Patterns of Marijuana Use among Public
Health Students
RICHARD H. SEIDEN, PhD, MPH KATHERINE R. TOMLINSON, BA MICHAEL O'CARROLL, BA, HDIP
The prevalent use of marijuana among future public health workers raises important questions in terms of current professional role expectation in areas of drug use prevention and education. More realistic and honest drug use policies are advocated as a public health responsibility.
Introduction Is the marijuana controversy a genuine public health concern? In recent studies authoritative medical investigators agree that it is and they have placed the marijuana question squarely in the province of the public health professions. For example, in a 1963 position paper combined committees of the American Medical Association and the National Academy of Science National Research Council came to the primary conclusion that "Cannabis is a dangerous drug and as such is a public health concern."' Similarly, the National Commission on Marihuana and Drug Abuse (NCMDA) in its March, 1972, report states that "policy makers and the public have begun increasingly to view marihuana and other illicit drug use as a public health concern."2 While the Commission concluded that present levels of marijuana usage constituted a relatively minor public health concern, they also foresaw some potential hazards and advocated that an epidemiological approach was needed to identify high risk population groups, i.e., the minority of persons who could run a greater than average chance of developing impaired psychological and psychiatric functioning if they used marijuana. Through employing this concept of "relative risk," public health officials Dr. Seiden is Associate Professor of Behavioral Sciences, Ms. Tomlinson is a Research Specialist, and Mr. O'Carroll is a graduate student in Behavioral Sciences, University of California School of Public Health, Berkeley, California 94720. This article was accepted for publication in September, 1972.
could then concentrate their attention most effectively toward preventive efforts for this high risk group. If the marijuana issue has become a public health concern which transcends the individual physician-patient relationship and requires instead a community approach geared to education and prevention, then what about those public health professionals charged with the responsibility for meeting this concern? How do they view the marijuana question? What personal experience have they had with the drug? Where do they stand on the issue of legalization? The present study was designed to answer some of these questions by investigating marijuana use patterns and beliefs of a key group: public health graduate students, the public health leaders of the future. Oddly enough, although there have been numerous surveys of college students concerning marijuana there have been no surveys of public health students on this issue.
Survey Design In the conviction that the personal experience and beliefs of public health students on the marijuana issue would be a significant factor influencing future role performance, a questionnaire was designed to survey their personal use patterns and beliefs regarding marijuana. Design and pretesting of the questionnaire were carried out as a supervised group- project by public health graduate students who were members of the senior author's research methods course. (The questionnaire appears in Appendix A.) PATTERNS OF MARIJUANA USE
613
Graduate students enrolled in the University of California, Berkeley, School of Public Health (UCB/SPH) comprised the population under study. From this population a stratified random sample was drawn consisting of approximately 25 per cent of the student body (N = 60). The sample was stratified for sex and possession of a medical degree. In March, 1972, questionnaires were mailed to the homes of those persons randomly selected for the sample group. Included with the questionnaires were self-addressed stamped return envelopes and instructions specifying that the individual responses would be treated as confidential material and that subject identity would remain anonymous. While participation in the survey was encouraged, cooperation by the respondents was completely voluntary. Sixty questionnaires were sent out; 42 completed questionnaires were returned producing a response rate of 70 per cent. An analysis of the 30 per cent nonrespondents indicated that respondents and nonrespondents were essentially similar in terms of the stratified population variables of sex and medical training (Table 1). On the basis of this comparative analysis, we were reasonably confident that our respondents comprised a representative sample of the population under study. With respect to other demographic characteristics, the respondents were predominantly white (87 per cent), U.S. citizens (90 per cent), and middle class (83 per cent rated their parents' socioeconomic background as middle class, 10 per cent rated them as lower class, and 7 per cent rated parental socioeconomic level as upper class). Our respondents' ages ranged from 22 to 40 years with a median age of 27. As previously indicated, at the time of the survey all subjects were college graduates enrolled in a professional school of public health at a large West Coast university.
Results The questionnaire was designed to yield responses along several dimensions; the first series of questions dealt with usage patterns for marijuana and other drugs.
Use Patterns
Survey results indicated a prevalence figure of 76 per cent of public health students who had ever used marijuana
and 24 per cent who had never used the drug. This figure corresponded very closely to speculations made by the respondents themselves. When asked to estimate the number of public health students who had tried marijuana, the respondents were quite accurate, estimating a 68 per cent prevalence figure which was very close to the obtained prevalence figure of 76 per cent. Regarding age of initial exposure, most respondents had their first contact with marijuana during their college years; slightly over half (52 per cent) initially tried the drug during their twenties. Table 2 provides a further breakdown of the patterns of marijuana use. Twenty-four per cent of the students had never used marijuana. The remaining prevalence figure of 76 per cent included 33 per cent who had experimented a few times and then discontinued use, yielding a point prevalence figure of 43 per cent who were using the drug at the time of the survey in March, 1972. The ratio of current-users as a percentage of ever-users was 56 per cent, placing it within the range of 50 to 80 per cent current-user:ever-user ratios obtained in 11 different college student surveys taken between 1967 and 1971.3 Table 3 compares the patterns of marijuana use between ever-users in the public health student sample and ever-users in the NCMDA National Survey of adults 18 and over.2 Inspection of Table 3 supports the National Survey finding that a significant fraction of persons experimenting with marijuana have discontinued its use. In both samples the proportion of persons reporting that they tried marijuana but no longer use it is similar (UCB/SPH 44 per cent; National Survey 41 per cent). Public health students' use patterns by sex and age were also consistent with the results obtained in the National Survey. For example, there was no sex differential among ever-users of marijuana; indeed the patterns were identical. In our sample 75 per cent of the males and 76 per ,cent of the females had used marijuana. Age, however, was a variable of great significance. Eighty-five per cent of the students under 30 had tried marijuana whereas only 57 per cent of those over 30 had ever used the drug. Although marijuana use was relatively pervasive, the "recreational" (i.e., not medically prescribed) use of "harder" drugs was substantially lower. The proportion of respondents ever using marijuana (76 per cent) was considerably higher than it was for drugs such as opiates (5 per cent), psilocybin (5 per cent), kava (5 per cent), cocaine (10 per cent), sleeping pills (12 per cent), LSD (14 per
TABLE 1-Population and Respondent Sample Characteristics, UCB/SPH Students, March, 1972 % in
% in Characteristics Sex M F Hold MD degree Yes No
*614
Population
Respondent Sample
53 47
58 42
20 80
17 83
AJPH JUNE, 1975, Vol. 65, No. 6
TABLE 2-Patterns of Marijuana Use, UCB/SPH Students, March, 1972 Patterns
%
Never used
24
Used but discontinued Use less than 3 times/week Use up to 3 times/week Use more than 3 times/week
33 17 21 5
57% current nonusers 43% current users
TABLE 3-Comparative Patterns of Marijuana Use among Ever-Users: UCB/SPH Students, March, 1972, and NCMDA National Survey Respondents 18 and Over, August, 1971 % of Ever-Users
Patterns
SPH
National Survey*
NCMDA Use Designation
Have used but no longer use Use up to 3 times/week Use more than 3 times/week No response
44 50 6 0
41 26 3 30
Experimenters Intermittent Moderate to heavy
*
Source: Reference 2.
