Nebraska voters overwhelmingly approved medical marijuana Tuesday while the neighboring Dakotas rejected broader legalization efforts.

The Nebraska medical initiatives passed decisively with Initiative 437 securing 70.7% approval and Initiative 438 garnering 66.9% support, according to Associated Press election results. The companion measures will allow patients to use marijuana with a doctor’s recommendation while creating a state commission to regulate production and sales.

“Today’s decision marks the end of unnecessary delays and the beginning of a modern medical cannabis program,” said John Mueller, CEO of Greenlight Dispensary, which heavily backed the Nebraska campaign. The company operates dispensaries across several Midwestern states.

BREAKING: Nebraska has voted to legalize medical cannabis!

— Marijuana Policy Project (@MarijuanaPolicy) November 6, 2024

Dakotas

However recreational marijuana faced stronger opposition in the Dakotas. North Dakota voters rejected Measure 5 by 52.5% with 99% of the votes in as of press time, marking the state’s third failed attempt at adult-use legalization since 2018. Similar efforts saw defeats in 2022 and 2018, though the state did approve medical marijuana in 2016.

South Dakota also rejected Initiated Measure 29, with 56.5% voting against allowing adults 21 and older to grow, possess and distribute cannabis. That’s now the third failed attempt at recreational legalization, following a 2022 measure that gained only 47% support and a 2020 initiative that passed but was later overturned through a lawsuit backed by Gov. Kristi Noem.

“While we respect the voters’ decision, this was a missed opportunity,” said Mueller, whose company also runs four dispensaries in South Dakota. “The illicit market will persist, depriving the state of tax revenue and leaving consumers without tested, regulated products.”

The results came shortly after Florida voters rejected recreational marijuana despite majority support. The measure gained 55.9% approval but soundly fell short of the 60% threshold needed for constitutional amendments. Florida giant Trulieve Cannabis Corp. (OTC: TCNNF), which bankrolled the effort, poured over $140 million in what became the most expensive legalization campaign to date. Operators will now focus on the medical-only market in the meantime.

For well over a decade now, cannabis legalization efforts via state ballots – whether medical or recreational – have seen great success. But starting on Tuesday, that track record may be in danger. There’s a decent chance that most – if not all – of the legalization questions this year will fail, potentially stalling political momentum for the cannabis industry.

The reasons are multifold, but a primary one is that there are few states remaining that have petition systems under which independent campaigns can put forth ballot questions to voters. Only 26 states have such mechanisms. In the other 24 – including Illinois, New York and several others that have already legalized recreational cannabis – the only way to change state laws is by lobbying the legislature.

That’s also a reason why many red states have not yet legalized; they have to wait for state lawmakers to act.

This year, it’s a handful of conservative states that reliably lean Republican that will have cannabis on the ballot. Florida, North Dakota and South Dakota will vote on recreational marijuana legalization, with Nebraska voting on medical. (A ballot question to expand Arkansas’ medical marijuana program was invalidated by the state Supreme Court.)

Both polling and history may be working against the cannabis questions.

Florida

In Florida – the most expensive and high-profile of the campaigns – marijuana also has the highest threshold to pass: 60% of voters because the measure amends the state constitution. Polls in recent months have shown support as high as 67% and as low as 49%, with the most recent two pegging support right at 60%. That means Election Night could be a nail-biter for supporters.

The measure also has a high-profile opponent. Gov. Ron DeSantis has gone to war against the amendment, although former President Donald Trump has expressed his support for it, meaning it’s even harder to tell where most voters will come down on the issue.

The first time that medical marijuana was on the Florida ballot, in 2014, it failed to pass, despite winning almost 58% of the vote. Two years later, cannabis activists succeeded and won with more than 71% support.

The Dakotas

In the Dakotas, history and politics are arguably even more stacked against marijuana supporters, with both states hoping third time’s the charm for adult-use legalization.

In North Dakota, the recreational cannabis question, Measure 5, polled at just 45% support as of September, with 40% of participants opposed and another 15% undecided, a survey by North Dakota News Service Cooperative found. The question only needs a simple majority to pass, but the campaign follows on the heels of back-to-back defeats in 2022 and 2018, when 55% and 59% of voters respectively rejected adult-use legalization.

North Dakota was, however, part of a green wave in 2016 (along with Florida) in which voters approved medical marijuana.

