Opinion
EDITORIAL
The Evolving Look and Vision of JAMA Pediatrics
Frederick P. Rivara, MD, MPH
The world of publishing, whether it is medical journals or the lay
press, is a rapidly evolving one, and we at JAMA Pediatrics and
The JAMA Network are dedicated to being at the forefront of
this evolution. This months issue represents the first major
redesign of the print journal in more than 2 decades. Starting
with the table of contents now appearing on the cover, the en-
tire journal format has been updated to improve the presen-
tation and readability both in print and on the web. Each is-
sue will lead with a highlights page, followed by opinion pieces
including viewpoints and editorials. Original investigations will
continue to make up the bulk of the journal. All of the jour-
nals in The JAMA Network share the same design, making it
easier for you to navigate and find what you want across these
journals.
As the oldest pediatric journal in the world (established in
1911), our vision is that JAMA Pediatrics will be the most-
respected source of information for investigators, health care
providers, and policy makers seeking the highest-quality evi-
dence to guide decision making. Our commitment to our read-
ers is clearly stated in our mission statement: JAMA Pediat-
rics seeks to provide state-of-the-art information to individuals
and organizations working to advance the health and well-
being of infants, children, and adolescents. The journal also
ARTICLE INFORMATION Corresponding Author: Frederick P. Rivara, MD,
Author Affiliation: University of Washington, Child MPH, University of Washington, Child Health
Health Institute, Seattle, Washington. Institute, 6200 NE 74th St, Ste 120B, Seattle, WA
98115-8160 (fpr@u.washington.edu).
Effects of Marijuana Policy on Children and Adolescents
Sharon Levy, MD, MPH
In this issue of JAMA Pediatrics, Wang et al1 report a spike in mari-
juana ingestion among children in Colorado, a state that legal-
ized medical marijuana in 2000 and 1 of the 2 states that legal-
ized marijuana use in November.
The finding reignites the debate
Editorial page 602 over whether and how legalized
marijuana impacts children and
adolescents. The question is criti-
Related article page 630
cally important to the public. A
nationally representative household survey conducted in 2011
found that adults rated drug abuse as the number one health
concern for youth, tied only with obesity, among a list of 23
health concerns.2 Reducing adolescent drug use remains a fix-
ture of Healthy People, the blueprint that guides the govern-
ments health priorities. As a nation, we are clearly invested in
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provides a forum for discussion of the most important issues
and policies affecting child and adolescent health and health
care. JAMA Pediatrics will use the most current technology to
make timely information available to readers wherever and
whenever it is needed.
Providing this information in as accessible and readable a
form as possible will occur through both our print and digital
publications. As part of The JAMA Network, we have a rede-
signed website that through semantic tagging allows readers
to search content not only within JAMA Pediatrics but also
across the 10 journals of The JAMA Network. The new app pro-
vides users with the content of the entire JAMA Network on
virtually any device or platform. We will also use social me-
dia to foster conversations about topics important to the health
and health care of children both here in the United States and
abroad.
As pediatricians, we revel in observing and are fascinated
by the growth and development of the children and adoles-
cents for whom we care. With its name change, more attrac-
tive style, new technologies, and closer relationship with other
journals in The JAMA Network, JAMA Pediatrics too is an evolv-
ing, dynamic entity that generates a similar sense of excite-
ment.
Conflict of Interest Disclosures: None reported.
preventing and reducing drug use by our children. Debates over
marijuana policy frequently center on the concern that legal-
ization will increase adolescent use by a combination of reduc-
ing perceived harm, increasing supply or access, and market-
ing of marijuana, which could affect adolescent behavior even
if campaigns are targeted at adults. The wealth of data on mari-
juana use rates has been used by marijuana legalization propo-
nents and opponents alikeeach side weaving the same num-
bers into a different storysomehow leaving the public
underinformed even as the public is increasingly being called
on to decide whether to legalize marijuana.
