The Cannabis Policy Framework by the Centre for Addiction and Mental Health: A proposal for a public health approach to cannabis policy in Canada

This editorial discusses the Cannabis Policy Framework proposed by the Centre for Addiction and Mental Health (CAMH) in Canada, which recommends legalisation, in conjunction with strict health-focused regulation, as the most effective means of reducing the harms associated with cannabis use. The article provides evidence on the harms of cannabis use and the limitations of decriminalisation, and proposes a public health approach to cannabis policy involving population-based measures and targeted interventions focused on high-risk users and practices. The article also offers ten principles to guide regulation of legal cannabis use.

Editorial
[3_TD$DIFF]The Cannabis Policy Framework by the Centre for Addiction and Me
Health: A proposal for a public health approach to cannabis policy
in Canada
Introduction
In October 2014 the Centre for Addiction and MentalHealth
(CAMH), Canada’s largest academic health science centre devoted
to mental illness and substance use (Rehm et al., 2011), released a
CannabisPolicy Framework (CAMH,2014). An interdisciplinary
expert group from across CAMH’s clinical and research (both brain
science and social/epidemiological research) programs studied the
evidence around cannabis-related harm, existing models of
cannabis control, and public health approaches to substance
use. Following nearly a year of debate, the group came to a
consensus on the position outlined in the Cannabis Policy
Framework:that legalisation,in conjunction with strict health-
focused regulation,appears to be the most effective means of
reducing the harms associated with cannabis use (CAMH,2014).
CAMH’s engagement in public policy development is rooted in
the work of the Addiction Research Foundation (ARF),one of its
four predecessor organizations (Rehm et al., 2011). In 1997 the ARF
released a paper calling for a public health approach to cannabis
(Addiction Research Foundation, 1997). In 2000, the newly formed
Centre for Addiction and MentalHealth recommended decrimi-
nalising simple possession of cannabis (CAMH, 2000); this position
was reiterated between 2002 and 2008 in a series of position
papers and policy submissions.In 2012, as part of its strategic
planning process, CAMH began conducting a systematic review of
its public policy positions,including cannabis.
By coincidence,the period in which CAMH conducted this
review was one in which cannabis reforms were occurring in other
jurisdictions, notably Uruguay, Colorado and Washington,and
cannabis policy was becoming a politically charged topic in
Canada. In July 2013, Liberal Party leader (and now Prime Minister)
Justin Trudeau announced that, if elected, his party would legalise
and regulate cannabis; the following month,he admitted having
smoked cannabis since becoming a Member of Parliament
(National Post, 2013). The ruling Conservative Party reiterated
its commitment to the status quo,emphasizing its opposition to
legal reform of cannabis control and widely stating that the Liberal
approach to legalisation would ‘‘make buying marijuana a normal,
everyday activity for young Canadians’’(National Post,2014).In
mid-2014 three physicians’ groups declined to join a Health
Canada anti-cannabis campaign,stating that it had become ‘‘a
political football on Canada’s marijuana policy’’ (CBC News, 2014).
It was into this shifting policy environment that CAMH released
the Cannabis Policy Framework in October 2014.
Cannabis and harm
In Ontario, 14% of adults and 23% of high-school students report
past-year cannabis use (Boak,Hamilton, Adlaf, & Mann, 2013;
Ialomiteanu, Hamilton, Adlaf, & Mann, 2014). Among young adults
aged 18 to 29, self-reported prevalence is 40% (Ialomiteanu, Adlaf,
Hamilton, & Mann, 2012). Approximately 4% of the adult
population and 3% ofhigh-school students use cannabis every
day (Boak et al.,2013; Health Canada,2013),and 20% of users
account for 80–90% of consumption (Room, Fischer, Hall, Lenton, &
Reuter,2010).These patterns,in which a small portion of users
account for a lion’s share of consumption, mirror those observed in
Canada for alcohol (Thomas,2012) and gambling (Williams &
Volberg,2013).
