States reject marijuana legalization, recognize potent drug’s harms

Carrie Bearden supervises a clinic for 12- to 25-year-olds showing signs of schizophrenia and other severe mental illnesses. In recent years, she’s noticed a growing number of her young patients are also regular cannabis users. Recreational marijuana use is legal in California. “The prevalence and frequency of use has increased over time,” said Bearden, who is a clinical psychologist and teaches at UCLA. “They have the perception that it’s helping their anxiety or helping them cope with things.”

But Bearden believes that, for many of her patients, cannabis exacerbates their symptoms. A growing body of scientific research links high-potency tetrahydrocannabinol (THC), the psychoactive component that gives cannabis users a high and can cause addiction, to severe mental illness. And the evidence shows young people are especially at risk.

On Tuesday, voters in three states rejected recreational marijuana measures. Opponents of the proposed measures say that the results indicate that this message may be going mainstream as more people are recognizing the drug may not be as harmless as it is often portrayed. But though the legalization tide may be turning, opposition groups are already gearing up for the next fight against an industry with millions at its disposal.

Initial results show Florida, North Dakota, and South Dakota refused to legalize marijuana for recreational use, though a large majority of Nebraska voters approved a medical marijuana measure. The Arkansas Supreme Court threw out a measure to expand the state’s medical marijuana program in the final weeks before the election because of how the measure was written, and though it remained on the ballot, the court ordered election officials not to tally any votes in favor or against it. And in Massachusetts, voters spurned an initiative that would have legalized psychedelics.

Marijuana is fully legal in 24 states plus the District of Columbia, and now 39 states have approved the drug for medical use. Ohio most recently legalized the drug recreationally in 2023. But in 2022 and 2023, four out of the seven states that weighed marijuana legalization initiatives rejected them, and yesterday’s results show the legalization wave may be further faltering.

“Voters across the United States, in both Republican and Democratic states, rejected soundly the legalization of marijuana and psychedelics despite pro-drug campaigns outspending opponents by more than 20 to 1,” Smart Approaches to Marijuana, a national group that opposes drug legalization, said in an emailed statement Wednesday morning. “Tonight was the strongest anti-drug vote we’ve seen in more than a decade. Americans from all backgrounds may have been divided about other races, but they were united in their belief that we do not need to legalize marijuana or psychedelics.”

Voters repudiated recreational marijuana even as the nations’ presidential candidates took a more liberal approach to the drug on the campaign trail. Vice President Kamala Harris pledged to legalize the drug recreationally at the federal level. During his campaign, President-elect Donald Trump indicated he supported Florida’s constitutional amendment to legalize the drug, though he argued for common-sense regulations around when and where people can use the drug in public.

Opponents of legalization point to evidence showing children are getting a hold of high-potency THC products, especially edibles—gummies and other food products that contain THC concentrate. Marijuana poisonings and emergency room visits among children under 18 increased after Canada legalized the drug in 2018. Another study shows senior adults are also inadvertently overdosing and ending up in the emergency room. The U.S. government website Just Think Twice noted potent edibles are more common in states that permit marijuana for recreational and medical use.

Earlier this fall, New York Times investigative reporters spoke to hundreds of public health officials and physicians who say more regular users are developing cannabinoid hyperemesis syndrome, a life-altering condition marked by severe vomiting and abdominal pain.

Mounting evidence also links the drug to severe mental illnesses. “Higher potency, THC, in cannabis is connected to increased risk of developing a psychotic disorder, and that’s particularly true for the younger age of onset of use,” said Bearden, the clinical psychologist at UCLA.

One study surveying patients at 11 sites across Europe and Brazil found daily cannabis users who consumed marijuana with a THC content at or above 10% were five times more likely to develop a severe psychiatric disorder such as schizophrenia or psychosis compared with individuals who had never used the drug. Researchers in Denmark found young men who are addicted to marijuana are particularly susceptible to triggering schizophrenia.

Another study published in JAMA Network Open that even teens who used marijuana occasionally, but were not addicted to the drug, were still two to four times more likely to experience an adverse psychological event, including major depression and suicidal thoughts. Marijuana may also negatively affect brain development in individuals under 25.

The marijuana these young people consume is a vastly different substance compared to the cannabis that was available in the 1960s, 70s, and 80s, Bearden noted.

A typical joint of marijuana before 1990 contained less than 2% of THC. But since then, marijuana’s THC content has skyrocketed as companies developed highly-potent strains of the drug and states legalized their products. Now, individuals smoke or vape marijuana with a THC potency between 17% to 28%. Some edibles, oils, and other concentrated forms of the drug may contain 95% THC.

Though several states put weight-based limits on the amount of flower or concentrate that can be sold in one transaction, that can still translate to a large number of THC doses—often larger than what a typical user consumes in a month—a study published in the American Journal of Preventive Medicine found. Only two states, Vermont and Connecticut, have enacted caps on the levels of THC a product may contain. According to the New York Times investigation, just 10 states require those products to come with warning labels.

