Realistically furthering the goals of public health through cannabis legalization with strict regulation: Response to Kalant

This article responds to select issues from Kalant’s Commentary on the Cannabis Policy Framework and its summary editorial, and the opportunity to selectively respond to some of the main issues raised.

Accepted Manuscript
Title: Realistically furthering the goals of public health by
cannabis legalization with strict regulation: Response to
Kalant
Author: Benedikt Fischer J ¨urgen Rehm Jean-Franc¸ois
Cr´epault
PII: S0955-3959(16)30196-7
DOI: http://dx.doi.org/doi:10.1016/j.drugpo.2016.06.014
Reference: DRUPOL 1812
To appear in: International Journal of Drug Policy
Received date: 20-1-2016
Revised date: 8-6-2016
Accepted date: 14-6-2016
Please cite this article as: Fischer, B., Rehm, J., and Cr ´epault, J.-F.,Realistically
furthering the goals of public health by cannabis legalization with strict
regulation: Response to Kalant, International Journal of Drug Policy (2016),
http://dx.doi.org/10.1016/j.drugpo.2016.06.014
This is a PDF file of an unedited manuscript that has been accepted for publication.

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Realistically furthering the goals of public health through cannabis legalization
with strict regulation: Response to Kalant.
Benedikt Fischer, PhDa,b,c,d*
Jürgen Rehm, PhDa,b,c,e
Jean-François Crépault, MAa
aInstitute for Mental Health Policy Research, Centre for Addiction and Mental Health
(CAMH), 33 Russell St., Toronto, ON, M5S 2S1, Canada
bDepartment of Psychiatry, University of Toronto, 250 College St., Toronto, ON, M5S
1A8, Canada
cInstitute of Medical Science (IMS), University of Toronto, 1 King’s College Circle,
Toronto, ON, M5S 1A8, Canada
dCentre for Criminology & Sociolegal Studies, University of Toronto. 14 Queen’s Park
Crescent West, Toronto, ON, M5S 3K9, Canada
eDalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7,
Canada
Resubmitted to the International Journal of Drug Policy as a Commentary
Word count (text body): 4,708
Resubmission date: 8 June 2016
*Corresponding Author:
Benedikt Fischer, PhD
Senior Scientist, Institute for Mental Health Policy Research
Centre for Addiction and Mental Health (CAMH) & Dept. of Psychiatry, University of
Toronto
33 Russell St., Toronto, Ontario, M5S 2S1, Canada
Tel.: [phone]; Fax: [phone]
Email: [e-mail]

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Realistically furthering the goals of public health by cannabis legalization with
strict regulation: Response to Kalant.
Abstract: We respond to select issues from Kalant’s Commentary (in this issue).
Keywords: cannabis, legalization, policy, public health, Canada

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Introduction
We welcome our esteemed colleague Prof. Kalant’s commentary (Kalant, 2016)
on the Cannabis Policy Framework (‘CPF’) and its summary editorial (Centre for
Addiction and Mental Health (CAMH), 2014; Crépault, Rehm, & Fischer, 2016), and the
opportunity to selectively respond to some of the main issues raised. In essence,
Kalant’s principal arguments are: that legalization may be an imperfect approach as a
policy to handle cannabis and related risks or problems; that the evidence for it to
provide the improved policy outcomes on which its promotion is footed largely does not
exist; and that – even if such evidence existed – good policy-making still involves
decisions on grounds of higher principles towards what is the ‘right’ thing to do.
Cannabis legalization definitely will be no miracle but an imperfect solution. It
constitutes (and has been concretely put forward as such by the CPF’s authors) the
policy option which, on net account of current evidence or reasonable evidence-based
assumptions from various fields, promises to yield the overall highest public health
benefits for Canada in the present situation (Rehm & Fischer, 2015). Such perspectives
and weightings, even when considering the same facts, of course, involve “value
judgments” – as Kalant correctly observes – and hence cannot be derived by way of
universally objective knowledges or even ‘truth claims’ but depend on normative
stances, interpretations and priorities. This, then, means that even when all the same
available facts and data are considered, different observers may still arrive at different
conclusions for best policy choices (Babor et al., 2010). Yet let us concretely address
some of the concrete points and issues raised by Kalant.

