LC LSIC Inquiry into Use of in Submission 1325 Inquiry into the use of Cannabis in Victoria

Professor Simon Lenton

Organisation Name:National Drug Research Institute Your position or role: Director

SURVEY QUESTIONS Drag the statements below to reorder them. In order of priority, please rank the themes you believe are most important for this Inquiry into the use of Cannabis in Victoria to consider:: 0

What best describes your interest in our Inquiry? (select all that apply) : Academic and research Decades of research into cannabis policy in Australia and internationally

Are there any additional themes we should consider?

Select all that apply. Do you think there should be restrictions on the use of cannabis? : Other – please explain. Please see attachment

YOUR SUBMISSION Submission: The National Drug Research Institute's submission in contained in the attached document.

Do you have any additional comments or suggestions?:

FILE ATTACHMENTS File1: 5f49966d82970-NDRI Submission-Inquiry into Cannabis Use in Victoria.pdf File2: File3:

Signature: Simon Lenton

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INQUIRY INTO CANNABIS USE IN VICTORIA

Submission from the National Drug Research Institute, Curtin University (NDRI) to Parliament of Victoria Legal and Social Issues Committee

August 2020

National Drug Research Institute Curtin University Building 609 (Level 2), 7 Parker Place Technology Park, Bentley WA 6102

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SUBMISSION FOCUS This submission, from the National Drug Research Institute (NDRI), focusses specifically on research related to points c) and e) of the Inquiry’s Terms of Reference: c) implement health education campaigns and programs to ensure children and young people are aware of the dangers of drug use, in particular, cannabis use; e) assess the health, mental health, and social impacts of cannabis use on people who use cannabis, their families and carers; and models of cannabis regulation internationally that might be adapted for the Victorian context. It also makes recommendations specific to each of those areas (see page 18).

ABOUT NDRI The National Drug Research Institute’s (NDRI) mission is to conduct and disseminate high quality research that supports evidence informed policy, strategies and practice to prevent and minimise alcohol and other drug-related health, social and economic harms among individuals, families and communities in Australia. Since its inception in 1986, the Institute has grown to employ about 30 research staff, making it one of the largest centres of drug research and public health expertise in Australia. Researchers have completed more than 500 research projects, resulting in a range of positive outcomes for policy, practice and the community. For example, NDRI research has significantly informed and contributed to policy and evidence-based practice such as the National Amphetamine- Type Stimulants (ATS) Strategy, the National Drug Strategy and the National Alcohol Strategy; contributed to Australia’s involvement in international strategies, such as WHO Global and Regional Strategy to Reduce Harmful Use of Alcohol; directly contributed to Australian and State government alcohol and illicit drug policy, including cannabis policy and naloxone availability; significantly contributed to international evidence-based school interventions; influenced NHMRC guidelines to reduce alcohol health risks; and been cited in development of policy documents for Aboriginal Australians. The Institute’s work was described as “research considered truly internationally competitive and making a major contribution to the advancement of knowledge” in the Research Quality Framework.

NDRI’S PREVIOUS INVOLVEMENT IN RESEARCH LEADING TO CANNABIS LAW REFORM NDRI, and Lenton in particular, has a long history of conducting research bearing on cannabis policy reform. We have previously documented the adverse impacts of a criminal conviction on individuals apprehended for a minor cannabis offence in and compared these with the impacts of a civil penalty in (Lenton, Humeniuk, Heale, & Christie, 2000). We have provided evidence that less than 1% of cannabis users in one year unlucky enough to be apprehended criminal charge (Lenton, 2000) and a conviction fails to provide a specific deterrent effect doing very little to affect the cannabis use of those who are convicted (Lenton & Heale, 2000). On the basis of such evidence, we recommended the application of civil rather than criminal penalties for minor cannabis offences in Victoria (Lenton, Heale et al., 2000) and Western Australia (Lenton, 2004), which led to the implementation of the Cannabis Infringement Notice scheme in Western Australia in 2004 under the Gallop government (Lenton & Allsop, 2010) (the scheme was repealed by the Barnett government in 2011). Beyond this, NDRI has recently been involved in

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research on the implementation of the legal cannabis regime in Colorado (Subritzky, Lenton, & Pettigrew, 2016, 2019, 2020; Subritzky, Pettigrew, & Lenton, 2016, 2017) and in a large international study of small-scale cannabis growers in 15 countries (Hakkarainen et al., 2015; Lenton, Frank, Barratt, Potter, & Decorte, 2018; Lenton, Frank, Barratt, Dahl, & Potter, 2015; Potter et al., 2015; Sznitman et al., 2019), the most recent survey of which is about to be launched in 19 countries in 11 languages from September 2020. With the developments in legal medical and ‘recreational’ cannabis markets internationally, consideration of cannabis policy options for which we have evidence of implementation and effects has moved beyond the comparison of strict criminal penalties schemes versus civil penalty schemes to consider both commercial and non-commercial models of cannabis regulation post prohibition (Kilmer & Pacula, 2017). Lenton and colleagues have recently published an edited book (Decorte, Lenton, & Wilkins, 2020) that brings together the best available evidence and expertise to investigate the lessons that can be learned from the regulation of cannabis and other psychoactive substances (such as alcohol, tobacco, pharmaceuticals and “legal highs”) and that can be translated to the effective regulation of cannabis markets.

