Chapter 8: Public Health

Vital Statistics

Overview

Vital statistics are the official records of life events that are essential for understanding population health, growth, and demographics. These statistics are collected by government agencies to track key events in a population over time.

Key Types of Vital Statistics

• Births
  • Total live births
  • Birth rates by age, location, marital status
• Deaths
  • Total deaths
  • Causes of death
  • Mortality rates (e.g., infant mortality, age-specific death rates)
• Marriages
  • Number of marriages
  • Marriage rates
  • Age at marriage
• Divorces
  • Number and rate of divorces
  • Duration of marriages
• Fetal Deaths (Stillbirths)
  • Deaths of fetuses at 20+ weeks gestation
• Abortions (in some jurisdictions)
  • Voluntary pregnancy terminations
  • Abortion ratios and rates

Why Vital Statistics Matter in Healthcare

• Guide public health policy and planning
• Track disease trends and health risks
• Allocate resources for maternal and child health
• Inform epidemiological studies and health research
• Support population projections and emergency planning

Sources of Vital Statistics

• Local and state health departments
• Vital records offices
• Centers for Disease Control and Prevention (CDC) – National Center for Health Statistics (NCHS)
• World Health Organization (WHO) for global data

Birth Records

What They Include

Full name of child; date and place of birth; sex of the child; parent(s)’ names and addresses; birth certificate number; attending physician or midwife.

Uses

Legal proof of identity, age, and citizenship; enrollment in school, voting, and passports; public health tracking (e.g., birth rates, infant health); population planning and demographic research.

Filed By

Hospital, birthing center, or midwife; sent to the state vital records office.

Death Records

What They Include

Full name of deceased; date and place of death; cause(s) of death; certifying physician or coroner; age, sex, race, occupation, marital status.

Uses

Legal proof for wills, insurance, and estates; public health monitoring (e.g., mortality rates, disease trends); epidemiological studies and health planning; tracking leading causes of death and life expectancy.

Filed By

Certifying medical personnel or coroner; funeral director submits to state vital records office.

Where Records Are Kept

State or local vital records offices; indexed by the National Center for Health Statistics (NCHS); access may be restricted for privacy reasons.

Who Can Sign a Death Certificate?

1. Attending Physician — Most common certifier if the patient died under medical care; must have recent knowledge of the patient’s health condition; signs the cause of death portion of the certificate.
2. Hospital Medical Officer — In hospitals, hospitalists or medical residents may sign under attending supervision; must be authorized under hospital policy.
3. Medical Examiner or Coroner — Required if the death is sudden, unexpected, violent, or suspicious; also signs in cases of accidents, suicides, homicides, or no recent medical history; may perform autopsies to determine cause of death.
4. Physician Assistant (PA) or Nurse Practitioner (NP) — In some states, may be allowed to complete the certificate under physician delegation; state law and facility policy determine eligibility.

Special Cases Requiring a Coroner or Medical Examiner: No attending physician; death under unusual, traumatic, or criminal circumstances; death in custody or public institution; death occurring at home without medical supervision.

Key Notes: The funeral director completes demographic sections, but only a medical professional can certify the cause of death. All death certificates must be filed with the state or local vital records office within a legally specified timeframe (often 72 hours).

Core Public Health Functions

The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) identify three core functions of public health, each supported by essential services.

Assessment

Involves gathering and analyzing health data to understand community health needs.

• Monitor health status to identify problems
• Diagnose and investigate health hazards
• Conduct surveys, screenings, and surveillance (e.g., COVID-19 tracking)

Policy Development

Uses data to create public policies and interventions that protect health.

• Inform, educate, and empower the public
• Develop community partnerships
• Create laws, guidelines, and health programs
• Promote evidence-based solutions (e.g., tobacco restrictions, vaccination plans)

Assurance

Ensures services are available, accessible, and high quality for the population.

