THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Monday, April 16, 2018
The Standing Senate Committee on Social Affairs, Science and Technology, to which was referred Bill C-45, An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, met this day at 2:00 p.m. to study its content.
Senator Art Eggleton (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I am Art Eggleton, senator from Toronto. I am the chair of the committee. I will ask my committee colleagues, both the regular ones and the substitutes, to please introduce themselves.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Omidvar: Ratna Omidvar from Toronto.
Senator Unger: I am Betty Unger from Edmonton, Alberta.
[Translation]
Senator Pratte: Senator André Pratte from Quebec.
[English]
Senator Munson: Jim Munson, Ottawa, Canada.
[Translation]
Senator Petitclerc: Senator Chantal Petitclerc from Quebec.
[English]
The Chair: Today we resume our hearings on Bill C-45, An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts.
We have three panels today, this one being an hour and a half in length. We have three panellists. I will introduce them as they speak. We have a third panellist who is not yet with us, Dr. Bernard Le Foll from Toronto, representing the Centre for Addiction and Mental Health, who is trying to get here. I got here this morning by train. It was the only way to get here because the air services were not working. He should be joining the panel at some point.
In the meantime, we do have Dr. Harold Kalant, Professor Emeritus, Faculty of Medicine at the University of Toronto. He is here by video conference. We also have, from the Canadian Centre on Substance Use and Addiction, Amy Porath, Director of Research.
Let me start with Dr. Kalant on our video conference. I would ask each of our panellists to give us seven minutes of introductory comments, and then we’ll open it up for questions from my Senate colleagues.
Dr. Harold Kalant, Professor Emeritus, Faculty of Medicine, University of Toronto, as an individual: Thank you very much, Mr. Chair and members of the committee, for allowing me to speak to you this afternoon. The weather in Toronto made my flight impossible.
Just before I make the points that I would like to talk about, I should give you a word or two about my qualifications, apart from my position as a professor at the University of Toronto. Since 1959, I was also the director of biological and behavioural research at the Addiction Research Foundation of Ontario. I have chaired or been a member of expert advisory groups to the World Health Organization, Health Canada, the U.S. National Institutes of Health, the Addiction Research Foundation of California and have published a great deal on alcohol, cannabis, opioids and other drugs of dependence.
In a debate that I published a couple of years back and that I know some of you have seen, I argue that decriminalizing cannabis now and pardoning those with past convictions for only the possession of small amounts for personal use would remove the harm caused by the present system without risking the problem of increasing the use in general and, therefore, increasing the harmful effects by those who use too much.
If one allowed an interval between the decriminalization and pardon to permit observation of what happens in other areas, in other jurisdictions that have legalized cannabis, and carry out necessary research, which I’ll describe in a moment, then, at the end of that observation period, one could do a rational cost-benefit analysis of legalization and make a well-informed decision on proceeding with it.
If the scheme that I’ve outlined is not possible, then the Senate’s task is to make legalization as safe as possible without the benefit of the observation period.
The CAMH recommendations and the task force on legalization and regulation both recommended that the motivation for legalization should not be for profit but for the protection of public health while correcting the harms done by the present criminal law. However, the stock market activity in recent months and the constant media focus on profit and on public use of such things as recipes for using marijuana in cooking, for using the marijuana leaf theme in all kinds of decorations, suggests that profit is a real risk for overriding the concerns for public health. Therefore, it’s extremely important to take every measure possible to protect the public health aspect.
Mature, occasional users of cannabis generally will not suffer any serious harms, except for those that result from acute over-effects, such as motor vehicle accidents, injuries and fatalities, myocardial infarcts or strokes in those with pre-existing vascular problems or psychosis in those with a family history of schizophrenia.
Occasional use is probably not the problem we have to deal with, but in any large population, there are always chronic, heavy users who use too much and suffer as a consequence a wide variety of physical and mental health harms and harms to their social functioning. A good deal of evidence from the study of alcohol, tobacco and other drugs shows that wider use is always accompanied by wider heavy use and therefore an increase in serious problems. The factors that favour such an increase in use are ease of access, lower price, social acceptance and higher potency of the drug.
Ease of access by legalization has been shown in Colorado and in Washington to increase the total use and the harms from the sort of things I’ve talked about. One measure that the Senate could take to help prevent that would be to limit the number of outlets, to provide for a local option of areas and municipalities that do not want legalization, and to cancel the provision for home growth, because it is obviously impossible to monitor that home growth will be restricted to four plants, what members of the family will have access to it, including even adolescents, and to ensure that none of it gets into the black market.
If price is lowered to compete with the black market, it will also increase use. Therefore, the proper measure for the Senate is to suggest a high price even at the cost of not competing with the black market. Moreover, price competition is not a realistic hope anyway because Colorado and Washington have shown that legalization has not resulted in a reduction in the black market. Police in both states have stated that the black market is flourishing. So if the price is lowered to compete with the black market, it will necessarily require a strict limit on the amount that can be sold to any purchaser on a single occasion or in a given period of time.
Social acceptance tends to foster the idea that the drug is harmless. The remedy or the prevention has to be educational programs, which I think Dr. Porath will talk about more extensively today. But education is not a one-shot wonder. It has to be sustained, long-term, varied in the means that are used to avoid boredom, realistic in tone and it has to involve peer groups. Young people especially are more amenable to education if it’s given by their own peer group leaders, the trendsetters, and somehow they have to be involved.
Potency. I’m puzzled as to why Health Canada did not set strict limits on the maximum concentration of THC in preparations to be used medically. It is even more important to limit that concentration in preparations used non-medically where there is no supervision of how and how often and how much is used.
Monitoring. If the results of legalization are to be monitored so that Parliament can correct any problems that may arise, it requires that we have good knowledge of what the present situation is because we can’t recognize changes from the present if we don’t know accurately what the present is. That also takes time.
My final suggestion is that the Senate should recommend a delay of a reasonable length of time between adoption of legalization and its implementation to allow education and to allow necessary research for defining the starting point to be carried out.
With that, I think I should stop here. I will be happy to answer any questions that you may wish to pose.
The Chair: Thank you, Dr. Kalant.
Now, Dr. Amy Porath, Director of Research, Canadian Centre on Substance Use and Addiction.
Amy Porath, Director of Research, Canadian Centre on Substance Use and Addiction: Good afternoon, Mr. Chair and members of the committee. My name is Amy Porath, and I am Director of Research at the Canadian Centre on Substance Use and Addiction, or CCSA.
The Centre on Substance Use and Addiction was created in 1988, and we are Canada’s only agency with a legislated national mandate to reduce the harms of alcohol and other drugs on Canadian society.
We welcome the opportunity to speak to you here today about Bill C-45. Cannabis has been a priority area of focus for our organization since 2008m and we have demonstrated our subject matter expertise through our research publications and our work with national and international partners on the health and social impacts of cannabis, drug-impaired driving and regulatory options.
To respect time constraints, my presentation today will be brief and will focus on the health effects of non-medical cannabis use as well as the importance of evidence-based public education. Should the committee wish, CCSA would be pleased to speak to other areas related to the bill at another date.
Canadian youth have among the highest rates of cannabis use in the world and, despite a decrease in use in recent years, cannabis remains the most commonly used illegal drug among Canadians aged 15 to 24. These young adults are more than twice as likely to have used cannabis in the past year as compared to adults aged 25 and older.
Youth are also at greater risk of experiencing cannabis-related harms because adolescence is a time of rapid brain development. The risks associated with use increase the earlier youth begin to use cannabis along with the frequency of use and quantity of cannabis that is consumed. Delaying the start of cannabis use as well as reducing the frequency, potency and quantity used can help to reduce this risk.
From the research, we also know that cannabis use affects cognitive functioning, including attention span, learning and decision making. Chronic or regular cannabis use has been associated with mild impairment of memory, attention and other cognitive functions, and it is uncertain how reversible these impairments are once cannabis use has stopped.
There is also consistent evidence that cannabis use impairs the ability to safely operate a motor vehicle. It doubles the risks of collisions, and the risk increases further when cannabis is mixed with even small amounts of alcohol.
With respect to mental health, there is consistent evidence that regular use during adolescence is associated with an increased risk of experiencing psychotic symptoms or schizophrenia, especially when there is a family history of such disorders. While there is emerging research indicating a relationship between chronic cannabis use and other mental health outcomes such as depression, anxiety and suicidal behaviours, we need more research to better understand the nature of these relationships.
We also know from the research that continued, frequent and heavy cannabis use can result in physical dependence and addiction. Youth are especially vulnerable, given their ongoing brain development. It is estimated that approximately 1 in 11, or 9 per cent, of those who use cannabis will go on to experience dependence. This rate increases to 1 in 6, or 17 per cent, for those who begin using during adolescence and is as high as 1 in 2 for those who use cannabis daily or near daily.
While there is certainly a lot we know about the health effects of non-medical cannabis use, there remain significant gaps in our current knowledge, which demonstrates the need for ongoing investment and research, particularly on the effects on youth. That is why the Government of Canada’s timely investment of $10 million in Budget 2018 for CCSA to further study the impact of cannabis use is so important as Canada moves towards legalization.
I also wanted to briefly emphasize the importance of a comprehensive, evidence-based approach to public education and prevention to provide Canadians, and especially young Canadians, with the knowledge and skills they need to make informed decisions about cannabis use. A comprehensive approach involves programming in and after school, resources for parents, families and communities, and earned and paid media to help educate about cannabis use to achieve the best outcomes. It also requires ongoing investment, as well as monitoring and evaluation, to ensure that it is having the desired impact.
CCSA is a research-generating organization, and we have conducted focus groups with Canadian youth to understand their perceptions of cannabis and cannabis use. They told us that they want information about cannabis that is fact-based as opposed to fear-based. For example, they want to know exactly how cannabis use and the level of consumption might impair their ability to drive a vehicle. They also told us they want to hear about harm reduction strategies so they are knowledgeable on how to reduce their risks if they do decide to use cannabis. To that end, education and prevention initiatives need to incorporate what we have heard from Canadian youth in order to have an impact.
Young Canadians also said they want information from sources they trust who can speak credibly about cannabis. Depending on age, these information sources can include parents and educators, but most importantly, it can also include their peers. To achieve this goal requires training, resources and consistent messaging for youth allies — such as teachers, counsellors, youth providers, coaches, health care practitioners — to really help them engage in these conversations with young people. CCSA is currently proactively engaged in the creation of what we’re calling a cannabis communication guide, which will be launched in the coming months to provide just this type of resource.
It is also important to include targeted messaging about high-risk cannabis use to assist young people in making informed decisions. This messaging includes information about the effects of frequent and heavy use, about use at an early age or in combination with other substances and about use by youth with mental health conditions and young women who are pregnant.
In closing, I would like to emphasize the importance of providing sustained investments in research, public education and prevention efforts to support the successful regulation of non-medical cannabis use.
I would like to thank the committee for the opportunity to speak here today and will be pleased answer your questions.
The Chair: Thank you very much.
Dr. Bernard Le Foll is, I think, going to be here very soon, and I’ll interrupt the question-and-answer period so that we hear from him when he arrives, but let’s go to questions from my colleagues. I start, as usual, with the deputy chairs.
[Translation]
Senator Petitclerc: Thank you all for being here and for your very relevant comments.
My first question goes to Ms. Porath. Like a number of people, I have read the report entitled Canadian Youth Perception on Cannabis that was produced as a result of a study in which 77 young people participated. A number of other young people have met with senators. The concepts of social acceptance and normalization often come up. I know that they are difficult to quantify. I also know that some people say that young Canadians are using a lot of cannabis anyway. It is already normalized and socially accepted.
What impact could Bill C-45 have on our young people, in your opinion?
[English]
Ms. Porath: Thank you for that question. Certainly something we’ve heard in our research is that there are some young people who think that Canadian youth are using cannabis all the time. There are young people we’ve spoken to as well that are clearly not using cannabis, so there is a real need in our public education efforts to try to address this social norming that everyone is using cannabis all of the time.
If we look at some of our prevalent studies that Statistics Canada and Health Canada are overseeing, I believe that, in 2015, it was about 20 or 21 per cent of young people that reported past-year use. I would say this is the type of evidence that we want to incorporate into some of our public education and prevention, just to dispel the myth that all young people are using cannabis all the time because, clearly, it’s not the majority of youth. It’s still a sizable proportion of youth, but I think, with Bill C-45, it’s a real opportunity to ensure we have evidence-based public education messaging that is sustained. What I mean by sustained is that it’s not just an one-off. I know there are some ads that are appearing now, and I would like to see those ads continue post-Royal Assent, but even ongoing in the first couple of years.
I would also suggest that it’s a comprehensive approach to public education so that parents know how to have these conversations with their young people and so that teachers and educators and schools, as well as health-care providers, are provided with key messaging and information. It really needs to be a comprehensive, sustained approach as part of the bill, I believe, to ensure that young people are knowledgeable about cannabis.
Senator Petitclerc: I don’t know, Dr. Kalant, if you have —
The Chair: Dr. Kalant, do you have any comment you want to add to that in terms of the question?
Dr. Kalant: Yes. Thank you, Mr. Chair. I agree completely with what Dr. Porath has said. I would like to emphasize the fact that “normalization” or acceptance does generate very strongly the idea that it’s safe because, if everyone is using it, obviously it can’t be hurting you so it must be okay. But if you look at alcohol, which is very widely used, much more so than cannabis so far, it’s clear that, even though it is built into our culture, built into our practices, it can and does produce a great deal of harm. Most people don’t really grasp that, and it needs to be driven home repeatedly.
Senator Seidman: Thank you both very much for your presentations.
Dr. Kalant, if I might begin with you, in fact, you’ve just started to mention alcohol, and I’d like to ask you a bit about that. We have heard that the rationale for this piece of legislation, Bill C-45, is sort of based on an assumption that legalization will reduce the number of cannabis users and, most importantly, that it will prevent access to marijuana by underage users. We have heard from supporters of legalization that alcohol control measures provide a good model for controlling youth access to cannabis after legalization. Could you speak to us a little bit about this and the success or failure of alcohol control measures in managing teenage drinking? Do you have reason to believe that a similar regime for marijuana will be effective?
Dr. Kalant: Thank you for that question. It’s a very important one. I think the experience with alcohol shows quite clearly that regulation alone does not control level of use by youth. Under present conditions, in Ontario, for example, surveys of Ontario secondary students have shown that, under the present regime in which it is illegal to sell or purchase or distribute alcohol to those under 19, there nevertheless is, even in the 12-year-olds, about 10 per cent who have used alcohol within the past year. By the time you reach 17-year-olds, there are about 20 per cent who have been either drunk or engaged in binge drinking within the past month. I think our experience with alcohol makes it perfectly clear that regulation alone is not the answer. Regulations can be ignored and have been ignored to a large extent.
