Ontario Medical Association Recommendations to the Ministry of the Attorney General on Recreational Cannabis Consultation
OMA Recommendations to the Ministry of the Attorney General on Recreational Cannabis Consultation The federal government has set Canada on a path to legalize marijuana, however, the nuts and bolts of the proposed Cannabis Act are provoking debate amongst physicians and healthcare workers, lawmakers and industry experts. The proposed federal Act outlines the following conditions for what recreational cannabis will look like in Canada: Adults who are 18 years old and older will be able to legally: o buy cannabis o possess up to 30 grams of legal cannabis or equivalent in non-dried form; o share up to 30 grams of legal cannabis with other adults o purchase dried or fresh cannabis and cannabis oil from a provincially licensed retailer o grow up to 4 cannabis plants, up to a maximum height of 100 centimeters, per residence for personal use from licensed seed or seedlings o make cannabis products, such as food and drinks, at home provided that organic solvents are not used This means that if the Cannabis Act passes as drafted, much of the implementation details will be left to provincial governments. Under the proposed Act, provinces will license and oversee the distribution and sale of cannabis according to the federal guidelines. Provinces will also be able to: increase the minimum age of sale, use and possession of cannabis lower the possession limit in their jurisdiction create additional rules for growing cannabis at home, such as lowering the number of plants per residence restrict where adults can consume cannabis, such as in public or in vehicles As a result of the proposed Cannabis Act, the Ministry of the Attorney General (MAG) undertook a consultation to inform its approach to legalizing cannabis in Ontario. The consultation focuses on five key areas: 1. Setting a minimum age for having, using, and buying cannabis 2. Regulating cannabis sales in Ontario 3. Deciding where people can use cannabis 4. Keeping our roads safe, and 5. Planning public education. This paper intends to propose recommendations to the key issues identified by MAG. The OMA recommendations have been written using public health and harm reduction approaches when considering the issues. Recommendations published by other health stakeholders, including provincial medical societies and the Canadian Medical Association were taken into account when this report was written. Page 1 of 10
As an overarching general principle, the OMA recommends that when possible, provinces work together to ensure regulations are consistent and streamlined across Canada. It is important to note that for the purpose of this paper and recommendations (in response to the consultation), cannabis refers only to recreational cannabis that is smoked. Future positions will be developed to look at other forms of consuming recreational cannabis, such as edibles, once appropriate rules for their production and sale are developed by the federal and provincial governments. Recreational cannabis is inherently harmful Despite its popularity, recreational cannabis is associated with a number of negative health risks, especially for those who use it frequently or begin to use it at an early age. These health impacts include addictive consequences, a range of respiratory and circulatory diseases and disorders, cognitive effects as well as harmful effects on the mental health of some individuals. Recreational cannabis is an inherently harmful substance and must be treated so when it is used legally and recreationally. Recommendation: The health risks caused by recreational cannabis use can best be avoided by abstaining from cannabis use. Setting a minimum age for having, using and buying cannabis Both the federal and provincial governments have outlined that one of the key reasons for legalizing cannabis is to protect youth and to establish safeguards so that illegal cannabis is not accessible to underage individuals. In order to achieve this goal, a minimum age to purchase, possess, and use cannabis must be set. Establishing a minimum age has been an important control measure for both alcohol and tobacco in Ontario. In regard to setting a minimum age for purchasing and possessing cannabis, the Ontario government must focus first and foremost on health risks. There is strong evidence showing cannabis use impacts brain development. It is known that the brain continues to develop through early adulthood, until the age of 25 (1, 2). Therefore, the OMA advocates that the minimum age for purchase and use of cannabis should be 25. In other North American jurisdictions where cannabis has been legalized, the minimum age has been set to mirror that of alcohol, usually at 21 years or older. In Ontario, the precedent set by the legal age of smoking tobacco at 19 will undoubtedly be used as reasoning to lower the age of sale, use and possession of cannabis to 19 years as well. Adopting a minimum age of under 25 years for cannabis use based on precedent set for tobacco and alcohol ignores scientific evidence around the negative health impacts on brain development. Recommendation: The minimum age for purchasing, possessing and using cannabis should be set at 25, given the negative impact that cannabis can have on health, particularly on brain development. Page 2 of 10