Cannabis use is associated with a range of harms. Use may lead
to cannabis use disorders (Lopez-Quintero et al.,2011) and may
cause short[5_TD$DIFF]-term and chronic health problems (Hall & De
2009; Volkow et al., 2016; World Health Organization, 2016). Most
important from a public health perspective apart from cannabis
use disorders are traffic injuries caused by driving under the
influence of cannabis[6_TD$DIFF],and lung cancers as a consequence of
smoking cannabis (Fischer, Imtiaz, Rudzinski, & Rehm,[7_TD$DIFF]2016;
Imtiaz et al.,2016).Youth are particularly vulnerable: there is a
strong and growing body of evidence that regular cannabis use in
adolescence can harm the developing brain (George & Vaccarino,
2015),possibly in a permanent way (Volkow et al.,2016).People
with a personal or family history of mental illness are at increased
risk of harm (McLaren,Silins,Hutchinson,Mattick, & Hall, 2009).
Apart from frequent use and early initiation, important risk factors
include product potency and formulation and delivery mechanism
(Fischer et al.,2011).
For health-focused cannabis policy,two facts about cannabis-
related harm are particularly important:
First, the legal status of cannabis has an impact on its users,
independent of the health effects. In Canada, where our approach
to cannabis relies primarily on law enforcement,and cannabis
possession and use are criminaloffences under the Controlled
Drugs and Substances Act,social harms of prohibition include
International Journal of Drug Policy 34 (2016) 1–4
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exposure of cannabis users to criminality and other illegal drugs,
and a criminal record for simple possession that can impact on
social status, employment and travel (Erickson & Fischer, 1995).
Further, cannabis possession laws tend to be applied inequitably,
with marginalized and vulnerable populations disproportion-
ately targeted (Khenti, 2014; Wortley & Owusu-Bempah, 2012).
Second, at the levels and patterns of use reported by most adult
cannabis users, the health risks are relatively modest –
significantly lower than those for tobacco or alcohol(Lachen-
meier & Rehm, 2015; Nutt, King, & Phillips, 2010; for a
comparison for Canada: Imtiaz et al., 2016). Chronic health
harms are concentrated among a limited sub-group of high-risk
users who use cannabis frequently and/or began to use it at an
early age (Fischer et al.,2011).
Criminalizing the use of psychoactive substancescauses a
variety of health and social harms without dissuading use or
preventing harm (Canadian Public Health Association, 2014; Room
et al., 2010). This is evident in Canada: Canadian youth rank first in
cannabis use but third from last in tobacco use – even though
cannabis is illegal while tobacco is legal (UNICEF Office of Research,
2013). In accessing cannabis they are exposed to illicit drug
markets and culture and have little or no reliable information
about the potency or quality of the cannabis they consume. While a
public health approach that focuses on modifiable risk factors like
age of initiation, frequency and intensity of use, consumption
practices and settings, and impaired driving could have a profound
impact in reducing cannabis-related harm (Fischer et al., 2011), the
illegal status of cannabis makes this challenging if not impossible
to implement such an approach effectively (Canadian Public
Health Association,2014).
Policy options
Uruguay and several US states have legalized recreational
cannabis use or taken steps towards doing so. In Canada,calls for
legal reform to cannabis controlhave been made since at least
1972,when the Le Dain Commission recommended repealing the
prohibition of cannabis use. In the intervening decades it has only
become clearer that prohibition is ineffective, costly, and
constitutes poor public policy.
CAMH’s previous position called for cannabis possession to be
converted from a criminal offence to a civil violation, based on the
assessment that the criminal justice system was an inappropriate
control mechanism: that the ‘‘individual consequences of a criminal
conviction, the costs of enforcement, and the limited effectiveness of
the criminal control of cannabis use’’ are overly harmful and
disproportionate to the effects of such use (CAMH,2000, p. 2).