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1.The failure/success of cannabis policy as measured by use:
Kalant suggests that cannabis prohibition may have been a success by curbing
cannabis use levels, and that ‘legalization’ may be a failure because it may result in
higher use. While the former suggestion is speculative, most systems which saw
liberalizations of their cannabis control policies away from prohibition did not experience
major changes in use levels directly attributable to the policy change (Hughes &
Stevens, 2010; Room, Fischer, Hall, Lenton, & Reuter, 2010). Similarly, there is no
convincing evidence that liberalizations through medical marijuana laws in US states
actually caused increases in cannabis use levels (Hasin et al., 2015; Wall et al., 2016).
At the same time, there were several phases (e.g., 1995 – 2005) where, under
prohibition, cannabis use prevalence – among both adults and young people – starkly
increased yet proponents of prohibition did not see this as an evident reason for the
need to modify policy.
We openly point to the possibility that – at least based on initial ‘straw fire’ or
curiosity effects leading to experimentation among previous abstainers – cannabis use
levels may even somewhat increase under ‘legalization’ in Canada (recent survey data
suggest this possibility; Forum Research Inc., 2015) from the already existent high
levels. Importantly, however, overall incidence or prevalence are not a primary concerns
from a public health perspective for cannabis policy. Rather, what matters – just as it
does principally in public health oriented frameworks for alcohol or other psychoactive
substances – is whether the extent of health and social harms associated with use
(including the collateral impacts primarily to be attributed to policy choices) will be
reduced (Fischer, Rehm, & Hall, 2009; Fischer, Burnett, & Rehm, 2015; Rehm et al.,

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2013; Room, Babor, & Rehm, 2005). Concretely, this means: Will the number of people
with risky/problematic use (including dependence or other health problems) change?
Will there be more cannabis-related injuries? Do fewer people buy cannabis illegally
and will fewer criminal justice resources be expended on cannabis incidents than under
the current prohibition regime? This is a conceptually and practically relevant
differentiation especially in the cannabis area, where the majority of cannabis use
episodes or trajectories are free of major harms, and major risks/harm outcomes are
largely concentrated in a sub-group of 25% – 30% of users who experience acute
and/or long-term problem consequences (e.g., injury, mental disorders including but not
limited to dependence, decrease in socio-educational functioning, yet also social harms
including criminalization or stigmatization, etc.; Fischer et al., 2011; Hall & Degenhardt,
2009; Volkow, Baler, Compton, & Weiss, 2014).
For these primary harm outcomes, those additional people who decide to
experiment with the smoking of a joint will be quite irrelevant (as long as they do not
engage in acute simultaneous risk-taking, e.g. driving a car); what will matter more
under a prospective regime of legalization with a principal focus on public health is what
proportion of cannabis users end up experiencing any of the major health or social
harms mentioned, and how different that proportion - and the harm burden incurred - is
compared to the previous control regime. In essence, the failure or success of policy
reform will be measured on whether it achieves a reduction of the overall harms and
costs associated with cannabis use upon society and its health and safety.
2.The severity and enforcement of criminal cannabis law:

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Kalant puts forward the argument that the severity of criminal cannabis control is
overstated by a focus on maximum penalties, as well as insufficient recognition of the
fact that only a minority of those charged with cannabis use related offenses are
actually convicted. While surely symbolic to some extent and rarely (if ever) imposed in
practice, the maximum penalties for cannabis possession (currently $1,000/6 months
imprisonment for 1st offense) express the severity Canadian society attributes to the
‘crime’ of cannabis use and how this violation of criminal law should be punished
(Roach, 2015). Current cannabis control law thus signals that personal possession of
cannabis is valued as a considerably more severe violation of societal norms than
running a red light with a car, selling cigarettes to a minor or trash dumping. Based on
repeated survey data, most Canadians categorically disagree with such a valuation; in
fact, close to half disagree with the notion that it should be viewed as a violation of
norms stipulated by law at all (Forum Research Inc., 2015).
However, the essential point is missed here. While it is proposed that the limited
actual conviction rates for cannabis possession documented by several studies
decisively soften the blow of cannabis law in reality, the details of this reality actually
constitute an essential problem of arbitrary and discretionary criminal justice practice
characterizing present cannabis law enforcement (Cotter, Greenland, & Karam, 2015;
Pauls, Plecas, Cohen, & Haarhoff, 2012). To illustrate: in Canada, no more than about
2% of the estimated total of 2 – 2.5 million current cannabis users – i.e., individuals who
mostly commit the criminal act of cannabis possession for use at least occasionally,
many even regularly – are subject to actual law enforcement (total of ~59,000 enforced
cannabis possession offenses in 2013) (Cotter et al., 2015). While enforcement patterns