Recommendation: Regulations that outline the age of sale in Ontario should be outlined with adjoining penalties for any retailer that violates the law. These penalties must be strictly enforced to ensure their effectiveness. Regulating cannabis sales in Ontario Legalizing cannabis gives governments an opportunity to regulate the substance as well as mitigate some of the associated health risks. Implementing a strategic regulatory framework on the sale of cannabis will be key to the overall success of legalization. There are a number of different distribution systems and models that Ontario can adopt that could include new infrastructure or existing infrastructure. The first model that utilizes existing infrastructure looks at using health care settings, such as pharmacies as a place of sale for cannabis. This model is unfavourable as placing cannabis in pharmacies may promote the idea that cannabis is healthy and or that recreational cannabis may be used as a pharmaceutical medication. Further, by placing recreational cannabis beside medications there is an increased chance for individuals to use marijuana in combination with medications, which may have dangerous implications. The second model that utilizes existing infrastructure could include non-health care settings, such as the Liquor Control Board of Ontario. Placing cannabis in a controlled environment would demonstrate that it is a substance that needs to be formally regulated, however, it is believed that co-sales and therefore co-use of cannabis and alcohol could become normalised. A third model would introduce a Crown corporation dedicated to the sale of cannabis. Such a Crown corporation would establish a monopoly on cannabis sales in the province. Should the province decide to allow cannabis lounges, such as the Dutch mode, where individuals can buy and use small amounts of cannabis, the Crown Corporation would also serve as the chief supplier to these establishments. Establishing a Crown corporation is the most favourable option as it allows the province to control the sale (including store hours), transportation and delivery of product (6, 7, 4). Further, a model regulated strictly by the province would ensure staff are well trained and knowledgeable around the following areas: Products sold and how they may affect users; Identification of customers who are already under the influence; and Identification of customers who are under the minimum legal age. There is evidence through experience of alcohol distribution models that supports a monopoly system and points to an increase in use of alcohol if monopolies are eliminated and privately owned retail outlets are established (6, 7). Another advantage to the Crown corporation model is that all retail information would be centralised. This would allow for better data collection around products sold, consumer demographics and density of cannabis use. This information could help to inform future legislation, policy as well as health and social-welfare programs. Page 3 of 10
Regardless of the distribution system that is ultimately selected by the province of Ontario, there must be strict regulations implemented on the marketing of recreational cannabis, using the current regulations for marketing tobacco as the minimum. Regulatory frameworks that address marketing for both tobacco and recreational cannabis should be updated in lockstep. Further, the OMA believes that a minimum price structure should be implemented. Recommendation: The Government of Ontario should sell cannabis and cannabis related products through a Crown corporation. The Crown Corporation should have a monopoly on the retail and distribution of cannabis and related products throughout the province. Recommendation: If the decision is made to sell recreational cannabis at the LCBO, strict regulations should be employed that limits the amount of alcohol sold with recreational cannabis. Recommendation: Staff at the place of sale of cannabis should be properly trained on all kinds of cannabis, the strength of different products sold, the intended use of each product and how each product might affect the user. Recommendation: The distributor of cannabis should not be able to sell other products, such as alcohol or tobacco. Recommendation: Should recreational cannabis be sold in an establishment that also sells alcohol, such as the LCBO, strict regulations should be employed that limits the amount of alcohol sold with recreational cannabis. Recommendation: Should the province of Ontario decide that cannabis can be sold and used through specialized lounges, the Crown Corporation established to sell cannabis to the public will also be the chief supplier of cannabis to said establishments. Recommendation: A comprehensive model for data collection around the cannabis products should be established through the retail distribution centre to inform future legislation, policy and health and social-welfare programs. Recommendation: There must be strict regulations implemented on the marketing of recreational cannabis, using the current regulations for marketing tobacco as the minimum. Deciding where people can use cannabis As previously mentioned, it is important to highlight that the following information and recommendations look strictly at recreational cannabis that is being smoked. Ensuring that cannabis users are educated on the health impacts that smoking cannabis can have as well as protecting the general public from the effects of second hand smoke are critical from a public health perspective. Smoking cannabis should not be permitted in any public space due to the risk of second hand smoke. This principle is consistent with existing smoking legislation in Ontario (8). Research shows Page 4 of 10