Upon review, the CAMH expert group found several flaws with
decriminalisation. Its main theoretical benefit is the removal of the
social harms of criminalisation.However:
It may encourage the production and distribution of cannabis[8_TD$DIFF],
without giving government any additional control tools.
It does not address the health harms of cannabis use.
The pattern of unequal enforcement ofcannabis laws that is
characteristic of many jurisdictions (including Canada) means
that decriminalisation may not reverse health inequities,but
rather may simply perpetuate or even increase them (Room et al.,
2010).
If the optimal approach to cannabis policy is one that will tackle
both the health and social harms associated with its use,
decriminalisation does not qualify.Despite its advantages over
the current Canadian model it is at best a half-measure.
What should be the goalof cannabis policy? Answering this
question necessarily involves an element of normative judgment.
In the case of CAMH, the answer has historically been that the
overriding goal of cannabis policy – and for that matter drug policy
in general – should be to reduce cannabis-attributable harm to
individuals and society. Our goal with the Cannabis Policy
Framework was to recommend, based on a thorough and
dispassionate review ofthe evidence,the legal and regulatory
approach most likely to effectively reduce the harms associated
with cannabis use.
A public health approach to substance use treats it as a health
issue – not a criminal one – using evidence-based policy and
practice and placing health promotion and the prevention of death,
disease,injury, and disability as its central mission (Canadian
Public Health Association,2014).
A public health approach to cannabis would involve both
population-based measures and targeted interventions focused on
high-risk users and practices. An illegal substance,of course,
cannot be regulated.Legalisation ofcannabis presents govern-
ments with the opportunity to exert control over risk factors, using
regulation to reduce health harms.Legalisation is just a starting
point; the key to ensuring that the effects of legalisation are
positive lies in choosing the right mix of health-focused regula-
tions and properly implementing them.
CAMH recommendations
It is important to note the parameters of our review.
Legalisation in Canada would be a complex undertaking requiring
changes to the federal criminal code and possibly to international
drug control treaties, as well as provincial rules of implementation
– but we did not make recommendations on those areas. Similarly,
cannabis production was beyond the scope of the review. Rather,
our focus was on policies to reduce the health and social harms of
cannabis use.
There are of course few examples oflegal markets for non-
medical cannabis,and none of them with an evaluation of mid-
term or long-term consequences. Although such markets had been
established in Colorado and Washington at the time of writing,
from our perspective regulations in those states were insufficiently
public health-focused. The guidelines we proposed in the Cannabis
Policy Framework were instead modeled after evidence-based
alcohol and,to a lesser degree,tobacco policies.
Over the past few decades a consensus has emerged regarding
effective policies and interventions to reduce alcohol-related
harms: strategies to reduce harm must be coordinated and multi-
sectoral, with effective controls on availability (e.g. retail location
density, hours of sale) and accessibility (e.g. minimum age
requirements, price levels), bans on marketing and advertisement
as well as targeted education and health promotion that sensitize
the public – particularly vulnerable groups – to harms and risks
(Anderson et al., 2016; Babor et al., 2010; World Health
Organization, 2010). The evidence also suggests that such
strategies – as well as measures ofquality control – are more
effectively implemented and maintained where the alcohol retail
system is government-run than where it is privately operated, and
that jurisdictions with public monopolies on alcohol sales tend to
have less alcohol-related harm relative to those with private
systems (Anderson,Chisholm,& Fuhr, 2009; Babor et al.,2010;
Giesbrecht, Her, Room, & Rehm, 1999). In Canada, some provinces
that privatized alcohol sales in whole or in part have seen an
increase in retail density, hours of sale, and sales to minors – with a
concomitant increase in alcohol-related harms (Stockwellet al.,
2013; Giesbrecht et al.,1999).
