CMA Submission

Legalization, Regulation and
Restriction of Access to Marijuana
Government of Canada – Task Force on Marijuana
Legalization and Regulation

August 29, 2016

 The Canadian Medical Association (CMA) is the national
voice of Canadian physicians. Founded in 1867, the
CMA’s mission is helping physicians care for patients.
On behalf of its more than 83,000 members and the
Canadian public, the CMA performs a wide variety of
functions. Key functions include advocating for health
promotion and disease/injury prevention policies and
strategies, advocating for access to quality health care,
facilitating change within the medical profession, and
providing leadership and guidance to physicians to help
them influence, manage and adapt to changes in health
care delivery.
The CMA is a voluntary professional organization
representing the majority of Canada’s physicians and
comprising 12 provincial and territorial divisions and over
60 national medical organizations.

2

 Introduction
The Canadian Medical Association (CMA) is pleased to make this submission in response to the
consultation led by the federal Task Force on Marijuana Legalization and Regulation, which has the
objective of providing advice to the government on the design of a new framework for marijuana for nonmedical, or recreational, purposes.
The CMA has over 83,000 physician-members. Its mission is helping physicians care for patients and its
vision is to be the leader in engaging and serving physicians, and the national voice for the highest
standards for health and health care.
The Government of Canada has made a commitment to legalize, strictly regulate and restrict access to
a 1 2
marijuana in response to the high rates of marijuana use among Canadians, particularly youth
,
despite its current illegal status. The existing approach to drugs has resulted in high rates of criminal
b 3
records for non-violent drug offences each year , affecting disadvantaged groups disproportionately.
Organized crime is supported by these high levels of use. This situation has resulted in considerable
harm to society.
Public opinion in Canada and internationally has risen steadily in support of the removal of criminal
sanctions for simple marijuana possession, as well as for the legalization and regulation of marijuana.
The federal Task Force has developed a discussion paper, Toward the Legalization, Regulation and
4
Restriction of Access to Marijuana , which includes the following objectives for the new regime for legal
access to marijuana:
•
•
•
•
•

•
•

•
•

Protect young Canadians by keeping marijuana out of the hands of children and youth;
Keep profits out of the hands of criminals, particularly organized crime;
Reduce the burdens on police and the justice system associated with simple possession of
marijuana offences;
Prevent Canadians from entering the criminal justice system and receiving criminal records for
simple marijuana possession offences;
Protect public health and safety by strengthening, where appropriate, laws and enforcement
measures that deter and punish more serious marijuana offences, particularly selling and
distributing to children and youth, selling outside of the regulatory framework, and operating a motor
vehicle while under the influence of marijuana;
Ensure Canadians are well-informed through sustained and appropriate public health campaigns,
and, for youth in particular, ensure that risks are understood;
Establish and enforce a system of strict production, distribution and sales, taking a public health
approach, with regulation of quality and safety (e.g., child-proof packaging, warning labels),
restriction of access, and application of taxes, with programmatic support for addiction treatment,
mental health support and education programs;
Continue to provide access to quality-controlled marijuana for medical purposes consistent with
federal policy and Court decisions; and
Conduct ongoing data collection, including gathering baseline data, to monitor the impact of the
new framework.

a

Marijuana is the most commonly used illegal substance in Canada. 43% of Canadians claim to have used marijuana at some point
in their life, despite almost a century of prohibition. Canadian youth has the highest rate of marijuana use among 29 developed
countries. Almost a quarter of the population aged 15 to 24 years reported past-year use.
b

According to a Stats Canada report, there were 73 thousand marijuana-related criminal offences (67% of all police-reported drug
offences) in 2013.

3

 Context
The CMA has longstanding concerns about the health risks associated with consuming marijuana,
5 6
particularly in its smoked form. Children and youth are especially at risk for marijuana-related harms,
given their brain is undergoing rapid, extensive development.
c 7 8 9

Our understanding of the health effects of marijuana continues to evolve.
Marijuana use is linked to
several adverse health outcomes, including addiction, cardiovascular and pulmonary effects (e.g., chronic
bronchitis), mental illness, and other problems, including cognitive impairment and reduced educational
attainment. There seems to be an increased risk of chronic psychosis disorders, including schizophrenia,
in persons with a predisposition to such disorders. The use of high potency products, higher frequency of
use and early initiation are predictors of worse health outcomes.
d

The lifetime risk of dependence to marijuana is estimated at about 9% , increasing to almost 17% in those
10
who initiate use in adolescence. In 2012, about 1.3% of people aged 15 and over met the criteria for
e
f
marijuana abuse or dependence – double that of any other drugs – due to the high prevalence of
11
marijuana use.
Another area of great concern is that of impairment and the operation of vehicles, as well as the
performing of work in an unsafe manner. There is an increased risk of motor vehicle collisions up to 6
hours after use, depending on method of use, dose and tolerance. As well, experience in the U.S. and
even in Canada has shown that there can be an increased risk of unintentional overdoses in children due
to marijuana edibles.
The CMA’s overarching recommendation to the federal government is that the government must take a
broad public health policy approach to address the legalization and regulation of marijuana for nonmedical use. A public health approach would place an increased focus on: preventing drug abuse and
dependence; the availability of assessment, counselling and treatment services for those who wish to
stop using; and harm reduction to increase the safety for those who are using.
This approach seeks to ensure that the harms associated with enforcement are not out of proportion to
the direct harms caused by substance abuse. Individuals with drug dependency should be diverted,
whenever possible, from the criminal justice system to treatment and rehabilitation. Monitoring,
surveillance and research of marijuana use are essential to better understand the short and long term
harms as well as to develop policy options to address prevention, treatment, harm reduction and
enforcement.
There are huge economic pressures at play that need to be considered in a new regime and it is essential
12
that public health objectives be central to the process of legalization and regulation. A recent report
c