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and rates vary greatly between jurisdictions, they involve a disproportionate number of
youth and young adults (Cotter et al., 2015). Moreover, domestic and international data
document that the chances of arrest for cannabis offenses are powerfully stratified by
race and other socio-demographic characteristics of suspects, and so contribute to
realities of systemic discrimination in drug law enforcement. In addition, arrests for
suspected cannabis violations are commonly used as a discretionary yet convenient
tool by law enforcement personnel for access to ‘suspicious populations’ for criminal
investigation purposes (Golub, Johnson, & Dunlap, 2007; Wortley & Owusu-Bempah,
2012).
Across Canada in 2013/14, four in ten (41%) of police-processed cannabis
offenses were ‘cleared’ by ‘discretion’ at the hands of law enforcement (i.e. “by giving a
warning, caution or referral to a community-based program rather than a charge”), and
as such these discretionary law enforcement practices are commonly influenced by
above factors (Carrington & Schulenberg, 2003; Cotter et al., 2015; Schulenberg, 2015).
Yet even among the - comparably small - number of cannabis possession charges
completed in court, only 43% result in a successful conviction (i.e., a guilty verdict);
instead, most are stayed or withdrawn, which in most instances means the use of
“alternative measures of justice”, e.g. community service, treatment or probation orders
(Cotter et al., 2015). So while many cannabis possession offenders processed within
the Canadian criminal justice system will not end up with a formal conviction,
dispositions like conditional sentences or even discharges entail the consequence of a
‘criminal record’ for the offender – a primary source of criminal labelling and other
severe obstacles to key personal, or professional opportunities usually for decades to

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come (Canadian Civil Liberties Association, 2014; John Howard Society of Ontario,
2014b; Powell & Winsa, 2008).
As seminal socio-legal scholars (e.g., Malcolm Feeley for the criminal processing
of lower level offenses in general, Howard Becker more specifically related to drug use;
(Becker, 1974; Feeley, 1979) have enlightened us decades ago, the main punitive
impact of criminal processing commonly is not the punishment per se, but the wider
social markings, labels or stigma imposed by the process, and consequential real-life
burdens, it brings primarily for young people in the specific case of cannabis use.
Concretely, a merely temporary criminal detention for a suspected cannabis violation
under current law results in records in police databases which may identify the person
as a ‘suspected offender’ at future encounters with police, and hence may feed the
dynamics of ‘secondary deviance’ (Canadian Civil Liberties Association, 2012; Cribb &
Rankin, 2014; John Howard Society of Ontario, 2014a).
In sum, also given that both general and specific deterrence effects remain un-
evidenced (Erickson & Hyshka, 2010; Lenton, 2000; MacCoun, Pacula, Chriqui, Harris,
& Reuter, 2009), the above-described collateral harms of criminalization of personal
recreational cannabis use – especially as they relate to the discretionary and arbitrary
enforcement practices shown – are excessive and incompatible with principles of public
health- and social justice-based or otherwise sensible public policy. At the same time,
we view the possibility of potentially continued enforcement “bias … in relation to
prosecution for illicit production and trafficking” (Kalant, 2016) as a rather irrelevant
argument against legalization. Such biases exist already now, and the protection of
constitutional rights or principles of proportional justice for illicit drug producers is far