Also, the idea that cannabis is safer than alcohol and that, therefore, it doesn’t make sense to have it illegal while alcohol is legal is also a very tricky argument. Sure, alcohol is more dangerous than cannabis in some respects. For example, you can die of an overdose of alcohol, and you can’t die of an overdose alone of cannabis. But, if you die in a motor vehicle accident caused by an impaired driver with cannabis use, you’re just as dead as if you died from an alcohol overdose.
We all have to recognize that the spectrum of harmful effects is different for alcohol and cannabis, so comparing them is not simple. I think it’s important to disabuse people of the idea that cannabis is safe and that it should be legalized in order to be rational in relationship to alcohol. These are poor arguments and misleading and dangerous to society.
Senator Seidman: So what you’re saying is that the model of alcohol control measures doesn’t really work as a model for cannabis. What would you say about the fact that it’s also said that legalization will reduce the number of cannabis users and prevent access to marijuana by underage users?
Dr. Kalant: There is no evidence to support that at all. In fact, the evidence that we have from Colorado, Washington and other areas that have made access extremely easy is quite the opposite. It increases use, total use. It increases the number of emergency room visits, it increases the number of hospitalizations for causes attributable to cannabis and it increases deviation to the black market. It has been shown that even with so-called medical marijuana in Colorado, and now increasingly with non-medical legal cannabis in Colorado, the Colorado product appears in other states that have not legalized. In other words, a significant proportion is being deviated to the black market. The argument that legalization will somehow reduce use simply does not make sense. It’s opposite to everything we have ever learned about other drugs.
Ms. Porath: On one point I wanted to pick up on about the comparison between alcohol and cannabis, I agree with what Dr. Kalant has said, and I think part of the reason people have this perception that cannabis is safer than alcohol is we simply have not had prevention and public education campaigns. The public is simply not knowledgeable about the effects of cannabis use.
The other piece is we’ve been studying alcohol and the effects of alcohol for decades, and we simply don’t have the same evidence base that we have for cannabis. If we move forward with legalization, I’m hopeful that this will help to make it easier to conduct this health research to better understand some of the health effects because it is currently very difficult and cumbersome to get through the various approvals to conduct this type of research.
Senator Pratte: Ms. Porath, you have explained in your presentation the various risks associated with cannabis use, and your organization has done quite extensive research on that. You haven’t told us what, if any, is your organization’s opinion on the bill itself and especially on the legalization of cannabis.
Ms. Porath: CCSA is an evidence-based organization, so my role here today and the role of our organization is to provide that expert advice to Parliament and to the Senate on different aspects of the bill. I know my colleague was at one of committees previously and spoke to it. I’m here today talking about some of the health effects. We have travelled to Washington and Colorado and pulled together a report on lessons learned, which I know my colleague has shared. My role here is to answer your questions, provide that expert advice and analysis to help you folks make the decisions you need for this bill to work.
I know that CCSA is supportive of a public health approach where we are minimizing harms to Canadians and providing Canadians with the information they need in order to make informed decisions about cannabis use.
Senator Pratte: In your qualitative research with young people, was legalization discussed, and did they have anything to say about it?
Ms. Porath: Absolutely. They had a lot to say about legalization. We had conducted this research after the Liberal government had announced that this would be part of its party’s platform.
The young people were mixed in what they were saying. We had some young people feeling this would be a good thing and would be a revenue generator for the government and would help to control the illicit drug market.
Other young people we spoke to weren’t as supportive. They felt that this was going to make it harder for them to access their cannabis. They felt that this is not a matter that the government should be getting involved in. They felt that the government will be placing limits on the THC content of the cannabis.
So we really heard both sides of the story from the young people we spoke to in our research.
Senator Pratte: Dr. Kalant, you mentioned a couple of times, based on, apparently, the experience in Colorado and Washington State, and I have heard different points of view on this so I guess it depends on who you talk to, the impact of legalization on illegal cannabis and on organized crime. Surely if some cannabis is bought legally, then at least this part will not belong to the illegal market any more. I mean, if you get 50 kilos of marijuana that is bought legally, that will not be sold by organized crime any more, so at least this part will not be illegally traded anymore.
Dr. Kalant: Yes, that’s quite true. The question is what proportion of the total consumption would come from the black market and what proportion would come from legal sources. If legalization increases total use, then the black market may not be affected in absolute terms, even if its proportion of the total sale is decreased, and that’s something that we really have to continue observing for a while yet.
During the first two years after legalization in Colorado, for example, there was a distinct increase in amount of use or in frequency of use in all age groups. However, by the third year after, the use among youth, that is underage users, started to decrease somewhat, and we don’t know yet whether that’s a temporary change or whether that’s going to be a long-term sequence because the use does not always go in a straight line. It has ups and downs over time for various incidental reasons. We need to observe in order to get a clear picture of what the effect on youth use will be.
However, use by the young adults, middle-aged and even older people has continued to increase. Total use has increased. I think that that is not a good sign for what is likely to happen with youth.
Senator Munson: We have all been listening to a number of witnesses, and the last time we talked to those who were leaders in Canadian cities who have to deal with this marijuana legislation when it becomes law, they used words like “loophole,” “black markets,” “precarious situation”; “Are you ready? No.” And I worry about the timetable that we seem to be on, July 1, and then 90 days later we would have the legislation becoming law. There is a recommendation here of a delay of one year to get a better handle on what we’re going to pass. I’m wondering, doctor, what would happen in that year that would enhance this legislation?
Dr. Porath, you talked about education. You both talked about education. I would like to see what form that would take. Where would it be? Would it be in individual elementary schools across the country, and would there be special teachers and so on? We seem to be using the idea of a public affairs approach, a communications approach and jazzy things on social media, but a one-on-one basis might be a better way to do it.
We have an ability here in the committee to amend legislation, and I think you are going to see amendments come from this committee. I’m throwing those ideas out to hear both of your reactions.
The Chair: We will start with Dr. Kalant. What would the one year produce in terms of better information?
Dr. Kalant: Yes, I think both of us have stated that education has to be a broad spectrum of different approaches aimed at different populations, using different methods, different language, but sustained, repeated frequently and realistic. In other words, it cannot be scare tactics. It has to be solidly information-based, delivered in a calm factual way and making clear which ideas are widely held that are wrong, why they are wrong and what the truth is.
I would leave more details of that to Dr. Porath, because she’s the expert on that, but I would like to mention that I have submitted a brief that I hope has been distributed to all of you which sets out in greater detail the points I made in my initial presentation, including some of the reasons behind the various recommendations. Time is essential. Both for education and for getting the necessary survey knowledge that we don’t yet have on certain aspects of the present state of affairs before legalization goes into effect. We need that in order to know what changes after legalization.
Ms. Porath: If I can just echo what Dr. Kalant said in his remarks, absolutely, I can’t overemphasize the importance of evidence-based public education. When CCSA travelled to Washington and Colorado, one of nuggets of advice that they provided us is that they simply didn’t have the resources or the capacity, pre-legalization, to come out with that messaging.
In my position at CCSA, I have been really fortunate to be working with Health Canada on some of their public education pieces. I believe the minister was here previously, and I can’t speak for Health Canada, but I know that there have been some efforts under way. I know Public Safety Canada has come out with some pre-legalization campaigns.
With the centre, in my position, I’m aware of what some other organizations are doing for key population groups: pregnant women, individuals with mental health conditions. So I know that there are some efforts that are under way, and at the centre we are also engaged in some efforts to increase awareness among Canadians, especially young Canadians.
As Dr. Kalant mentioned, there are a lot of key populations and a need for targeted messaging. A message that might be effective for a young person will not necessarily be effective for an older adult who is starting to use cannabis.
My advice would be to ensure we continue to onboard these public education initiatives. I know they are under way and I know there are plans for some post Royal Assent. We just need to make sure it is a sustained effort.
If we look at the public education for drinking and driving, it took almost four decades before we saw that culture change where it is now socially unacceptable to be driving while impaired by alcohol. This is going to take some time to change public perceptions. I think we first need to educate the public before we can start changing the perceptions that cannabis use is safe to drive, it’s safe to drive after using cannabis or cannabis is a safer drug than others.
Senator Munson: Are we moving too fast on this legislation? From both of you.
Ms. Porath: What we had heard when we travelled to Washington and Colorado is both jurisdictions told us to take the time needed to get it right. I believe it was in Colorado that they felt like they were building the plane while trying to fly it.
I know there are a lot of efforts under way, and the provinces and territories are trying to get ready for the legislation, so I don’t want to underestimate the efforts under way, but we really do need to ensure we are looking at all aspects of the bill to ensure we do get it right for Canadians.
The Chair: Do you have anything to add to that, Dr. Kalant?
Dr. Kalant: Yes, thank you. I would like to point out that clearly one must consider political realities in deciding how legislation is enacted, but the longer the interval between actually completing the legislation, passing it in Parliament, and enacting it, proclaiming it and putting it into effect, the longer that interval is, the more opportunity it provides for setting up the education programs and getting them going before increased use becomes strongly established.
And secondly, for answering some research questions that we ought to have in order to be able to recognize what the consequences of legalization are in our society, what is a realistic period is — how to put it — really up to you as senators to decide how much of a period of delay you could recommend. All I can say is: The longer, clearly, the better.
Senator Raine: Thank you very much, both of you. It’s very important that your words be heard as widely as possible.
I’d like to address my first question to Ms. Porath. You mentioned the age and that with youth using it, 9 per cent had done it regularly and then 17 per cent — these are youth who became vulnerable to the effects of cannabis — 17 per cent as teens, and 50 per cent of those teenagers who used it on a daily or near daily basis. I had never heard that 50 per cent of regular teenage users would go on to be very vulnerable to becoming addicted to it. I would like you to confirm if I heard that right. I have not heard it be that high, but I’m afraid it is.
Ms. Porath: That’s a great question. Of those who started using cannabis during adolescence, the rate is 1 in 6, or 17 per cent, and the rate increases to as high as 1 in 2 for those using cannabis daily or on a near daily basis. This statistic is cited from the World Health Organization’s 2015 report looking at the social and health effects of non-medical cannabis use. I can provide the reference to that report at the end, if that would be helpful.
Senator Raine: I find that very alarming, listening to both of you discuss the need to go a little slower and to really focus on public education around what would be determined to be a safe use of marijuana.
I guess I look at we have had medical marijuana available legally in Canada for some years now. Dr. Kalant, in my experience in talking to a family practitioner who practiced in an area of our province, British Columbia, where there was a high use of cannabis, he is reluctant or will not prescribe marijuana because he said the medical research has just not been done and there has never been a pharmacological product introduced and legalized for use in our country without the controls that normal pharmaceuticals go through. Could you comment on the existing state of knowledge about the pharmacological use of cannabis and how that’s going? We have now been doing it for several years. Is the research coming forward as to how doctors should prescribe it?
Dr. Kalant: Thank you. Again, I think that’s an important piece of knowledge that both Parliament and the public at large have to consider.
I would first say that, in my view, medical and non-medical use should be clearly recognized as separate issues. Just as a reminder, it is legal in Canada to prescribe heroin for patients in terminal stages of cancer. It’s almost impossible to find the heroin because there was so little demand for it that the company that imported it from the U.K. simply stopped bringing it in. It didn’t pay them. Nevertheless, it is legal. There is also some very small, limited legal use of cocaine in nose and throat surgery, yet nobody says that because there is legal use, therefore cocaine and heroin and other drugs that have medical use should be freely available to anybody for non-medical use. It simply does not make sense. They are two separate issues and should be regarded as such.
However, to come back to the question of so-called medical use, there are certain symptoms or illnesses that cannabis can be useful for treating. It has not received approval from Health Canada for a rather routine reason. Ordinarily, when Health Canada is asked to approve a new drug, the company that proposes the manufacturing of it has done research or has financed research in universities and elsewhere that establishes its effectiveness, its safely and its comparative effectiveness relative to other drugs used for treating the same problems.
Since cannabis is a natural product, you can’t patent it. Therefore, no drug company has had an interest in applying to Health Canada for permission to legalize plant cannabis. Only those who have produced pure cannabinoids, the active ingredients or modified extracts that have a high percentage of CBD and a moderate or low percentage of THC, only those have applied for and received approval from Health Canada. But there is not likely to be an application for approval of the plant material, so we have to rely on what clinical trials have shown.
With that, I would like to say briefly that there are a few functions for which moderately high or moderately low THC is useful and higher CBD is even more useful. These include relief of chronic pain of certain types, stimulation of appetite in people with cancer chemotherapy, for example, treatment of certain forms of epilepsy, especially in children in whom you don’t want the THC, but CBD is effective. These are uses that are continuing to be developed.
I would say that there is a place for certain forms of cannabis or cannabinoids, and there is a need to educate physicians more broadly on what those proper uses are and what claimed uses are not. For example, a claim that it’s useful in treating high intraocular pressure that results in damage to the eye is not a valid use because it has been shown that you need to control the intraocular pressure in glaucoma 24 hours a day to prevent damage to the retina. If you want to use cannabis therapeutically, you would have to use it repeatedly, day and night, and this is simply not practical.
I think that’s all I can usefully add at this point.
The Chair: Our third panellist has joined us. I’ll ask him to make his opening remarks. I have hardly given you time to sit down and breathe. You had quite a journey to get here, but I appreciate you are here.
Dr. Bernard Le Foll, Medical Head, Centre for Addiction and Mental Health, CAMH as we know it, could you please give us your opening remarks.
[Translation]
Dr. Bernard Le Foll, Medical Head, Centre for Addiction and Mental Health: Honourable senators, I am pleased to be here with you today. I would like to start by introducing the Centre for Addiction and Mental Health (CAMH), which I represent. CAMH is Canada's largest mental health and addiction teaching hospital. It is also one of the world's leading research centres in those areas. I am the physician responsible for out-patient addiction treatment. I am also a clinical researcher working on cannabis for about 15 years. I am particularly interested in improving the treatment for cannabis addiction, in the effect of cannabis on driving, and in the use of cannabis for medical purposes.
As you know, in October 2014, CAMH published a document describing its position on cannabis. The document is available online under the title Cannabis Policy Framework. I was honoured to play a role in the development of the recommendations with other physicians and researchers such as Dr. Benedikt Fischer and Dr. Jürgen Rehm. In the document, we examined the state of knowledge on cannabis policy and came to the following conclusions. Cannabis use carries health risks, particularly for those who use it frequently or who begin to use it at an early age. Criminalization aggravates those problems and causes social harm. A public health approach focussing on high-risk users and practices, similar to the approaches used for alcohol and tobacco, would allow for better control of the risk factors associated with cannabis-related harm. We also concluded that legalization, combined with strict health-focused regulation, provides an opportunity to reduce the harm associated with cannabis use.
Cannabis is the most commonly used illegal drug in Canada. We know that, despite the prohibition of cannabis, more than one third of young adults are users and our current approach exacerbates the harms. It is time to reconsider our approach to cannabis control.
