Regulating Cannabis Use in Canada Based on Public Health Criteria

This commentary argues that the economic, social and health consequences of legalizing cannabis in Canada will depend on the exact stipulations and on the implementation, regulation and practice of the legalization act. A strict regulatory framework is necessary to minimize the health burden attributable to cannabis use.

The Devil Is in the Details! On Regulating Cannabis Use in
Canada Based on Public Health Criteria
Comment on “Legalizing and Regulating Marijuana in Canada: Review of Potential
Economic, Social, and Health Impacts”
Jürgen Rehm1,2,3,4,5,6,7*, Jean-François Crépault8, Benedikt Fischer1,3,4,9
Abstract
This commentary to the editorial of Hajizadeh argues that the economic, social and health consequences of
legalizing cannabis in Canada will depend in large part on the exact stipulations (mainly from the federal
government) and on the implementation, regulation and practice of the legalization act (on provincial and
municipal levels). A strict regulatory framework is necessary to minimize the health burden attributable to
cannabis use. This includes prominently control of production and sale of the legal cannabis including control of
price and content with ban of marketing and advertisement. Regulation of medical marijuana should be part of
such a framework as well.
Keywords: Cannabis, Marijuana, Health Burden, Legalization, Regulation, Production, Sale, Medical Marijuana
Copyright: © 2017 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Citation: Rehm J, Crépault JF, Fischer B. The devil is in the details! On regulating cannabis use in Canada based
on public health criteria: Comment on “Legalizing and regulating marijuana in Canada: review of potential
economic, social, and health impacts.” Int J Health Policy Manag. 2017;6(3):173–176. doi:10.15171/ijhpm.2016.114
*Correspondence to:
Jürgen Rehm
Email:[e-mail]
Article History:
Received: 1 July 2016
Accepted: 13 August 2016
ePublished: 20 August 2016
Commentary
Full list of authors’ affiliations is available at the end of the article.
http://ijhpm.com
Int J Health Policy Manag 2017, 6(3), 173–176 doi 10.15171/ijhpm.2016.114
The Current Situation in Canada: Waiting for a Federal
LegalizationFramework
Canada will become one of the first countries to fully legalize
cannabis consumption on a national level (as announced at
the United Nations General Assembly Special Session on
drugs 2016),1 and Hajizadeh2 tries to summarize the potential
economic, social and health consequences of such a move. We
will argue here that all of these consequences will depend in
large part on the exact stipulations (mainly from the federal
government)and on the implementation,regulationand
practice of the legalization act on provincial and municipal
levels (for similar considerations for the United States see).3,4
The federal government’s point person on the legalization
of marijuanahas declaredthat legalizationwould be
implemented within a public health framework,5 and he spoke
about strict controls (for a general overview on regulation and
public health).6,7 However, even with such a framework there
are different options, and further, the provinces will likely be
given some latitude to regulate legal cannabis. The devil will
be in the details.
As a generalbackground,substancepolicies matter.8
Psychoactivesubstanceuse is amongthe leadingrisk
factors for global burden of disease,9 and the last decades
have shown that wrong policies may even lead to reversals
in the monotonous upward trends of life expectancy that
characterized most of the last century.10,11 The importance
for public health of getting substance policies right has been
shown in regards to legal substances,12,13illegal substances,14
and pharmaceuticals10 (for more general discussions see8,10,15
).
There are also economic costs to society, which depe
the policies implemented,16 and these costs affect not only the
healthcare system but also the educational, legal, an
systems.17,18The mere fact of whether a substance use is leg
or not does not predict the resulting burden of disease, an
consequently, legalization may result in negative or posit
health outcomes, depending on how the legal and regula
framework is designed and implemented.
Given the above background and the situation in Canada,
current contribution has two main objectives. First, we wi
give an overview of how regulations and implementation
impact on the main behavioural drivers of cannabis-relate
harm. Second, we give a few examples of how the details
these regulations may impact on the actual outcomes.
Cannabis-Related Health Harms and Policy
As cannabis use per se in a legalized framework has
criminalconsequences,we needto establishregulations
which would reduce the cannabis use behaviours link
most of the health burden. This current health burden ma
comprises cannabis use disorders as the most important
fatal health outcome, and injury fatalities, especially
injury fatalities19 as the most important mortality outcom
(for a quantification for Canada see20,21
). The most important
behaviours linked to burden are the following (see al21
):
• Heavy use/frequent use over time22,23
• Mixing of cannabis use and operating machinery

