Alternative Systems of Cannabis Control in New Zealand: Part 4

Introduction

As noted in Section 2, one of the principal goals of a reformed cannabis policy is to promote public health. The impact of implementing an alternative policy will depend in substantial part on the extent to which (1) cannabis use is increased, (2) this increased use produces harms, and (3) increased use leads to decreases in the use of (and harms resulting from) alcohol and tobacco.

Considering first the extent to which repeal of prohibition might lead to the increased use of cannabis throughout New Zealand society, it seems likely that at least some people who would not try cannabis while it was illegal would do so it were legal. Of these, some proportion will continue to use over a more or less lengthy period of time, and some further proportion of these users will develop psychological dependence.(1) Further, some people who already use cannabis will use more and for longer periods if legal sanctions on such use were reduced.

So much seems commonsensical, yet evidence in support of these assumptions is hard to find. One of the most complete reviews of the relevant evidence was conducted by the Australian Institute of Criminology in its 1995 report on alternative systems of cannabis control.(2)

In The Netherlands, where total prohibition is encased in an administrative expediency principle, no significant increases in drug use or changes in patterns of use have been identified (Engelsman 1989;(3) van Vliet 1990;(4) Wijingaart 1988a, cited in Wardlaw 1992(5)), and there may even have been a decline in cannabis use (Reuter 1988 [sic](6)). This option may also lead to users adopting safer methods of consuming cannabis (van Vliet 1990(7); Cohen 1988(8)). For instance, when restrictions are removed from the sale of water pipes, fewer users consume cannabis in cigarette papers, which is the form of consumption most damaging to the lungs (Kleiman & Saiger 1989-90(9); Reuter 1987(10)). . . .

In South Australia, where possession and cultivation of small quantities of cannabis for personal use are dealt with by civil sanctions rather than criminal ones, the data do not indicate increases in cannabis use (Sarre, Sutton & Pulsford 1989(11); Christie 1991(12); Donnelly, Hall & Christie in press). NCADA Australian household drug use survey data covering the period 1985 to 1993 indicate that, although there have been increases in self-reported cannabis use in South Australia, similar increases occurred in other states where there have been no changes in the legal status of personal cannabis use. Thus, increases in cannabis use in South Australia cannot be attributed to the effects of the legislative changes there. . . .

In the United States, where eleven states decriminalised the use of marijuana during the 1970s, either no significant increases in marijuana use were detected after decriminalisation (Oregon: Carr 1975(13); Nebraska: Suggs 1981(14)) or, where increases did occur, they were no greater than those which arose in states in which no changes in cannabis legislation had taken place (Johnston et al. 1981(15); Vallance 1993(16)). Thus, any increases in marijuana use rates that did occur could not be attributed to the change in the law. . . .

Australian survey results. . . reveal that many people, in the states where expiation notice schemes have been introduced, erroneously believed that the laws on cannabis had been revoked completely. For example, McGeorge (1994)(17) found that 31 per cent of ACT university students sampled incorrectly believe that it is not an offence to possess cannabis in the ACT, compared with five per cent of the Melbourne students sampled. Bowman & Sanson-Fisher (1994)(18) made similar observations in their national overview.

A similar situation arose in California in the 1970s after the relaxing of that state's laws towards marijuana. Despite a media campaign to inform the public that the drug had not been legalised, more than one in four respondents believed that legalisation had taken place (Budman 1977)(19). If there is a widespread misunderstanding surrounding the legal status of cannabis, it is remarkably encouraging that the extent of cannabis use has remained relatively constant. . . .

The important point is that cannabis legislation does not seem to impact upon cannabis consumption in any noticeable way. A survey of drug use trends in Europe revealed that cannabis use has been declining since the early to mid-1970s, and seems unrelated to the type of control regime in place in specific countries (Reuband 1991).(20) North American research also demonstrates fairly conclusively that legal sanctions do not deter or inhibit future illegal drug usage (Walters 1994).(21) In Canada, a study of first-time offenders who were awaiting hearings for cannabis possession revealed that 89 per cent expected to continue using marijuana despite the legal trouble they were facing (Erickson 1980).(22)

Thus, the international literature does not support the claim that repeal of cannabis prohibition will substantially increase cannabis use in New Zealand.

