21 May 2014
Cannabis is widely available despite its use and production being illegal in most countries. Rebecca Coombes looks at recent moves to regulate production and the potential effects on public health
Cannabis is the world’s most widely used illicit drug. But for how much longer? In a short space of time we have moved from absolute global prohibition of the drug, with the emergence of legalised and regulated production and retail not in just one nation (Uruguay) but also, surprisingly, in two US states (Colorado and Washington). Do these and other new permissive models in Spain and Belgium, for example, point to a tipping point in the debate? Could cannabis step out of the shadows and join the ranks of alcohol and tobacco, the world’s most popular legal and regulated drugs?
Even in the Netherlands, so long at the forefront of forward thinking policies on cannabis, local politicians have joined forces to urge the government to go much further and complete the job it started nearly 40 years ago when it agreed to tolerate the licensing of “coffee shops” to sell cannabis in small quantities. Then, it stopped short of legalising the cultivation and distribution of cannabis, leaving the supply side to criminal gangs, whose activities today increasingly tarnish an otherwise successful policy.
But at this crucial stage—as other countries and US states keenly watch the fortunes of the pioneers Colorado, Washington, and Uruguay and no doubt marvel at the tax windfalls—can regulatory approaches to the use of cannabis reduce health and social harms more effectively than prohibition? Is the commercial model pursued in Colorado, for example, where shops sell customer friendly goods such as edible cannabis in the form of candy “gummy bears,” really a solution that public health can get behind? Perhaps the stricter government control favoured by Uruguay is the model to watch.
Unregulated criminal markets
Currently the majority of the world’s cannabis users, who number between 119 million and 224 million, are supplied by unregulated criminal markets.1 The health and social harms associated with this illegal trade motivated Uruguay in 2013 to become the first country to legalise and regulate the production and sale of cannabis for non-medical use. Its government said, “As things stand today, drug dealers try to push harder drugs on teenagers who go to them for cannabis. This law will change that and prevent cannabis from at least being a step to more potent drugs.”2
“For most jurisdictions cannabis offers a blank canvas,” says Steve Rolles, senior policy analyst for Transform, a UK based think tank on drug policy. “It provides an opportunity to learn from past errors and replace criminal markets with regulatory models that are built on principles of public health and wellbeing from the outset, without a large scale legal commercial industry resisting reform.”
In Europe this wind of change is evident in the Netherlands, where the Dutch cabinet is under pressure to revise its soft drug policies, specifically the “back door problem,” where cannabis can be sold at the front of a coffee shop but not supplied at the back. Between 5000 and 6000 illegal cannabis plantations are dismantled every year in the Netherlands, and the number of coffee shops is in decline. But as the coalition government dithers, local politicians have challenged it to explore new regulation models and allow council run production of cannabis.3
“The nationwide introduction of certified and regulated [cannabis] production is the solution that addresses the health of users and community safety and tackles organised crime,” reads a manifesto now signed by 54 local mayors. It goes on to say that the current regime “undermines the fabric of Dutch society.”
Paul Depla, mayor of Heerlen, in the southeast of the country, started the manifesto and says he is confronted with the consequences of illegal cannabis plantations daily. “In Heerlen we have 90 000 inhabitants but last year dismantled 130 illegal plantations. Thirty per cent of Dutch house fires are caused by illegal hemp plantations. Our soft drug policy leaves the coffee shops dependent on criminal organisations for supply. So ordinary people become an instrument of criminal gangs.”
Marith Rebel is a Labour member of the Dutch parliament, a general practitioner, and a fierce critic of the minister of justice for failing to listen to the mayors. “The local problems show that the current system doesn’t work,” she says. “The Dutch have always been in front on this issue. But now Uruguay is way ahead. The coffee shops were a way of getting around the international treaties [which nominally permit the Netherland’s tolerance approach but draw a line at regulated production]. Dutch policy now is too repressive, and a side effect is that we don’t pay enough attention to prevention.”
Cannabis social clubs
The cannabis regulation debate has also become part of the political mainstream in Spain, where activists have pioneered the non-profit “cannabis social club” model. Spain’s decriminalisation policy permits small amounts of cannabis for personal use, including growing one or two plants. By pooling this allocation to a single grower the club members can effectively ensure a regular de facto legal supply.4 Operating in a grey area legally, around 600 clubs now exist in Spain, mostly in Catalonia and the Basque Country. Members commonly pay a fee according to how much cannabis they consume. Personal allowances are rationed to around 3 g a day, and new members are usually required to have the support of existing members. The government of the Basque Country is now discussing whether to formalise such clubs in law.
