Scientific evidence and public acknowledgement of the harms and failure of cannabis prohibition have been increasing in recent years, along with support for cannabis legalization. What is missing from the public and scientific debate, however, is a discussion about the relative merits of different regulatory frameworks. This paper aims to inform the debate by offering a proposal for cannabis regulation derived from evidence-based, public health–oriented recommendations for alcohol and tobacco. The public health evidence base for cannabis regulation as an alternative to prohibition is limited, whereas there is a substantial body of evidence on the public health effects of tobacco and alcohol control strategies. With this in mind, we examined international syntheses of evidence-based recommendations for alcohol and tobacco regulation to identify options with proven public health benefits. We describe a model for regulating cannabis to control availability and accessibility; purchase, consumption, and use; supply; and drivers of demand. This model could be researched to evaluate its applicability in a public health–based strategy for cannabis regulation. Because public support for cannabis legalization is growing, proactive and rigorously evaluated action using a public health approach needs to be taken. Otherwise, a commercial exploitation model may result in health and social problems similar to those associated with alcohol and tobacco.
"What is missing from the public and scientific debate, however, is a discussion about the relative merits of different regulatory frameworks."
Mark Haden, MSW, is Adjunct Professor at the University of British Columbia School of Population and Public Health and former Clinic Supervisor of the Raven Song Community Health Centre, Vancouver Coastal Health, Vancouver, BC. Brian Emerson, MD, MHSC, is Chair of the Psychoactive Substances Committee, Health Officers Council of British Columbia, and Medical Consultant with the Population and Public Health Division, BC Ministry of Health, Victoria, BC.
There is growing evidence and awareness that the prohibition of cannabis is not achieving its purported objective of reducing use and potential harms, and instead has had considerable adverse consequences.(1,2,3) Uruguay, Colorado, and Washington State are jurisdictions where regulatory regimes not based in criminal law have recently been established for cannabis. However, there is widespread uncertainty regarding the potential benefits and harms of a non-prohibition–based regulatory framework for cannabis. This paper addresses this uncertainty by proposing a public health–oriented model for cannabis regulation that is derived from evidence-based recommendations for public health approaches to alcohol and tobacco control.
Lessons learned from alcohol and tobacco control: a proposed regulatory model
A large body of research on alcohol- and tobacco-control measures to protect public health has been distilled in two key international evidence-based documents: Alcohol: No Ordinary Commodity, by Babor and colleagues(4) and the WHO Framework Convention on Tobacco Control (FCTC).(5) Drawing upon these sources, we constructed comparative tables organized according to the public health–oriented regulatory framework for psychoactive substances proposed by the Health Officers Council of British Columbia.(6) This framework proposes controls with respect to availability, accessibility, supply, purchase, consumption, and use, as well as measures to reduce demand.
Tables 1 through 4 list evidence-based regulatory strategies for alcohol and tobacco from Babor and colleagues(4) and the FCTC5; these recommendations are also summarized in Box 1. In this article, we examine how these measures could be applied to cannabis. Where there are gaps in the regulatory recommendations, we propose measures that would be consistent with the objective of protecting public health.
Availability and accessibility
Control structure. Experience has shown that a government monopoly can be effective in limiting alcohol consumption and related harms by (1) reducing the profit motive to promote sales and thereby encourage consumption; (2) reducing the political influence of special interests that would benefit from relaxed restrictions on availability; (3) limiting the number of sales outlets and their hours and days of business; and (4) having better-trained staff to reduce the likelihood of sales to minors.(7) (See Table 1.)
We suggest that jurisdictions develop similar legislation and regulatory oversight with respect to cannabis, such as by establishing a governing body (e.g., a provincial “Cannabis Control Commission”) with a clear mandate explicitly guided by public health goals. Generating government revenue should not be a primary driver of the policies of such a commission, which should operate at arm’s-length from government to allow for stability and clarity of focus, to provide insulation from industry influence, and to resist the pressures of revenue-generation imperatives that would undermine the protection of public health.
The commission would control cannabis production, packaging, distribution, retailing, and revenue allocation and would play an important role in reducing demand. Processing and packaging would be done according to set standards in commission-licensed facilities. Direct sales from producers to retailers or consumers would not be allowed.
