Council of Chief Medical Officers of Health and Public Health Physicians of Canada: Joint submission to Cannabis Legalization Panel

In 2016, prior to the legalization of cannabis in Canada, the Provincial and Territorial Chief Medical Officers of Health in Canada (except Quebec) and the Urban Public Health Network submitted their expert advice Public Health Perspectives on Cannabis Policy and Regulation ^{Footnote 1} to the task force that was making recommendations to the federal government about cannabis legalization. Now, as part of the 5-year review of national cannabis legislation, the Council of Chief Medical Officers of Health (CCMOH)^{Footnote 2} and the Public Health Physicians of Canada are again providing expert advice, from a public health perspective, this time on the experience of legalized cannabis in Canada. The goal of this submission is to support continued protection and improvement of the health of populations in the existing regulatory environment.

The introduction of federal legislation for the legalization of cannabis with clear public health-oriented objectives, and with the intention to mitigate the potential risk of harms to vulnerable populations, particularly youth, was a milestone for Canada, and the world, and a major step forward in reducing the health and public safety harms associated with an illegal market.

Legalization has allowed for the availability of quality-controlled products in a regulated manner, comprehensive product labelling with public health warnings, age limits on access, and very importantly, strong limits on promotion and advertising. We have also seen progress in implementation of impaired driving laws and enforcement, public education campaigns on the use and harms of cannabis, the creation of Lower Risk Cannabis Use Guidelines (PDF), and a substantial funding increase for a broad range of cannabis research. We have seen the early success of these efforts, in that an estimated 71% of cannabis users are obtaining their cannabis from the legal market, cannabis use among youth (15–19 years) has remained stable since legislation, and people who use cannabis report increased recognition of the health risks associated with cannabis use.

However, given the magnitude and unprecedented nature of the policy shift that the Cannabis Act represents for Canada, it was clear from its introduction that the act would need to be examined and iterated with time, as evidence on its impacts evolved. Indeed, there are areas of concern to public health with the legalization of cannabis, regarding where regulations should be maintained or strengthened to mitigate public health harms, as outlined below.

Maintaining public health objectives of the legislation

Since legalization, we are aware that there has been mounting pressures from the cannabis industry to weaken the controls designed to protect public health. Industry has contended that public health controls, such as tetrahydrocannabinol (THC) limits in cannabis products and restrictions on promotions and advertising, need to be relaxed due to the ongoing existence of illicit markets which compete with the legal market. As noted above, we are aware that a substantial proportion of cannabis users, estimated at 71%^{Footnote 3} and rising, are now obtaining their cannabis from the legal market. While we are supportive of measures to ensure that the cannabis industry continues to develop and can further undermine the illegal market, undermining public health controls that prevent harms to try to accelerate this shift is not justified. Only 1 of the purposes of the Cannabis Act, section 7 (c), relates to this objective, while 4 of the purposes, sections 7 (a), (b), (f) and (g), relate to public health protection. That is:

The purpose of this Act is to protect public health and public safety and, in particular, to:

• a. protect the health of young persons by restricting their access to cannabis;
• b. protect young persons and others from inducements to use cannabis;
• c. provide for the licit production of cannabis to reduce illicit activities in relation to cannabis;
• d. deter illicit activities in relation to cannabis through appropriate sanctions and enforcement measures;
• e. reduce the burden on the criminal justice system in relation to cannabis;
• f. provide access to a quality-controlled supply of cannabis; and
• g. enhance public awareness of the health risks associated with cannabis use.

Therefore, while one of the public health purposes of legalization should be to move individuals who consume cannabis from the illicit market to the legal market to reduce health risks associated with illegal products, it is also very important to maintain public health safeguards to protect against potential harms associated with over-commercialization of legal cannabis products.

Since legalization there has been an increase in adult mental and behavioural disorder hospitalizations related to cannabis, as well as increasing rates of pediatric hospitalizations due to accidental cannabis ingestion, which seem to be associated with the increasing availability of edible cannabis products that can be appealing to younger audiences ^{Footnote 4}. It is not clear what proportion of these poisonings are due to illegal edible products versus legal edible products, representing an important evidence gap. Nevertheless, to reduce the risk of accidental pediatric ingestion, controls on legal edible products should be maintained and strengthened to minimize harms, such as:

• limiting the maximum concentration of THC in all non-medicinal product forms
• controls, such as mandating lock box sales, for limiting children's access in the home
• limiting youth attractive products (e.g., chocolate, baked goods, candy)
• requirements for products to indicate cannabis content once removed from outer packaging

Further research is required on effective ways to limit the risk of accidental cannabis ingestion among children from illicit sources and homemade edible products from legal sources.

