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Cannabis legalization: adhering to public health best practice

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Added on  2023-06-14

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This article analyzes cannabis legalization policies through a public health lens using a framework created from extensive data on tobacco and alcohol regulation. It provides a resource for Canadian policy-makers looking to reform cannabis laws and a tool for researchers evaluating cannabis policies and their outcomes.

Cannabis legalization: adhering to public health best practice

   Added on 2023-06-14

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AnalysisCMAJ©2015 8872147 Canada Inc. or its licensors CMAJ, November 3, 2015, 187(16) 1211
ccording to the 2011 United Nations
World Drug Report, the prevalence of

cannabis use in the Netherlands, where

cannabis has been de facto legal for the last 40

years, is lower than in many other European

countries, the United States and Canada.
1 Juris-
dictions that have recently legalized cannabis

(Uruguay and four US states) or redefined can
nabis legalization policies (Catalonia) may be

expecting a similar result. However, if their poli
cies governing cannabis are different, they may

see different outcomes.

In this article, we analyze cannabis legaliza
tion policies through a public health lens using a

2 created from extensive data on to-
3 and alcohol regulation.4 The aim of this
article, and indeed the framework, is to go be
yond reduction in use and include minimization

of harms and realization of benefits.
5 Cannabis
policy will be a topic of debate in Canada in the

lead-up to the federal election in October. The

governing party favours the status quo, one of

the competing political parties has promised

decriminalization, and another party supports le
6 Surveys have shown that most Can-
adians are looking for change.
7,8 We provide a
resource for Canadian policy-makers looking to

reform cannabis laws and a tool for researchers

evaluating cannabis policies and their outcomes.

A broad picture of cannabis use

and legality

A 2013 UNICEF study found that the prevalence

of cannabis use among youth in the preceding

year was highest in Canada (28%) and lower in

Spain (24%), the US (22%) and the Netherlands

9 A 2014 survey in Uruguay found that
17% of secondary school children reported using

cannabis in the preceding year.
10 According to the
2011 UN World Drug Report, cannabis use in the

general population was higher in Canada, the US

and Spain than in Uruguay and the Netherlands.
There are an estimated 180.6 million cannabis

users worldwide,
11 most living in jurisdictions
where cannabis is illegal.

In the past three years, Uruguay and four US

states have gone beyond the limited legalization

policies in Spain and the Netherlands to fully legal
ize the possession, production and sale of cannabis.

Many other jurisdictions have removed criminal

penalties for possession or have legalized cannabis

for medical use, or both. Canada legalized the use

of cannabis for medical indications in 2001 and

implemented updated regulations for medical use

and production in 2014.
12 Possession of cannabis
for nonmedical use remains a criminal offence, and

about 60 000 Canadians are charged yearly.
Legalization of cannabis for nonmedical use

remains contrary to the 1961 UN Single Conven
tion on Narcotic Drugs.
Signatory countries can
address this by renegotiating, withdrawing from

or ignoring the treaty. Uruguay has chosen the

third approach, arguing that its legalization

framework follows the more important UN val
ues of human rights, public health and safety.
What are the harms from cannabis

use and its prohibition?

Policies that prohibit cannabis cause harm.
15 They
funnel money into the illegal market and drive

criminal activity. They harm individuals through

imprisonment, marginalization and the creation of

barriers to treatment. This burden falls dispropor
tionately on vulnerable groups; even though white

and black Americans use cannabis at about the

Cannabis legalization: adhering to public health best practice

Sheryl Spithoff MD, Brian Emerson MD MHSc, Andrea Spithoff MA

Competing interests:

This article has been peer


Correspondence to:

Sheryl Spithoff,

2015. DOI:10.1503

Prohibition of cannabis has failed to achieve its goal of reducing use

and causes substantial public health and societal harm.

Two of Canada’s three main political parties promise to reform

cannabis policies if voted into power.

If Canadian policy-makers move away from prohibitionist policies and

create a legal framework for cannabis, public health promotion and

protection must be the primary goals.

Lessons learned from permissive alcohol and tobacco regulation can

guide public health–oriented policy-making; in particular, a ban on

promotion and advertising of cannabis to prevent commercialization

will be important.

Policy-makers should look to jurisdictions with legalized cannabis that

prioritize public health and use evidence, not ideology, to guide policies.