Provision to consumers. Cannabis would be sold only through commission-operated or licensed outlets explicitly designed and required by law to support public health objectives. To minimize cannabis promotion, a standardized, neutral (i.e., bland-looking) and non-promoting environment for cannabis sales would be required. The clustering of cannabis outlets would not be allowed, as an aggregate presence could have undesirable effects on neighbourhoods, and outlets would be prohibited within 500 metres of a school, playground, or alcohol retail outlet.
Health promotion messages would be prominently displayed, and would include information about the laws against and risks of driving or operating heavy machinery while intoxicated. Information and referral mechanisms for cannabis dependency treatment would also be standardized and prominently displayed.
In line with evidence in relation to alcohol on the effectiveness of restricting the hours of sale (see Table 1), the hours of business of cannabis outlets would be limited.
Price. There is strong evidence that taxation and price are important elements of a strategy to reduce alcohol consumption and tobacco use (see Table 1). Pricing and taxation policy should be balanced to establish a pricing structure that competes with the illegal market and allows for the needs of patients using cannabis for therapeutic purposes, while ensuring a sufficiently high price to restrict youth access and limit overall consumption.
Purchase, consumption, use
Purchase. A minimum purchase age for alcohol and tobacco products has been found to be an important strategy for controlling these substances (see Table 2). Similarly, the model for cannabis regulation that we propose would require sales to be limited to those over a specified age (e.g., 19). Purchases could involve filling out a form to access behind-the-counter cannabis; this could include a declaration that the cannabis is intended only for the purchaser or for others of legal age. Also, rationing has been found to be moderately effective, especially for heavy drinkers (see Table 2), and so we propose that customers would be allowed to make purchases only up to a certain amount (e.g., 10 grams a day). This small volume would also prevent the purchased cannabis from being diverted to young people or traded in an unregulated market.
Cannabis use locations. The public use of alcohol and tobacco is contentious, and issues related to the public use of cannabis will no doubt arise in cannabis public use policy. Although public drinking is widely restricted in Canada, there is insufficient evidence of the public health effectiveness of bans on public drinking (see Table 2). With respect to tobacco, restrictions on the location of use are driven by the health hazards of environmental (second-hand) tobacco smoke. Given our lack of knowledge about the effects of environmental cannabis smoke—two recent reviews(2,8) of health effects contain no mention of the specifc effects of cannabis smoke—and the public health concern about exposure to any type of smoke, we propose that cannabis smoking be restricted to licensed locations or to private homes. The health of workers at cannabis use locations could be protected by providing separate, ventilated spaces for customers and prohibiting cannabis smoking by workers on shift.
Cannabis lounges should have a standardized, neutral, external and internal appearance, should be free of promotional materials or activities, and should display health promotion and referral information prominently. These locations would thus also offer the opportunity for public health promotion by providing a central, accessible, and social venue through which information dissemination and demonstration of potential harm reduction and health promotion approaches can occur, such as encouraging the use of smokeless modes of cannabis consumption that may reduce exposure to particulates.(9)
To support the public health objective of separating cannabis, alcohol, and tobacco consumption, no alcohol or tobacco use should be permitted in public cannabis use locations.
Consumption locations would obtain their supply from the commission, would be permitted to sell to customers, would have restrictions on the size of the outlet and its days and hours of operation, and would be required to establish “good neighbour” agreements. Training would be required in recognizing and intervening with people experiencing problems related to their consumption patterns. No “special price reductions” or “happy hour discounts” would be permitted.