What about the impact of cannabis law liberalisation on use by teenagers, in particular?

The AIC discussed the possible impact of normalising adult cannabis use on encouraging use among young people:

As mentioned previously, controls against the use of cannabis by young people may be implemented (with or without decriminalisation) but they are unlikely to be able to prevent children's access to these substances completely. Should decriminalisation occur, it is also possible that accessibility to cannabis by young people would increase. In addition to this, it is possible that decriminalisation would result in a greater risk of children being exposed to cannabis use through adult role models (Kleiman & Saiger 1989-90)(23). Currently, it seems reasonable to assume that marijuana smoking is a fairly clandestine activity, not normally witnessed by children. But should changes to legislation make it more acceptable, the act of using marijuana may become less taboo and no longer be concealed from younger family members.(24)

On the other hand, what actual evidence exists is encouraging. As noted in Section 2 of the discussion paper, The Netherlands' government has addressed this issue:(25):

In recent years [cannabis] use has once again been considerably higher in other countries (including the United States) than in the Netherlands. This is also true as far as use among minors is concerned. The decriminalisation which took place in the 1970s did not lead to an increase in the use of soft drugs among young people then either. The Dutch objective of protecting young adults who wish to use soft drugs at a certain stage in their lives from the world of hard drugs has also proved to be a realistic one. Only a very small proportion of the young people who use soft drugs make the transition to hard drugs.

Further, according to Dr John Morgan and Professor Lynn Zimmer,

Despite easy availability, marijuana prevalence among 12 to 18 year olds in Holland is only 13.6 percent -- well below the 38 percent use-rate for American high school seniors. . . . Whereas approximately 16 percent of youthful marijuana users in the U.S. have tried cocaine, the comparable figure for Dutch youth is 1.8 percent. Indeed, Holland's policy of allowing marijuana to be purchased openly in government-regulated "coffee shops" was designed specifically to separate young marijuana users from illegal markets where heroin and cocaine are sold.(26)

This latter observation also provides evidence against the claim that cannabis use in itself tends to promote the subsequent use of heroin or cocaine.

Another reason why teenage use of cannabis is unlikely to increase substantially following repeal of total prohibition is that, unlike many adults, young people typically have ready access to cannabis at schools. Thus, it is likely that teenagers who wish to use are already using. Because any change in the cannabis law would pertain only adults (supplying cannabis to minors would remain an offence), it seems unlikely that teen use would increase under such a system. Moreover, removing the aura of total prohibition will reduce the glamourous appeal of cannabis to young people.(27)

This substantial body of evidence notwithstanding, let us assume that cannabis use were to rise substantially following repeal of prohibition. What health effects might follow?

Health Effects

The scientific literature on the health effects of cannabis is enormous, and cannot be reviewed here in any detail. Instead, we again cite from the 1995 Australian Institute of Criminology report,(28) which in turn refers to a report prepared by the National Centre for Drug and Alcohol Research (NDARC) at the University of New South Wales:

The health consequences of cannabis use have been extensively studied. A contemporary review was conducted for the National Task Force on Cannabis;(29) this review is now accepted internationally as the most credible summary of current knowledge. . . . A central conclusion which may be drawn from the review is that, although adverse impacts on health and psychological functioning certainly result from cannabis consumption, those impacts are not so serious as to justify (on their own) the total prohibition of the drug.