Tuesday was the second time that South Dakota voters refused to legalize the drug. In 2022, 53% of voters rejected legalization and, as of Wednesday morning, unofficial results show about 56% of voters spurned the measure this time around. South Dakotans approved legalization in 2020, but the state Supreme Court struck down that measure because it violated state rules against ballot measures containing more than one subject. Protecting South Dakota Kids, the grassroots advocacy group that opposed the legalization in 2022 and 2024, attributes the states’ turnaround to opponents’ efforts to draw attention to the ways the drug harms children.

“The more people that understand what marijuana does across our country … how marijuana affects a child’s mind … they’re going to vote no, they don’t want that for their communities,” said Rhonda Milstead, the group’s executive director and a former state representative. Milstead believes legalization will soon be back on the ballot and her group of primarily volunteers are already gearing up for the next fight. “After this is over, we’re going to regroup, make sure everybody understands what worked,” she added.

North Dakota voters also decided to keep the drug illegal Tuesday, after previously rejecting the drug in 2018 and 2022. This year, roughly 52% of voters turned down the measure which would have permitted adults 21 and older to possess and use the drug and create a state entity to regulate its use and sale. The state’s chief medical and law enforcement associations opposed the measure.

Florida’s constitutional amendment to legalize marijuana required a super-majority support to pass, and it failed to convince more than 60% of voters. The Sunshine State’s measure garnered the most national attention since the amendment’s fiercest opponent, Florida Gov. Ron DeSantis, vocally campaigned against the measure up until the final days of the election. He warned the amendment would negatively “impact the quality of life in Florida,” and described the legalization effort as a “money-grab” by medical marijuana companies seeking to expand the industry.

The marijuana company Trulieve Cannabis contributed $141.9 million of the total $149.7 million spent on the ballot measure.

“This is clearly one of Big Marijuana’s biggest defeats yet,” Kevin Sabet, Smart Approaches to Marijuana president, said in an emailed statement. “Normalizing a new addiction-for-profit industry won’t change the known harms of these drugs.”

Psychedelics were also on the ballot Tuesday. And so far, results indicate that more than 57% of Massachusetts voters rejected a push to legalize and regulate the use of naturally occurring psychedelic substances, including psilocybin, more commonly known as magic mushrooms. Massachusetts’ Question 4 would have allowed individuals older than 21 to grow and use psychedelics in their homes. Licensed facilitators such as therapy centers could also provide the drugs, but retailers are not permitted to dispense them.

Chris Keohan is a spokesperson for the Coalition for Safe Communities, a group that opposed the measure. He argued the initiative did not put enough regulations in place for therapeutic facilities administering the drug. And while the measure prohibited retailers from dispensing the drug, it still allowed 12-foot by 12-foot growing areas in homes and would have permitted individuals to give the drugs away to friends and family. “It’s just the creation of another potential black market,” he said.

Proponents of expanding access to psychedelics point to research showing the drugs may have a role to play in treating post-traumatic stress disorder and addiction. Peter Hendricks is a clinical psychologist and professor of psychiatry and behavioral neurobiology at the University of Alabama at Birmingham, where he conducts clinical trials evaluating the use of psychedelics in treating drug and alcohol addiction and other mental health conditions. “It does seem that psilocybin and maybe other psychedelics too, can help some of those people stop,” Hendricks said.

Still, he pointed out that “the evidence base around psychedelics is relatively modest.” The evidence that we do have, he added, is based on a handful of small clinical trials that carefully select their participants to maximize safety and ensure only licensed professionals administer the drugs. Expanding access too quickly discounts the drug’s potential for significant harm, he argued. There is some evidence that even in highly-controlled settings, psychedelics may cause some individuals to make impulsive decisions that they later regret, and, while relatively rare, in some cases the drugs may increase suicidal behavior.

“In these very small and very carefully conducted randomized clinical trials, the results suggest that these drugs are safe and effective,” Hendricks said. “But that doesn’t mean at all that we can generalize from these randomized clinical trials to what might happen outside of very carefully controlled settings.”

The Food and Drug Administration has not approved psychedelics for any medical use, though it has granted breakthrough therapy designations to some psychedelic drugs for the treatment of certain mental health disorders. The status isn’t the same as full approval, but it helps fast track the review process. In August, the agency rejected a bid to approve the psychedelic drug known as MDMA for the treatment of PTSD, citing concerns about the quality of the research.

So far, only Oregon and Colorado have legalized some psychedelics at the state level and at least a dozen other states are considering legislation that would remove criminal penalties around psychedelics or have created working groups to explore their therapeutic effects.

Until Tuesday, legalization appeared to be gaining steam, but Massachusetts’ rejection revealed many voters still have significant concerns. “The home growth component of this really is what propelled us to victory,” Keohan, with the opposition coalition said. “We don’t want our children visiting homes that would be growing this.”

Still, Keohan said his coalition is already preparing for legalization proponents to file new legislation in order to put psychedelics back on the ballot. Without significant changes and more safeguards, his group will likely oppose another attempt.

“We’re going to take a close look at what gets filed and make sure that they don’t try and refile the same thing that voters just overwhelmingly rejected,” he said.