• Enforce health regulations (e.g., restaurant inspections, quarantine laws)
• Link people to healthcare services
• Train and certify the public health workforce
• Evaluate effectiveness and improve health programs

The 10 Essential Public Health Services

1. Assess and monitor health status
2. Investigate and diagnose health problems
3. Inform and educate the public
4. Strengthen community partnerships
5. Develop policies and plans
6. Enforce public health laws
7. Ensure access to care
8. Maintain a competent workforce
9. Evaluate health services
10. Innovate through research

Reportable Diseases and Injuries

Reportable conditions are diseases, infections, or injuries that healthcare providers, labs, or other authorities are legally required to report to public health agencies.

Purpose of Reporting

Detect and control outbreaks; protect the public from threats (e.g., TB, STIs, COVID-19); monitor trends and plan interventions; comply with state and federal public health laws.

Examples of Reportable Diseases and Injuries

Infectious Diseases:

• COVID-19
• Tuberculosis (TB)
• HIV/AIDS
• Hepatitis A, B, and C
• Measles, Mumps, Rubella
• Meningitis
• Gonorrhea, Syphilis, Chlamydia
• Pertussis (Whooping Cough)
• Salmonella, E. coli (foodborne illnesses)

Occupational and Environmental Exposures:

• Lead or mercury poisoning
• Pesticide exposure
• Work-related illnesses (e.g., asbestosis, silicosis)

Injuries and Violence:

• Gunshot wounds
• Stabbings
• Burn injuries
• Suspected child or elder abuse
• Sexual assault or rape
• Certain workplace injuries (OSHA-reportable)

Who Must Report and Where

Who Must Report: Physicians; hospitals and clinics; laboratories; schools and child care centers; employers (in some cases).

Reporting is Mandatory and Time-Sensitive: Some diseases (like measles or meningitis) require immediate notification; others may be reported within 1–7 days depending on jurisdiction.

Where to Report: Local or state public health departments; some cases go to the CDC or national surveillance systems.

Immunization Programs, Liability, and State Policy

National Childhood Vaccine Injury Act of 1986 (NCVIA)

Purpose: Compensate individuals harmed by certain vaccines; protect vaccine manufacturers and providers from liability; maintain public confidence in vaccination programs; establish a streamlined system for reporting, reviewing, and responding to vaccine injuries.

Key Components:

1. National Vaccine Injury Compensation Program (VICP) — A no-fault alternative to the traditional legal system; individuals can file claims for compensation if they believe a vaccine caused injury or death; funded by a $0.75 tax per vaccine dose.
2. Vaccine Injury Table — Lists covered vaccines and recognized injuries with time frames; if an injury listed occurs within the timeframe, it is presumed to be caused by the vaccine.
3. Vaccine Adverse Event Reporting System (VAERS) — Co-managed by CDC and FDA; requires healthcare providers to report certain adverse events; collects national data on vaccine safety and side effects.
4. Informed Consent Requirement — Providers must give patients (or parents) a Vaccine Information Statement (VIS) before each dose of a covered vaccine; VIS includes information about risks, benefits, and what to do in case of adverse effects.

Legal Protections: Vaccine manufacturers and providers are shielded from liability in most cases; civil lawsuits may only proceed if the VICP process is exhausted first.

Vaccines Covered (examples): DTaP/Tdap; MMR (Measles, Mumps, Rubella); Hepatitis B; Polio; Varicella (chickenpox); HPV; Influenza (injection), and others.

National Vaccine Injury Compensation Program (VICP)

Established: 1988, under the National Childhood Vaccine Injury Act of 1986.

Purpose: To provide a no-fault alternative to traditional legal action for individuals who suffer an injury or death caused by certain covered vaccines.

Why It Was Created: Prevent vaccine shortages caused by lawsuits against manufacturers; encourage continued vaccine production; maintain public trust in vaccines; compensate individuals fairly without needing to prove negligence.

How the VICP Works:

• Filing a Petition — Injured party (or their legal guardian) files with the U.S. Court of Federal Claims; must be filed within 3 years of injury or 2 years of death.
• Medical Review — Reviewed by medical experts from Health Resources and Services Administration (HRSA).
• Hearing and Decision — Special masters determine eligibility and compensation; if criteria are met, compensation is awarded.
• Funding — Paid from the Vaccine Injury Compensation Trust Fund, funded by a $0.75 tax per vaccine dose.