CAMH neither makes a moral statement on cannabis nor encourages its use. We are grateful that the Task Force on Cannabis Legalization and Regulation has reflected the CAMH’s recommendations and that they also support Bill C-45, an Act respecting cannabis.
I would now like to talk about cannabis use. I will not go into detail on the medical uses that seem promising to me. Patients already have access to cannabis for therapeutic purposes under the current legislation.
Cannabis use has health risks. Cannabis is not a benign substance. Its health harms increase with intensity of use, particularly when it is used frequently, on a daily or almost daily basis. Then, cannabis is associated with an increased risk of problems with cognitive and psychomotor functioning, dependence and mental health, among others.
In terms of the problems with cognitive and psychomotor functioning, I will simply say that cannabis use is known to negatively affect memory, attention span and psychomotor performance. Frequent use may reduce motivation and learning performance. In adults, these changes are not generally permanent; effects usually dissipate several weeks after use is discontinued.
One significant aspect for public health is the impact of cannabis use on the skills necessary for safe driving. Although alcohol seems to present a higher risk of traffic accidents than cannabis, it is nevertheless a serious concern.
I now want to provide more details about the risk of dependence and the impact on mental health.
Cannabis is an addictive drug. Quitting the use of cannabis, after regular and prolonged use, is associated with a recognized withdrawal syndrome that includes anxiety, dysphoria, disturbed sleep, irritability and anorexia. Although the cannabis withdrawal syndrome can be agonizing, it is not life-threatening. Unlike other drugs, like alcohol and opiates, overdoses are generally not associated with cannabis use. The main challenge is a loss of control over use, a dependency, which develops in a small number of users. This risk is higher among the young. It is defined as “cannabis use disorder”. It is estimated that 9 per cent of cannabis users develop dependence, which is the most severe form of cannabis use disorder. A greater proportion of users will develop a less intense disorder. It is worth noting that most of them will not need specialized treatment.
Recently, in collaboration with the Cochrane group, we reviewed all the literature on the treatment of cannabis dependence. The good news is that we have effective treatments. Specifically, psychotherapy approaches, such as cognitive behavioural therapy and motivational enhancement therapy, have been shown to be effective. However, the not-so-good news is that we currently have no pharmacological treatment.
In terms of the mental health problems, there is a strong statistical correlation between frequent cannabis use and various mental illnesses. I will be talking about psychotic, depressive, and anxiety disorders.
It is clear that, with some subjects, exposure to cannabis can cause psychotic disorders. However, it seems unlikely that exposure to cannabis can produce the illness referred to as schizophrenia, because that illness has not increased in prevalence despite a strong increase in exposure to cannabis in the population. In the last 20 years, there has been a fivefold increase in the concentration of THC and an increase in the number of users. Despite all that, the prevalence of schizophrenia has not changed and has remained stable. It seems rather to be the case that symptoms similar to schizophrenia can be brought on by cannabis or can be produced in users with a pre-disposition.
There is a correlation between cannabis and anxiety and depression disorders. Prospective studies in this area seem to indicate that the frequent use of cannabis increases the risk of developing depression. The risk among intermittent users seems to be low. For anxiety, the correlation is less clear. We must recall that statistical correlation does not mean causation. It is possible that some of those users are self-medicating with cannabis.
In conclusion, it is the CAMH’s position that legalization with a public health objective could result in a net benefit to public health. Benefits could also come from a move to cannabis from more harmful drugs like opiates and alcohol. Complications for the public are basically linked to cannabis addiction and the impact on driving. Those two areas are therefore the priorities in terms of reducing the negative effects of cannabis on the public.
Our health care system must be prepared to use valid treatment methods and to support more clinical studies in this area. CAMH has just opened a clinic that provides valid treatment. I would also like to mention the lower-risk cannabis use guidelines developed by Dr. Fischer`s team, which can reduce the negative effects of cannabis.
Thank you for giving me the opportunity to speak to you today.
The Chair: Thank you very much, Dr. Le Foll.
[English]
Senator Omidvar: My question is for Dr. Kalant. Thank you so much for your brief that I have in front of me. I appreciate very much the way you set out what you think are the problems and suggested solutions.
I do have a question, though, about the evidence that you have cited from Colorado. One of our challenges with this bill is that there is evidence coming at us from different sides that doesn’t seem to agree with each other.
I will cite to you the evidence from Colorado that we have from the national survey on drug use and health in the United States. They have found that — and in fact, the executive director of the department of revenue said — in the three years since they legalized marijuana, 70 per cent of the market is now legalized and 30 per cent of the market is in the grey zone because of home sales. There are conflicting numbers, conflicting with the numbers that you have given us, on use going up or down. I just wonder if we could perhaps get the citations from your evidence so that we can look at it and compare it with what we have. So that’s a request, not a question as much.
My question, though, is around — I’m trying to pick up from what Senator Seidman had asked around comparing alcohol and cannabis. I wonder, though, if it’s fairer to compare tobacco with cannabis, because alcohol regulations are looser than those governing tobacco. The government has quite successfully reduced tobacco consumption rates from 50 per cent in 1965 to 15 per cent in 2013. Do you think that with the appropriate controls in place, Canadians could see a decline in cannabis consumption among young people, much like what’s been done with tobacco?
Dr. Kalant: I would say, first of all, that I would differ with your statement that the government was successful in lowering tobacco use. It was actually the public itself, and particularly youth, who led the pressure drive to reduce the use of tobacco. I remember quite well. I am old enough to have a memory that goes back a long way. I remember the statements that many youngsters made to their parents: Do you want to leave us as orphans? They pressured their parents to stop smoking. That is an important thing to remember in relation to cannabis. If the children themselves were able to do that, why do they not do that with cannabis? That’s what we have to learn —how to recruit young people to persuade other young people, and through them, to put pressure on the public at large.
On the question of differences of opinion of the information from Colorado, for example, I agree with you there have been conflicting reports, but one has to look at what the reports were and what they were based on. For example, for the first two years after legalization, a report that was based on the national survey of drug use all across the country used a balanced, structured population sample that was representative of the population in each state. That survey showed an increase in use by young people after legalization.
There was, at the same time, a survey carried out by the high schools of the state, by certain high schools, which was not a representative sample, which was based on only 10 or 12 schools and did not include any in the areas of the state that were known to have the heaviest use of cannabis. They found no increase or a very small increase. Surprisingly, in the third and fourth years after use, the national survey showed the beginning of a downturn in use by youth while the high school one now started to show an increase.
We have to have a very careful look and very thorough, well-organized surveys to get at the facts in these cases. In terms of the national surveys, which are the best, there is no doubt that total use altogether — including, surprisingly, use by those over 65 years of age — has definitely gone up.
Senator Omidvar: Thank you, Dr. Kalant. This is, again, a question for you, but please feel welcome to chime in.
From all the research that has been provided to us, we are told that 21 per cent of youth aged 15 to 19 and 30 per cent of young adults 20 to 24 use cannabis in Canada. You are asking — and I think Ms. Porath, you, too, are asking — to take a slow and steady approach, do the research, which makes perfect sense. When we don’t know something as much as we should, we should take it slow and steady. On the other hand, we have a growing number of people using a drug, buying it illegally, not tested, not safe. Would you not agree that the provision of safe, tested and potency-labelled cannabis with clear warnings about health risks sold in a highly regulated way is safer and healthier?
Ms. Porath: Absolutely. I think that having regulated cannabis available for Canadians will be much safer than what we see right now with the illicit market, having more education and information to Canadians so that they can make an informed decision. As I said earlier, there are a lot of efforts currently under way to prepare for this change in legislation, and I think if we can draw from the lessons learned from those U.S. states that have legalized, that will be very helpful as well in terms of informing the bill. They have four years of experience. I think if we can look at their experiences and take from that what we need to do here in Canada, that would be very helpful.
The Chair: Dr. Le Foll, do you have a response you would like to give to that or anything supplementary?
Dr. Le Foll: Yes, sure.
[Translation]
One example is the situation in the United States. You can also look at the situation in Europe. In the Netherlands, for example, access to cannabis has existed for a very long time, whereas France has a total prohibition. In the Netherlands, there is less cannabis use than in France, and there was no increase in cannabis use after access to cannabis was opened. Situations like that, which have existed for decades, also provide valuable information.
[English]
Senator Unger: I would like to thank the doctors present for their wonderful and very interesting presentations.
Dr. Porath, I would like to ask you about a group of people that we haven’t talked about yet, and that is the economic and social problems that will persist in middle-aged people who are regular users, where they experience downward social mobility and more financial problems. They lack initiative. In theory, young people who become regular users, who possibly had dreams and high aspirations, will never try to accomplish those.
Dr. Kalant, I would like to ask you — it doesn’t matter if you both answer — cannabis has 400 to 500 different properties or chemicals or substances, and yet we only know something, really, about three, possibly four. What about all of the other toxic chemicals that THC does possess, about which we know nothing?
I wondered also — and, Dr. Le Foll, if you wish to comment as well — there is a fair amount of debate about the length of time that THC stays in the body. Since it is oil soluble, it cannot really be compared with alcohol because the properties are completely different. Could you comment about that?
[Translation]
Dr. Le Foll: You are quite right. Various compounds have been identified in cannabis plants. Currently, we are very familiar with Delta-9-THC and cannabidiol. Other compounds are also biologically active, but at much lower concentrations.
Very little research into these compounds has been done to date. The basic research has been done on animal models. We do not have information on the direct effects of these substances on humans. Some indications suggest that they could have medical benefits, but I would say that that is in the realm of research.
[English]
Ms. Porath: Perhaps I can address the first question that you had posed. Certainly for some individuals who start using cannabis early in life, they will go on to use it later in life and continue to use. For those individuals, yes, there can be negative effects.
I know there was a study just released a few weeks ago from Monitoring the Future. This is a study in the U.S. that has been tracking the behaviours and perceptions of young people since starting high school and then following them up, and they have been following them for several years and looking at the outcomes of those who had started using early in life and sort of what are the outcomes later in life, I believe, in the late 40s, early 50s. They did show that, for a group of individuals, they were still continuing to experience negative effects.
I will point out, though, that, for some individuals who do use in adolescence, the rates of prevalence do tend to drop off in that early adulthood. It sort of corresponds with when people start to get employed, get married and have children. The majority will essentially stop using cannabis. That pattern is not unique to cannabis, but it’s for other illicit drugs as well.
Dr. Kalant: I would like to comment on two questions that have been raised.
First of all, with respect to the composition of cannabis, I agree with Dr. Le Foll that there are a number of other constituents of cannabis that probably do have pharmacological effects. The point to remember, however, is that their concentrations in cannabis material are extremely low, and they contribute very little to the overall effect of cannabis, as used in its crude form. If we want to study their possible medical applications or their harmful effects, side effects of intended therapy, it will be through isolating them and getting pure preparations of these other compounds that can be used in higher concentrations or higher doses than is possible with crude cannabis itself.
On the question of what happens to older people who have started use in their younger years, it is true that, as Dr. Porath said, the majority who have not been heavy users in youth, who have fortunately used only occasionally at parties and so on, generally tend to give up their use as they get older, acquire other responsibilities and find that cannabis has been bothering their memory or their degree of enthusiasm for what they have to do, et cetera.
However, it is now becoming clear that, even people in their 60s, 70s and later, more of them are continuing or even starting to use cannabis, and the Canadian Academy of Geriatric Psychiatry is currently engaged in a study to determine the risk of cannabis abuse and cannabis dependence in seniors. This is a sign that, in fact, part of the normalization that we’ve both spoken of before is gradually extending use into years in which it was previously unknown.
I think those were the only two points I wanted to make.
[Translation]
Senator Mégie: My question is about the awareness and prevention campaigns. I know that the Centre for Addiction and Mental Health prepares documents, as does Health Canada. I have even gathered that companies profiting from cannabis are also going to establish prevention and awareness programs.
Would it not be logical to consider a higher body that would be able to look at the various messages being transmitted? In that way, we could perhaps avoid mixed messages. With alcohol, for example, we do the right thing by informing the public about the hazards of alcohol abuse, but, at the same time, we say that a nice little glass of wine can be good for us. I would not be comfortable with similar messages about marijuana, especially from the companies producing it. What do you think about having a higher body to look after all that?
[English]
Ms. Porath: I think you raise a very excellent point. This is a question I was posed a couple of weeks ago when I was doing a media interview with a reporter about public education and if there was any way to ensure that these messages and resources are evidence-based and providing accurate information.
To my knowledge, I’m not aware of an oversight body that vets these messages. I would urge Canadians to look at who is involved with it. I know that Health Canada is developing a website where they’re going to be featuring evidence-based programs and resources that they support. My organization, CCSA, is also in the process of developing and tooling up our website where we will be promoting the work of other organizations. There are a lot of organizations that are doing really excellent work, and I think there is such a demand and so many different types of resources that we need, and I think it’s great to see this.
Your suggestion is a really good one about who is overseeing and providing that stamp of approval for these guides.
Dr. Kalant: I have read a report that has been produced by a youth group concerning cannabis that was financed by a grant from the largest cannabis producer in Canada. I found that the report was, on the whole, fairly good. But in general, both professional and scientific bodies tend to look askance at information prepared under the auspices of drug producers because there is, obviously, a conflict of interest. The company in question has been very good in declaring an arm’s-length relationship and not taking part in the production of the report.
However, one can’t assume that that will be true of all information put out by producers because there is an intrinsic risk of conflict of interest, and editors of professional and scientific journals will generally require a statement of conflict of interest when a report is submitted for publication that has been affected in any way by a drug or alcohol producing company. That suggests that your suggestion, senator, is indeed important, that there should be an independent appraisal group that has to pass judgment on the quality of material that is put out where there is any reason to suspect the possibility of a conflict of interest, and that’s something that might be considered in modification of the legislation.
The Chair: Thank you.
Dr. Le Foll, do you have anything to add?
[Translation]
Dr. Le Foll: I would also like to say that it is a good idea, especially the comparison with the alcohol situation. We know that some promotions do not cover the risks in the same way as the potential benefits of use. So it is clear that, with cannabis, we should have a stricter approach in order to avoid the same problems.
[English]
The Chair: That completes round one. I do have four senators for round two, and we have six minutes left. We probably won’t get through the whole list, but I would ask you to limit to one question each, please, and we’ll see how far we get.
Senator Seidman: Given all this talk about not enough evidence, not enough education, some kind of quality control over the education — which will be critical — do you think that there should be some kind of monitoring, evaluating and reporting requirement built into the legislation so that, in fact, some kind of arm’s-length oversight body or statutory review committee, mandated reports to Parliament, as the evaluation of the effects of the legislation and the scientific evidence — which isn’t here yet — starts to come in? Should there be some kind of mandatory reporting system and oversight built in, and if so, what could that be?