Based on this evidence, the Cannabis Policy Framework proposes a
public monopoly on cannabis sales and controls on availability and
Editorial / International Journal of Drug Policy 34 (2016) 1–42

accessibility[9_TD$DIFF],as well as implementing interventions impacting the
risk factors identified in Fischer et al.,2011,e.g.age of initiation,
frequency/intensity of use, use practices and settings, and impaired
driving. It offers ten principles to guide regulation of legal cannabis
use. These were deliberately kept quite broad, framed as ‘‘a starting
point – minimum requirements for a public health-focused
regulatory framework’’(CAMH, 2014,p. 12).They are reproduced
here verbatim from the Framework (CAMH, 2014,pp. 12–13):
1) Establish a governmentmonopoly on sales. Control board
entities with a social responsibility mandate provide an
effective means of controlling consumption and reducing
harm.
2) Set a minimum age for cannabis purchase and consumption. Sales
or supply of cannabis products to underage individuals should
be penalised.
3) Limit availability.Place caps on retail density and limits on
hours of sale.
4) Curb demand through pricing.Pricing policy should curb
demand for cannabis while minimising the opportunity for
continuation of lucrative black markets. It should also
encourage use of lower-harm products over higher-harm
products.
5) Curtail higher-risk products and formulations.This would
include higher-potency formulations and products designed
to appeal to youth.
6) Prohibit marketing, advertising,and sponsorship.Products
should be sold in plain packaging with warnings about risks
of use.
7) Clearly display productinformation.In particular, products
should be tested and labelled for THC and CBD content.
8) Develop a comprehensive framework to address and prevent
cannabis-impaired driving.Such a framework should include
prevention,education,and enforcement.
9) Enhance accessto treatmentand expand treatmentoptions.
Include a spectrum of options from brief interventions for at-
risk users to more intensive interventions.
10) Invest in education and prevention. Both general (e.g. to promote
lower-risk cannabis use guidelines) and targeted (e.g. to raise
awareness of the risks to specific groups, such as adolescents or
people with a personal or family history of mental illness)
initiatives are needed.
The Framework notes that in order for legalisation to result in a
net benefit to public health and safety, any government reforming
Canada’s system of cannabis control must commit to public health
and safety as the primary and overriding imperative,establish
measurable indicators, build in the capacity and flexibility to adjust
as needed based on the measured impact of reforms, and protect the
resulting regulatory framework from commercial and fiscal inter-
ests (both private and public).The next steps would be operatio-
nalization of these principles and concrete implementation.For
example, a comprehensive framework on impaired driving will need
to include a per se law on driving under the influence of cannabis as
well as guidelines for its enforcement via sobriety checkpoints or
random testing (World Health Organization, 2015). Similarly,
operationalizing the curtailing of high-risk formulations will involve
concrete recommendations to avoid mixing cannabis with tobacco
as well as other recommendations along the lines of the lower-risk
guidelines for cannabis use (Fischer et al., 2011).
Conclusion
CAMH’s review of the evidence led to the conclusion that
legalisation is a necessary – but not a sufficient – condition for
reducing health and socialharms associated with cannabis use.
Some people will use cannabis regardless of its legal status,and a
significant advantage of legalisation is that it creates the opportunity
for more control over the risk factors associated with cannabis-
related harm through a public health approach to regulation.
Conflict of interest
The authors declare to have no conflict of interest[1_TD$DIFF].
References
Addiction Research Foundation (ARF) (1997).Cannabis,health and public policy.Re-
trieved from http://www.camh.ca/en/hospital/about_camh/influencing_public_
policy/Documents/Cannabis%20HealthPublicPolicy1997.pdf
Anderson, P., Chisholm, D., & Fuhr, D. (2009). Alcohol and Global Health 2: Effectiveness
and cost-effectiveness of policies and programmes to reduce the harm caused by
alcohol.Lancet,373,2234–2246.
Anderson, P., Braddick, F., Conrod, P., Gual, A., Hellman, M.,Matrai, S., et al. (2016). The
new governance of addictive substances and behaviours.Oxford: Oxford University
Press.