Types of Compensation: Medical and rehabilitative care; lost wages; pain and suffering (up to $250,000); death benefits (if applicable).

Covered Vaccines Include: DTaP / Tdap; MMR (Measles, Mumps, Rubella); Polio; Hepatitis A and B; HPV; Influenza (injectable); COVID-19 (currently handled under a separate program, CICP).

Advantages: No need to prove fault or negligence; faster, less adversarial than court; fair compensation and due process.

Smallpox Emergency Personnel Protection Act (SEPPA) of 2003

Purpose: To provide compensation and protection to healthcare workers and emergency personnel vaccinated against smallpox as part of a national bioterrorism preparedness plan.

Why It Was Passed: In response to the threat of bioterrorism after 9/11; the U.S. government launched a voluntary smallpox vaccination program; concerns arose over risks to vaccinated individuals and lack of legal protection.

Key Features of SEPPA:

1. Compensation for Injury or Death — Covers medical expenses, lost income, and death benefits for vaccinated individuals and their close contacts; claims reviewed by the U.S. Department of Health and Human Services (HHS).
2. Legal Liability Protections — Protects healthcare entities and personnel from lawsuits related to smallpox vaccination injuries.
3. Who Is Eligible? — Healthcare workers; public health and emergency responders; volunteers participating in approved vaccination programs.
4. Time Limits: — Claims must be filed within 1 year of the date the person knew (or should have known) they were injured.

Related Law: SEPPA complements the Public Readiness and Emergency Preparedness (PREP) Act, which provides broader liability protection for public health emergencies.

Recommended Vaccines for Children and Adolescents

The American Academy of Pediatrics (AAP) recommends a comprehensive immunization schedule to protect children and adolescents from various preventable diseases. These recommendations are developed in collaboration with the Centers for Disease Control and Prevention (CDC) and are updated annually to reflect current scientific evidence.

Recommended Vaccines (birth through 18 years):

• Hepatitis B (HepB)
• Rotavirus (RV)
• Diphtheria, Tetanus, and Acellular Pertussis (DTaP)
• Haemophilus influenzae type b (Hib)
• Pneumococcal conjugate (PCV13)
• Inactivated Poliovirus (IPV)
• Influenza (Flu)
• Measles, Mumps, and Rubella (MMR)
• Varicella (VAR)
• Hepatitis A (HepA)
• Tetanus, Diphtheria, and Acellular Pertussis (Tdap)
• Human Papillomavirus (HPV)
• Meningococcal conjugate (MenACWY)
• Serogroup B Meningococcal (MenB)
• COVID-19

The specific timing and number of doses for each vaccine are outlined in the official immunization schedule. For the most current and detailed information, please refer to the AAP’s official immunization schedule (publications.aap.org).

State-Level Vaccination Laws in the U.S.

While federal agencies like the CDC and AAP provide immunization recommendations, states hold legal authority over most vaccination requirements and policies.

What State Vaccination Laws Cover:

1. School and Childcare Entry Requirements — States require children to be vaccinated against diseases such as MMR, DTaP, Polio, Varicella, and Hepatitis B to attend public and private K–12 schools and preschools/childcare facilities.
2. College and Healthcare Worker Requirements — Many states require college students and healthcare employees to be vaccinated (e.g., MMR, meningococcal, influenza, COVID-19).
3. Exemptions Allowed by States
   • Medical Exemptions (allowed in all 50 states)
   • Religious Exemptions (allowed in many states)
   • Philosophical/Personal Belief Exemptions (allowed in fewer states)
   • Exemption rules vary by state.
4. Documentation and Enforcement — Parents must submit official immunization records or exemption forms; schools often report compliance rates to state health departments.

Examples of State Differences:

State	Religious Exemption	Philosophical Exemption	Strict Enforcement?
California	No	No	Yes
Texas	Yes	Yes	Less strict
New York	No	No	Yes
Florida	Yes	No	Moderate

Emergency and Public Health Authority: States can mandate vaccines during emergencies (e.g., outbreaks, pandemics). They may issue temporary vaccination orders for school closures, quarantines, or exclusions.