Unlike pharmaceuticals, marijuana is a complex combination of more than 100 different chemicals. The main psychoactive
component is delta-9-tetrahydrocannabinol (THC), but other components, such as cannabidiol (CBD), also act on the central
nervous system and may modify the effects of THC. The concentration of these compounds can vary substantially, making it difficult
to characterize the specific positive or negative health effects of marijuana, especially in uncontrolled and epidemiological studies.
As well, the average content of THC in marijuana has increased substantially in the last 30 years. For these and other reasons,
research and attribution of harm and benefit are challenging.
d

Similar estimates for other substances are 15% for alcohol, 23% for heroin and 32% for nicotine.

e

Abuse is characterized by a pattern of recurrent use where at least one of the following occurs: failure to fulfill major roles at work,
school or home, use in physically hazardous situations, recurrent alcohol or drug related problems, and continued use despite social
or interpersonal problems caused or intensified by alcohol or drugs.
f

Dependence is when at least three of the following occur in the same 12 month period: increased tolerance, withdrawal, increased
consumption, unsuccessful efforts to quit, a lot of time lost recovering or using, reduced activity, and continued use despite
persistent physical or psychological problems caused or intensified by alcohol or drugs.

4

 estimates that it could create a $10 billion a year industry in Canada, including production and
distribution. As well, legalizing marijuana will bring in considerable tax revenue, and governments could
collect as much as 50% or more of that if the rate of taxation is high, as in the ‘sin’ tax on the sale of
alcohol and tobacco. As well, legalization could also lead to substantial savings in enforcement and
incarceration. Given these pressures by private corporations, governments and other lobby groups, it is
essential that the federal and provincial/territorial governments be held accountable to public health
objectives of decreasing harms of marijuana use, particularly in children and youth.
The CMA’s submission does not address the question of whether marijuana should be legal; the current
federal government has already made it clear that this is their intent. Instead, this submission focuses on
specific recommendations from physicians as they apply to the regulatory framework, with the objective of
protecting individual and public health. It is based on input from CMA’s members, discussions with key
stakeholders and experts from specialty societies, a review of reports on the experience in jurisdictions
13 14 15 16
that have legalized marijuana for non-medical use, such as Colorado, Washington and Uruguay
17
18 19
, as well as expert literature
.
The Task Force’s discussion paper presents the potential elements of a new system, which were grouped
into five themes: 1) minimizing harms of use; 2) establishing a safe and responsible production system; 3)
designing an appropriate distribution system; 4) enforcing public safety and protection; and 5) accessing
marijuana for medical purposes. Each theme includes questions on specific concerns for which the Task
Force is seeking input. Presented below are the CMA’s recommendations to the federal government for
each section of the discussion paper. A summary of all recommendations is listed at the end of the brief.
RECOMMENDATION:
The CMA recommends that the federal government take a broad public health policy approach in
legalizing marijuana for non-medical purposes, and that it be held accountable to these public
health objectives.

1. MINIMIZING HARMS OF USE
1.1. Do you believe that these measures are appropriate to achieve the overarching
objectives to minimize harms, and in particular to protect children and youth? Are there
other actions which the government should consider enacting alongside these
measures?
Legalization and strict regulation of marijuana for recreational use seeks to reduce health and social
harms, particularly in higher risk groups; however, with the increased access, there could be an inverse
effect, with the potential that harms could be intensified. There is also the considerable risk that the
degree of “normalization” of use that already exists could increase.
Colorado has seen an increase in marijuana-related traffic deaths and an increase in the use of health
care due to intoxication, burns and cyclic vomiting syndrome, as well as overdoses in children due to
20 21 22
marijuana in edibles.
Many of the regulatory interventions used in reducing tobacco normalization and rates, as well as
controlling the harms of alcohol at a population level, are proposed in the Task Force’s discussion paper
as part of a framework for marijuana legalization and regulation. These include:

5

 1) Minimum age for legal purchase with the objective of protecting children and youth, particularly
since the risks of marijuana use are higher in ages where the brain is still in development.
2) Advertising and marketing restrictions to minimize the profile and attractiveness of products,
seeking to prevent or at least reduce the “normalization” of use in society, particularly among
children and youth.
3) Taxation and pricing to discourage use and provide the government with revenues to offset
related costs (such as substance abuse services, law enforcement and regulatory oversight).
4) Restrictions on marijuana products, particularly with regards to the THC component, given higher
concentration products have added risks and unknown long term impacts, with most impact on
children and youth. Restrictions would include maximum THC limits and prohibition of highpotency products.
5) Restrictions on types of marijuana products, particularly edibles, to prevent accidental or
unintentional ingestion, particularly by children. Limits would be placed on dosing and potency.
6) Limitations on quantities for personal possession, with the objective of helping to reduce demand
and to minimize opportunities for resale of legally purchased marijuana on the illicit market
(particularly to children and youth).
7) Limitation on where marijuana can be sold in order to minimize harms.
Despite the merit of each of the proposed measures, collectively these may not adequately protect
children and youth. A pathway to better implementation would require:


Taking the time to adequately prepare for the implementation, including developing the capacity
to meet demand, administer the system, enforce regulations and deal with adverse effects. A
phased-in approach or pilots in certain jurisdictions should be considered before going
nationwide.



Learning from the lessons gained in jurisdictions that have made changes in drug policy,
including the U.S. states of Colorado and Washington, Uruguay, the Netherlands and Portugal.



Learning from successes and failures in the regulation of tobacco and alcohol, with respect to the
objectives of reducing or eliminating use for all Canadians (tobacco) and promoting responsible
use among adults, while prohibiting use in youth (alcohol).



