Table 1:
Policy strategies for the legalization of cannabis, and level of adherence by jurisdiction, based on an analysis of public health best evidence from the regulation of tobacco and alcohol2,3
| Strategy | Portion of core policies adhered to by jurisdiction | |||||
|---|---|---|---|---|---|---|
| The Netherlands | Oregon State | Washington State | Colorado State | Uruguay | Catalonia | |
| Availability and accessibility | ||||||
| Control structure: The government should form a central commission with a monopoly over sales and control over production, packaging, distribution, retailing, promotion and revenue allocation. The primary goal should be public health promotion and protection (to reduce demand, minimize harms and maximize benefits). The commission should be at arm’s length from the government to resist interference with this goal, such as industry influence and the government’s desire to increase revenues from promoting sales, fees and taxation. | Few or none | Few or none | Few or none | Few or none | Most | NA |
| Provision to consumers: Cannabis should be sold only at licensed or commission-operated retail outlets. Public health objectives should determine the locations and the appearance of the outlets. Health promotion messages should be displayed. Hours of operation should be limited. | Few or none | Some | Some | Some | Most | NA |
| Price: The price should be set high enough to reduce demand, and low enough to undercut the illegal market. | Few or none | Few or none | Some | Few or none | Most | NA |
| Purchase, consumption and use | ||||||
| Purchase: There should be a minimum age for purchase. Purchases should involve completing a form. A limit should be placed on the amount of daily purchases. | Most | Most | Most | Most | Some | Most |
| Locations for use: The public should not be exposed to cannabis smoke. Use should be restricted to licensed locations (or private homes). Cannabis lounges should be neutral, not promote cannabis use and include health promotion material. Alcohol and tobacco use should not be permitted. Locations, hours and amounts of a sale to an individual should be restricted. | Some | ND | NA | NA | NA | Most |
| Cannabis and driving:† Cannabis-impaired driving should be an offence with a range of available legal sanctions. There should be active and visible enforcement along with prevention campaigns. Testing should be effect based (i.e., road-side impairment testing) confirmed with blood testing. Zero tolerance is not recommended because THC detection may occur long after effects have resolved. There should be lower thresholds for the combination of cannabis and alcohol because the effects are additive. | Some | Some | Some | Some | Most | Some |
| Supply | ||||||
| Production: The commission should be the only organization permitted to purchase cannabis from producers and sell to retailers. It should support small producers to prevent the growth of large, multinational corporations with lobby power to achieve their profit-driven goals. Individuals should be permitted to grow cannabis for personal use but not be allowed to sell privately. | Few or none | Few or none | Some | Few or none | Most | Most |
| Product: The cannabis product should be regulated (constituents and emissions). The THC percentage should be clearly labelled, with pricing policies to favour products with low THC concentrations. Only bulk products should be sold (i.e., no pre-made cigarette-type products), with the exception of processed products for oral consumption to avoid the harms of inhalation. | Few or none | Some | Some | Some | Most | Few or none |
| Demand drivers/mitigators | ||||||
| Promotion and packaging: All branding and promotion (e.g., advertising, sponsorship and product placement§) should be banned. Partial bans have little effect. Labels should include information on health risks. | Most | ND | Few or none | Few or none | Most | Most |
| School and public education campaigns:‡ The government should support evidence-based school and public education campaigns to temper demand. Large, mass-media campaigns should be avoided because they can stimulate interest and increase use. | NE | NE | NE | NE | NE | NE |
| Dedicated revenue | ||||||
| Dedicated revenue: The revenue should be used for health and social initiatives. | Few or none | Most | Most | Most | Most | NA |
Note: ND = not yet defined, NA = not applicable, NE = not evaluated, THC = tetrahydrocannabinol.
Items in italics have moderate to strong evidence from the tobacco, alcohol and cannabis literature to support them. Other items have weaker evidence to support them or are the authors’ recommendations2 based on the cannabis literature and public health goals.
Because cannabis-impaired driving was not addressed in the framework article,2 we relied on other similar sources to create this section.19,20,28–30,34,39 This area is rapidly evolving, with a currently unclear association between cannabis levels in bodily fluids and effects on driving. Policies should change as the evidence changes. Evidence currently supports a blood THC level of 3.5–5 ng/mL (serum level 7–10 ng/mL) as a reasonable threshold for impaired driving. Per se laws (automatic ticketing above a threshold concentration in blood even without demonstrated impairment) are gaining popular support. These laws concern some experts because they may lead to charges for individuals who are not impaired.
Evidence-based school and public education campaigns can be effective measures in reducing demand and harm. However, we excluded them from our analysis because of the complexity and difficulty of ascertaining what is happening in each jurisdiction.
See examples in Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.150657/-/DC1).