AUSTRALIA AS A VENUE FOR CANNABIS POLICY EXPERIMENTS The fact that drug possession and supply law has effectively been state and territory law has meant Australia has provided an opportunity for natural policy experiments, such as those studies referred to above. Consistent with that, a number of Australian states and territories have implemented various civil and cautioning schemes for cannabis, while maintaining prohibition. Prohibition with civil penalties schemes were introduced for minor cannabis offences in South Australia in 1987, the Australian Capital Territory in 1992, the in 1996 and in Western Australia from 2004 to 2011. Furthermore, prohibition with cautioning and diversion schemes were introduced for cannabis in the non-civil penalty jurisdictions and for all other illegal drugs (, amphetamine- type stimulants, , LSD, ecstasy, etc.) for all Australian states and territories under the Illicit Drug Diversion Initiative (IDDI) introduced under the Howard Government in 1999. However, the federal prohibition on cannabis has provided a legislative impediment on non-prohibition policy reforms at a state and territory level, even if to date, none have been actively proposed or implemented.

PUBLIC SUPPORT FOR LEGALISATION OF CANNABIS IN AUSTRALIA There has not been a recent comprehensive public debate in Australia about the pros and cons of legalising cannabis for non-medical or ‘recreational use’. Support for the legalisation of cannabis (for recreational purposes) among the general Australian population has increased from 26% in 2013 to 41% in 2019 (Australian Institute of Health and Welfare, 2020). Given that this may be an underestimate, it is possible that support for the legalisation of cannabis for recreational purposes is approaching 50% of the Australian population aged 14 years and over. According to the AIHW, use of cannabis in the last 12 months has increased from 10.4% in 2016 to 11.6% in 2019, the latter figure including those who have been prescribed the drug for medical treatment under provisions, which came into effect in Australia in February 2016. Support for legalisation of cannabis was highest (91%) among people who had used the drug recreationally, but support was almost as high (89%) among those who used it for medical but not recreational reasons.

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C) IMPLEMENT HEALTH EDUCATION CAMPAIGNS AND PROGRAMS TO ENSURE CHILDREN AND YOUNG PEOPLE ARE AWARE OF THE DANGERS OF DRUG USE, IN PARTICULAR, CANNABIS USE Section author: Associate Professor Nyanda McBride

Response focus: School-based illicit/cannabis education 1. Recent illicit and cannabis use of secondary school aged youth 14-17 years of age 2. School-based Drug Education Programs: 2.1 Level of evidence 2.2 The evidence status of drug/cannabis school-based education programs 2.3 Possible ways to increase impact 2.3.1 Developmental period 2.3.2 Alternative programs in primary and early secondary school 2.3.3 Systematic development of prevention approaches to optimise behavioural effectiveness of future programs 3. The school setting – enablers and barriers

1. Recent illicit and cannabis use of secondary school aged youth 14-17 years of age Data in this section is a summary of the 2019 National Drug Strategy Household Survey – Illicit Use of Drugs supplementary tables (Australian Insitute of Health and Welfare, 2020), and details recent illicit and cannabis use and experience of Australian secondary school aged youth 14-17 years and, when available, Victorian students in the same age bracket.

Illicit Drug Use Just over 13% (13.4%) of secondary school aged youth 14-17 years had used illicit drugs in their lifetime equating to approximately 160,000 youth. Males (13.3%) and females (13.7%) in this age group were equally as likely to have used illicit drugs in their lifetime. In the previous 12 months, 9.7% of secondary school aged youth 14-17 years had used an illicit drug, equating to 110,000 youth having used an illicit drug in the previous 12 months. Males (10.2%) and females (9.2%) were similarly likely to have used an illicit drug in the previous 12 months. People aged between 14 and 19 years are the age group least likely to have used an illicit drug in the previous 12 months (8.4%). The most likely age groups to use an illicit drug in the previous 12 months are 20-29 year olds (32.8%), 30-39 year olds (20.5%) and 40-49 year olds (15.3%). The mean age at which Australians first tried an illicit drug was 18.9 years. Unfortunately, data on frequency of illicit drug use combines 14-17 year olds (the least likely group to use an illicit drug) with 18-19 year olds (the age group most likely to use an illicit drug). Therefore, this data is of limited value and is not reported. Factors that influence first use of an illicit drug for those who have ever used in the 14-17 age group include:  To see what it was like/curiosity (65.7%)  Friends or family member were using it/offered by friend or family member (49%)  To do something exciting (24.6%)  Thought it would improve mood/to stop feeling unhappy (23.4%)  To enhance an experience (16.2%)  Other (3.4%)

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Reasons why youth continue to use illicit drugs for those who have ever used in the 14-17 age group include:  Enjoyment/wanting to have fun (87.7%)  Wanting to improve mood (34.5%)  Wanting to do something exciting (32.2%)  Wanting to enhance an experience (25.1%)  Influence of family or friends (18.2%)  Addiction/dependency (2%)

In the previous 12 months, the most common reason why youth aged 14-17 years continued to use an illicit drug was to improve their mood/to stop feeling unhappy. In the previous 12 months, 5.9% of youth aged 14-17 years had experienced an illicit drug related harm (verbal abuse, physical abuse, put in fear). In the previous 12 months, 25.2% of 14-17 year olds were offered or had the opportunity to use an illicit drug (25.2% cannabis, 6% ecstasy, 2.7% cocaine and 1.3% meth/amphetamines).

Cannabis Use Data in this section is a summary of the 2019 National Drug Strategy Household Survey (NDSHS) – Illicit Use of Drugs supplementary tables (Australian Insitute of Health and Welfare, 2020), and from the 2017 Australian Secondary Students’ Alcohol and Drug Survey (ASSAD) use of tobacco, alcohol, over-the-counter drugs, and illicit substance (2nd ed.) Statistics and Trends (Guerin & White, 2020a, 2020b). This section details cannabis use and experience of Australian secondary school aged youth 14-17 years and, when available, Victorian students in the same age bracket (NDSHS) and school students aged 12-15 years and 16-17 years (ASSAD).