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less important than that of a young person engaging in nothing more than occasional
recreational cannabis use for personal pleasure.
3.The distinct vulnerability of young cannabis users:
Kalant re-states the fact that a large proportion of cannabis users are
adolescents or young adults, and that these feature a distinct vulnerability especially for
long-term or chronic cannabis-related harms. There is no disputing this: the developing
brain, yet also the processes of social and educational development of youth and young
adults make them distinctly susceptible to possible long-term problem consequences
from intensive and/or chronic cannabis use (George & Vaccarino, 2015; Squeglia,
Jacobus, & Tapert, 2009). Related, the overall burden of illness to society from a young
person incurring acute (e.g., injury) or long-term (e.g., dependence, educational
attainment related) problems from cannabis use are distinctly higher than if these occur
in a person of older age (Degenhardt et al., 2013).
However, none of these observations put forward logical or necessary arguments
against legalization; rather, they underscore existent vast inconsistencies in regards to
overall psychoactive (including legal and illegal) drug control policies in most democratic
societies. First, the above-mentioned severe consequences of cannabis use – even
among young people – occur only in a minority of users; the vast majority of young
people who have experienced cannabis use will neither incur brain damage nor
experience schizophrenia or dependence (Degenhardt et al., 2009; Hall & Degenhardt,
2009; Imtiaz et al., 2015; Squeglia et al., 2009). Second, there is no evidence that the
prevalence or occurrence of above problems would be different – i.e., more severe –

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under legalization than it has been under prohibition. In fact, one of the main
advantages from a legalization-based policy approach will be that it allows for open and
proactive prevention/education regarding concrete cannabis use risks focusing
especially on young people (e.g., in educational settings) and specifically the modifiable
risk factors (e.g., intensive/frequent or high THC product use, cannabis-impaired
driving) known to predict the acute and/or chronic health problem outcomes that
urgently need to be addressed in this vulnerable population (Babor et al., 2010). Tools
like evidence-based ‘lower risk cannabis use guidelines’ have been developed and are
available to inform such efforts (Fischer et al., 2011).
And finally, we are left confused in regards to the consistency of consideration of
serious health risks for policy-making for other psychoactive substances use and/or
recreational activities. For example, many more young (including underage) people use
alcohol than cannabis in Canada, and the risks for brain health harms from alcohol are
at least as high if not higher (Bava & Tapert, 2010; Squeglia et al., 2009); other risks
(e.g., injury, physical/mental health problems) are at least equal but likely worse
(Lachenmeier & Rehm, 2015; Nutt, King, & Phillips, 2010; Rehm, Lachenmeier, &
Room, 2014; Squeglia et al., 2009; Zeigler et al., 2005). There is extensive evidence of
negative associations of alcohol and tobacco use – and little evidence on their
‘reversibility’ - on various aspects of intelligence among young people (Odgers et al.,
2008; Trinidad & Johnson, 2002). Notably, for illustrative comparison, a large number of
youth and young adults incur severe head/brain injuries from sports – concretely
relevant for Canada: hockey - each year, amounting to an illness burden among young

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people that is quite possibly higher than for cannabis (Cusimano et al., 2013; Forward et
al., 2014).
We are however not aware of any active calls by Kalant or other leading
opponents of cannabis legalization to criminalize recreational alcohol use (or hockey
playing) among young people with reference to their distinct vulnerabilities for
respective documented health risks, as so prominently emphasized for cannabis. If the
same arguments as aimed at cannabis control were applied, these activities should be
categorically illegal due to their extensively documented acute and chronic risks for
severe harms among young people. The essential points are these: public health-
oriented substance policy should be as effective as possible in overall preventing and
reducing harms, however it can never be perfect in doing so and some risk for harms
will inevitably remain. The evidence suggests clearly that the risks for health harms from
cannabis use among young people is, proportionally, not greater than other
(psychoactive substance and other) activities in which young people commonly engage
(or are broadly encouraged and expected to engage in) in today. The principles of good
public health-oriented policy-making however should be applied consistently and
proportionately on best available data, and not arbitrarily rest on selectively applied and
emphasized evidence for risks or harms (Anderson et al., 2016). If such was done for
comparable activities as described, most aspects of young people’s daily lives should
be illegal for their supposed protection; at the same time, it is the collateral harms of the
supposed protection (i.e., criminalization) that causes many of the other harms
legalization seeks to overall reduce in its overall approach and objectives.

