Heart Failure Admissions Ran 3.7 Percent Higher for Every Year the West Sold Legal Pot

Colorado’s recreational retailers opened at 8 a.m. on New Year’s Day 2014, and one of the first customers at the 3D Cannabis Center in Denver was Sean Azzariti, a military veteran with PTSD who had campaigned for Amendment 64. He paid $59 for an eighth of an ounce of Bubba Kush and a cannabis-infused truffle. “Now I get to use recreational cannabis to alleviate my PTSD,” he told NBC News, while the cashier called the moment “pretty surreal.” The whole morning was framed as relief, for veterans like him and for a country tired of a prohibition that had failed on its own terms, and nobody at that counter was thinking about the cardiology ward.

Nearly thirteen years later, the receipts that matter are hospital discharge records. In a paper published October 22 in BMJ Open, a team led by S. D. Slavin reports that after recreational sales began in the Western states, admissions for three heart conditions rose faster there than in regions that had not legalized. After adjustment, each year of legal sales was associated with a 3.7 percent higher admission rate for heart failure, 3.1 percent for heart attack and 2.3 percent for atrial fibrillation, as the Epoch Times reported. Ischemic stroke, venous blood clots and ventricular tachycardia moved in the same direction without reaching statistical significance.

The data set is enormous: 50,042,564 discharges from the National Inpatient Sample between 2012 and 2018, from participating states that hold about 97 percent of the U.S. population, according to the BMJ Group’s release. The design is a difference-in-differences comparison. The Western region, thirteen states from Alaska to Wyoming, opened legal recreational sales in January 2014, almost five years ahead of any other region, and its trends were measured against regions that had not legalized, with 2012 and 2013 as the baseline. Patients admitted in the West were younger, 51 on average against 55, and more often came from higher-income ZIP codes, 26 percent against 19 percent. Before legal sales, the West had lower admission rates for these diagnoses than the comparison regions. After legal sales began, its rates climbed faster.

The region is a blunt instrument, and the authors say so. They could not separate individual states, which matters because seven of the thirteen (Arizona, Hawaii, Idaho, Montana, New Mexico, Utah and Wyoming) had no legal recreational sales at any point in the study window. Their answer is that by 2018 more than 98 percent of Western residents lived in or next to a state with legal sales, a fair point about how far people will drive for a dispensary, though it doesn’t tell you who used what. The records also can’t say whether any individual patient used cannabis, how or how much, and the analysis could not account for trends in illegal use. Because the West started from a lower rate, some of the climb could be a region catching up to the national level. The authors call the work observational and stop short of causation. In News-Medical’s summary they describe theirs as “the first study to examine the association with [cardiovascular] hospitalizations,” following earlier legalization research on psychiatric conditions, emergency visits and traffic crashes, and they conclude that the findings “point to potential adverse effects of recreation legalization on population health.”

The plant got stronger, and Marlboro got interested

Advocates had serious arguments in 2014, about arrests, about black-market product of unknown content, about adults choosing their own relief, and Azzariti’s was the most sympathetic of them. The industry that grew up behind those arguments drew a particular kind of investor. In December 2018, Altria, the Richmond company that makes Marlboro, agreed to put $1.8 billion into a 45 percent stake in the Toronto cannabis producer Cronos Group, with a warrant that could take it to 55 percent, Fox Business reported. When the company that spent decades selling Americans a smokable product with a cardiovascular death toll buys into the next smokable product, somebody ought to be asking what it does to the heart.

The product changed along the way. According to NIDA’s potency data, drawn from DEA and police seizures analyzed by the University of Mississippi, average THC content rose from 3.96 percent in 1995 to 11.92 percent in 2014, the year Azzariti made his purchase, then to 14.64 percent in 2018 and 16.14 percent in 2022. Seizure samples are not a census of dispensary shelves, and they leave out the concentrates and vapes that legal markets sell. Still, whatever the marketing copy says about a natural plant, it isn’t the same chemical product an earlier generation smoked.

Taken alone, the BMJ Open paper would be a population-level warning built on regional averages. It isn’t alone, and the individual-level evidence is more direct. A study of 434,104 adults in the CDC’s Behavioral Risk Factor Surveillance System, published in the Journal of the American Heart Association, found that daily cannabis use was associated with 25 percent higher odds of heart attack and 42 percent higher odds of stroke compared with non-use, after adjustment for tobacco use, age, diabetes, body mass and socioeconomic status. “We know that toxins are released when cannabis is burned, similar to those found in tobacco smoke,” lead author Abra Jeffers said in NHLBI’s announcement.