Current events: According to the Centers for Disease Control (CDC)’s website, as of May 29, 2025, there have been almost 1100 cases of measles reported in the United States. There have been cases reported in 33 of the 50 states. Of those cases, 96% were either unvaccinated or their vaccination status was unknown. There have been 3 confirmed deaths. The epicenter of the outbreak was a community in West Texas where there is a large population of children who are unvaccinated.

When 95% or greater members of a community are vaccinated, most people are protected by herd immunity. In the 2019–2020 school year, 95.2% of incoming kindergarteners were vaccinated with the Measles, Mumps and Rubella (MMR) vaccine. By the 2023–2024 school year, that percentage had dropped to 92.7% of incoming kindergarteners. This means that over 250,000 kindergarteners are susceptible to the measles virus.

Reportable Injuries in Healthcare and Public Health

Reportable injuries are injuries that, due to their public safety, legal, or public health implications, must be reported to appropriate government or law enforcement agencies.

Category	Examples	Reported To
Violent Injuries	Gunshot wounds, stab wounds, blunt force trauma	Law enforcement
Abuse	Suspected child abuse, elder abuse, domestic violence	Child Protective Services or APS
Burn Injuries	Large, suspicious, or chemical/explosion-related burns	Fire marshal, law enforcement
Sexual Assault	Rape, sexual battery, related trauma	Law enforcement and victim services
Workplace Injuries	Amputations, crush injuries, chemical exposure	OSHA
Infectious Exposure	Needlestick injuries with exposure to HIV/HBV/HCV	Hospital infection control, public health department
Poisoning or Overdose	Drug overdoses (opioids), toxic exposures	Poison control, health departments
Deaths from Injury	Any death due to trauma, suspected crime, or unknown cause	Coroner/medical examiner

Why Reporting Is Required: To ensure public safety and legal accountability; to activate protective services for vulnerable populations; to enable epidemiologic surveillance of violence and occupational hazards. In some states, failure to report is a criminal offense.

Who Must Report: Physicians and nurses; hospitals and clinics; emergency responders; school officials (in child-related cases); employers (for OSHA-reportable injuries).

Abuse Reporting and Related Federal Laws

Child Abuse Prevention and Treatment Act (CAPTA)

Originally Enacted: 1974. Latest Reauthorization: Most recently amended by the CAPTA Reauthorization Act of 2010 (additional updates ongoing).

Purpose: Provide federal funding and guidance to states for prevention, identification, and treatment of child abuse and neglect; develop protective systems, reporting protocols, and data collection; improve child welfare services.

Key Provisions:

1. Definition of Child Abuse and Neglect — “Any recent act or failure to act on the part of a parent or caregiver, which results in death, serious physical or emotional harm, sexual abuse or exploitation.”
2. Mandatory Reporting Requirements — All states must have laws requiring certain professionals (e.g., healthcare providers, teachers, social workers) to report suspected child abuse; CAPTA mandates immunity from liability for good-faith reporting.
3. State Grant Requirements — States must appoint a Child Protective Services (CPS) agency; establish citizen review panels; ensure confidentiality protections; have provisions for investigation and intervention.
4. Focus on Prevention and Training — Provides grants for community-based prevention programs; funds education and training for child welfare professionals; encourages multidisciplinary approaches.
5. Data Collection — Supports national systems like the National Child Abuse and Neglect Data System (NCANDS); collects data on reports, investigations, outcomes, and services provided.

Reauthorizations Expanded CAPTA to Include: Infants affected by prenatal drug exposure; enhanced services for children with disabilities; addressing human trafficking of children.

Elder Abuse Reporting in Healthcare

What Is Elder Abuse? Intentional or negligent acts by a caregiver or other person that cause harm or risk of harm to an older adult (typically age 60+).