Developing the capacity to carry out a rigorous national-level evaluation of the impact of
legalization of marijuana on the health and safety of Canadians. Data collection and analysis
cannot be conducted if national surveillance systems do not exist. Important data to be monitored
include marijuana-related emergency room visits and hospitalizations, rates of drug-impaired
driving, recreational injuries, unintentional poisonings, product contamination, overconsumption
23
and food-borne illness from edible products.



Support for a research agenda to better understand harms of marijuana, particularly among
vulnerable groups such as children and youth, pregnant women, people with mental illness and
chronic diseases. Research should also support policy interventions, including those to address
second hand smoke, harm reduction measures, treatments and effective education strategies.

6

 The CMA is supportive of the regulatory interventions proposed by the government to reduce the harms,
regarding:
Marketing and advertising: The CMA recommends that the marketing and advertising of marijuana be
prohibited, as is currently the case for tobacco and cigarettes. Measures such as plain packaging,
prohibition of appealing flavours and shapes, adequate content and potency labelling, as well as health
warnings, should be incorporated to discourage experimentation. A package insert should outline health
risks and supporting references, the need for securing the product in the home, preventing access by
youth and children, and recommendations not to drive or work with hazardous chemicals or equipment.
The insert should include information detailing the health and social consequences, including legal
penalties for providing marijuana to those under a designated minimum age for purchasing.
Taxation and pricing: Taxation and pricing levers should be used to discourage use, with revenues
clearly earmarked for covering the health and social costs of legalization. In Colorado, for example,
revenue is used in substance abuse programs, regulation of marijuana and for public school construction.
However, as with tobacco, final pricing must be such as to discourage the illegal production and
trafficking of marijuana. Most of future tax revenues should be redistributed to the provinces and
territories. This is because they will feel the impact of legalization directly as they have jurisdiction over
health care, education, social and other services, as well as responsibility for enforcement.
Restrictions on the potency of marijuana products: Experience in jurisdictions where marijuana has
been legalized has shown that restrictions on the potency of products (i.e., THC limits) are necessary,
given the higher risks of harm associated with higher potencies. Prohibition of high potency products is
important. However, there is a risk that the prohibition could lead to an illicit market of more potent
marijuana preparations.
Restrictions on types of marijuana products: It is essential that restrictions be placed on the dosing of
products, particularly of edibles, given the incidence of accidental overdoses of children. Content in a
package should not be sufficient to cause an overdose. Because of these incidents, child proof packaging
should also be required.
Limitations on quantities for personal possession: Placing maximum limits on quantities that can be
purchased would help to reduce the opportunities for illegal distribution and sale, especially to those
below the established minimum age limit.
The proposed measures related to minimum age for legal purchase and limitation on where
marijuana can be sold are discussed in Sections 1.2 and 3, respectively, below.
In addition to the regulatory interventions proposed in the “Minimizing Harms of Use” section of the
discussion paper, others are equally fundamental, including:
A clear process for identifying, testing and charging individuals who are driving under the
influence of marijuana should be in place prior to legalization (see further discussion under
Section 4).
Public education: The use of public education tools to inform youth and families of the risks and
harms of marijuana use is necessary. Awareness of Canadians of the harms of marijuana is
24 25 26
generally low.
Youth tend to emphasize the drug’s ability to help them focus, relax, sleep,
reduce violent behaviour and improve creativity. There are also many dangerous myths, such as

7

 that marijuana can counter the harmful effects of smoking tobacco by preventing cancer or that
marijuana makes people better drivers. There is also a perception amongst some that marijuana
is not an addictive substance because it is “natural”.
However, traditional public campaigns and educational programs for youth have been shown to
be minimally effective. There is a need for more effective programs, including those that
incorporate skills-based training that teaches youth how to handle situations that involve drugs
and/or alcohol.
Harm reduction measures, such as those outlined in the Lower Risk Cannabis Use Guidelines for
g 27
Canada
should be discussed, particularly with teens, in an effort to minimize harm, even if they
choose to continue to use.
It is important that these education programs be designed by governments and health
professionals, and not marijuana producers or distributers. However, costs of such programs
could come from the profits of such industries.
Expanded access and immediate availability of substance use, mental health and social
stabilization services is another very important measure to minimize harm. These services are
currently difficult to access in the community and have long wait times; in many parts of Canada
they are simply unavailable. A plan to expand training programs in addiction medicine and access
to treatment should be in place prior to legalization.
Enforcement of regulations: Licensed producers and retail outlets should be held accountable
in their compliance with policies, guidance and good practices to prevent contaminants that may
cause additional health issues if consumed, particularly by minors (See also Section 3).

1.2. What are your views on the minimum age for purchasing and possessing marijuana?
Should the minimum age be consistent across Canada, or is it acceptable that there be
variation amongst provinces and territories?
In order to achieve the first objective of legalization, i.e., to protect young Canadians by keeping
marijuana out of the hands of children and youth, a minimum age for its purchase and possession must
be adopted. This has been an important measure in tobacco and alcohol regulations. Existing evidence
on marijuana points to the importance of protecting the brain during its development. Since that
development is only finalized by about 25 years of age, this would be an ideal minimum age based on
currently accepted scientific evidence, although knowledge on brain development is still evolving.
However, marijuana use among youth (ages 15 to 24) is still double that of the general population, at
28
20%, even though there has been a slight decrease in use in recent years. A 2011 report on student
alcohol and drug use in Canada showed that of those youth who had used marijuana in the past 3
months, 25% had used it daily. The average age of initiation was 16.1 years. In some provinces, about
29
50% of students in grade 12 have reported using marijuana in the past year.

g

These include delaying use until early adulthood; avoiding frequent use; preferring smokeless delivery systems; using less potent
products; not driving after use; and abstaining from use when at higher risk of cannabis-related problems (people with a personal or
family history of psychosis, cardiovascular problems and pregnant women).

