Interviewed by Kimberly Dennis, MD, CEDS

Featured expert on marijuana, drug policy, substance use and addiction treatment.

Kevin A. Sabet, PhD
Fellow, ISPS, Yale University
President and CEO, Smart Approaches to Marijuana (SAM)
President and CEO, Foundation for Drug Policy Solutions (FDPS)
Author, Smokescreen: What the Marijuana Industry Doesn’t Want You to Know (Forefront, Simon & Schuster)

Tell me about the drug policy project you and Patrick Kennedy started, when, why, and how has it helped? 

Patrick Kennedy and I co-founded Smart Approaches to Marijuana (SAM) in 2013, recognizing the need for a non-partisan drug policy organization to educate Americans on the misconceptions surrounding marijuana and its policy choices. We were concerned, and still are, with a false dichotomy that forces us into a choice between criminalization and legalization/commercialization. Since then, SAM has become a leading voice in the conversation about the health-related harms of marijuana. We’ve also taken an active role in opposing the industry-backed ballot measures to legalize marijuana and successfully defeated four of the last six. SAM has grown over the years and now has a sizable team of full-time staff members who work on federal and state-level issues. 

Following the success of SAM, Patrick and I, along with a leadership council also launched the Foundation for Drug Policy Solutions in late 2022. Unlike SAM’s narrower focus on marijuana, this organization focuses on the impacts of all illicit drugs and advocates for prevention, treatment, and recovery. 

We see so many more young people with Cannabis Use Disorders that the total number of underage users must have skyrocketed in Illinois. Is there any way to know whether that is true or not? 

According to the National Survey on Drug Use and Health, the percentage of 12–17-year-olds in Illinois who were past-month users of marijuana increased from 7.01% in 2018-2019 to 8.78% in 2021. Among those between the ages of 18 and 25, the percentage increased from 21.74% to 27.42%. We think these numbers, in all honesty, just scratch the surface. There have also been decreases in the perceived risks of marijuana among youth and young adults in Illinois, which is a predictor of use. Though the state-level report doesn’t specify cannabis use disorder, the increase in past-month use, which is indicative of more frequent use, paired with decreasing risk perceptions, suggests that there was an increase in cannabis use disorder in Illinois following legalization. 

Daily use of cannabis among middle school and high school-age children has also increased. Many of them say they smoke during school or before and after school. How is this possible? 

Many kids now favor the use of marijuana-infused vapes because they can be easily concealed and mask the smell better than traditional joints. Because of this, some students like to use them in their school’s bathrooms, as we saw with the nicotine vaping crisis a few years ago. It’s not surprising that some students get high before or after school, just as many adults get high before or after work. It’s also worth noting that many of these individuals likely have a cannabis use disorder and have an increased likelihood of being lifelong users. Gone are the days of irregular use where an individual may use marijuana once a month at a party on the weekend.

We have found that early use, regular use, and high-dose use cause addictions in addiction medicine. For cannabis, are all 3 contributing to the epidemic of CUD? 

Yes, the earlier one initiates marijuana use, the more likely they are to develop a cannabis use disorder. Given that use peaks in the early 20s, if an individual does not use marijuana by then, they are unlikely to ever do so. Similarly, daily users and those who favor the use of high-potency products are at an increased risk of developing cannabis use disorder. This last point is being driven by the for-profit marijuana industry, which has been producing and promoting stronger strains of marijuana and stronger concentrated products, including vapes and dabs. 

Some parents have said that cannabis is harmless or safer than alcohol, which is also illegal and ill-advised for underage use. What would you say to these parents? 

Though alcohol causes more deaths each year than marijuana, it does not mean that marijuana is safe or harmless. Of course, the healthiest option is not to use any substance. Like alcohol, marijuana use can have a negative impact on learning, brain development, and poses increased risks for impaired driving. States that have legalized marijuana have seen increases in traffic accidents and fatalities involving impaired driving after legalization. Additionally, unlike alcohol, marijuana poses unique harm to an individual’s mental health, including by increasing the likelihood of developing depression, anxiety, psychosis, and schizophrenia. 

