Initial indicators of the public health impacts of non-medical cannabis legalization in Canada

Abstract

On 17 October 2018, Canada implemented the legalization of non-medical use and supply of cannabis - a significant policy reform milestone internationally. Canada was the first high-income nation to do so with a public health rationale [[1]Fischer B. Russell C. Boyd N A century of cannabis control in Canada: A brief overview of history, contexts and policy frameworks from history to legalization.in: Decorte T Lenton S. Wilkins C. Routledge Publishers, Legalizing Cannabis: Experiences, Lessons and Scenarios2020Crossref Google Scholar]. As studies of cannabis legalization's impact in US states and Uruguay have been inconclusive [[2]Hall W. Stjepanović D. Caulkins J. Lynskey M. Leung J. Campbell G. et al.Public health implications of legalising the production and sale of cannabis for medicinal and recreational use.The Lancet. 2019; 394: 1580-1590Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar,[3]Leung J. Chiu V. Chan G.C. Stjepanović D. Hall W.D What have been the public health impacts of cannabis legalisation in the USA? A review of evidence on adverse and beneficial effects.Concurrent Addiction Reports. 2019; 6: 418-428Crossref Scopus (10) Google Scholar], it is worth and timely considering the short-term impacts of legalization in Canada. Traditionally, Canada has had comparatively high rates of population cannabis use, especially among young people. Key indicators of cannabis-related harm (e.g., hospitalizations) were increasing pre-legalization [[4]Fischer B. Russell C. Rehm J. Leece P Assessing the public health impact of cannabis legalization in Canada: core outcome indicators towards an ‘index’ for monitoring and evaluation.J Public Health. 2019; 41: 412-421Crossref Scopus (22) Google Scholar]. Furthermore, there was ready availability of cannabis before legalization through illegal and ‘grey’ sources, including diversion from liberal national ‘medical cannabis access’ provisions in place for numerous years. The main goals of Canadian cannabis legalization include undermining illegal cannabis markets while restricting cannabis use among young people. The regulatory efforts to achieve these goals however involve heterogeneous policy frameworks. The core legal framework is provided by the (federal) Cannabis Act. However, regulations, for example regarding age and place-of-use restrictions, and retail distribution are provincial and vary considerably. For example, minimum legal purchase ages range from 18 – 21 years; some but not all provinces allow public use; critically, the cannabis retail distribution systems in different provinces comprise a mix of private and public (or hybrid) models. Consequently, Canada's legalization project comprises a potpourri of provincial sub-experiments under different regulations that may differentially influence key policy outcomes. Some data on post-legalization developments are available from newly implemented, national (government-sponsored) population surveys [[5]Roterman M. What has changed since cannabis was legalized?.Health Reports. 2020; 31: 11-20PubMed Google Scholar,[6]Government of CanadaCanadian Cannabis Survey 2019: summary. Government of Canada, Ottawa, ON2019https://www.canada.ca/en/health-canada/services/publications/drugs-health-products/canadian-cannabis-survey-2019-summary.htmlGoogle Scholar]. These feature some limitations regarding methods, including sampling frames, yet provide initial insights on select cannabis-related outcomes about one year after legalization (2019). Concretely, these find that around one-in-six Canadians report active (e.g., in the past 3 months) cannabis use, with one-third of users reporting daily or near-daily use. Notwithstanding some inconsistent trends, cannabis use remains concentrated among young adults, while use has reportedly increased among multiple age-groups – including young adults but not adolescents – since 2018. ‘Smoking’ of herbal cannabis remains the most common use mode but others, including edibles and vaping, have increased. Half of cannabis users claim that at least some of their use is for (sanctioned or un-sanctioned) ‘medical reasons’. Between one-in-eight and one-in-five users, depending on the measure applied, report driving a motor-vehicle after using cannabis, though only a negligible minority reports any contact with law enforcement related to cannabis-impaired driving [[5]Roterman M. What has changed since cannabis was legalized?.Health Reports. 