In South Dakota, state voters made political history in 2020 with the approval of two cannabis ballot questions at once – one to legalize medical and the other to legalize recreational, a victory that had never before been achieved by marijuana activists.

But while the medical initiative was implemented, the recreational one was overturned by a lawsuit brought by marijuana opponents, with the support of GOP Gov. Kristi Noem. A second attempt at the ballot box in 2022 lost with just 47% support from voters.

This time around, recreational cannabis supporters still have their work cut out for them, according to several polls. An Emerson College survey last month found 45% of voters supporting the question, while 50% are opposed and just 4% are undecided. An earlier poll conducted in May found 42% support, 52% opposed and 7% undecided.

Nebraska

Nebraska may be a bright spot this year, if the polls are to be believed. Voters there have a pair of cannabis questions to weigh: Initiative 437, which would legalize marijuana possession and consumption for medical purposes, and Initiative 438, which would establish a regulatory system for cannabis businesses. An Emerson College poll in September and October found solid 59% support for Initiative 437.

But like Arkansas, Nebraska’s campaign could lose on a legal technicality. As of Friday, a trial is underway in the state to determine whether the marijuana campaign used “fraudulent” means to qualify for the ballot, putting the fate of the initiatives in question.

A new report from the National Academies of Sciences, Engineering, and Medicine called for urgent federal action on U.S. cannabis policy, warning that state-level legalization efforts prioritize commercial interests over public health.

The government-sponsored study found that cannabis use has increased in many populations, a result of public perception of risk declining and availability surging. In 2022, more people reported daily or near-daily cannabis use than daily alcohol use.

In addition, the THC concentration in products, which researchers identified as one of the greatest public health issues related to cannabis, has markedly increased as well. And this is where policy often falls short.

“Cannabis policy often focuses on regulating sales and revenue first, and protecting public health second,” said Steven Teutsch, chair of the committee behind the report and senior fellow at the University of Southern California’s Schaeffer Center for Health Policy and Economics.

Setting standards

The vast majority of U.S. states have legalized cannabis for adult or medical use, and because of the continued federal illegality and lack of interstate commerce options, this industry has evolved under a patchwork of regulations.

Despite that, the report says the federal government “could assist those states that have chosen to legalize.”

Specifically, the study said the Centers for Disease Control and Prevention should draw on existing tobacco and alcohol policies to develop best practices for protecting public health in states with legal cannabis, including “marketing restrictions, age restrictions, physical retail and retail operating restrictions, taxation, price restrictions, product design, and measures to limit youth access.”

The recommendations also call on state cannabis regulators to adopt and enforce the quality standards being developed by the U.S. Pharmacopeia to ensure product safety.

“Once the Centers for Disease Control and Prevention’s best practices have been developed, they should be incorporated into the model legislation,” the report says.

The study also addresses the hemp industry and recommends that Congress refine the definition of the plant to close loopholes that have led to “a booming industry … for largely unregulated hemp-derived products, which competes with legal cannabis markets.”

The committee suggested a definition that clearly states that no form of tetrahydrocannabinol or semisynthetic cannabinoid derived from hemp is exempt from the Controlled Substances Act.

Establishing safeguards

“A federal public health campaign targeting those most at risk of the negative impacts of cannabis would go a long way toward supporting public health,” said Yasmin Hurd, the committee’s vice chair and director of the Addiction Institute at Mount Sinai.

At the same time, the study points to a lack of safeguards against lobbying and raises concerns about “revolving-door practices” and financial entanglements between regulators and the industry in some states. Researchers cited examples where lobbying efforts in Washington state and Colorado blocked attempts to limit THC concentration and restrict pesticide use.

Economist Boyoung Seo, who has studied cannabis markets in Colorado and Washington, recently told Green Market Report that states face a complex balancing act between generating revenue and mitigating negative societal effects.

“The fact that each state has different regulatory entities or authorities that govern the marijuana market probably also shaped how marijuana is regulated,” Seo said.

Because of the vast differences between state markets, the report noted that the CDC should undertake efforts to track the impacts of state legalization. The committee suggested that creation of a public health surveillance system to monitor cannabis sales, use patterns and health impacts. It also emphasized the need for more research into cannabis and more support from federal agencies to assess how state and local cannabis regulations influence public health outcomes and health equity.

The report was sponsored by several federal health agencies including the Centers for Disease Control and Prevention and the National Institute on Drug Abuse.