Rational approach to drug use in society. Legalisation of cannabis could be part of a rational reconfiguration of the societal response to drug use of all kinds. The current UK classification of drugs into 'legal' and 'illegal', with three illegal categories (Class A to C) from 'hard' to 'soft' is irrational and failing - in terms of both public health and law and order. ASH's position is grounded in a civil liberties perspective that promotes public policy interventions proportional to the harm caused. We generally favour legal sanctions where there are risks to others, and persuasion of all forms, taxation and controls on producers where the risk is to the user him or herself.
Focus on harm. ASH is non-judgemental about drug effects on the individual - stimulation, relaxation, intoxication, euphoria etc. These effects are widely sought after in society through legal drugs such as alcohol, nicotine, caffeine and herbal remedies. But our prime concern is harm - to the user and, especially, to others (for example through passive smoking, fires, accidents, violence, and crime). A comprehensive assessment of the harm caused by cannabis use showed that there are clear health risks - cannabis is not benign1. But, the question with all drugs is not whether they are harmless (none are) but whether the harm is sufficient to justify the societal action taken to control them, with particular consideration given to whether the harm afflicts the individual or is inflicted on others. If harm is the guiding criterion of drugs policy, we believe that the response to tobacco (and alcohol) is at present insuffient, whereas cannabis is over-regulated (ie. completely banned).
Legitimacy of prohibition. ASH subscribes to the civil liberties argument that legal force is justified where one person (or company's) behaviour causes harm to another - legislators should be much more wary when they seek to legislate to control individual risk taking behaviour. This general principle is most famously expressed by John Stuart Mill in his essay, On liberty2.
The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise, or even right.
This does not mean that public health authorities should simply walk away, but that a more persuasive approach should be used. Mill continues:
These are good reasons for demonstrating with him, or reasoning with him, or persuading him, or entreating him, but not for compelling him, or visiting him with any evil in case he do otherwise. Over himself, over his own body and mind, the individual is sovereign.
This is very much the approach adopted in modern tobacco and alcohol policy - legal force is used to prevent harm to others, and persuasion to limit harm to the individual. This approach justifies, for example, legal enforcement of smoke free areas to prevent passive smoking (tobacco, cannabis) and a ban on driving while intoxicated (alcohol, cannabis), but uses a variety of incentives to promote healthy behaviour - education, bans or restrictions on advertising, taxation, support for cessation, consumer information and warnings. Legal restrictions on marketing, product composition or requirements for warnings are justified as they represent behaviour by one 'person' (a tobacco company), which can harm another (consumers, young people). Many elements of a model tobacco policy would be the appropriate approach to the societal management of cannabis, and potentially other drugs.
This 'libertarian' approach should never be applied absolutely - Mill recognised this, and defined exemptions to his general principle:
It is, perhaps, hardly necessary to say that this doctrine is meant to apply only to human beings in the maturity of their faculties. We are not speaking of children, or of young persons below the age which the law may fix as that of manhood or womanhood. Those who are still in a state to require being taken care of by others, must be protected against their own actions as well as against external injury.
This reasoning may be used to justify legal restrictions on use by young people and where the product is addictive - effectively where the user's ability to exercise their own independent decisions has been compromised, perhaps by a youthful initiation into the drug. These conditions are far more likely to apply to tobacco than cannabis, both on account of the age of initiation and the addictiveness of the drug.
Legalise the drug... Legalisation of cannabis would help in promoting rational drugs policy across the board - in which priority was given to tackling harm and regulating the supply and use of drugs so as to reduce harm and risks, rather than moral censure or ascetic denial. An editorial in The Lancet (1998)3 argued for a realist liberal approach to drugs per se:
The desire to take mood-altering substances is an enduring feature of human societies worldwide and even the most draconian legislation has failed to extinguish this desire--for every substance banned another will be discovered, and all are likely to have some ill-effect on health. This should be borne in mind by social legislators who, disapproving of other people's indulgences, seek to make them illegal. Such legislation does not get rid of the problem; it merely shifts it elsewhere.
