (Karila et al., 2014), and psychosis (Patrilli et al., 2022).

Historically, the regulatory regimes of alcohol and adult-use cannabis both proceeded from prohibition regimes, which provided a blank slate for substance regulation. Following Prohibition, US states pursued varied approaches to alcohol regulatory regimes: 15 states took on public monopoly, or Alcohol Beverage Control (ABC), models where states own and operate the sale of alcohol while the remainder eventually took up for-profit regulatory models that permit the operation of private liquor establishments (Levine & Reinarman, 1991; Pennock & Kerr, 2007; Room, 1984). By contrast, among the 24 US states that have legalized the sale and consumption of adult-use cannabis, all have established a for-profit model of business licensing that parallels the present-day status of for-profit state liquor and alcohol licensing regimes. The ubiquity of the for-profit commercial model reflects the framing of adult-use cannabis as a novel revenue source within legalization debates (Orenstein & Glantz, 2020).

Additionally, unlike the nationwide repeal of Prohibition passed by way of constitutional amendment, adult-use cannabis legalization has only been enacted at the state level. The most popular modes of legalization include citizen-led ballot initiatives and referenda (hereafter “ballot measures”) and state legislation. Only 26 US states and Washington DC have a ballot initiative or referendum process available to constituents (Adams, 2012). Accordingly, an increasing number of states have turned to the legislative process to pursue legalization.

Internationally, countries have taken a broad array of approaches to adult-use cannabis regulation. In Canada, which legalized adult-use cannabis in 2018, provinces were given considerable discretion in their regulatory frameworks (Shanahan & Cyrenne, 2021). Alberta and Saskatchewan, for instance, pursued a similar for-profit licensing model as US states and integrated their cannabis regulatory agency into extant alcohol and gambling regulatory agencies. Quebec, on the other hand, operates the Quebec Cannabis Corporation (SQDC), a provincially-controlled firm with a legal monopoly over the distribution and sale of cannabis. Uruguay, the first country to legalize the sale and consumption of adult-use cannabis, maintains a state-controlled regime with strict price and production levels, a limited number of commercial pharmacies, and “cannabis clubs,” not-for-profit cooperatives that can distribute cannabis to small groups of registered individuals, as well as home grown for personal use (Obradovic, 2021; Walsh & Ramsey, 2015).

Compared to the robust body of literature on alcohol regulation, there is a small literature on what responsible adult-use cannabis regulation might entail. Blanchette et al. (2022) assessed 18 different policy choices, whether for regulators or for other kinds of policy makers, for their potential in “reducing youth use of cannabis, excessive cannabis use among the general population, and cannabis- impaired driving.” Most of the policies that were rated highly in all three dimensions were options for adoption specifically by cannabis regulators, such as physical retail availability and retail price restrictions. Moreover, research on the potential regime directions that cannabis regulation may take has broadly assumed a consensus that countries and US states which take a control-oriented approach to market regulation are best suited to address the potential public health and safety consequences of legalization (Blanchette et al., 2022; Crawford, 2023; Kilmer, 2014; Kilmer, 2017; Neely & Richardson, 2023).

Research demonstrates that there is significant variation in both the means and extent to which US states regulate issues of public health for regulated substances, such as alcohol and tobacco (Dobbs et al., 2021; Mosher et al., 2013; Neely & Richardson, 2023). Barry and Glantz (2018) find that the policy texts of the first four states to legalize adult-use cannabis followed the language of alcohol regulation; among these states, less than half of all cannabis-use legislation, including general, supply-side, and demand-reduction policies, adhered to public health “best practices.”

Moreover, there is significant variation in the location of agencies placed in charge of adult-use cannabis regulation within state governments. Three states, Washington, Oregon, and Maryland, place cannabis and alcohol under the same regulatory agencies. All other states have either created an independent regulatory agency or have nested the responsibilities of cannabis regulation within extant departments. Appendix A1, Appendix A2 provides details on the regulatory body for adult-use cannabis and alcohol for all states which have legalized adult-use cannabis. Nearly half of states (46 %) have created independent executive bodies for the regulation of adult-use cannabis. Among US states where adult-use cannabis regulation is housed within existing state departments, over half of cannabis regulatory bodies are located within finance and licensing departments. A similar makeup is found with respect to alcohol regulation, with 39 % of alcohol agencies operating as independent regulatory bodies and 39 % located under licensure and finance departments. Only approximately 20 % of both adult-use cannabis and alcohol regulatory bodies are located under the supervision of public health or public safety departments.