cent), mescaline (14 per cent), tranquilizers (15 per cent), or amphetamines (17 per cent). In contrast, the trio of presently legal and culturally acceptable drugs have been widely used: alcohol, 93 per cent; coffee, 81 per cent; cigarettes, 60 per cent. It seems noteworthy that more public health students reported the use of marijuana than reported the use of the legal, if hazardous, tobacco cigarette (76:60 per cent). Despite the general pervasiveness of marijuana use, attitudes toward marijuana were considerably ambivalent, indicating some discrepancy between behavior and attitudes. In response to the question, "What is your general attitude toward marijuana now?" the responses were: favorable, 33 per cent; unfavorable, 19 per cent; and mixed feelings, 48 per cent. Clinical Effects A second series of questions was designed to elicit knowledge and opinions about the clinical effects of marijuana. On the whole our respondents displayed a degree of knowledge in this area that was consistent with the known effects reported in the scientific literature. There was general agreement with experimentally validated effects such as distortion of the time sense, increased passivity, and greater sensitivity to such stimuli as food and music. Nonetheless, there was considerable uncertainty about many of the drug's presumed effects. In over one-quarter of the cases (28 per cent) respondents checked the "don't know" column, indicating an uncertainty or lack of knowledge. This should not be too startling since there is in fact a great deal of confusion and much inadequate information regarding the clinical effects of marijuana usage. As such, our respondents simply mirrored the uncertainty and inconsistency evident in this area among the public and professionals alike. For example, there is considerable disagreement as to whether marijuana actually increases sexual desire, lowers achievement, or increases self-knowledge. The large number of "don't know" responses reflected this uncertainty. On the other hand, there were several instances where some respondents seemed surprisingly misinformed about the known effects of this drug. For example, only one-third of the respondents rejected the idea that one "develops increasing tolerance to the drug," despite the scientific and medical
literature which indicates that the buildup of any progressive tolerance is minimal and requires heavy, long term usage.4 In addition, there is some anecdotal evidence that the situation may be exactly the opposite, that is, experienced users appear to develop a "reverse tolerance" whereby they require less of a dose to reach a desired state than do nonexperienced users.5 Forty per cent of the respondents did not dispute the opinion that marijuana is "potentially poisonous due to its high toxicity," an opinion that flies in the face of a large body of scientific evidence which indicates that cannabis products have extremely low toxicity. There is no evidence of a single fatality in the United States resulting from marijuana ingestion and the NCMDA has clearly stated that "the dose required for overdose is enormous and for all practical purposes unachievable for humans who smoke marihuana."2 Fortythree per cent of the sample did not disagree with the belief that marijuana had "habit-forming, addictive qualities" although there is no evidence for abstinence symptoms, physical dependence, or addiction potential in the scientific literature and the NCMDA has flatly commented: "In a word, cannabis does not lead to physical dependence."2 Considering the general uncertainty about clinical effects plus the cited examples of ignorance or misinformation by our respondents, it is not altogether surprising to find so few of them giving positive answers to the question, "Do you think that marijuana has potential for medicinal purposes?" Only 18 per cent of our respondents replied "Yes" it does, 24 per cent stated "No" it does not, and most (58 per cent) stated that they "don't know." What is especially interesting is that none of the seven medical doctors in our sample felt that marijuana has any potential medical use. All of them stated either that it has no potential use or that they did not know of any potential use, even though the Secretary of Health, Education, and Welfare has proposed that "In the future, cannabis or its synthetic analogues may prove to be a valuable therapeutic agent."6 Further, by denying that marijuana has any potential medicinal use, the seven physicians in our sample are at variance with historical facts. Mikuriya in a 1969 article4 explored the historical use of Cannabis sativa for medical ailments such as anorexia, muscle spasms, migraine, depression, anxiety, and withdrawal from opiate addiction. He further pointed out that C. sativa preparations were only "removed from the United States Pharmacopoeia and PATTERNS OF MARIJUANA USE
615
National Formulary in 1941."4 Grinspoon also noted widespread medical use of C. sativa in Westem culture for "'various ailments and discomforts, such as coughing, fatigue, rheumatism, asthma, delirium tremens, migraine headache and painful menstruation."7 It is unlikely that the negative attitude toward any potential medicinal use of marijuana expressed by our seven MD respondents can be explained solely as a function of medical training. Since all of the physicians in our sample were over 30 years of age, the variables of medical training and chronological age were completely confounded. Upon reflection, the factor of chronological age appears to be the more important variable since most younger doctors and members of the Student Medical Association are reported to be disposed toward greater liberalization of marijuana laws, including "the complete elimination of criminal penalties for simple marijuana use."8
Legislation and Control A third group of questions was designed to elicit opinions regarding legalization and control of marijuana. The overwhelming majority of respondents (90 per cent) felt that the present marijuana laws were "too strict." In this respect they agreed with an increasing number of health professionals including numerous members of the American Medical Association. At their recent convention in San Francisco the House of Delegates of the AMA recommended that "personal possession of insignificant amounts of that substance [marijuana] be considered at most a misdemeanor with commensurate penalties applied."9 However, from this point onward our respondents departed from the Establishment position.regarding future legal controls. The AMA position called only for a reduction of the legal penalties; the NCMDA has proposed a more liberal program of "partial prohibition" featuring the "decriminalization" of small amounts (1 to 2 ounces) intended for personal use.2 Our survey respondents favored even greater liberalization than indicated in either the AMA or the NCMDA positions. Responding to the question, "What position would you advocate concerning future marijuana laws?" only 3 per cent advocated that the drug continue to be legally unavailable, another 5 per cent felt that it should be available only by prescription or for medical research purposes, and, at the other end of the spectrum, 10 per cent of our sample expressed the conviction that no legal restrictions should be placed upon its use. By far the majority of the respondents (82 per cent) advocated that marijuana should be granted the same availability and legal status as tobacco and alcohol, a position consistent with their general belief that, as a problem, marijuana ranks equally with tobacco and alcohol. The NCMDA has opposed legalization on the grounds that making marijuana legal and freely available would greatly increase the population at risk and escalate marijuana use to the point where it could potentially become a major public health problem.2 Although there is no way to verify this fear (short of legalization), we did ask our respondents to predict whether "marijuana will be 616
AJPH JUNE, 1975, Vol. 65, No. 6
legalized within the next 5 years." Most subjects (74 per cent) believed that marijuana would be legal by 1977. However, their responses to questions concerning their own future use of marijuana, should it become legal, indicate no dramatic shift in use patterns. When the 57 per cent of our sample who had never used marijuana or who had experimented with it but discontinued its use were asked whether they would use it if it were legalized, two-thirds responded that they would refrain from using it; of the remaining one-third almost all were undecided. In only one instance did a nonuser anticipate using marijuana were it legalized and he was a person who had tried marijuana but discontinued its use. There was a greater self-anticipated shift in usage among the 43 per cent of our sample who were currently using the drug. Twenty-two per cent of this group did state that they would increase their use if it were made legal; however, the remaining 78 per cent claimed that their patterns of usage would remain unchanged. It is informative to note that none of the current users indicated that legalizing marijuana would cause them to decrease their usage. This finding runs counter to the frequently heard speculation that many people use marijuana primarily because it represents a defiance of authority. Our survey results did not support the view that legalization, by removing the "mystique" supposedly associated with using illicit drugs, would cause decreased use. Upon analysis it seems that legalization of marijuana will not decrease the population at risk nor will it significantly increase the population at risk; however, what is may do is increase the degree of exposure to risk for persons currently using the substance. Other Controversial Issues Are the liberal attitudes and behavior expressed by our respondents toward marijuana specific to that issue or are they related to positions on other important and controversial sociopolitical issues? Since numerous observers have linked marijuana use with radical politics, we included three questions designed to determine the positions of our respondents on the Vietnam war, Gay
Liberation, and abortion reform. Results indicated that the Vietnam war and abortion reformn could hardly be considered controversial issues among our sample of respondents. When asked what they would "advocate as American policy in Vietnam," 89 per cent endorsed "complete and immediate withdrawal," 9 per cent advocated then-current U.S. policy of "limited de-escalation," and only one respondent proposed "increased military escalation." A similar situation occurred regarding abortion reform. Only two persons advocated that "abortion should not be legalized," another three felt that "abortion should be legalized under extenuating circumstances," and the remaining majority (88 per cent) felt that abortion either "should be legalized" or should be "legalized and funded by the government." Since we obtained so little response variation on these supposedly controversial topics it was not possible to correlate positions on these issues with marijuana use. One can state,
however, that the attitudes expressed by UCB/SPH students on these sociopolitical issues are extremely liberal when compared to the views expressed by the general population on these topics. On the matter of Gay Liberation there was considerably more controversy, a larger variation of responses, and a much greater degree of uncertainty. In answer to the question, "How do you feel about the Gay Liberation Movement?" the responses were favorable, 51 per cent; unfavorable, 15 per cent; and undecided, 34 per cent. Given this distribution of responses it was possible to test the relationship between the ever-use of marijuana and attitudes toward Gay Liberation (Table 4). Statistical analysis by the chi-square test corrected for continuity indicated a statistically significant relationship between the ever-use of marijuana and Gay Liberation attitudes, leading to the conclusion that marijuana ever-use was positively associated with favorable attitudes expressed toward the Gay Liberation Movement.