We support the legalisation of cannabis into a robust regulatory framework with good public health education expenditure replacing money wasted on law enforcement. We also favour strengthened regulation of tobacco to reflect its harm in proportion to cannabis. Regulation of legal cannabis would include: growing, marketing, promotion, branding, retailing, purity and quality, pricing. It could also include the form in which the drug is made available (eg. edible, infusion, smoking, pharmaceutical preparation of the pure drug - the cannabinoids).
Cannabis is less harmful than legal drugs. The UK Police Foundation's "Runciman Commission"4, which investigated different drugs in depth and reported in 1999, concluded that:
When cannabis is systematically compared with other drugs against the main criteria of harm (mortality, morbidity, toxicity, addictiveness and relationship with crime), it is less harmful to the individual and society than any of the other major illicit drugs or than alcohol and tobacco.
In the light of its published review of medical evidence1, The Lancet editorial 3 concluded:
... on the medical evidence available, moderate indulgence in cannabis has little ill-effect on health, and that decisions to ban or to legalise cannabis should be based on other considerations.
Tobacco kills many times more than cannabis. It is difficult to give figures on a consistent basis, but where comparisons are made, tobacco dominates the death toll. For example, a parliamentary answer gives the following annual death toll from drug use in England and Wales (1996)5:
All illegal drugs:307
1998 figure. Note: though many premature deaths among the elderly life-years lost for tobacco 687,434 (England)6
Does not include accidents or violence (Note Total (not necessarily related to alcohol) annual deaths in UK: Road accident deaths (3,444); other accidental deaths (8,986); murder and manslaughter (503)7.
Alcohol Concern details substantial costs associated with alcohol in the UK - notably absenteeism8.
Does not include assessment of long-term mortality, for which there is inadequate epidemiological data.
These figures should be used with caution - because of the illegal status of a drug like cannabis, there has been no systematic monitoring or long term epidemiology to provide comparative data to tobacco.
Smoke effects dominates cannabis harm. Although it has been stated that smoking cannabis has comparable risks to smoking tobacco9, this is a probably an element of misunderstanding in this. According the Lords' Committee the health effects of the smoke are most important:
4.17 Most of our witnesses regard the
consequences of smoking cannabis as the most important long-term risk
associated with cannabis use.
A report by the US Institute of Medicine10 came to a similar conclusion, highlighting the role of smoking in the main harmful effects:
Marijuana is not a completely benign substance. It is a powerful drug with a variety of effects. However, except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications. […] When interpreting studies purporting to show the harmful effects of marijuana, it is important to keep in mind that the majority of those studies are based on smoked marijuana, and cannabinoid effects cannot be separated from the effects of inhaling smoke from burning plant material and contaminants.
The World Health Organisation also noted the similarity between cannabis and the legal drugs, tobacco and alcohol11.
Many of these risks are shared with alcohol and tobacco, which is not surprising given that cannabis is an intoxicant like alcohol which is typically smoked like tobacco. On existing patterns of use, cannabis poses a much less serious public health problem than is currently posed by alcohol and tobacco in Western societies.
Cannabis users smoke less. Though cannabis may be similar or worse to tobacco when comparing a joint and a cigarette12, few cannabis users ever consume as much smoke as a 20-a-day tobacco cigarette smoker. The pattern of use of cannabis is quite different to tobacco - though there are 'abusers' or heavy users who may smoke many joints in a day, the prevailing habit is occasional use - much closer to 'social cigarette smoking'. In contrast, most smokers are comparatively heavy users, smoking an average of 15 cigarettes per day. Cannabis users may be smoking cannabis with tobacco, but they would have a similar approach to this as to tobacco use.