Ms. Porath: I think what you’re suggesting would really strengthen the bill. I think that Canadians are going to be very interested in the outcomes. As you said, there is a lot we don’t know, and I think there will be a lot of scrutiny to examine the impacts of this change in legislation. I think having built-in monitoring and evaluation would help the government make adjustments as we go. One thing we heard when we went to Washington and Colorado is to expect the unexpected and to be able to make changes incrementally. I think your suggestion is a good one, and it would really help to inform the bill moving forward in the law.
The Chair: Let me ask the other panellists to say something if they have something they want to add, because we need to move on. Anything you wish, either one of you, to add? No? Okay.
[Translation]
Senator Pratte: My question goes to Dr. Le Foll. You are in favour of legalizing cannabis. Do you not believe that legalizing cannabis may well bring about a kind of normalization, that a legalized product will mean a safe product with no danger, and therefore that the message will bring about an increase in consumption?
Dr. Le Foll: In the current situation, we have dealers of illicit products providing information to young people. I believe that legalization has the advantage of moving that aspect into the realm of legality and allowing health institutions to disseminate a valid, evidence-based message.
We can use tobacco as an example; it shows that, as soon as the risks are presented clearly to users, their consumption gradually changes. At the CAMH, we think that the same thing can happen with cannabis if we focus our educational efforts on the risks of consumption.
[English]
Senator Raine: My question is around the age. I’m very sorry the legislation has the minimum age of 18. Some provinces have raised that age, which then becomes a patchwork of regulations across Canada. What would you recommend to be the minimum age?
The Chair: Maybe we could get a quick answer to that from all three of you. I’ll start with Dr. Kalant. Should be there an age limit? The question from Senator Raine was the matter of age limit. The legislation says 18. Some provinces are 19. She’s asking each one of you what you think the age should be in the legislation.
Dr. Kalant: May I start on that?
The Chair: Yes, quickly, please.
Dr. Kalant: The medical evidence is that the susceptibility of maturation of important parts of the brain to detrimental effects from cannabis continues to an age of about 24 or 25. I think there is very little possibility of expecting that Parliament will accept an age limit of 25. All I can say is that the later it is, the better. I think 21 is definitely better than 18 or 19. That has a ring that might possibly be convincing to members of Parliament, because it was formerly the age of defining adulthood.
The Chair: Thank you, Dr. Kalant. I’m sorry; I’ve got to move on. Dr. Porath on this question.
Ms. Porath: I think the age of 18 strikes a nice balance. We know from the medical literature that 25 would be best, but we know that youth under the age of 18 are using. We know that for those youth who are using, there can be criminal sanctions. We really need to minimize harms with this bill, and I think the provinces and territories have the latitude to increase the age. If we can emphasize the importance of public education, this will really help to get the message out for young people that they need to delay use as much as possible to protect their brain health.
[Translation]
Dr. Le Foll: The position of the CAMH is that 19 is probably an appropriate age for Ontario in order to align with the alcohol situation. We feel that it is a pragmatic approach that takes into account not only the medical factors but also the social factors of the current situation.
[English]
Senator Omidvar: My question is for Dr. Le Foll. Can you clarify if cannabis is or is not a gateway drug to harder drugs?
[Translation]
Dr. Le Foll: It has been said that cannabis is the gateway to other substances. That idea is now largely rejected in the scientific world. Studies have been done on animals exposed to THC or to other drugs in order to find out whether they are more at risk of self-administering other substances or of finding pleasure in being exposed to other substances.
If we subject those substances to that kind of test, we see no evidence to support the idea of THC being a gateway. Conversely, nicotine seems to have the properties that provide a sensitivity to subsequent effects of much more significant drugs. Also, the sequences of exposure to the drugs show that it is true that some users are going to progress from one drug to another. So there does seem to be a gateway effect. If you study a group of at-risk subjects from an epistemological point of view, they will move from nicotine to cannabis to alcohol, and so on. However, when you look at the population more broadly, there is no direct evidence of a gateway effect from using cannabis.
[English]
The Chair: We have come to the end of this session. I want to thank our three panellists very much — Dr. Kalant, Dr. Porath and Dr. Le Foll — for giving us evidence and answering our questions.
We will now proceed to our second panel for our continued study of Bill C-45, An Act respecting cannabis. The day’s theme is health effects, but this specific panel will deal more with the smoking aspects of this subject matter. In that connection, I’m pleased to welcome David Sweanor, Adjunct Professor, Faculty of Law, University of Ottawa, who is here as an individual; and two people from the Non-Smokers’ Rights Association, Melodie Tilson, Director of Policy, and Pippa Beck, Senior Policy Analyst.
Welcome to all three of you. I will ask you to give us seven minutes of opening comments, and then we’ll proceed with questions from the members of the committee. I’ll start in the order you are listed here. Mr. Sweanor, please go ahead.
David Sweanor, Adjunct Professor, Faculty of Law, University of Ottawa, as an individual: Thank you, Mr. Chair. In addition to being an adjunct professor with the Faculty of Law at the University of Ottawa, I’m also Chair of the Advisory Board for the Centre for Health Law, Policy and Ethics at the University of Ottawa.
I think the reason I was invited to testify is because I worked as a lawyer on policy measures to reduce cigarette smoking since 1993. I played a key role in anti-smoking policies.
I’ll immediately contradict what Dr. Kalant was saying. Smoking didn’t fall because of something that was done by kids talking to their parents. Like so many other things, it was policy. It was government measures that made a difference. Changing rules and economics and doing things to get people better information and better options make a real difference.
My interests go well beyond issues of smoking and health, though. I work on a lot of different areas of public health. I work on them, I mentor people and I fund these things. Among other things, I was honoured with an award as Ottawa’s Outstanding Individual Philanthropist in 2016 because of a lot of the interests I have in these things, having come to terms with the idea that my life expectancy is not long enough to handle all the issues I’m personally interested in. I have to find other people working on them.
The goal we need to keep in mind is that we should be trying to rationally and pragmatically work to do things that essentially make the world a better place. Those are the principles of the enlightenment. How do we use science, have rational debate and move ahead on some areas where we can have huge advances for society at little cost and effort if we are willing to show vision, have that rationality and show that pragmatism?
Cigarette smoking has been a prime example of that. We have had major advances. We still lack the vision necessary to do much more, which we could. It is still killing 20,000 people a day globally. They are dying not just because they are inhaling smoke, which is a deadly delivery system for getting a drug into their bodies, which is relevant to Bill C-45, but because of a lack of vision by governments not doing the things necessary to change that delivery system — to do something so people don’t have to die because they are using a drug.
With Bill C-45, one of fundamental concerns I have with the legislation is that it is still treating drug use as a crime, not a public health issue. This is decades past the Le Dain Commission of 1972 that I think had a very sensible approach, or the Senate Special Committee on Illegal Drugs in 2002 that also stated: “Governments must promote autonomy as far as possible and therefore only make sparing use of the instruments of constraint.”
Criminal law is just a really bad way to deal with public health issues. A public health approach makes a whole lot of sense. Criminal law has given us approaches to illicit drugs that have not only not worked but that have been a catastrophe, not only in Canada but even more so in our neighbour to the south. Bill C-45 gives some exemptions, often in confusing ways, but still maintains the overall “let’s treat it as a crime” problem.
It is saying someone can have up to 30 grams of cannabis. You and I could each go into a store and buy 25 grams, as long as it is a legal store, but if, upon leaving, I say, “I have to go somewhere else before the party. Can you take mine with you?” you are potentially looking at five years. If the store is closed, but I know a guy over here who sells it, it’s five years. If you have four plants and I have four plants and we decide we are going to move in together and keep our plants, we now have more than four plants in our residence. That’s five years in prison, potentially.
What happens when you have somebody just over the age of 18 giving someone just under the age of 18 cannabis? That’s potentially 14 years. As much as we can say these sorts of penalties would not be imposed in Canada and that they’re only imposed in places like the United States, we know from history that laws are imposed in unacceptable ways that treat different people differently. It causes a lot of confusion with the public.
A major problem with the legislation is that it allows cannabis to be smoked, but it doesn’t allow people to get the drug in a non-combustible form, which is how a lot of people are already accessing it. I think I was invited because I have written articles on issues of cannabis as well as smoking cigarettes. The smoke is the problem. That’s the biggest health risk. That’s the dirtiest way to deliver a drug. It is the smoke that is the most dangerous. There is already a market for vaping cannabinoids and for edibles. Health Canada has approved a product, the Volcano Medic, for vaping marijuana.
What I think we end up with, similar to the problems I see with Bill S-5 — which I really wanted to testify about but wasn’t allowed to — is that we are protecting the most dangerous delivery system, the smoking. We’re missing issues of relative risks; it’s a basic issue of moral philosophy to be able to distinguish between relative harms. We are ignoring consumer rights about the rights of people to have a less hazardous delivery system.
We are distorting or banning truthful information. Bill S-5 does this in spades. It makes it illegal for a company to tell people differences in risk between their products, even when that difference in risk is enormous. We are banning less hazardous alternatives such as what we are seeing with Bill C-45. Although we’re saying that we’ll be able to change this later, why are we talking about changing it later? Why are we acting like it’s the smoking of cannabis that’s okay and that it’s the vaping that would be a problem?
We are misleading the public, and we’re doing things that are in violation of our Charter of Rights and Freedoms. I think both bills, S-5 and C-45, could be tossed out fairly easily by a constitutional challenge.
It’s important to recognize it’s the smoke. In the case of cigarettes, we could essentially end the epidemic of cigarette-caused disease in short order by application of some rationality, pragmatism and vision. In the case of illicit drugs, we should take an overall public health approach to all illicit drugs — not a criminal law approach. We can greatly reduce the harms of illicit drugs, including cannabis, by focusing on the underlying public health issues. Most of the harms are caused by the laws we have put into place rather than by the drugs themselves. In case of the drugs themselves, a legal market could allow us to deal with those harms far more effectively, and a rational approach of looking at different delivery systems makes a lot of sense. Thanks.
The Chair: Next we have the Non-Smokers’ Rights Association. Two representatives will share the time. Melodie Tilson, please go ahead.
Melodie Tilson, Director of Policy, Non-Smokers’ Rights Association: Thank you for the opportunity to speak to you today regarding the regulation of cannabis products.
My colleague Pippa Beck and I together have more than 40 years of experience in tobacco control. Our organization has been at the forefront of tobacco reforms in Canada since 1974, leading campaigns for the federal Tobacco Products Control Act, its successor the Tobacco Act for plain packaging as far back as 1994 and for world-precedent-setting graphic health warnings on packages to name just a few. It is this wealth of experience in the effective regulation of an addictive and harmful product, one that is primarily smoked, that we bring to bear on your consideration of issues related to the appropriate regulation of cannabis.
We are pleased the government has stated from the outset the importance of taking a public health approach to the regulation of cannabis. However, we cannot emphasize enough that where there is a profit to be made in the selling of an addictive drug, public health is at risk. The tobacco industry has shown us what it is willing to do in the pursuit of profit. Canada’s legalization needs sufficient protection from commercial interests or Canada could face big tobacco 2.0, big cannabis.
Indeed, we’ve all witnessed the meteoric rise in cannabis stocks over the past year or so. Bloomberg data shows that there are 84 cannabis-related companies trading on Canadian stock exchanges that are collectively worth $37 billion. While we acknowledge that there is medical cannabis to be supplied domestically and exported, much of the hype has to do with recreational cannabis use.
The goal of these companies will be to continue to grow the Canadian recreational cannabis market. We believe that the measures currently proposed for the regulation of cannabis are insufficient to adequately protect public health in the face of a new industry poised to make billions.
I’ll now turn over the mike to Pippa Beck, who will focus on two issues: the need for tighter restrictions on promotion and the need for adequate public education.
Pippa Beck, Senior Policy Analyst, Non-Smokers’ Rights Association: Thank you, Melodie. A public health approach to cannabis regulation should focus on denormalizing smoking and providing adequate public education via mass and social media, and importantly, through health warnings on the package about the risks of use, about the risks of breathing second-hand cannabis smoke and about relative risks.
There is little public understanding of the fact that smoke is smoke and the fact that the harm comes from inhaling it, whether it's tobacco or cannabis, or of the fact that vaping poses much less risk than smoking. We’ve spent decades legislating and educating so that tobacco smoking is no longer a social norm. However, smoking cannabis is currently the most prevalent form of consumption recreationally, 94 per cent according to the 2017 Canadian Cannabis Survey.
We know from tobacco research that package warnings can be a highly targeted, effective and cost-effective form of public education. However, the current proposal for six warnings includes no warning regarding the relative risks of smoked versus other forms of consumption, no warning of the dangers of exposure to second-hand cannabis smoke and no warning of the risks of combining tobacco and cannabis. We urge senators to recommend that warnings on these issues be included in the list of mandatory health warnings on cannabis products.
Turning to promotion, the Task Force on Cannabis Legalization and Regulation rightly concluded that marketing, advertising and promotion of marijuana would only serve to normalize it in society and increase and encourage its consumption. We believe Bill C-45 should be amended to prohibit promotions directed at retailers and distributors. This is Division 2(a), section 16(c) and (d).
Our experience with tobacco indicates that when opportunities for promotion are restricted, manufacturers turn to retailers to promote on their behalf using contracts, incentive programs, reward programs, et cetera, to achieve category growth. As was described by British American Tobacco in 2010, the closer we are to the retailer, the closer we are to the consumer. This amendment will be important in provinces where private companies can apply for a retail licence to sell, including Alberta, B.C., Manitoba and Saskatchewan. The system is open to abuse. It’s much better to have a federal law banning this kind of promotion as opposed to a patchwork of provincial laws.
We also recommend that section 17(6) of the bill be amended to prohibit the use of cannabis brand elements on items that are not cannabis or cannabis accessories, regardless of whether they would be considered appealing to young people or associated with an attractive lifestyle. Brand stretching is a marketing strategy that is effective in increased brand awareness to help increase consumption.
Furthermore, our experience with tobacco control has demonstrated that companies often count on lax enforcement of provisions, particularly those that require interpretation. Permitting cannabis brand elements on T-shirts and ball caps, mugs, you name it, is not in keeping with a public health approach.
Another important promotional vehicle is the packaging, and we agree with the stipulation that the brand name cannot be in a font that is larger than that used for the health warning. However, we are concerned that there are no restrictions on brand names themselves, and we know from Australian experience with tobacco plain packaging that when the package design elements are curtailed, tobacco companies get very creative in the names they use for brands and brand variances, using them to connote aspirational lifestyles.
We are concerned that without restrictions here in Canada, the same thing could happen regarding cannabis brands. We did a quick Internet search and found evocative names such as SuicideGirls, Pura Vida Health and Everyone Does It cannabis brand. Furthermore, with no limit on the number of words in a brand name, the name could serve to distract the eye from the health warning.
Likewise, we’re concerned there are no restrictions on additional permitted brand elements other than font size if it’s a slogan or absolute size if it’s a logo. The slogan could thus be long enough to take up the remaining white space on the packaging, not only detracting from the health warning but also conveying significant promotional messaging.
