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bmj.com ЖЖNews: legalises sale and production of (BMJ 2013;347:f7499) ЖЖResearch: Acute consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis (BMJ 2012;344:e536) Cannabis regulation: high time for change? Cannabis is widely available despite its use and production being illegal in most countries. Rebecca Coombes looks at recent moves to regulate production and the potential effects on public health

annabis is the world’s most widely tion of cannabis, leaving the supply side to crim- While Amsterdam’s “coffee houses” depend on used illicit . But for how much inal gangs, whose activities today increasingly criminal gangs for their supplies, in Uruguay it is longer? In a short space of time we tarnish an otherwise successful policy. now legal to grow small amounts at home have moved from absolute global pro- But at this crucial stage—as other countries hibition of the drug, with the emer- and US states keenly watch the fortunes of the ated with this illegal trade motivated Uruguay in Cgence of legalised and regulated production pioneers Colorado, Washington, and Uruguay 2013 to become the first country to legalise and and retail not in just one nation (Uruguay) but and no doubt marvel at the tax windfalls—can regulate the production and sale of cannabis for also, surprisingly, in two US states (Colorado and regulatory approaches to the use of cannabis non-medical use. Its government said, “As things Washington). Do these and other new permissive reduce health and social harms more effectively stand today, drug dealers try to push harder models in and , for example, point than prohibition? Is the commercial model pur- on teenagers who go to them for cannabis. to a tipping point in the debate? Could cannabis sued in Colorado, for example, where shops sell This law will change that and prevent cannabis step out of the shadows and join the ranks of customer friendly goods such as edible cannabis from at least being a step to more potent drugs.”2 and , the world’s most popular in the form of candy “gummi bears,” really a solu- “For most jurisdictions cannabis offers a blank legal and regulated drugs? tion that public health can get behind? Perhaps canvas,” says Steve Rolles, senior policy analyst Even in the , so long at the fore- the stricter government control favoured by Uru- for Transform, a UK based think tank on drug front of forward thinking policies on cannabis, guay is the model to watch. policy. “It provides an opportunity to learn from local politicians have joined forces to urge the past errors and replace criminal markets with government to go much further and complete the Unregulated criminal markets regulatory models that are built on principles job it started nearly 40 years ago when it agreed Currently the majority of the world’s cannabis of public health and wellbeing from the outset, to tolerate the licensing of “coffee shops” to sell users, who number between 119 million and without a large scale legal commercial industry cannabis in small quantities. Then, it stopped 224 million, are supplied by unregulated crimi- resisting reform.” short of legalising the cultivation and distribu- nal markets.1 The health and social harms associ- In Europe this wind of change is evident in the Netherlands, where the Dutch cabinet is under pressure to revise its soft drug policies, specifi- cally the “back door problem,” where cannabis can be sold at the front of a coffee shop but not supplied at the back. Between 5000 and 6000 illegal cannabis plantations are dismantled every year in the Netherlands, and the number of coffee shops is in decline. But as the coalition govern- ment dithers, local politicians have challenged it to explore new regulation models and allow council run production of cannabis.3 “The nationwide introduction of certified and regulated [cannabis] production is the solution that addresses the health of users and commu- nity safety and tackles organised crime,” reads a manifesto now signed by 54 local mayors. It goes on to say that the current regime “undermines the fabric of Dutch society.”

BLAINE HARRINGTON III/ALAMY BLAINE HARRINGTON Paul Depla, mayor of Heerlen, in the southeast Medicine Man Denver is the single largest medical and recreational marijuana in Denver, Colorado of the country, started the manifesto and says he

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Is the commercial model pursued in Colorado, for example, where shops sell customer friendly goods such as edible cannabis in the form of candy “gummi bears,” really a solution that public health can get behind?