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4.The impact of legalization on black markets:
Key aspect of legalization’s objectives aim at improved ways to - legally - control
and regulate the supply of cannabis to recreational users, which under prohibition is left
entirely to illegal processes (the ‘black market’). If implemented successfully,
legalization should result in a substantial reduction of involvement by users in black
markets for cannabis procurement, and their role in supplying cannabis to users. A large
extent of this will, indeed, depend on pricing yet also quality and diversity of cannabis
products offered through legal dispensing mechanisms. While we are not economists,
we do not agree that ‘significantly lower’ prices for legally compared to illicitly distributed
products are needed to make most users rely on legal and regulated cannabis
distribution. In fact, for comparison, the vast majority of the population in high-income
countries uses legal alcohol distribution outlets (even though clandestinely produced
liquor can be found and is usually much cheaper) (Babor, Caetano, Casswell, Edwards,
& Giesbrecht, 2010; Rehm et al., 2014). Historical experiences following prohibition saw
the number of illegal alcohol outlets gradually decreasing (Harrison & Laine, 1936).
It can reasonably be assumed that most current cannabis users in Canada –
drawn from an overall rather law-abiding population – would prefer to rely on legal
cannabis distribution if this offered desirable and quality products with pricing that was
at least competitive with black markets, and if remaining black market activities were
subject to targeted law enforcement and reasonable risk of detection (McSweeney,
Turnbull, & Hough, 2008; Pacula, Kilmer, Grossman, & Chaloupka, 2010; Pudney,
Adda, & Boone, 2010). Where such ‘competitive pricing’ without unduly increasing
opportunistic demand exactly sits may need to be subject to ‘trial and error’ and

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subsequent adjustments (for which taxation and/or minimum pricing will be practical
steering tools). The case study of tobacco pricing – e.g., in Ontario – over the past
years has impressively demonstrated the effects of price increases of tobacco as a
main legal psychoactive commodity beyond tipping points where illegal markets (here
helped by easy cross-jurisdictional smuggling opportunities) became lucrative and
proliferated (Breton, Richard, Gagnon, Jacques, & Bergeron, 2006; Gruber, Sen, &
Stabile, 2003). It also ought to be assumed that cannabis products for purposes of
distribution control are more sensitive to pricing (e.g., compared to alcohol), simply
because cannabis is a more easily produced commodity than alcohol.
One of the most challenging issues in a context of cannabis legalization with
regulated distribution will concern young (i.e., underage for what will likely become the
age limit for legal cannabis procurement in Canada under legalization) people. While
cannabis use rates are high (e.g., ~25% current use prevalence among 16 – 18 year-
olds; Health Canada, 2014) and the distinct vulnerability of underage individuals is a
primary incentive to prevent them from black market involvement, it will need to be seen
how authorities will propose to address legal cannabis access for this age group. Given
that it is not realistic to assume that policy-makers will allow for legal cannabis access
for this age group, nor that the desires for cannabis use by underage people will
suddenly wane under legalization, this would mean that most young cannabis users will
need to continue to rely on either black or otherwise illegal (e.g., indirect, through older
peers, family members, etc.) ways for cannabis procurement. Based on experiences
with alcohol and tobacco or even prescription (e.g., opioid) pharmaceuticals used non-
medically, it can be expected that these indirect ways will likely remain the main ways of

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procurement (Gendall, Hoek, Marsh, Edwards, & Healey, 2014; Ogilvie, Gruer, & Haw,
2005; Schepis & Krishnan-Sarin, 2009). While this is not ideal from the perspective of
public health-oriented policy including the best possible protection of young people’s
well-being and safety, it is more desirable than predominant or inevitable black market
engagement, which is the current status quo, and which may actively facilitate exposure
to other illicit drugs or drugs which are less likely to be quality-controlled.
5.The role and benefits of cannabis taxation:
Kalant suggests that the prospect of tax revenue from cannabis sales is a
primary motive for many proponents of legalization, yet that fiscal benefits may be
outweighed by the overall costs of cannabis-related harms (as is the case for alcohol
and tobacco) (Anderson & Baumberg, 2006; U.S. Department of Health and Human
Services, 2014). First, under current prohibition control, all cannabis transactions occur
in a (sizeable) black market/shadow economy from which there is no taxation or public
revenue benefit whatsoever; legalization, including regulated and taxed distribution
would at least improve this fiscal cost-benefit situation if this was of primary interest
(Flanagan, 2015; Miron, 2005; Werb et al., 2012). However, we would like to emphasize
that the prospects of tax revenue from cannabis sales ought not to be a primary
incentive or driver of legalization reform. Such dynamics have led to questionable policy
decisions elsewhere (e.g., the legalization of casino gambling in Ontario; Korn, 2000;
Williams & Wood, 2007), and should not detract from the primary focus on public health
(rather than budgetary) objectives and considerations. Taxation, rather – as it is used
for alcohol and tobacco products with reasonable success within legal markets (Babor

