Forty years ago, it was hard to imagine, today it is reality: Although being classified as an illegal drug on a federal level in the USA, 30 US States approved Cannabis for medicinal use and 10 States declared Cannabis as free to use for leisure purposes1. Following Uruguay (2014), Canada now declared its intent to legalise Cannabis for recreational use as well2. This is despite the fact that the medical benefits of Cannabis are low and multiple adverse effects have been known to the medical community for years3–7. Since mid-2016, marijuana products with a Δ9-tetrahydrocannabinol (THC) content of less than 1% have been legally available in Switzerland and following the legalisation, 580 companies entered the legal Cannabis business. In 2017, the upturn in these businesses added 15 million Swiss francs to the treasury8.
In the meantime, an enormous Cannabis industry has emerged in the US, with businesses worth millions9. These businesses could rely on the experiences and knowledge of the tobacco industry10, 11. In the States that made Cannabis legal, sales reached 8 billion USD in the last year; sales in 2025 are estimated at 24 billion USD1. In the process, these states received 745 million USD in taxes last year, and by 2025 they are estimated to be around 4.3 billion USD. However, this revenue will not cover future follow-up costs of Cannabis use such as health costs, occupational losses and social costs, as it was the case with the tobacco epidemic.
The number of Cannabis users in the US aged 12 years and older, is estimated at 22 million. 10% use Cannabis only for medical purposes. The number of Cannabis smokers has increased from 6.2% in 2002 to 8.3% in 201512, Cannabis addicts were estimated at 2.7 million in 2014, with 9% of all Cannabis users becoming addicted. This rate increases to 17% if Cannabis use starts in adolescence, and to 25–50% if Cannabis is consumed on a daily basis1. Since 1992, the average level of Δ9‑tetrahydrocannabinol (THC), the major psychoactive substance of Cannabis, has increased from 3 to 12% in 2012. THC content in concentrated Cannabis oil can be as high as 75%1,13,14.
“National Families in Action” (NFA) published an indepth report, “Tracking the money that’s legalizing marijuana and why it matters”, documenting the money flow used to vote for the legalisation of Cannabis in the US over the past 20 years for the first time15. In this report, it becomes clear how the fight for the authorisation of Cannabis for medical purposes was used as a preliminary stage for a subsequent full legalisation. Since 1996, three billionaires – George Soros, Peter Lewis and John Sperling – have contributed about 80% of the money used for the votes on Cannabis matters in multiple US States. Back in 1992, George Soros, who made his fortune as a financial speculator, donated USD 15 million to the legal battle to legalise Cannabis for medical purposes and later used his Open Society Foundation to fight for a full legalisation, starting in Uruguay16. Peter Lewis and John Sperling, both deceased today, made their fortunes in the insurance industry and the for profit education movement. All three of them saw the opportunity to fully legalise Cannabis by first introducing a legal use for medicinal purposes. In 1993, Richard Cowen, former director of the National Organization for the Reform of Marijuana Laws (NORML), stated in a press conference that “the key to it [full legalisation] is medical access. Because, once you have hundreds of thousands of people using marijuana medically, under medical supervision, the whole scam is going to be blown. The consensus here is that medical marijuana is our strongest suit. It is our point of leverage which will move us toward the legalisation of marijuana for personal use”15.
Scientific data on the medical use of Cannabis and positive effects is rare. Systematic and high-quality scientific research, in particular prospective, randomized, placebo-controlled, double-blind studies, hardly exist7. Back in 1975, Nabilone – a fully synthetic derivative of THC – was patented by the US company Eli Lilly as an anti-emetic and tranquilizer. Later it was approved by the US Food and Drug Administration (FDA) for treating anorexia and cachexia in AIDS patients. It was also approved to be used as an anti-emetic for nausea and vomiting side effects accompanying cytostatic or radiation therapy in the course of cancer treatment. Another drug containing THC, Dronabinol, was approved for the same indications. In Switzerland, medical use is possible with an exemption permit issued by the Federal Office of Public Health (FOPH). The active substance is mainly administered in the form of a solution and may be used for loss of appetite and nausea due to serious illnesses, severe pain and spasticity.