Discussion Results of our study indicated that the use of marijuana was a pervasive phenomenon among public health students. About three-fourths of the student body of the UCB/SPH (76 per cent) have tried the substance on at least one occasion (prevalence) and almost half (43 per cent) were using the drug at the time of our survey in March, 1972 (point prevalence). These prevalence figures were noticeably higher than results obtained from other population surveys. For instance, the Gallup Poll of October, 1969,'0 sampled the national population of persons 21 years old and older. They estimated that 4 per cent of the adult population had used marijuana on at least one occasion. The poll further illustrated that usage patterns varied with age, sex, educational background, and place of residence. Use prevalence was greater for younger persons (21 to 29), men, the college-educated, and persons living in the Northeast and West as opposed to those living in the South and Midwest. A later (August, 1971) and more comprehensive National Survey sponsored by the NCMDA2 concluded that marijuana use was considerably more prevalent than had previously been indicated. This National Survey estimated that 15 per cent of the adults (18 and over) had TABLE 4-Attitudes toward Gay Lib by Marijuana Use, UCB/SPH Students, March, 1972
Marijuana Use
Attitude toward Gay Lib
Never used
Ever used*
Total
2 8 10
20 12 32
22 20 42
Favorable Unfavorable or undecided Total
*X2 = 3.94; df 1;p < 0.05. =
TABLE 5-Comparative Patterns of Drug Use, Public Health Students, March, 1972, and Law School Students, Spring, 1969, UCB %of Students
%of Law School Students*
76 43 14 92
73 50 15 >80
Public Health Patterns
Marijuana ever-users Marijuana current-users LSD ever-users Favor legalization of marijuana *
Source: Reference 12.
used marijuana on at least one occasion. Usage patterns varied in the same direction by age, educational background, and region of the country although the sex differential, which previously indicated that men were twice as likely to smoke marijuana than were women, had decreased considerably. In fact, studies of youthful populations revealed that in many instances the prevalence of marijuana use was almost identical for males and females. Age remained one of the most significant factors associated with use since about half of the persons using marijuana were in the 16- to 25-year age range. As the Gallup Poll had earlier disclosed, use prevalence was higher in the Northeast and West and educational attainment continued to be an important correlate of marijuana use with 44 per cent of the students in college or graduate school estimated to have used marijuana. A more current estimate of ever-use of marijuana by college students is that recently revealed by the American Institute of Public Opinion. Its interview survey conducted in December, 1971, among 1063 students on 57 campuses revealed that 51 per cent had tried marijuana at least once.' 1 Because the population sampled in the present survey shared many of the demographic characteristics associated with relatively prevalent marijuana use and was not representative of the U.S. population at large, a direct comparison of our results with national surveys such as the Gallup Poll and the NCMDA National Survey is somewhat contentious. Our respondents were young (median age 27 years), were highly educated (university graduate students), and resided in an area where marijuana use is and was greater than average (West Coast). A more valid comparison can be made between public health students and students at the Boalt Law School located on the same Berkeley campus. According to a 1969 surveyl 2 performed upon a random sample comprising one-seventh of the law students, 73 per cent had tried marijuana, half of the sample were using marijuana at the time of the survey (Table 5), and half of those current-users said they used it at least once a week. The prevalence and point prevalence figures compare very closely in both surveys. Additionally, in both schools there was an almost identical proportion who had used LSD. The percentage of law school students who had used LSD was 15 per cent; among public health students the percentage was 14 per cent. There was also strong agreement regarding the question of legalizing marijuana. PATTERNS OF MARIJUANA USE
617
Over 80 per cent of the law students said the drug should be legalized and 92 per cent of the public health students agreed. Our survey data indicate that the degree and pattern of marijuana use among law students and public health students were remarkably similar and that they were considerably greater than prior college surveys have suggested. Moreover, in neither survey did it appear that marijuana use necessarily led to harder drugs. Clearly marijuana was the "illicit" drug of choice and there was surprisingly little carryover to the use of other drugs. What are the implications for a society in which more than 80 per cent of the law students-the judges, district attorneys, and legislators of the future-are opposed to current drug laws and where about half of them reported flaunting the criminal laws with great regularity? One likely implication was expressed by the satirical humorist and social critic, Lenny Bruce, who remarked that "Pot will be legal in ten years. Why? Because in this audience probably every other one of you knows a law student who smokes pot, who will become a senator, who will legalize it to protect himself.",l 3 While time will judge the accuracy of Bruce's remarks concerning law students, one does not need the gift of prophecy to predict serious conflicts about the roles which are being forecast for public health students in terms of future drug control programs. These suggested roles include, on the one hand, total prevention of marijuana use and, on the other, actions aimed at discouraging use, particularly heavy use, of marijuana. If the total prevention of marijuana use is encouraged as a goal then how can such responsibility be delegated to a group who themselves comprise such a large number of marijuana users? Either we are asking our future public health leaders to be completely hypocritical or else to place themselves in a situation which seems bound to result in exacerbated strain between their personal and professional roles. An end to hypocrisy has already been advocated by Lipp and Benson, two psychiatrists who conducted a national survey of marijuana use among physicians. Twenty-five per cent of the national sample had used the drug, which led the authors to conclude that their medical colleagues should "soon come to grips with the facts of cannabis use among themselves and cease talking about marijuana use as something that happens only to adolescents and patients."'1 4 If past experience is any indication, public health students are likely to take an active stand on this issue when they enter the health professions. For instance, in 1969, 96 health professionals (including 34 physicians working at Public Health Service facilities) sent an open letter to the White House asserting that federal law enforcement agencies had made many "spurious claims and charges" about marijuana. Marijuana, they said, "is one of the safest pharmaceuticals known to mankind." Furthermore, they urged serious clinical research of the substance which they claimed "has the potential to be a valuable drug" in medical practice and which, if confirmed by laboratory and clinical trials, might prove to be "much safer 618 AJPH JUNE, 1975, Vol. 65, No. 6
than present medication" for use as a "tranquilizer, sleeping pill or muscle relaxant."' S A similar viewpoint was expressed by physicians at various university health centers. According to the NCMDA: A number of medical doctors who serve at
university health centers object strenuously to the marihuana phenomenon being labeled a "marihuana problem." They say that except for a minute number
of students who may use marihuana to excess or are harmed because of the impurity of the product resulting from a mixture with foreign substances, the use of marihuana generally has caused few health
problems.' 6
It seems more reasonable to expect our future health
professionals to accept the limited preventive goal recommended by the NCMDA. These recommendations included "a social control policy seeking to discourage marihuana use, while concentrating primarily on heavy and very heavy use" (more than once daily).2 This policy is to be implemented by educational programs on the part of health professionals, particularly physicians and health educators. The Commission called for realistic education including a truthful appraisal of the personal and public health risks involved in the use of marijuana and other drugs. But according to our survey results even this more limited goal may run into some difficulty since, in several instances, a number of our respondents seemed just as uninformed or misinformed about marijuana as anyone else. There has been so much deliberate misinformation and distortion on the marijuana issue that it was not very surprising to find inaccurate beliefs expressed by some of our respondents. But if these are the very people selected to dispense accurate information so that the public can make enlightened decisions, then, as a sine qua non we must require that these future drug educators be well informed themselves. We can profit from the unfortunate examples provided by the many school districts who feel called upon to present drug education programs. This task is frequently assigned to a teacher or school nurse, although many teachers and school nurses are not well prepared in this area. Nevertheless, they find themselves responsible for directing programs for which they have not received even the most minimal training. The NCMDA report makes mention of this problem in their contention that: Because most schoolteachers have a minimum knowledge about drugs, even the common selfadministered medicine cabinet variety, it may be presumptuous and counter-productive for them to conduct classes unless they are adequately prepared. Sufficient preparation is not acquired in attending a weekend workshop or listening to one expert give a two-hour lecture on his own specialty. Confronted with evidence of drug usage, the untrained classroom teacher frequently reacts in a negative and harmful manner. He assumes that marihuana and drugs are an unmitigated evil and he is fully aware that their use is illegal. As a result, he either tries to ignore the students' use of drugs or he adopts a hard intemperate attitude in trying to prevent their use.' 6
If he.dth professionals are expected to offer the public effective educational programs it is up to the schools of public heelth in our universities to supply adequate training in this area. According to the NCMDA, "While a number of schools have informal programs and conferences relating to drugs for both students and faculty, mainly infonnational, the Commission in its survey [of 13 university campuses] learned of no school which offered regular scheduled programs on marihuana or other drugs.",I16 Actually there are some programs currently being offered. For instance, the senior author and Dr. Donald Cahalan are presenting a year-long course funded by the National Institute of Mental Health on the subject of alcohol and other drugs. Nevertheless, the number of university-level drug education courses offered nationally are few and far between. Such courses should be presented on a more widespread basis and accordingly it is recommended that all schools of public health offer courses giving accurate drug education information presented as an essential part of public health training. In addition to much miseducation about drugs by school personnel, the vacuum in the drug education field has frequently been filled by agents of various law enforcement institutions. Drug programs emanating from these law enforcement sources have even more often been characterized by zealous but inaccurate and exaggerated reports which have proved ineffective in preventing drug abuse. For instance, consider the remarks by the Director of the Bureau of Narcotics and Dangerous Drugs to the California Peace Officers Association in May, 1972: If we lose in our efforts to keep these drugs from being legalized have we not lost altogether? We must become active spokesmen on these crucial issues. It is our duty not only to protect the public in the streets from these vicious criminals but to protect the public from harmful ideas when we clearly recognize them.' '
The American College Association in their position statement on drug abuse affirmed that guidelines for drug use were the responsibility of the health professions, and made a clear cut and necessary distinction between the proper role for health professionals and law enforcement agents in these matters: Controls appropriate for each "drug" can be established only on the basis of information from thoughtful and carefully controlled observations of its physical and emotional effects, not by hasty and a priori judgments based upon the fears of law enforcement agents or the opinions of others who assume responsibility for the orderliness of our college communities. Thus, it is a responsibility of the health professions to recommend appropriate regulations, not to enforce them; it is the responsibility of law enforcement agencies to enforce regulations, not to establish them.' 8
The public at large has grown increasingly resentful about being lied to, even when it may be done with the best of intentions. It is the responsibility of health professionals, among others, to remedy this situation, to provide accurate and truthful information, honestly informing the public of
the abuse potential involved in all varieties of drug use. The "demythologizing" of the drug question is but a beginning step which needs to be taken by public health professionals in meeting this important responsibility. One means of increasing public understanding would be to confront the fact that we are already a drug-oriented society. For example, a public drug education program could profitably analyze the way in which magazine advertisements, television commercials, and other mass media approaches are geared to promote a reliance upon various patent medicines and remedies. Increasing public awareness of the constant push to get them to depend upon such freely available substances as aspirin, Alka-Seltzer, Rolaids, Sominex, coffee, cola drinks, tobacco, and alcohol (not to mention prescription drugs) would help to place the drug use problem in its proper perspective. It would also illustrate the degree to which we are continually conditioned into believing that ingesting various chemical substances can improve our lives and fortunes. As a consequence of a melange of misinformation, the cornucopia of readily available and popularly consumed drugs, and the "scare" tactics used to "educate" youngsters about the dangers of drugs, many of our young people have become quite skeptical and cynical. Some of them tend to deny the very real abuse potential associated with the use of relatively dangerous drugs such as the opiates, amphetamines, and barbiturates. As a result of this kind of approach we have created a potentially disastrous "credibility gap" which can only be remedied by frankness and honesty. With the ever-increasing number of people ingesting a variety of drugs about which they know so little, the need for public health professionals to provide honest education in the drug use area is accentuated. One is reminded of a comment attributed to Gandhi. Looking from his window at the crowds surging by he is reported to have said, "I must hurry and catch up with them for I am their leader." To those of us in the public health professions the moral should be clear.