Types of Elder Abuse:

Type	Examples
Physical abuse	Hitting, pushing, improper restraint
Emotional abuse	Threats, humiliation, isolation
Sexual abuse	Non-consensual sexual contact or harassment
Neglect	Failing to provide food, hygiene, medications
Financial abuse	Stealing money, forging checks
Abandonment	Desertion by caregiver

Who Must Report? Under state mandatory reporting laws, healthcare professionals such as physicians, nurses, medical assistants, caregivers, social workers, hospital administrators, home health aides, and long-term care staff are typically required to report suspected elder abuse.

What Must Be Reported? Any reasonable suspicion or evidence of abuse, neglect, or exploitation. Proof is not required — a good-faith report is sufficient.

When and How to Report: Immediately or within 24–48 hours (varies by state). Contact Adult Protective Services (APS); Long-Term Care Ombudsman (for nursing homes); local law enforcement for immediate danger or criminal behavior. Some states require written reports in addition to verbal ones.

Legal Protections: Reporters are protected by immunity laws if they report in good faith. Failure to report can lead to civil or criminal penalties.

Domestic Abuse Reporting in Healthcare

What Is Domestic Abuse? Also called intimate partner violence (IPV), includes physical, sexual, emotional, and financial abuse between people in a current or former intimate relationship.

Forms of Domestic Abuse:

Type	Examples
Physical Abuse	Hitting, slapping, choking, restraining
Emotional Abuse	Threats, intimidation, gaslighting
Sexual Abuse	Forced sex, unwanted touching
Economic Abuse	Controlling money, withholding financial access
Psychological Control	Isolation, constant monitoring, verbal threats

Healthcare Providers’ Responsibilities:

• Required to Screen: Many hospitals and clinics follow Joint Commission standards requiring routine IPV screening; screening should be private, trauma-informed, and non-judgmental.
• Required to Document: Document patient statements and observed injuries in medical records; use objective language and include photos (with consent).

Mandatory Reporting: Varies by state.

State Policy	What’s Required
Some states	Mandatory reporting of injuries caused by weapons or abuse
Others	No reporting unless the patient consents
All states	Reporting required if children, elders, or vulnerable adults are at risk

Legal and Ethical Duties: Encourage help (safety planning, hotline info); maintain confidentiality unless required by law; know your state’s reporting laws.

Unborn Victims of Violence Act (UVVA)

Also known as: “Laci and Conner’s Law.” Signed into law: April 1, 2004.

Purpose: Recognize an unborn child as a separate legal victim when injured or killed during the commission of certain federal violent crimes.

Key Provisions:

1. Legal Status of the Unborn Child — Defines an “unborn child” as “a child in utero, meaning a member of the species Homo sapiens, at any stage of development, who is carried in the womb.” Grants independent victim status in federal criminal cases.
2. Scope of Application — Applies to federal crimes of violence including assault, murder, kidnapping; crimes on federal property; crimes involving interstate commerce.
3. Penalties — Offenders can be charged separately for harm done to the pregnant individual and the unborn child; if the unborn child dies, the charge may be fetal homicide; no requirement to prove intent to harm the fetus.
4. Exclusions — Does not apply to legal abortion; does not apply to medical treatment of the pregnant woman or fetus; exempts actions by the pregnant person.

Context and Controversy: Sparked national debate about fetal rights vs. reproductive rights; supported by advocates for victims of violence and unborn children; opposed by some who argue it could affect abortion access and personhood laws.

Identifying Abuse: A Guide for Professionals

Abuse can affect individuals of any age and often occurs in private settings, making detection and intervention critical. Abuse may be physical, emotional, sexual, financial, or take the form of neglect.

General Signs of Abuse:

Type of Abuse	Possible Indicators
Physical	Unexplained bruises, burns, fractures; frequent injuries; fearful of touch
Emotional/Psychological	Depression, anxiety, withdrawal, low self-esteem, overly apologetic
Sexual	Genital pain, STIs, inappropriate sexual knowledge (especially in children), fearful behavior
Neglect	Malnutrition, poor hygiene, unattended medical needs, unsafe living conditions
Financial	Sudden bank changes, missing belongings, unpaid bills, unusual gifts to caregivers

Clues From Behavior and Interaction: Caregiver speaks for patient or prevents answers; patient appears nervous or intimidated; delay in seeking care for injuries; frequent missed appointments or vague explanations; victim may deny or minimize harm.