8

 A minimum age lower than 25 years should be considered in order to deter youth from seeking marijuana
from organized crime groups, where they are exposed to other more dangerous drugs, sometimes even
laced into marijuana.
In jurisdictions where marijuana has been legalized, the minimum age has been set at the same minimum
age for purchase of alcohol, i.e., 21 years. In Canada, the age limits for acquiring alcohol and tobacco are
either 18 or 19 years of age, depending on the province or territory. In a survey carried out with a sample
of the CMA membership, 25.4% recommended age 21, 20.3% age 25, 19.7% age 18, and 14.2% age 19.
The CMA recommends that the minimum age should be set at 21, and that quantities and the potency of
marijuana be more restricted to those under age 25 to discourage use and sharing with underage friends.
The CMA recommends that the minimum age be established at the national level, and federally
regulated, to avoid differences at the provincial/territorial level. This would reduce problems with
enforcement in areas near provincial/territorial borders.
SECTION 1 RECOMMENDATIONS:
The CMA recommends that the federal government incorporate the following measures to support
improved implementation of the legalization of marijuana:
a) Ensure sufficient time to adequately prepare for the implementation of the legalized
regime, including a phased-in approach and piloting legalization in smaller regions prior to
national roll-out;
b) Assess international experience with legalization and incorporate lessons-learned from
other jurisdictions into Canada’s approach;
c) Assess the domestic experience in the regulation of tobacco and alcohol against meeting
the national objectives for each substance and incorporate lessons-learned from those
experiences; and,
d) Develop capacity for national surveillance to ensure rigorous national-level monitoring
and evaluation.
e) Support for a research agenda.
The CMA recommends that the federal government prohibit the marketing and advertising of
marijuana and that packaging requirements include plain packaging, potency labelling and health
warnings. The CMA further recommends that the federal government prohibit flavouring and
shapes.
The CMA recommends that the federal government employ taxation and pricing levers to
discourage consumption and that the revenues of this taxation be allocated to the provinces and
territories and clearly allocated for health and social services.
The CMA recommends that the federal government establish potency restrictions to reduce the
harms associated with higher potencies.
The CMA recommends that the federal government establish dosing restrictions on marijuana
products, notably edibles.
The CMA recommends that the federal government establish maximum limits on quantities of
marijuana that can be purchased.

9

 The CMA recommends that the federal government employ effective public education tools,
including skills-based training, to inform youth and families of the risks and harms of marijuana
usage.
The CMA recommends that the federal government expand access and availability of substance
use, mental health and social stabilization services simultaneously to the legalization of
marijuana.
As part of this initiative, the CMA recommends that the federal government implement a plan to
expand training programs in addiction medicine.
The CMA recommends that the federal government set the minimum age of purchase and
consumption at 21 and that quantities and potency be restricted for those under the age of 25.
The CMA recommends that the federal government establish the minimum age at the national
level to ensure consistency across all jurisdictions.

2. ESTABLISHING A SAFE AND RESPONSIBLE
PRODUCTION SYSTEM
2.1. What are your views on the most appropriate production model? Which production
model would best meet consumer demand while ensuring that public health and safety
objectives are achievable? What level and type of regulation is needed for producers?
There will be no perfect production model, with each one having its risks and benefits. The CMA would
support a tightly regulated competitive model. A set number of licenses should be granted to producers,
who are part of a competitive system, and there should be a reasonable cost associated to offset
regulatory expenses. Producers would have to comply with policies and guidelines set by Health Canada,
and be subject to inspections.
It is fundamental that commercialization is rigorously controlled through taxation, regulation, monitoring
and advertising controls.

2.2. To what extent, if any, should home cultivation be allowed in a legalized system?
What, if any, government oversight should be put in place?
The CMA does not recommend home cultivation in a legalized system for non-medical purposes, as it
presents many challenges to municipal, enforcement and public health authorities, particularly given the
potentially high number of homes that could seek to cultivate marijuana.
There are many health and safety hazards in cultivation, such as high humidity and temperatures, risk of
fire, as well as the use of hazardous chemicals, including pesticides used for the control of fungi, bacteria
and insects. There is little quality control regarding contamination and potency of the product. As well,
home cultivation has an enhanced risk of abuse, if individuals use the production for sale rather than
exclusively for personal use. Access to marijuana by children and youth is also a serious concern with
home cultivation.
In the present marijuana for medical purposes system, where some users have been allowed to continue
to grow for personal use, there is great difficulty in monitoring and inspecting these properties. However,

10

 this has been allowed given the Allard v Canada court decision, to not hinder access for medical
purposes.
Washington has not permitted home cultivation, but Colorado has allowed the growth of a small number
of plants for personal use (up to 6 plants, with a maximum 3 mature ones, in an enclosed, locked space).

2.3. Should a system of licensing or other fees be introduced?
Should limited home cultivation for non-medical purposes be an option, a system of registration and
licensing would have to be set up to allow for tracking and inspections of home production. It would also
allow penalties for non-registered producers as well as larger scale operations. This would be a system
that would require intense government regulation, oversight and tremendous resources to be effective.

2.4. The MMPR set out rigorous requirements over the production, packaging, storage
and distribution of marijuana. Are these types of requirements appropriate for the new
system? Are there features that you would add or remove?
The requirements for production, packaging, storage and distribution of marijuana set out by the MMPR
are appropriate for the new system. However, a rigorous review of the MMPR should be conducted to
determine if there are weaknesses that need to be corrected before expanding to a non-medical market.
Ongoing evaluation will be warranted as well. Distribution would have to expand beyond the mail service.