References 1. Committee on Problems of Drug Dependence, National Research Council, and Council on Mental Health and Committee on Alcoholism and Drug Dependence, American Medical Association. Marihuana and Society. J. A. M. A. 204:1181-1182, 1968. 2. First Report of the National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Stock 5266-0001, pp. 32-34, 79, 83-84, 87, 90-91, 134,150-154. U.S. Government Printing Office, Washington, DC, 1972. 3. Technical Papers: National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Appendix, Vol. I, Stock 5266-0002, p. 257. U.S. Government Printing Office, Washington, DC, 1972. 4. Mikuriya, T. H. Historical Aspects of Cannabis Sativa in Western Medicine. New Physician 18:902-908,
1969.
5. Weil, A. T., Zinberg; N. E., and Nelsen, J. M. Clinical and Psychological Effects of Marihuana in Man. Science 162:1234-1242,1968. PATTERNS OF MAR IJUANA USE
619
6. Marihuana and Health. A Report to the Congress from the Secretary, Department of Health, Education, and Welfare, p. 87. U.S. Government Printing Office, Washington, DC, 1971. 7. Grinspoon, L. Marihuana. Sci. Am. 221:17-25, 1969. 8. San Francisco Chronicle, p. 22. June 21, 1972. 9. 1972 American Medical Association Convention Daily Newsletter, San Francisco, 68:1, 1972. 10. American Institute of Public Opinion (Gallup). The Gallup Poll: Public Opposed to Legalizing Marijuana; Opinions Differ Sharply by Age, Region. Princeton, NJ, October 23, 1969. 11. American Institute of Public Opinion (Gallup). Gallup Opinion Index: Results of 1971 Survey of College Students. Princeton, NJ, February, 1972. 12. Green, E., and Blumberg, B. Boalt Hall Survey: Casing the Joint. University of California Boalt School of
Law, Berkeley, 1969. 13. Cohen, J. (ed.). The Essential Lenny Brucez, p. 149. Ballantine, New York, 1967. 14. Psychiatric News, p. 9. June 7, 1972. 15. San Francisco Chronicle, p. 10. November 13, 1969. 16. Technical Papers: National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Appendix, Vol. II, Stock 5266.0002, pp. 1202, 1205, 1206. U.S. Government Printing Office, Washington, DC, 1972. 17. Ingersoll, J. E. (Director, Bureau of Narcotics and Dangerous Drugs, U.S. Dept. of Justice). Presented to California Peace Officers Association, Anaheim, California, May 24, 1972. 18. American College Health Association. Position Statement on Drug Abuse, p. 2. American College Health Association, Evanston, IL, 1968.
APPENDIX A
MARIJUANA SURVEY QUESTIONNAIRE I nstructions The use of marijuana has become a major health issue. We feel that it is important to determine the opinions of a group of public health professionals in training conceming this issue. Accordingly, we request that you cooperate by answering the questionnaire below. All replies are ANONYMOUS and CONFIDENTIAL. Your participation is greatly appreciated.
1. How would you rank marijuana as a problem? ----equal to narcotics (e.g., heroin) ----equal to prescription drugs (e.g., tranquilizers) ----equal to tobacco or alcohol ----not a serious problem 2. Where did you get most of your information about marijuana? ----personal experience ----experience of others (e.g., clinical experience, experience of friends) ----communications media (e.g., radio, TV, magazines, newspapers) ----professional sources (e.g., conferences, clinicians, journals) 3. In your opinion, which of the following effects are produced by marijuana? Yes
Has habit-forming qualities (addictive) Potentially poisonous (due to its high toxicity) c. Decreases inhibitions d. Develops increasing tolerance to the drug e. Causes permanent mental disorders (e.g., insanity) f. Lowers achievement g- Provides unusual perceptual experiences (lightheadedness, time distortions) h. Increases aggressions i. Improves social interaction and sociability J. Increases sensitivity (e.g., to food, music, sex) k. Increases passivity 1. Worsens social relations m. Increases sexual desire n. Leads to other drugs (especially heroin) 0. Increases self-knowledge P. Leads to mental deterioration q. Any other effects (specify) 4. How do you feel about present marijuana laws? ----too strict ----not strict enough a. b.
620
AJPH JUNE, 1975, Vol. 65, No. 6
- - - -satisfactory
No
Don't Know
5. What position would you advocate concerning future marijuana laws? Not available legally under any circumstances a. ----b. Available by prescription only (and for medical research) Same availability and legal status as tobacco and liquor ----c. ----d. No restrictions on its use 6. What is your general attitude toward marijuana now? ----mixed feelings ----unfavorable ----favorable 7. How often have you used marijuana? ----never ----tried it a few times ----up to 3 times per week ----more than 3 times per week 8. (a) If you DO NOT use marijuana, and it were legalized, would you then use it? ----no ----undecided ----yes (b) If you DO use marifuana, and it were legalized, how would your pattern of usage change? ----remain unchanged ----decreased use ----increased use 9. Have your attitudes toward marijuana changed since you've been in the School of Public Health? ----yes, more favorable toward marijuana ----yes, less favorable toward mariJuana ----no, unchanged 10. If you have used marijuana, at what age did you first use it?---------11. Which of the following drugs have you ever used "recreationally" (i.e., not medically prescribed)? ----Cigarettes (nicotine) ----Amphetamines ("pep" pills) ----Opiates - ---Alcohol - ---Tranquilizers ----Mescaline ----Coffee (caffeine) ----LSD ----Sleeping pills ----Other (Specify) ----Cocaine 12. What percentage of public health students do you think have tried marijuana?----S% What percentage of law school students do you think have tried marijuana?----% 13. Do you think that marijuana has potential for medicinal purposes? ----don't know ----no ----yes (if yes, please specify below)
14. Do you think marijuana will be legalized within the next 5 years? ----no ----yes 15. What would you advocate as American policy in Vietnam? ----Increased military escalation ----Limited de-escalation ----Complete and immediate withdrawal 16. How do you feel about present abortion laws? Abortion should not be legalized ----a. Abortion should be legalized under certain extenuating circumstances ----b. ----c. Abortion should be legalized ----d. Abortion should be legalized and funded by the government 17. How do you feel about the Gay Liberation Movement? - --unfavorable ----undecided ----favorable ----Male Sex:----Female Age: Academic status: ----Student ----Faculty College major: Usual occupation: ----Foreign country Citizenship: ----U.S..A. Ethnic group (please specify): Estimate in which of the following social "class" category your parents would fall: - - --upper-middle class ----lower-lower class - - - -upper-lower class ----lower-upper class - - - -lower-middle class - ---upper-upper class ----middle-middle class Use the space below for any additional comments:
PATTERNS OF MARIJUANA USE
621
Health Students
RICHARD H. SEIDEN, PhD, MPH KATHERINE R. TOMLINSON, BA MICHAEL O'CARROLL, BA, HDIP
The prevalent use of marijuana among future public health workers raises important questions in terms of current professional role expectation in areas of drug use prevention and education. More realistic and honest drug use policies are advocated as a public health responsibility.
