A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

How to Legalize Marijuana

My interview on CBC’s The House had such a positive reception that I wanted to follow up with a short essay summarizing most physicians’ recommendations for legalizing marijuana. My own perspective is that of a psychiatrist whose patients are all adolescents and young adults. This means I am concerned about the short-term impact of marijuana intoxication in the young people that I see, but I am even more worried about the long-term impact of cannabis on the developing brain as well as the links between cannabis use and psychotic illnesses.

Most physicians hope that the federal government will approach the legalization of marijuana emphasizing public health concerns as the most important consideration in the drafting of legislation. There are also law enforcement and government revenue aspects of the legislation but in jurisdictions where these considerations were emphasized, health outcomes were affected. Doctors in Canada – and Canadians in general – will find that negative health outcomes will eliminate any possible benefits to legalizing and regulating marijuana.

The government’s vision is to have marijuana legally available for non-medicinal purposes by Canada Day 2018. For the implementation to fully consider the public health implications, the government can look to its experience with the legalization and regulation of tobacco and alcohol. There are lessons to be learned from this experience from a public health perspective and I hope Canadians can benefit from that experience. We can also learn from those countries and jurisdictions that have already legalized marijuana. Also, now is the time to set up an evaluation and research agenda to ensure that we continue to learn from our experience with legalizing marijuana.

Some of the main health concerns with marijuana are related to its impact on the developing brain. The brain continues to develop until age 25 and there is significant evidence that cannabis use interferes with brain development. While it would be ideal if the minimum age to purchase marijuana could be 25, Young Canadians are already using twice as much marijuana as any other age group in Canada. Young Canadians also have a higher rate of cannabis use than youth in any other G8 country. With use being this high (20% of Canadians aged 16-24), it is more realistic to focus on reducing cannabis use to the extent that is possible. The Canadian Medical Association recommends setting a national standard where minimum legal age for purchasing marijuana would be 21, but with restricted strength and purchasing limits until age 25.

As well as brain development, child psychiatrists have also noticed increased prevalence of psychotic symptoms in young people using marijuana. We notice that psychotic symptoms emerge at a younger age for those with a predisposition for these conditions who use marijuana. We also notice that cannabis use is associated with the more serious chronic symptoms of schizophrenia.

Many physicians are also concerned that that rigorous research has never been applied to whether marijuana has any medicinal value. Marijuana has been available for medicinal purposes in Canada for many years, but there are few, if any, studies confirming its efficacy. Given the health risks, is it not time to insist on research to determine whether medicinal marijuana is effective?

Finally, one of the most important public health impacts will be related to the consequences of driving while intoxicated.  One’s capacity to safely operate a motor vehicle after using marijuana can be affected for as long as 6 hours after use. There is no currently no adequate way to identify or evaluate whether a driver is under the influence of cannabis. A method to evaluate intoxication must be developed before legalization. In this regard, the experience of Colorado should inform Canadian legislators. This excellent review outlines the increase in traffic accidents and Emergency Room visits since marijuana was legalized. Traffic accidents are one concerns but there are others. Colorado legislation was focused primarily on the revenue generating aspects of marijuana legalization. The negative health outcomes should be a cautionary tale for Canadians.

I have focused on those aspects of marijuana legalization that are most important in my practice but the Canadian Medical Association prepared a detailed submission for the Government of Canada Task Force on Marijuana Legalization and Regulation. Canadian doctors and the Canadian Medical Association are extremely concerned about this legislation. Great effort has been taken to alert the federal government to the risks involved in legalizing marijuana. I mentioned earlier that I wished the legal age to purchase marijuana could be 25. I can see how unrealistic this is, given how much marijuana young Canadians use right now, when it is not legal. After the fact of negative health outcomes from legal tobacco and alcohol, Canadian governments have had to launch massive public health and education campaigns. It would be good to roll these out now, in the hope that we can avoid some of the negative health outcomes doctors know are coming.

Benjamin Franklin made what must be one of the first public health statements in America. We can remember this as marijuana legislation moves forward, even if Colorado didn’t:

“An ounce of prevention is worth a pound of cure.”