It’s also vital that the regulations prohibit the use of technologies that can be used to violate the spirit of the law, for example, linking to promotional materials such as websites, images or videos when scanned with a smartphone.
To conclude, we believe that stronger public education, including mass and social media, and a wider range of package warnings, as well as further restrictions on promotion, will go a long way to further safeguard the interests of public health. It’s much easier to loosen things down the road than to try to reign in a burgeoning market in a powerful industry.
Thank you. We look forward to your questions.
The Chair: Thank you for both of those presentations. Now my colleagues have questions.
Senator Seidman: Thank you very much for your presentations. I think I might address my question to David Sweanor.
We had Dr. Le Foll here from CAMH before. He’s still here, and I probably should have asked him this question, but I think you will probably be able to answer it as well. The Centre for Addiction and Mental Health wrote a Cannabis Policy Framework in October 2014, and it has been cited and used repeatedly as the basis for the current legislation that’s in front of us. CAMH offered 10 basic principles to guide the regulation of legal cannabis use, and they said these would be the minimum requirements. One of them says, number 5, curtail higher-risk products and formulations. This would include higher-potency formulations and products designed to appeal to youth.
This is a minimum requirement, according to CAMH; however, we don’t see a lot of harm reduction in this piece of legislation. So what I would like to ask you is you yourself have called for the government to recognize the harms associated with smoking cannabis. We know that 90 per cent or so of young people, when they use cannabis, smoke it. The other aspect, of course, of the fact that they smoke cannabis, so it’s combustive, is the THC content. There is no attempt to regulate the potency of the cannabis being used.
Could you address perhaps what kind of policy measures you would recommend the government take to limit the harms associated with smoking cannabis? And how could Bill C-45 be amended to incentivize the use of non-combustible products and, in fact, the whole concept of harm reduction?
Mr. Sweanor: Thank you for the question.
I think it’s important to recognize in the whole history of public health that many of our biggest advances have come from two simple things: First, you give people enough information to make an informed decision, and second, you give them the ability to act on that. In recent years, we’d add “nudge” as well, use things that encourage people to move from one to the other. This legislation is doing the opposite by saying that we will allow the most hazardous way of getting marijuana, not the less hazardous ways.
I think what we need to do is encourage Health Canada to move quickly to give information, which we don’t have now either on cannabis or on the relative risk of vaping as a way of getting nicotine, and start giving that information to consumers so they can act on it. We are seeing the most rapid declines we have ever seen in smoking rates in countries and various places around the world simply because they have allowed substitutions. They’ve given people access to less hazardous products and people get to know about it.
Illicit drug users have known this for years. Bleach was used to sterilize needles even in the United States during the War on Drugs because even IV drug users could get information and share information to do things like saving their lives.
Our government needs to be providing people with accurate information with the ability to act on it: what sorts of products, what are the potencies? We have the situation now that a lot of people are getting their THC through vaping, and visiting any head shop is highly recommended because you will find many people are concerned about the risks of smoking marijuana and are vaping it instead. We are going to take a whole lot of Canadians who are already using that and saying we are making that illegal. That just is not good health policy.
Ms. Beck: Thank you for the question.
I did see the government has indicated that in terms of bringing forth regulations for edibles and for liquids that can be vaped with THC, those won’t come for another year. I went online to watch dubious instructional videos on how to make your own THC vape juice. In terms of dosing and people able to titrate, I’m extremely concerned that we will have people trying to make their own, getting the potencies all over the place and it will not be in the best interests of public health.
I would encourage the government to fast track the regulations for the THC E-juice that can be vaped and for edibles. I know there are a lot of fine details that need to be worked out around the dosing around edibles and I understand why it is coming as a second wave. I think we need to focus on those alternatives that are going to reduce harm and bring those to market so people are not left to make their own, and we will be in better position in terms of public health.
Ms. Tilson: During our testimony, we emphasized the need for public education about the difference in risk depending on the method of use. This is not widely known by the public.
The last panel addressed health issues. That was the main focus, and yet we didn’t see an emphasis by any of those speakers on the fact that vaping cannabis is much less harmful than smoking it. It’s the fifth recommendation in the CAMH Lower-Risk Cannabis Use Guidelines, and yet it is not widely understood and recognized.
The other thing we want to emphasize is that about one third of young people using cannabis are combining it with tobacco in their joint and smoking it, and that greatly increases the risk not only of addiction but also of health consequences related to smoking tobacco.
Senator Seidman: So that, in fact, could lead to increased smoking rates among young people, given 90 per cent of them smoke cannabis. Is that what you are suggesting?
Ms. Tilson: Absolutely. Well, there has not been much study on the long-term repercussions of combining tobacco with marijuana, but it makes sense that since they are taking in nicotine, they are at greater risk of becoming addicted to tobacco but also greater risk of becoming addicted to marijuana, to cannabis.
Senator Seidman: Just to finish up quickly here, my question had to do with some kind of way to incentivize a lower-risk approach to cannabis — not smoking it, for example. Is there some way in this legislation that we could incentivize that, from your point of view?
Mr. Sweanor: To begin with, you legalize it so that you have these options available. Second, you give people information about relative risk. People can only make as good a decision as the information available to them allows. They do not have that information now on the vaping of marijuana, just like they don’t have on the vaping to replace cigarettes. Give people information and they can make better decisions.
We then have policy options in terms of differential taxation once we move into a legal market. I published on that in the New England Journal of Medicine on issues of nicotine and relative risk. It worked really well in moving people from leaded to unleaded gasoline and various other things. We can use differential marketing and promotional standards.
We had these measures in the Tobacco Products Control Act of 1988, which ended up being tossed out with a challenge from tobacco companies, but would have completely transformed the tobacco market. I think we can do the same thing here.
Senator Petitclerc: Thank you very much for your comments and being here. I want to hear from Mr. Sweanor first, but also all of you on how the bill addresses — or if it does address — the possible effect of smoking cannabis in public. The way I understand it, where it’s legal and possible to smoke tobacco in public, it will be legal and possible to smoke cannabis in public. I know that it will be regulated by different provinces and/or municipalities, but I’m curious to hear your perspective on that in terms of health effects, of course, but also normalization, maybe, on the act of smoking cannabis versus other things. Do you have any input on that?
Mr. Sweanor: I spent many years on legislation dealing with second-hand smoke and restricting smoking in many places, as did the chair. What is going to happen in terms of public use of marijuana is going to be dictated by the provinces and municipalities, as has happened with cigarette smoking.
One of problems we talked about was the misinformation and people not distinguishing between relative risks. We are already seeing municipalities saying we are going to treat vaping the same as smoking. If we actually look at issues of relative risk, there is no basis for doing something like that and that merely further confuses the public and gives less reason to use the less hazardous product. People are being misled by what they see in the community.
This is the situation we had with cigarette smoking when I first got involved. It was everywhere. You saw lifestyle ads and people smoked in elevators, grocery stores and on airplanes. There were no warnings of any consequence on packs. It was no wonder we had 42 per cent of 15- to 19-year-olds smoking daily in the early 1980s. The message from the environment told people this was fine.
If we send the message from the environment that there is no difference between smoking and using a non-combustible product, we are again misleading people. What will happen? Logically, you will end up with more people smoking a product rather than vaping a product or using some other lower-risk way of getting it.
We are running into that problem now with issues of nicotine, and I think we need to avoid it on issues of marijuana. One of problems we have is that if we don’t even have regulations — if it isn’t even allowed yet — what do we do, and what do we do to the people who are already vaping to get their marijuana?
Ms. Beck: Our organization is concerned about an increase of exposure to second-hand cannabis smoke, particularly within multi-unit housing. This is an issue that has literally been heating up over the last few months. It has been in the news a lot.
Here in Ontario, the government has announced there will be virtually no public consumption, smoking or vaping of cannabis, and we are really concerned that if people are going to be driven indoors, there will be an issue for folks who do not have a backyard or balcony. They will be using it, and probably smoking it, inside their homes. The number one reason the public contacts the Non-Smokers’ Rights Association is because of unwanted exposure to smoke in their own homes. Again, it goes back to public education about vaping versus smoking versus other kinds of consumption and encouraging governments to really reach out and do some public education and to permit.
Now, government doesn’t have jurisdiction within people’s private homes, but landlords and condominium boards and housing co-ops and so forth can be educated so that, when they start putting in no-smoking policies, which are becoming more and more common, it’s not a blanket ban. It’s a no smoking policy, not a no vaping policy. There is no science that’s indicating that vapour, this aerosol, is travelling through cracks or gaps or ventilation units. There is no reason to be banning vaping inside people’s private homes.
Senator Petitclerc: Ms. Beck, I was trying to find scientific data, because we do have that for tobacco. What is the real risk to others of second-hand smoke of cannabis? Do we have that kind of solid data? Does it exist, or is it too early to know? How does it compare, if you do have that information?
Ms. Beck: Because it’s been illegal and continues to be in most of the world, we don’t have the same kind of robust body of evidence that we do for tobacco. However, we do know that there are something like 33 similar toxic components in cannabis smoke that are in tobacco smoke. California put it on it’s Proposition 65, which is its list of known carcinogens and chemicals known to cause birth defects. Health Canada does have a warning, one of its proposed warnings, but people don’t appreciate. They think,“ Oh, cannabis. It’s green. It’s organic. It’s natural. It doesn’t have the chemicals added to it that those evil tobacco companies add into cigarettes.” And it’s absolutely incorrect. It’s the combustion that causes all of those harmful byproducts. So we have a lot of work to do.
I’m quite shocked that I haven’t seen anything yet from the government. I’ve gone to their website, and there is information there, but we need mass and social media. It should have been happening months ago, educating people, because exposure to any kind of smoke is harmful to the lungs. It’s harmful to the heart. It’s harmful to lots of parts of the body.
Senator Pratte: In your statement, Ms. Beck and Ms. Tilson, you mentioned that a public health approach to cannabis regulation should focus on de-normalizing smoking. There are many people who believe that legalizing will normalize not only smoking marijuana but simply using marijuana in any form, with the associated health risks that go with that. I would ask both groups of witnesses: What is your response to this concern that legalization will lead to normalization of marijuana use?
Ms. Beck: We’re absolutely concerned about an increase in consumption, and I think it’s going to be linked directly to how these companies are regulated in terms of what they’re permitted to do with advertising and promotion and what goes on the package and how they’re able to communicate their brands to consumers. With edibles and all of these other forms, I think we are going to see an increase. So, again, it’s going back to public education, which needs to have started yesterday, mass and social media, any possible way. I’ll turn it over to my colleague to expand on that.
Ms. Tilson: Public education for sure, but, in terms of what the companies are allowed to do, this is why we’ve made a number of specific recommendations regarding tightening up what the companies are able to do in terms of advertising and promotion.
We’ve talked a little bit this afternoon about the experience with tobacco control over the last 30 or 40 years, and one of most effective things that government has done is really reign in the way the industry has been able to promote the product, not only through different marketing vehicles but through the packaging itself, the branding. While the legislation goes a long way in that regard — it doesn’t quite mandate plain packaging, but it’s close — there still needs to be tighter controls on what companies can do in order to inhibit the extent to which cannabis becomes normalized.
There is no doubt that the public will have a different perception when the product is legal. The perception regarding how harmful the product is or isn’t will be affected by how widely available it is, the cost, and, again, how these products are able to be marketed. This is where I think this committee has a very important role to play.
Mr. Sweanor: On normalization, let’s be clear. Taking a criminal law approach, making drugs illegal, has not done a very good job of de-normalizing them. We have higher usage of marijuana than smoking among young people. I think contemporary culture — we all grew up with it — plays a huge role in having normalized drugs, but the treatment of drugs as illicit probably normalizes it within the circles of people likely to use drugs.
An interesting example is Portugal, having taken a public health approach saying that they’re all legal. If you’re using a drug, you might be sent for psychiatric counselling, but you’re not going to be thrown in jail. The argument was that, if you do this, everybody is going to be using drugs. The answer was that, actually, it appears that far fewer people are using drugs. You think of us as 17-year-olds. “Hey, I’ve got some marijuana. Do you want to go smoke it at lunch?” If people say, “You could go to jail for that,” we’re really cool. If they say, “You could get a psychiatric assessment for that,” you’re probably going to say no.
We have to look at what actually normalizes and de-normalizes something. I think it’s interesting that, as we come up with alternative products, if we normalize the less hazardous products the way we’ve seen in various markets where there are alternatives to cigarette smoking, we end up with far less use of cigarettes. It’s almost like saying to a teenager, “How about you use this flip phone instead of a smartphone.” There is no interest. As vaping has taken off in various markets, we have seen youth smoking decline very rapidly.
I think we can play various roles in this and, certainly, the idea of information. But, if we’re taking an approach of making a drug illegal while people are listening to contemporary music and comments about drug use, we’re going to lose.
Senator Raine: Thank you very much for being here. I’d like to address my questions to the ladies from the Non-Smokers’ Rights Association. I, too, am concerned about the ambiguity that is potentially in the laws, especially if they’re all different across the country because they will be left to provincial jurisdiction. That is the laws around a landlord’s ability to evict somebody if they’re smoking, prohibiting. We need to look at what’s happening right now in a transition period. Is your organization working on a template that could be recommended to all of the provinces as a type of landlord-tenancy contract that would make it very clear that smoking marijuana or smoking tobacco is or is not allowed on their premises? It’s important. There may be landlords out there that are happy to have people smoke on their premises and others who don’t want it. It should be left up to the investor in the building. That’s point one.
The second answer I want from you is: Would your group be able to pull together information on how to recommend to strata corporations all across the country what kind of bylaws they can put in place that would be enforceable? I know this is an issue that many strata corporations just don’t have the expertise to get right, and I would hope that you would be looking at that.
Could you comment on those two opportunities that you have?
Ms. Beck: Absolutely. As I said earlier, this has been a huge issue for our organization. We actually have a dedicated website, smokefreehousingon.ca, and it is a sister website to similar ones in Quebec, Nova Scotia and British Columbia. I think that might be it at this point.
We’ve never advocated a law that would require landlords to prohibit smoking. We’ve always advocated that there be a balance between demand and supply, and right now the supply is woefully inadequate. But landlords think that it’s discriminatory or that it’s illegal or somehow unenforceable to bring in a no smoking policy.
We do have a template available on our website. There are similar templates on the websites of our colleagues in other provinces because the laws are all slightly different, also for strata corporations as well. There’s information on human rights as well. We have started to talk more about cannabis in those. A landlord can absolutely prohibit any kind of smoking in their building, but, again, we’re being very careful to ensure that we differentiate between vaping and smoking. If people can’t even vape in their own homes, where are they going to consume what they want to consume? I think that’s an important distinction. But there is lots of information at smokefreehousingon.ca.