Introduction Is the marijuana controversy a genuine public health concern? In recent studies authoritative medical investigators agree that it is and they have placed the marijuana question squarely in the province of the public health professions. For example, in a 1963 position paper combined committees of the American Medical Association and the National Academy of Science National Research Council came to the primary conclusion that "Cannabis is a dangerous drug and as such is a public health concern."' Similarly, the National Commission on Marihuana and Drug Abuse (NCMDA) in its March, 1972, report states that "policy makers and the public have begun increasingly to view marihuana and other illicit drug use as a public health concern."2 While the Commission concluded that present levels of marijuana usage constituted a relatively minor public health concern, they also foresaw some potential hazards and advocated that an epidemiological approach was needed to identify high risk population groups, i.e., the minority of persons who could run a greater than average chance of developing impaired psychological and psychiatric functioning if they used marijuana. Through employing this concept of "relative risk," public health officials Dr. Seiden is Associate Professor of Behavioral Sciences, Ms. Tomlinson is a Research Specialist, and Mr. O'Carroll is a graduate student in Behavioral Sciences, University of California School of Public Health, Berkeley, California 94720. This article was accepted for publication in September, 1972.
could then concentrate their attention most effectively toward preventive efforts for this high risk group. If the marijuana issue has become a public health concern which transcends the individual physician-patient relationship and requires instead a community approach geared to education and prevention, then what about those public health professionals charged with the responsibility for meeting this concern? How do they view the marijuana question? What personal experience have they had with the drug? Where do they stand on the issue of legalization? The present study was designed to answer some of these questions by investigating marijuana use patterns and beliefs of a key group: public health graduate students, the public health leaders of the future. Oddly enough, although there have been numerous surveys of college students concerning marijuana there have been no surveys of public health students on this issue.
Survey Design In the conviction that the personal experience and beliefs of public health students on the marijuana issue would be a significant factor influencing future role performance, a questionnaire was designed to survey their personal use patterns and beliefs regarding marijuana. Design and pretesting of the questionnaire were carried out as a supervised group- project by public health graduate students who were members of the senior author's research methods course. (The questionnaire appears in Appendix A.) PATTERNS OF MARIJUANA USE
613
Graduate students enrolled in the University of California, Berkeley, School of Public Health (UCB/SPH) comprised the population under study. From this population a stratified random sample was drawn consisting of approximately 25 per cent of the student body (N = 60). The sample was stratified for sex and possession of a medical degree. In March, 1972, questionnaires were mailed to the homes of those persons randomly selected for the sample group. Included with the questionnaires were self-addressed stamped return envelopes and instructions specifying that the individual responses would be treated as confidential material and that subject identity would remain anonymous. While participation in the survey was encouraged, cooperation by the respondents was completely voluntary. Sixty questionnaires were sent out; 42 completed questionnaires were returned producing a response rate of 70 per cent. An analysis of the 30 per cent nonrespondents indicated that respondents and nonrespondents were essentially similar in terms of the stratified population variables of sex and medical training (Table 1). On the basis of this comparative analysis, we were reasonably confident that our respondents comprised a representative sample of the population under study. With respect to other demographic characteristics, the respondents were predominantly white (87 per cent), U.S. citizens (90 per cent), and middle class (83 per cent rated their parents' socioeconomic background as middle class, 10 per cent rated them as lower class, and 7 per cent rated parental socioeconomic level as upper class). Our respondents' ages ranged from 22 to 40 years with a median age of 27. As previously indicated, at the time of the survey all subjects were college graduates enrolled in a professional school of public health at a large West Coast university.
Results The questionnaire was designed to yield responses along several dimensions; the first series of questions dealt with usage patterns for marijuana and other drugs.
Use Patterns
Survey results indicated a prevalence figure of 76 per cent of public health students who had ever used marijuana
and 24 per cent who had never used the drug. This figure corresponded very closely to speculations made by the respondents themselves. When asked to estimate the number of public health students who had tried marijuana, the respondents were quite accurate, estimating a 68 per cent prevalence figure which was very close to the obtained prevalence figure of 76 per cent. Regarding age of initial exposure, most respondents had their first contact with marijuana during their college years; slightly over half (52 per cent) initially tried the drug during their twenties. Table 2 provides a further breakdown of the patterns of marijuana use. Twenty-four per cent of the students had never used marijuana. The remaining prevalence figure of 76 per cent included 33 per cent who had experimented a few times and then discontinued use, yielding a point prevalence figure of 43 per cent who were using the drug at the time of the survey in March, 1972. The ratio of current-users as a percentage of ever-users was 56 per cent, placing it within the range of 50 to 80 per cent current-user:ever-user ratios obtained in 11 different college student surveys taken between 1967 and 1971.3 Table 3 compares the patterns of marijuana use between ever-users in the public health student sample and ever-users in the NCMDA National Survey of adults 18 and over.2 Inspection of Table 3 supports the National Survey finding that a significant fraction of persons experimenting with marijuana have discontinued its use. In both samples the proportion of persons reporting that they tried marijuana but no longer use it is similar (UCB/SPH 44 per cent; National Survey 41 per cent). Public health students' use patterns by sex and age were also consistent with the results obtained in the National Survey. For example, there was no sex differential among ever-users of marijuana; indeed the patterns were identical. In our sample 75 per cent of the males and 76 per ,cent of the females had used marijuana. Age, however, was a variable of great significance. Eighty-five per cent of the students under 30 had tried marijuana whereas only 57 per cent of those over 30 had ever used the drug. Although marijuana use was relatively pervasive, the "recreational" (i.e., not medically prescribed) use of "harder" drugs was substantially lower. The proportion of respondents ever using marijuana (76 per cent) was considerably higher than it was for drugs such as opiates (5 per cent), psilocybin (5 per cent), kava (5 per cent), cocaine (10 per cent), sleeping pills (12 per cent), LSD (14 per
TABLE 1-Population and Respondent Sample Characteristics, UCB/SPH Students, March, 1972 % in
% in Characteristics Sex M F Hold MD degree Yes No
*614
Population
Respondent Sample
53 47
58 42
20 80
17 83
AJPH JUNE, 1975, Vol. 65, No. 6
TABLE 2-Patterns of Marijuana Use, UCB/SPH Students, March, 1972 Patterns
%
Never used
24
Used but discontinued Use less than 3 times/week Use up to 3 times/week Use more than 3 times/week
33 17 21 5
57% current nonusers 43% current users
TABLE 3-Comparative Patterns of Marijuana Use among Ever-Users: UCB/SPH Students, March, 1972, and NCMDA National Survey Respondents 18 and Over, August, 1971 % of Ever-Users
Patterns
SPH
National Survey*
NCMDA Use Designation
Have used but no longer use Use up to 3 times/week Use more than 3 times/week No response
44 50 6 0
41 26 3 30
Experimenters Intermittent Moderate to heavy
*
Source: Reference 2.