“Money is falling from the sky in Colorado,” says Susan Weiss, associate director for scien- tific affairs at the US National Institute on Drug Abuse. And in common with any other commer- cial market in the US, consumer choice is vast. Cannabis is marketed in the same way as alcohol, not in places likely to be seen by under 21s. But attractive products that might appeal to children are available, such as the “edibles” containing

XINHUA/ALAMY (THC), the psychoactive compound in cannabis. These include “sour is confronted with the consequences of illegal Inspired by this model back in the Nether- gummi bears,” “cherry bombs,” and “water- cannabis plantations daily. “In Heerlen we have lands, Utrecht’s mayor, Victor Everhardt, wants melon tarts.” However, these edibles have to be 90 000 inhabitants but last year dismantled 130 permission to set up a closed labelled, and there are potency limitations on illegal plantations. Thirty per cent of Dutch house of 100 people who wish to produce cannabis for packs, though the products within are indistin- fires are caused by illegal plantations. Our their own consumption. It’s a way of eliminating guishable from confectionery. soft leaves the coffee shops dependent the criminal involvement and protecting health Weiss fears that loosening restrictions on can- on criminal organisations for supply. So ordinary through quality controls on the product, says nabis in the US, in combination with new, highly people become an instrument of criminal gangs.” Everhardt. “We want to take responsibility for efficient electronic systems to deliver potent Marith Rebel is a Labour member of the Dutch public health, so you can go into a coffee shop cannabis oils and concentrates (products with parliament, a general practitioner, and a fierce and know where the end product has come from.” names such as wax, glass, and shatter) could critic of the minister of justice for failing to listen Belgium has four cannabis social clubs. The cause a “perfect storm” and result in an epidemic to the mayors. “The local problems show that oldest, Trekt Uw Plant, set up in 2006, now has of health problems. the current system doesn’t work,” she says. “The 300 members. But, as in the Netherlands, any She said, “These are anecdotal reports, Dutch have always been in front on this issue. call for change is coming from the grassroots and but we hear e-cigarettes are taking off mas- But now Uruguay is way ahead. The coffee shops is not being led by national government. Tom sively, not just with but with hash were a way of getting around the international Decorte, professor of criminology at the Univer- oil. E-cigarettes are putting people into con- treaties [which nominally permit the Nether- sity of Ghent, says, “The social clubs are bottom- tact with high concentrations of THC of up to land’s tolerance approach but draw a line at up initiatives, set up by activists working around 75-90%. I don’t believe the states are coming regulated production]. Dutch policy now is too bad legislation. Belgian drug law says you can up with the necessary systems of regulation to repressive, and a side effect is that we don’t pay cultivate one female plant, so these clubs bring minimise harm. These levels are huge in rela- enough attention to prevention.” together 50 people, who grow 50 plants. We want tion to those we are used to thinking about in a new debate on the alternatives. But in Antwerp relation to cannabis. We have no idea what the Cannabis social clubs the mayor is waging a new , and it health consequences are at this The cannabis regulation debate has also means investing talented police officers in this war sort of potency, and we need become part of the political mainstream in when they could be used in other types of crime.” to watch this very carefully. Spain, where activists have pioneered the As cannabis policy and law is now being E-cigarettes are marketed non-profit “cannabis social club” model. debated in the mainstream, what can be learnt to children with different Spain’s decriminalisation policy permits small from the legislative reforms that are already colours and types.” amounts of cannabis for personal use, includ- under way? Such new “disruptive ing growing one or two plants. By pooling this technologies” are rapidly allocation to a single grower the club mem- Colorado’s commercial model emerging into the new US bers can effectively ensure a regular de facto Of all the new models of cannabis regulation markets, says Rolles. legal supply.4 Operating in a grey area legally, springing up, Colorado’s is the most overtly These e-cigarettes around 600 clubs now exist in Spain, mostly commercial. And it provides some lessons. and mini-vaporisers in Catalonia and the Basque Country. Members The state allows private business to grow, for consuming can- commonly pay a fee according to how much produce, process, and sell cannabis for non- nabis concentrates “are very cannabis they consume. Personal allowances medical uses. The first cannabis shop opened discreet, with no odour or are rationed to around 3 g a day, and new for business in January, and Colorado reaped smoke, and very potent,” members are usually required to have the sup- $2m (£1.2m; €1.5m) in tax in the first month potentially giving port of existing members. The government of alone. That figure rose to $3.5m if tax receipts young people more the Basque Country is now discussing whether from the established medical marijuana firms opportunities to use to formalise such clubs in law. are included. cannabis clandestinely.

