Good morning to the committee, and thank you for the opportunity to speak to you today. I'm appearing on behalf of the chief medical officers of health for the 13 provinces and territories. I'm providing a collective public health perspective, not jurisdictional positions from any of the provinces and territories.
My remarks will be focused on this morning's topic of prevention, treatment, and low-risk use, but by necessity will touch base on other topics such as legal age, labelling, and packaging, which have been discussed in other sessions.
I have assumed that by prevention you mean the prevention of population and individual harm in relation to how cannabis is produced, distributed, retailed, and used, the prevention or at least the delaying of onset of use by those below the legal age, and the prevention of harm to populations that may be at increased risk.
Prevention is not just about providing information and education about risks and harms. Appropriate education and social marketing can be effective but only if they are part of a comprehensive strategy. Policy decisions related to how cannabis will be sold, how it will be priced, how it will be labelled and marketed, and the level of availability and accessibility are the most critical when it comes to preventing population harms, preventing harmful individual use, and minimizing underage use.
To be more specific, to have the strongest prevention approach, we make the following recommendations:
Cannabis should be distributed and sold through government monopolies where the primary objective is protecting public health and safety, and not revenue generation.
As recommended by the task force that advised the federal government, there should be no co-sale of cannabis with tobacco and alcohol products.
At the outset, price will need to be set to maximize purchase from the legal market, but over time, price needs to be used as a key tool in decreasing overall demand as well as encouraging consumption of lower-harm products, such as products with lower THC concentration and non-smokable forms.
Product promotion such as advertising, marketing, sponsorship, and product placement, including at the retail environment, needs to be prohibited at the federal level and complemented by similar provincial restrictions.
Product packages should be plain with clear and prominent warnings about risk.
At the retail level, prepackaged products such as cigarette-type joints should not be allowed as those can facilitate marketing, promotion, and glamorization of cannabis use.
The number, location, and density of retail locations, along with hours of operation, need to be carefully developed to balance access to legal products—and accounting for the current legislation's allowance of personal growing and online or mail order purchases—with prevention objectives.
Over the long term, a minimum age of 21 would be better than 18 or 19 at balancing between shifting young adults to legal supplies and decreasing use by those under age 18. I'm going to explain that recommendation a little more, because it is a key point that keeps coming up.
We know that one of the objectives is to move people from an illegal to a legal market. Certainly, setting age 19 or 18 will bring young adults into the legal market in the short term, but if one of our key objectives is to decrease use amongst youth who are under 18, and will always remain underage no matter if the age is 18, if they are using cannabis, they are going to have to access it from an illegal source. We know from clear evidence around tobacco and alcohol that setting an age of 21 versus 18 or 19 will, over time, have a greater impact on decreasing cannabis use rates and therefore keeping those individuals out of any market for cannabis for those under age 18. If one of our primary objectives is to have a set of circumstances that decreases use of cannabis by those who are underage, we are far better off with an age of 21 than of 19.
Moving along, public smoking and vaping of cannabis should, at a minimum, follow the current approach to public tobacco smoking and vaping, to prevent further normalization of cannabis smoking and re-normalization of smoking behaviours in general.
The approach to bringing edible and other concentrated and derivative products into the legal market needs to be done extremely carefully to minimize the normalization of cannabis consumption and protect children and youth. With respect to edible products, it must be made clear through legislative requirements that products that contain cannabis plant materials and extracts and active ingredients are not food products.
Since it is easier to loosen regulations than to tighten them, the initial regulatory approaches should err on the side of being more restrictive. Adjustments can be made as time progresses based on comprehensive monitoring and research. Such monitoring and research will need to be adequately resourced and established.
Programs that shape social and physical environments to support health and well-being in general, such as supporting healthy pregnancies, enhancing early childhood development, and ensuring adequate housing and income, are all important measures for primary prevention of problematic substance use in general and are and will be important in preventing problematic cannabis use.
Along with this submission, I'm pleased to attach a more detailed position paper from the provincial and territorial chief medical officers of health, as well as the Urban Public Health Network, who are the medical officers of health in urban centres. That more detailed report has been provided to the committee.
With respect to treatment, I do not have experience or expertise in the treatment of cannabis use disorders, but I would say that there are no treatment approaches or therapies that are specific to cannabis use disorder. There is a need for improving appropriate access to treatment of people with cannabis use disorder today as part of the need to improve treatment and access for people with a range of substance disorders. Whether the need for treatment will increase or decrease will really depend on decisions and the implementation of policies that I've discussed previously.
With respect to lower-risk use, an updated set of guidelines for lower-risk cannabis use, the development of which was led by Canadian experts, was publicly released in June of this year. Those guidelines have been endorsed in principle by the council of the chief medical officers of health. In summary, these guidelines recommend that the most effective way to decrease risk is to abstain; that the older one is when cannabis use is initiated the lower the risk of developing problematic use and adverse health effects over the lifetime. Higher THC concentration products have greater risks, so low THC concentrated products should be used. Synthetic cannabinoids, such as shatter, expose users to more acute and severe risk and should be avoided.
To protect lung health, routes of intake that involve smoking and combusted cannabis material should be avoided. Along with that, methods such as deep inhalation and breath holding that increase the psychoactive ingredient absorption also should be avoided. Frequent or intensive use has the highest risk of harm, so if people choose occasional use, one day a week or only on weekends is recommended. Avoiding driving while using alcohol and/or cannabis is extremely important.
Populations that are at higher risk from harm from cannabis and therefore should avoid use are pregnant women, people with a history or close family history of psychosis or substance use disorder. The combination of risk behaviours, such as early age of onset and frequent use, likely magnifies the risk. These low-risk cannabis use guidelines should form a key part of public awareness and educational initiatives related to cannabis legalization and should be incorporated in product labelling and should inform legalization policy decisions by all three levels of government.
With respect to Bill C-45, the provincial and territorial chief medical officers of health and Urban Public Health Network recommended in the paper I have provided that this initiative be guided by public health goals and objectives written into a statute. We were very pleased to see the public health orientation adopted by the federal government for this initiative and the explicit articulation of public health objectives as codified in the purpose section of the act, proposed section 7. We encourage provinces and territories to adopt similar public health orientation and include explicit articulation of similar objectives in their statutes.
Last, we suggest that the bill be amended to replace the word “illicit” with the word “illegal”. The term “illicit“ is stigmatizing in nature, and since stigma and discrimination reduction are important aspects of this initiative, we suggest avoiding using the term “illicit” whenever possible. We suggest using the term “illegal” instead, as it is a simple, clear, and unambiguous term that refers to the legal status of possession of the substance and it avoids the stigmatizing nature of the word “illicit”.
Thank you for your time and this opportunity. I look forward to our discussions.