However, the effect of these two THC-containing drugs are low and can easily be achieved with other medications. In 2017, the US National Academies of Sciences (NAS) published a very comprehensive publication on Cannabis: The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research12. Analysing a total of 10,700 abstracts taken from publications on Cannabis use since 1999, the report concludes that medicinal effects have only been scientifically proven when used for chemotherapy-induced nausea and AIDS-induced cachexia, and partly when used for chronic pain and muscle spasms in multiple sclerosis patients. While the positive effects are low, the NAS points out that Cannabis use increases the risk of traffic accidents and the risk of intoxications, especially in children, as well as the risk of developing schizophrenia, anxiety and psychoses. In addition, the report also points out how Cannabis use results in a limited attention span, memory loss and a decreased learning ability. When used in childhood and adolescence, Cannabis is highly likely to lead to addiction. A recent paper highlights devastating effects of Cannabis use on the brain development of unborn children and newborns and hence, strongly discourages pregnant women and nursing mothers to use Cannabis17.
Legalising Cannabis for recreational use opens up vast opportunities for commercialisation. Consequences following these opportunities are difficult to foresee10,11. Debates on how to limit health problems caused by the use of Cannabis, for example by means of new regulatory measures, will tie up enormous financial and legal resources14. The Cannabis industry might again take notes from the tobacco industry, which managed to turn a cigarette into a perfect nicotine dispenser in the course of the last century. Adding to that, the tobacco industry perfidiously promoted their products and the number of cigarette smokers rose from 1 % in 1880 to 50% in 195010,18,19. While only a few will benefit financially from commercialising Cannabis, the legalisation of this drug will, as it was with tobacco, entail a series of unprecedented health and safety issues, as well as financial consequences for individuals affected and for society as a whole14,20. Like alcohol, Cannabis will become a relevant issue in workplaces and on the road. THC has long-lasting effects, which will have an impact on the quality of work; injuries and endangering human lives will become more frequent. THC is stored in adipose tissue due to its high fat solubility which means that it can be released back into the bloodstream hours after use and be detected in urine for days6. In addition, an increasing number of young people quit school or apprenticeships due to the so-called, Cannabis-induced “amotivational syndrome” and need the help of social workers and various state institutions to return to a more normal life, or end up needing long-term care3, 13, 21–23.
In addition to organic Cannabis products, an increasing number of synthetic cannabinoids have been produced in countless laboratories since the 1980s. Today, these cannabinoids are beyond control and have led to numerous deaths24, 25. Cannabinoids are also becoming increasingly popular among young people for “vaping” in modern multifunctional e-cigarettes, which have become particularly popular in France26.
Like tobacco, trading Cannabis means to do business with an addictive substance with well-known physical and psychological consequences. To reach the goal of legalisation, the effects of Cannabis have been actively downplayed, and a few are making billions of dollars with it13. The Tobacco Framework Convention on Tobacco Control (<link http: www.fctc.org>www.fctc.org) has achieved its first successes worldwide fighting the tobacco epidemic. With the legalisation of Cannabis, a new epidemic will be created, with unforeseeable consequences. For this reason, various medical organisations such as the German Society of Pneumology or the American Thoracic Society published position papers and reports to call attention to the dangers of Cannabis use7, 27. •
1 Haffajee RL, MacCoun RJ, Mello MM. Behind Schedule Reconciling Federal and State Marijuana Policy. N Engl J Med. 2018;379(6):501–4.
2 Felder K. Kanada – eine Grossmacht im Cannabis-Geschäft. “Neue Zürcher Zeitung”. 16 Mai 2018; p. 26.
3 Taeschner KL. Cannabis – Biologie, Konsum und Wirkung. 4., expanded edition. Deutscher Ärzte-Verlag; 2005.
4 Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2018;370(23):2219–27.
5 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698):1383–91.
6 Schuurmans MM, Befruia N, Barben J. Factsheet 1: Cannabis. Primary and Hospital Care – Allgemeine Innere Medizin. 2016;16(20):384–6.
7 Kreuter M, Nowak D, Ruther T, Hoch E, Thomasius R, Vogelberg C, et al. Cannabis-Position Paper of the German Respiratory Society (DGP). Pneumologie. 2016;70(2):87–97.