One approach to assessing the impact of legalizing mari-
juana is to compare use rates before and after a ballot initia-
tive passes. To date, 18 states have passed laws legalizing medi-
cal use of marijuana for adults, beginning with California in
jamapediatrics.com
 Editorial Opinion

1996. Data from before and after are available from the Center
for Disease Control and Prevention Youth Risk Behavior Sur-
vey for 13 of these states.3 None of these states found a sig-
nificant rise in adolescent marijuana use within 2 to 3 years fol-
lowing passage of the medical marijuana laws. But these data
are hardly reassuring. It can take many years for a newly passed
ballot initiative to mature into a fully operating system of mari-
juana dispensaries and even longer until this system can im-
pact adolescents. In fact, Youth Risk Behavior Survey data are
not available for California, a state with some of the most no-
table marijuana marketing and distribution systems. Passing
a law to legalize marijuana may not lead to a rise in adoles-
cent use, but these data do not assess the impact of a fully es-
tablished marijuana marketing and distribution system.
A recent study found that rates of marijuana use by 12- to
17-year-olds were higher, and perceived risk of harm lower, in
states that passed medical marijuana laws between 2002 and
2008.4 This study did not account for baseline marijuana rates,
and it is plausible that states with more liberal cultural atti-
tude toward marijuana use would both have higher baseline
use rates and be more likely to pass a medical marijuana law.
In fact, 8 of the states included in the analysis had higher than
average baseline rates of adolescent marijuana use. While this
study may also fall short of assessing the impact of legalizing
marijuana, it does confirm a basic and familiar principle: ado-
lescents are responsive to the cultural attitudes around them;
those who live in areas that condone marijuana use are more
likely to use marijuana themselves. It is simply unreasonable
to speculate that a policy that increases use of marijuana by
adults would not also increase adolescent use.
One trend is very clear: nationwide rates of adolescent
marijuana use are climbing rapidly. Between 2008 and 2011,
rates of lifetime marijuana use rose by 21% and past-year mari-
juana use rose by 31%, surpassing tobacco. Nine percent of teens
in grades 9 to 12 use marijuana daily or nearly every day, an
increase of 80% compared with 2008.5 Likely driving these in-
creases are declines in the perceived risk of harm that has been
associated with the national conversation regarding legaliza-
tion; specifically, some/many legalization proponents por-
tray marijuana use as harmless, ignoring a growing body of lit-
erature linking marijuana use in adolescence to mood,6,7
anxiety,8 and thought disorders9,10 as well as an association
with neurocognitive decline over time.11
Legalization proponents have been outspoken and seem
to have struck a chord with parts of the populationballot ini-
tiatives that legalize marijuana use by adults passed easily in
both Colorado and Washingtonand it seems that a segment
of the electorate wants unimpeded access to marijuana for
adults. This presumably will increase adult use and may well
increase adolescent marijuana use in those states. New laws
leave several loose ends for legislators to grapple with, such
as developing a definition for driving while impaired absent a
reliable biomarker and lack of information specifying safety
thresholds for secondhand smoke on bystanders, especially
children. The public health community needs to be vigilant for
unintended consequences of legalized marijuana, such as in-
creased ingestion by children as reported by Wang et al.1 Un-
fortunately, as with tobacco, some of the most significant health
consequences will likely take years to manifest.
In the meantime, we can inform the public about the
known harms of marijuana even in states where use has been
made legal. This has been happening with tobacco. While rates
of adolescent tobacco use remain unacceptably high, they have
fallen dramatically since their peak in 1996.12 It is nearly im-
possible to be sentient in 2013 and not know about the health
consequences of tobacco. Anecdotally, nearly all of the pa-
tients treated in the Adolescent Substance Abuse Program at
Boston Children's Hospital who use tobacco would like to quit
because of health concerns, while few adolescents can under-
stand why we advise them to stop using marijuana. The sky-
rocketing rates of adolescent marijuana use indicate that we
are losing an important public health battle and we have a lot
of work to do if we want to reverse these trends. Physicians
have a key role to play in educating our young patients and their
families about the health consequences of marijuana use re-
gardless of its legal status.