National Drug Strategy Household Survey (Australian Insitute of Health and Welfare, 2020) The percent of secondary aged students 14-17 years old who had ever used cannabis has decreased from 34.3% in 2001 to 18.2% in 2019. In the previous 12 months, males (10.7%) and females (9.1%) were similarly likely to have ever used cannabis. This equates to approximately 100,000 Australian secondary school aged youth have ever used cannabis. The percentage of youth aged 14-17 years who have used cannabis in the previous 12 months is 8.2%, with males (8.7%) and females (7.8%) similarly likely to have used. Approximately 100,000 youth aged 14-17 years have used cannabis in the previous 12 months. The risk for cannabis use in youth aged 14-17 year age group is low (87.6%) to moderate (11.8%). Moderate risk indicates use that may be hazardous or harmful. Slightly more youth aged 14-17 years in Victoria (9.3%) and (10%) reported cannabis use in the previous 12 months than the Australian average (8.2%).

Australian Secondary Students’ Alcohol and Drug Survey (approximately 20,000 secondary students) (Guerin & White, 2020b) In 2017, 9% of students aged 12-15 years old had ever used cannabis, 8% had used in the past year, 5% in the past month and 3% in the past week. During the same year, 30% of students 16-17 years old had ever used cannabis, 28% had used cannabis in the last year, 16% in the past month and 8% in the past week.

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2. School drug education programs 2.1 Level of evidence There are three levels of evidence-of-impact that provide information about the behavioural effectiveness of a program in schools and other settings. These levels may not be readily or comprehensively considered by education systems, alerting school staff to evidence/impact-based programs. These three levels include: 1) Evidence-based programs which have been developed and informed by past knowledge in the field (i.e. inclusion of systematic literature reviews findings), and when this is not available by current best practice informed by practice wisdom 2) A program with proof-of-impact is one that has undergone rigorous longitudinal impact assessment resulting in statistically significant behaviour change in the target population 3) A program has well established proof-of-impact when it has been replicated in another jurisdiction under the lead of another research team, with statistically significant behaviour change that supports the original study. If a program is evidence-based, there is no proof that behaviour change will result from implementation. If a program has well established proof-of-impact there is an understanding that if it is delivered as intended, with the intended target group, by trained staff, then some level of behaviour change can likely be expected. However, there can be some strong barriers to the implementation of drug education programs in schools. These barriers extend from a system level to an individual school level (see point 3).

2.2 The evidence status of drug/cannabis school-based education programs Systematic reviews and meta-analyses on drug/cannabis school-based education programs published post 2010 identify some impact on cannabis use, however, the majority of effect sizes (impact) are identified as trivial or small (Agabio et al., 2015; Bas, Salam, Arshad, Finkelstein & Bhutta, 2016; Lize et al., 2017; MacArthur, Harrison, Caldwell, Hickman, & Campbell, 2015; Norberg, Kezelman & Lin-Howe, 2013; Onrust, Otten, Lammers, & Smit, 2016). The source programs for these reviews have an earlier publication date, therefore an updated global review is required to fully capture programs evaluated in the past several years. Most programs with some impact on cannabis use included multi-lessons, skill-based development (including refusal skills training), social competence, social influence approach or a multi-model approach. One-off lectures are not accepted as an evidence-based approach and is not an approach with proof-of-impact. In the Australian context, a 2012 review of the efficacy of alcohol and other drug programs (harm reduction focussed) trialled in Australian schools reported two programs that included cannabis and both are combined with alcohol. One of these programs published in 2009/10 reported an impact on frequency of cannabis use at 6 and 12 months using an internet-based program (Newton, Andrews, Teesson, & Vogl, 2009; Newton, Teesson, Vogl, & Andrews, 2010). The other was published in 2004 and reported effect on any use in a year and any weekly use (Bond et al., 2004). Both programs were complex with multi-lessons, and both studies reported low effect size (impact).

2.3 Possible ways to increase impact 2.3.1 Developmental period Behaviourally effective school-based alcohol education programs may assist in identifying at least one reason for the low impact of cannabis/illicit education programs. Alcohol programs that are placed at developmentally appropriate periods are the most successful in impacting alcohol-related behaviours. In particular, alcohol programs placed in the year just prior to when the majority start to

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experiment (inoculation), with booster intervention placed in the year when the majority start to use regularly (relevancy), are the most behaviourally successful (McBride, 2016). In Australia, this equates to providing alcohol programs in years 8-10. Youth aged between 14 and 19 years are the age group least likely to have used an illicit drug in the previous 12 months (8.4%) in Australia. The most likely age groups to use an illicit drug in the previous 12 months are 20-29 year olds (32.8%), 30-39 year olds (20.5%) and 40-49 year olds (15.3%). The mean age at which Australians first tried an illicit drug was 18.9 years. Applying a developmental approach to illicit drugs would mean that increased impact might occur in cannabis/drug education if it targeted young adults aged 17.9 years (inoculation) with booster intervention at 18.9 years (relevancy). These age groups equate to upper secondary education and early tertiary education for those youth engaged in education. For those youth not engaged in education, the setting of potential intervention is less clear. Illicit drug use by young people (including cannabis) tends to be less prevalent than alcohol use in school aged youth 14-17 years (alcohol: drank in previous 12 months 30.3%; cannabis: use in previous 12 months 9.8%). Given these figures, consideration needs to be given as to whether illicit drug education programs that aim to reduce use and harm associated with use are best provided as universal programs within the school setting, targeted to high risk groups within the school setting, or provided as universal or targeted programs in alternative settings. If provided in the school setting, this style of program also has ethical implications related to burden of involvement, as targeted programs may overtly or inadvertently identify at risk students, resulting in reputation damage. If universal illicit programs are implemented in the school setting, it is less likely that a statistically significant effect (less use, less risky use) will be attained in a group where only a small proportion of the cohort is currently displaying a behaviour or will engage in the behaviour in the future. When effect size is taken into account, there is limited evidence for applying universal harm reduction education to illicit drugs in the school setting at the current time. Further formative research (see point 3) needs to be conducted to refine how and when illicit drug education is provided and whether schools are the most appropriate setting for illicit drug education with young people. This research should extend beyond risky use and outcomes for illicit drug users to include potential benefits of resilience/safety education around illicit drug use, for example, how to respond to someone using an illicit drug.

