Since cannabis is now legal for recreational and medical use in over half of the states in the United States, it is of the utmost importance to do a thorough examination of these evolving regulations to see how they will affect public health and if they can be responsibly implemented in countries like Indonesia. To begin with, cannabis, or marijuana, was illegal in the United States. European and American legislators began to prohibit the use of drugs in 1910, followed by the actual cannabis prohibition in 1920 (Narconon International, 2018). Moreover, the Boggs Act (1952) demonstrated that the government had increased the penalties for marijuana consumption, while the Controlled Substances Act (1970) categorized marijuana as a Schedule I drug, indicating its high potential for abuse, lack of recognized medical use, and the need for supervised consumption. Cannabis use has increased significantly, according to a 2023 survey performed by the National Institute on Drug Abuse, which found that 81% of American people believed marijuana had at least one medical advantage. In 1996, California was the first state to authorize medicinal marijuana usage. Washington, Alaska, and Oregon followed in 1998. Colorado and Washington were the first states to allow marijuana usage for recreational purposes in 2012. However, a movement advocating for the legalization of marijuana emerged in the late 1960s, aiming to modify the federal laws controlling its usage (Single, 1989).
In the context of evaluating cannabis legalization policies in the United States, the application of the RE-AIM Framework provides a strong foundation for holistically understanding the impact of these policies on medical and recreational access, effectiveness in addressing public health issues, and the level of adoption, implementation, and maintenance of these policies. By examining all five domains: reach (proportion of the population with access), effectiveness (impact on public health), adoption (number of states legalizing), implementation (fidelity to policy), and maintenance (long-term sustainability), RE-AIM offers a comprehensive picture.
Reach analysis could explore which types of individuals have benefited from this policy. The legalization policy is believed to offer benefits to multiple parties, particularly in recreational aspects, where cannabis or marijuana is seen as advantageous for local communities in the United States as it boosts the state’s tax revenue (Pew Research Center, 2024). Although there are multiple perspectives on cannabis use, this policy could be beneficial for those who suffer from neurological conditions, seizures, nausea, or cancer-related appetite loss (Rogers, 2023). The exact number of people directly benefiting is unknown, but it’s evident that economically and from a medical perspective, a broader stratum of society is impacted.
Effectiveness might examine the policy through changes in public outcomes. According to a policy analysis by Dills et al. (2021), the legalization of marijuana has proven to enhance tax revenue in states like California, Colorado, Washington, and Oregon shortly after its legalization, with Washington, for instance, generating nearly $70 million in tax revenue solely from recreational marijuana sales within the first year. Moreover, Felix (2022) clarifies that recreational sales of marijuana are more likely to be much higher compared to medical sales. Although opinions on the medicinal advantages of marijuana are still divided, research has shown that states that have legalized marijuana for recreational use did so because of the drug’s ability to treat medical conditions (Brown et al., 2023; Pratt et al., 2019). Cannabis or marijuana has to be used under prohibition; if not, it can cause cannabis dependence (Budney et al., 2019) and psychiatric disorders (Marconi et al., 2016). In the domain of adoption, the analysis focuses on the quantity aspect. As per DISA (2023), the majority of states in the U.S. have adopted fully legalized marijuana for both recreational and medical purposes, while only four states continue to maintain its illegal status.
The implementation and maintenance domains are designed to examine the policy enactment process and how governments ensure the ongoing effectiveness of policies. According to the journal by Schauer (2021), licensing restrictions are implemented in several states for activities related to the production, processing, and sale of cannabis, with limited availability of licenses, except in the state of Washington, which prohibits financial ties between different industry segments. By having licenses and rules, governments can control who can do certain activities related to cannabis. Furthermore, he clarifies that state governments also establish taxes on marijuana products related to recreational usage to avoid criminalization, with the resulting tax revenues showing promise for state budgets.
Sales and purchases of marijuana also require all states to mandate testing for cannabis products based on the ISO 17025 standard before they can be sold to ensure public safety. Consumption is also regulated so that legal cannabis is typically restricted to private residences. While using it in rental properties or government housing is often prohibited, some states are exploring allowing consumption at licensed cannabis stores or other designated businesses. Cannabis or marijuana use under prohibition can lead to cannabis dependence (Budney et al., 2019) and psychiatric disorders (Marconi et al., 2016). The government now also regulates homegrown cannabis, with Illinois and Washington only allowing cultivation for medical purposes. However, other states that permit fully recreational cannabis consumption allow their residents to grow marijuana plants. Regulations for These retail stores aim to balance consumer access with public health and safety concerns. These regulations may include location restrictions, age verification measures, limitations on selling non-cannabis products, and, as seen in Nevada, even mandatory lockboxes (Schauer, 2021). However, it has been discussed in another journal that some limitations exist as the cases of fraud in the industry occur, such as documented instances of “lab shopping,” where businesses seek out laboratories that provide the highest THC test results (Schwabe et al., 2023).
