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Official websites use. Share sensitive information only on official, secure websites. Correspondence Eric L. Email: esevigny gsu. Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. This evidence and gap map EGM summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps. Additions to the pool of potentially eligible studies from supplemental sources were made through November Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws MCLs , limited medical cannabidiol laws CBDLs , recreational cannabis laws RCLs , industrial hemp laws IHLs , and decriminalization of cultivations laws DCLs. Eligible outcomes include intermediate responses i. Both dual screening and dual data extraction were performed with third person deconfliction. The EGM includes studies, comprising primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. Of the distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions. An evidence and gap map EGM provides a systematic and visual representation of available research on a specific issue or topic. This EGM presents evidence on the effects of cannabis policies. The map reveals areas of both evidence concentration, which can aid systematic review and policy decisions, and evidence gaps, which can inform research and funding priorities. Studies examining the effects of medical and recreational cannabis laws on cannabis use are relatively common. The evidence base for other laws and outcomes remains underdeveloped. The map provides descriptive and interactive displays of empirical evidence on the effects of cannabis liberalization laws. Specific interventions include laws that create or expand access to cannabis by removing criminal penalties, allowing medical use, or legalizing use for adults. Main outcomes include health, safety, and socioeconomic factors that are potentially linked to cannabis liberalization. The aim of this EGM is to present evidence on the effects of cannabis liberalization laws, including laws that create or expand access to cannabis by removing criminal penalties, allowing medical use, or legalizing use for adults. Most cannabis liberalization research focuses on the effects of medical cannabis laws and recreational cannabis laws. These studies primarily investigate overall effects, but a sizable number also explore the specific effects of cannabis dispensaries. Studies targeting other relevant laws—including medical cannabidiol laws, industrial hemp laws, and cultivation decriminalization laws—are relatively rare. The map documented distinct outcomes, with cannabis use outcomes investigated most frequently. Although no geographic restrictions were applied, most of the evidence is from North America, predominantly the USA. Five reviews were assessed as minimal quality and two as low quality. The literature search is current through 15 August , with final study additions from other sources occurring on 12 November Since the late s, countries have increasingly abandoned strict prohibition in favor of alternative approaches legalizing the use and sales of cannabis Decorte, Dozens of other countries have also permitted access to cannabis under various decriminalization, medicalization, and legalization regimes Belackova, ; Decorte, ; Rehm, Most notably, Uruguay became the first country to fully legalize recreational cannabis in Queirolo, , followed by Canada in Fischer, and Malta in Bubola, With strong economic, public health, and social justice incentives driving domestic cannabis policy reforms Newman, ; Oldfield, , these trends will only accelerate. This evidence and gap map EGM summarizes the empirical evidence on cannabis liberalization policies, highlights current knowledge gaps, and identifies opportunities for future research. This EGM provides the first comprehensive review of the available evidence on cannabis liberalization reforms, capturing important heterogeneity in target populations, research designs, and study quality that is crucial to understanding this literature Choo, ; Hunt, ; Pacula, Accordingly, the EGM offers stakeholders both a timely summary of the evidence and a roadmap for prioritizing future research. Harrell et al. Harrell, also examined cannabis use as part of a larger scoping review of factors linked to vaping, and Pacula and colleagues Pacula, ; Smart, investigated alcohol use both alone and in combination with cannabis, updating an earlier review by Guttmannova et al. Guttmannova, A smaller number of systematic reviews have investigated specific harms linked to cannabis liberalization. Several reviews examined cannabis use disorders, but none could draw firm conclusions Leung, ; O'Grady, ; Smart, A narrative review of roadway safety by Hasan et al. Hasan, determined the evidence was insufficient to draw strong conclusions with respect to driving under the influence of drugs. However, a narrative review by Vingilis et al. In summary, existing systematic reviews of the effects of cannabis liberalization policies primarily focus on cannabis use, despite primary studies investigating a much broader and arguably more salient set of outcomes Sznitman, Recent conceptual mappings across varied national contexts have identified dozens of performance indicators in the public health, community safety, and economic sectors that are relevant for understanding the full scope of cannabis policy impacts Campeny, ; Fischer, ; Maslov, Develop a clear conceptual framework linking cannabis liberalization laws to associated health, safety, and socioeconomic outcomes. Provide a structured summary of the empirical evidence, research setting and context, and study quality from existing primary empirical studies and systematic reviews for use by policymakers, researchers, and other stakeholders. Identify study clusters that can support further systematic review, and document evidence gaps where additional