Favour non-smoked forms of cannabis. Smoking cannabis is harmful, but less harmful than smoking tobacco cigarettes, by virtue of the quantity smoked as a regular user. However, cannabis has already been licensed for medical uses and is delivered in non-smoked forms. It is also used in non-smoked forms recreationally - for example in coffee houses in the Netherlands. Given that most of the serious harm is from smoking, consideration should be given to legalising (or otherwise favouring) cannabis in its non-smoked forms, either as cakes or tea, or as the pure cannabinoid (the active drug) as an inhaler or sub-lingual tablet.
Tobacco addiction on a par with heroin and cocaine. An important reason for control of any drug is its addictiveness, in which the denial of choice and loss of control is a significant harm. Tobacco is addictive on a par with heroin and cocaine, whereas cannabis appears to have much lower dependence forming characteristics. The Royal College of Physicians has analysed the comparative addictiveness of tobacco and other drugs, (not including cannabis) and concluded13.
We can, however, conclude, as was concluded in the 1988 Report of the US Surgeon-General, that: "The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine." We can further conclude that tobacco dependence is a serious form of drug addiction which, on the whole, is second to no other.
Cannabis relatively easy to give up. On the other hand, the House of Lords 9 did take evidence on addictiveness of cannabis and concluded that dependence was less serious:
Giving up cannabis is widely believed to be relatively easy: according to the Department of Health, "studies report that of those who had ever been daily users only 15 per cent persisted with daily use in their late twenties" (4.31)
Policing time and cost - and opportunity cost;
Removing sense of police harassment from some users;
Removing violence as controlling influence within the distribution system;
Decriminalising the existing users (and potential threat to employment prospects etc);
Removing the organised criminal element from supply;
Reducing exposure of cannabis users to criminals - removing the 'real gateway';
Ability to control quality and purity and have proper consumer protection;
Ability to control marketing activity of suppliers;
Ability to insist on (or otherwise favour) cannabis in its least harmful forms - ie. not smoked;
Possibility of reduced access for minors;
The option to use taxes to control retail price;
Improved distribution of revenue - away from organised crime to growers, legitimate traders and, through taxation, to the public sector.
Justifying mass criminalisation. In 1999, in the UK 88,548 drugs offenders (74 per cent of the total) had committed offences involving cannabis (alone or with other drugs). About half of these received a caution.14 This implies a very substantial number of people each year are gaining criminal records - with numerous knock-on consequences for their employment and lives.
A recent survey in The Economist magazine highlighted the scale and economics of the trade in illegal drugs15. According to The Economist survey, estimates of the size of the global illegal drug market is US$150 billion at retail prices (compared to about US$200 billion for tobacco) with some estimates up to US$400 billion. That represents a great deal of criminal activity - mostly by final consumers who are not harming anyone else - and often not harming themselves any more than they would through use of legal drugs. Society has to justify carefully why these people should be subject to the serious sanction of criminalisation.
Tackle abuse rather than ban use. There are undoubtedly problems that come with drug use, for example driving or abuse in the workplace. However, these already exist because of the illegal use of the drug, or because alcohol may have similar problems. The right approach is to try prevent abuse rather than taking a sledgehammer to the problem by banning all use of the drug in all circumstances. This approach is already central to the policies proposed by alcohol campaigners16. The illegal status of cannabis stands in the way of a comprehensive control strategy based around education, responsible moderate use, avoidance of accidents etc. The government can hardly introduce a policy on the responsible use or abuse of cannabis if the drug remains illegal.
Gateway theory - driven by criminals rather than the drug itself. It is asserted by some that cannabis is a gateway to so-called hard drugs. The Runciman Commission regarded this as one of the most important issues and it investigated thoroughly4. It's conclusion was that:
In our view nothing has emerged to disturb the conclusions of the Advisory Committee on Drug Dependence in 1968, when they said that there was no convincing evidence that cannabis use in itself led to heroin use.(7.16)
If there is anything at all in the gateway theory, it is likely to be found in the structure of illegal markets. (7.18)
The World Health Organisation17 also considered this question and concluded that the most plausible explanation for some cannabis users also using other drugs was:
'....a combination of selective recruitment into cannabis use of non-conforming and deviant adolescents who have a propensity to use illicit drugs, and the socialisation of cannabis users within an illicit drug-using subculture which increases the opportunity and encouragement to use other illicit drugs.'
