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125 such practice knowledge that its conclusions about effects are often mistaken, when subjected to the harsh test of well-designed outcome and impact studies. It would be advantageous, with respect to cannabis policy, and for that matter policy on all psychoactive substances, to move to an ‘evidence-based’ standard of policymaking. This requires a substantial investment in developing the evidence on which the policymaking can be based.
Some specific lessons from alcohol and tobacco
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One option for such regulation is a kind of prescription or permit system, issuing licences to individuals to purchase cannabis. This could be a system organised with physicians and pharmacists as the gatekeepers, like prescription systems for psychoactive medications. Such a system, with a mental health screening component, might be adopted if there is a major policy concern about cannabis precipitating schizophrenia.
But it seems more likely that a more bureaucratised system, as for driver’s licences, would be adopted. Sweden’s ‘Bratt system’ for alcohol in the decades before 1955 had a version of such individualised controls (Frånberg, 1987).
A second option is a rationing system, which allots a maximum purchase amount to the purchaser in a particular time period. The Swedish Bratt system included a rationing system, and there are also some more recent examples of alcohol rationing (Schechter, 1986).
A third option is a government monopoly system, where the state monopolises one or more levels of the production, distribution and sale of the substance. Such monopoly systems presently exist for alcohol in 18 US states and all Canadian provinces (though only a few of the states and nine of the provinces have monopoly stores at the retail level), as well as in all Nordic countries, except Denmark. There have been state monopoly systems for cannabis in India, and monopoly systems for opiates were a feature in the Asian territories of the empires of the first half of the 20th century (Brook and Wakabayashi, 2000). The medicinal cannabis office set up by the Dutch government may be seen as a similar monopoly. There is a recent Canadian proposal for government shops to take over the sale of tobacco (Callard et al., 2005), and there have also been proposals in Canada and in the US northwest for cannabis to be legalised for sale in government alcohol stores.
The fourth option is a licensing system, where private commercial enterprises are licensed to sell the product, with the licence conditional on the seller abiding by the rules of a regulatory system. Such a system is common for alcoholic beverages, as an alternative to a government monopoly. A licensing system is used in the Netherlands to regulate the ‘coffee shops’ that allow non-criminalised retail purchase of cannabis (see Korf, this monograph). Specific licensing systems for retail tobacco sales have become common, for instance, in the USA in recent years (www.healthpolicycoach.org/doc.
asp?id=3147).
Is a rationing system effective?
There is good evidence that rationing systems for alcohol hold down the levels of problems from alcohol, whether in terms of violence (Schechter, 1986) or long-term
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Is a government monopoly system effective?
It has been shown that government monopoly of retail sales can be quite effective in holding down retail sales of alcoholic beverages (Her et al., 1999). The effects are partly through associated characteristics which have been shown to be effective in holding down sales: limitation of the number of sales outlets, and limitation of hours and days of sale. Government management of the system also results in more professionalised employees, less likely, for instance, to sell to those who are under legal age. And it removes the private profit motive, which tends to drive consumption upwards, not only in terms of sales promotion but also in terms of political influence from private actors to loosen restrictions in availability (Room, 2001).
Do taxes on psychoactive substances affect the amount of consumption?
As already indicated in Table 2, the answer to this from both the tobacco and the alcohol literature is an emphatic ‘yes’.
Can regulatory policies affect the potency of the psychoactive substance used?
The answer to this question is clearly ‘yes’. At least a dozen US states, for instance, ban Everclear spirits, a product that is 95 % pure ethanol. The legal availability of lesser-strength alcoholic beverages (including regular-lesser-strength spirits) means that there is no substantial black market for Everclear.
Prior to 1915, spirits were the main form of alcohol consumed in all Nordic countries.
By the 1980s, the main form was beer (wine has now replaced beer in Sweden as the most used form in terms of alcohol content). The changeover from spirits to beer was accomplished very quickly in Denmark by a swingeing tax on spirits imposed during the First World War (Bruun et al., 1975). In other Nordic countries the change was more gradual, accomplished partly by differential taxation and partly by making low- and middle-strength beer more widely available than other alcoholic beverages.
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Whether a more potent form of the psychoactive substance is more harmful than a less potent form is an apparently easy question to answer for alcohol, in the sense that most of the harm from drinking alcohol comes from the psychoactive ingredient itself.