2.3.2 Alternative programs in primary and early secondary school Universal resilience education may be useful alternative/additional programs to provide in primary and early secondary school to reduce illicit drug use. A recent systematic review and meta-analysis of resilience education in adolescents to reduce substance use (Hodder et al., 2017) reported on 11 studies specific to illicit drugs. A significant overall effect was reported for illicit drug use in resilience programs with multidimensional content using a universal approach in school settings (Hodder et al., 2017).

2.3.3 Systematic development of prevention approaches to optimise behavioural effectiveness of future programs A systematic approach to program development can increase potential for behavioural change (McBride, 2016) and therefore it is important that, prior to program adoption, the program is rigorously assessed against the point below before acceptance and use.

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A systematic process ensures the most pertinent impact/evidence is captured and applied to program development. A systematic approach to program development goes beyond attempting to incorporate findings from a systematic literature review. The School Health and Alcohol Harm Reduction Project empirical model for developing intervention to increase the potential for behaviour change (McBride, 2020) uses a systematic approach to program development and includes:  Relevant findings from past literature. Identifying age of delivery, program components, strategies, content and mode of delivery from programs selected for inclusion in systematic literature reviews that have demonstrated some potential for behavioural effectiveness. If past literature provides limited findings, review of similar literature may help uncover possible aspects that can guide program structure and content (e.g. alcohol harm reduction programs).  Incorporate relevant theory. Theories relevant to the focus of the program can help to conceptually identify the range of factors that impact the behaviour. Identification of these factors can be used to help build a comprehensive list of factors that may help to modify behaviour.  Incorporate expert advice. The range of experts who can provide guidance to program development include content, intervention and setting experts comprising academic researchers, policy/practice professionals, and others who work directly with the target/consumer group. Expert involvement should occur from the inception of program development to optimise potential for behavioural impact and adequate measurement of behavioural impact (so that future programs will be accepted in to systematic reviews and provide guidance to subsequent programs).  Target/consumer group involvement in development and pre-assessment of programs. Target/consumer involvement in program development is critical for behaviour change as it ensures that strategies, content and mode of delivery are meaningful and relevant to the target/consumer groups. If target/consumer involvement is not included then the possible behavioural effectiveness of the program is reduced (McBride, 2016). Several steps are required to ensure that target/consumer experiences guide program development. These include asking target/consumers about their experiences, knowledge, values and beliefs; asking target/consumers about their recommendations for program components, strategies, content and mode of delivery; systematically incorporating target/consumer identified detail in a pilot of the program; piloting the program with the target/consumer groups to refine the program.  To ensure the inclusion of all relevant findings from the systematic program development process, methodically table all key findings and plan placement of findings into projects, activities, recommendations and guidelines. Maintain a table noting where placement has occurred by element (systematic review, theory, target/consumer groups’ input, expert input) so that regulation is more readily achieved, and is documented in detail in reporting to enable future replication and to enable a clearer understanding of inclusions that contribute to behaviour change (when analysis is linked to fidelity of implementation data).  A systematic approach to program development needs to be teamed with appropriate evaluation methodology. Evaluation design should be established prior to the conduct of the program as pre-assessment of measurement domains, for example, knowledge, attitudes, previous experiences, behaviours and behavioural intentions, is required to statistically analyse against post program measures to identify change. Evaluation design and methodology is complex and requires expert input to reduce bias and increase the reliability of evaluation findings. Quality evaluation design and methodology will result in acceptance into systematic literature reviews and help build the knowledge base of the field.

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3. The school setting – enablers and barriers There are a number of compelling reasons to include drug education in schools. Schools are an important component of a whole of community approach to prevention (Lenton, 2005). At a school level there is some demand for illicit drug education programs, either because the topic is politically mandated or, if not mandated, because it is a current school, district or central educational priority. Additionally, teachers in schools regularly select illicit drug education programs for their students irrespective of mandates or priorities.

Schools are a valuable setting for health education (the usual subject in which illicit drug education would sit) as they have existing staff, structures and supports that enable programs to be effectively delivered. Teachers are skilled program providers with experience in program implementation combined with a direct knowledge of young people’s developmental capacities and interests. The school environment, particularly though the curriculum aspect, provides direct and sustained contact with most young people in an environment that engenders learning. School staff, however, have a wide variety of choice in the selection of illicit drug education programs that they decide to implement, and with devolved decision making, staff knowledge of selection issues are increasingly important. Central education systems also alert school staff to evidence-based programs, however, understandings and definitions of evidence vary (see point 2.1) (Gorman & Huber, 2009).

Although there is a long history of the education sector developing in-house drug education programs for schools, behaviourally effective interventions documented in systematic literature reviews are largely those emanating from research organisations (Strom, Adolfsen, Fossum, Kaisee, & Martinussen, 2014).