To the extent there is evidence for a gateway effect, then it is linked to the illegal status of cannabis. To the extent that legalisation would remove the influence of illegal suppliers, it would be more likely to attenuate any gateway effect.
Decriminalisation is flawed. Decriminalisation of cannabis has been raised as an option. This approach is weak as it leaves in place the criminal supply infrastructure in place and leaves no scope for regulating the production, distribution, marketing and taxation the drug. Many of the advantages of legalisation listed above may be lost if cannabis is only decriminalised, though it may be a useful interim step - and more immediately politically viable.
Value for tobacco policy in legalising cannabis. The processes by which cannabis is legalised will be instructive by virtue of comparison to tobacco. For example, 'libertarian' proposals for legalisation for recreational use stress restrictive regulation of sales and marketing18. However, even the banning of tobacco advertising remains controversial - especially among libertarians. Valuable lessons in the perception and regulation of tobacco regulation may be learned from the process of legalising cannabis.
Focussing debate and regulation on the distinction between drug effects and harm would raise awareness about the relative position of tobacco and partly dismantle the sense that tobacco's legal status implies that it is not very harmful or addictive.
The difference in addictiveness of tobacco and cannabis would be brought into focus and tobacco may come to be seen as a more menacing drug.
Tobacco manufacturers often claim that the legal status of their product justifies no regulatory intrusion into their business practices and marketing. Legalisation of cannabis into a tough regulatory framework would be an important comparison.
Cannabis may be legalised for recreational use in its pure drug form (cannabinoids) - this would require an adjustment in pharmaceutical regulation that would be beneficial if applied to nicotine. There is considerable scope to reduce the harm to tobacco users through
Legalising or otherwise favouring non-smoked forms of cannabis would be helpful in identifying smoke as the prime toxic agent in smoking tobacco. This may also cause tobacco users to seek or demand less toxic forms of nicotine - for example chewing tobacco, oral snuff, or non-tobacco nicotine products.
There would be great pressure to prevent heavy advertising and promotion of legal cannabis - this would stand in marked contrast to advertising of tobacco.
Tobacco industry involvement. It is feared that the tobacco companies may dominate the trade in cannabis - deploying their customary business practices. This may be inevitable, but it underscores the importance of tight regulation of marketing and promotion. However, if the product was legalised in its less harmful, non-smoking forms, the tobacco companies would have no obvious advantage. The people and organisations currently involved in the trade are not conspicuously better than the tobacco companies - but governments can more easily control the marketing activities of the tobacco industry if they have the political will.
Heroin, cocaine and other drugs. Some of the argument set out above would apply equally to other widely used drugs like amphetamines, ecstasy and even to 'Class A' drugs like heroin and cocaine. However, should there be a process of legalising cannabis, then many lessons will be learnt from this experience - and possibly mistakes made. It would be prudent to follow a stepwise approach, beginning with cannabis and learning from this experience before deciding if, when or how to extend legalisation to other drugs.
1 Hall W. and Solowij N. Adverse effects of cannabis, Lancet 1998; 352: 1611-16 [PDF]
3 Anon (editorial). Dangerous habits. Lancet (1998) Volume 352 Issue 9140 Page 1565 [PDF]
7 Mortality statistics 1998., Office for National Statistics, 1999; General Register Office for Scotland, 1998; Registrar General Northern Ireland, Annual Report, Statistics & Research Agency, 1998.
11 Hall W. Bondy S. WHO Project on Health Implications of Cannabis Use: A Comparative Appraisal of the Health and Psychological Consequences of Alcohol, Cannabis, Nicotine and Opiate Use. August 28, 1995. [View Report]
17 'Cannabis: a health perspective and research agenda'. Geneva, World Health Organisation, 1997. Section 5.4.
18 For example, Rt Hon Peter Lilley MP, pamphlet for Social Market Foundation, 6 July 2001.