2.5. What role, if any, should existing licensed producers under the MMPR have in the
new system (either in the interim or the long-term)?
The CMA’s policy position does not extend to whether the existing licensed producers should be suppliers
to the recreational market. The experience in Colorado, however, showed that having the industry set up
for medical purposes first allowed a smoother transition, in contrast with Washington, which did not have
an industry.
SECTION 2 RECOMMENDATIONS:
The CMA supports a tightly regulated competitive model wherein production and distribution is
heavily regulated and includes strict oversight.
The CMA recommends that the federal government prohibit home cultivation in the legalized
system for non-medical use.
The CMA recommends that the federal government evaluate the requirements established by the
MMPR system for production, packaging, storage and distribution to introduce improvements for
implementation in the new legalized system for non-medical use.

3. DESIGNING AN APPROPRIATE DISTRIBUTION SYSTEM
3.1. Which distribution model makes the most sense and why?
There is the need to continue mail availability for patients accessing marijuana for medical purposes to
ensure nationwide access, however, a distribution system based exclusively on mail service would
probably not meet the objectives of a recreational system.

11

 When a sample of our membership was asked about distribution models, first preference was given to
existing non-health care structures, such as liquor stores. In some provinces, they would have the
additional benefit of having a tightly regulated government monopoly by control board entities with a
social responsibility mandate. Restrictions could be placed to limit the acquisition of both alcohol and
marijuana. As stated earlier, marketing should be prohibited. Staff in these stores receives training and
hours can be limited.
A close second preference was given to legal storefronts, similar to the independent dispensaries.
Several municipalities have been in varied degrees of discussion on the regulation of the presently illegal
dispensaries, and those regulations could be looked at as models in a legalized environment.
When asked about health care settings, such as pharmacies, respondents to the survey did not support
this model. Almost 60% disagreed or strongly disagreed. A reason for this lack of support could be that
placing marijuana in pharmacies could lend it credibility as a pharmaceutical medication, whereas placing
it in liquor stores would send the message that it needs strict and formal controls.
As per previous discussion, the creation of private industries for production and distribution would have to
be very tightly controlled to avoid commercialization. As we have learned from the alcohol and tobacco
industries, private companies have an interest in recruiting customers and encouraging high levels of
ongoing consumption. It is important that the regulatory framework be protected from these commercial
and fiscal interests.
Regardless of the actual point of sale, storefront densities should be federally set and restrictive. There is
good evidence from the regulation of alcohol that the less restrictive retail outlet density is, the more
harms associated with alcohol use occur. Restrictions would also be placed on distances from schools,
parks, playgrounds, colleges and universities, as well as on hours of sale. Regulations would lay out
standards, including for the control of product sources, proof of minimum age required for purchase and
restrictions on quantities sold.

3.2. To what extent is variation across provinces and territories in terms of distribution
models acceptable?
In the CMA’s survey of our members, there was not a consensus among respondents as to whether
provincial and territorial governments should decide on their own distribution mechanisms. Many
comments stated that a federal standard is warranted due to the need for initial close oversight and the
ability to make effective changes more quickly. The CMA position is that there is an important role for the
federal government to play in ensuring consistency across the country and avoiding provincial/territorial
variation.

3.3. Are there other models worthy of consideration?
The CMA recommends a phased in approach to the roll out of the system of distribution. Several pilot
locations could be considered before going nationwide. Given the novelty and impact of this new
legislation, particular caution is absolutely necessary from a regulatory and public health perspective.

SECTION 3 RECOMMENDATIONS:
The CMA recommends that the distribution model should occur outside health care structures, for
example, in liquor stores, and that storefront densities should be federally set and restrictive.

12

 The CMA recommends that the distribution model should be established at the federal level and
be consistent across jurisdictions.
The CMA recommends a phased implementation approach prior to national availability.

4. ENFORCING PUBLIC SAFETY AND PROTECTION
4.1. How should governments approach designing laws that will reduce, eliminate and
punish those who operate outside the boundaries of the new legal system for marijuana?
The severity of punishment for simple possession and personal use of marijuana should be eliminated
with the removal of criminal sanctions. The CMA recommends that resources currently devoted to
combating simple marijuana possession through the criminal law be diverted to public health and
education strategies, particularly for youth. Having a criminal record limits employment prospects, and the
impact on health status is profound, disproportionately among marginalized populations. Laws should
include such things as the facilitation of access by individuals to services to address substance use,
mental health and social stabilization. Laws should be drafted in a clear fashion to minimize ambiguity
and provide as much guidance and direction to users, health care providers, enforcement authorities,
producers, distributors and others.

4.2. What specific tools, training and guidelines will be most effective in supporting
enforcement measures to protect public health and safety, particularly for impaired
driving?
The use of marijuana is associated with an increased risk of impairment, and is incompatible with the
operation of vehicles and work in safety sensitive positions due to risk of injury to oneself, coworkers or
the general public.
Marijuana use is associated with an increased risk of motor vehicle crashes. Young people, particularly
males, are more likely to drive after using marijuana. The Cross-Canada Report on Student Alcohol and
30
Drug Use states that 14–21% of students in Grade 12 reported having driven within an hour of using
marijuana, and more than 33% of Grade 12 students reported having been a passenger in a car where
the driver had used the drug. Often, marijuana is associated with alcohol use, having an additive effect.
A clear and reliable process for identifying, testing and imposing consequences on individuals who use
marijuana and drive absolutely needs to be in place nationally prior to legalization. This will be
complicated by the fact that a roadside test for marijuana use is not in widespread use; blood and urine
testing also pose challenges. Another issue is the fact that recent use does not necessarily equate to
impairment and no scientific standard for impairment exists in the literature.
All individuals charged with impaired driving should have a specialist assessment to determine whether a
substance use disorder is present. Individuals with substance use disorders should have immediate
access to addiction treatment, mental health services and social stabilization.
There is also a need for the development of guidelines for employers for the assessment and
management of risk.