Rehm et al
International Journal of Health Policy and Management, 2017, 6(3), 173–176174
particular driving a car)24,25
• Using cannabis with high tetrahydrocannabinol (THC)26
• Smoking cannabis, especially mixed with tobacco22
• Using cannabis in early and mid-adolescence26,27
How could regulation play a role in reducing these behaviours?
Education and guidelines may play a role in reducing heavy
and frequent use (for guidelines see22
). One way to finance
such efforts would be via a dedicated tax, which would be
used for prevention,research,education,and treatment.
Examples of such taxes exist in the alcohol and tobacco field,28
and justification could be derived from classical economic
theory.29,30 Anotherway to impacton frequencyof use,
especially in adolescents (above legal age) and young adults,
is via price (and indirectly via taxation). Alcohol and tobacco
policies have shown that price is a powerful tool to influence
level of use,31,32and specific taxation schemes may even impact
on onset of substance use.33,34 Finally, again drawing from
alcohol and tobacco, a ban on marketing and advertisement
contributes to establish cannabis as no ordinary commodity
where certain caution in use patterns are required.15
Mixing cannabis use and driving (or operating machinery)
should be avoided independently of the policy environment.
Even though there had been studies showing no significant
results of cannabis use on driving,35 systematic reviews of all
relevant studies and subsequent pooling of results show an
impact,24,25and the biological pathways on reaction time and
psychomotor coordination are similar between operating a
car and other machinery.19,36Thus, per se laws similar to the
ones governing blood alcohol level to prevent such behaviour
(ie, no driving or operating machinery with active levels of
Δ9-tetrahydrocannabinol which could impair reaction time
and psychomotor coordination) should be established.37,38
Using cannabis in early and mid-adolescence poses specific
health risks,26,27including risk on the developing brain. Thus,
a minimum purchasing age needs to be implemented similar
to alcohol39 (which has similar or even more detrimental
effects40
). Moreover, this laws needs to be well-enforced, and
experience with alcohol has shown that best enforcement can
be achieved can be achieved through a state monopoly on
sales.39
Usingcannabiswith high tetrahydrocannabinolcontentis
becomingmore commonin some countries,41 and the
effects on health (compared to lower THC) can be more
detrimental.19,26 Obviously, THC content can and should be
regulatedin legalizedenvironments,similarto regulated
ingredientsin food, alcoholicbeveragesor other legal
substances. This could take the form of pricing policies that
make higher-potency products are more expensive than those
with lower potency.
Smoking cannabis, especially with tobacco, adds additional
risk, especially with respect to respiratory disease.19 Again,
there should be more education on these specific risks, and
there should be encouragement of smoke-free and tobacco-
free modes of cannabis use in a legalized environment.
Furthermore, there may be some short-term public health
consequencesof legalizationrelatedto cannabis-related
emergency department visits,42,43which may be avoided with
specific implementations (see recent proposed changes in
Colorado as listed in43
).
… and Further Details
The above examples show that regulation can contribute
a reduction in behaviours which have been associate
health harm. However, things are not that simple. Much w
depend on controlling the way the legal substance is prod
and sold (and we will restrict the following discussion to t
latter point).
For cannabis another complication comes into play, w
does not exist for other legal psychoactivesubstances
like alcohol or tobacco: medical use.44 Medical marijuana
programs have proliferated in the United States and Cana45
in part because they allowed higher availability of an illeg
substance without changing narcotic laws. Depending
the jurisdiction, some of the usual regulatory principl
pharmaceuticalproductapprovalare not required,with
the consequencethat cannabisis frequentlyprescribed
for conditions where its effect is not clear46 or may even be
detrimental, such as depression or anxiety disorders.47-49In a
regulated legal environment, medical use of cannabis sho
be restricted to disorders where clear evidence of effectiv
has been established through the same rigorous proc
approval as other pharmaceuticals, usually via a serie
phases ending with randomized controlled trials in human
to establish efficacy in treating certain conditions.50 This
would ensure avoidance of problems such as mis-indicatio
as mentioned above. It should be stated that medical rese
with cannabis has historically faced barriers in the U
States,51 but this is not an issue in Canada.
Even if these principles are adhered to, there is a q
of what should happen to currently established canna
dispensaries in the interim, or in the long run. The controv
in Toronto after the recent police raids of illegal dispensar
provides some illustration.52 In these controversies, some
argued that no police action should be have been ta
because cannabis will be legalized within less than a
while others maintained that they were justified because
dispensaries violate the current law for medical marijuana
addition, the type of dispensaries setting up shop in Toron
may not have a place in the new legal framework, but the
presence (and increasing numbers) is creating facts o
ground. The longer this persists, the more challengin
will be for the federal government’s preferred legal canna
framework to succeed.
Again, the situation is not entirely historically new as illeg
producers and sellers of alcohol had to be integrated into
new system after the prohibition of alcohol was lifted
North America. This worked quite well, and moonshine an
other illicitly produced alcohol currently play little rol
either Canada or the United States.53 The creation of a state
monopoly that offers market prices to producers may
solution here, which had worked for unrecorded alcohol in
Germany at the time.54
Thus, while the debate on legalization of cannabis has oft
been categorical between its proponents and adversaries
true challenge will be the exact implementation. If C
does not get these regulations correct, public health prob
may be created,with subsequentcoststo society,which
may exceed the new tax revenues.16 On the other hand, if
regulations are carefully introduced based on best av
evidence (and admittedly some of this evidence will

Rehm et al
International Journal of Health Policy and Management, 2017, 6(3), 173–176 175
from other fields),55 with independentmonitoringand
surveillance, and with openness to change in case of negative
developments, Canada has a chance to become a leader as an
experimentingsociety.56-58
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
JR wrote the drafts for the original and revised version of the
commentary. All authors significantly contributed to the text, and have
approved of the final version.
Authors’ affiliations
1Institute for Mental Health Policy Research, Centre for Addiction and
Mental Health (CAMH), Toronto, ON, Canada.2Addiction Policy, Dalla
Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
3Institute of Medical Science, University of Toronto, Faculty of Medicine,
Toronto, ON, Canada. 4Department of Psychiatry, University of Toronto,
Toronto, ON, Canada.5Institute of Clinical Psychology and Psychotherapy,
Technische Universität Dresden, Dresden, Germany. 6Center of
Clinical Epidemiology and Longitudinal Studies (CELOS), Technische
Universität Dresden, Dresden, Germany.7Campbell Family Mental Health
Research Institute, CAMH, Toronto, ON, Canada. 8Communications and
Partnerships, CAMH, Toronto, ON, Canada.9Centre for Applied Research
in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser
University, Vancouver, BC, Canada.
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