Inspired by this model back in the Netherlands, Utrecht’s mayor, Victor Everhardt, wants permission to set up a closed cannabis social club of 100 people who wish to produce cannabis for their own consumption. It’s a way of eliminating the criminal involvement and protecting health through quality controls on the product, says Everhardt. “We want to take responsibility for public health, so you can go into a coffee shop and know where the end product has come from.”
Belgium has four cannabis social clubs. The oldest, Trekt Uw Plant, set up in 2006, now has 300 members. But, as in the Netherlands, any call for change is coming from the grassroots and is not being led by national government. Tom Decorte, professor of criminology at the University of Ghent, says, “The social clubs are bottom-up initiatives, set up by activists working around bad legislation. Belgian drug law says you can cultivate one female plant, so these clubs bring together 50 people, who grow 50 plants. We want a new debate on the alternatives. But in Antwerp the mayor is waging a new war on drugs, and it means investing talented police officers in this war when they could be used in other types of crime.”
As cannabis policy and law is now being debated in the mainstream, what can be learnt from the legislative reforms that are already under way?
Colorado’s commercial model
Of all the new models of cannabis regulation springing up, Colorado’s is the most overtly commercial. And it provides some lessons. The state allows private business to grow, produce, process, and sell cannabis for non-medical uses. The first cannabis shop opened for business in January, and Colorado reaped $2m (£1.2m; €1.5m) in tax in the first month alone. That figure rose to $3.5m if tax receipts from the established medical marijuana firms are included.
“Money is falling from the sky in Colorado,” says Susan Weiss, associate director for scientific affairs at the US National Institute on Drug Abuse. And in common with any other commercial market in the US, consumer choice is vast. Cannabis is marketed in the same way as alcohol, not in places likely to be seen by under 21s. But attractive products that might appeal to children are available, such as the “edibles” containing tetrahydrocannabinol (THC), the psychoactive compound in cannabis. These include “sour gummi bears,” “cherry bombs,” and “watermelon tarts.” However, these edibles have to be labelled, and there are potency limitations on packs, though the products within are indistinguishable from confectionery.
Weiss fears that loosening restrictions on cannabis in the US, in combination with new, highly efficient electronic systems to deliver potent cannabis oils and concentrates (products with names such as wax, glass, and shatter) could cause a “perfect storm” and result in an epidemic of health problems.
She said, “These are anecdotal reports, but we hear e-cigarettes are taking off massively, not just with nicotine but with hash oil. E-cigarettes are putting people into contact with high concentrations of THC of up to 75-90%. I don’t believe the states are coming up with the necessary systems of regulation to minimise harm. These levels are huge in relation to those we are used to thinking about in relation to cannabis. We have no idea what the health consequences are at this sort of potency, and we need to watch this very carefully. E-cigarettes are marketed to children with different colours and types.”
Such new “disruptive technologies” are rapidly emerging into the new US markets, says Rolles. These e-cigarettes and mini-vaporisers for consuming cannabis concentrates “are very discreet, with no odour or smoke, and very potent,” potentially giving young people more opportunities to use cannabis clandestinely.
“Historically, prohibition has contributed to the emergence of even more potent products,” he says. “In an illegal market dynamic, higher potency products command higher prices, so there’s a profit incentive to push them. Obviously things like cannabis edibles that look like children’s sweets are a terrible idea, but if you can regulate the potency of alcohol and cigarettes—as well as what products can be sold, and how they are marketed—why not cannabis?”
Public health advocates, however, favour the Uruguay model because it is far more restrictive than that in Colorado and Washington. The government has a state monopoly at wholesale level, and licensed firms produce cannabis—limited to around five strains with upper limits on potency—which is then sold in authorised pharmacies. Non-medical use is also rationed to no more than 40 g a month per user. Advertising is banned, as is smoking in smoke-free areas. In addition to state licensed cultivation, the government allows limited home production of up to six plants, and it permits cannabis clubs, which can plant a maximum of 99 plants. All purchasers are registered by a new state agency called the Institute of Regulation and Control of Cannabis.
One of the concerns about moving to regulation is that increased availability will lead to increased consumption. Weiss says the evidence is that THC consumption is going up, citing a Norwegian study in 2013 that looked at the mean concentration of THC in the blood of apprehended drivers in Norway between 2000 and 2010. The study found that THC levels rose substantially (by 58%) over the decade.5 “THC is going up, while alcohol use is flat over the decade. I think we are naive about the young people getting these high potency hits,” says Weiss. National level evidence from the US also shows that cannabis dependency is increasingly a primary cause of admission to substance misuse treatment centres for young people.6
However, supporters of reform point out that this rise has happened under prohibition, which has not prevented cannabis being widely available. They also argue that levels of use are driven by a complex range of social and cultural variables, and that legal supply does not have to mean increased use, citing the Netherlands, where despite cannabis effectively being legally available for 40 years use remains similar to that in neighbouring countries, and below the European average.