The quality of drug education programs implemented in the school setting are also influenced by the subject area in which content usually resides. Traditionally, illicit drug education programs are delivered as part of the Physical/Health Education subject area and there are inherent problems associated with this placement. As a subject area, the status of Physical/Health Education is traditionally low. This is reinforced in the Australian National Curriculum where Physical and/or Health Education are allocated one hour per week (Australian Curriculum Assessment and Reporting Authority, 2014) and illicit drug education may not be allocated any time. The low status is also commonly reinforced at the school level where room allocation, teacher allocation and teachers’ skill base are given low priority when administrative structuring and timetabling occurs (Farringdon, 2010). This means illicit drug education may be taught by untrained teachers who have been allocated that task to fill their teaching load (Farringdon, 2010; Tupper K, 2008). This is the worst case scenario, however. There are insightful and interested staff who develop some research knowledge and apply it to program selection, and supportive school administration who may prioritise health education (usually for a finite period of time).

There is potential to place illicit drug education in an alternative subject area such as the English learning area, which has high level status. There is some research evidence reporting that this placement can be successful (McBride, 2002).

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E) ASSESS THE HEALTH, MENTAL HEALTH, AND SOCIAL IMPACTS OF CANNABIS USE ON PEOPLE WHO USE CANNABIS, THEIR FAMILIES AND CARERS Section authors: Dr Robert Tait and Professor Steve Allsop

A recent analysis from a national group, led by NDRI, estimated that the cost of cannabis use to Australian society in 2015/16 was $4.5 billion (Whetton et al., 2020). A significant proportion of these were related to law enforcement costs associated with enforcing current laws and any related crimes and their consequences. There were also costs to the health system, and workplaces (see Infographic summary on the next page). Although not included in the overall total, due to limited available data, the report also provided preliminary estimates for other costs, for example, to partners and children living with a person dependent on cannabis and also the lost quality of life from having cannabis dependence (Whetton et al., 2020).

Using information from the National Drug Strategy Household Survey and the Global Burden of Disease Study (Australian Institute of Health and Welfare, 2017; Global Burden of Disease Collaborative Network, 2018), it was estimated that there are 27,212 partners and 45,660 children living with a cannabis dependent person. Again, it is important to highlight that the research team observed that the limitations of data meant that only a tentative estimate could be made. The estimated value of their reduced quality of life was $2.6 billion.

At the most severe end of these problems, cannabis can be a contributory factor in child protection cases. The report estimated that about 8% of cases involved cannabis, at a cost of nearly $400 million. There are also an estimated 147,000 other people who are co-resident with a person who was defined as dependent on cannabis. While the impact on these individuals may be lower than for partners and children, the large number potentially affected means that their lost quality of life may equate to more than $3.4 billion. Again, we emphasise the tentative nature of these results.

The Global Burden of Disease study identifies that some episodes of both psychosis/schizophrenia and depression are partly attributable to cannabis use. Not only would such conditions impact the individual and their families, they have significant economic repercussions too. The analysis noted that cannabis related psychosis and schizophrenia were the most costly of the cannabis attributed hospital events, at an estimated cost of more than $62 million, with a further $14 million identified in prescription medications for these conditions. Clearly, there could be other costs, for example, through the use of general practitioner and community mental health services, but the report did not partial out the costs by specific conditions.

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Figure 1. Summary of the social costs of cannabis

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MODELS OF CANNABIS REGULATION INTERNATIONALLY Section author: Professor Simon Lenton

There are a number of jurisdictions internationally that have embarked or are embarking on a variety of legalisation measures (Decorte et al., 2020). The sale of cannabis for adult, recreational use has been made legal in in Uruguay since 2013; 11 US states, beginning with Colorado in 2014; and in Canada since 2018. Evidence on the resulting benefits and costs is starting to accrue but it may take ten years (Homel & Brown, 2017) or up to a generation (Caulkins & Kilmer, 2016) before all the evidence is in. Australia is well placed to learn from international examples, yet the evidence is still accruing.

Legalisation in Uruguay contrasts with the fully commercialised models in the US and Canada. It is characterised by strong government legal and regulatory controls that aimed to control consumption and achieve public health goals. Users have three ways to access legal cannabis for recreational purposes: via home cultivation; through pharmacies; and via cannabis social clubs (described below). All users must be registered by the government, it is forbidden to sell to tourists, no type of advertising is allowed, and edibles are banned. Registered users may access up to 40g of cannabis per month (Queirolo, R., 2020; Queirolo, Rosario, 2020). While there have been problems with the scheme, such as shortfalls in legal government supply, only small numbers of pharmacies participating in the scheme and the problem of requiring users to register with the government, it is estimated that five years after its implementation, 54% of all cannabis users in Uruguay are accessing their cannabis from legal sources, thus reducing their exposure to illegal networks (Queirolo, Boidi, & Cruz, 2016; Queirolo, Rosario, 2020).

In 2018 Luxembourg announced that it would be legalising recreational cannabis by 2023 (Sensi Seeds, 2020), but opposition from other EU countries has resulted in the president calling on other EU states to also legalise the drug and cannabis legalisation in Luxembourg remains a work in progress (Bercea, 2020).

