Critique of Cannabis Legalization Proposals in Canada

Commentary
A critique of cannabis legalization proposals in Canada
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Harold [ 6 _ T D $ D I F F ] Kalant
Department of Pharmacology & Toxicology, University of Toronto Medical Sciences Building, 1 King’s College Circle Toronto, ON, Canada M5S 1A8
Introduction
The editorial by Cre ́ pault, Rehm & Fischer (p. 1 of this issue)
provides a detailed description of the origins and rationale of a
CAMH document entitled Cannabis Policy Framework (Cre ́ pault,
2014), referred to below as the CPF. As described in the editorial,
the CPF concluded with a recommendation for legalization of non-
medical use of cannabis, with reliance on strict application of
regulations to prevent access to cannabis by underage users who
are most vulnerable to its adverse effects on health and social
functioning. As the editorial explains, the CPF grew out of an earlier
document from the Addiction Research Foundation (ARF) that
called for a public health approach to cannabis policy and for
decriminalization of possession for personal use (Addiction
Research Foundation, 1997). This recommendation was also made
in the LeDain Commission Report (Canadian Government, 1972),
and was maintained in CAMH statements that preceded the CPF. It
is therefore useful to examine the reasons that led to the changed
recommendation in the CPF and other recent similar publications
(Haden & Emerson, 2014; Spithoff, Emerson, & Spithoff, 2015).
Among the important considerations mentioned in the editorial
are the following:
 social harms caused by prohibition, and by its inequitable
application,
 the relative modesty of the health harms attributable to cannabis
use in the majority of users,
 costliness and ineffectiveness of prohibition, combined with its
deterrence of public health measures aimed at prevention and
treatment of drug-induced harm,
 superior ability of legalization to prevent harm to vulnerable
groups by the use of regulatory controls that cannot be
implemented under decriminalization,
 the risk that decriminalization could actually encourage the
production and distribution of cannabis.
International Journal of Drug Policy 34 (2016) 5–10
A R T I C L E I N F O
Article history:
Received 11 November 2015
Received in revised form 27 April 2016
Accepted 9 May 2016
Keywords:
Cannabis policy
Legalization
Decriminalization
Harms caused by prohibition
Harms to adolescent users
Cost-benefit assessment
A B S T R A C T
An editorial in this issue describes a cannabis policy framework document issued by a major Canadian
research centre, calling for legalization of non-medical use under strict controls to prevent increase in
use, especially by adolescents and young adults who are most vulnerable to adverse effects of cannabis. It
claims that such a system would eliminate the severe personal, social and monetary costs of prohibition,
diminish the illicit market, and provide more humane management of cannabis use disorders. It claims
that experience with regulation of alcohol and tobacco will enable a system based on public health
principles to control access of youth to cannabis without the harm caused by prohibition.
The present critique argues that the claims made against decriminalization and for legalization are
unsupported, or even contradicted, by solid evidence. Early experience in other jurisdictions suggests
that legalization increases use by adolescents and its attendant harms. Regulation of alcohol use does not
provide a good model for cannabis controls because there is widespread alcohol use and harm among
adolescents and young adults. Government monopolies of alcohol sale have been used primarily as
sources of revenue rather than for guarding public health, and no reason has been offered to believe they
would act differently with respect to cannabis.
Good policy decisions require extensive unbiased information about the individual and social benefits
and costs of both drug use and proposed control measures, and value judgments about the benefit/harm
balance of each option. Important parts of the necessary knowledge about cannabis are not yet available,
so that the value judgments are not yet possible. Therefore, a better case can be made for eliminating
some of the harms of prohibition by decriminalization of cannabis possession and deferring decision
about legalization until the necessary knowledge has been acquired.
ß 2016 Elsevier B.V. All rights reserved.
E-mail address: [e-mail].
Contents lists available at ScienceDirect
International Journal of Drug Policy
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o
http://dx.doi.org/10.1016/j.drugpo.2016.05.002
0955-3959/ß 2016 Elsevier B.V. All rights reserved.

The validity of the model proposed in the CPF and reproduced
verbatim in the editorial can be assessed by examining the
available evidence concerning these and some related issues.
Is prohibition ineffective or a failure?