So we are at a crossroads in this debate. But what are the barriers to countries wanting to decriminalise use and legally regulate the production, distribution, and sale of cannabis for non-medical use? Important are several global or transnational treaties, specifically the United Nations Drug Conventions adopted in 1961, 1971, and 1988 that criminalise the use and possession of controlled drugs, including cannabis, for uses other than medical and scientific purposes. They also strictly prohibit any domestic market in the substances. A recent policy paper on cannabis regulation for the Addiction and Lifestyles in Contemporary Europe—Reframing Addictions Project (ALICE RAP), a €10m research project funded by the European Commission to feed scientific evidence into policy making, concluded: “The world is saddled with drug treaties which are not fit for purpose.”2
Robin Room, a member of the World Health Organization’s expert advisory panel on alcohol and drugs and a professor at Stockholm University’s Centre for Social Research on Alcohol and Drugs, says that the path taken by Colorado, Washington, and Uruguay involves flouting international drug control treaties, something no European government is yet willing to do. He says, “The treaties are not fit for purpose in the modern world, but how can they be changed? The EU countries are not likely to do something that contravenes a treaty, especially with the Ukraine crisis. The Dutch are trying to stay within the treaty by not legalising production, but that leaves them with the ‘back door’ problem. The political system is stuck. The change from the US is coming from below [not federal government], and politicians are reluctant to be the first mover.”
US president Barack Obama has cautiously welcomed the experiments in Washington and Colorado 7 but the country has been rapped over the knuckles by the International Narcotics Control Board. In a strongly worded statement its president, Raymond Yans, said, “We deeply regret the developments at the state level in the US. The INCB reiterates that these developments contravene the provisions of the drug control conventions, which limit the use of cannabis to medical and scientific use only.” It also reminded Uruguay of the need to “respect the conventions.”
Rolles comments: “Cannabis treaties have reached the point where they are clearly not fit for purpose. This debate is beginning to open up now, and in 2016 there will be a UN General Assembly special session on drugs where the future of the treaties will be discussed.
“Historically, the US has been the bully boy of the international drug control regime, giving the Netherlands a hard time, for example. But that role has diminished as the global drug policy landscape has transformed, and it has not criticised Uruguay. This may provide some space to experiment.”
Cannabis regulation in the UK
The state of cannabis control in the United Kingdom has been in flux over the past decade and is somewhat confusing. Possession of cannabis remains an arrestable offence carrying a potential five year prison sentence, but there are substantial differences in the way that regional police forces enforce the law. The police have a variety of options, including a verbal warning, a penalty notice for disorder that incurs a £80 (€100; $135) fine, a caution, a conditional caution, or a full prosecution. Caution and prosecution result in a criminal record.8 There have been transient, localised examples of shops in the UK almost openly selling cannabis that are tolerated by police as long as they “stay under the radar.” Other pockets of quasi-official tolerance exist. For example, local police at large music festivals may take a pragmatic decision not to arrest people for possessing cannabis.
Of the major political parties, the Liberal Democrats are the only one to have an official platform advocating reform of cannabis policy, having supported a decriminalisation and regulation approach for a decade. In the past two years its leader, Nick Clegg, has become increasingly outspoken on the issue—openly supporting exploration of the options for cannabis regulation. The Home Office has been surveying drug policies around the world and has met officials from Uruguay and Washington. A report is slated for release this autumn.
An Ipsos MORI poll of 946 people in 2013, commissioned by Transform, showed that more than half (53%) supported either legal regulation of the production and supply of cannabis or decriminalisation of possession. Around two thirds (67%) supported a comprehensive independent review of all the options for controlling drugs, including a legal market.9
Cite this as: BMJ 2014;348:g3382
Many of the people quoted were speaking at the New Cannabis Debate held in Amsterdam on 12 May and organised by the ALICE RAP project. A video of the debate can be found at www.alicerap.eu. I thank Stephen Rolles for his help with this article.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
Vindenes V, Strand DH, Kristoffersen L, Boix F, Mørland J. Has the intake of THC by cannabis users changed over the last decade? Evidence of increased exposure by analysis of blood THC concentrations in impaired drivers. Forensic Sci Int2013;226:197-201.Republish