2020; 31: 11-20PubMed Google Scholar,[6]Government of CanadaCanadian Cannabis Survey 2019: summary. Government of Canada, Ottawa, ON2019https://www.canada.ca/en/health-canada/services/publications/drugs-health-products/canadian-cannabis-survey-2019-summary.htmlGoogle Scholar]. Some early data on cannabis supply exist. The price of legal cannabis products has remained relatively steady (∼$10/gram) but prices of illegal cannabis products have dropped substantially (to ∼$6/gram), creating an increasing price advantage for the illicit market [[7]CBC NewsAffordable legal cannabis should be a priority as illegal pot prices drop, experts say: cbc news.2020https://www150.statcan.gc.ca/n1/pub/13-610-x/cannabis-eng.htmGoogle Scholar]. These price discrepancies, and likely other retail dynamics, may explain why about 50% of users reported utilizing legal sources, yet only three-in-ten exclusively use legal sources for cannabis purchases. There were initial concerns about shortages of legal cannabis product immediately after legalization. The federal government has now licensed >260 commercial cannabis producers, resulting in rapidly growing cannabis inventories, or an ‘over-stock’ situation, and an anticipated need for ‘consolidation’ of the booming industry [[8]Statistics CanadaCannabis Stats Hub. Statistics Canada, Ottawa, ON2019Google Scholar]. Alcohol sales data have shown a recently accelerated decline in beer sales after cannabis legalization, which may point to a possible substitution effect [[9]BNN BloombergLegal pot takes a bite out of beer consumption in Canada.2020https://www.bnnbloomberg.ca/legal-pot-takes-a-bite-out-of-beer-consumption-in-canada-1.1370298Google Scholar]. These data provide initial insights into possible public health impacts of cannabis legalization in Canada. As documented for other ‘legalization’ contexts, it is not possible to draw firm conclusions on its overall impact [[2]Hall W. Stjepanović D. Caulkins J. Lynskey M. Leung J. Campbell G. et al.Public health implications of legalising the production and sale of cannabis for medicinal and recreational use.The Lancet. 2019; 394: 1580-1590Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar,[3]Leung J. Chiu V. Chan G.C. Stjepanović D. Hall W.D What have been the public health impacts of cannabis legalisation in the USA? A review of evidence on adverse and beneficial effects.Concurrent Addiction Reports. 2019; 6: 418-428Crossref Scopus (10) Google Scholar]. In fact, many of the present indicators may reflect policy transition effects. They however underscore outcomes that require rigorous ongoing and future monitoring, even if Canadian data-systems are less well-developed and more fragmented than their US counterparts [[4]Fischer B. Russell C. Rehm J. Leece P Assessing the public health impact of cannabis legalization in Canada: core outcome indicators towards an ‘index’ for monitoring and evaluation.J Public Health. 2019; 41: 412-421Crossref Scopus (22) Google Scholar]. It is of concern that rates of cannabis use among may be increasing among large user sub-groups after legalization in Canada. These developments may differ from trends observed in other legalization settings [[10]Melchior M. Nakamura A. Bolze C. Hausfater F. El Khoury F. Mary-Krause M. et al.Does liberalisation of cannabis policy influence levels of use in adolescents and young adults? A systematic review and meta-analysis.BMJ Open. 2019; 9e025880Crossref PubMed Scopus (25) Google Scholar]. Population-level data on key harms (e.g., hospitalizations, impairment-related injuries or deaths) are not yet available. Data on the extent to which legal cannabis products have supplanted illicit ones are limited. Illegal cannabis markets seem to be resilient, and increasingly price-competitive. Moreover, the legal cannabis industry appears to have become more ‘commercialized’ than the originally proposed public health-framing of legalization implied. These data suggest that the primary policy objectives of legalization may not immediately be achieved. It will require more time and more rigorous data to more conclusively assess the fundamental impact of Canada's cannabis legalization experiment on public health and safety [1Fischer B. Russell C. Boyd N A century of cannabis control in Canada: A brief overview of history, contexts and policy frameworks from history to legalization.in: Decorte T Lenton S. Wilkins C. Routledge Publishers, Legalizing Cannabis: Experiences, Lessons and Scenarios2020Crossref Google Scholar, 2Hall W. Stjepanović D. Caulkins J. Lynskey M. Leung J. Campbell G. et al.Public health implications of legalising the production and sale of cannabis for medicinal and recreational use.The Lancet. 2019; 394: 1580-1590Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 4Fischer B. Russell C. Rehm J. Leece P Assessing the public health impact of cannabis legalization in Canada: core outcome indicators towards an ‘index’ for monitoring and evaluation.J Public Health. 2019; 41: 412-421Crossref Scopus (22) Google Scholar]. Current interim indicators suggest mixed effects at best, and much room for improvement. Other key data will not be available for some time. Canadian governments should allocate some of the tax revenue from cannabis sales to fund more rigorous evaluations of the impacts of cannabis legalization. External funders had no involvement in any stage or aspect of the paper.

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