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et al., 2010; Chaloupka, Straif, Leon, & Working Group, International Agency for
Research on Cancer, 2011) – should be used principally as a policy tool to direct pricing
for cannabis sales under legalization towards above ends (e.g., keeping cannabis
demand as low as possible while away from illegal markets). This ought not to be
“naïve” as Kalant suggests, if the principles of public health are enshrined a-priori in the
cannabis legalization policy, and operational details like pricing and taxation, to be
implemented. To further these ends, while taxation from legal cannabis sales would
generate (a yet undefined yet expectedly modest amount of) tax income to governments
(Cheadle, 2016), we recommend that at least a substantial share of tax revenue should
be earmarked for targeted purposes directly furthering cannabis-related public health
instead of flowing into general revenue streams (dedicated tax; for an overview of this
issue for tobacco, see Thomson, 2007). For example, tax revenue from cannabis sales
could be used to implement evidence-based prevention and education programs (e.g.,
targeting young people), research and delivery of effective treatment, as well as to
resource the monitoring of outcomes of reform policy.
6.Decriminalization as a ‘half-measure’:
The CPF authors have indeed characterized – and rejected as a desirable policy
option – decriminalization as a ‘half-measure’ as it presents itself as ineffective in
addressing several of the key problems or harms associated with cannabis prohibition,
whereas legalization provides a more concrete and promising basis to do so on key
fronts. The principal reasons why we reject decriminalization as a policy option include
that we a) view it as a policy option that maintains more ambiguity than it resolves, and

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b) in many ways takes policy from the proverbial ‘rock to a hard place’ on many key
fronts, i.e. it likely creates new problems where old ones are addressed.
Let us be more concrete with illustrative examples: Under decriminalization, what
is the essential policy signal or message about cannabis use? While the severity of
penalties are reduced, cannabis use will be maintained as a violation of (some kind of)
law, as has been the case in existing decriminalization regimes (MacCoun & Reuter,
2001; Pacula et al., 2005). So are running a red light with a car, selling tobacco to
minors or fare-jumping – they are ‘decriminalized’ yet illegal acts including the
consequence of punishment because, in principle, society believes that people should
abstain from these activities as they constitute harm to society. We do not believe going
forward that personal/recreational cannabis use without risking harm to others (e.g.,
impaired driving, environmental smoke effects) should be considered a norm violation in
Canadian society, but rather should be governed and regulated as a normalized activity,
so as to occur with the least possible harms to users and society.
Without this, we will continue to see major barriers to the legitimacy and
feasibility with key interventions (“what is not legal cannot be regulated”) (Room et al.,
2010), for example with the legitimacy of cannabis prevention/education for users
(including young people). This is also why we do not endorse cannabis policy options
that maintain a material (or, at best, arbitrary) normative signal that cannabis use is
categorically wrong, and thus should be punishable, even if only in non-criminal ways
(e.g., by ‘ticketing’ or even alternative penalties like mandated treatment, education,
community service). We also did not seek to advocate for a cannabis policy regime
where the socio-legal consequences of ‘softened prohibition’ are complemented by the

