A common public health-oriented policy framework for cannabis, alcohol and tobacco in Canada?

Kirst, Maritt ; Kolar, Kat ; Chaiton, Michael 等

Recent policy shifts to the legal regulation of cannabis in Colorado, Washington State, Oregon, Alaska and Uruguay have led experts and policy-makers across Canada to explore possibilities for regulatory models that could replace the current framework of prohibition. (1-4) These unprecedented policy shifts provide an opportunity to apply public health lessons from alcohol and tobacco regulation to cannabis, and to address the harms and limitations of strict prohibition with respect to controlling illegal cannabis markets and individual use. (2-6) To explore these policy reform opportunities, an interdisciplinary drug policy meeting was held in May 2014 in Toronto, Canada with 19 national experts and knowledge users in the area of substance use interventions and regulatory practices, including: addiction researchers from across Canada; professors and doctoral students in public health, sociology, medicine and law; addiction medicine physicians; and knowledge users from Toronto Public Health, Ontario Ministry of Health and Long-Term Care, and the Canadian Drug Policy Coalition. The meeting explored possibilities for applying cross-substance learning to policy interventions associated with tobacco, alcohol and cannabis, with the goal of advancing a public health framework for reducing substance use-related harms. Such a harm reduction-oriented public health framework involves a pragmatic orientation which explicitly focuses on harms from drug use rather than use itself, and prioritizes reductions in health risks and social harms over other goals, such as punishment or drug abstinence. (1,7) This commentary summarizes the insights generated at this meeting and outlines next steps for advancing a public health policy framework for substance use in Canada.

Meeting participants agreed that current policies regulating tobacco, alcohol and cannabis in Canada do not correspond to the relative risks of these substances. Tobacco is responsible for the greatest burden of illness and has no known safe exposure level, yet is regulated as a widely available commercial product. (1-3) Alcohol ranks second with respect to burden of illness, and like tobacco, is a legally regulated commercial product subject to various production and distribution controls. (1-3,8,9) Research outlines several cannabis-related harms (e.g., acute effects such as anxiety/panic and injuries consequent to intoxication; chronic effects such as risk of dependence and risks to youth development). For example, 4-12% of vehicle-related fatalities and/ or injuries in Canada are estimated to involve cannabis, indicating need for improved interventions to deter cannabis-impaired driving and treat substance use disorders. (10) However, this evidence does not indicate that cannabis causes as much harm as alcohol or tobacco. (2,3,5) Complicating the cannabis harm discourse is a growing literature and examination by many jurisdictions (including Canada, 23 US states, and the District of Columbia) of the potential therapeutic utility of cannabis. (1,2,5) Yet in Canada, cannabis possession in the absence of a medical marijuana license is a criminal offense punishable by a $1,000 fine and/or six months imprisonment and a criminal record. Enforcement of cannabis criminalization is costly, has failed to significantly deter use at a population level or minimize potential harms of use, and may result in serious social harms for individuals convicted of cannabis offenses. (2,3,7) In response, the newly elected federal Liberal party has proposed the legalization of cannabis in Canada.

At the meeting, there was general consensus that the harms of cannabis criminalization are disproportionate to the harms of use. (1,2) When cannabis regulation was considered from a harm reduction, public health perspective, consensus was reached that we cannot ignore the potential benefits of legal regulation. Research on jurisdictions legally regulating production, distribution and use of cannabis suggests that such benefits may include reduction of drug market-related violence, potential reduction of alcohol and illegal substance use through drug substitution, separation of cannabis from other illegal drug markets, and less criminalization of users. (1-3,11-13) Thus, from a public health point of view, there may be net benefit of legally regulating cannabis. (7)

Developing a public health approach for cannabis regulation provides an opportunity to explore policy reform for tobacco and alcohol as legal substances associated with a heavy burden of illness. (6) Participants agreed that policy frameworks governing tobacco, alcohol or cannabis should all aim to promote public health, restrict advertisement and promotion, and establish monitoring and surveillance capacity. Policy frameworks should be tailored to account for different risk profiles, administration routes, use patterns and psychoactive effects of each substance. Further, tobacco, alcohol and cannabis require different approaches to denormalization--that is, actions and programs taken to influence social norms so as to discourage harmful use such as binge drinking of alcohol, excessive adult use of cannabis, and any use of tobacco. (13)

Lessons from tobacco control indicate that aggressive public education campaigns, regulation of access to tobacco products, and denormalization efforts are powerful means for reducing tobacco use and related harms. (14) However, critics suggest that overly restrictive tobacco smoking environments contribute to stigmatization of smokers, which may undermine smoking cessation efforts and exacerbate health-related inequalities among marginalized groups. (13)

Alcohol regulation is experiencing a different trajectory from tobacco control in Canada, as privatization of alcohol sales (and thus increased alcohol availability and promotion) has been implemented (British Columbia, Alberta and Quebec) or is being explored (Ontario and Saskatchewan). (3,8) Denormalization of alcohol may be difficult because the majority of those who drink, do so without significant harm. Although tobacco policy lessons indicate that denormalization of alcohol is possible, strategies for denormalizing tobacco may not be directly applicable to alcohol (e.g., warning labels demonstrate limited effectiveness for changing drinking behaviour). (3,8)

Criminalization and anti-drug messaging have failed in stemming the cannabis normalization trend. (1,2,11) Lessons from control efforts, and from research on cannabis regulatory changes in Uruguay, Colorado and Oregon, suggest that a state monopoly on cannabis markets may best serve to avoid negative public health impacts of psychoactive substance commercialization (e.g., reducing product promotion and price competition; supply control and licensing), as well as to curtail political influence of profit-driven interests. (2-4,6) Participants agreed that state-centred legal regulation remains the most favourable policy route through which to pursue harm minimization goals.

