Analysis of Child Mortality Following State Legalization of Recreational Cannabis

Background: Marijuana sales are prohibited at a federal level, but state-level policies differ. Some states allow recreational marijuana sales while other states enforce prohibition of all marijuana sales. States with legalized marijuana have seen an increase in adult marijuana use and pediatric exposures to marijuana. We sought to determine if there were differences in non-natural deaths among children < 19 years of age between states with recreational marijuana sales verses states with where marijuana sales are prohibited.

Methods: In this cross-sectional study using the CDC Detailed Mortality file for 2016 - 2018, we compared non-natural deaths (accidental, homicidal, suicidal, and undetermined) among children < 19 years of age between states where recreational marijuana sales are legal (Colorado, Washington, Alaska, Oregon) and states where marijuana sales are completely prohibited (Virginia, North/South Carolina, Indiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Texas, Missouri, Iowa, Wisconsin, Nebraska, Kansas, South Dakota, Wyoming, Utah, Idaho). Negative binomial regression was used to model the outcome of death (treated as a count) with year, legal status, and the interaction of the two. High-school graduation rates, unemployed, insurance status, and median household income were covariates controlled for in the model as these are associated with pediatric mortality. A marginal model was constructed for population-level inferences and a mixed-effects model, with a random intercept for state, was constructed for state-level inferences.

Results: There were a total of 24,033 deaths during the study time period across the study states. Adolescents 15 – 19 years of age accounted for the highest proportion of deaths (49.5%) with 23.6% of deaths occurring in children under 1 year of age. Across all age groups, 48.3% of deaths were accidental in nature. In the unadjusted marginal model, the incidence rate ratio (IRR) of non-natural death in recreational verses prohibition states was 0.75 (CI 0.52-1.09) in 2016, 0.84 (CI 0.59-1.21) in 2017, and 0.80 (CI 0.55-1.15) in 2018. After adjusting for the aforementioned covariates, the adjusted IRR of non-natural death in recreational states verses prohibition states was 0.75 (CI 0.57-0.98) in 2016, 0.83 (CI 0.64-1.09) in 2017, and 0.80 (CI 0.62-1.04) in 2018.

Conclusion: Pediatric non-natural deaths are not greater in states with legalized recreational marijuana. Results are limited by the small number of states with recreational marijuana sales and the overall small number of pediatric deaths. Repeated exploration is warranted as more states begin to legalize recreational marijuana sales.