13

 4.3. Should consumption of marijuana be allowed in any publicly-accessible spaces
outside the home? Under what conditions and circumstances?
No public smoking should be permitted, due to the risk of second hand smoke. Second hand marijuana
smoke contains many of the same toxins, including carcinogens, found in directly inhaled marijuana
smoke, in similar amounts, if not more. There is special concern for harmful health effects, especially
among children. The CMA does not recommend the exposure of children to second hand smoke in public
areas or in the home. The success in the reduction of tobacco use rates is significantly related to banning
of smoking in public places.
In the CMA’s survey of a sample of its members, 51.7% disagreed with consumption in designated public
places, such as the Dutch model of coffee shops.

SECTION 4 RECOMMENDATIONS:
The CMA recommends that the federal government reallocate resources currently dedicated to the
enforcement of marijuana infractions, to public health, education and treatment programs.
The CMA recommends that the federal government ensure that a clear and reliable process for
identifying, testing and imposing consequences on individuals who operate a motor vehicle under
the influence of marijuana be in place nationally prior to the legalization of marijuana.
The CMA recommends that the federal government prohibit smoking of marijuana for non-medical
purposes in public places.

5. ACCESSING MARIJUANA FOR MEDICAL PURPOSES
5.1. What factors should the government consider in determining if appropriate access to
medically authorized persons is provided once a system for legal access to marijuana is in place?
The CMA recognizes that some individuals suffering from terminal illness or chronic disease for which
conventional therapies have not been effective may obtain relief with marijuana used for medical
purposes. However, clinical evidence of medical benefits is limited and there is very limited guidance for
the therapeutic use, including indications, potency (levels of THC, CBD), interactions with medications
and adverse effects. Health Canada does not approve of marijuana as a medicine, as it has not gone
through the approvals required by the regulatory process to be a pharmaceutical.
The present system poses a serious challenge for physicians in providing the best care to patients. The
CMA has long called for more research to better understand potential therapeutic indications, as well as
its risks. It is important that there be support for research of marijuana in order to develop products that
can be held to pharmaceutical standards, as is the case with dronabinol (Marinol®), nabilone (Cesamet®)
and THC/CBD (Sativex®).
The present marijuana for medical purposes regime operates as an exception to a criminal prohibition for
production, possession and trafficking of marijuana. It was developed in reaction to court challenges
regarding the right to legal access of individuals to marijuana for medical purposes.
With the new legal system for marijuana for non-medical use, the requirement to maintain a separate
regulatory framework would not be necessary, given court-mandated access will be provided. As well, the
experience of legalization for non-medical use in Colorado and Washington has shown that two separate

14

 regimes with distinct regulations can be very difficult to enforce given the dual standards (including
different minimum ages, purchase quantities and taxation).
Provisions would have to exist within the new system to attend to legitimate medical needs of individuals
who are under the minimum age for purchase of marijuana, or for those with a requirement for a more
potent product than that which is legally available. Consideration might also be given to affordable access
for those with low incomes.
As stated previously, the option of distribution through mail would have to continue, to facilitate access in
remote areas. As well, patients or their families would be able to access marijuana through the
distributors of marijuana for non-medical purposes, such as storefronts or liquor store-like entities, which
would have employees trained to support patients and their needs.
The use of marijuana products for medical indications, through this system, should preferably be done
under research protocols. This framework would contribute to the provision of more robust scientific data.

SECTION 5 RECOMMENDATION:
The CMA recommends that there be only one regime for marijuana, following legalization of nonmedical marijuana, with provisions for the medical needs of those who would not be able to
acquire marijuana in a legal manner, e.g., those below the minimum age or those with a
requirement for a more potent product than legally available.

6. Summary of Recommendations
The CMA appreciates the opportunity to provide feedback on this important matter to physicians and the
public. Legalization of marijuana for non-medical purposes is a fundamental shift in the approach to
drugs. The CMA’s position is that it is essential that the government consult with experts, key
stakeholders and the general public not only at this phase in preparation for legislation on this matter, but
throughout the process of the development of regulations and implementation.
Recommendations:
1) The CMA recommends that the federal government take a broad public health policy approach in
legalizing marijuana for non-medical purposes, and that it be held accountable to these public health
objectives.

Section 1
2) The CMA recommends that the federal government incorporate the following measures to support
improved implementation of the legalization of marijuana:
a) Ensure sufficient time to adequately prepare for the implementation of the legalized regime,
including a phased-in approach and piloting legalization in smaller regions prior to national rollout;
b) Assess international experience with legalization and incorporate lessons-learned from other
jurisdictions into Canada’s approach;

15

 c) Assess the domestic experience in the regulation of tobacco and alcohol against meeting the
national objectives for each substance and incorporate lessons-learned from those experiences;
and,
d) Develop capacity for national surveillance to ensure rigorous national-level monitoring and
evaluation.
e) Support for a research agenda.
3) The CMA recommends that the federal government prohibit the marketing and advertising of
marijuana and that packaging requirements include plain packaging, potency labelling and health
warnings. The CMA further recommends that the federal government prohibit flavouring and shapes.
4) The CMA recommends that the federal government employ taxation and pricing levers to discourage
consumption and that the revenues of this taxation be allocated to the provinces and territories and
clearly allocated for health and social services.
5) The CMA recommends that the federal government establish potency restrictions to reduce the
harms associated with higher potencies.
6) The CMA recommends that the federal government establish dosing restrictions on marijuana
products, notably edibles.
7) The CMA recommends that the federal government establish maximum limits on quantities of
marijuana that can be purchased.
8) The CMA recommends that the federal government employ effective public education tools, including
skills-based training, to inform youth and families of the risks and harms of marijuana usage.
9) The CMA recommends that the federal government expand access and availability of substance use,
mental health and social stabilization services simultaneously to the legalization of marijuana.
10) As part of this initiative, the CMA recommends that the federal government implement a plan to
expand training programs in addiction medicine.
11) The CMA recommends that the federal government set the minimum age of purchase and
consumption at 21 and that quantities and potency be restricted for those under the age of 25.
12) The CMA recommends that the federal government establish the minimum age at the national level to
ensure consistency across all jurisdictions.