A 2025 meta-analysis in Heart by W. Storck and colleagues pooled 24 observational studies covering roughly 200 million people and found cannabis use associated with a 29 percent higher risk of acute coronary syndrome, a 20 percent higher risk of stroke and about twice the risk of cardiovascular death, according to News-Medical’s account. The authors were candid that most of the included studies carried a moderate to high risk of bias and measured exposure loosely, which is the honest condition of this whole literature. Older hospital data lean the same way with the same complications: a Cureus analysis of the 2003 to 2011 Inpatient Sample found marijuana use an independent predictor of stress cardiomyopathy (odds ratio 1.83) in patients who averaged 44 years old against 66 for non-users, though the users also smoked tobacco at far higher rates, 73 percent against 29 percent.

Cardiologists have seen this coming for a while. A 2020 review in the Journal of the American College of Cardiology estimated that more than 2 million Americans with established cardiovascular disease use or have used marijuana, urged screening for cannabis use especially in young patients presenting with heart disease, and noted that Schedule I classification had limited rigorous study of its cardiovascular effects. Nobody has run a randomized trial of years of daily, high-potency THC. What exists instead is a stack of population, survey and chart-level studies, each with its own blind spot, and none of them points toward harmless.

A scheduling decision without a scheduling procedure

That Schedule I barrier is now the subject of a federal fight. In December 2025, President Trump signed Executive Order 14370, Increasing Medical Marijuana and Cannabidiol Research, directing the Justice Department to take all necessary steps to complete rescheduling to Schedule III. A DEA final rule in April 2026 moved FDA-approved marijuana drug products and marijuana covered by a state medical license to Schedule III, according to Regulatory Oversight’s account of the docket, but it left open the separate question of rescheduling all marijuana, which went to merits hearings from June 29 to July 15.

The BMJ Open authors are not prohibitionists. “We believe our results support the proposed US federal reclassification of cannabis from Schedule I to the less-restrictive Schedule III to allow for research clarifying the CV effects of cannabis,” they wrote, as the Epoch Times reported, and they urged “a cautious approach to legalisation laws accompanied by data collection on CV outcomes.” That is more caution than the commercial market showed in the years their data cover. An administration that has promised to make Americans healthier should want the cardiovascular record in front of it before it decides the broader question, and it should be wary of an industry with Marlboro money in it pushing to get there first.

The broader question is on hold. On September 29, DEA Chief Administrative Law Judge Derek C. Julius stayed the proceeding after a motion from DUID Victim Voices, Dr. Kenneth Finn and the National Drug and Alcohol Association, who asked him to admit a new GAO report. That report, per Regulatory Oversight, found that the FDA lacks policies or procedures specifying how its staff should conduct scheduling evaluations, and that the DEA lacks policies identifying roles, responsibilities and procedures related to drug scheduling. The 50 million discharge records arrived 23 days into the pause. Whenever the hearing resumes, the agency deciding how dangerous marijuana is will be doing it without, by the GAO’s account, any written policy on how it decides how dangerous anything is.

Sources

1. BMJ Open: Slavin et al., cannabis legalisation and cardiovascular hospitalisations in the United States, 2012–2018 (2026)
2. BMJ Group’s release: US cannabis legalization linked to rise in cardiovascular hospital admissions, via EurekAlert (2026)
3. News-Medical’s summary: Study links recreational cannabis legalization to rising heart attack admissions (2026)
4. the Epoch Times reported: Increased heart hospitalizations linked to marijuana legalization (2026)
5. NHLBI’s announcement: Jeffers et al., Journal of the American Heart Association (2024)
6. News-Medical’s account: Storck et al. meta-analysis in Heart (2025)
7. review in the Journal of the American College of Cardiology: DeFilippis et al., Marijuana Use in Patients With Cardiovascular Disease (2020)
8. Cureus analysis: Modi, Singh and Shirani, Marijuana Use and Stress Cardiomyopathy in the Young (2021)
9. NIDA’s potency data: cannabis potency in DEA-seized samples, 1995–2022
10. Regulatory Oversight’s account of the docket: Pending marijuana rescheduling put on hold (2026)
11. Fox Business reported: Marlboro maker places $1.8 billion bet on marijuana (2018)
12. NBC News: Colorado’s legal recreational pot industry off to smoking start (2014)