ARTICLE INFORMATION
Author Affiliations: Department of Pediatrics,
Harvard Medical School, Boston, Massachusetts
(Levy); Division of Developmental Medicine and
Center for Adolescent Substance Abuse Research,
Boston Childrens Hospital, Boston, Massachusetts
(Levy).
Corresponding Author: Sharon Levy, MD, MPH,
Division of Developmental Medicine, Children's
Hospital Boston, Harvard Medical School, 300
Longwood Ave, Boston, MA 02115 (sharon.levy
@childrens.harvard.edu).
Published Online: May 27, 2013.
doi:10.1001/jamapediatrics.2013.2270.
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Wang GS, Roosevelt G, Heard K. Pediatric
marijuana exposures in a medical marijuana state
[published online May 27, 2013]. JAMA Pediatr.
2013;167(7):630-633.
2. University of Michigan C. S. Mott Children's
Hospital. Drug abuse now equals childhood obesity
as top health concern for kids. http://www
.uofmhealth.org/news/top-ten-national-poll-0815.
Published August 15, 2011. Accessed April 25, 2013.
3. Youth online: high school YRBS. United States
2011 results. Centers for Disease Control and
Prevention website. http://apps.nccd.cdc.gov
/youthonline/App/Default.aspx. Accessed February
6, 2013.
4. Wall MM, Poh E, Cerd M, Keyes KM, Galea S,
Hasin DS. Adolescent marijuana use from 2002 to
2008: higher in states with medical marijuana laws,
cause still unclear. Ann Epidemiol. 2011;21(9):
714-716.
5. The Partnership at DrugFree.org; MetLife
Foundation. The Partnership Attitude Tracking
Study: 2011 parents and teens full report.
https://www.metlife.com/assets/cao/foundation
/PATSFULL-ReportFINAL-May.pdf. Published May
2, 2012. Accessed April 25, 2013.
6. Degenhardt L, Hall W, Lynskey MT. Exploring the
association between cannabis use and depression.
Addiction. 2003;98(11):1493-1504.
7. de Graaf R, Radovanovic M, van Laar M, et al.
Early cannabis use and estimated risk of later onset
of depression spells: epidemiologic evidence from
the population-based World Health Organization
World Mental Health Survey Initiative. Am J
Epidemiol. 2010;172(2):149-159.
8. Patton GC, Coffey C, Carlin JB, Degenhardt L,
Lynskey M, Hall W. Cannabis use and mental health
in young people: cohort study. BMJ.
2002;325(7374):1195-1198.
9. Bossong MG, Niesink RJM. Adolescent brain
maturation, the endogenous cannabinoid system
and the neurobiology of cannabis-induced
schizophrenia. Prog Neurobiol. 2010;92(3):
370-385.
10. Sugranyes G, Flamarique I, Parellada E, et al.
Cannabis use and age of diagnosis of schizophrenia.
Eur Psychiatry. 2009;24(5):282-286.

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 Opinion Editorial
11. Meier MH, Caspi A, Ambler A, et al. Persistent 12. Johnston LD, O'Malley PM, Bachman JG,
cannabis users show neuropsychological decline Schulenberg JE. Monitoring the Future National
from childhood to midlife [published online August Results on Adolescent Drug Use: Overview of Key
27, 2012]. PNAS. doi:10.1073/pnas.1206820109.
Anticipated Medical Effects on Children From Legalization
of Marijuana in Colorado and Washington State
A Poison Center Perspective
William Hurley, MD; Suzan Mazor, MD
On November 4, 2012, Amendment 64 passed in Colorado and
Initiative 502 passed in Washington State to legalize the pos-
session of small amounts of marijuana and marijuana-related
products by adults. Possession by anyone younger than 21 years
and the growing of marijuana without authorization remain
illegal in both states. In Colorado, adults are permitted to pos-
sess up to 1 oz of marijuana or 6 marijuana plants. In Wash-
ington, adults are permitted to possess up to 1 oz of mari-
juana, 16 oz of marijuana-infused product in solid form, 72 oz
of marijuana-infused product in liquid form, or any combina-
tion of all 3. The possession of marijuana remains illegal un-
der federal law and marijuana remains a Schedule I agent un-
der the Drug Enforcement Administration.