As the debate over marijuana legalization continues to gain momentum in the United States, the Consolidated Framework for Implementation Research (CFIR) emerges as a valuable tool for evaluating the factors that influence the successful adoption and implementation of these policies, which involve complex interactions between the social context, health system, regulation, and risks associated with cannabis use. The CFIR framework outlines various domains that influence the implementation of an intervention. Hence, intervention characteristics, outer setting, and character of individuals are selected domains for diffusion or pull factors in the RE-AIM framework for this topic.
Analyzing intervention characteristic domains mostly focuses on cost factors and empirical data. According to research, compared to non-medical marijuana users, medical marijuana users have reduced rates of anxiety, alcoholism, and opioid use disorders but a greater frequency of diabetes, cancer, and pain (Wall et al., 2019). Moreover, marijuana or cannabinoids may prove to be effective for chronic pain, neuropathic pain, and spasticity (Hill, 2015). Positive results from all of these studies demonstrate the potential efficacy of cannabis or cannabinoids for these purposes. As a result, this research may contribute to the legalization of marijuana in more states around the country.
With case studies from several states that have seen increased tax revenue since the legalization of marijuana, this paper also examines the estimated risks and benefits of the costs that government agencies might incur. Legalization of marijuana in states that have not yet legalized it is supported by the fact that the enactment of recreational marijuana laws leads to an increase in work capacity. According to Abouk et al. (2021), countries that allowed marijuana use for recreational purposes saw decreases in worker compensation claims, rates of non-traumatic workplace injuries, and the prevalence of impairments that prevented an individual from performing their job. Considering that this decrease is related to an increase in work capacity, most likely due to access to various types of pain management medication, this study might play a role in the legalization of marijuana in states that have not yet authorized it. This might raise tax revenue since healthy and productive workers tend to earn greater wages, which can be taxed more. Marijuana can thus be a cost-effective tool for maximizing government budgets. Moreover, if marijuana is legalized, the government would not need to allocate additional funds for the arrest and incarceration of nonviolent drug offenders, as the prisons in the United States are already overcrowded. Raphael & Stoll’s book (2009) explains that the increase in state budgetary expenses can be felt without marijuana legalization.
In the analysis of the outer setting domains, the primary focus is placed on understanding the characteristics of the community, the policy context, and the organizational culture. This analysis is drawn from a paper authored by Spetz et al. (2019), where it is indicated that several external factors can significantly influence the implementation of marijuana legalization. Political affiliations play a crucial role in influencing the adoption of marijuana legalization for both medical and recreational purposes in the United States, with the majority coming from Democratic control of legislatures. The pattern is further demonstrated by the Pew Research Center (2024), which reports that 62% of conservative and moderate Democrats support legalizing marijuana for medicinal and recreational use, while 84% of liberal Democrats agree. Therefore, the impact of political affiliation on the adoption of marijuana legalization can be considered a significant factor in the organizational culture in which democratic political affiliation influences these policies the most. When evaluating the chances for marijuana legalization, it is critical to consider policy context and community characteristics. Policy context describes the state of affairs and public opinion around the legalization of marijuana. Furthermore, Spetz explains that there has been increasing public support for the legalization of marijuana, as seen by national polls indicating that most Americans are in favor of legalizing recreational usage. In addition, the growing acceptance of medicinal marijuana, including the FDA’s approval of a marijuana-derived medication, undermines the case for full prohibition.
Regarding Community, The legalization of marijuana’s characteristics are connected to the unique characteristics of communities that have embraced marijuana policy liberalization. Liberalized states frequently have excessive immigrant populations, low religious beliefs, and political liberalism. States that are against liberalization, on the other hand, are frequently known for their strict religious practices and political conservatism. Liberal citizen traits are highly supportive of the legalization of marijuana in the United States for both recreational and medical uses. The correlation shows that liberal citizens’ characteristics are strongly in support of legalizing marijuana.