Nevertheless, it can be questioned how much effect the Nordic political effort to channel consumption toward beer and wine and away from spirits had on alcohol-related problems. The political intent was to moderate drinking customs along with the change in beverage, but there is little evidence that this happened. At least in the short run, the
‘trouble per litre’ of alcohol did not decline when beer was made much more available in Finland in 1969, and consumption rose by about 50 % (Mäkelä et al., 1981).
For tobacco, as for cannabis, the issue of whether greater potency is more harmful is obviously more complicated, since much of the harm results not from the psychoactive ingredient but from what accompanies it, particularly in smoked form (tars, carbon monoxide). Thus, low-nicotine, high-tar tobacco cigarettes are likely to cause more health harm than high-nicotine cigarettes, since the smoker will get more tar and carbon monoxide in the course of reaching the same level of nicotine. Analogously, it should not be assumed that a higher THC content will be more harmful.
Interacting with the issue of potency is the issue of mode of ingestion. It is likely that there is less risk to health from eating or vapourising marijuana than from smoking it. However, for licit as well as illicit psychoactive substances, there is relatively little systematic knowledge on the effects in a population of measures designed to favour one mode of ingestion over another. Often policies are made on the basis of vague fears rather than systematic knowledge. For instance, the Swedish form of snuff, known as snus, is banned for sale in the European Union, other than in Sweden, on the grounds that it is a health hazard. There are good public health arguments for promoting the use of snus as a much less harmful alternative to smoking cigarettes, although these arguments are also disputed (Gilljam and Rosaria Galanti, 2003). But at present the European legal system considers that it must make decisions on whether snus should remain banned on the basis of suppositions.
Snus is much less deadly than smoked tobacco ... [But] one cannot conclude with certainty whether offering snus on the market would principally have the effect of encouraging smokers to stop smoking (a ‘substitution effect’) or of facilitating, on the contrary, the path towards consumption of tobacco (a ‘passage-way effect’) ... The insufficiency of data and the scientific uncertainty [is about] the supposed behaviour of the public. The question which poses itself is that of knowing if, in these circumstances, the ban on snus can be considered as a protective measure efficacious for public health.
(Geelhoed, 2004; translated from French version)
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Can regulatory policies affect the location and circumstances of use?
Again, the answer to this is clearly positive. One result of prohibitory policies is to push consumption into private or semi-private places. The Dutch coffee shop model of limited cannabis availability in designated places may be seen as holding down the public nuisance from cannabis smoking (see Korf, this monograph).
Again, however, the issue of which locations of use are more harmful has turned out to be complicated in the alcohol field. Drinking in streets and parks is usually seen as increasing the nuisance for others (Törronen, 2003), but the perception has varied at different times on whether drinking in a tavern or restaurant is more or less harmful than drinking at home. On the one hand, control laws in US states at repeal of prohibition often forbid sale of ‘liquor by the drink’, since at that time the ‘old-time saloon’ was defined as the seat of most alcohol problems. But when ‘liquor by the drink’ was finally allowed in North Carolina, no effect on alcohol-related harm statistics could be detected (Blose and Holder, 1987). On the other hand, Finnish authorities in the 1970s presumed that drinking in a bar or restaurant would be more restrained than drinking at home. But in fact, Partanen (1975) found that the empirical results in Helsinki were the opposite: ‘people do not drink any more at home than in a restaurant, but they do it in a more leisurely manner, which seems to lead to a lower degree of intoxication’. The issue of the harm associated with specific circumstances of use should be treated as an empirical question rather than a matter of ‘expert knowledge’.
What about the impact of the European single market and of trade agreements and disputes?
The prohibition on cannabis sales under the international drug control regime is presumably primarily responsible for the fact that there have been so far no challenges to any legislation that discriminates, for instance, between cannabis grown in the country and imported cannabis. Such challenges have been a regular occurrence for both tobacco and alcohol, and both the single market mechanisms of the European Union and the trade agreements administered by the World Trade Organisation have created substantial difficulties for alcohol and tobacco control regimes (e.g., Room and West, 1998; Taylor et al., 2000). The new Framework Convention on Tobacco Control may help to remedy this situation, but the issue of whether it overrides trade agreements is not settled (Room, 2006). It would thus be wise for any move to legalise cannabis, however restrictive the regulations, to take into account the need to exempt hazardous substances from coverage under trade agreements and disputes.
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