Section 2
13) The CMA supports a tightly regulated competitive model wherein production and distribution is
heavily regulated and includes strict oversight.
14) The CMA recommends that the federal government prohibit home cultivation in the legalized system
for non-medical use.
15) The CMA recommends that the federal government evaluate the requirements established by the
MMPR system for production, packaging, storage and distribution to introduce improvements for
implementation in the new legalized system for non-medical use.

16

 Section 3
16) The CMA recommends that the distribution model should occur outside health care structures, for
example, in liquor stores, and that storefront densities should be federally set and restrictive.
17) The CMA recommends that the distribution model should be established at the federal level and be
consistent across jurisdictions.
18) The CMA recommends a phased implementation approach prior to national availability.

Section 4
19) The CMA recommends that the federal government reallocate resources to the enforcement of
marijuana infractions to public health, education and treatment programs.
20) The CMA recommends that the federal government ensure that a clear and reliable process for
identifying, testing and imposing consequences on individuals who operate a motor vehicle under the
influence of marijuana be in place nationally prior to the legalization of marijuana.
21) The CMA recommends that the federal government prohibit smoking of marijuana for non-medical
purposes in public places.

Section 5
22) The CMA recommends that there be only one regime for marijuana, following legalization of nonmedical marijuana, with provisions for the medical needs of those who would not be able to acquire
marijuana in a legal manner, e.g., those below the minimum age or those with a requirement for a
more potent product than legally available.

References
1

Rotermann M, Langlois, K. Prevalence and correlates of marijuana use in Canada, 2012. Health
Reports. 2015 Apr;26(4):10-5. Statistics Canada Catalogue no. 82-003-X. Available:
http://www.statcan.gc.ca/pub/82-003-x/2015004/article/14158-eng.pdf (accessed August 12, 2016).
2

UNICEF Office of Research. Child Well-being in Rich Countries: A Comparative overview. Innocenti
Report Card 11. Florence: UNICEF Office of Research; 2013. Available: https://www.unicefirc.org/publications/pdf/rc11_eng.pdf (accessed August 12, 2016).
3

Cotter A, Greenland J, Karam M. Drug-Related Offences in Canada, 2013. Juristat. 2015 Jun 25;1-38.
Catalogue no. 85-002-X. Available: http://www.statcan.gc.ca/pub/85-002-x/2015001/article/14201eng.pdf (accessed 2016 Aug 11).
4

Task Force on Marijuana Legalization and Regulation. Ministry of Justice, Ministry of Public Safety and
Emergency Preparedness and Ministry of Health. Toward the legalization, regulation and restriction of
access to marijuana. Discussion paper. Ottawa: Cannabis Legalization and Regulation Secretariat; 2016.
Available: http://www.healthycanadians.gc.ca/health-system-systeme-sante/consultations/legalizationmarijuana-legalisation/alt/legalization-marijuana-legalisation-eng.pdf (accessed July 25, 2016).
5

Canadian Medical Association (CMA). Health risks and harms associated with the use of marijuana.
CMA Submission to the House of Commons Standing Committee on Health. Ottawa: Canadian Medical
Association; 2014. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/BriefMarijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2016 Aug 12).

17

 6

Canadian Medical Association (CMA). A public health perspective on cannabis and other illegal drugs.
CMA Submission to the Special Senate Committee on Illegal Drugs. Ottawa: Canadian Medical
Association; 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed
2016 Aug 16).
7

Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med.
2014 Jun 5;370(23):2219–2227. Available:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827335/pdf/nihms762992.pdf (accessed 2016 Aug 15).
8

Wilkinson ST, Yarnell S, Radhakrishnan R, Ball SA, D'Souza DC. Marijuana Legalization: Impact on
Physicians and Public Health. Annu Rev Med. 2016 Jan 14;67:453-466. doi:
http://dx.doi.org/10.1146/annurev-med-050214-013454. (accessed 2016 Aug 12).
9

World Health Organization (WHO). Management of substance abuse: Cannabis. Geneva: World Health
Organization; 2016. Available: http://www.who.int/substance_abuse/facts/cannabis/en/ (accessed 2016
Aug 16).
10

Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. The Lancet, 2009 Oct
23;374(9698):1383-91. doi: http://dx.doi.org/10.1016/S0140-6736(09)61037-0. (accessed 2016 Aug 12).
11

Statistics Canada. Canadian Community Health Survey – Mental Health, 2012. The Daily. Ottawa:
Statistics Canada; 2013 Sep 18. Component of Statistics Canada catalogue no. 11-001-X. p. 1-2.
Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2016 Aug 12).
12

Shenfeld A. Growing Their Own Revenue: The Fiscal Impacts of Cannabis Legalization. Economic
Insights. Toronto: CIBC World Markets Inc.; 2016 Jan 28. p. 7-8. Available:
http://research.cibcwm.com/economic_public/download/eijan16.pdf (accessed 2016 Aug 11).
13