cent), mescaline (14 per cent), tranquilizers (15 per cent), or amphetamines (17 per cent). In contrast, the trio of presently legal and culturally acceptable drugs have been widely used: alcohol, 93 per cent; coffee, 81 per cent; cigarettes, 60 per cent. It seems noteworthy that more public health students reported the use of marijuana than reported the use of the legal, if hazardous, tobacco cigarette (76:60 per cent). Despite the general pervasiveness of marijuana use, attitudes toward marijuana were considerably ambivalent, indicating some discrepancy between behavior and attitudes. In response to the question, "What is your general attitude toward marijuana now?" the responses were: favorable, 33 per cent; unfavorable, 19 per cent; and mixed feelings, 48 per cent. Clinical Effects A second series of questions was designed to elicit knowledge and opinions about the clinical effects of marijuana. On the whole our respondents displayed a degree of knowledge in this area that was consistent with the known effects reported in the scientific literature. There was general agreement with experimentally validated effects such as distortion of the time sense, increased passivity, and greater sensitivity to such stimuli as food and music. Nonetheless, there was considerable uncertainty about many of the drug's presumed effects. In over one-quarter of the cases (28 per cent) respondents checked the "don't know" column, indicating an uncertainty or lack of knowledge. This should not be too startling since there is in fact a great deal of confusion and much inadequate information regarding the clinical effects of marijuana usage. As such, our respondents simply mirrored the uncertainty and inconsistency evident in this area among the public and professionals alike. For example, there is considerable disagreement as to whether marijuana actually increases sexual desire, lowers achievement, or increases self-knowledge. The large number of "don't know" responses reflected this uncertainty. On the other hand, there were several instances where some respondents seemed surprisingly misinformed about the known effects of this drug. For example, only one-third of the respondents rejected the idea that one "develops increasing tolerance to the drug," despite the scientific and medical
literature which indicates that the buildup of any progressive tolerance is minimal and requires heavy, long term usage.4 In addition, there is some anecdotal evidence that the situation may be exactly the opposite, that is, experienced users appear to develop a "reverse tolerance" whereby they require less of a dose to reach a desired state than do nonexperienced users.5 Forty per cent of the respondents did not dispute the opinion that marijuana is "potentially poisonous due to its high toxicity," an opinion that flies in the face of a large body of scientific evidence which indicates that cannabis products have extremely low toxicity. There is no evidence of a single fatality in the United States resulting from marijuana ingestion and the NCMDA has clearly stated that "the dose required for overdose is enormous and for all practical purposes unachievable for humans who smoke marihuana."2 Fortythree per cent of the sample did not disagree with the belief that marijuana had "habit-forming, addictive qualities" although there is no evidence for abstinence symptoms, physical dependence, or addiction potential in the scientific literature and the NCMDA has flatly commented: "In a word, cannabis does not lead to physical dependence."2 Considering the general uncertainty about clinical effects plus the cited examples of ignorance or misinformation by our respondents, it is not altogether surprising to find so few of them giving positive answers to the question, "Do you think that marijuana has potential for medicinal purposes?" Only 18 per cent of our respondents replied "Yes" it does, 24 per cent stated "No" it does not, and most (58 per cent) stated that they "don't know." What is especially interesting is that none of the seven medical doctors in our sample felt that marijuana has any potential medical use. All of them stated either that it has no potential use or that they did not know of any potential use, even though the Secretary of Health, Education, and Welfare has proposed that "In the future, cannabis or its synthetic analogues may prove to be a valuable therapeutic agent."6 Further, by denying that marijuana has any potential medicinal use, the seven physicians in our sample are at variance with historical facts. Mikuriya in a 1969 article4 explored the historical use of Cannabis sativa for medical ailments such as anorexia, muscle spasms, migraine, depression, anxiety, and withdrawal from opiate addiction. He further pointed out that C. sativa preparations were only "removed from the United States Pharmacopoeia and PATTERNS OF MARIJUANA USE
615
National Formulary in 1941."4 Grinspoon also noted widespread medical use of C. sativa in Westem culture for "'various ailments and discomforts, such as coughing, fatigue, rheumatism, asthma, delirium tremens, migraine headache and painful menstruation."7 It is unlikely that the negative attitude toward any potential medicinal use of marijuana expressed by our seven MD respondents can be explained solely as a function of medical training. Since all of the physicians in our sample were over 30 years of age, the variables of medical training and chronological age were completely confounded. Upon reflection, the factor of chronological age appears to be the more important variable since most younger doctors and members of the Student Medical Association are reported to be disposed toward greater liberalization of marijuana laws, including "the complete elimination of criminal penalties for simple marijuana use."8
Legislation and Control A third group of questions was designed to elicit opinions regarding legalization and control of marijuana. The overwhelming majority of respondents (90 per cent) felt that the present marijuana laws were "too strict." In this respect they agreed with an increasing number of health professionals including numerous members of the American Medical Association. At their recent convention in San Francisco the House of Delegates of the AMA recommended that "personal possession of insignificant amounts of that substance [marijuana] be considered at most a misdemeanor with commensurate penalties applied."9 However, from this point onward our respondents departed from the Establishment position.regarding future legal controls. The AMA position called only for a reduction of the legal penalties; the NCMDA has proposed a more liberal program of "partial prohibition" featuring the "decriminalization" of small amounts (1 to 2 ounces) intended for personal use.2 Our survey respondents favored even greater liberalization than indicated in either the AMA or the NCMDA positions. Responding to the question, "What position would you advocate concerning future marijuana laws?" only 3 per cent advocated that the drug continue to be legally unavailable, another 5 per cent felt that it should be available only by prescription or for medical research purposes, and, at the other end of the spectrum, 10 per cent of our sample expressed the conviction that no legal restrictions should be placed upon its use. By far the majority of the respondents (82 per cent) advocated that marijuana should be granted the same availability and legal status as tobacco and alcohol, a position consistent with their general belief that, as a problem, marijuana ranks equally with tobacco and alcohol. The NCMDA has opposed legalization on the grounds that making marijuana legal and freely available would greatly increase the population at risk and escalate marijuana use to the point where it could potentially become a major public health problem.2 Although there is no way to verify this fear (short of legalization), we did ask our respondents to predict whether "marijuana will be 616
AJPH JUNE, 1975, Vol. 65, No. 6
legalized within the next 5 years." Most subjects (74 per cent) believed that marijuana would be legal by 1977. However, their responses to questions concerning their own future use of marijuana, should it become legal, indicate no dramatic shift in use patterns. When the 57 per cent of our sample who had never used marijuana or who had experimented with it but discontinued its use were asked whether they would use it if it were legalized, two-thirds responded that they would refrain from using it; of the remaining one-third almost all were undecided. In only one instance did a nonuser anticipate using marijuana were it legalized and he was a person who had tried marijuana but discontinued its use. There was a greater self-anticipated shift in usage among the 43 per cent of our sample who were currently using the drug. Twenty-two per cent of this group did state that they would increase their use if it were made legal; however, the remaining 78 per cent claimed that their patterns of usage would remain unchanged. It is informative to note that none of the current users indicated that legalizing marijuana would cause them to decrease their usage. This finding runs counter to the frequently heard speculation that many people use marijuana primarily because it represents a defiance of authority. Our survey results did not support the view that legalization, by removing the "mystique" supposedly associated with using illicit drugs, would cause decreased use. Upon analysis it seems that legalization of marijuana will not decrease the population at risk nor will it significantly increase the population at risk; however, what is may do is increase the degree of exposure to risk for persons currently using the substance. Other Controversial Issues Are the liberal attitudes and behavior expressed by our respondents toward marijuana specific to that issue or are they related to positions on other important and controversial sociopolitical issues? Since numerous observers have linked marijuana use with radical politics, we included three questions designed to determine the positions of our respondents on the Vietnam war, Gay
Liberation, and abortion reform. Results indicated that the Vietnam war and abortion reformn could hardly be considered controversial issues among our sample of respondents. When asked what they would "advocate as American policy in Vietnam," 89 per cent endorsed "complete and immediate withdrawal," 9 per cent advocated then-current U.S. policy of "limited de-escalation," and only one respondent proposed "increased military escalation." A similar situation occurred regarding abortion reform. Only two persons advocated that "abortion should not be legalized," another three felt that "abortion should be legalized under extenuating circumstances," and the remaining majority (88 per cent) felt that abortion either "should be legalized" or should be "legalized and funded by the government." Since we obtained so little response variation on these supposedly controversial topics it was not possible to correlate positions on these issues with marijuana use. One can state,
however, that the attitudes expressed by UCB/SPH students on these sociopolitical issues are extremely liberal when compared to the views expressed by the general population on these topics. On the matter of Gay Liberation there was considerably more controversy, a larger variation of responses, and a much greater degree of uncertainty. In answer to the question, "How do you feel about the Gay Liberation Movement?" the responses were favorable, 51 per cent; unfavorable, 15 per cent; and undecided, 34 per cent. Given this distribution of responses it was possible to test the relationship between the ever-use of marijuana and attitudes toward Gay Liberation (Table 4). Statistical analysis by the chi-square test corrected for continuity indicated a statistically significant relationship between the ever-use of marijuana and Gay Liberation attitudes, leading to the conclusion that marijuana ever-use was positively associated with favorable attitudes expressed toward the Gay Liberation Movement.