The medical use of marijuana and marijuana-infused prod-
ucts is legal in 18 states and the District of Columbia. Seven ad-
ditional states are considering legalization of medical mari-
juana. The medical use of marijuana has been legal in Colorado
since 2009.
In this issue, Wang et al1 describe an increase in cases of
accidental ingestion of marijuana by children after decrimi-
nalization of medical marijuana in Colorado. Marijuana in-
gested by the majority of the children described in the article
was in the form of a food prod-
uct. The medical marijuana in-
Editorial page 600 dustry provides attractive and
palatable marijuana-infused
Related article page 630 solid and liquid products, includ-
ing cookies, candies, brownies,
and beverages. The legalization of recreational marijuana, es-
pecially the solid and liquid-infused forms permitted in Wash-
ington, will provide children greater access to cookies, can-
dies, brownies, and beverages that contain marijuana.
Ingestion of marijuana results in the absorption of
delta-9-tetrahydrocannibinol (THC) and stimulation of can-
nabinoid receptors in the central nervous system. This pro-
duces stimulation with hallucinations and illusions, fol-
lowed by sedation.2 Toxic reactions are usually mild after
acute accidental ingestion but can cause significant seda-
tion in children.3 Respiratory insufficiency and the need for
ventilatory support are described in the article. In older chil-
dren, the stimulatory phase and hallucinations can produce
anxiety and panic episodes when not anticipated in an acci-
dental ingestion. The potency of marijuana in the United
States has progressively increased over the past 40 years,
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Findings, 2011. Ann Arbor: Institute for Social
Research, the University of Michigan; 2012.
with THC levels climbing from around 2% to nearly 8%.4
The risk of significant toxic reactions from exposures is
more likely today than in the past.
Emergency medicine, pediatric emergency medicine, and
primary care pediatric providers will be first to see patients ac-
cidentally exposed to marijuana. They may need additional
training to recognize and manage significant marijuana toxic
reactions. Signs and symptoms can include anxiety, halluci-
nations, panic episodes, dyspnea, chest pain, nausea, vomit-
ing, dizziness, somnolence, central nervous system depres-
sion, respiratory depression, and coma.5 Similar signs and
symptoms occur in a large variety of diseases and poisonings.
The providers and staff should investigate the availability of
marijuana in the childs environment and use rapid tests to
identify the metabolites of marijuana in the urine.6 No anti-
dote exists for marijuana toxic reactions and supportive care
should be provided, including control of anxiety, control of
vomiting, airway control, and ventilation as needed. The re-
gional Poison Center should be contacted to report the epi-
sode and obtain additional advice on evaluation and manage-
ment.
Increased accidental exposure after increased availabil-
ity of an agent is a consistent lesson in toxicology. Our cur-
rent increase in laundry-pod ingestion in children is the re-
sult of increased availability coupled with attractive packaging.7
The ready availability of pain medications led to opioids sur-
passing motor vehicle crashes as the leading cause of acciden-
tal death in the United States. This profound poisoning prob-
lem went unrecognized for nearly a decade and has only
recently come to the attention of health care providers and
policy makers.8 A recent analysis of Poison Center data shows
a parallel increase in severe poisonings, emergency depart-
ment visits, and hospitalizations in children.9 A similar rise in
marijuana exposure and toxic reactions is anticipated from the
increased availability of marijuana in the childs environ-
ment. Timely analysis of Poison Center data and emergency
department records will provide an opportunity to quickly rec-
ognize and respond.
Intervention strategies in Washington State have begun to
reduce the death rate from opioid exposure. These were mod-
eled on successful interventions in poison prevention and in-
clude public education on the risks of opioid use, provider edu-
cation on safe prescribing practices, prescription monitoring
programs, and home naloxone hydrochloride programs.10,11
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