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CANNABIS REGULATION IN THE UK The state of cannabis control in or a full prosecution. Caution and one to have an official platform the United Kingdom has been in prosecution result in a criminal advocating reform of cannabis flux over the past decade and is record.8 There have been transient, policy, having supported a somewhat confusing. Possession localised examples of shops in the decriminalisation and regulation An Ipsos MORI poll of 946 of cannabis remains an arrestable UK almost openly selling cannabis approach for a decade. In the people in 2013, commissioned offence carrying a potential five that are tolerated by police as long past two years its leader, Nick by Transform, showed that more year prison sentence, but there as they “stay under the radar.” Clegg, has become increasingly than half (53%) supported either are substantial differences in Other pockets of quasi-official outspoken on the issue—openly legal regulation of the production the way that regional police tolerance exist. For example, local supporting exploration of the and supply of cannabis or forces enforce the law. The police at large music festivals may options for cannabis regulation. decriminalisation of possession. police have a variety of options, take a pragmatic decision not The Home Office has been Around two thirds (67%) including a verbal warning, a to arrest people for possessing surveying drug policies around the supported a comprehensive penalty notice for disorder that cannabis. world and has met officials from independent review of all the incurs a £80 (€100; $135) fine, Of the major political parties, Uruguay and Washington. A report options for controlling drugs, 9 a caution, a conditional caution, the Liberal Democrats are the only is slated for release this autumn. including a legal market.