Prohibition has indeed failed to prevent all use of the drug, but
this is not a reasonable expectation. No prohibition, whether of
something as minor as smoking too close to a hospital entrance, as
common as exceeding speed limits, or as grave as murder, is
expected to be 100% effective. All one can reasonably expect from
prohibition of any undesirable behavior is that it asserts society’s
disapproval, and makes the disapproved behavior substantially
less frequent than it would otherwise be.
Prohibition of alcohol in North America in the 1920s and early
1930s did markedly reduce consumption and public intoxication
(Dills, Jacobson, & Miron, 2005) as well as the death rate from
alcoholic cirrhosis (Dills & Miron, 2004). However, it also had
various socially harmful consequences such as the growth of
bootlegging and organized crime, corruption of police forces, loss
of employment in alcohol-related industries and loss of important
tax revenues (Blocker, 2006). It deprived millions of moderate
drinkers of what was for most of them a harmless pleasure, and
possibly of alleged health benefits of moderate consumption
(Kalant & Poikolainen, 1999). Therefore, prohibition did work, but
at the cost of important social harms. One must make a value
judgment as to whether the costs to society outweighed the
benefits, but that is not the same as saying that prohibition was
ineffective.
Neither can one say that cannabis prohibition is ineffective if
use is significantly less than it would be under legalization. The
percentage of past-year users of cannabis among the Canadian
general population in 2012 was only 10% while that of the legal
drug alcohol was 78% (Health Canada, 2014). A recent study found
that 10% of US high school students who had not yet used
marijuana intended to use it if it became legal, and 18% of those
who had already used it declared intention to use more frequently
(Palamar, Ompad, & Petkova, 2014). These probably represent
minimum increases, because when the more decisive users
increase consumption, their attitudes and behaviors affect other
members of their peer groups to act similarly (Keyes et al., 2011;
Salvy, Pedersen, Miles, Tucker, & D’Amico, 2014).
Greater permissiveness in the United States has been accom-
panied by a doubling of rates of use and of use disorders from
2002 to 2012 (Hasin et al., 2015). American states that adopted
very poorly controlled medical marijuana laws (MML) tantamount
to legalization had higher rates of marijuana use, abuse and
dependence than states without such laws, even among adoles-
cents who were not eligible for medical permits (Cerda` , Wall,
Keyes, Galea, & Hasin, 2012; Wall et al., 2011). ‘‘Medical’’
marijuana was deviated to illicit use in non-MML states
(Thurstone, Lieberman, & Schmiege, 2011), a risk that also applies
to legalization in Colorado (RMHIDTA, 2015). In contrast, Choo
et al. (2014) did not find increased use by adolescents in states
adopting MML, and Masten and Guenzburger (2014) found that
some MML states experienced a significant increase in cannabis-
related traffic fatalities while other MML states did not. Until the
difference between the results of these studies can be explained, it
is unwarranted to argue that we know how to prevent increased
use after legalization.
Preliminary evidence to date indicates that in Colorado
cannabis use among 1217, 1825, and over-26 age groups
increased by between 17% and 63% in the 2 years after legalization
compared to the 2 years before, while national averages for the
same groups were either unchanged or lower (RMHIDTA, 2016).
We will not know for some years yet whether the increases were
temporary or permanent, nor the resulting social costs in terms of
school and work performance, physical and mental health,
automobile accidents and deaths, etc. Without such knowledge,
there is no factual basis for saying that legalization is a better policy
for society than prohibition or decriminalization. Legalization is in
harmony with the democratic ideal of restricting individual liberty
of action only when necessary for the common good, but judging
what constitutes the common good requires comprehensive
knowledge of the consequences of each policy option, which we
do not yet have.
Does cannabis prohibition impose serious personal harms on
society that would be removed by legalization?
The editorial refers only briefly to the social harms caused by
prohibition of cannabis, but the CPF states that ‘‘Around 60,000
Canadians are arrested for simple possession of cannabis every
year’’. The figure is based on data from Statistics Canada
(2014). This statement, combined with the CPF reference to only
the maximum possible sentences provided for in the law, gives the
impression that large numbers of Canadians suffer severe penalties
every year for simple possession of cannabis under the present
prohibition. However, Statistics Canada records all cannabis
incident reports by the police in each province, regardless of
whether cannabis possession is the principal object of the incident
or only a minor accompaniment to other more serious charges, and
the statistics give no indication of the outcomes.