Discussion Results of our study indicated that the use of marijuana was a pervasive phenomenon among public health students. About three-fourths of the student body of the UCB/SPH (76 per cent) have tried the substance on at least one occasion (prevalence) and almost half (43 per cent) were using the drug at the time of our survey in March, 1972 (point prevalence). These prevalence figures were noticeably higher than results obtained from other population surveys. For instance, the Gallup Poll of October, 1969,'0 sampled the national population of persons 21 years old and older. They estimated that 4 per cent of the adult population had used marijuana on at least one occasion. The poll further illustrated that usage patterns varied with age, sex, educational background, and place of residence. Use prevalence was greater for younger persons (21 to 29), men, the college-educated, and persons living in the Northeast and West as opposed to those living in the South and Midwest. A later (August, 1971) and more comprehensive National Survey sponsored by the NCMDA2 concluded that marijuana use was considerably more prevalent than had previously been indicated. This National Survey estimated that 15 per cent of the adults (18 and over) had TABLE 4-Attitudes toward Gay Lib by Marijuana Use, UCB/SPH Students, March, 1972
Marijuana Use
Attitude toward Gay Lib
Never used
Ever used*
Total
2 8 10
20 12 32
22 20 42
Favorable Unfavorable or undecided Total
*X2 = 3.94; df 1;p < 0.05. =
TABLE 5-Comparative Patterns of Drug Use, Public Health Students, March, 1972, and Law School Students, Spring, 1969, UCB %of Students
%of Law School Students*
76 43 14 92
73 50 15 >80
Public Health Patterns
Marijuana ever-users Marijuana current-users LSD ever-users Favor legalization of marijuana *
Source: Reference 12.
used marijuana on at least one occasion. Usage patterns varied in the same direction by age, educational background, and region of the country although the sex differential, which previously indicated that men were twice as likely to smoke marijuana than were women, had decreased considerably. In fact, studies of youthful populations revealed that in many instances the prevalence of marijuana use was almost identical for males and females. Age remained one of the most significant factors associated with use since about half of the persons using marijuana were in the 16- to 25-year age range. As the Gallup Poll had earlier disclosed, use prevalence was higher in the Northeast and West and educational attainment continued to be an important correlate of marijuana use with 44 per cent of the students in college or graduate school estimated to have used marijuana. A more current estimate of ever-use of marijuana by college students is that recently revealed by the American Institute of Public Opinion. Its interview survey conducted in December, 1971, among 1063 students on 57 campuses revealed that 51 per cent had tried marijuana at least once.' 1 Because the population sampled in the present survey shared many of the demographic characteristics associated with relatively prevalent marijuana use and was not representative of the U.S. population at large, a direct comparison of our results with national surveys such as the Gallup Poll and the NCMDA National Survey is somewhat contentious. Our respondents were young (median age 27 years), were highly educated (university graduate students), and resided in an area where marijuana use is and was greater than average (West Coast). A more valid comparison can be made between public health students and students at the Boalt Law School located on the same Berkeley campus. According to a 1969 surveyl 2 performed upon a random sample comprising one-seventh of the law students, 73 per cent had tried marijuana, half of the sample were using marijuana at the time of the survey (Table 5), and half of those current-users said they used it at least once a week. The prevalence and point prevalence figures compare very closely in both surveys. Additionally, in both schools there was an almost identical proportion who had used LSD. The percentage of law school students who had used LSD was 15 per cent; among public health students the percentage was 14 per cent. There was also strong agreement regarding the question of legalizing marijuana. PATTERNS OF MARIJUANA USE
617
Over 80 per cent of the law students said the drug should be legalized and 92 per cent of the public health students agreed. Our survey data indicate that the degree and pattern of marijuana use among law students and public health students were remarkably similar and that they were considerably greater than prior college surveys have suggested. Moreover, in neither survey did it appear that marijuana use necessarily led to harder drugs. Clearly marijuana was the "illicit" drug of choice and there was surprisingly little carryover to the use of other drugs. What are the implications for a society in which more than 80 per cent of the law students-the judges, district attorneys, and legislators of the future-are opposed to current drug laws and where about half of them reported flaunting the criminal laws with great regularity? One likely implication was expressed by the satirical humorist and social critic, Lenny Bruce, who remarked that "Pot will be legal in ten years. Why? Because in this audience probably every other one of you knows a law student who smokes pot, who will become a senator, who will legalize it to protect himself.",l 3 While time will judge the accuracy of Bruce's remarks concerning law students, one does not need the gift of prophecy to predict serious conflicts about the roles which are being forecast for public health students in terms of future drug control programs. These suggested roles include, on the one hand, total prevention of marijuana use and, on the other, actions aimed at discouraging use, particularly heavy use, of marijuana. If the total prevention of marijuana use is encouraged as a goal then how can such responsibility be delegated to a group who themselves comprise such a large number of marijuana users? Either we are asking our future public health leaders to be completely hypocritical or else to place themselves in a situation which seems bound to result in exacerbated strain between their personal and professional roles. An end to hypocrisy has already been advocated by Lipp and Benson, two psychiatrists who conducted a national survey of marijuana use among physicians. Twenty-five per cent of the national sample had used the drug, which led the authors to conclude that their medical colleagues should "soon come to grips with the facts of cannabis use among themselves and cease talking about marijuana use as something that happens only to adolescents and patients."'1 4 If past experience is any indication, public health students are likely to take an active stand on this issue when they enter the health professions. For instance, in 1969, 96 health professionals (including 34 physicians working at Public Health Service facilities) sent an open letter to the White House asserting that federal law enforcement agencies had made many "spurious claims and charges" about marijuana. Marijuana, they said, "is one of the safest pharmaceuticals known to mankind." Furthermore, they urged serious clinical research of the substance which they claimed "has the potential to be a valuable drug" in medical practice and which, if confirmed by laboratory and clinical trials, might prove to be "much safer 618 AJPH JUNE, 1975, Vol. 65, No. 6
than present medication" for use as a "tranquilizer, sleeping pill or muscle relaxant."' S A similar viewpoint was expressed by physicians at various university health centers. According to the NCMDA: A number of medical doctors who serve at
university health centers object strenuously to the marihuana phenomenon being labeled a "marihuana problem." They say that except for a minute number
of students who may use marihuana to excess or are harmed because of the impurity of the product resulting from a mixture with foreign substances, the use of marihuana generally has caused few health
problems.' 6
It seems more reasonable to expect our future health
professionals to accept the limited preventive goal recommended by the NCMDA. These recommendations included "a social control policy seeking to discourage marihuana use, while concentrating primarily on heavy and very heavy use" (more than once daily).2 This policy is to be implemented by educational programs on the part of health professionals, particularly physicians and health educators. The Commission called for realistic education including a truthful appraisal of the personal and public health risks involved in the use of marijuana and other drugs. But according to our survey results even this more limited goal may run into some difficulty since, in several instances, a number of our respondents seemed just as uninformed or misinformed about marijuana as anyone else. There has been so much deliberate misinformation and distortion on the marijuana issue that it was not very surprising to find inaccurate beliefs expressed by some of our respondents. But if these are the very people selected to dispense accurate information so that the public can make enlightened decisions, then, as a sine qua non we must require that these future drug educators be well informed themselves. We can profit from the unfortunate examples provided by the many school districts who feel called upon to present drug education programs. This task is frequently assigned to a teacher or school nurse, although many teachers and school nurses are not well prepared in this area. Nevertheless, they find themselves responsible for directing programs for which they have not received even the most minimal training. The NCMDA report makes mention of this problem in their contention that: Because most schoolteachers have a minimum knowledge about drugs, even the common selfadministered medicine cabinet variety, it may be presumptuous and counter-productive for them to conduct classes unless they are adequately prepared. Sufficient preparation is not acquired in attending a weekend workshop or listening to one expert give a two-hour lecture on his own specialty. Confronted with evidence of drug usage, the untrained classroom teacher frequently reacts in a negative and harmful manner. He assumes that marihuana and drugs are an unmitigated evil and he is fully aware that their use is illegal. As a result, he either tries to ignore the students' use of drugs or he adopts a hard intemperate attitude in trying to prevent their use.' 6
If he.dth professionals are expected to offer the public effective educational programs it is up to the schools of public heelth in our universities to supply adequate training in this area. According to the NCMDA, "While a number of schools have informal programs and conferences relating to drugs for both students and faculty, mainly infonnational, the Commission in its survey [of 13 university campuses] learned of no school which offered regular scheduled programs on marihuana or other drugs.",I16 Actually there are some programs currently being offered. For instance, the senior author and Dr. Donald Cahalan are presenting a year-long course funded by the National Institute of Mental Health on the subject of alcohol and other drugs. Nevertheless, the number of university-level drug education courses offered nationally are few and far between. Such courses should be presented on a more widespread basis and accordingly it is recommended that all schools of public health offer courses giving accurate drug education information presented as an essential part of public health training. In addition to much miseducation about drugs by school personnel, the vacuum in the drug education field has frequently been filled by agents of various law enforcement institutions. Drug programs emanating from these law enforcement sources have even more often been characterized by zealous but inaccurate and exaggerated reports which have proved ineffective in preventing drug abuse. For instance, consider the remarks by the Director of the Bureau of Narcotics and Dangerous Drugs to the California Peace Officers Association in May, 1972: If we lose in our efforts to keep these drugs from being legalized have we not lost altogether? We must become active spokesmen on these crucial issues. It is our duty not only to protect the public in the streets from these vicious criminals but to protect the public from harmful ideas when we clearly recognize them.' '
The American College Association in their position statement on drug abuse affirmed that guidelines for drug use were the responsibility of the health professions, and made a clear cut and necessary distinction between the proper role for health professionals and law enforcement agents in these matters: Controls appropriate for each "drug" can be established only on the basis of information from thoughtful and carefully controlled observations of its physical and emotional effects, not by hasty and a priori judgments based upon the fears of law enforcement agents or the opinions of others who assume responsibility for the orderliness of our college communities. Thus, it is a responsibility of the health professions to recommend appropriate regulations, not to enforce them; it is the responsibility of law enforcement agencies to enforce regulations, not to establish them.' 8
The public at large has grown increasingly resentful about being lied to, even when it may be done with the best of intentions. It is the responsibility of health professionals, among others, to remedy this situation, to provide accurate and truthful information, honestly informing the public of
the abuse potential involved in all varieties of drug use. The "demythologizing" of the drug question is but a beginning step which needs to be taken by public health professionals in meeting this important responsibility. One means of increasing public understanding would be to confront the fact that we are already a drug-oriented society. For example, a public drug education program could profitably analyze the way in which magazine advertisements, television commercials, and other mass media approaches are geared to promote a reliance upon various patent medicines and remedies. Increasing public awareness of the constant push to get them to depend upon such freely available substances as aspirin, Alka-Seltzer, Rolaids, Sominex, coffee, cola drinks, tobacco, and alcohol (not to mention prescription drugs) would help to place the drug use problem in its proper perspective. It would also illustrate the degree to which we are continually conditioned into believing that ingesting various chemical substances can improve our lives and fortunes. As a consequence of a melange of misinformation, the cornucopia of readily available and popularly consumed drugs, and the "scare" tactics used to "educate" youngsters about the dangers of drugs, many of our young people have become quite skeptical and cynical. Some of them tend to deny the very real abuse potential associated with the use of relatively dangerous drugs such as the opiates, amphetamines, and barbiturates. As a result of this kind of approach we have created a potentially disastrous "credibility gap" which can only be remedied by frankness and honesty. With the ever-increasing number of people ingesting a variety of drugs about which they know so little, the need for public health professionals to provide honest education in the drug use area is accentuated. One is reminded of a comment attributed to Gandhi. Looking from his window at the crowds surging by he is reported to have said, "I must hurry and catch up with them for I am their leader." To those of us in the public health professions the moral should be clear.