“Historically, prohibition has contributed to misuse­ treatment centres for young people.6 Ukraine crisis. The Dutch are trying to stay within the emergence of even more potent products,” However, supporters of reform point out the treaty by not legalising production, but that he says. “In an illegal market dynamic, higher that this rise has happened under prohibition, leaves them with the ‘back door’ problem. The potency products command higher prices, so which has not prevented cannabis being widely political system is stuck. The change from the US there’s a profit incentive to push them. Obviously available. They also argue that levels of use are is coming from below [not federal government], things like cannabis edibles that look like chil- driven by a complex range of social and cultural and politicians are reluctant to be the first mover.” dren’s sweets are a terrible idea, but if you can variables, and that legal supply does not have US president Barack Obama has cautiously regulate the potency of alcohol and cigarettes—as to mean increased use, citing the Netherlands, welcomed the experiments in Washington and well as what products can be sold, and how they where despite cannabis effectively being legally Colorado 7 but the country has been rapped are marketed—why not cannabis?” available for 40 years use remains similar to that over the knuckles by the International in neighbouring countries, and below the Euro- Control Board. In a strongly worded statement Uruguay model pean average. its president, Raymond Yans, said, “We deeply Public health advocates, however, favour the So we are at a crossroads in this debate. But regret the developments at the state level in the Uruguay model because it is far more restric- what are the barriers to countries wanting to US. The INCB reiterates that these developments tive than that in Colorado and Washington. The decriminalise use and legally regulate the pro- contravene the provisions of the drug control government has a state monopoly at wholesale duction, distribution, and sale of cannabis for conventions, which limit the use of cannabis to level, and licensed firms produce cannabis— non-medical use? Important are several global medical and scientific use only.” It also reminded limited to around five strains with upper limits or transnational treaties, specifically the United Uruguay of the need to “respect the conventions.” on potency—which is then sold in authorised Nations Drug Conventions adopted in 1961, Rolles comments: “Cannabis treaties have pharmacies. Non-medical use is also rationed to 1971, and 1988 that criminalise the use and pos- reached the point where they are clearly not fit no more than 40 g a month per user. Advertising session of controlled drugs, including cannabis, for purpose. This debate is beginning to open is banned, as is smoking in smoke-free areas. In for uses other than medical and scientific pur- up now, and in 2016 there will be a UN General addition to state licensed cultivation, the govern- poses. They also strictly prohibit any domestic Assembly special session on drugs where the ment allows limited home production of up to six market in the substances. A recent policy paper future of the treaties will be discussed. plants, and it permits cannabis clubs, which can on cannabis regulation for the Addiction and “Historically, the US has been the bully boy plant a maximum of 99 plants. All purchasers Lifestyles in Contemporary Europe—Reframing of the international drug control regime, giv- are registered by a new state agency called the Addictions Project (ALICE RAP), a €10m research ing the Netherlands a hard time, for example. Institute of Regulation and Control of Cannabis. project funded by the European Commission to But that role has diminished as the global drug One of the concerns about moving to regu- feed scientific evidence into policy making, con- policy landscape has transformed, and it has lation is that increased availability will lead cluded: “The world is saddled with drug treaties not criticised Uruguay. This may provide some to increased consumption. Weiss says the evi- which are not fit for purpose.”2 space to experiment.” dence is that THC consumption is going up, Robin Room, a member of the World Health Rebecca Coombes magazine editor, The BMJ, London, c­iting a Norwegian study in 2013 that looked at Organization’s expert advisory panel on alcohol UK [email protected] the mean concentration of THC in the blood of and drugs and a professor at Stockholm Univer- Many of the people quoted were speaking at the New apprehended drivers in Norway between 2000 sity’s Centre for Social Research on Alcohol and Cannabis Debate held in Amsterdam on 12 May and organised by the ALICE RAP project. A video of the debate and 2010. The study found that THC levels rose Drugs, says that the path taken by Colorado, can be found at www.alicerap.eu. The BMJ received 5 substantially (by 58%) over the decade. “THC Washington, and Uruguay involves flouting funding from ALICE RAP for this article. is going up, while alcohol use is flat over the international drug control treaties, something I thank Stephen Rolles for his help with this article. decade. I think we are naive about the young no European government is yet willing to do. He Competing interests: None declared. people getting these high potency hits,” says says, “The treaties are not fit for purpose in the Provenance and peer review: Commissioned; not externally Weiss. National level evidence from the US also modern world, but how can they be changed? peer reviewed. shows that cannabis dependency is increas- The EU countries are not likely to do something References are in the version on bmj.com ingly a primary cause of admission to substance that contravenes a treaty, especially with the Cite this as: BMJ 2014;348:g3382

16 BMJ | 24 MAY 2014 | VOLUME 348 MEDICINE AND THE MEDIA

bmj.com ЖЖRead Simon Chapman’s blogs on the tobacco industry at blogs.bmj.com/bmj/category/simon-chapman/ ЖЖWatch The BMJ’s video on Richard Doll: The man who stopped smoking at http://bit.ly/1gdHWxV The not so independent tobacco experts The media don’t always make clear the potential conflicts of interests of interviewees, writes Meg Carter. For example, panellists on a recent radio debate about plain packaging were not asked about their links to big tobacco