Central to a public health approach to psychoactive substance regulation is the concept of harm reduction. (1) Meeting participants identified a tension with regard to the concept of "harm reduction" across tobacco, alcohol and illegal drug policy domains: some tobacco control experts have been reluctant to endorse less harmful modes of tobacco administration, such as "smokeless" delivery systems, including electronic cigarettes, because they are produced and marketed by the tobacco industry with the aim of maintaining tobacco use and circumventing indoor smoke-free policies. (15) Conversely, harm reduction interventions for alcohol and illegal drugs are often promoted by the public health community to reduce harms related to these substances (e.g., managed alcohol programs; safe injection facilities), as opposed to reducing use itself. (1,7) These differences in policy aims across substance research and policy communities, unless resolved, may act as a barrier to collaboration and advocacy for a shared public health-oriented regulatory approach.

There is a need for the substance use policy community to recognize the different, sometimes divergent goals between current alcohol and tobacco policy approaches: whereas alcohol experts advocate for "responsible use," some tobacco control experts aim for an "endgame" of eliminating use, as no tobacco use is seen as safe. (3) Respect for individual autonomy is one means to bring these approaches together: if people choose to use substances, public health efforts are best focused on reducing harms of use, especially because goals of substance use elimination have never been achieved in the history of drug policy. (1) Thus, an effective cross-substance public health model must balance policy goals between promoting health and reducing substance use in a way that recognizes the limitations of both prohibition and commercialization.

Moving forward

Our meeting highlighted how lessons from alcohol and tobacco policies, and the negative impacts of cannabis criminalization illustrate a need to critically examine regulatory frameworks and their impacts on health. In the event that a non-prohibitionist regulatory framework were to be effected for cannabis in Canada, employing an overly restrictive framework poses the risk of an illegal market, and of marginalizing disadvantaged users. (1,3,5,7,13) However, an overly commercial market will likely normalize use and stimulate demand and associated harm--a concern emerging from research on cannabis commercialization in Washington and Colorado. (2-5)

Non-prohibitionist approaches to cannabis regulation have emerged only recently, so knowledge gaps on potential adverse impacts and benefits of various aspects of legal regulation (e.g., impacts on normalization, drug substitution effects, commercialization, among others) are considerable. (2-5) The challenge for researchers and policy-makers remains one of how best to achieve public health aims of promoting wellness and reducing health inequalities, while simultaneously ensuring that the harms associated with specific policy interventions are not disproportionate to the harms of substances themselves. (1) Work has already begun in this area, and needs to be expanded to consider practical issues such as: funding for monitoring drug trends and evaluating impacts of regulatory changes, and development of clear public messaging on medical versus recreational cannabis use. (1-3,10) Furthermore, a diverse group of people need to be involved in substance use policy reform, including decision-makers, researchers, non-governmental organizations, and advocacy groups, if we are to identify realistic public health goals across substances, and to direct the momentum of recent changes in drug policy towards the pursuit of such goals.

REFERENCES

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Received: July 4, 2015

Accepted: November 6, 2015

Maritt Kirst, PhD, [1] Kat Kolar, MA, [2] Michael Chaiton, PhD, [3] Robert Schwartz, PhD, [3] Brian Emerson, MD, MHSc, [4] Elaine Hyshka, MA, [5] Rebecca Jesseman, MA, [6] Philippe Lucas, MA, [7] Robert Solomon, LLB, LLM, [8] Gerald Thomas, PhD [9]

[1.] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON

[2.] Department of Sociology, University of Toronto, Toronto, ON

[3.] Ontario Tobacco Research Unit, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[4.] British Columbia Ministry of Health, Victoria, BC

[5.] School of Public Health, University of Alberta, Edmonton, AB

[6.] Canadian Centre on Substance Abuse, Ottawa, ON

[7.] Centre for Addictions Research of British Columbia, Victoria, BC

[8.] Faculty of Law, University of Western Ontario, London, ON

[9.] Okanagan Research Consulting, Summerland, BC

Correspondence: Maritt Kirst, Toronto Central Community Care Access Centre, 250 Dundas St. West, Toronto, ON M5T 2Z6, Tel: 416-217-3850, ext. 2551, E-mail: maritt.kirst@utoronto.ca

Acknowledgement of source of support: Faculty of Medicine, University of Toronto. E. Hyshka was also supported by Alberta Innovates: Health Solutions and the Killam Trusts.

Conflict of Interest: None to declare.