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Twenty years ago, California became the first state in the nation to approve the use of marijuana for medical purposes.

On Tuesday, Californians voted to legalize it for recreational use — a move expected to reduce drug arrests, raise up to $1 billion in new tax dollars for the state and regulate a growing industry that has largely gone unchecked.

California was one of four states to approve recreational marijuana Tuesday, along with Nevada, Maine and Massachusetts. Four other states — Montana, Florida, Arkansas and North Dakota — voted to allow marijuana for medical use.

The number of states with laws permitting marijuana consumption underscores a national cultural shift toward wider acceptance of the drug, despite the existing federal prohibition and limited evidence on the public health impacts of legalization.

“More and more states are going to be passing these,” said Kevin P. Hill, an assistant professor of psychiatry at Harvard Medical School. “It is not an issue that is going away. … But we really need to address it in way that results in good policy.”

A Gallup poll last month showed that 60 percent of Americans believe marijuana should be legalized, up from 31 percent in 2000.

Consumption of marijuana has also increased steadily over the past decade, with more than 22 million Americans reporting they had used it in the previous month, according to the . It is the most commonly used illicit drug in the United States, and many Americans don’t believe it is harmful, according to the .

“There is no question that a majority of Americans now think that marijuana prohibition no longer makes sense,” said Ethan Nadelmann, executive director of the , which promotes legalization initiatives nationwide.

Nadelmann predicted the votes in California and elsewhere could accelerate the momentum to end marijuana prohibition federally, provided the incoming administration under Donald Trump doesn’t challenge state laws.

Opponents of legalization, including Kevin Sabet, an assistant professor of psychiatry at the University of Florida, have said the marijuana industry is profiting from addiction. Sabet said Wednesday that his organization, , would explore legal options against the industry. Legalization opponents have also raised money for a project to hold the industry accountable and empower cities to ban stores and cultivation sites.

With passage of the new ballot initiatives, there are now seven states, along with Washington, D.C., that allow marijuana for recreational use. Colorado, Washington, Oregon and Alaska already had permitted it before Tuesday’s election.

Beau Kilmer, a senior policy researcher at the in Santa Monica, said states are taking advantage of the Obama administration’s decision not to enforce the federal ban where it conflicts with local and state laws. The federal government has said it generally wouldn’t challenge state and local laws or prosecute marijuana businesses following those laws.

“You have got an administration that is willing to tolerate these experiments at a state level even though it’s illegal at a federal level,” Kilmer said.

Trump has indicated some support for medical use of marijuana, but he has not made clear what he thinks about states approving it for recreational use.

California’s initiative, Proposition 64, allows adults aged 21 and over to grow, buy and possess small amounts of marijuana for personal use. The initiative also regulates recreational marijuana businesses and imposes taxes, which will help pay for drug education and prevention programs. And the measure allows people serving time for certain marijuana convictions to petition for their sentences to be reduced.

The new law does include some restrictions, in addition to the age limit. It prohibits using marijuana in public and driving under the influence of it — though opponents of the measure noted that for marijuana-related DUIs yet exists. California residents can begin growing up to six plants immediately, but the state is not expected to begin licensing recreational marijuana businesses for more than a year.

Proposition 64 supporters argued the law would create a safe and legal system for adults to use marijuana while still protecting youths. Critics maintained that legalizing marijuana could increase traffic accidents, expand the black market and lead to widespread smoking ads on television.

California is considered a linchpin in the fight for legalization around the country, in part because of its large population, Nadelmann of the Drug Policy Alliance said. The fact that California voters approved it is “really monumental,” he said. “California is a national policy innovator and leader in the country.”

He said the California measure is unlike any other, because it integrates sentencing reform, social justice, youth protection, tax revenue allocation and public health. “It is hopefully a model for others nationwide,” he said.

The passage of Proposition 64 is not expected to increase the use of marijuana dramatically. Cannabis consumption is already largely mainstream and the rules governing the use of medical marijuana have been lax, said John Hudak, senior fellow at the .

“Because marijuana use is so pervasive for those who want to use it regularly, I can’t imagine Proposition 64 really changing that,” Hudak said. “Whoever wanted to access marijuana through a legal market [before the measure passed] … could do so.”

Mike Bertolina, 39, who lives in Los Angeles, got a medical marijuana card about a year and a half ago. He said the process was easy — and seemed a bit like “a joke.”

“The doctor had a stack of certificates on his desk,” said Bertolina. “He just basically stamped it and said, ‘Here you go.’” Bertolina said he primarily uses marijuana to relieve aches and pains.

He said he voted for Proposition 64 because he believes in the decriminalization of marijuana and in the tax revenue that it will bring to the state.

Public health officials and experts plan to monitor and study the impact of the new state law, paying attention to youth consumption, traffic safety and addiction.

So far, many of the public health and safety fears have not materialized where recreational marijuana is legal, said Hill, the Harvard Medical School professor who is author of the book, “Marijuana: The Unbiased Truth about the World’s Most Popular Weed.” He added that, “a lot of people predicted doomsday scenarios that haven’t really played out.” For example, there wasn’t a statistically significant increase in use by adolescents in Colorado after that state legalized marijuana, Hill said.

There has been a small spike in emergency department visits among children, he said, but the state addressed that by changing labeling and packaging to discourage accidental consumption.

Driving under the influence is still a concern for many people, as more states pass recreational marijuana laws. A report by the AAA Foundation for Traffic Safety found earlier this year that fatal crashes among drivers who recently used marijuana doubled in Washington after legalization. But Hill said there is no evidence that the drug led to the accidents. With increased use overall, it’s not surprising that more people in accidents have marijuana in their system, he said.

Hudak, the Brookings fellow, said states need to take safety and public health concerns into consideration, though they might not get their policies right on the first try. “It is incumbent on the state to recognize the risks,” he said. “Having a regulated system in place … is not necessarily a cure-all.”

Proponents of pot legalization say the medical marijuana movement has paved the way for lifting the ban on recreational use. More than two dozen states now allow patients to possess marijuana for medical purposes.

San Diego resident Starlight Mundy has held a medical marijuana card for the last two years, and she regularly uses cannabis to reduce anxiety and “take the edge off” after a long day, she said. Mundy voted for Proposition 64, saying she believes pot should be allowed not only for people with medical conditions.

Mundy hopes California’s new law will continue increasing acceptance of marijuana.

“This is not the finish line,” Mundy said. “But it is a big step that affects a lot of people who are not patients.”