May 31, 2017Attorney General
Honourable Yasir Naqvi
McMurtry-Scott Building
720 Bay Street, 11th Floor
Toronto, ON M7A 2S9

Re: Provincial Implications of the Federal Cannabis Act (Bill C-45)

Dear Minister Naqvi,

On behalf of the Ontario Public Health Association (OPHA) Cannabis Task Group, we wanted to convey our appreciation for being invited to meet with officials from your as well as other ministries to discuss the implications for Ontario of the federal government’s Cannabis Act (Bill C-45). We believe it is paramount to focus on the health of Ontarians as your government moves forward with the creation of a regulatory system for the distribution and sale of cannabis. Highlighted below are our key recommendations for achieving this goal.

Specifically, our Task Group encourages the Ontario Government to adopt a public health approach ^([1]) to cannabis regulation to allow for more control over the risk factors associated with cannabis‐related harms.  We have been struck by the evidence from North America’s long experience with the tobacco, alcohol and medical drug industries, as well as the recent developments related to medical and non-medical cannabis usage in the United States that clearly demonstrates that commercialization increases prevalence of use, which in turn generates significant risks and harms for health.  Consequently, we urge you to consider the following evidence-informed recommendations:

• Set a minimum age of 21 for cannabis purchase and consumption;
• Adopt a government-owned and controlled store-front system with no    
  co-location of alcohol or tobacco with the sale of cannabis;
• Place restrictions on where cannabis can be consumed; and
• Invest in prevention, public health education, research, enforcement,
  treatment and surveillance.

Outlined below is our rationale and evidence for these key recommendations.

Set a minimum age of 21 for cannabis purchase and consumption.
Evidence shows that cannabis use carries significant health risks, especially for people who use it frequently and/or begin to use it at an early age.  Furthermore, regular use of cannabis during adolescence can be associated with changes to brain structure and function, which may limit a young person’s educational, occupational and social potential ⁽²⁾.  However, it is also important to keep in mind that alcohol and tobacco are also clearly linked with youth related harms and that research has identified a legal age of access of 21 as best-practice in terms of preventing or delaying initiation of the use of these substances ^(3,4).

Furthermore, OPHA would like to emphasize the notion that Ontario consult with the rest of the Canadian provinces and territories to ensure that the minimum age is consistent across the country.  A consistent minimum age would eliminate cross-border variations which limit the effectiveness of minimum legal age regulations to protect young people.  Setting an appropriate minimum age is imperative given that a significant portion of cannabis users are young adults (ages 18-29) ⁽⁵⁾.

Adopt a government owned and controlled store-front system with no co-location of alcohol or tobacco with the sale of cannabis.
Evidence from North America’s long experience with the tobacco, alcohol and medical drug industries, as well as the recent developments related to medical and non-medical cannabis in the United States, clearly demonstrate that commercialization increases prevalence of use, which in turn generates significant risks and harms for health.  We urge the Province to adopt a government-owned and controlled store-front system in order to establish a safe and responsible supply chain of cannabis in Ontario ^{(6, 7)}.  A government monopoly on cannabis distribution would ensure direct control over the entire chain and can function as an effective prevention measure provided it is mandated to be socially responsible and it pursues public health objectives ⁽⁶⁾.  For this model to operate effectively, it will be important that the Province:

·         limit availability and place caps on retail density and limits on hours of sale ⁽⁷⁾
·         curb demand through pricing ⁽⁷⁾
·         adopt plain packaging ^(11,12)
·         prohibit the production and sale of products that are attractive to youth ^{(6, 8)}
·         avoid all forms of cannabis product promotion, including sponsorship, endorsement, branding and point-of-sale advertising ^{(6,7,8, 9)}
·         provide adequate staff training to ensure staff are capable of enforcing the minimum-age restrictions and communicating evidence-based information on the potential health effects of using cannabis to consumers ⁽¹⁰⁾

We also agree with Canada’s federal Task Force recommendation that cannabis should not be sold alongside other products such as alcohol and tobacco.  As discussed in the Task Force’s final report, this approach would avoid exposing a larger population to cannabis products, assist cannabis consumers who are trying to avoid alcohol and could help mitigate the risks of co-use on health and, with alcohol, the exponential effect on impairment ⁽¹⁰⁾.

In addition, we have  heard from various municipalities that they would greatly benefit from clear guidance from the provincial government in terms of setting limits on the density and location of storefronts (should this be necessary) ahead of legalization.

Place restrictions on where cannabis can be consumed.
Given that cannabis smoke contains many of the same carcinogens as tobacco smoke ⁽¹³⁾, we urge the provincial government to extend current restrictions on public smoking of tobacco products to the smoking of cannabis products and implement similar restrictions to cannabis vaping products prior to legalization.

Invest in prevention, education, research, enforcement, treatment and surveillance.
To ensure the public is fully aware of the health harms associated with cannabis use, we recommend the government develop and implement an evidence-informed public education campaign ahead of provincial legislation being passed.  Both general awareness (e.g. to promote lower‐risk cannabis use guidelines) and targeted (e.g. to raise awareness of the risks to specific groups, such as adolescents, those who are pregnant, and people with a personal or family history of mental illness) initiatives are needed ⁽⁷⁾.

It is also crucial that the Province commit to using a high percentage of revenue gains from the sale of cannabis products as a source of funding for public health education campaign(s)— especially for youth—surrounding the risks, prevention of misuse and harms, enforcement and the development of sound policies.  Our Task Group also emphasizes the need for investing in baseline surveillance systems and research as well as a comprehensive policy monitoring and evaluation framework.  This will allow your government and its partners to track the impact of recreational cannabis and modify policies as needed.