A recent report on cannabis prepared by the New Zealand Ministry of Health also relied heavily on the NDARC report in assessing health effects. The report concluded:

Overall, the current public health risks of cannabis use are small to moderate in size, and are significantly less than the public health risks of tobacco and alcohol. However . . . if there were a significant increase in the number of long-term cannabis users . . . the assessment of the public health importance of cannabis use would increase.(30)

Our reading of the literature on cannabis and health leads us to conclude that cannabis appears to be relatively harmless for about 90 percent of the people who use it (including young people, most of whom use only transiently). The remaining 10 percent of users will experience a variety of mostly (but not entirely) reversible problems with short-term memory, worsening of pre-existing psychological problems, compulsive use, or respiratory difficulties due to smoking.(31) For the most part, those people who experience substantial problems of dependence and excessive use probably have difficulty with impulse control in general.

It is widely accepted in the research community that the adverse health effects of cannabis, while real, are substantially less severe than those associated with excessive alcohol and tobacco.(32) Two recent studies tend to confirm this view. In the first of these, conducted by the National Drug and Alcohol Research Centre at the University of New South Wales, investigators interviewed 268 cannabis smokers and 31 non- using partners and family members. The researchers concluded that the health of long-term marijuana users is virtually no different from that of the general population.(33)

A much larger American study examining ten years of mortality data for over 65,000 men and women found no statistically significant association between marijuana smoking and death. (34)The study's statistical methodology controlled for the use of tobacco and alcohol so that deaths from marijuana smoking could be clearly identified.

The above research evidence notwithstanding, the Forum trustees understand that many people, and young people in particular, have been harmed by excessive or harmful cannabis use. We do not believe that cannabis is completely safe, of course(far from it. In the final analysis, however, the health effects of cannabis(however one might view them(are largely irrelevant to the problem of deciding which cannabis control policy to adopt. Indeed, the more harmful we judge cannabis to be, the more important it is to exercise control over its distribution. Such control cannot be exercised in a prohibition environment, which in effect abdicates control to the black market.

Alcohol/Tobacco Substitution Effects

Finally, the public health impact of increased cannabis use cannot be considered in isolation from the effect such an increase would have on the associated use rates of (and harm from) other drugs, particularly alcohol and tobacco. In fact, there is evidence that cannabis can serve as a substitute for both of these latter drugs.

With respect to alcohol, a consistent finding in field research of cannabis use is the tendency of many cannabis users to decrease their alcohol intake when cannabis is available, and to increase alcohol use when cannabis is unavailable. This was a significant finding of Rev McFerran's during his extensive field work in New Zealand during the early 1970's.

When the observer first entered into the marihuana social networks in the Auckland area, he found that among those whom he initially contacted this was the case. There were actually users of marihuana who had ceased using alcohol at that time. One heard alcohol being described as an aggressive, sordid and unpleasant drug and used only to acquire an ego trip. However, as the study progressed it became apparent that the use of alcohol and marihuana are not necessarily exclusive although a marked change in attitude by marihuana users to alcohol developed.

When enquiry was made regarding the informants' attitude to alcohol, none were strongly favourable to its use, either before or after the commencement of marihuana use. Yet there was an extreme shift in attitude away from alcohol. . . .

The study shows that slightly less than half of those who were formerly favourable to alcohol use moved to an unfavourable attitude after using marihuana. Half of those who had been uncertain decided either for or against. More than four times as many informants 'became unfavourable and twice as many became strongly unfavourable in the attitude held about alcohol prior to using marihuana. -The comments of informants followed the theme that marihuana was preferable to alcohol.(35)

Alcohol was still used by many cannabis users, but to a more restrained an controlled extent:

There is a decided move away from alcohol use as the general or necessary social lubricant, but with most users it still has its place. Of the 160 informants 153 (96%) of them had used alcohol prior to marihuana. . . .(36) Asked how they rated their personal use of alcohol, not one of the informants felt that they presently had a problem associated with alcohol . . . Alcohol for some marihuana users is the alternative drug when marihuana supplies become limited.(37)

Similar observations were made in a more recent study of cannabis use in Maori communities in the far north. The report notes that many Maori use cannabis to decrease their alcohol intake, and that this substitution is considered desirable:

Many people prefer to smoke a couple of joints before going out to the pub so they need only have one or two drinks, making it a cheaper option than buying alcohol all night. . . .