Key points

Podcasts: author interview at
Cannabis legalization: adhering to public health best practice_1
Analysis1212 CMAJ, November 3, 2015, 187(16)
same rate, the latter are 3.73 times more likely to

be arrested for possession.
16 Finally, society pays
with high policing, court and prison costs.
Harms from regular cannabis use may be less

than those associated with other psychoactive

18 but they are still substantial at a pop-
ulation level. At higher doses, cannabis is a well-

established risk for motor vehicle crashes.
Combining alcohol with cannabis results in

greater impairment than either substance alone.
A recent study estimated that 6825–20 475 inju
ries from cannabis-attributed motor vehicle

crashes occur in Canada annually.
19 Each year in
Canada, 76 000–95 000 people undergo cannabis

addiction treatment and 219–547 cannabis-related

deaths occur (from injuries in motor vehicle

crashes and lung disease).
19 Youth are particularly
vulnerable to the effects of cannabis: regular users

frequently report loss of control over their canna
bis use,
22 have lower educational attainment23 and
may have, according to one cohort study, a drop

in IQ that persists into adulthood.
Often the harms from prohibition versus harms

from potential increased use of cannabis are

falsely pitted against each other. Evidence shows,

however, that cannabis prohibition has no effect

on rates of use, at least in developed countries.
Some have advocated for the removal of crimi
nal penalties for possession instead of legalization.

With Portugal’s experience in decriminalizing can
nabis, users benefit from reduced marginalization,

imprisonment and barriers to treatment, and soci
ety benefits from reduced policing, court and

prison costs.
17 The illegal supply chain, however,
continues to fund criminal activity. In addition, be
cause the government does not control the produc
tion, processing, supply or price of cannabis, it has

a limited ability to achieve public health goals.

What objectives should underpin


If policy-makers opt to legalize cannabis, careful

planning and comprehensive governmental con
trols would provide the greatest likelihood of

minimizing harms and maximizing benefits. A

cannabis legalization framework should explic
itly state that public health promotion and pro
tection are its primary goals. It should list spe
cific objectives,
5,29,30 including delayed onset of
use by youth; reduced demand; reduced risky

use (e.g., reduced impaired driving); decreased

rates of problematic use, addiction and concur
rent risky use of other substances; reduced con
sumption of products with contaminants and un
certain potency; increased public safety (e.g.,

reduced drug-related crime); reduced discrimina
tion, stigmatization and marginalization of users;

and realization of therapeutic benefits.

A frequently cited concern with legalization is

that it will allow the rise of Big Cannabis,
31 simi-
lar to Big Tobacco and Big Alcohol. These pow
erful multinational corporations have revenues

and market expansion as their primary goals, with

little consideration of the impact on public health.

They increase tobacco and alcohol use by lobby
ing for favourable regulations
32 and funding huge
marketing campaigns.
33 It is important that the
regulations actively work against the establish
ment of Big Cannabis.

Evaluating cannabis regulations

through a public health lens

There is scant direct evidence to guide the cre
ation of public health–oriented cannabis policies.

Fortunately, there is an extensive evidence base

for two other substances with potential for addic
tion and other harms: tobacco
3 and alcohol.4
With these data, researchers have proposed pol
icy frameworks for cannabis.
For our analysis, we built on previous

29,35–38 using a framework created by Can-
adian public health researchers
2 that was based
on a report by the Health Officers Council of

British Columbia.
5 We included jurisdictions
with well-articulated cannabis policies and regu
lations, which we analyzed from a public health

perspective using a systematic method (Table 1).


Uruguay follows the key public health best prac
40 It has established a central, governmental,
arm’s length commission to purchase cannabis

from producers and sell to distributors. The com
mission will have control over production, quality

and prices, and the ability to undercut the illegal

41 Uruguay has banned cannabis-impaired
driving and has set the cut-off for impaired driv
ing to a serum tetrahydrocannabinol (THC) level

of 10 ng/mL. Because of its zero-tolerance policy

for alcohol-impaired driving, the country has cre
ated a lower threshold for the combination of can
nabis and alcohol. Tax revenues will fund the

commission and a public health campaign. (Can
nabis will initially be sold tax free to undercut the

illegal market.) Uruguay bans all promotion of

cannabis products. Pharmacies will sell bulk can
nabis in plain bags, labelled only with the THC

percentage and warnings. (Sales are slated to start

early in 2016.) Individuals are permitted to grow

their own cannabis and to form growing co-

operatives. People who purchase or grow canna
bis will be registered and fingerprinted to prevent
Cannabis legalization: adhering to public health best practice_2
AnalysisCMAJ, November 3, 2015, 187(16) 1213
Table 1:
Policy strategies for the legalization of cannabis, and level of adherence by jurisdiction, based on an analysis of public
health best evidence from the regulation of tobacco and alcohol
Portion of core policies adhered to by jurisdiction