Ms. Tilson: This is an issue that, as Pippa mentioned, has been at the forefront of our mission for at least 10 years, and it is the issue that has caused the public to contact us more than any other. This is largely in relation to tobacco smoke, but in the last three years the calls have been coming in more frequently in relation to exposure to second-hand cannabis smoke. There has been a lot in the news over the last number of months about landlords being concerned about people smoking cannabis in their multi-unit housing, but the bigger issue is still people smoking tobacco in multi-unit dwellings.
As Pippa mentioned, there are about four provinces that have comprehensive resources. This is not across the country, and Health Canada could play an important role in helping other provinces get the resources.
Senator Raine: You would support separating smoking and vaping. If I walk out of my door and there are three or four people vaping and I inhale the vapour, is that harmful to me?
Mr. Sweanor: Nothing compared to what it would be like having a candle on your table at a restaurant. There have been very good assessments of this done, and though we can find chemicals in vape, it’s at a level that’s so low compared to cigarettes. Igor Burstyn of Drexel University, a Canadian, has published widely on this. There is good information from public health sources in the U.K. Nothing is risk-free, but the risk from exposure to second-hand vape is very low compared to the risk associated with the products of combustion.
Ms. Beck: There have been so many confusing mixed messages in the media. At this point, in terms of vaping and aerosol, we don’t have standardized methods for study, so some scientists are using machines and others are using humans. The machines sometimes overheat and create all these toxins that would never be tolerated by humans, and then they announce there are sky-high levels of formaldehyde in aerosol and it’s going to be super bad for everyone. Unfortunately, we know vaping is significantly less harmful than smoking, but we have a lot of noise to work through, and we have some standardization and methodological biases that need to be sorted out so we can get some better data, because right now, it’s been pretty misleading. But as David said, it’s an order of magnitude less harmful than exposure to second-hand smoke.
Senator Omidvar: Mr. Sweanor, you mentioned almost in passing, I thought, that Bill C-45 is in violation of Charter rights. Could you elaborate on that statement?
Mr. Sweanor: Sure. If we look at issues of being able to vape to get the product and this legislation not allowing that, it’s only allowing a more hazardous route. If we look at the InSite decision from our Supreme Court talking about IV drug use and saying that someone who is using a drug is seen as having a disease, an addiction or a dependence, and if they’re forced to get it in a way that’s more hazardous, then that’s a violation of their section 7 rights, just as with R. v. Smith on marijuana. I’m talking about this having lost electricity in the Glebe today, so I wasn’t able to pull up all the stuff that I would otherwise bring in, so I will do this from memory. I just flew back from Europe, so we’ll see how jet-lagged I am. It was R. v. Smith on marijuana, the ability to get something as an edible rather than have to smoke it, and, again, right to life.
I think we also have the issue of truthful speech. What are we going to allow people to say? It’s very hard when you make one system illegal. It’s the same problems you had with Bill S-5, dealing with vaping and alternative tobacco products. The government is about to make it illegal for a company to give truthful information about the difference in risk between tobacco products. I don’t think there is any question. That’s a violation of the Charter. No matter what somebody thinks of the legislation, it’s no use to anyone if it just gets tossed out.
I think we need to be careful about these things. I’m amazed at the tendency of bringing forward legislation that, to me, on the face of it, is unconstitutional.
Senator Omidvar: My next question is for Ms. Beck. I’m curious, and I couldn’t find the correct answer on the net: When you vape cannabis, does the odour get reduced or go away?
Ms. Beck: I don’t know if I can answer that.
Mr. Sweanor: You can vape a product in a way that no one can tell that you’re doing it. If you talk to experienced vapers, they will show you how they do it. The odour goes away very quickly, and it’s part of the reason that those who are saying we’re going to have a ban on anyone vaping in their own residence — not only can you find no health basis for doing that, there is no real way of enforcement other than having closed circuit television cameras in everyone’s place and being monitored. You can do it so there is no smell as well as being no risk. That’s why people vape on airplanes. They learn how to vape without anyone knowing that they’re vaping.
There are new products coming out. Technology changes. If we look at Calestous Juma’s book, Innovation and Its Enemies, there is constantly opposition to new technology, as we see with vaping and we have seen with refrigeration, printing presses, farm mechanization and everything else. One of the responses when anyone says, “I don’t like something about this” is “Wait two years.”
We have massive markets here. As I say, we have companies in Canada valued at tens of billions of dollars collectively. There is an enormous market for safer forms of THC delivery, just as there is an absolutely gigantic market for safer ways of getting nicotine for people who are smoking cigarettes. We allow innovation to work and we encourage it to move in a certain direction. We replicate what we saw with the 1906 pure food law in the United States. It revolutionized the food business by giving incentives to less hazardous products. In 1938, with the FDA moving on science-based pharmaceutical products, within 12 years, 90 per cent of all the pharmaceutical products sold in the United States were products that did not exist before that law came into force.
I think we have the ability to shape it, and it goes back to the role that policy plays in saying: Where do we as a nation want to go? What can we do to make a better world, and what’s your role in bringing forward the laws that empower that, that grab market forces and facilitate the change that we want to see? We’ve done it so many times. We’ve reduced the rate of automobile deaths by over 80 per cent since the time I was a teenager. That wasn’t a coincidence. That’s policy. We greatly reduced cigarette smoking. That was policy. We stopped reducing cigarette smoking. That was bad policy. We can do these things, and it’s a matter of what sort of incentives do we want to use. What is the power you have as legislators?
Senator Munson: Thank you for being here. In my reporter days in China back in the late 1980s and early 1990s, we talked about the marketing processes. When this country was going through the throes of not allowing smoking in restaurants, in China, they were advertising new cigarettes called “longevity.” I did a story on that: longevity cigarettes. I was just thinking about that. I had a line in one of the stories where I said that in Canada it’s illegal not to smoke in restaurants in China. Why wait? It was quite a sight to see. It still is.
On your chat about the $37 billion and the stock exchanges, there seems to be a lot of conversation about the fact that companies and lots of people are going to get rich, and lots of people who are associated with governments and police forces are now stockholders and so on. But I don’t hear very much about governments and their new tax base. I think governments feel that they will get rich based on what’s coming forward, whether in one year, six months or whatever. What would your view be on using that extra money that the government is going to earn on the sales of cannabis? Should it be directed and used for health and education programs? I know it’s a Catch-22 of some sort, but I haven’t heard very much in terms of witnesses on that issue.
Mr. Sweanor: This is a favourite topic of mine. Governments are a problem. We can use Ontario as an example. We had the Liquor Control Board which is supposed to reduce alcohol use. They are now opening more stores and have self-service discounts and give Air Miles. The government is making $3 billion a year off alcohol in Ontario and putting virtually none of that into treatment programs. They are not giving people adequate information.
Having been involved in suing tobacco companies over the way they’ve behaved, I think the Ontario government on the issue of alcohol, lotteries and casinos and cigarettes, trying to prevent people from moving to alternatives, it is a problem. We have to recognize that governments can become addicted to the revenue. There is inertia. I am very concerned about what is going to happen when we have governments like Ontario saying they want to run the retail business.
I think they should be held to account. When governments are taking money from among the most disadvantaged people in our society, there is an ethical obligation on them to put that money back. There needs to be some way to hold them to account, if they’re taking money from people who are addicted — and I highly recommend reading Addiction by Design about video lottery terminals and keeping in mind who is running those things — if you’re addicting people, you’re taking money from them and money from people who are disadvantaged, low-income people and those who have, in many cases, psychiatric conditions, that’s not general revenue. You need to find a way to give that back, and I think we should indeed be paying far more attention to that and where the money goes. This isn’t a cash cow. This should be a public health approach. What are we doing to make a better society? We’re not doing it to date.
Ms. Tilson: We wholeheartedly agree that a key element of the public health approach is ensuring adequate public information, adequate monitoring and research. There will be enough money in the system because of the new-found source of revenue when this product becomes legal. It is incumbent upon government to direct a proportion of the new revenue to public education.
Senator Bernard: Thank you for your testimony this evening. One of my questions has already been asked. This is for you, Professor Sweanor. We’ve heard a lot about the over-representation in prisons of Indigenous and Black people due to cannabis use and criminalization. Does that mean that there a higher prevalence of use amongst those populations? We could include the poor and other disadvantaged people as well. If yes, how might the public health approach address or redress this?
Mr. Sweanor: Sure. There are various books I really recommend on this, Hari'sChasing the Scream but many others, and I would be pleased to follow up with anyone who is interested.
In many cases we find there is no difference in the use of drugs within different communities. The United States is a very good example of this. If you’re Black or Hispanic, you’re more likely to go to jail for using those drugs. I’ve visited people in U.S. prisons. It is recognized that this is a racist approach. That’s one of the concerns I have when you have discretion. There are things that you or I might do that a policeman would just laugh off, but what if you are racialized, are seen as having an attitude and the police don’t like you for some reason? That’s why I don’t like the criminal law approach. If we each buy 25 grams and you carry mine to the party for me because I want to stop at the hardware store, does a police officer laugh it off or does he charge you and you go to jail for five years? If an 18-year-old passes a joint to a 17-year-and-11-month-old at a high school party, might he be treated differently depending on how the police see them?
A public health approach is saying that there are sometimes different rates of use and there are reasons for that. People use drugs for various reasons, such as entertainment. We seek to alter consciousness, whether that’s jogging or looking at a sunset or sticking a needle in our arm. As a species, we seek to alter consciousness. We do it for various reasons. Sometimes it is for mere entertainment and other times for seeking oblivion. There are different reasons people use drugs. To treat that is as a criminal law issue rather than a public health issue is atrocious. We are seeing huge problems associated with that.
Take someone who is using a drug seeking oblivion because, as Gabor Maté writes in In the Realm of Hungry Ghosts about downtown east side Vancouver, IV drug users are by and large people who are abused as children. They are seeking oblivion, and yet we throw them in jail.
Ms. Beck: We know that tobacco smoking rates among the Indigenous populations are significantly higher than the average rate. The average rate is less than 20 per cent. In many Indigenous communities, it is over 60 per cent. There needs to be more focus on policy work being done in those Indigenous communities with adequate resources directed toward them so they are able to bring into place the same kinds of smoke-free policies and the same kind of taxation policies, the same kinds of policies that are life saving that we have amongst the general population.
We do see the beginnings of self-government in terms of tobacco control, and I would hope that we could focus resources to bring not just cannabis but also tobacco policies into place into Indigenous communities. The smoking rate is higher, and I think there is a correlation between cannabis smoking and tobacco smoking. I fear we will start to see increased rates of cannabis use in First Nations communities as well.
Senator Unger: Thank you for your presentations. You seem to unanimously be promoting vaping over smoking. When you smoke a cigarette, it’s an assault on your lungs. What is the ratio of one tobacco cigarette versus one marijuana cigarette? Do you know?
Mr. Sweanor: In terms of relative risk?
Senator Unger: Yes.
Mr. Sweanor: There are various estimates on that. The ones I find most credible, given the tendency of holding marijuana smoke in the lungs longer, is somewhere in the range of probably three to one ratio. The difference is people don’t smoke 20 marijuana joints a day so the overall health risk of marijuana is less from smoking cigarettes just because of the infrequency of the use.
Senator Unger: So you don’t think one is more toxic than the other?
Mr. Sweanor: I think on a one-for-one basis, the marijuana is going to be more toxic just by holding it in longer. If we’re sitting by a campfire and the smoke is coming and you suck it into your lungs and see how long you can hold, it is going to be more hazardous than trying to avoid the smoke.
Ms. Beck: My colleague said people aren’t smoking 20 cannabis cigarettes a day, but if advertising and promotion are not carefully restricted, we will see start to see changes in patterns of use and more harm to heart and lungs and all parts where tobacco is harmful.
Going back to the importance of public education and restricting the advertising and promotional abilities of these companies to promote their products, that’s going to increase the social acceptability of it.
The Chair: I want to thank Professor Sweanor, Pippa Beck and Melodie Tilson for being with us today and giving us your thoughts about Bill C-45 and about the direction that we’re headed with this piece of legislation.
We will now welcome our third panel today to continue dealing with the health effects of Bill C-45, the proposed act respecting cannabis. I’m very pleased to welcome two very distinguished individuals who are going to speak with us. By video, we have Dr. Meldon Kahan, Medical Director, Substance Use Service, Women’s College Hospital — my favourite hospital; I was born there — part of the Department of Family Medicine, University of Toronto. Here in the room, we have Dr. Sharon Levy, Medical Director, Adolescent Substance Abuse Program, Boston Children’s Hospital. She’s also an Associate Professor of Pediatrics at Harvard Medical School. Welcome to both of you.
I’ll start with Dr. Levy. I’m going to ask both of you to give us about seven minutes of opening remarks, and then we will engage with questions and answers from committee members. Dr. Levy.
Dr. Sharon Levy, Medical Director, Adolescent Substance Abuse Program, Boston Children’s Hospital; Associate Professor of Pediatrics, Harvard Medical School: Thank you for the opportunity to comment on Bill C-45.
As a developmental behavioural pediatrician, addictions medicine specialist and a researcher in the field of adolescent substance use, I’m deeply concerned about the potential impacts of the bill on the health of children and adolescents. I’ve served as the chair of the American Academy of Pediatrics Committee on Substance Use and Prevention, and I’ve been the director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital since its inception in 2000. Over the past 18 years, I’ve evaluated and treated thousands of teens with substantial use disorders. I have personally witnessed the toll of addiction on these young lives as well as on the lives of countless friends, parents and siblings. Drawing from my experience as both a researcher and a clinician, I would like to offer three suggestions regarding Bill C-45.
Number one, prepare the health care workforce by adding addiction medicine and, in particular, pediatric addiction medicine to the list of needed medical specialties in Canada. With the legalization of cannabis, there will inevitably be more youth with cannabis use disorders, resulting in an ever-increasing need for health care providers specialized in youth addictions. Addiction medicine is newly recognized by the American Board of Medical Specialties, and I’m pleased to report that the first physician to acquire specialized training in pediatric addiction medicine in North America is a Canadian who is currently training at Boston Children’s Hospital. However, addiction medicine is currently not on the list of needed specialties, creating barriers for Canadian physicians. Adding it would help enable physicians to develop expertise in the treatment of addictive disorders and also be prepared to lead the field in the future.
Number two, tighten the definition of “cannabis” for legislative purposes. Bill C-45 defines “cannabis” as “a cannabis plant and anything referred to in Schedule 1 but does not refer to anything referred to in Schedule 2.” This definition is too broad. The efforts to legalize marijuana have altered our language such that the word “cannabis” can now be used to refer to any product that contains cannabinoids, from the original meaning of stems and leaves of the cannabis sativa plant to the concentrated oils in cannabis-infused candies. This loophole should be closed, because innovations to cannabis-based products are significant public health risks, and adolescents in particular are more likely to seek novelty and try new products.
Number three, increase the minimum age for purchasing cannabis to 21. Age restrictions can be effective at reducing substance use by youth. Brain development continues through the mid 20s. Setting a minimum age of 21 within federal law will not only push the average age of initiation higher, but the uniform standard will also ease enforcement.