In contrast, Pauls, Plecas, Cohen, & Haarhoff (2012), with the
help of the RCMP, had access to the complete files (names
removed) of all case reports in British Columbia over a 3-year
period and were able to separate them into subgroups according to
the nature of the charges and the outcomes. The results present a
dramatically different picture from that implied by the CPF. In
2011, of 22,561 files coded for marijuana possession in British
Columbia, 4,355 were dropped because of insufficient evidence. Of
the 18,206 cases in which possession was demonstrated, the great
majority were let off without being charged, e.g. with a warning or
simply a decision not to proceed. In 4,257 cases charges were laid,
but in most cases the possession charge was a minor addition to
charges of more serious crimes such as trafficking, violence,
impaired driving or others. Of the 249 charged only with simple
possession, one-third had the charges dropped and did not come to
trial. Of those that came to trial, only 42 were convicted, the others
being acquitted, discharged, or directed to treatment. Finally, only
seven of those convicted were sentenced to jail for 114 days, and
these were all repeat offenders with long criminal histories. Very
similar proportions of outcomes were found in each of 2009,
2010 and 2011. It is clear, therefore, that in British Columbia very
few people accused only of simple possession of marijuana actually
come to trial, and extremely few are convicted and fined or jailed.
Correspondingly detailed figures for Ontario and for all of
Canada are not available. However, in Ontario in 2013 there were
17,641 reported incidents of cannabis possession; of these 8,045
were cleared without charges, 8,706 led to charges, and 890 were
not yet cleared (CANSIM, 2013). Among detained youth, 1,281
were charged whereas 3,804 youths were released without
charges. Generally, similar figures were found for Canada as a
whole (Boyce, 2013). These figures are proportionally very
different from those prevalent in the United States, though federal
law in both countries prohibits non-medical use of cannabis. The
difference demonstrates that the manner of enforcement, rather
than prohibition per se, determines the magnitude of the social
cost. The foregoing discussion does not in any way deny the
seriousness of arrests and criminal records for simple possession of
cannabis, but in the weighing of costs and benefits of different
policy options, the size of the problem matters. There is a clear
H. Kalant / International Journal of Drug Policy 34 (2016) 5–106

need for full and accurate nationwide information, which we do
not yet have.
Statistics Canada does indicate that over 699,000 Canadians
have criminal records as a result of convictions on charges of
cannabis possession, many of which occurred decades ago during
their adolescence before the Youth Criminal Justice Act came into
effect. This is certainly an important harmful effect of prohibition
of cannabis possession, and either legalization or decriminalization
would prevent it from happening in the future. However, neither
would undo the harm to those who already have criminal records.
A legislated amnesty would be required, but this could be done in
connection with decriminalization or even with continued
prohibition, and is not necessarily linked to legalization.
As in the United States, some Canadian provinces show greater
severity of application of cannabis prohibition than others. That
could just as logically call for federal government action to impose
uniform moderate sentencing rules across the country as for
legalization of cannabis use.
Does prohibition of cannabis impede the application of
measures to reduce drug-related harm to health?
The editorial’s statement to this effect is more cautious than the
CPF statement that ‘‘The law enforcement focus of prohibition
drives cannabis users away from prevention, risk reduction and
treatment services’’, for which it cites no supporting literature. In
fact, prohibition of cannabis possession is not necessarily in
conflict with treatment of dependent persons. Diversion of cases
from the justice to the health care system has been occurring with
increasing frequency in Australia (Feeney, Connor, Young, Tucker,
& McPherson, 2005), Portugal (Hughes & Stevens, 2010), Canada
(Pauls et al[7_TD$DIFF]., 2012) and the UK and elsewhere in Europe (Hamilton,
Lloyd, Monaghan, & Paton, 2014) where possession is still illegal.
Are adolescents and young adults especially vulnerable to the
adverse effects of cannabis on health and wellbeing?