Although Babor and colleagues(4) and the FCTC5 provide no guidance with regard to public health–oriented regulatory recommendations for the supply of alcohol and tobacco, supply management is an implicit feature of the government monopoly favoured for public health purposes and has been strongly recommended as a component of a public health approach to tobacco.(10,11)
Production. To control supply, the commission would be the only organization authorized to purchase cannabis from licensed growers, to import it into a province, and to supply retailers. Supply management systems similar to agriculture marketing boards could be established to manage the supply and protect small producers. People would be allowed to grow cannabis for their own personal consumption but not to resell it; this would be similar to the home brewing of beer and wine, which does not require a licence. To legally grow cannabis for the purpose of selling it would require a licence and adherence to processes to ensure quality and safety. This model of for-profit private growers with controlled distribution and retailing is similar to the provincial or state alcohol monopolies and models that have been proposed for tobacco.(10,11)
Many public health problems are determined by social and economic factors,(12) particularly unequal wealth distribution.13 An equitable approach to the distribution of cannabis-related wealth that supported many small-scale growers and producers and prevented large concentrations of wealth by multinational corporations would be consistent with the promotion of public health goals: the formulation of cannabis policy should be alert to the potential for multinational corporations to economically exploit the legitimization of the cannabis trade and subsequently exert profit-motive-driven pressure on public health policy related to cannabis control.
Product. The FCTC requires that constituents and emissions of tobacco products be regulated (see Table 3). Similar requirements should be applied to cannabis. The concentration of the psychoactive ingredient delta-9-tetrahydrocannabinol (THC) has been noted to have increased over the years,(14) likely for a variety of reasons (e.g., increased effect per dose, easier storage and transport). This parallels the availability of concentrated alcohol products that emerged during the Prohibition era, when illegal dealers preferred to import and transport spirits rather than beer and wine because moving smaller volumes helped them avoid detection.(15) Concentrated products increase the risk of harm and are often not preferred by users. It has been observed in the Netherlands, where cannabis is de facto legal, that users prefer relatively lower THC concentrations.16 In this model, retailers could sell a variety of strains with clearly labelled concentrations of THC in both smokable and edible products.
Only bulk products should be made available, to allow individuals to determine their dose rather than being exposed to a predetermined per-unit dose, as is the case with manufactured cigarettes. This would also prevent the potential for attractively marketing cannabis as cigarette-like products. Processed products (e.g., tinctures, cookies) packaged in child-proof containers and prepared according to specific regulatory requirements should also be available to avoid the harms of smoke inhalation.
Promotion and packaging. Recommendations to limit advertising, promotion, and sponsorship as a means of reducing psychoactive substance use and harms are well supported by research evidence (see Table 4). This suggests that one of the most important lessons of the commercialization of tobacco and alcohol is that product promotion is a significant driver of consumption and related harms. Branding of products is critical to promotion—and, once branding is allowed, promotion is very difficult to prevent. Therefore, all branding and promotion of cannabis products should be prohibited, and plain packaging should be required (i.e., no logos, brand names, or colourful packaging).
Labelling about product constituents and health risks are considered important to prevent the harms of tobacco (see Table 4). For cannabis, the packaging should describe the concentration of important constituents and the strain, and should include dominant, standardized warning labels that mention the respiratory irritation of inhaling smoke, using cannabis with alcohol, using cannabis while driving or operating other machinery.
Public education. Demand could be tempered through evidence-based public and school education, but such efforts should avoid large public anti-cannabis prevention campaigns, which have been shown to have the potential to unintentionally stimulate interest in and actually increase the use of cannabis.(17,18)
The revenue raised from cannabis regulation should be used for health and social initiatives such as early childhood development, education, housing for marginalized people and improving mental health and addictions services.
Public support for cannabis “legalization” is growing, in part because of increasing recognition of the lack of effectiveness and the harms of cannabis prohibition, together with the pressing need for proactive measures based on a public health approach. Otherwise, a commercial exploitation model may result, such that public health and social problems similar to those associated with alcohol and tobacco will be repeated.
In Canada there are legal mechanisms that could allow a cannabis regulation pilot project in a province without violating federal laws, such as by obtaining a Controlled Drugs and Substances Act19 section 56 exemption (see Box 2) and/or using the exemption and regulation provisions of section 55. Such exemptions could allow a province to establish a province-level scientific project, explicitly guided by public health oriented goals and objectives, with allowance for specific demonstration sites in accepting communities.
Changes to cannabis regulation will require detailed analysis grounded in the experience with alcohol and tobacco as described by Rolles,(20) and must include rigorous evaluation to monitor for unintended consequences, potential harms, and anticipated benefits of a new regime.
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