In support of these recommendations, I offer the following observations from my years of clinical practice and research.
Cannabis is an addictive drug that is particularly harmful to developing adolescent brains. Teens that consume cannabis have poorer life outcomes on a number of measures. They have more mental health disorders, including depression, anxiety and thought disorders such as schizophrenia. As a group, they complete less school and are more likely to be unemployed or underemployed than their peers.
As a director of an adolescent substance use disorder program serving youth ages 12 to 24, I regularly work with children and young adults who use cannabis. In fact, more than 90 per cent of my patients have a cannabis use disorder. Almost all of my patients treated for opioid addiction started with cannabis, and most continue to use it heavily. I have treated a number of teen cannabis users who developed schizophrenia right in front of my eyes. I do not know what would have happened to them had they not used cannabis, but the statistics always make me wonder if their lives might have been different had it not been for a completely preventable risk factor.
While frank psychotic disorders are uncommon, psychotic symptoms are under-recognized. In a recent study of healthy teens at our hospital, we found that more than one in four cannabis users reported having at least one hallucination, and nearly one in three reported experiencing paranoia related to their use. Overall, more than 40 per cent of these healthy teens had at least one mental health symptom.
More teens use cannabis when it’s legal. In Colorado, the number of teen cannabis users increased by 20 per cent in the two years immediately following legalization, while falling 4 per cent nationally. As a pediatrician and the parent of two teenage children, I might add, this finding is not surprising. The retail sale of cannabis normalizes use. When cannabis is portrayed as benign, harmless or even healthful, more teens try it and more use it heavily.
As the director of the Pediatric Addiction Medicine Fellowship training program in Boston, my impression is that the health care system in Canada, as in the U.S., is not adequately prepared to provide appropriate treatment for teens who do develop cannabis use disorders. This problem stands to become much worse after legal sales of cannabis begin.
Over the course of my career, I have seen an evolution in the presentation of cannabis use among my adolescent patients that has corresponded with shifts in the types and strengths of cannabis-based products available. Plants have been selectively bred to increase their THC content, and edible products and highly concentrated oils — which were not available 20 years ago, and by the way, are nothing like the plant material that parents might think of when they hear the word “cannabis” — are now commonly used by teens. With these changes, I see more teens with mental health symptoms and also more chronic vomiting. When I started practising years ago, Cannabinoid Hyperemesis Syndrome was something you could read about in a textbook. Now I see it frequently.
These changes are a direct result of the liberalized cannabis policies in the United States, and industry has been enabled to experiment and create better-selling products, which typically are more addictive and usually more harmful. New-and-improved is tried-and-true marketing technique that encourages both experienced and new users to buy more products. But in the case of addictive substances such as cannabis, it’s harmful, and teens pay the highest price. New regulatory approaches for addictive substances that restrict this type of development are desperately needed.
Bill C-45 would prohibit the sale or marketing of cannabis to adolescents and young adults under the age of 18, but this approach has failed in the past. Marketing restrictions are of limited utility tested against the potential for substantial profits. While it is illegal for tobacco companies to market cigarettes to youths under age 18, the familiar story of Joe Camel is a good example of how pernicious advertising can be.
Raising the age limit and tightly restricting product development are among the best ways to protect children from the industrialization of cannabis.
Thank you for your time and attention to these important issues. I would be happy to provide more information on the impact of marijuana legalization on adolescents, and the best way to get in touch with me is via email.
The Chair: Thank you very much, Dr. Levy.
Dr. Meldon Kahan, Medical Director, Substance Use Service, Women’s College Hospital, Department of Family Medicine, University of Toronto, as an individual: It is an honour and privilege to present to the Senate committee, and I want to thank Dr. Levy for an excellent presentation that is consistent with the message I want to give.
I have practised addiction medicine in Toronto for 34 years. I’m actively involved in policy and medical education. I and many of my colleagues have serious concerns about the impact of this legislation on public health. I will briefly summarize these concerns and propose some solutions.
The major concern is that cannabis use will increase both among those over 18 and those under 18. As Dr. Levy said, with legalization, cannabis will be easy to obtain: you simply need to go to a store. It will be inexpensive; apparently, it will only be $10 a gram. It will be socially acceptable, and kids will be able to use it, presumably, in their parents’ basement, and it will be perceived as safe by the public. These are all consequences of legalization.
Cannabis use will increase not just among those over 18 for whom it is legal, but it will increase in the underage group too. Eighteen-year-olds will sell to 17-year-olds. Why wouldn’t the 17-year-old want to buy it from an older friend when he gets a legal, pure product of known potency? Illicitly grown cannabis will decline in price to compete with the market for legally purchased cannabis. In other words, the legal and black market will feed off each other, just as they do with opiates where you have legal products mixing with illegal ones.
In California, there is good evidence for this. For youth who are entering a cannabis addiction program, the major source for their marijuana is medical marijuana card holders. In other words, they buy it from people who purchase it legally.
This has been well shown in Colorado. There is a survey of over 5,000 Colorado college students. Of those above age 21, 40 per cent of them reported using cannabis in the year before legalization. After legalization, 61 per cent of those over 21 reported use — a 21 per cent increase. But there was also a large increase in those younger than 21, which is the legal age in Canada. It went up from 45 per cent to 53 per cent, showing that legalization with an age limit increases use even among youth who are under age.
Along with legal use, many people will use it without harm, but there is no question that cannabis-related harms will increase. This has been shown for all substances: alcohol, opiates and tobacco. When population use increases, harms increase. This has also been shown in Colorado, where visits to the emergency department by adolescents under the legal age for cannabis-related harms increased from 1.8 per thousand visits before legalization to 4.9 per thousand visits after legalization.
So what are some suggestions for change? I really believe, as do many of my peers, that the legal limit should be increased from 18 to 25 years. Twenty-five is an age which is shown to be where the brain is fully matured and there seems to be somewhat fewer harms from cannabis after that age. That increase in age will make it more difficult for youth to use cannabis. In the 18-to-25 year group, it won’t be legal, and the 16- to 17-year-olds won’t be able to purchase cannabis from their friends who bought it legally from a store, and the black market won’t have to compete with the legal market and lower its price. I think we have to realize that there is no way this legislation will get rid of the black market. If anything, it will increase it, and that is because cannabis is really easy to grow and cultivate. It doesn’t require any sophisticated machinery or anything like that. If we make the age 25, this will send a powerful public health message to youth that cannabis use is dangerous and should be avoided.
I also suggest that there be limits on the amount and potency of cannabis. Harms of cannabis are related to the THC percentage in the cannabis, and also the amount. Current law allows for the purchase of up to 30 grams at a time with no limit on potency, so companies are cultivating plants that contain 25 per cent of THC or higher. As Dr. Levy alluded to, back in the 1960s cannabis had concentrations of THC of around 3 per cent. We are talking not about a harmless plant but a drug, and we know that the harms of cannabis are very much related to THC percentage in terms of impairment of cognition, perception, motor skills and risk of addition and psychiatric illness.
We would suggest that there be limits put on cannabis, perhaps of no more than 15 grams for a single purchase and a maximum of 15 per cent THC concentration, or maybe even a higher cost for higher-THC potency, as we do with alcohol. That is, a bottle of whiskey costs a lot more than a bottle of beer.
Finally, this may sound paradoxical, but the penalties for selling cannabis in C-45 are really harsh and seem to contradict the whole aim of the bill, which is to avoid the criminalization of youth and ruining people’s lives. With this legislation, they are talking about putting people in jail for up to three years for selling what is basically a legal product. It really doesn’t make sense and doesn’t seem just, and this will destroy young people’s lives and defeat the purpose of the legislation.
In summary, we think this legislation will cause a significant amount of public health harm. It will increase cannabis use and increase cannabis-related harms, and these harms could be mitigated by raising the legal purchase age, by limiting the amount and potency of the purchase and by reducing penalties for cannabis selling.
Thank you very much.
The Chair: Thank you both.
Senator Petitclerc: Thank you both for your presentations and knowledge. I do want to go back. I want to hear a little more on the age limit that you’ve mentioned, because both of you have said that 18 is not the age that you would suggest, but this is the legal age that is suggested in the bill. We’ve heard from many that while everybody agrees that the brain is vulnerable until 24 or 25, 18 is what, if I may say, “logistically” makes sense, because it aligns with adulthood for many reasons. We have seen and read about many medical associations and organizations that do support 18 or 19, and yet you support 21 or even 25.
First, what do you say to those who say that it needs to align with the adulthood legal age of buying alcohol or other things, and those who say that those over 18 will go to the illicit unregulated products if this is the age that we choose? How important is that older age limit in your medical opinion?
Dr. Levy: I would say that the older the better. I had suggested 21 because there are some precedents for using 21, but from a medical point of view, I think 25 would be better. You could say, “Well then, 18-year-olds will go to the illicit market,” but if you set it at 18, you can say that 16- and 17-year-olds will go to the illicit market. Wherever you set the limit, you will have that as an issue.
As a developmental pediatrician, I can tell you that adolescence, although it has always been part of human nature, is only recently recognized. The law has not always gotten it right. Particularly these days, when adolescence is often more drawn out — people aren’t typically more independent until their early 20s — 18 is simply the wrong age. We’re still seeing very adolescent behaviour in kids of that age group, and I think it might be a historical mistake that 18 is set as the age of adulthood.
Dr. Kahan: I don’t think the logistical issue is that hard to overcome. Presumably, you simply present proof of age. The various associations promoting this are not necessarily reflective of the opinions of people who actually work with adolescents and with addicted patients. I feel there is a unanimous concern among my colleagues about the harmful impact of this age limit.
Is there an inconsistency? Yes, I guess, but so what, if it’s going to benefit the public. I really don’t think these medical associations are really speaking for the broad number of experts who work on the ground.
Senator Seidman: Thank you both very much for your presentations.
You both have been very clear that the evidence shows that after legalization, with social acceptance, both the proportion of users and the frequency of use will increase. I’m pretty concerned, hearing that, that there has not been any attempt to limit the dose and THC concentration of medical cannabis. Both of you addressed this issue.
We’ve heard that cannabis is safer than alcohol, for example, or other drugs, because it’s impossible to overdose. Is that really true? Also, would it be better if the government set limits on the amount of THC in all cannabis products? Perhaps I’ll start with Dr. Levy, and then Dr. Kahan could follow.
Dr. Levy: I agree with Dr. Kahan entirely on this. It is not impossible to overdose on cannabis. We have seen it in very young children who can develop respiratory suppression, but it is very rare, honestly. Nevertheless, that is just one marker of harm. You really can’t overdose on nicotine, and yet cigarette smoking is not considered a safe health behaviour. The real concerns with cannabis are the more chronic harms: the increases in poor life outcomes and in mental health disorders.
The type and the concentration of THC in the products is very much tied to the rates that we see these problems occurring at — the rates of addition, mental health symptoms, mental health disorders. All the negative outcomes are very much tied to it. We are already seeing, in the United States certainly, a changing presentation as we see the drug change.
The other issue is that once a product becomes industrialized and there is an industry that’s ready to produce all different types of it, you get these new products that are very intriguing to new users. That’s particularly risky to kids, who are the most likely to try new products. Typically those products are attractive to them, even though they aren’t supposed to be.
For all those reasons, it really behooves the Senate to consider tightly restricting the concentration of THC in the product and also the types of products and the types of paraphernalia that will inevitably go along with the products that are allowable.
Senator Seidman: Do you have something specific to recommend in terms of the restrictions around the limits and the level of THC?
Dr. Levy: One thing that would be important would be to go back to a more standard definition of what cannabis even is. Again, it is plant material you are talking about. Historically, back in the 1960s, as Dr. Kahan noted, the level of THC was 3 to 4 per cent. Nowadays, it is much higher. I don’t know the right level. I just point out that allowing the level to increase is concerning.
Dr. Kahan: It’s important to note parallels between what the cannabis industry is doing now and what the tobacco industry and the opiate industry did. Tobacco deliberately increased the concentration of nicotine in their product to make it more addicting. The opiate manufacturers did a similar thing. There is no question that cannabis manufacturers are making products way beyond necessary in terms of any medical or recreational use, and they are doing it specifically to make their product more attractive to youth. There is no other explanation why they are coming up with these incredibly dangerous potent products like 25 per cent. I think it’s time for us to take a stand and face up to the industry while it’s still fairly young and maybe more vulnerable to regulation.
We can note that the studies indicate that medical marijuana uses concentrations no more than 9 per cent THC, so perhaps the recreational level can be something like that — or 12 per cent. It’s something one can argue or discuss, but it should be much less than 25 per cent.
Senator Pratte: Thank you, Dr. Levy. First, I would like to clarify something. You mentioned that when cannabis is legal, more teens use cannabis, and you mentioned the case of Colorado two years after following legalization. The data I had seen for Colorado, coming from the National Survey on Drug Use and Health, showed an increase and then a decrease — 12.6 in 2013-14 down to 9.1 in 2015-16. So there seems to have been an increase and then a decrease. The state of Washington saw the same phenomenon: an increase and then a slight decrease for 12- to 17-year-olds. Can you clarify where your data come from? Maybe it's from a different source.
Dr. Levy: I have a referenced version here that comes from the Rocky Mountain High Intensity Drug Trafficking Area that’s referenced in here.
It’s always complicated to make assessments. There is more than one influence on youth marijuana use rates. The empirical evidence is actually pretty strong with legalization and particularly with commercialization. It’s not just that a law is passed but that these products are out in marketplaces and people can buy them.
One thing that has been very consistent that we have seen across the United States is a very substantial drop in perceived risk of harm, and that is one of the best harbingers of future use and not only future use but future heavy use. So more kids use, and, among the kids who do use, more kids will use very heavily.
There are other influences. These numbers we took out of the report that was done by the government in Colorado, but there are certainly other influences on youth use rates that some of them counterbalance. But, again, I think that, when you look at the empirical data overall, young adult use has increased the most. Then, there have been some increases in 12 to 17 year-olds as well, and then, when you look at the perceived risk of harm, that’s dropping pretty drastically. That is going to have big consequences.
Senator Pratte: I’d like to go back to the age issue, 18 years old. I ask my question to the other witness also. Dr. Levy, you seem to be saying that 18 being the age of majority, or 21 in most states, is maybe an arbitrary date, but whatever. Here it is 18, where, for instance, youth can drive a car at 16. Eighteen is the age of majority for most decisions. You can be in the army at 17. So 21 or 25 would be seen as arbitrary because we, for many years now, have decided, as a society, that 18 was the age where you could make those kinds of autonomous decisions. So why not for cannabis?