8 Friedli D. Cannabis bringt Millionen ein. NZZ am Sonntag, 8. April 2018; p. 9.
9 Grundlehner W. Cannabis benebelt die Investoren. Neue Zürcher Zeitung. 27 June 2017; p. 29.
10 Richter KP, Levy S. Big marijuana – lessons from big tobacco. N Engl J Med. 2014;371(5):399–401.
11 Barry RA, Hiilamo H, Glantz SA. Waiting for the opportune moment: The tobacco industry and marijuana legalization. Milbank Q. 2014;92(2):207–42.
12 National Academies of Sciences. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. 2017. nap.edu/24625.
13 Yazdi K. Die Cannabis-Lüge – Warum Marihuana verharmlost wird und wer daran verdient. Berlin: Schwarzkopf-Verlag; 2018.
14 Kilmer B. Recreational Cannabis – Minimizing the Health Risks from Legalization. N Engl J Med. 2017;376(8):705–7.
15 Rusche S. Tracking the Money That’s Legalizing Marijuana and Why It Matters. 2017. <link http: www.nationalfamilies.org survey_report.html external-link seite:>www.nationalfamilies.org survey_report.html .
16 Monsanto plant gentechnisch verändertes Marihuana. Deutsche Wirtschaftsnachrichten. 17. Dezember 2013. <link https: deutsche-wirtschafts-nachrichten.de monsanto-plant-gentechnisch-veraendertes-marihuana external-link seite:>deutsche-wirtschafts-nachrichten.de/2013/12/17/monsanto-plant-gentechnisch-veraendertes-marihuana.
17 Jansson LM, Jordan CJ, Velez ML. Perinatal Marijuana Use and the Developing Child. JAMA. 2018;Jul 16 [Epub ahead of print].
18 Barben J. Tabaklobby und Kinderfänger – wie cool ist rauchen wirklich? Teil 1: Tabakepidemie, Werbung und Manipulation. Schweiz Med Forum. 2011;11:370–5.
19 Barben J. Tabaklobby und Kinderfänger – wie cool ist rauchen wirklich? Teil 2: Passivrauchen und Strategien der Tabakindustrie. Schweiz Med Forum. 2011;11:389–93.
20 Rusche S, Sabet K. What Will Legal Marijuana Cost Employers? 2017. <link www.nationalfamilies.org reports what_will_legal_ external-link seite:>www.nationalfamilies.org/reports/What_Will_Legal_ Marijuana_Cost_Employers--Complete.pdf.
21 Lynskey M, Hall W. The effects of adolescent cannabis use on educational attainment: a review. Addiction. 2000;95(11):1621–30. 22 Bray JW, Zarkin GA, Ringwalt C, Qi J. The relationship between marijuana initiation and dropping out of high school. Health Econ. 2000;9(1):9–18.
22 Bray, J.W.; Zarkin, G.A.; Ringwalt, C.; Qi, J. The re lationship between marijuana initiation and drop ping out of high school. Health Econ. 2000;9(1):9–18
23 Horwood LJ, Fergusson DM, Hayatbakhsh MR, Najman JM, Coffey C, Patton GC, et al. Cannabis use and educational achievement: findings from three Australasian cohort studies. Drug Alcohol Depend. 2010;110(3):247–53.
24 Trecki J, Gerona RR, Schwartz MD. Synthetic Cannabinoid-Related Illnesses and Deaths. N Engl J Med. 2015;373(2):103–7.
25 Adams AJ, Banister SD, Irizarry L, Trecki J, Schwartz M, Gerona R. “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. N Engl J Med. 2017;376(3):235–42.
26 Pourchez J, Forest V. E-cigarettes: from nicotine to cannabinoids,the French situation. Lancet Respir Med. 2018;6(5):e16. doi: 10.1016/S2213-2600(18)30069-9.
27 Douglas IS, Albertson TE, Folan P, Hanania NA, Tashkin DP, Upson DJ, et al. Implications of Marijuana Decriminalization on the Practice of Pulmonary, Critical Care, and Sleep Medicine. A Report of the American Thoracic Society Marijuana Workgroup. Ann Am Thorac Soc. 2015;12(11):1700–10.
Source: Schweizerische Ärztezeitung – Bulletin Des Médecins Suisses – Bollettino Dei Medici Svizzeri 2018; 99(48): 1710–1712
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