primary research and funding resources are needed. This EGM focuses on the impacts of laws and policies that expand legal access to cannabis. The vertical axis of the map captures this policy dimension. The horizontal axis of the map captures health, safety, and socioeconomic outcomes that are theoretically or practically responsive to cannabis liberalization. The framework distinguishes policy from practice. Cannabis laws are statutes and regulations governing the production, availability, and use of cannabis. Conceptual framework of the effects of cannabis liberalization laws on health, safety, and socioeconomic outcomes. The conceptual framework also highlights how laws and practices affect intermediate changes in attitudes and behaviors e. These intermediate factors are themselves worthy of study, especially since ultimate outcomes e. We received comments from multiple domain experts that helped improve the research protocol, including conceptualization and scope of the project, coding guide development, and selection of academic and gray literature database sources. Eligible studies included policies that create or expand access to a legal or decriminalized supply of cannabis. As summarized in Table 1 , this scope encompasses five distinct types of laws: comprehensive medical cannabis laws MCLs e. This delimitation excludes, for instance, studies of decriminalization laws that only remove penalties for cannabis use or possession, industrial hemp laws that legalize cannabis cultivation solely for producing textiles and other nonconsumable products, and other policies that do not establish clear regulatory authority over cannabis supply. Studies were included in the EGM if they measured health, safety, or socioeconomic outcomes. We also included studies focusing on intermediate outcomes reflecting changes in structural conditions and incentives, including attitudes and behaviors e. As our purview was purposely broad, we placed no a priori restrictions on specific outcomes within this framework, nor did we limit the measurement modality e. Table 2 describes and provides examples of these eligible intermediate and ultimate outcomes. However, because cannabis liberalization research is often concerned with unintended consequences among groups not directly targeted by these laws e. Eligible study settings included any national or subnational jurisdiction that decriminalized, medicalized, or legalized the supply of cannabis since , a starting year that encompasses all modern cannabis policy reforms. Studies not published in English were excluded because the study team had no fluency in other languages. We included both completed and ongoing primary studies and systematic reviews in the EGM. We excluded studies if they used only simulated data or forecasting techniques, were primarily descriptive in nature, or employed only qualitative evidence. We included systematic reviews of all types if the reviews reported replicable methods and summaries of impact MacEntee, We searched academic databases and gray literature sources and implemented supplemental search strategies to locate relevant citations. All retrieved references were downloaded into EndNote software for bibliographic management. Between August 13—15, , we searched the following 23 indexed academic databases and systematic review registries with vendor noted :. We used both natural language and controlled vocabulary terms to search databases using Boolean logic across three domains: 1 cannabis, 2 policy change, 3 and quantitative methods. Natural language terms were used to query title, abstract, and keyword fields. Controlled vocabulary terms were used to query subject fields. See Supporting Information: Appendix 1 for the complete database search strategy. Don M. The search strategy for gray literature was simplified to accommodate their less sophisticated search engines, which commonly disallowed the use of wildcards, delimiters, or more advanced search logic. We augmented our systematic search by including studies from our personal libraries. We also reached out to subject matter experts for new, updated, or unpublished research. Finally, to identify additional potentially relevant studies, we i reviewed the references of eligible studies and reviews and ii used Google Scholar to forward citation search for eligible studies. The final addition to our pool of potentially eligible studies from any of these supplemental sources was entered on November 12, , although we continued to update the bibliographic information of working papers and prepublication articles as we were alerted to newer versions of record. Before screening, duplicate records were removed using the EndNote deduplication protocol outlined by Bramer et al. Bramer, All three authors took part in the study screening and selection process. Initially, the titles and abstracts of retrieved records were independently screened by two reviewers according to the following three criteria:. Does the study examine a cannabis liberalization law or policy that expands legal access to cannabis supply for personal consumption? Screening conflicts were resolved by reaching consensus with a third reviewer. Next, two reviewers independently and manually examined the full texts of all potentially eligible studies according to the same three screening questions i. Any additional reasons why a study was deemed ineligible e. Discrepancies were deconflicted by consensus, with a third reviewer arbitrating when needed. We coded bibliographic information, study setting and data years, publication type, funding information, policies and provisions, outcomes, study design, and study quality. For instance, if a study used multiple research designs e. The final coding guide is presented in Supporting Information: Appendix 2. All studies were assessed for quality. SMS robustness is determined by the study's