The CFIR Framework’s Individual Characteristics domain focuses on the individuals engaged in conducting an intervention. The primary objective is to investigate how their political beliefs, racial and ethnic groupings, and age affect the effectiveness of this policy’s implementation. A Pew Research Center conducted surveys that revealed data that strongly favors the implementation of marijuana legalization by offering deeper knowledge of how public opinion is divided into several categories. 64% of Democrats and Democratic-leaning independents agree that legalizing marijuana for recreational use improves local economies, and 58% believe it improves the fairness of the criminal justice system. On the other hand, fewer Republicans and Republican-leaning voters—41% and 27%, respectively—think that legalizing marijuana for recreational use enhances regional economies and the criminal justice system. About 34% of conservative Republicans support legalizing marijuana for medicinal and recreational use, while 57% of moderate and liberal Republicans approve. Similarly, 62% of conservative and moderate Democrats support legalizing marijuana for both medical and recreational uses, while 84% of liberal Democrats agree. Younger Americans are more supportive of legalizing marijuana for recreational use than their older counterparts. A clear majority of those under 30, around 71%, believe it benefits local economies, and approximately 59% think it makes the criminal justice system fairer. In contrast, roughly a third of Americans aged 65 and older agree that legalizing recreational marijuana is advantageous to local economies, with a similar proportion believing it enhances the fairness of the criminal justice system. A survey conducted across all races indicates that more than 50% of individuals from each racial group believe that legalizing recreational marijuana is beneficial to local economies. However, just 46% of Asian adults believe this. The data obtained supports the fact that age, political preferences, and racial and ethnic groups can influence the perspective on the implementation of marijuana legalization. For example, someone with Democratic political preferences tends to be more supportive of this implementation, as supported by the fact that the majority of Democratic legislators in parliament support marijuana legalization.
Despite some countries agreeing to legalize cannabis, Indonesia has imposed imprisonment for people using marijuana for both medical and recreational purposes. However, this contradicts the fact that the Aceh legislative council released the minutes of the Meeting of the Consultative Body No. 01022023, approving the submission of a draft qanun on the legalization of medical cannabis. The analysis result states that Indonesia is still unable to legalize marijuana for medical and recreational consumption due to several circumstances. Legalization of marijuana may result in a surge in heavy users, self-reported dependence, and associated social consequences like increased homelessness and crime, potentially leading to economic repercussions such as reduced labor force participation and productivity (Brown et al., 2023).
Meanwhile, in Indonesia itself, as quoted from The Publication of Crime Statistics 2023, the crime rate in Indonesia has been increasing year by year. This is further supported by data from Habitat for Humanity from 2021, which shows that almost 25 million households live in urban slums along roadways, riverbanks, and railroad lines. This data also shows how unprepared Indonesia is to address this problem. Furthermore, Sanderson (2022) argues that the legalization of recreational marijuana increases homelessness, particularly in states that were among the first to adopt the practice. Maclean et al. (2021) discovered an increase in social security disability after marijuana was legalized. Several journals present conflicting conclusions regarding the legalization of marijuana for medical purposes due to inconsistent findings and a lack of strong evidence. As a result, perspectives differ on whether marijuana or cannabinoids are useful for chronic pain, neuropathic pain, and spasticity (Hill, 2015), whether mild side effects are often observed, and whether the risks of cannabis-based therapies may exceed the benefits (Pratt et al., 2019). Despite opposing perspectives, medical marijuana gets legalized before recreational marijuana in all states in the US (Brown et al., 2023).
The legalization of marijuana sparks contrasting approaches across the globe. The U.S., with over half of its states embracing full legalization, offers a unique perspective. Analyzing this process through the RE-AIM framework reveals potential benefits like increased tax revenue and medical access, but also raises concerns about dependence and social impact. Public opinion as well as other evidence revealed in the CFIR Framework of the U.S. leans towards legalization, while Indonesia, battling rising crime rates and unprepared for potential social issues, maintains prohibition. Ultimately, the decision of whether or not to legalize marijuana requires careful consideration of both positive and negative effects, with each country needing to navigate this complex landscape based on its specific context. The legalization in the United States itself is concluded beneficial for citizens’ recreational purposes because the functionality in the public health landscape is still under debate by many scholars. However, the legalization of cannabis or marijuana for recreational and medical usage in Indonesia is not applicable since researchers have mixed perceptions about Indonesia’s internal condition of unpreparedness.