In addition to the concerning trends in pediatric hospitalizations from cannabis poisonings, we would like to highlight additional priority measures that should be considered to further protect public health, which are:

• implementing controls on retail density to reduce public exposure and to minimize the risk of increasing population uptake through supply induced demand
• restricting the amount of allowable distribution, purchase, or possession of cannabis concentrates, such as hashish, 'shatter,' rosin, resins, wax, hash oil, THC oil, 'diamonds', etc.
• restricting flavoured inhaled cannabis products (e.g., vaping products) as previously proposed to reduce youth initiation and use
• prohibiting the co-sale of alcohol and cannabis to limit exposure and prevent co-use
• continuing strong restrictions on the promotion and advertising of cannabis, ensure ongoing enforcement of advertising rules for online sales, and restrictions on the use of promotions as part of advertising
• using rotating health warning labels, akin to tobacco products, and the inclusion of warning labels about risk of psychosis
  • this includes use of warning labels about the delay between consumption and effect and the prolonged duration of effects for all edible products
• consideration of raising the legal age of purchase to 21 years of age, along with increasing the legal age of purchase for alcohol and tobacco

Advancing understanding of cannabis use

While we have learned much from the experience of cannabis legalization over the past 5 years, we know that some of the potential harms associated with cannabis use at a population level may not be apparent for many more years. There is an ongoing need to support research and evaluation. In addition, the guidance needs updating for individuals who use cannabis, as well as for health care providers. Specific measure that could assist in continuing to advance knowledge and support cannabis harm reduction include:

• developing a defined measure of a 'standard dose' of cannabis to guide individuals who use cannabis, for research, and for epidemiological surveillance on health impacts of use as this has been very helpful to support alcohol research and policy development
• expanding research into the impacts of cannabis use on impaired driving, as well as impaired functioning in occupational settings, and current knowledge, attitudes and beliefs regarding driving after consuming cannabis
• supporting the development of new and updated cannabis resources for health care providers to share with their patients as the evidence and products on the legal market evolve
• expanding access to and availability of clinicians and services specifically intended to support individuals with cannabis use disorder
• addressing known gaps in knowledge and competencies in primary care related to screening, diagnosis and management of cannabis use disorder and other negative biomedical and psychiatric sequelae of cannabis consumption
• bolstering surveillance and research in key areas such as:
  • harms from pediatric accidental ingestion
  • use and harms among key populations (e.g., pregnant or breastfeeding individuals, people with a family or personal history of mental health disorders, 2SLGBTQI+ individuals)
  • long-term implications of use
  • long-term trends in patterns of use (e.g., age of onset, frequency of use)
  • harms from vaping cannabis as well as cannabis concentrates
  • polysubstance use
• advancing research on the interactions and effects of THC with CBD and other cannabinoids
  • this includes further research on Delta-9-THC and products with high concentrations of THC, as well as the components and aerosols from inhalant forms of cannabis
• advancing understanding on the prevalence of, reasons for and consequences of use of cannabis as self-management of mental distress and disorders
• advancing research and evidence in cannabis use by adequately funding and reducing barriers to conducting cannabis research in Canada

Conclusion

In conclusion, while we commend the federal government for adopting a public health approach to cannabis legalization along the lines we recommended in our original submission to the task force in 2016, we recognize it is early days in the process and that ongoing attention needs to be paid to maintaining an emphasis on the public health objectives of the Cannabis Act. Important progress has been made in implementing cannabis legalization while protecting and promoting public health, and we remain available to provide further advice and to be involved in this process to support the best possible health and well-being outcomes for Canadians.

About this joint submission

This is a joint submission to the Cannabis Act Legislative Review panel on behalf of the Council of Chief Medical Officers of Health^{Footnote 2} and the Public Health Physicians of Canada.

The Council of Chief Medical Officers of Health includes:

• the Chief Medical Officer of Health from each provincial and territorial jurisdiction
• Canada's Chief Public Health Officer
• the Chief Medical Advisor of Health Canada
• the Chief Medical Officer of Public Health of Indigenous Services Canada
• the Chief Medical Officer from the First Nations Health Authority
• ex-officio members from other federal government departments

The Public Health Physicians of Canada is the national specialty society for Public Health and Preventive Medicine (PHPM) Specialists. Its membership includes both PHPM specialists and other physicians working in public health across Canada.

Date modified:

2023-07-24