ability to identify a causal effect according to the following design criteria:. These studies may control for confounders or use propensity score matching, but do not account for unobservable differences between groups. If a study reported multiple designs e. Note that because no RCT studies have been conducted in this policy domain, we used only the first four quality levels. We analogously summarized overall confidence in the results of each review according to AMSTAR 2 scoring criteria: Minimal more than one critical flaw with or without noncritical weaknesses , low one critical flaw with or without noncritical weaknesses , moderate more than one noncritical weakness , and high no more than one noncritical weakness. The unit of analysis is a systematic review or primary study, represented as an entry within a cell of the EGM. Cannabis liberalization policies form one axis of the map; health, safety, and socioeconomic outcomes form the other axis. The search strategy yielded 44, records, including 43, from academic databases, from protocol registers, from gray literature source, and from other sources. After removing 27, duplicates, we retained 16, records for title and abstract review. At this point, we additionally reviewed the studies with the highest predicted likelihood of being either incorrectly included or incorrectly excluded, ultimately determining that no studies were wrongly classified. Overall, we manually excluded records and automatically excluded 10, by machine learning. We sought reports for retrieval, but could not locate the full texts for eight potentially eligible studies. Overall, we retrieved reports for the eligible studies. In this section, we discuss the major policy and outcome groupings in the EGM. Note : The first figure in each cell refers to the number of primary studies, the second figure to the number of systematic reviews, and the third figure to the total number of studies. Looking specifically at primary studies, the most populated cells in the map aligned in three tiers across both MCLs and RCLs. Research on RCLs followed a similar overall pattern. The number of primary studies across cells corresponding to CBDLs, IHLs, and DCLs was relatively sparse, reflecting the nascent policy environment and emergent nature of research on these other cannabis laws. Few systematic reviews targeted other policies and outcomes. The exceptions are Melchior et al. Melchior, , who reported on the effects of DCLs on adolescent and young adult cannabis use, and a preregistered review by Busse et al. Figure 3 presents the number of primary studies by years of data coverage, aggregated by decade. Six studies did not report the data period. As described previously, cannabis liberalization laws vary considerably in their overarching policy objectives. Table 4 presents the number of primary studies by year of publication and policy. During the first eight publication years covered by the EGM — only eight studies were produced, with the very first study by Williams Williams, examining the effect of Australian state decriminalization of cannabis consumption and cultivation on cannabis use. Policy design and implementation also differs substantially within major law types. Certain MCL jurisdictions, for instance, allow retail dispensaries and home cultivation, whereas others do not. Understanding how such policy heterogeneity affects outcomes is an important, and often overlooked, aspect of cannabis liberalization research Pacula, Other cannabis liberalization policies are not presented in the table because no existing studies have investigated their specific policy dimensions. Other MCL policy provisions i. Lastly, rather than focus on specific policy provisions, 10 studies operationalized policy indexes as measures of overall medical program leniency or restrictiveness. Our analysis of cannabis policies and provisions reveals that the research tends to be unidimensional, largely focusing on MCLs and RCLs. Moreover, despite including a broad range of cannabis policy provisions in our coding guide, outside of a few key dimensions e. Comparative policy research requires that statutes and laws be reliably and consistently coded across jurisdictions Ritter, Although most study authors either developed their own policy indicators or did not report this information, Figure 4 depicts the number of studies for which specific policy data sources were reported, all of which describe policies across US states. Multiple outcomes, both within and across domains, were commonly investigated within a single study. Figure 5 presents the outcome distribution of primary studies that investigated specific attitudes and behaviors. The distribution of market and environment outcomes, reported across 43 primary studies, is presented in Figure 6. By comparison, other crime and criminal justice outcomes were infrequently investigated. Workplace safety issues, including injuries and fatalities occurring on the job, were rarely studied. Notably, no studies investigated environmental outcomes. More broadly, across five domains and 21 subdomains, we documented distinct outcomes that have been investigated in the cannabis liberalization literature since While more than half the studies in this EGM collected primary data, used proprietary data sources, or analyzed other public data, many studies operationalized key outcomes from federally sponsored US serial data collections. Figure 11 depicts 37 target populations coded for this EGM. Overall, the diversity of target populations is indicative of the broad range of outcomes identified and researcher interest in understanding the indirect effects of cannabis policy e. Figure 12 breaks down the target populations by age group. For studies, subject age was either not reported or not applicable. The ubiquity of the DID design meant it was often estimated in concert with