Many people surveyed felt strongly that alcohol was more dangerous than marijuana, 'I think alcohol has killed and hurt more people than marijuana, that it is responsible for road deaths, behavioural changes, domestic violence, depression and aggression. Many users justified their use of cannabis alone, believing that it has no harmful effects to either their health or their behaviour. 'I get totally out of control on alcohol whereas smoking makes me passive. . .'

Although many reports about cannabis use discuss the detrimental effects cannabis has on drivers,(38) this report could uncover no anecdotal or written evidence to substantiate this. This may be due to a further lack of understanding regarding such dangers. Certainly many people in the survey cited alcohol as being a 'killer on the roads', while no one identified cannabis as having the same risk.(39)

There is additional research evidence for a cannabis-alcohol substitution effect.(40) (41) For example, researcher Karyn Model examined the impact of substituting civil penalties for criminal sanctions for cannabis possession on hospital emergency room admissions for drug abuse in the mid-1970's.(42) As the substitution hypothesis would suggest, emergency room episodes related to drugs other than cannabis were 12 percent lower in the states that had decriminalized. Lowering the effective "price" of cannabis appeared to reduce the harmful use of other substances. The data did not permit the isolation of alcohol emergencies from those caused by the use of heroin, cocaine or prescription drugs. But based on previous research Model concluded that alcohol was far and away the most likely drug replaced by cannabis.

This finding was reported in the New York Times:(43)

Drug policy is grounded on the premise that illicit drugs are birds of a feather -- that reducing the availability of one decreases the consumption of others. But economists who measure the demand for illicit substances . . . challenge this conventional wisdom. Their identification of a strong substitution effect between marijuana and alcohol suggests that the full court press against the weed is partly responsible for stubbornly high levels of binge drinking by teenagers. . . .

To those who focus on the risk of accidental injury and other medical crises, heavy drinking seems a more serious worry than marijuana. Ms. Model found that other factors equal, states decriminalizing marijuana reported lower overall rates of drug- and alcohol-related emergencies.

And while both substances have been implicated in auto accidents, Frank Chaloupka, an economist at the Chicago campus of the University of Illinois, believes that substitution toward marijuana is, on balance, a life saver. In a statistical analysis that parallels Ms. Model's, he found that states without criminal sanctions against marijuana possession suffered fewer auto fatalities.

This latter finding is congruent with most of the studies cited in Section 4 concerning cannabis and driving. Finally, it has been reported anecdotally that cannabis can be used therapeutically to assist alcoholics in reducing or eliminating alcohol intake.(44)

The substitution of cannabis for alcohol would be particularly beneficial from the perspective of violence and violent crime. As noted by the U.S. National Commission on Marihuana and Drug Abuse in its report, Marihuana: A Signal of Misunderstanding:(45)

In sum, the weight of the evidence is that marihuana does not cause violent or aggressive behavior, if anything, marihuana generally serves to inhibit the expression of such behavior. Marihuana- induced relaxation of inhibitions is not ordinarily accompanied by an exaggeration of aggressive tendencies. no evidence exists that marihuana use will cause or lead to the commission of violent or aggressive behavior by the large majority of psychologically and socially mature individuals in the general population.

More recently, the 1994 NDARC report concluded that cannabis "appears to play little role in injuries caused by violence."(46)

The mainstream scientific community has long accepted that of all drugs, only alcohol has a consistent causal role in producing violent behaviour. For example,

Of all psychoactive substances alcohol is the only one whose consumption has been shown to commonly increase aggression. After large doses of amphetamines, cocaine, LSD, and PCP, certain individuals may experience violent outbursts, probably because of preexisting psychosis.(47)

With respect to a possible salutary effect of cannabis use on tobacco use and related harm, two recent studies from the UCLA School of Medicine are of interest. Both studies were headed by Dr. Donald Tashkin, one of America's foremost experts on marijuana smoking and lung function. In the first,(48) a total of 394 young men and women participated in the study. Researchers classified 131 of the participants as heavy cannabis smokers who did not smoke tobacco cigarettes, while 112 smoked both tobacco and cannabis. An additional 65 men regularly smoked tobacco only and the remaining 86 participants were non- smokers. All participants were screened for pre-existing chronic chest diseases and found to be healthy upon entering the study.

