Legalisation of non-medical cannabis in Canada: will supply regulations effectively serve public health?

A major social and health policy experiment will begin in Canada on July 1, 2018: the legalisation of non-medical cannabis.1Task Force on Cannabis Legalization and RegulationA framework for the legalization and regulation of cannabis in Canada: the final report of the Task Force on Cannabis Legalization and Regulation. Government of Canada, Ottawa, ON2016Google Scholar This major national cannabis policy reform, which is unique in the G20, has been framed by the fundamental objective to protect and improve cannabis-related public health and safety.1Task Force on Cannabis Legalization and RegulationA framework for the legalization and regulation of cannabis in Canada: the final report of the Task Force on Cannabis Legalization and Regulation. Government of Canada, Ottawa, ON2016Google Scholar The prospective success of achieving this goal is an open question, as indicated by emerging evidence from other jurisdictions undergoing legalisation experiments.2Hall W Lynskey M Evaluating the public health impacts of legalizing recreational cannabis use in the United States.Addiction. 2016; 111: 1764-1773Crossref PubMed Scopus (188) Google Scholar Although much attention has been on possible adverse outcomes related to use (eg, use in young people, impaired driving, and brain and mental health harms), the possible effects of cannabis legalisation will depend on many implementation details, including effective regulation of cannabis production and retail distribution.3Rehm J Fischer B Cannabis legalization with strict regulation, the overall superior policy option for public health.Clin Pharmacol Ther. 2015; 97: 541-544Crossref PubMed Scopus (49) Google Scholar This regulation constitutes a complex challenge, for several reasons, especially in the Canadian context. On one hand, there are obvious good reasons to restrict cannabis production and distribution as tightly as possible for the benefits of limiting consumption and related harms. At the same time, the public health and safety effects of legalisation will crucially hinge on its success in effectively shifting users from illegal to legal distribution environments, with the latter offering products that are quality controlled and predictable, and as low risk as possible. However, conditions for legalised cannabis production and distribution are not being developed on neutral grounds in Canada. Rather, they are being built in the long-existing context of both flourishing black markets and extensive supply structures for medical cannabis, including hundreds of illegal dispensaries across Canada, which have evolved to expand their cannabis distribution far beyond supply for therapeutic purposes.4Fischer B Rehm J Crepault JF Realistically furthering the goals of public health by cannabis legalization with strict regulation: Response to Kalant.Int J Drug Policy. 2016; 34: 11-16Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar Furthermore, jurisdictional challenges exist: although cannabis legalisation in Canada is principally enabled by federal legislation, many of its key practical details, especially regarding retail distribution, will be defined by provincial regulations, possibly creating lateral and vertical inconsistencies or tensions. Some of these tensions are already emerging or present. Even before legislation of non-medical cannabis, a vast and rapidly growing landscape of (currently >60) licensed producers of cannabis exist and are functioning under Canada's national medical cannabis distribution regime.5Government of CanadaAccess to cannabis for medical purposes regulations.http://laws.justice.gc.ca/PDF/SOR-2016-230.pdfDate: 2017Google Scholar This industry expects production of non-medical cannabis to be its primary future business and profit source. On this basis, the existing commercial cannabis industry is keen to keep its future marketplace and products as unencumbered as possible from regulatory restrictions, including those focusing on product types, advertising and promotion, and restrictions on sales—all of which are factors that influence use and subsequent harm outcomes, as ample evidence from alcohol and tobacco control shows.6Pacula RL Kilmer B Wagenaar AC Chaloupka FJ Caulkins JP Developing public health regulations for marijuana: lessons from alcohol and tobacco.Am J Public Health. 2014; 104: 1021-1028Crossref PubMed Scopus (172) Google Scholar, 7Richter KP Levy S Big marijuana—lessons from big tobacco.N Engl J Med. 2014; 371: 399-401Crossref PubMed Scopus (53) Google Scholar Regulations for recreational cannabis retail distribution in Ontario, Canada's most populous province, propose to restrict distribution under a public monopoly and to operate a limited number of government-controlled outlets (similar to, but separate from the provincially-owned alcohol retail monopoly).8Government of OntarioOntario's cannabis retail and distribution model.https://news.ontario.ca/mof/en/2017/09/ontarios-cannabis-retail-and-distribution-model.htmlDate: 2017Google Scholar However, these plans overlook the possible regulation and integration of the many existent private community-storefront cannabis dispensaries, which could therefore continue to operate illegally in competition with state-run outlets. Other provinces are still developing their cannabis retail distribution schemes, which might evolve to be different from Ontario's and, for example, provide to include private retail outlets. Supply provisions for legislation of non-medical cannabis in Canada comprise another distinct element. The federal cannaabis legalisation bill includes provisions for home-growing of up to four cannabis plants per adult household in private homes. Such provisions would be extremely difficult to monitor and enforce, and so could allow many (including underage) people access to mainly unregulated cannabis products, and also expose many non-users to the adverse consequences of cannabis growing and use in domestic environments. As extensive experiences from other fields show, the restrictions around production and retail distribution of psychoactive products for recreational consumption strongly influence population-level use and health outcomes.7Richter KP Levy S Big marijuana—lessons from big tobacco.N Engl J Med. 2014; 371: 399-401Crossref PubMed Scopus (53) Google Scholar, 9Babor T Caetano R Casswell S Edwards G Giesbrecht N Alcohol: no ordinary commodity: research and public policy.2nd edn. Oxford University Press, London2010Crossref Scopus (2158) Google Scholar Empirical evidence on these fronts in the cannabis arena is scarce, but includes (rather conflicting) experiences. In the USA, commercialised approaches to distribution of legalised cannabis have been associated with a variety of public health-relevant problems.2Hall W Lynskey M Evaluating the public health impacts of legalizing recreational cannabis use in the United States.Addiction. 2016; 111: 1764-1773Crossref PubMed Scopus (188) Google Scholar In Uruguay, a starkly restricted system for distribution of legal cannabis (eg, including user registration and restricted product and distribution options) has been rejected by many users, thus lowering its potential for achievement of optimal public health benefits.10Ramsey G Getting regulation right: assessing Uruguay's historic cannabis initiative. Washington Office on Latin America, Washington, DC2016Google Scholar Effective regulation of cannabis supply and distribution constitutes a pivotal determinant of the success of cannabis legalisation towards public health outcomes. Regulations must strike a meaningful balance between tightly restricting products and availability, while simultaneously creating a legal supply environment that is appealing and accessible for consumers to actively embrace and utilise. Whether existing legalisation regimes have yet found that balance is an open question, and it remains to be seen whether the proposed plans for Canada will succeed. These emerging lessons are also relevant for other jurisdictions contemplating similar fundamental cannabis policy reforms. I acknowledge funding support from the Canadian Institutes of Health Research for the Ontario Canadian Research Initiative in Substance Misuse Node Team (grant number SMN-139150), as well as from the Endowed Chair in Addiction Psychiatry, Department of Psychiatry, University of Toronto. I declare no competing interests.

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