supplementary designs. For instance, the synthetic control method was used in 33 studies, but DID was a supplemental method in 21 of these studies. We documented seven completed and two ongoing systematic reviews in the EGM. Both ongoing studies appear stalled, however, as the registered protocols have not been updated recently. Five reviews focused on cannabis liberalization laws generally including one that was part of a broader review of opioid interventions , whereas two targeted just MCLs. Five reviews were delimited to the United States, one to both the United States and Canada, and one was not delimited geographically. The number of included studies ranged between 9 and Five reviews were rated lowest as having minimal, and two were rated marginally better as having low confidence in the results. Notably, no reviews achieved a moderate or high rating. As shown in Figure 14 , common review limitations include the lack of a prespecified research protocol, implementation of a limited search strategy two reviews queried just a single database , single study screening or coding, failure to document the source of funding or list of excluded studies, and inadequate risk of bias or effect heterogeneity assessment. The objectives of this EGM were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps. This section contextualizes our results by reviewing patterns observed in the literature and presenting a holistic overview of the evidence base. Virtually all This clustering is also reflected in the seven completed systematic reviews in the EGM: all assessed substance use outcomes, and three specifically targeted cannabis use. While primary studies of substance use predominated, a fair degree of evidence saturation emerged across other subdomains. These are areas where ongoing and future systematic review efforts are warranted. We observed, across both MCLs and RCLs, that most policy provision studies sought to understand the effects of legal sales through retail outlets or dispensaries. The EGM also highlighted major gaps in the evidence. This research gap can be explained in part by the later adoption, slower diffusion, and narrower scope of these laws. Still, even when there was a modicum of evidence on MCLs and RCLs across certain subdomains, the number of studies addressing specific outcomes was often slim. Studies appraised moderate to high quality are generally considered more robust for making causal claims than studies rated minimal or low quality. Among the nine systematic reviews included in the EGM, five were rated minimal quality according to AMSTAR 2 Shea, , two were rated low quality, and two were not rated as they are technically still in progress. Notably, no systematic reviews were rated as being of moderate or high quality, suggesting a critical need for more robust syntheses of existing evidence. Despite this, there are several limitations to our search process. First, we included only English language studies in the EGM, which may have limited the inclusion of eligible studies from other countries. Second, we used artificial intelligence screening tools to increase screening efficiency, but it is possible that some eligible studies that we did not manually screen were erroneously excluded. Third, this is a policy area with research being published at a rapid pace, so the EGM will not capture the most recent evidence. After rerunning our original search for the recent period August 10, to August 10, , we retrieved an additional 4, potentially relevant citations to screen. The EGM will therefore need to be updated regularly. Although we used the SMS to assess the robustness of study designs, we did not fully assess the implementation quality of these designs. Future evidence syntheses should enhance quality appraisal. Accordingly, our categorization of these outcomes and target populations, although embedded within a clear conceptual framework, was not thoroughly prespecified in our protocol. Across the globe, the international status quo of strict cannabis prohibition is rapidly ceding to a range of cannabis policy reforms aimed at liberalizing access to cannabis for medical and recreational purposes. This EGM provides a comprehensive summary of existing research examining the public health, community safety, and socioeconomic implications of these reforms. It highlights areas of evidence concentrations and evidence gaps to inform future research needs, including both primary studies and systematic reviews. This EGM, as well as other recent conceptualizations of cannabis policy outcomes e. Moreover, future research might productively employ more nuanced cannabis use measures e. This EGM has also highlighted the heterogeneous nature of cannabis liberalization laws. We observed a critical need for research addressing industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. To the extent that specific policy provisions were investigated, studies predominantly assessed the effects of cannabis dispensaries. Future research should prioritize understanding how other key policy provisions impact relevant outcomes. The existing body of research on cannabis liberalization policy is derived primarily from the United States. More research is desperately needed from other countries to diversify our understanding of these laws, as current evidence may not be generalizable to other settings. Methodologically, cannabis policy research would greatly benefit from improvements in measurement and design aimed at enhancing causal validity and inference Hunt, As a result, researchers commonly default to operationalizing general arrest and crash outcomes instead. However, researchers are overcoming these deficiencies by using novel data systems and more advanced methods. For example, Firth et al. As another example, Sevigny Sevigny, accounted for missing data in FARS by using multiple imputation to more