ransparency in lobbying was one of Monbiot some pretty odd reasons for its failure the hoped for outcomes from the UK to ask Littlewood about the donations the IEA government’s controversial lobbying receives from big tobacco, including that the act, due for royal assent this year.1 IEA does not publicise these interests.2 This legislation has been criticised Commercial broadcasters in the UK must Tfor, among other things, its narrow definition also meet impartiality requirements, though of lobbying and a new register of declared these are set by Ofcom, managing editor for interests that would cover only a fraction of ITV News at ITN, Robin Elias, explains. “We lobbyists. Now attention is settling on a sector have numerous checks and balances,” he beyond the bill’s remit: the media. insists. “Commercial influence—in the health “All too often the media perpetuates the illu- and drugs arena, especially—is a very impor- sion that lobbyists—think tanks, especially— tant issue and we are alert to it.” are independent sources of information and Smoke and mirrors Why, then, do lobbyists and think tanks get ideas,” said Tamasin Cave, director of the so much media space, and why aren’t their transparency campaigning group Spinwatch. you?” That said, all news organisations could vested interests always made clear? “Many “While I understand the need for opinion and do better, he thinks: “They may have editorial commercial media organisations are so des- comment, media organisations do their audi- guidelines, but do they often point journalists perate to shore up flagging businesses they are ences a disservice by not explaining these con- towards them? Evidence would suggest not.” increasingly reliant on paid-for editorial—at tributors’ financial backing or vested interests.” Another example, highlighted by Tobacco best marked as advertorial, increasingly not,” Her comments follow the launch of a peti- Tactics, a website that monitors tobacco mar- according to Aidan White, director of the Ethi- tion on change.org by the author and Guard- keting, concerns the former police officer Will cal Journalism Network. ian columnist George Monbiot, urging the BBC O’Reilly, who fronts a campaign about the Limitations on time and space may make it always to disclose the relevant financial inter- potential for standardised packaging of tobacco unfeasible for every news report that mentions ests of the people it interviews.2 Monbiot’s products to boost smuggling. Though O’Reilly a lobbyist or think tank to carry a disclaimer— call has come after several articles in which has been clear that the campaign is funded by but many biomedical journals have policies he criticised the BBC for letting think tanks Phillip Morris, the media have not always made in place along these lines.10 And it may not argue the tobacco companies’ case against the his tobacco company backing obvious.5 always be easy for the audience to discover introduction of plain packaging.3 4 Lobbyists are active wherever a business’s think tanks’ potential conflicts of interest Citing an edition of Radio 4’s Today pro- activities are under threat or, indeed, where otherwise. gramme on 28 November 2013, Monbiot new opportunities arise, and healthcare is Some, however, suggest market forces will condemned a news item in which Mark Little- no exception, with in-house and third party favour openness. “Viewers tend to go to those wood, director general of the rightwing think lobbyists seeking to influence tobacco and news sources they trust most,” Elias says. “In an tank the Institute of Eco- alcohol legislation6 7 and increasingly competitive market, news organi- nomic Affairs (IEA), claimed In-house and third party the debates concerning sations whose news isn’t balanced, honest, and that there is no evidence that lobbyists actively seek salt, sugar, obesity, climate clear will have a poorer reputation and suffer as uniform packaging affects to influence tobacco and change, and, of course, health a result.” Which is as it should be, Cave believes. the number of people who alcohol legislation. And service reorganisations.8 And “Because this isn’t about being anti-lobbying smoke and, furthermore, that their tactics are as subtle their tactics are as subtle as but being pro-transparency,” she insists. its introduction would stimu- as they are diverse they are diverse. “Lobbyists and the interests they represent late a black market. These are Such activities are well have a right to be heard. But all of us—includ- two arguments made by Philip Morris, one of known to professional journalists and the news ing the media—must engage in a more mature several tobacco giants that funds the IEA—a organisations they work for, of course, and all discussion of lobbyists’ role. End the secrecy connection that Today failed to clarify, as professional media organisations have editorial and everyone will benefit.” Monbiot pointed out. guidelines. The BBC’s, for example, state, “It Meg Carter is a freelance journalist, Bath, UK “I’ve long been critical of the BBC’s uncritical would be important to identify a contributor’s [email protected] use of [think tank spokespeople], treating them allegiances if there may be a conflict of inter- Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to as independent voices,” he says. “It is more est or if a contributor appears neutral but is declare. trusted as a media organisation and has statu- actually aligned to one side or another of an Provenance and peer review: Commissioned; not externally torily enforced regulations on impartiality—if argument,” David Jordan, the BBC’s director peer reviewed. you can’t get it right at the BBC, where can of editorial policy stressed. But the BBC gave Cite this as: BMJ 2014;348:g2908

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