The editorial asserts that harms caused to most users by
cannabis are relatively modest, significantly less than those for
tobacco or alcohol. It does say ‘‘at the levels and patterns of use by
most adult cannabis users’’, and this is an important qualification,
because the use of cannabis in Canada, as noted earlier, is much less
than that of alcohol. It has long been recognized that the extent of
harm caused by a drug is proportional to its use (CANYS, 2009;
Hughes et al., 2014). If cannabis legalization should prove to be
followed by an important increase in its use, as discussed
elsewhere in this commentary, the difference between the extent
of harms caused by alcohol and by cannabis would almost certainly
be considerably reduced.
A more important reservation even now relates to harms
caused to young users. Both the editorial and the CPF do discuss
the potentially serious effects of cannabis use by adolescents on
mental health and maturation of cognitive functions (Hall &
Degenhardt, 2007). The importance of this topic for policy
considerations warrants a more detailed consideration. The
Dunedin study in New Zealand followed a birth cohort of over
1400 newborns through childhood, adolescence, young adult-
hood and into early middle age. Histories and mental and
physical examinations were repeated at intervals throughout
the study, measuring among many other things the effects of
early acquisition of drug-taking behavior and its maintenance or
cessation (Milne et al., 2009). A thorough analysis of the
Dunedin results (Meier et al., 2012) demonstrated that children
who did not acquire cannabis-taking behavior had a small but
significant increase in age-adjusted intelligence score from age
13 to age 38. Those who began cannabis use during adolescence
had a decrease in IQ at age 38, which was more marked the
earlier they had begun use, and the more intensively and
persistently they used. Similar findings were obtained in other
cohort studies (Silins, Horwood, Patton, Fergusson, & Olsson,
2014).
All tested domains of cognitive functioning were affected, and
the effect was recognizable in everyday living, including poor
school performance, higher drop-out rates, and subsequent
restriction of career possibilities. It could not be explained by
decreased years of schooling, persistent drug presence in the
body, socioeconomic status, or other potential confounders.
Cessation of use was followed by recovery of cognitive functions
in those who began use as young adults, but not in those who
began early in adolescence. The findings are consistent with
experimental studies showing that cannabinoids prevent mature
synapse formation in maturing brain pathways involved in
‘‘executive functioning’’ (Kalant, 2014), and that the same chronic
cannabis regimen (with dosage adjusted for body mass) that
caused permanent impairment of learning and memory in
adolescent rats did not do so in mature adult rats (Stiglick &
Kalant, 1985).
A clinical diagnosis of cannabis dependency by DSM-IV criteria
was found in about 810% of adult users, but in about 16% of
adolescent users (Anthony, 2006). A prospective 3-year study of
young adult frequent users, aged 18 to 30 years at baseline, found a
37% cumulative incidence of dependence (van der Pol et al., 2012).
The risk of future lung cancer in heavy cannabis users of military
conscription age represents another type of vulnerability (Call-
aghan, Allebeck, & Sidorchuk, 2013).
These findings are especially significant for cannabis policy
decisions because adolescents and young adults are dispropor-
tionately represented among cannabis users. By combining the
provincial statistics of the population age distribution in 2013
(Ontario Ministry of Finance, 2014) with the percentages of past-
year users in different age groups as shown in the CPF, one can
estimate that 43% of users are adolescents and young adults
(Table 1).
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Table 1
Calculation of approximate numbers of cannabis users in Ontario population groups below and above 25 years of age in 2013.
Age group Adjusted Population Subtotals * % past-year users Number of users Totals
1214 298,240 23% 68,595[ 4 _ T D $ D I F F ]
720,7211519 871,460 30% 261,438
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2025 967,000 40.4% 390,668
2629 962,600 40.4% 388,890[ 5 _ T D $ D I F F ]
1,102,294
3039 1,825,900 17.3% 315,881
[
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4049 1,988,000 8.4% 166,992
5074 3,907,300 5.9% 230,531
* The population totals in the Provincial data are given in 5-year age groups, but the percentages of cannabis users in the CPF document are given by school grades that
begin at about age 12 years, and by decade in those above 20 years of age. The adjustments are attempts to reconcile the age groups with the corresponding percentages of
users.
H. Kalant / International Journal of Drug Policy 34 (2016) 5–10 7