Dr. Levy: Well, I think that, as you’re pointing out, there actually already is a graded system. You’re allowed to drive a car at 16. You’re allowed to join the army at 17. At 18, you get other decisions, including alcohol consumption. It doesn’t all happen at once. I think many of those ages have been set fairly arbitrarily. The suggestion to push the age limit higher is really one to protect the public health because the scientific data is so clear that the developing brain is really at risk from marijuana use. This age range from adolescence into early adulthood is when people become addicted to substances, particularly marijuana. The people who experience the greatest harms are those who are using in this age range. So anything that you can do to delay that age of initiation is protective of the public health.
The Chair: Do you have anything to add to that, Dr. Kahan?
Dr. Kahan: I think it’s important to note that cannabis is a drug, and we put a lot of limitations on drugs. Cannabis use is not a right the same way that driving or voting are rights. We make use of cocaine illegal at any age, so I don’t see why we can’t say that, from a public health point of view, it’s dangerous for youth to use cannabis and that we are, as a society, going to protect our youth, protect our families, and are going to put this age limit on. I think it’s a misconception to say that cannabis use or use of heroin or any other drug is a universal right.
Senator Omidvar: I just want to make a point that, in fact, Dr. Kahan, there are limits to THC proposed in the regulations. I had it right in front of me, but I’ve lost it. But I do think it’s important to note that the regulations do state certain limits for THC, dried cannabis, cannabis in capsules, cannabinoid, et cetera.
My question, though, is: You’re proposing that the legal age of access be 25, and yet we know that it is people under 25 and under 19 that are very heavy users of cannabis. Would we not then be driving them into the black market even more so? This is the concern I would have.
Dr. Kahan: I think that the black market is going to expand greatly with legalization because you’re going to have a lot of people who are selling cannabis to youth, to those under 18 or whatever the law is. I think, overall, legalization will increase cannabis use among those less than 18 or less than 25 or whatever is limited. It’s not going to stop the black market. It will enhance the black market, and that’s been shown with other drugs as well, like opiates. The fact is, like I say, it’s so easy to grow cannabis and sell it, so the idea that, somehow, you’ll get rid of the black market with this is simply not true.
Senator Omidvar: But if you’re taking a health-centred approach to legalization of cannabis, don’t you think the provision of safe, tested, potency-labelled cannabis, with clear warnings of health risks, sold in a highly regulated and controlled environment is eventually safer and healthier? Because they’re going to do it regardless. They’re going to get it the other way from the black market. I’m having a bit of trouble with this.
Dr. Kahan: I think that cannabis legally purchased that contains 25 per cent THC, like the products that they’re making now, is actually more dangerous than street cannabis that has less, like 15 per cent THC. They’re the same drug; they’re the same plant. The potency, though, is what determines the danger.
I’m sure you’re right. I looked through the legislation, and I didn’t see any mention of limits. I only saw mention of amount.
Senator Omidvar: It’s in the regs. My apologies. They are in the regs.
An Hon. Senator: There are no regs.
Senator Raine: They’re not done yet.
The Chair: There are proposed regulations that the government has put out for discussion purposes. Those are not part of the bill, but they will follow the bill and will be put into place, according to the government, at the same time as the bill is put into effect. That is one of the reasons they’re asking for an 8 to 12 week period following adoption of the bill before they get those regulations into effect. They will cover THC.
Senator Omidvar: Perhaps Dr. Kahan would look at those proposed regulations and give us his comments on those.
Dr. Kahan: Sure, I’d be very pleased to look at them.
Dr. Levy: I would add that we see patients that are 13, 14 years old all the time. So, wherever you set the cut-off, you will have younger kids who are trying to get it and have to access it illegally.
The other point I would make is that commercializing tobacco and having people buy it from the stores didn’t make it any safer for youth or for public health.
Senator Raine: I would just ask if both of our panellists today — and thank you very much for being here — would comment on the distribution systems that we are having in Canada versus your experience, because we are now going to have a patchwork effect of different regulations and different age groups and different systems of distributing across our country. I’m wondering if you have any comments on that.
Dr. Kahan: I think that, if the provinces have different age limits, that is going to create difficulties. If Alberta’s limit is two years younger than B.C.’s, then people will move from one to the other to purchase their cannabis and come back. I think it would be better if there were some common consensus among the provinces. Maybe there will be. I really just don’t know.
In terms of the distribution system, I’m only familiar with Ontario’s proposal for sort of stand-alone stores, similar to the LCBO liquor stores but that will only sell cannabis products. I think that, regardless of how you distribute them, they are going to make it much easier for people to get cannabis, and that’s the bottom line and the harm of this legislation.
Dr. Levy: The distribution system, as I understood it, is a combination of public and private access. Is that right? There are some state distribution centres as well as private shops?
The Chair: It depends in which province.
Senator Raine: I might add that at present, medical marijuana is accessible by mail as well as in stand-alone shops in some provinces and regulated distributors in others. It’s very complicated. I’m wondering if you have any comments on that and if you understood what happened when they legalized marijuana in Colorado and Washington. How did they do it, and does it work?
Dr. Levy: One of the points we’ve argued for in various American states, where it really is a patchwork, is to use a public distribution system, like that for alcohol. Some states still use that system, and there’s a better ability to regulate. There’s a better ability to restrict the profits people might go after, and so I think that that’s a better system.
My understanding was that there was concern that if it was strictly a public system, that there might be competition in dealing with the black market, and I honestly can’t imagine that that’s a realistic concern because I think that if people can get legal cannabis, overwhelmingly they will. I don’t think that they’ll be uninterested in cannabis unless it’s in a private shop.
[Translation]
Senator Mégie: My question goes to our two witnesses. In your practice, you see young patients who are already identified as cannabis users. Now, with legalization, you may be seeing other children who do not declare that they are users because it is illegal. Once it is legalized, people from 18 to 25 will be comfortable making the declaration, which will result in an increase in the rate of positive declarations, of people who are users.
What impact could legalizing cannabis have on research? As there would be more declarations in the number of users, since not all users declare themselves as such, could legalization help to provide more reliable data that would allow us to go further with our research into the adverse or positive medical effects of cannabis?
[English]
Dr. Kahan: I think it’s possible that people will be more willing to disclose their cannabis use on research studies. I don’t know if that’s much of a justification for putting in a law that I think will substantially increase the use of cannabis, and I think there will be harms from that.
I can tell you one thing about people reporting to their doctors about cannabis use. The youth I see are militant that cannabis is a harmless herb and, if any kind of attack on it or advice to cut down is seen, they’re fiercely resistant. They’re parroting a message that they’re getting from the media and the public, sometimes from other doctors and certainly from the industry that cannabis is a safe product and that any concern about it is overblown and is part of the war on drugs. I think that legalization is going to make that problem worse. Canada is certainly perhaps the most pro-marijuana country in the developed world, and that is a very big problem that is accompanying this legislation.
Dr. Levy: I agree with Dr. Kahan that that is a very minor benefit. Also, if you’re looking at research, there is very good evidence that when you’re doing research and allowing people to respond confidentially, that’s considered to be the criterion standard regardless of whether it’s legal or illegal behaviour.
I would also say, in this day and age, that although we still use survey data and it’s still important, we’re moving to other mechanisms: things like social media and big data, and in the future that will be where we get this information from at any rate on a population level.
Senator Unger: Thank you to both of you for your presentations. They were clear and succinct and I agree with everything you said.
Dr. Levy, I have a question for you about your statement in which you talk about treating teen users of cannabis. You say, “They developed schizophrenia right in front of our eyes, and who will ever be unable to care for themselves.” Could you elaborate on that, please?
Dr. Levy: Yes. I have seen a number of adolescents who have come in typically as younger kids, say 13, 14 or 15 years old, who are already using marijuana heavily and have then gone on to develop the symptoms of a psychotic disorder and who have needed treatment for their whole lives. They have been unable to live independently, and their parents have had to file with the Department of Mental Health Health in the state to really keep guardianship over them even well into their adulthood.
Now, we don’t know who was going to develop schizophrenia and who wasn’t, but I have seen kids come in who didn’t have much of a prodromal history who started developing symptoms after they were using cannabis. There is a very strong association between cannabis use, particularly during adolescence. The best estimate is about a six-fold increase in the development of psychotic disorders.
Some publications, including The Lancet, have said there is enough information to say there is at least some causal component of cannabis use. A little bit more is understood now of the neurobiology, and we know that cannabis users have some of the same deficits that patients with schizophrenia have on brain scans. It’s very concerning.
Senator Unger: I would like to ask about another study related to this topic. It concerns brain changes being associated with casual marijuana use in young adults, and the focus has always been on older teens and those aged 20 to 25. This is a study that was done in the Journal of Neuroscience, and it talks about the brains of much younger children being altered, in particular the two areas of the brain dealing with desire. It does show from MRIs and autopsies, after the fact, of course, that brain’s amygdala and nucleus accumbens are changed, and they are the areas involved in reward processing.
So even younger, we’re having a debate about whether it should be age 25, 21 or 18, but this is talking about children, literally. So to me, I would like to see age 25 be the number. Age 21 would be acceptable rather than age 18. I really have a problem with children being able to use this drug.
Dr. Levy: I agree.
Senator Unger: I really didn’t have a question. I’m sorry.
The Chair: I thought you might want a response.
Senator Unger: If there is one.
Senator McIntyre: Thank you both for your presentations. My question has to do with the negative mental health impacts of cannabis. As noted by both of you in your presentations, individuals may experience anxiety or even psychotic symptoms after using cannabis, particularly for inexperienced users or those with pre-existing mental health problems.
I agree with your presentation on that issue. For 25 years, I acted as chairperson of the New Brunswick review board. There is a board in every province and territory. In a nutshell, the board deals with individuals who are suffering from a mental disorder and commit a criminal act. Under the law, they’re charged and, in most cases, are found either unfit to stand trial or fit to stand trial but not criminally responsible on account of mental disorder. They are either remanded in a jail setting in a psychiatric ward or released into the community pending a disposition hearing by the board. Ninety per cent of the cases I heard as chairperson of the board were related to the usage of marijuana. In other words, they were vulnerable to the negative mental health effects of cannabis.
We know that THC may increase symptoms. You have read Bill C-45. I don’t know how the bill will manage the negative mental health impacts of cannabis, but the bill does talk about awareness campaigns. Is the information concerning the effects of THC too scientific for a public awareness campaign?
Dr. Levy: I would say no. We’ve advocated strongly in the United States that health care providers really give a clear and consistent message that non-use is best for health. That’s a very easy message to spread. It’s certainly my experience in teaching kids and parents that it’s a fairly easy point to make. It’s a good question, because the strict “non-use is best for health” message can feel too perfunctory for kids, so we’ll often go a little deeper with our patients who are already begun using. The message can be boiled down in a way adolescents can understand.
Senator McIntyre: In other words, we need to find ways to deal with the negative mental health impacts of cannabis. That’s the bottom line, as far as I’m concerned.
Dr. Levy: That’s right. Also, one of the points I made was around increasing the addiction medicine resources and increasing training for physicians and other health care professionals who will take care of these kids. It can be quite challenging as a family to find someone who knows what to do when they have a child who has this problem.
Senator McIntyre: Dr. Kahan, do you wish to elaborate?
Dr. Kahan: No. Dr. Levy described it pretty well. I don’t have anything to add.
Senator Munson: Thank you very much for being here. We’ve heard a lot of concerns, and we do have a lot of concerns. I’m sure there will be amendments from the Senate to this bill, but whether we like it or not, legalization is going to take place in this country sometime in the future. Some of us would like it to slow down a bit.
Dr. Levy, you teach in Boston. You’re in pediatrics, and you have concerns. I just went to the website. We’ve been talking about Colorado, but a headline in the Boston Globe is “Everything you need to know about Massachusetts’ new pot rules.” It’s coming soon to your theatre, where you can buy it. They’re talking about medical dispensaries and so on. It will be taking place in Massachusetts soon. Can you give us the feel in Massachusetts today from the medical community’s look at it? Perhaps it may be unfair, but what about the political community and just the overall community of the state?
Dr. Levy: In Massachusetts, legalization was passed by ballot initiative, by the population voting for it. The medical community had come out loudly and strongly against the proposition. It won anyway. Its proponents actually had a lot of money to spend campaigning for it, and it was largely portrayed as an issue around civil liberties.
That’s unfortunate, because we’re presented with legal versus illegal as a black-and-white, and I don’t think it really needs to be that way. There are many points in between. This hearing is about finding the points in between where it might be legal but you really prevent the far end of the spectrum that allows an industry to take control. We’ve seen it before. We’ve seen it with tobacco and opioids. We’re really risking going down the same pathway again. If we’re creative about restricting what you can do with the product, how much you can develop it and how much profit you can gain from it, we may be able to avert some of those tragedies.
Senator Munson: As a supplementary, Dr. Kahan, you said that Canada is setting a bad example. What about Massachusetts?
Dr. Kahan: In Canada, we’re really out on a limb internationally. Our per capita use of cannabis is already among the highest in the world, despite the previous laws we’ve had. It’s because we’re such a pro-cannabis country. It’s a general perception that cannabis is safe, enjoyable and cool. This message is being reinforced in the media and, I think, very unfortunately, among a group of doctors who give false statements about its medicinal effects. I think this law is going to enhance that perception.
I think we’re going to regret it if we just allow easy access to cannabis among 18-year-olds. I think 10 years from now, we’ll have newspapers filled with horrible stories of the kind Dr. Levy has described of young people and their families who have been harmed. I really hope this committee can put some kinds of mitigating factors in place to prevent that. The whole goal of the legislation was to stop harm from criminalization of it, and as Dr. Levy said, this could have been done in ways that didn’t involve outright promotion of cannabis.
The Chair: We are going to our last question.
Senator Poirier: Thank you for being here. In speaking with different people over the last months about the cannabis bill, I came to realize that there seems to be a perception out there that there is no danger in taking or smoking cannabis and being out there and driving. At first, it was among some of the youth that I was hearing this, but I’m even hearing it among some adults lately. They don’t see the danger of it. They would not drive with someone who has drunk alcohol, but they don’t see the danger when they’re smoking cannabis. I know you work with people who have had cannabis issues and addictions in the past. Do you feel that somebody smoking cannabis or under the influence of cannabis is safe at the wheel and driving?
Dr. Levy: Absolutely not. There is good empirical data that backs that up. People who are regular cannabis users often feel they are better drivers. There is a reason for that. Because of the way cannabis affects the brain, they feel more confident. Their actual skills are poor. We’ve seen it in the United States. The rates of car accidents go up.
The Chair: Dr. Kahan, you have the final word on this.
Dr. Kahan: There is no question. They’re continuing to do studies on it, but the risk of cannabis-related car accidents goes up with the amount consumed and the amount of cannabis in the blood. There are good experimental and case-controlled studies to show that cannabis unquestionably impairs driving ability and is a risk factor for fatal accidents. The combination of cannabis and alcohol is even worse than either alone.
The Chair: Thank you very much. I thank both Dr. Levy and Dr. Kahan for being part of our discussions and dialogue today.
(The committee adjourned.)