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risks of exacerbated discretionary powers for law enforcement (e.g., where police have
formalized choices between ‘ticketing’ or criminally processing a cannabis user), as was
proposed for previous iterations of cannabis decriminalization proposals in Canada
(Fischer, Ala-Leppilampi, Single, & Robins, 2003). Broad-based effects of ‘net-widening’
– for example, where suddenly many of Canada’s >2 million cannabis users are subject
to ‘ticketing’ enforcement for personal cannabis use or possession, possibly propelled
by the state’s appetite for revenue generation – does not translate into sensible policy
reform.
Perhaps most importantly, any non-legal cannabis control regime will necessarily
make it impossible to openly control and regulate cannabis production and distribution.
Many of the primary risks and harms – directly or indirectly – root in this realm, and
require the state’s ability to openly intervene for improvement’s in the interest of public
health (for example, by regulating cannabis product access, how and to whom cannabis
products are dispensed, product quality standards and labeling, etc.). While various
decriminalization regimes have taken the punitive edge off from previous regimes, they
largely fail to openly and comprehensively address the various important supply control
issues and force these to remain largely in some grey/shadow area (e.g., see remaining
‘back door’ problem in the Netherlands, or emerging cannabis clubs in various
European countries; Coombes, 2014; Decorte, 2015; R. J. MacCoun, 2011). Effective
and direct regulation of cannabis production, supply and distribution are essential
elements of a public health oriented policy; they are not sufficiently possible with a ‘half-
measure’ of decriminalization yet require the ‘full measure’ of legalization.

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Conclusions
Kalant emphasizes that “sound policy decisions” for cannabis require both
empirical and “objective” evidence as well as “value judgments”. While this is correct of
course, this combination may justify almost any policy option or scenario, as in case of
doubt, the ‘value judgment’ may always trump good evidence in desired directions. Yet
then Kalant concludes that we “lack major portions of the necessary evidence for
making [a] rational choice” for legalization as a population-wide policy reform, and that
such a choice “cannot really be evidence-based and must rest primarily on broader
social values, ideals and hopes”. These are - somewhat condescending – claims that, in
the absence of the ‘final proof’ for legalization’s overall superiority downplay the
incremental and indirect evidence that at least reasonably and plausibly supports the
suggestion of its benefits. Moreover, such statements also reflect an inherent bias and
tautological referral in regards to evidence in favour of the status quo, and against novel
policy options that are empirically un-tested or -proven. On this basis of logic, no space-
craft should have ever been launched, nor should gay sexual orientation or abortion
have been legalized (as it was without material evidence that this would not lead to
disaster).
It is correct that cannabis legalization regimes - and their impacts - are largely
empirically un-tested; however this does not imply that the informed argument for
legalization as a preferred policy option is fabricated based on misguided speculation or
merely hope. Rather, it is the amply documented empirical evidence of the many
undesirable effects and consequences of cannabis prohibition (as incurred for
decades), together with global case studies of legal/regulated control of other

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psychoactive substances, make us advocate for cannabis legalization as a presumably
more desirable and sensible policy alternative in a context where the current regime is
evidently not working well in the interest of public health. While this is the essence of
our policy reform advocacy, we - as empirically oriented scientists - are by no means
ideologically or pre-emptively convinced that legalization will be the be-all-and-end-all of
policy solutions.
Rather, we are advocating, based on the principles outlined in the CPF and the
best evidence in front of us, to put legalization with strict regulation to a fair and
empirical real-life test in Canada (following the logic of Campbell, 1969; and his vision of
an experimenting society). This, in practice, would mean the implementation of a
rigorously evaluated national cannabis legalization policy experiment for a defined
period of at least five years (i.e., to overcome erratic ‘strawfire’ effects, assess sufficient
over-time impacts, etc.). If at the end of this experiment key indicators of policy impact,
harms and costs – defined in a public health framework – are substantially worse than
for prohibition on net account, policy options should categorically and openly be re-
considered. Given the circumstances, visionary scholars with an exceptional record of
scientific discovery like our colleague Professor Kalant should give such a sincere
empirical test not only the benefit of the doubt but support it even if just to enrich our
scientific knowledge about what works and what does not work in cannabis control
policy. In addition, beyond possible benefits to domestic public health, Canada would be
able to bring about exceptional leadership and most valuable and innovative evidence
to cannabis policy science globally, as there is enormous appetite and need for such
information, yet very few nations are prepared or equipped to generate it.

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Acknowledgements: The authors thank Ms. Cayley Russell for her assistance in
preparing this manuscript. Dr. Fischer acknowledges support from a CIHR/PHAC
Applied Public Health Chair Award.

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