Closer to home, in Australia, the ACT introduced a limited cannabis legalisation scheme that came into effect on 31 January 2020. On the books, the new ACT law made it legal to possess up to 50g of dry cannabis or 150g of "wet" (freshly harvested) cannabis, and for adults to cultivate two plants per person and four per household, ensuring the plants and stored cannabis aren’t accessible to the public or children. Unlike other jurisdictions around the world, the sale or supply of cannabis, including technically passing a to a friend, remains a criminal offence, as does consumption in public. The scheme was complicated by the fact the Australian Federal Police enforce the drug laws in the ACT and there was ambiguity as to how they would enforce the new ACT laws, with the Federal Attorney-General saying that cannabis use remained illegal (Alcohol and Drug Foundation, 2020; Mannheim & Lowrey, 2020). The ACT laws are set for review in three years from implementation, but as yet we are aware of no data emerging on their implementation or impact. New Zealand is scheduled to go to a referendum vote on a proposal to legalise cannabis in October along with the National election that has been delayed due to COVID-19. The draft NZ Cannabis Legalisation and Control Bill (Little, 2020; NZ Government, 2020) describes a tightly regulated commercial cannabis market, loosely based on the Canadian approach, which also includes provision for home cultivation and community trust operations (Wilkins, C. & Rychert, 2020; Wilkins, Chris, 2018). But it is uncertain whether the proposal will be passed and, if implemented, rolled out in its current form.

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Most current evidence of legalisation is based on fully commercialised models Most of the evidence on the impact and effects of cannabis legalisation has been based on the North American examples, primarily those US states that have changed laws, and mostly the early adopters, beginning with Colorado. These examples have been dominated by fully commercialised, profit-driven models in a society dominated by ‘free market’ ideology and limitations on controlling ‘free speech’, which make it a challenge to regulate such things as advertising and promotion.

Summary of key research on the impact of commercial cannabis legalisation  It is too early to determine the effects of cannabis legalisation in Uruguay, 11 US states and Canada. It will likely take some time for consumption patterns of users to stabilise after legalisation and many of the health and other effects are time lagged. Furthermore, evaluation research is complicated by the impact of earlier medicinal cannabis legal changes in some locations, differing legal frameworks in different places, the impacts of pre-change levels of cannabis use, and, in the US examples, the impact of the continued Federal prohibition on cannabis use and sale affecting how markets emerge and grow (Hall et al., 2019; Smart & Pacula, 2019).  As yet, legalisation does not appear to have resulted in significant increases in youth cannabis use, however, cannabis use by adult regular users does seem to have increased (Smart & Pacula, 2019), and there is emerging evidence of increased use among college students (Bae & Kerr, 2020).  The impact of cannabis legalisation on motor vehicle accidents at this point is mixed (Anderson, Hansen, & Rees, 2013; Aydelotte et al., 2017; Sevigny, 2018) but more recent evidence suggests a short term increase in both states that have introduced commercial legal cannabis regimes and in neighbouring states (Lane & Hall, 2019).  There is good evidence of substantial price decreases and significant increases in potency of cannabis products, and that higher potency products are comprising a greater proportion of market share over time. Thus, in the first four years of the recreational cannabis market in Colorado, the average cost of a 57.1mg serving of inhaled THC from cannabis flower decreased 50.8% from $US3.68 in 2014 to $US1.81 in 2017. From 2014 to 2017, the share of total legal cannabis market due to concentrates (hash, waxes, shards, shatter and vape cartridges) sales increased from 11.6% to 23.4% (Orens, Light, Lewandowski, Rowberry, & Saloga, 2018).  Cannabis legalisation has substantially reduced to almost nil the number of people receiving criminal records and being incarcerated for minor cannabis offences, with a large reduction in associated criminal justice costs (e.g. Mosher & Atkins, 2020).  Early experience of cannabis legalisation suggests that legal cannabis markets can attract substantial demand away from the black market, but some level of black market activity persists possibly related to regulatory controls such as purchase age restrictions, bans on particularly high risk product types, absence of legal retail outlets, and shortfalls in legal supply (Decorte et al., 2020; Parnes, Bravo, Conner, & Pearson, 2018).  The evidence from Colorado, the first state to introduced a fully legalised commercial cannabis market, was that the industry, which was involved in the process of regulation making as part of the ‘Collaborative Governance’ approach, sought to weaken regulations such as those relating to pesticide use (Subritzky et al., 2016).  Ultimately the public health effects of the legalisation of cannabis will substantially be affected by what impact the cannabis law changes affect, not only use and harms associated with cannabis but also the impacts on use of alcohol and other drugs such as opioids (Hall, W. & Lynskey, M., 2020). Whilst there have been some early claims regarding some of these impacts,

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particularly around opioid use and harm, results are mixed and it is still too early to determine what they will be (Lopez et al., 2020).  Existing legal cannabis markets have confirmed that problematic cannabis users are responsible for the majority of legal cannabis sales. For example, in Colorado those using on a daily or near- daily basis comprised 22.5% of cannabis users but were responsible for 71.1% of the cannabis consumed in the legal market (Orens et al., 2018). Furthermore there was evidence that the cannabis industry recognised the importance of these regular users to their bottom line and as such were targeting them (Subritzky et al., 2016).  Although most legal cannabis markets put restrictions on marketing and promotion, online ‘strain reviews’, celebrity branding and social media postings seem to be effectively used to market the products and are difficult to regulate (Subritzky et al., 2020). Recent evidence suggests that in US states with legal retail cannabis markets adolescents are exposed to cannabis marketing through social media and such exposure is related to recent cannabis use (Whitehill, Trangenstein, Jenkins, Jernigan, & Moreno, 2020).  Given the complexities of regulating legal cannabis markets, and the risk that vulnerable cannabis users will be exploited by commercial cannabis sellers, there is a strong case for an initially restrictive regulatory framework and conservative implementation of a legal cannabis market (Decorte et al., 2020).  One of the oft stated motivations for cannabis legalisation is to move the cannabis industry out of the black market and to use taxes to redirect funds to education, treatment and other public goods including general revenue (Subritzky et al., 2019). There is no doubt that the revenues raised have not been trivial. In 2018, Washington made an estimated $US318 million, California $US300 million and Colorado $US260 million (McCarthy, 2019). However, with most US states imposing taxes on the retail cannabis product sales, as prices have fallen so have the per unit tax revenue, with increasing sales volumes required to maintain, or grow, the overall cannabis government tax take (Orens et al., 2018). Furthermore, a price linked taxing structure can skew the market towards high potency products (Hall, W. & Lynskey, M., 2020).  In Canada, despite an intention of the designers of the Canadian scheme to have a public health focus that limited the impact of industry, multinational alcohol and tobacco companies have invested billions in a number of leading Canadian cannabis producers and other cannabis companies (Hall, W. et al., 2019). As a consequence they have been left with:

‘…a vastly expansive cannabis industry – striving for sale and profit maximization in highly competitive settings – is driving a commercialized environment in which the armory of public health may simply be too slow and weak for effective checks and protections.” (Fischer, Bullen, Elder, & Fidalgo, 2020, p. 187)

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Middle ground options It should be clear from the above that, while there is still much to learn about the consequences of legalisation, from a public health standpoint, it is clear that a fully commercialised profit-driven model, like we have seen in the new North American legal recreational cannabis markets, and which we have a longer experience of with alcohol and tobacco, is not the ideal supply model for cannabis. Rather, any government considering legalising cannabis for recreational purposes should take a conservative regulatory approach that limits and monitors the impacts of market changes and limits the power of industry to shape regulations and controls to maximise profits. This makes more sense than spending decades struggling to roll back the adverse consequences of rampant commercialism, as we have done with tobacco and alcohol.

To this end, a number of scholars and cannabis policy options have noted that there are a number of non-commercial ‘middle-ground’ options for cannabis (e.g. Caulkins & Kilmer, 2016; Decorte et al., 2020). Such approaches are likely to have less adverse impacts on public health, and even though revenue to the government through GST and sales taxes are likely to be far less than that generated by a fully commercialised model, there are examples of how potential revenue flows may be generated, managed and used for community benefit (Wilkins, 2018). Kilmer and Caulkins provide perhaps the best representation of the options. This is reproduced in Figure 2 here:

Figure 2: Twelve alternatives to status quo prohibition of marijuana supply (From Caulkins & Kilmer, 2016, p. 2083)

Beyond prohibitive approaches, Australia has had most experience with the Prohibit, but decrease sanctions options, through the prohibition with civil penalty schemes that have been in operation in SA since 1987, in the ACT from 1992 to 2020, in the NT since 1996 and in WA from 2004 to 2011. One could classify the recent ACT legalisation change as an example of Allow adults to grow their own cannabis. To date, no Australian state or territory has introduced a scheme that legalises the supply side of the recreational (non-medical) cannabis market.

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Any cannabis reform proposal, which aims to undermine the black market and separate cannabis users from criminal elements, needs to have a mechanism to meet the cannabis supply needs of the bulk of cannabis users, who will not grow their own cannabis. Indeed, having done research on cannabis users and growers for some 30 years, we believe this describes the vast majority of cannabis users. For example, studies with first time minor cannabis offenders suggested that less than 30% grow their own cannabis as their main source of the drug (Chanteloup, Lenton, Fetherston, & Barratt, 2005) and in 2010, the last time the question was reported in the National Drug Strategy Household Survey, only 3% of respondents who used cannabis in the past 12 months said they grew the drug themselves as their main source of supply (Australian Institute of Health and Welfare, 2011). Even if more people decide to grow the drug within a legalised regime, it is likely that they will only be a small proportion of cannabis users and the majority will be left to obtain cannabis from others.

One approach would be to build on the ACT approach, which allows adults to grow their own cannabis by allowing the gifting of cannabis, i.e. supply at no financial cost. This kind of transaction, which is common among small scale cannabis users (Lenton, Grigg, Scott, Barratt, & Eleftheriadis, 2015; Scott, Grigg, Barratt, & Lenton, 2017) and growers (Potter et al., 2015), may be necessary if a grow your own market is to function. However, it is unlikely that even legalising this ‘social supply’ will be enough to meet the cannabis needs of most cannabis users, leaving many to go to the black market. There are other middle-ground approaches to address cannabis supply.

Cannabis Social Clubs One of the ‘middle-ground’ approaches is Cannabis Social Clubs, which are examples of communal own-grow distribution in the Caulkins and Kilmer (2016) graphic. Cannabis Social Clubs have operated in Spain, Belgium, UK, Italy, Slovenia, the Netherlands and Uruguay (Queirolo, Boidi, & Cruz, 2016). The (CSC) model provides a demonstrated and viable way of meeting the supply needs of the vast majority of cannabis users who will not grow the drug themselves. CSCs have been shown to be viable low-risk and self-sustaining models of regulated cannabis supply that address the cannabis needs of regular users whom, because of their lack of knowledge, time, suitable physical space or interest, are unwilling or unable to cultivate their own cannabis for personal use.

Decorte (2018) outlines what he sees should be some of the key features of CSCs, while noting that in practice there is also a great deal of difference between how clubs have evolved and operate in the countries where they currently exist. Some of the key elements are:

 Cannabis users who are unable or unwilling to grow their own cannabis for personal use can give the responsibility for taking care of their plant(s) to a Cannabis Social Club (CSC).  CSCs produce cannabis exclusively for their members’ personal consumption.  CSCs are non-profit organisations that must be established and registered as such and are subject to transparent record keeping and auditing requirements.  The Board and employees of CSCs are subject to conditions regarding their probity (e.g. no criminal or commercial associations).  CSCs are required to meet a number of strict conditions to hold a licence to operate and these are monitored and regulated by an appropriately constituted and knowledgeable regulatory body.