At-Risk Populations: Children and teens; elderly individuals or those with disabilities; intimate partners (IPV survivors); non-English speakers or isolated individuals; those dependent on others for care or housing.

What to Do If You Suspect Abuse: Document clearly and factually (objective terms, visible injuries, quote patient when possible); ask safely and privately (trauma-informed, non-judgmental language); report according to state law (mandatory reporters include healthcare providers, teachers, social workers); report to Adult or Child Protective Services, law enforcement, or appropriate agency; offer support resources (hotlines, safety planning, referral to social work).

Federal Drug Regulations

Overview of Major Federal Drug Laws

Federal drug laws are designed to ensure that prescription and non-prescription drugs are safe, effective, and properly used. These laws cover manufacturing, distribution, prescribing, and dispensing.

1. Food, Drug, and Cosmetic Act (FDCA) – 1938 — Administered by the U.S. Food and Drug Administration (FDA); requires that all drugs be safe and properly labeled; drugs must be approved by the FDA before marketing; FDA can recall unsafe drugs and regulate labeling.
2. Controlled Substances Act (CSA) – 1970 — Administered by the Drug Enforcement Administration (DEA); classifies drugs into five schedules (I–V) based on abuse potential and medical use; regulates prescribing, storage, and record-keeping of controlled substances.
3. Drug Listing Act – 1972 — Requires manufacturers to register all marketed drugs with the FDA; each drug assigned a unique National Drug Code (NDC).
4. Prescription Drug Marketing Act (PDMA) – 1987 — Prohibits re-importation of U.S.-made drugs by anyone other than the manufacturer; regulates drug samples, hospital repackaging, and wholesaler licensing.
5. Drug Supply Chain Security Act (DSCSA) – 2013 — Creates a system to track and trace prescription drugs through the U.S. supply chain; designed to prevent counterfeit or contaminated drugs from reaching patients.
6. FDA Modernization Act – 1997 — Streamlined clinical trials, labeling, and drug approvals; expanded off-label use communications between manufacturers and providers.

Additional Oversight Agencies: FDA (safety, approval, labeling, recalls); DEA (controlled substances and prescribing laws); FTC (advertising of over-the-counter drugs).

Controlled Substances Act (CSA)

Enacted: 1970. Administered by: U.S. Drug Enforcement Administration (DEA).

Purpose: Regulate the manufacture, importation, possession, use, and distribution of certain substances based on medical use and potential for abuse or dependence.

Schedule	Examples	Medical Use?	Abuse Potential
I	Heroin, LSD, MDMA, cannabis*	No accepted use	High
II	Oxycodone, fentanyl, Adderall, Ritalin	Severe restrictions	High (severe dependence)
III	Ketamine, anabolic steroids, codeine combinations	Accepted use	Moderate to low
IV	Xanax, Ativan, Valium	Accepted use	Low
V	Cough preparations with codeine, Lomotil	Accepted use	Very low

*Marijuana remains a Schedule I drug under federal law but is legal for medical/recreational use in many states.

Key Provisions:

1. Registration Requirements — Prescribers, pharmacists, manufacturers, and researchers must register with the DEA and follow documentation and storage rules.
2. Recordkeeping and Inventory — Controlled substances require detailed logs, inventories, and audit trails; records must be kept for at least 2 years.
3. Prescription Rules — Schedule II: no refills; written/e-prescribed (except emergencies). Schedules III–V: refillable up to 5 times within 6 months.
4. Security Measures — Store controlled substances in locked, secure cabinets; subject to inspections by the DEA or state boards.

Penalties for Violations: Civil fines and criminal prosecution for unlawful prescribing, dispensing, or diversion; penalties vary by schedule and quantity.

Marijuana Legalization in the United States: A 2025 Overview

Marijuana legalization in the U.S. involves a complex and evolving landscape of state laws, federal restrictions, and public policy debates.

Federal Law (Still in Effect): Marijuana is a Schedule I controlled substance under the CSA; illegal to possess, distribute, or cultivate under federal law (even in states where legal). Federal enforcement is limited in legalized states but not eliminated.

