Question

From the three pieces of legislation MAID, Harm Reduction and Cannabis. Take one topic, identify the issues presented by those lobbying for the new legislation and those who were opposed to the legislation. Identify how both groups influenced the legislation.

Answer 1

The Canadian government is “taking a public health approach to legalizing, strictly regulating and restricting access to cannabis.” There is, however, no universally accepted definition of a public health approach to cannabis. This paper presents what such an approach is, and is not, and discusses its applicability to legal psychoactive substances more generally. It critically reflects on the role of the public health sector in the governance of addictive substances and activities, noting its function of “responsibilizing” individuals and coaxing them to self-regulate—and the contradiction involved when other state actors involved in governance are actively inciting consumption of those substances and activities.

Keywords: cannabis, drug policy, public health policy, cannabis legalization, regulation

Introduction

On June 19, 2018, the Canadian Parliament passed Bill C-45—the Cannabis Act—to legalize and regulate the production, distribution, and consumption of cannabis. At the time of writing, Bill C-45 awaits the formality of Royal Assent. In all likelihood, by the time this piece is published, Canadian adults will be able to legally purchase and consume cannabis for non-medical/recreational purposes.

The language of public health has permeated discussions of the form legalization should take and the specific policies to be implemented. The federal government is, in the words of the Minister of Health, “taking a public health approach to legalizing, strictly regulating and restricting access to cannabis” (1). At the same time, cannabis producers propose to advertise and promote their legal products in order to “protect public health and safety” (2). What is a public health approach, exactly? And what role does the public health sector play? This paper will explore these questions, which are relevant not only in view of cannabis legalization, but because the notion of applying a public health approach to the governance of psychoactive substances appears to be gaining currency in Canada (3).

What a public health approach is

There is no universally accepted definition of a public health approach to cannabis. However, among Canadian proponents of such an approach, there appears to be consensus on its main principles [see (4–8)]. An important initial premise is the pragmatic acknowledgment that humans have used psychoactive substances for millennia, and that drug use occurs on a spectrum, from beneficial/benign to problematic/harmful. Harm is a multidimensional concept, encompassing health harms (to self, to others) and social harms (criminalization, stigmatization, etc.) (9, 10). Implicit in this distinction is the recognition that the laws and regulations governing a substance can themselves cause harm, independent of its intrinsic (chemical) properties.

In the specific case of cannabis, proponents of a public health approach contend that:

the illegal status of cannabis causes harm to its users by exposing them to criminalization, which furthermore tends to be arbitrarily and inequitably applied (11); and

for the average adult user, cannabis is relatively benign, with the health harms1 concentrated among a subset of users who use it frequently and/or began using it early in life [see (12)]; and therefore

society is better served by legalizing cannabis, strictly regulating it, and managing the risks through the health system (13, 14).

Public health approaches are characterized by a primary focus on population-level (as opposed to individual-level) factors and outcomes, utilizing measures that “attempt to control the determinants of incidence, to lower the mean level of risk factors, [and] to shift the whole distribution of exposure in a favorable direction” [Rose, cited in (15), p. 239; emphasis added]. Thus, the policies associated with a public health approach to psychoactive substances are aimed at the risk factors for related harm, rather than substance use per se (6). They include measures curbing availability (e.g., via permitted retail locations, hours of sale, etc.) and accessibility (through controls on price2 as well as advertising and promotion), and regulations on the product itself (e.g., its potency and quality). A public health approach also involves education and health promotion interventions that target activities and groups deemed to be higher-risk, e.g., impaired driving and use by children and youth. Finally, it ensures that evidence-based treatment and harm reduction services are available.3

Decades of research from the fields of alcohol and tobacco have yielded strong evidence of the effectiveness of these policies—especially controls on price and other restrictions on availability (10, 16, 17). Researchers have also found that these policies are most effectively implemented when a public entity controls distribution and sales (10, 16, 17). These population-level policies ultimately “aim to hold down use” using “soft control measures which apply across the board without singling out specific users” [(1 Crucially, such policies can only be implemented when a substance is legal, leading to the conclusion that “legalization is a necessary—but not a sufficient—condition for reducing health and social harms associated with cannabis use.”4 By freeing people who use cannabis from the threat of criminal sanctions, legalization will reduce social harms; to the extent that accompanying regulation is guided by public health principles, it should reduce health harms as well.

This particular control model is not necessarily a blueprint for public health approaches to all drugs, however. The case for legalization of cannabis, as opposed to some form of decriminalization, rests partly on its risk profile, which is favorable relative to most illicit drugs as well as alcohol and tobacco [see (9]. Indeed, another proposal from some advocates of health-focused drug policy reform is ensuring that the level of control on a substance is proportionate to the level of risk or harm it poses

In Canada, senior government officials leading the legalization process have stated that they are committed to implementing a public health approach to cannabis (1, 21). Bill C-45 and its accompanying regulations are for the most part in line with this stated intention, with strong controls on product packaging, advertising, and taxation/price. However, many areas of regulation have been left to the provinces and territories. Most notably, each province and territory will be responsible for determining the legal minimum age (with 18 as the lowest the federal government will allow), how cannabis will be sold within its borders, and where it can and cannot be consumed (e.g., in public, in licensed premises, etc.). Provincial approaches vary greatly []. All have opted to harmonize their minimum ages for cannabis and alcohol−18 in Manitoba and Québec, and 19 everywhere else. Some will allow cannabis smoking and vaping wherever tobacco smoking and vaping are allowed, while others will restrict it entirely to private residences. And while some jurisdictions are opting for a retail model in which cannabis distribution is regulated by government but operated by the private sector, others are establishing a public monopoly on sales )—a model that, as mentioned, is more consisteith a public health approach and more likely to lead to positive health outcomes

What a public health approach is not

Drug policy is frequently described as a spectrum, with total prohibition at one pole and an unfettered free market at the other ). Neither extreme is compatible with a public health approach. As Canada moves away from prohibition toward legalization with strict regulation, the social and health harms associated with the former should decrease. However, a new challenge presents itself: ensuring that the new regime does not swing too far in the direction of a commercial system. For on this matter there is consensus in the world of public health: cannabis and the entities producing and selling it should be tightly regulated, with health considerations taking precedence over commercial and fiscal ones at every step (5, 7, 14). The rationale for this position is simple:

Cannabis use comes with risks, and these risks rise substantially with frequent/heavy use. It is, as often stated of alcohol, “no ordinary commodity”

Businesses are profit-maximizing entities; in the case of the cannabis industry, the primary and overriding goal is, and will continue to be, maximizing revenues.

Taken individualy, neither of these statements is novel or controversial. They are, in fact, rather banal. Yet when considered together, they are in clear contradiction, which from a health perspective can only be reconciled through strict controls on the entities in question. As already mentioned, a public health approach to cannabis by definition involves measures designed to hold down consumption levels.

Canada has a rapidly expanding cannabis production industry—a creation, in effect, of the federal government. In 2013, the then-Conservative federal government introduced a number of reforms to Canada's medical cannabis system, one of which was to open cannabis production to the private sector (While for-profit production is by no means the only possible model in a legal market,6 events since then have essentially negated the alternatives. As early as 2013—almost 2 years before legalization had become a federal election issue—observers were reporting a “green rush” of cannabis investment by investors seeking to “make billions on the legalization of pot” (since then, the number of licensed cannabis producers has gone from just one to over 100; collectively, they have been valued at over $29 billion (

he purpose of business—indeed, in the famous words of Milton (ts sole responsibility—is to increase its profits. To expect anything else from the cannabis industry would be naive.