Further recommendations related to the legalization of the recreational use of cannabis in Ontario can be found in our attached paper: The Public Health Implications of the Legalization of Recreational Cannabis.  

Through effective, public-health-focused policy interventions for cannabis, Ontario can further its goal to make “Ontario the healthiest place in North America to grow and grow old.” We welcome the opportunity to collaborate with your government to achieve this shared goal and will continue to offer our local, provincial and national networks, evidence-based information, knowledge and expertise. 

Thank you for your consideration.

Sincerely,

Pegeen Walsh                         Michelle Suarly                          

Executive Director                  Chair                                                     
                                                   OPHA Cannabis Task Group           

References:

1.     Ontario Public Health Unit Collaboration on Cannabis (OPHUCC)^[2]. (2016). Toward Legalization, Regulation and Restriction of Access to Marijuana: Submission to Federal Task Force.
2.     Canadian Centre on Substance Abuse. Substance Abuse in Canada: The Effects of Cannabis Use during Adolescence. [Report online]. Ottawa Canada: Canadian Centre on Substance Abuse, 2015 [Last accessed 2017 Apr 19]. Available from: http://www.ccsa.ca/Resource%20Library/CCSA-Effects-of-Cannabis-Use-during-Adolescence-Report-2015-en.pdf
3.     IOM (Institute of Medicine). Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. [Report online]. Washington, DC: The National Academies Press, 2015 [Last accessed 2017 May 1]. Available from: https://www.nap.edu/catalog/18997/public-health-implications-of-raising-the-minimum-age-of-legal-access-to-tobacco-products
4.     Giesbrecht N, Wettlaufer A, April, N, Asbridge M, Cukier S, Mann R, McAllister J, Murie A, Plamondon L, Stockwell T, Thomas G, Thompson K, Vallance K. Strategies to Reduce Alcohol-Related Harms and Costs in Canada: A Comparison of Provincial Policies. [Report online]. Toronto: Centre for Addiction and Mental Health, 2013 [Last accessed 2016 Aug 15]. Available from: https://www.camh.ca/en/research/Documents/Provincial%20summary_ON_final.pdf
5.     Ialomiteanu A R, Hamilton H A, Adlaf E M, Mann R E. CAMH Monitor e-Report: Substance Use, Mental Health and Well-Being Among Ontario Adults, 1977–2015. [Report online]. Toronto, ON: Centre for Addiction and Mental Health; 2016 (CAMH Research Document Series No. 45) [Last accessed 2017 Apr 28]. Available from: http://www.camh.ca/en/research/news_and_publications/CAMH%20Monitor/CAMH-Monitor-2015-eReport-Final-Web.pdf
6.     Institut National de Sante Publique du Quebec. Legalization of Non-medical Cannabis: A Public Health Approach to Regulation. [Government report online]. Quebec: Government du Québec; 2017 [Last accessed 2017 Apr 28]. Available from: https://www.inspq.qc.ca/sites/default/files/publications/2233_legalization_non_medical_cannabis_0.pdf
7.     Crépault J-F. Cannabis Policy Framework [Report online]. Toronto: Centre for Addiction and Mental Health; 2014 [Last accessed 2017 Apr 19]. Available from: http://www.camh.ca/en/hospital/about_camh/influencing_public_policy/Documents/CAMHCannabisPolicyFramework.pdf
8.     Liccardo Pacula R, Kilmer B, Wagenaar A C, Chaloupka F J, Caulkins J P. Developing Public Health Regulations for Marijuana: Lessons From Alcohol and Tobacco. AJPH [serial online]. 2014; 104(6): 1021-1028 [Last accessed 2017 Apr 19]. Available from: http://people.oregonstate.edu/~flayb/MY%20COURSES/H671%20Advanced%20Theory%20Winter16/Alternative%20readings/Pacula%20etal14%20PH%20regs%20for%20marijuana%20-%20lessons%20from%20alc%20and%20tob.pdf
9.     DeVillaer M. Cannabis Law Reform in Canada: Pretense & Perils. [Report online]. Hamilton Canada: McMaster University, The Peter Boris Centre for Addictions Research; 2017 [Last accessed 2017 Apr 28]. Available from: https://fhs.mcmaster.ca/pbcar/documents/Pretense%20&%20Perils%20FINAL.PDF
10.   Health Canada. A Framework for the Legalization and Regulation of Cannabis in Canada: The Final Report of the Task Force on Cannabis Legalization and Regulation. [Government report online]. Ottawa: Health Canada; 2016 [Last accessed 2017 May 1]. Available from: http://healthycanadians.gc.ca/task-force-marijuana-groupe-etude/framework-cadre/alt/framework-cadre-eng.pdf
11.   Australian Government Department of Health. Post-Implementation Review: Tobacco Plain Packaging 2016. [Government report online]. Australia: Australian Government; 2016 [Last accessed 2016 Aug 9]. Available from: https://ris.govspace.gov.au/files/2016/02/Tobacco-Plain-Packaging-PIR.pdf
12.   White V, Williams T, Wakefield M. Has the Introduction of Plain Packaging with Larger Graphic Health Warnings Changed Adolescents’ Perceptions of Cigarette Packs and Brands? Tob Control BMJ [serial online]. 2015; 24: ii42-ii49 [Last accessed 2016 Aug 11]. Available from: http://tobaccocontrol.bmj.com/content/24/Suppl_2/ii42.full
13.   McInnis O A, Plecas D. Clearing the Smoke on Cannabis: Respiratory Effects of Cannabis Smoking – An Update. [Report online]. Ottawa Canada: Canadian Centre on Substance Abuse, 2016 [Last accessed 2018 Apr 28]. Available from: http://www.ccsa.ca/Resource%20Library/CCSA-Cannabis-Use-Respiratory-Effects-Report-2016-en.pdf

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