Each participant underwent pulmonary function testing at the start of the study, and again on multiple occasions over the course of the next eight years. During that interval, a number of patients were lost to follow up, but 255 participants (65 percent) completed the study and were tested again at up to six additional sessions.

The authors concluded:

Findings from the present long-term, follow-up study of heavy, habitual marijuana smokers argue against the concept that continuing heavy use of marijuana is a significant risk factor for the development of [chronic lung disease]. Neither the continuing nor the intermittent marijuana smokers exhibited any significantly different rates of decline in [lung function] as compared with those individuals who never smoked marijuana. . . . No differences were noted between even quite heavy marijuana smoking and non-smoking of marijuana.

These findings were in stark contrast to those experienced by tobacco-only smokers, who suffered a significant rate of decline in lung function. The study also found that people who smoked both cannabis and tobacco did not suffer any faster rate of decline in lung function than individuals who smoked cannabis alone. This is finding implies that cannabis might actually protect against some of the detrimental effects of tobacco smoking.

This latter conclusion was reinforced by the second, more recent UCLA study,(49) which showed that people who smoke both tobacco and cannabis consume 50 percent less tobacco over their lifetime and fifty percent less on a daily basis than tobacco-only smokers. Note, however, that in analysing these studies it is important to consider possible alternative causal explanations for the observed findings. For example, if say cannabis smokers are on average better-educated, and if better-educated tobacco smokers tend to smoke less tobacco, then one would find a measurable, but spurious, negative correlation between cannabis and tobacco. The UCLA results show that tobacco smokers who also smoke cannabis smoke less tobacco than tobacco smokers who don't smoke cannabis. But this doesn't show that, e.g., inducing a tobacco smoker to start smoking cannabis will reduce that person's tobacco consumption.(50)

This caveat notwithstanding, the findings summarised above indicate that any increased use of cannabis as a result of liberalising cannabis laws is likely to produce off-setting benefits in terms of reduced use of (and harm from) the more intrinsically harmful substances, alcohol and tobacco.

In summary, the substantial weight of evidence indicates that the repeal of cannabis prohibition (1) would likely result in only a minor increase in use, (2) that such increased use would be largely concentrated among adults and (3) would not have significant negative health effects, in part because cannabis is intrinsically a relatively benign substance for most people, and in part because any increase in cannabis use would likely be accompanied by a concomitant decrease in alcohol and tobacco use. The net effect of this scenario on public health would, if anything, be mildly positive.

Toward a Smarter Policy

As an American physician who has lived and worked in Wellington for three years, I have come to appreciate the common sense and maturity of New Zealand society. The United States often falls short in comparison, I'm afraid.

A striking example of this disparity is that Kiwis are permitted to buy codeine-containing medicines without a doctor's prescription, even though codeine is a narcotic(chemically related to heroin and carrying similar risks, including the possibility of addiction. These risks are communicated to adult users, who are credited with sufficient good judgement to use the drug safely. The fact that a few people purposely abuse codeine (as by making 'homebake') is not considered sufficient reason to keep this useful drug away from the rest of us.

Such a policy would not be acceptable in the United States, where codeine is available only on prescription. Indeed, anyone suggesting codeine be sold over the counter would be labeled 'soft on drugs'. I can hear it now: "What?! Make codeine more available?! But that would send the wrong message to America's youth(that it's all right to take drugs. We can't have that!"

Fortunately, New Zealanders are far too sensible for such foolishness.

But now we are faced with a riddle. Why would a society mature enough to buy and sell codeine over the counter embrace American-style prohibition policies towards cannabis?