State-Level Legalization (as of 2025):

Recreational (Adult-Use) Marijuana Legalized in 24+ States — Legal for adults (typically 21+), with possession limits and in some states home cultivation.

State	Recreational Use	Medical Use	Notes
Alaska	Yes	Yes	Legalized recreational use in 2014
Arizona	Yes	Yes	Legalized recreational use in 2020
California	Yes	Yes	First state to legalize medical marijuana in 1996
Colorado	Yes	Yes	Among the first to legalize recreational use in 2012
Connecticut	Yes	Yes	Recreational sales began in 2022
Delaware	Yes	Yes	Recreational use legalized in 2023
Illinois	Yes	Yes	Recreational sales began in 2020
Maine	Yes	Yes	Recreational use legalized in 2016
Maryland	Yes	Yes	Recreational use legalized in 2022
Massachusetts	Yes	Yes	Recreational sales began in 2018
Michigan	Yes	Yes	Recreational use legalized in 2018
Minnesota	Yes	Yes	Recreational use legalized in 2023; sales expected to begin in 2025
Missouri	Yes	Yes	Recreational use legalized in 2022
Montana	Yes	Yes	Recreational use legalized in 2020
Nevada	Yes	Yes	Recreational sales began in 2017
New Jersey	Yes	Yes	Recreational sales began in 2022
New Mexico	Yes	Yes	Recreational use legalized in 2021
New York	Yes	Yes	Recreational use legalized in 2021
Ohio	Yes	Yes	Recreational use legalized in 2023
Oregon	Yes	Yes	Recreational sales began in 2015
Rhode Island	Yes	Yes	Recreational use legalized in 2022
Vermont	Yes	Yes	Recreational sales began in 2022
Virginia	Yes	Yes	Possession legalized in 2021; retail sales pending
Washington	Yes	Yes	Among the first to legalize recreational use in 2012
Washington, D.C.	Yes	Yes	Possession and cultivation legal; sales not permitted

Medical Use Only (15 States):

State	Recreational Use	Medical Use	Notes
Alabama	No	Yes	Medical use legalized in 2021
Arkansas	No	Yes	Medical use legalized in 2016
Florida	No	Yes	Medical use legalized in 2016; recreational legalization failed in 2024
Georgia	No	Yes	Limited medical use; low-THC oil permitted
Hawaii	No	Yes	Medical use legalized in 2000
Iowa	No	Yes	Limited medical use; low-THC products permitted
Kentucky	No	Yes	Medical use legalized in 2023
Louisiana	No	Yes	Medical use legalized in 2015
Mississippi	No	Yes	Medical use legalized in 2022
Nebraska	No	Yes	Medical use legalized in 2024; implementation pending
New Hampshire	No	Yes	Medical use legalized in 2013
North Dakota	No	Yes	Medical use legalized in 2016
Oklahoma	No	Yes	Medical use legalized in 2018
Pennsylvania	No	Yes	Medical use legalized in 2016; recreational legalization under consideration
South Dakota	No	Yes	Medical use legalized in 2020

Fully Illegal (No Legal Use) (6 States):

State	Recreational Use	Medical Use	Notes
Idaho	No	No	No legal use; strict laws in place
Indiana	No	No	No legal use; limited CBD use permitted
Kansas	No	No	No legal use; discussions ongoing
North Carolina	No	No	No legal use; advisory council formed to consider legalization
South Carolina	No	No	No legal use; medical legalization efforts ongoing
Texas	No	No	No legal use; limited CBD use permitted

Decriminalization vs. Legalization: Decriminalization reduces penalties for possession but does not legalize sale/use; legalization permits possession, use, and regulated sale under state law.

Key Issues in Legalization:

Area	Considerations
Public Health	Risk of youth use, impaired driving, cannabis use disorder
Economy	Tax revenue, job creation, cannabis industry growth
Criminal Justice	Reduction in marijuana arrests, efforts to expunge past convictions
Regulation	Licensing, quality control, marketing restrictions, potency limits
Employment	Workplace drug policies still apply in most states