reliably measure cannabis positivity among drivers involved in fatal crashes. Since these features are common in cannabis policy research, there is a critical need for replication using alternative DID estimators that counter the potential bias inherent in the canonical TWFE implementation e. Despite the global proliferation of cannabis liberalization policies and the associated accumulation of empirical research, especially over the last decade, clear implications of this massive social policy experiment remain elusive. Accordingly, this EGM highlights a critical need for more robust primary studies and systematic reviews on a broader range of salient outcomes. Eric L. Sevigny : Conceptualization; methodology; software; validation; formal analysis; investigation; resources; data curation; writing—original draft; visualization; supervision; project administration; funding acquisition. Danye N. Medhin : Software; validation; investigation; data curation; writing—review and editing. Jared Greathouse : Software; validation; formal analysis; investigation; data curation; writing—review and editing; visualization. The authors have no vested interest in the outcomes of this EGM, nor any incentive to represent findings in a biased manner. Sevigny has published primary research in this policy area, including two studies included in this EGM. He was not involved in the coding of these studies. Once published, we plan to update the EGM on a regular basis, contingent upon the availability of external funding. At present, we have rerun our systematic literature search for the period August 10, to August 10, and retrieved an additional unduplicated references for further screening and coding. The lead author will be responsible for updating the EGM. The protocol for this EGM was previously published Sevigny et al. No deviations were made to study eligibility criteria or the literature search strategy. In the final review, we also revised our coding guide in planned and unplanned ways. However, we amended our coding of interventions. In the protocol, we listed contingent provisions under various categories e. In the final review, we coded specific provisions nested by policy type. In adopting this strategy, we aggregated, dropped, or added certain provisions to simplify the coding. Lastly, we did not anticipate the use of AI during study screening in the protocol because we were unaware of these tools during protocol development. However, after DistillerSR launched these tools on its platform, we decided to learn about them and use them to screen studies when conducting the final review. Aloe for their critical assistance in shaping the design and implementation of this EGM. We would also like to thank La Loria Konata for her assistance and advice with library reference searching. Sevigny, E. Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and rgap map. Campbell Systematic Reviews, 19, e Evidence and gap map. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Campbell Syst Rev. Find articles by Eric L Sevigny. Find articles by Jared Greathouse. Find articles by Danye N Medhin. Collection date Dec. Open in a new tab. Law or Policy Description Medical cannabis law MCL Grants qualified patients with a physician's recommendation or prescription the legal right to use and possess cannabis and, in some jurisdictions, cultivate cannabis to treat approved medical conditions. Tetrahydrocannabinol THC is the main psychoactive constituent of cannabis, whereas cannabidiol CBD is a key nonpsychoactive compound. Recreational cannabis law RCL Legalizes adult cannabis use and regulates the modes of cannabis production and supply. Attitudes and behaviors Markets and environments Health Safety Socioeconomic Row total Medical cannabis law 9 22 1 23 81 6 87 73 1 74 29 0 29 9 CBD law 1 0 1 1 0 1 3 0 3 0 0 0 1 0 1 5 0 5 Recreational cannabis law 7 24 1 25 53 5 58 68 1 69 28 0 28 7 Industrial hemp law 1 0 1 1 0 1 0 0 0 1 0 1 0 0 0 2 0 2 Decriminalization of cultivation law 3 1 4 0 0 0 0 0 0 0 0 0 0 0 0 3 1 4 Column total 9 43 1 44 6 1 48 0 48 9 Review Review type Review focus Setting and window Included studies and quality appraisal a Ansari et al. Overall confidence in results: Minimal. United States, through March 15, Included 16 studies. Guttmannova et al. United States, through Included 15 studies. Leung et al. Melchior et al. Any country, through March 1, Included 41 studies. Sarvet et al. Overall confidence in results: Low. Vyas et al. United States, through July Included 10 studies. Click here for additional data file. Linked Article Evidence and gap map. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Grants qualified patients with a physician's recommendation or prescription the legal right to use and possess cannabis and, in some jurisdictions, cultivate cannabis to treat approved medical conditions. Legalizes adult cannabis use and regulates the modes of cannabis production and supply. Perceptions of harm, prevalence of cannabis use, prevalence of other drug use, routes of administration. Availability of cannabis, cannabis prices, and potency, product marketing and advertising. Substance use disorders, overdose, suicide, mortality, mental and physical health. Crime, drugged driving, traffic accidents, workplace safety. Housing values, educational attainment, productivity, environmental consequences. Ansari et al. United States and Canada, January 1, through July 19, Included 9 relevant studies. Chihuri and Li Effects of cannabis liberalization laws on opioid overdose, mortality, and related health outcomes. Included 16 studies. Included 15 studies. Effects of cannabis liberalization laws on cannabis use and cannabis use disorder. Effects of cannabis liberalization laws on adolescent and young adult cannabis use. Included 41 studies. Effects of MCLs on prescription opioid use and opioid use disorder. Included 10 studies.