Consider the following facts:

• According to a recent University of Otago study, more than half of all 21-year-olds use cannabis, exposing at a glance the futility and hypocrisy of prohibition.
• Based on an extensive medical literature (and on my own experience as an emergency room physician), cannabis is far less hazardous than alcohol or tobacco(or codeine. True, a small proportion of users will experience problems, including psychological dependence, but often these are the same people who have trouble with alcohol and with self-control in general.
• The lucrative black market created by prohibition guarantees that cannabis will be more available to school children than even alcohol or tobacco. Prohibition abdicates control of supply and distribution to criminals, gangs(and teenagers.
• By transforming drug-taking into criminal behaviour, prohibition discourages personal responsibility and impedes the prevention and treatment of drug-related problems.
• Police search-and-destroy operations cannot substantially affect cannabis supplies, as acknowledged by police commissioner Peter Doone shortly after the recent big bust near Wanganui.
• Cannabis law enforcement has been responsible for hundreds of cases of police perjury since 1976 (Dominion 31.5.96), staining an otherwise remarkably pristine force.

In view of these facts, why would a pragmatic and sensible society cling to such a counterproductive policy?

Part of the explanation lies, I believe, in New Zealand's geographical isolation, which makes it vulnerable to parochialism when international events are not fully reported by news media.

For example, most Kiwis are probably unfamiliar with the following recent events:

• Luxembourg's parliament adopted a motion urging the Government to open talks with Belgium and the Netherlands on a three-nation Benelux zone where cannabis can be smoked freely.
• In Spain, where adults are already permitted to smoke cannabis, a high-level court ruled they may also cultivate cannabis for personal use.
• California and Arizona legalised cannabis for medical purposes, and South Australia is actively considering such a move (Advertiser 15.3.97).
• The Victorian Premier's Drug Advisory Council recommended that adults be permitted to cultivate up to five cannabis plants (to order to reduce or eliminate the black market).
• The new police commissioner of New South Wales, Peter Ryan, recommended legalising cannabis (Daily Telegraph 22.2.97). The NSW director of public prosecution, Nicholas Cowdrey QC, supported Ryan's call, saying, "I think that when a regime is shown not to be working we should examine it very carefully and work out whether or not there is a better regime that should be in place."

These items (and others like them) have not been widely reported in New Zealand. As a result, Kiwis are largely unaware of the world-wide trend toward smarter cannabis policies( including regulation and taxation.

International experience also serves to allay two widely held fears concerning liberalisation of cannabis policy. First, evidence from Australia, Europe, and the U.S. has shown that making cannabis more available does not necessarily result in increased use. Indeed, teenage use tends to decline when cannabis loses its 'forbidden fruit' or 'rebel' status.

Second, use of cannabis does not lead to hard drugs. In fact, when access to cannabis is relaxed, use of hard drugs is reduced. This has been shown most clearly in Holland, where cannabis is available to anyone aged 16 and older. Use of hard drugs in Holland is among the lowest in Europe (much lower than in zero- tolerance France).

A second explanation for New Zealand's counterproductive cannabis policy is that the issue has been captured by self-styled (but often unqualified) 'experts', who are quick to disparage those who would promote debate. Too often, anyone brave (or foolish) enough to suggest a re-think on cannabis policy is condemned(even branded a drug user.

For this reason, most scientists and (real) experts have excused themselves from the debate, ensuring perpetuation of policies based solely on emotionalism and rhetoric. As such, New Zealand's cannabis policy stands as a major exception to the widely accepted principle of evidence-based policy making.

Albert Einstein once observed that insanity consists of doing the same thing over and over and expecting a different result. It's time to abandon failed prohibition policies and adopt something sensible that can actually work.

A society that can handle codeine over the counter can learn to live with cannabis.

David Hadorn, MD
Originally published in The Dominion (Wellington) 17 April 1997, p.9.
Permission to reprint pending