Our city is progressive and seemed to believe that cannabis restrictions were regressive and legalization progressive. How would you counter that argument? 

Unfortunately, those are the terms set by this billion-dollar movement to commercialize addiction. If one looks objectively, they’d find that legalization has had numerous unintended consequences and has perhaps been most harmful to low-income communities and racial minorities. That is why we are proud to partner with the NAACP of Illinois, and its President, Teresa Haley, to get the word out. But the bullying and intimidation still remain. Though certain advocates were especially concerned about public health during the pandemic, many of these same individuals and news outlets have been oddly quiet about the adverse effects of marijuana. 

Cannabis use is commonly associated with what medical, psychiatric, educational, and social consequences? 

Marijuana users are nearly 25% more likely to be hospitalized than non-users. As I mentioned before, marijuana is also associated with depression, anxiety, psychosis, and schizophrenia. We’ve also seen that most individuals with other substance use disorders, such as opioids or cocaine, first began their drug use with marijuana. The impairment associated with marijuana also threatens an individual’s productivity and ability to perform at school or work. 

Now that Illinois has legalized, what would you suggest a parent should do? 

Parents should be aware of the health-related risks of marijuana and discourage their child’s use. They should also know that the products have changed. Though marijuana flower averaged 1-3% THC in the 1990s, it’s now 15-20%. It’s also sold in vapes that are often above 90%. Parents should recognize that occasional use can quickly progress into a cannabis use disorder, also known as addiction to marijuana. The 2021 National Survey on Drug Use and Health found that 46% of past-year users between the ages of 12 and 17 had a cannabis use disorder, which is a shocking number and the highest of any age group. 

How many children reject all substances and are non-users? Is there a way to help them grow in % of the class? 

Only 10.5% of 12–17-year-olds used marijuana in 2021, meaning that nearly 90% of kids didn’t try marijuana even once at any point in the year. Only 5.8%, or approximately 1 in 17, were past-month marijuana users. The numbers are even lower for tobacco and all other illicit drugs. Youth are slightly more likely to use alcohol at some point in the year, at 17.8%, but that still indicates the overwhelming majority of kids choose not to drink. Some may feel that “everyone does it,” or that they need to do it to be cool, but it’s worth reminding them that most kids choose not to use drugs, alcohol, or tobacco. It’s also important for them to find like-minded friends who also avoid these substances and support healthy lifestyles.

Opioid use disorder (OUD) is a major public health threat, posing risks to morbidity and mortality from addiction, overdose, and related medical conditions. While many have embraced harm reduction approaches and mocked Mrs. Reagan’s “Just Say No” or vilified DARE and related prevention-focused policies, deaths from drug overdoses in 1982 were only 2,862 compared to > 110,000 in 2022. How would you explain this to parents and their children? 

Part of the reason we’re here is the rampant, reckless prescribing of opioids in the late 90s and early 2000s. The opioid epidemic decimated communities, normalized drug use, and paved the way for stronger opioids to take over the drug supply. We didn’t get here because of illegal drugs, but because of legal drugs.

Part of the issue is that the illicit drug supply has changed. Fentanyl, a synthetic opioid, is 50-100x stronger than heroin and contributes to a majority of overdose deaths. This drug is being laced with other drugs, including cocaine and heroin, as well as fake prescription pills. Someone may intend to take a Xanax they bought online and die because it was unknowingly laced with fentanyl. The purity of cocaine and meth has also increased, just as it has for the potency of marijuana. Simply, today’s drugs are much more deadly than they used to be. Given this, prevention-focused messages are now more important than ever because one wrong pill can result in death. We need societal-wide messages that discourage initiation, urge people to get help if they have started to use, and celebrate and promote recovery. Tens of millions of people who have recovered from addiction are a testament that no matter how devastating this disease is to you or your family, hope is possible. This is the kind of thing that keeps me going every day.

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