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 These regulations include but are not limited to conditions on its organisational structure and aspects of its cannabis growing processes and system for product quality, storage, and distribution to members.  CSC members must be over 18, residents of the jurisdiction, subject to an intake interview, which includes agreement with the rules of the CSC (e.g. no secondary distribution), and an assessment of their current cannabis use, a willingness for this to be monitored in an ongoing way, and be willing to receive advice about use and harm reduction as appropriate.  There are limits on the maximum number of members (e.g. 250) that a CSC can have and the maximum number of plants per member (e.g. 6).  Individual plants are owned by individual CSC members and are cared for by the CSC. Using a bar code or similar system, it must be clear which plants are owned by which members throughout the whole production and distribution process.  Production must be undertaken consistent with public health goals including:  Utilising organic methods using only organic nutrients and pesticides.  Producing products of known THC concentration and THC:CBD ratio.  Production facilities should be secure and fireproof with approved electrical wiring, and produce no disruption to surrounding areas.  Cannabis products should meet strict labelling requirements including health warnings, information on THC/CBD content and should not include branding or design.  CSCs can take one of two forms: with, or without, facilities. Those with, are subject to specific rules pertaining to this.

Mixed approaches Both the Uruguayan scheme and that proposed for New Zealand integrate a number of elements of the middle-ground options mapped out in the Caulkins and Kilmer (2016) graphic (Figure 2.). The Uruguayan model includes Allowing adults to grow their own, Communal own-grow & distribution (Cannabis Social Clubs) and elements of government operation of the supply chain (small number of government registered growers supplying), with very few monitored for-profit licences (pharmacies) (Queirolo et al., 2016). The NZ proposal includes Allowing adults to grow their own, elements of government operation of the supply chain (government licensing of cannabis production), non-profit organisations (community charitable trusts) and limited monitored, for profit licences (Little., 2020; NZ Government, 2020; Wilkins, Lenton, & Decorte, 2020).

It may be that, should governments wish to legalise cannabis, a model comprising a number of elements of the ‘middle ground’ options, combined and tailored to meet the local needs and issues regarding cannabis, makes good sense. Such an approach may provide the most effective way to provide legal access to cannabis in a way that reduces the adverse impacts of criminalisation on users, families and communities, avoids or minimises many of the adverse public health effects of profit-driven commercialisation.

Of course, the impacts of any scheme will only be evident once it has been implemented and evaluated, but prudence is likely to be found in cautions steps, which can be modified or reversed as impacts emerge and can be ‘relaxed’ gradually if the evidence supports this.

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RECOMMENDATIONS

Section C  Schools should be encouraged to provide illicit drug education programs including cannabis programs that have established proof-of-impact and/or well established proof-of-impact.  Avoid investment in approaches that do not have proof-of-impact and/or those where there is evidence of unintended adverse outcomes.  Given that cannabis prevalence is low in early secondary school (12-15 years) and increases in upper secondary school (16-18 years) consideration should be given to placement of cannabis education in secondary schools or in alternative settings to link into developmental phases.  Development of programs in school and other settings require a systematic process to optimise potential for behavioural impact.

Section E  The largest cost area relates to law enforcement and justice system costs. This suggests that the greatest gains could be made by amendments to legal responses that reduced police costs and justice system costs, with health interventions prioritised.  The Australian evidence on cannabis involvement in road traffic accidents relies heavily on identification of cannabis metabolites, which are indicative of “recent use”, when recent may be several hours or days previously. There needs to be a stronger focus on the impact of cannabis intoxication, usually most prominent in the first three hours after use. It is also relevant to note that much of the evidence about the contribution of cannabis to road traffic accidents is more than a decade old and it would be important to ensure more currency. These two elements (intoxication and currency) are even more important when there are likely to be changing patterns of use under legislative change, any increases in medicinal cannabis use and/or potency of cannabis used.

Learnings from models of cannabis regulation internationally  Most emerging research evidence on cannabis legalisation is based on fully commercialised, profit-driven models in North America. While there is still much to learn, from a public health standpoint, it is clear that such fully commercialised profit-driven models are not the ideal supply model for cannabis. Experience from alcohol and tobacco shows that it can take decades to roll back the consequences of profit-driven commercial models for drugs.  Rather, any government considering legalising cannabis for recreational purposes should take a conservative regulatory approach that limits and monitors the impacts of the market changes and restricts the power of industry to shape regulations and controls to maximise profits. This makes more sense than spending decades struggling to roll back the adverse consequences of rampant commercialism, as we have had to do with tobacco and alcohol.  There are a number of non-commercial, ‘middle-ground’ options for cannabis that are likely to have less adverse impacts on public health. While such models may provide less for governments in terms of tax revenue, there are examples of how potential revenue flows may be generated, managed and used for community benefit.

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 It may be that, should governments wish to legalise cannabis, a model comprising a number of elements of the ‘middle ground’ options, combined and tailored to meet the local needs and issues regarding cannabis, makes good sense. Such an approach may provide the most effective way to provide legal access to cannabis in a way that reduces the adverse impacts of criminalisation on users, families and communities, but also avoids or minimises many of the adverse public health effects of profit-driven commercialisation.  The impacts of any scheme will only be evident once it has been implemented and evaluated, but prudence is likely to be found in cautions steps, which can be modified or reversed as impacts emerge and can be ‘relaxed’ gradually if the evidence supports this.

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