Canadian Centre on Substance Abuse (CCSA). Cannabis Regulation: Lessons Learned In Colorado
and Washington State. Ottawa: Canadian Centre on Substance Abuse, 2015. Available:
http://www.ccsa.ca/Resource%20Library/CCSA-Cannabis-Regulation-Lessons-Learned-Report-2015en.pdf (accessed 2016 Aug 15).
14

Canadian Centre on Substance Abuse (CCSA). Marijuana for Non-Therapeutic Purposes: Policy
Considerations. Ottawa: Canadian Centre on Substance Abuse, 2014. Available:
http://www.ccsa.ca/Resource%20Library/CCSA-Non-Therapeutic-Marijuana-Policy-Brief-2014-en.pdf
(accessed 2016 Aug 15).
15

Retail Marijuana Public Health Advisory Committee. Monitoring Health Concerns Related to Marijuana
in Colorado: 2014. Denver (CO): Colorado Department of Public Health and Environment; 2015.
Available:
http://www2.cde.state.co.us/artemis/hemonos/he1282m332015internet/he1282m332015internet01.pdf
(accessed 2016 Aug 16).
16

Blue Ribbon Commission on Marijuana Policy. Pathways Report: Policy Options for Regulating
Marijuana in California. Denver (CO): Blue Ribbon Commission on Marijuana Policy; 2015. Available:
https://www.safeandsmartpolicy.org/wp-content/uploads/2015/07/BRCPathwaysReport.pdf (accessed
2016 Aug 15).
17

Walsh J, Ramsey G. Uruguay’s Drug Policy: Major Innovations, Major Challenges. Washington (DC):
Brookings Institution, Washington Office on Latin America; 2015. Available:
https://www.brookings.edu/wp-content/uploads/2016/07/Walsh-Uruguay-final.pdf (accessed 2016 Aug
15).
18

Centre for Addiction and Mental Health (CAMH). Cannabis Policy Framework. Toronto: Centre for
Addiction and Mental Health; 2014. Available:
http://www.camh.ca/en/hospital/about_camh/influencing_public_policy/documents/camhcannabispolicyfra
mework.pdf (accessed 2016 Aug 10).

18

 19

George T, Vaccarino F. (eds.). Substance abuse in Canada: The effects of cannabis use during
adolescence. Ottawa: Canadian Centre on Substance Abuse; 2015. Available:
http://www.ccsa.ca/Resource%20Library/CCSA-Effects-of-Cannabis-Use-during-Adolescence-Report2015-en.pdf (accessed 2016 Aug 16).
20

Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System
(BRFSS) Survey. Atlanta (GA): Centers for Disease Control and Prevention; 2016. Available:
http://www.cdc.gov/brfss/ (accessed 2016 Aug 10).
21

Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA). Legalization of Marijuana in
Colorado. The Impact. 2014 Aug;2:1-166. Available:
http://www.rmhidta.org/html/august%202014%20legalization%20of%20mj%20in%20colorado%20the%20
impact.pdf (accessed 2016 Aug 15).
22

Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA.
2015;313(3):241-42. Available:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404298/pdf/nihms679104.pdf (accessed 2016 Aug 15).
23

Retail Marijuana Public Health Advisory Committee. Monitoring Health Concerns Related to Marijuana
in Colorado: 2014. Denver (CO): Colorado Department of Public Health and Environment; 2015.
Available:
http://www2.cde.state.co.us/artemis/hemonos/he1282m332015internet/he1282m332015internet01.pdf
(accessed 2016 Aug 16).
24

Cunningham JA, Blomqvist J, Koski-Jannes A, Raitasalo K. Societal Images of Cannabis use:
Comparing Three Countries. Harm Reduct J. 2012 Jun 18;9:21. Available:
http://www.biomedcentral.com/content/pdf/1477-7517-9 -21.pdf (accessed 2016 Aug 15).
25

Porath-Waller A, Brown J, Frigon A, Clark H. What Canadian youth think about cannabis: Technical
report. Ottawa: Canadian Centre on Substance Abuse; 2013. Available:
http://www.ccsa.ca/Resource%20Library/CCSA-What-Canadian-Youth-Think-about-Cannabis-2013en.pdf (accessed 2016 Aug 12).
26

Health Canada. Canadian Addiction Survey (CAS): A national survey of Canadians' use of alcohol and
other drugs: Public opinion, attitudes and knowledge. Ottawa: Health Canada; 2006. Available:
http://publications.gc.ca/site/eng/349980/publication.html (accessed 2016 Aug 15).
27

Fischer B, Jeffries V, Hall W, Room R, Goldner E, Rehm J. Lower Risk Cannabis Use Guidelines for
Canada (LRCUG): A Narrative Review of Evidence and Recommendations. Can J Public Health. 2011
Sep-Oct;102(5):324-27. Available: http://journal.cpha.ca/index.php/cjph/article/view/2758 (accessed 2016
Aug 16).
28

Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS). Ottawa: Health
Canada; 2013. Available: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaireeng.php (accessed 2016 Aug 12).
29

Young MM, Student Drug Use Surveys Working Group (SDUS). Cross-Canada report on student
alcohol and drug use: Technical report. Ottawa: Canadian Centre on Substance Abuse; 2011. Available:
http://www.ccsa.ca/Resource%20Library/2011_CCSA_Student_Alcohol_and_Drug_Use_en.pdf
(accessed 2016 Aug 16).
30

Young, M.M. et al. (2011) Cross-Canada report on student alcohol and drug use: Technical report.
Ottawa, ON: Canadian Centre on Substance Abuse. Available:
http://www.ccsa.ca/Resource%20Library/2011_CCSA_Student_Alcohol_and_Drug_Use_en.pdf
(accessed 2016 Aug 16).

19