Babor, T., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N.,Graham, K., et al. (2010).
Alcohol:No ordinary commodity – Research and public policy (Revised edition).
Oxford: Oxford University Press.
Boak, A., Hamilton, H., Adlaf, E. M., & Mann, R. E. (2013).Drug use among Ontario
students, 1977–2013: Detailed OSDUHS findings. CAMH Research Document Series N
36.Toronto: CAMH.
Centre for Addiction and Mental Health (2000).The legal sanctions related to cannabis
possession/use.Retrieved from http://www.camh.ca/en/hospital/about_camh/
influencing_public_policy/Documents/CannabisPositionPaper2000.pdf
Centre for Addiction and Mental Health (2014).Cannabis policy framework.Retrieved
from http://www.camh.ca/en/hospital/about_camh/influencing_public_policy/
Documents/CAMHCannabisPolicyFramework.pdf
Canadian Public Health Association (2014). A new approach to managing illegal psycho-
active substances in Canada,CPHA Position Paper.Ottawa: CPHA.
CBC News (2014).Canada’s doctors decline to join anti-marijuana campaign.Retrieved
from http://www.cbc.ca/news/politics/canada-s-doctors-decline-to-join-anti-
marijuana-campaign-1.2738595
Erickson, P. G., & Fischer, B. (1995). Canadian cannabis policy: The impact of criminaliza
tion, the current reality and future policy options. Retrieved from http://www.parl.gc.
ca/Content/SEN/Committee/371/ille/presentation/erickson1-e.htm
Fischer,B., Jeffries,V., Hall, W., Room,R., Goldner,E., & Rehm,J. (2011).Lower risk
cannabis use guidelines: A narrative review of evidence and recommendations.
Canadian Journal of Public Health,102,324–327.
Fischer,B., Imtiaz, S.,Rudzinski,K., & Rehm,J. (2016).Crude estimates of cannabis-
attributable mortality and morbidity in Canada: Implications for public health
focused intervention priorities.Journal of Public Health,38,183–188.
George,T., & Vaccarino,F. (Eds.).(2015).Substance abuse in Canada:The effects of
cannabis use during adolescence.Ottawa: Canadian Centre for Substance Abuse.
Giesbrecht, N., Her, M., Room, R., & Rehm, J. (1999). Impacts of privatization: What do
we know and where should we go? Addiction,94,1146–1153.
Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use.
Lancet,374,1383–1391.
Health Canada, Controlled Substancesand Tobacco Directorate (2013).Canadian
Alcohol and Drug Use Monitoring Survey (CADUMS)– Detailed tablesfor 2012.
Ottawa: Health Canada.
Ialomiteanu, A. R., Adlaf, E. M., Hamilton, H., & Mann, R. E. (2012). Addiction and mental
health indicators among Ontario adults, 1977–2011. CAMH Research Document Serie
No. 35.Toronto: CAMH.
Ialomiteanu,A. R., Hamilton, H., Adlaf, E. M., & Mann, R. E. (2014).CAMH Monitor
eReport 2013:Substance use,mentalhealth and well-being among Ontario adults,
1977–2013.CAMH Research Document Series No.40.Toronto: CAMH.
Imtiaz, S., Shield, K. D., Roerecke, M., Cheng, J., Popova, S.,Kurdyak, P., et al. (2016). The
burden of disease attributable to cannabis use in Canada in 2012.Addiction,111,
653–662.
Khenti, A. (2014). The Canadian war on drugs: Structural violence and unequal
treatment of Black Canadians.International Journal of Drug Policy,25,190–195.
Lachenmeier, D. W., & Rehm, J. (2015). Comparative risk assessment of alcohol, tobacco
cannabis and other illicit drugs using the margin of exposure approach.Scientific
Reports,5, 8126.