References 1. Committee on Problems of Drug Dependence, National Research Council, and Council on Mental Health and Committee on Alcoholism and Drug Dependence, American Medical Association. Marihuana and Society. J. A. M. A. 204:1181-1182, 1968. 2. First Report of the National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Stock 5266-0001, pp. 32-34, 79, 83-84, 87, 90-91, 134,150-154. U.S. Government Printing Office, Washington, DC, 1972. 3. Technical Papers: National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Appendix, Vol. I, Stock 5266-0002, p. 257. U.S. Government Printing Office, Washington, DC, 1972. 4. Mikuriya, T. H. Historical Aspects of Cannabis Sativa in Western Medicine. New Physician 18:902-908,
1969.
5. Weil, A. T., Zinberg; N. E., and Nelsen, J. M. Clinical and Psychological Effects of Marihuana in Man. Science 162:1234-1242,1968. PATTERNS OF MAR IJUANA USE
619
6. Marihuana and Health. A Report to the Congress from the Secretary, Department of Health, Education, and Welfare, p. 87. U.S. Government Printing Office, Washington, DC, 1971. 7. Grinspoon, L. Marihuana. Sci. Am. 221:17-25, 1969. 8. San Francisco Chronicle, p. 22. June 21, 1972. 9. 1972 American Medical Association Convention Daily Newsletter, San Francisco, 68:1, 1972. 10. American Institute of Public Opinion (Gallup). The Gallup Poll: Public Opposed to Legalizing Marijuana; Opinions Differ Sharply by Age, Region. Princeton, NJ, October 23, 1969. 11. American Institute of Public Opinion (Gallup). Gallup Opinion Index: Results of 1971 Survey of College Students. Princeton, NJ, February, 1972. 12. Green, E., and Blumberg, B. Boalt Hall Survey: Casing the Joint. University of California Boalt School of
Law, Berkeley, 1969. 13. Cohen, J. (ed.). The Essential Lenny Brucez, p. 149. Ballantine, New York, 1967. 14. Psychiatric News, p. 9. June 7, 1972. 15. San Francisco Chronicle, p. 10. November 13, 1969. 16. Technical Papers: National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding, Appendix, Vol. II, Stock 5266.0002, pp. 1202, 1205, 1206. U.S. Government Printing Office, Washington, DC, 1972. 17. Ingersoll, J. E. (Director, Bureau of Narcotics and Dangerous Drugs, U.S. Dept. of Justice). Presented to California Peace Officers Association, Anaheim, California, May 24, 1972. 18. American College Health Association. Position Statement on Drug Abuse, p. 2. American College Health Association, Evanston, IL, 1968.
APPENDIX A
MARIJUANA SURVEY QUESTIONNAIRE I nstructions The use of marijuana has become a major health issue. We feel that it is important to determine the opinions of a group of public health professionals in training conceming this issue. Accordingly, we request that you cooperate by answering the questionnaire below. All replies are ANONYMOUS and CONFIDENTIAL. Your participation is greatly appreciated.
1. How would you rank marijuana as a problem? ----equal to narcotics (e.g., heroin) ----equal to prescription drugs (e.g., tranquilizers) ----equal to tobacco or alcohol ----not a serious problem 2. Where did you get most of your information about marijuana? ----personal experience ----experience of others (e.g., clinical experience, experience of friends) ----communications media (e.g., radio, TV, magazines, newspapers) ----professional sources (e.g., conferences, clinicians, journals) 3. In your opinion, which of the following effects are produced by marijuana? Yes
Has habit-forming qualities (addictive) Potentially poisonous (due to its high toxicity) c. Decreases inhibitions d. Develops increasing tolerance to the drug e. Causes permanent mental disorders (e.g., insanity) f. Lowers achievement g- Provides unusual perceptual experiences (lightheadedness, time distortions) h. Increases aggressions i. Improves social interaction and sociability J. Increases sensitivity (e.g., to food, music, sex) k. Increases passivity 1. Worsens social relations m. Increases sexual desire n. Leads to other drugs (especially heroin) 0. Increases self-knowledge P. Leads to mental deterioration q. Any other effects (specify) 4. How do you feel about present marijuana laws? ----too strict ----not strict enough a. b.
620
AJPH JUNE, 1975, Vol. 65, No. 6
- - - -satisfactory
No
Don't Know
5. What position would you advocate concerning future marijuana laws? Not available legally under any circumstances a. ----b. Available by prescription only (and for medical research) Same availability and legal status as tobacco and liquor ----c. ----d. No restrictions on its use 6. What is your general attitude toward marijuana now? ----mixed feelings ----unfavorable ----favorable 7. How often have you used marijuana? ----never ----tried it a few times ----up to 3 times per week ----more than 3 times per week 8. (a) If you DO NOT use marijuana, and it were legalized, would you then use it? ----no ----undecided ----yes (b) If you DO use marifuana, and it were legalized, how would your pattern of usage change? ----remain unchanged ----decreased use ----increased use 9. Have your attitudes toward marijuana changed since you've been in the School of Public Health? ----yes, more favorable toward marijuana ----yes, less favorable toward mariJuana ----no, unchanged 10. If you have used marijuana, at what age did you first use it?---------11. Which of the following drugs have you ever used "recreationally" (i.e., not medically prescribed)? ----Cigarettes (nicotine) ----Amphetamines ("pep" pills) ----Opiates - ---Alcohol - ---Tranquilizers ----Mescaline ----Coffee (caffeine) ----LSD ----Sleeping pills ----Other (Specify) ----Cocaine 12. What percentage of public health students do you think have tried marijuana?----S% What percentage of law school students do you think have tried marijuana?----% 13. Do you think that marijuana has potential for medicinal purposes? ----don't know ----no ----yes (if yes, please specify below)
14. Do you think marijuana will be legalized within the next 5 years? ----no ----yes 15. What would you advocate as American policy in Vietnam? ----Increased military escalation ----Limited de-escalation ----Complete and immediate withdrawal 16. How do you feel about present abortion laws? Abortion should not be legalized ----a. Abortion should be legalized under certain extenuating circumstances ----b. ----c. Abortion should be legalized ----d. Abortion should be legalized and funded by the government 17. How do you feel about the Gay Liberation Movement? - --unfavorable ----undecided ----favorable ----Male Sex:----Female Age: Academic status: ----Student ----Faculty College major: Usual occupation: ----Foreign country Citizenship: ----U.S..A. Ethnic group (please specify): Estimate in which of the following social "class" category your parents would fall: - - --upper-middle class ----lower-lower class - - - -upper-lower class ----lower-upper class - - - -lower-middle class - ---upper-upper class ----middle-middle class Use the space below for any additional comments:
PATTERNS OF MARIJUANA USE
621