Uruguay Catalonia
Availability and accessibility

Control structure:
The government should form a central commission
with a monopoly over sales and control over production, packaging,

distribution, retailing, promotion and revenue allocation. The primary

goal should be public health promotion and protection (to reduce

demand, minimize harms and maximize benefits). The commission should

be at arm’s length from the government to resist interference with this

goal, such as industry influence and the government’s desire to increase

revenues from promoting sales, fees and taxation
Few or


Few or


Few or


Few or


Provision to consumers:
Cannabis should be sold only at licensed or
commission-operated retail outlets. Public health objectives should determine

the locations
and the appearance of the outlets. Health promotion messages
should be displayed.
Hours of operation should be limited.
Few or


Some Some Most NA
The price should be set high enough to reduce demand, and low
enough to undercut the illegal market
Few or


Few or


Few or

Purchase, consumption and use

There should be a minimum age for purchase. Purchases should
involve completing a form.
A limit should be placed on the amount of
daily purchases
Most Most Most Some Most
Locations for use:
The public should not be exposed to cannabis smoke. Use
should be restricted to licensed locations (or private homes). Cannabis lounges

should be neutral, not promote cannabis use and include health promotion

material. Alcohol and tobacco use should not be permitted.
Locations, hours
and amounts of a sale to an individual should be restricted
Cannabis and driving:†
Cannabis-impaired driving should be an offence
with a range of available legal sanctions. There should be active and visible

enforcement along with prevention campaigns
. Testing should be effect
based (i.e., road-side impairment testing) confirmed with blood testing.

Zero tolerance is not recommended because THC detection may occur long

after effects have resolved. There should be lower thresholds for the

combination of cannabis and alcohol because the effects are additive
Some Some Some Most Some

The commission should be the only organization permitted to
purchase cannabis from producers and sell to retailers
. It should support
small producers to prevent the growth of large, multinational corporations

with lobby power to achieve their profit-driven goals. Individuals should be

permitted to grow cannabis for personal use but not be allowed to sell


Few or


Few or


Few or

The cannabis product should be regulated (constituents and
. The THC percentage should be clearly labelled, with pricing policies
to favour products with low THC concentrations. Only bulk products should be

sold (i.e., no pre-made cigarette-type products), with the exception of

processed products for oral consumption to avoid the harms of inhalation.

Few or


Some Some Most Few or

Demand drivers/mitigators

Promotion and packaging:
All branding and promotion (e.g., advertising,
sponsorship and product placement§) should be banned. Partial bans

have little effect. Labels should include information on health risks.

ND Few or

Few or


School and public education campaigns:‡
The government should
support evidence-based school and public education campaigns to temper

demand. Large, mass-media campaigns should be avoided because they

can stimulate interest and increase use.

Dedicated revenue

Dedicated revenue: The revenue should be used for health and social


Few or


Most Most Most NA
Note: ND = not yet defined, NA = not applicable, NE = not evaluated, THC = tetrahydrocannabinol.

*Items in italics have moderate to strong evidence from the tobacco, alcohol and cannabis literature to support them. Other items have weaker evidence to support

them or are the authors’ recommendations
2 based on the cannabis literature and public health goals.
†Because cannabis-impaired driving was not addressed in the framework article,
2 we relied on other similar sources to create this section.19,20,28–30,34,39 This area is
rapidly evolving, with a currently unclear association between cannabis levels in bodily fluids and effects on driving. Policies should change as the evidence changes.

Evidence currently supports a blood THC level of 3.5–5 ng/mL (serum level 7–10 ng/mL) as a reasonable threshold for impaired driving. Per se laws (automatic

ticketing above a threshold concentration in blood even without demonstrated impairment) are gaining popular support. These laws concern some experts because

they may lead to charges for individuals who are not impaired.

‡Evidence-based school and public education campaigns can be effective measures in reducing demand and harm. However, we excluded them from our analysis

because of the complexity and difficulty of ascertaining what is happening in each jurisdiction.

§See examples in Appendix 1 (available at
Cannabis legalization: adhering to public health best practice_3

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