that smoke-free policies and smoking bans are associated with reduced youth initiation rates as well as improved health outcomes of smoking related diseases (9). As such, products that are smoked, including cannabis should remain a priority for such bans and policies. Exposure to all smoke, including cannabis smoke, can trigger acute and chronic health issues, including cardiovascular events, asthma, cancers, chronic obstructive pulmonary disease, and a range of respiratory conditions. Exposure to second hand cannabis smoke contains many of the same toxins found in cannabis smoke that is directly inhaled, including carcinogens (10). As with second hand tobacco smoke, particular attention should be focused on second hand cannabis smoke and children. Therefore, in addition to restrictions in public spaces, other restrictions might be considered to ensure children are not exposed to the harmful health impacts of second hand cannabis smoke (11). The OMA commends the province of Ontario s decision to implement strong restrictions on where recreational cannabis can be used. That said, the province must address the issue of second hand smoke exposure to individuals living in a private residence with a recreational cannabis smoker, for example, in multi-unit dwellings. Recommendation: The Ontario government should prohibit smoking cannabis in public and certain private spaces, including the following (11): Outdoor patios Child care facilitates Motor vehicles Enclosed workplaces Smoking shelters Areas where home health care workers work Hospitals (public, private and psychiatric facility) Common areas of hotels, motels and inns Common areas of multi-unit residences Residential care facilities Schools (public and private school property) Children s playgrounds and publicly owned sports fields Recommendation: The government of Ontario should prohibit smoking recreational cannabis in a private residence if children are present. Recommendation: Recreational cannabis should be stored in a safe place where children can not access the product. Keeping our roads safe The role of marijuana use in traffic collisions is becoming clear and while the increase in risk is less dramatic than with alcohol use, it is still substantial. A meta-analysis of studies on driving while under marijuana s influence found that a person is twice more likely to get into a fatal collision after Page 5 of 10
smoking marijuana than when sober (12). In fact, 28% of fatally injured drivers in the United States were found to have a drug other than alcohol in their systems, and the most common of those was marijuana (12). While the effects of marijuana are different from alcohol, it similarly impairs reaction times and the ability to concentrate on the road. When a person consumes marijuana, his/her heart rate increases, short-term memory is impaired, and attention, motor skills, reaction time, and the organization of complex information are all reduced. All of these impacts are crucial for driving a vehicle (13, 14). Further, when individuals consume recreational marijuana, it is often with the intention of feeling its effects and its high. This is in contrast to alcohol, where some individuals may drink with the intention of becoming drunk, while others may consume alcohol moderately and responsibly without feeling its effects. Recommendation: The Government of Ontario should develop a comprehensive safety framework around impaired driving and cannabis use. This framework should address prevention, education as well as enforcement and the legal consequences to an impaired driver. The OMA and other key stakeholders should be key informants of this framework. Recommendation: Police training must be developed to capture changes to legislation, as well as education around the identification of impaired drivers. Recommendation: The Government of Ontario should develop a public safety campaign aimed at cannabis users that are pedestrians or cyclists. Planning public education It is critical that the province of Ontario develop a comprehensive public education campaign using a public health approach that focuses on prevention and increasing awareness of the risk factors associated with cannabis use. General education and awareness campaigns should be geared toward the general public. More focused public education should be developed to target youth and as well as specific populations that are more at risk for cannabis use and its adverse effects (4). Public education campaigns should be deployed before recreational cannabis becomes legal. Successful campaigns used in the past have increased awareness of the health impacts of tobacco use have and led to greater public knowledge around the issue as well as a decrease in the number of users. Principles from these past campaigns could serve as a foundation to underpin future work around public awareness of the harmful risks of recreational cannabis use. Physicians play a critical role in planning and executing education on the harmful health impacts that cannabis can have. Patients turn to physicians as a trusted voice on a wide array of health issues, including the impacts of cannabis. However, to date, there have been insufficient resources allocated to properly research cannabis use at the provincial level. This lack of evidence-based information poses a public health risk and leaves physicians ill equipped to inform and best support patients. Page 6 of 10