Lopez-Quintero, C., Pe´rez de los Cobos, J., Hasin, D. S., Okuda, M., Wang, S.,Grant, B. F.,
et al. (2011). Probability and predictors of transition from first use to dependence
on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic
Survey on Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence,
115,120–130.
McLaren, J., Silins, E., Hutchinson, D., Mattick, R., & Hall, W. (2009). Assessing evidence
for a causal link between cannabis and psychosis: A review ofcohort studies.
International Journal of Drug Policy,21,10–19.
National Post (2013). Justin Trudeau set ‘poor example for all Canadians’ by smoking pot
since becoming an MP: Conservatives. Retrieved from http://news.nationalpost.com/
news/canada/justin-trudeau-set-poor-example-for-all-canadians-by-smoking--
pot-since-becoming-an-mp-conservatives
Editorial / International Journal of Drug Policy 34 (2016) 1–4 3

National Post (2014). Conservative government asks Canadian doctors to endorse taxpay-
er-funded ad campaign against marijuana. Retrieved from http://news.nationalpost.
com/news/canada/conservative-government-asks-canadian-doctors-to-endorse--
taxpayer-funded-ad-campaign-against-marijuana
Nutt, D. J., King, L. A., & Phillips, L. D. (2010).Drug harms in the UK: A multicriteria
decision analysis.Lancet,376,1558–1565.
Rehm,J., Giesbrecht,N., Gliksman,L.,Graham,K., Le,A. D., Mann, R. E.,et al.(2011).
Substance abuse research in a modern health care centre: The case of the Centre for
Addiction and Mental Health.Addiction,106,689–697.
Room,R.,Fischer,B.,Hall, W., Lenton,S.,& Reuter,P. (2010).Cannabis policy: Moving
beyond stalemate.Oxford: Oxford University Press.
Stockwell, T., Zhao, J., Macdonald, S., Vallance, K., Gruenewald, P., Ponicki, W., et al. (2013).
Impact on alcohol-related mortality of a rapid rise in the density of private liquor
outlets in British Columbia: A local area multi-level analysis. Addiction, 106, 768–776.
Thomas, G. (2012). Analysis of beverage alcohol sales in Canada. Alcohol Price Policy Series:
Report 2.Ottawa: Canadian Centre on Substance Abuse.
UNICEF Office of Research (2013).Child well-being in rich countries:A comparative
overview.Innocenti Report Card 11.Florence: UNICEF Office of Research.
Volkow, N. D., Swanson, J. M., Evins, A. E., DeLisi, L. E., Meier, M. H.,Gonzalez, R., et al.
(2016).Effects of cannabis use on human behavior,including cognition,motiva-
tion, and psychosis: A review.JAMA Psychiatry,73,292–297.
Williams, R. J., & Volberg, R. A. (2013). Gambling and problem gambling in Ontario. Report
prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry
of Health and Long-Term Care.Retrieved from https://www.uleth.ca/dspace/
handle/10133/3378
World Health Organization (2010). Global strategy to reduce the harmful use of alcohol.
Geneva: WHO.
World Health Organization (2015).Globalstatus report on road safety 2015.Geneva:
WHO.
World Health Organization (2016). The health and social effects of non-medical cannabis
use.Geneva: WHO.
Wortley, S., & Owusu-Bempah, A. (2012). Race, ethnicity, crime and criminal justice in
Canada. In A. Kalunta-Crumpton (Ed.), Race,ethnicity, crime and criminal justice in
the Americas.New York: Palgrave Macmillan.
Jean-Franc¸ois Cre´pault*
Centre for Addiction and Mental Health,Canada
Ju¨rgen Rehma,b
Benedikt Fischera,b
a
Centre for Addiction and Mental Health,Canada
b
University of Toronto,Canada
*Corresponding author.Tel.: [phone]
E-mail address: [e-mail] (J.-F.Cre´pault).
Editorial / International Journal of Drug Policy 34 (2016) 1–44