Public health warnings on recreational cannabis products should also be a core component to public education. The province of Ontario should follow the federal tobacco products labelling regulations that state that 75% of the front and back of cigarette and little cigar packages be covered in health warning messages. Further, in anticipation to changes in federal tobacco regulations to include plain and standardized packaging (PSP), the province of Ontario should require PSP for all recreational cannabis products. Recommendation: Public education campaigns that focus on prevention and increasing awareness of the risk factors associated with recreational cannabis use should be deployed before legalization. Recommendation: The Government of Ontario work with the Ontario Medical Association to develop proper tools to inform physicians and support patients. Recommendation: Invest in necessary research to inform physicians and health care providers about the health impacts of cannabis use. Recommendation: The province of Ontario should require plain and standardized packaging for all recreational cannabis products as well as follow the federal tobacco products labelling regulations to ensure public health warnings are included on all packaging for recreational cannabis products. Page 7 of 10
Summary of Recommendations 1. The health risks caused by recreational cannabis use can best be avoided by abstaining from cannabis use. 2. The minimum age for purchasing, possessing and using cannabis should be set at 25, given the negative impact that cannabis can have on health, particularly on brain development. 3. Regulations that outline the age of sale in Ontario should be outlined with adjoining penalties for any retailer that violates the law. These penalties must be strictly enforced to ensure their effectiveness. 4. The Government of Ontario should sell cannabis and cannabis related products through a Crown corporation. The Crown Corporation should have a monopoly on the retail and distribution of cannabis and related products throughout the province. 5. If the decision is made to sell recreational cannabis at the LCBO, strict regulations should be employed that limits the amount of alcohol sold with recreational cannabis. 6. Staff at the place of sale of cannabis should be properly trained on all kinds of cannabis, the strength of different products sold, the intended use of each product and how each product might affect the user. 7. The distributor of cannabis should not be able to sell other products, such as alcohol or tobacco. 8. Should recreational cannabis be sold in an establishment that also sells alcohol, such as the LCBO, strict regulations should be employed that limits the amount of alcohol sold with recreational cannabis. 9. Should the province of Ontario decide that cannabis can be sold and used through specialized lounges, the Crown Corporation established to sell cannabis to the public will also be the chief supplier of cannabis to said establishments. 10. A comprehensive model for data collection around the cannabis products should be established through the retail distribution centre to inform future legislation, policy and health and social-welfare programs. 11. There must be strict regulations implemented on the marketing of recreational cannabis, using the current regulations for marketing tobacco as the minimum. Page 8 of 10
12. The Ontario government should prohibit smoking cannabis in public and certain private spaces, including the following: Outdoor patios Child care facilitates Motor vehicles Enclosed workplaces Smoking shelters Areas where home health care workers work Hospitals (public, private and psychiatric facility) Common areas of hotels, motels and inns Common areas of multi-unit residences Residential care facilities Schools (public and private school property) Children s playgrounds and publicly owned sports fields 13. The government of Ontario should prohibit smoking recreational cannabis in a private residence if children are present. 14. Recreational cannabis should be stored in a safe place where children can not access the product. 15. The Government of Ontario should develop a comprehensive safety framework around impaired driving and cannabis use. This framework should address prevention, education as well as enforcement and the legal consequences to an impaired driver. The OMA and other key stakeholders should be key informants of this framework. 16. Police Officer training must be developed to capture changes to legislation, as well as education around the identification of impaired drivers. 17. The Government of Ontario should develop a public safety campaign aimed cannabis users that are pedestrians or cyclists. 18. Public education campaigns that focus on prevention and increasing awareness of the risk factors associated with recreational cannabis use should be deployed before legalization. 19. The Government of Ontario work with the Ontario Medical Association to develop proper tools to inform physicians and support patients. 20. Invest in necessary research to inform physicians and health care providers about the health impacts of cannabis use. 21. The province of Ontario should require plain and standardized packaging for all recreational cannabis products as well as follow the federal tobacco products labelling regulations to ensure public health warnings are included on all packaging for recreational cannabis products. Page 9 of 10
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