US cannabis legislation experience
HISTORICAL PERSPECTIVE RELATING TO PUBLIC POLICY ON THE USE OF MARIJUANA
C. E. Edwards
The United States, once again, finds itself experiencing national and local campaigns directed toward, and intent upon, changing perceptions of marijuana from that of a dangerous, addictive drug of abuse1 to one where marijuana is perceived as a medicine that treats illnesses. Therefore, it is relevant and appropriate to review, from an historical perspective, the U.S. experience with liberal marijuana-use legislation and ballot initiatives, as well as the experience of other countries where the message has been promoted that marijuana is not a harmful, addictive drug.
Nationally and internationally there exists documented historical experiences which may be drawn upon when considering marijuana-use public policy changes.
The historical experience:
United States: Decriminalization, more lenient laws, lax enforcement and judicial opinion (Alaska) of existing state (11 states) and federal laws in the 1970s preceded an enormous surge in marijuana use that peaked in 1979 when 30 million Americans smoked marijuana as compared to just a few hundred thousand users in the early 1960s.
In 1977, then President Jimmy Carter asked Congress to replace all federal criminal penalties for possession of less than one ounce of marijuana with a $100 fine with the effect being that marijuana would essentially be decriminalized at the federal level. The proposal died in Congress. During the period that the 11 states and the president were actively creating the perception that marijuana was not a harmful drug, marijuana use increased, peaking at 22.5 million current users in 1979. By the end of the 1970s, an estimated 50 million individuals had tried marijuana. One in ten high school seniors smoked pot daily, nearly four in ten were current smokers.
Parents and others, alarmed at the levels of drug use, took action. State and federal anti-drug policies were strengthened. Marijuana use declined steadily until the early 1990s. By 1997, such use still stood nearly 40 percent below that of twenty years earlier. Marijuana smoking (monthly) among young adults aged 18 to 25, dropped from 36 percent in 1979 to 11 percent by 1992 and rose to 12.8 percent by 1997. As of 2004, current (monthly) marijuana use in the country stood at 14.6 million users (6.1% of the population), which is approaching two-thirds the levels recorded in 1979.
Marijuana as medicine efforts in U.S. states:
Eleven U. S. states have passed some form of legislation or ballot initiative allowing marijuana for alleged 'medical use' - AK, AZ, CA, CO, HI, ME, MT, NV, OR, VT, WA. Consequences to those states have been varied, based upon the scope of the bill or initiative passed. Nationally, on average, 5.1 percent of persons aged 12 years or older reported being current marijuana users 1999 through 2001 and 6.2 percent of the population reported current marijuana use in both 2002 and 2003. There are also several states with recent campaigns and legislative support to allow the use of marijuana and/or to decriminalize possession of the drug (MA, NM, RI).
States with the most marijuana users: In the 12 to 17 years age group, seven of the aforementioned states ranked in the top ten for both use of any illicit drug and use of marijuana. Those states are: Colorado*, Hawaii*, Massachusetts**, Montana*, New Hampshire*, New Mexico**, and Vermont*. Eight of the states were common to the top ten for past month marijuana use (current use) among persons aged 12 or older and youths aged 12 to 17: Alaska*, Colorado*, Maine*, Massachusetts**, Montana*, New Hampshire*, Rhode Island**, and Vermont*.
States with lowest perception of risk in using marijuana: States in the Northeast (Maine*, Massachusetts**, New Hampshire*, Rhode Island, and Vermont*) and the West (Alaska*, Colorado*, Oregon*, and Washington*) had the lowest rates of perceived great risk of using marijuana occasionally (once a month) among persons aged 12 or older.
*States that allow marijuana use and promote the message that marijuana is medicine. [Note: NH allows only if marijuana FDA approved; MT and VT marijuana as medicine approved in 2004]
**States with active public campaigns promoting marijuana as medicine either through elected officials and/or local or town non-binding ballot initiatives.
Following aggressive media campaigns portraying marijuana as a medicine and passage in 1996 (AZ and CA) of the first of the most recent efforts to legalise marijuana under the guise of 'medical' use, the U.S. Dept. Of Health and Human Services added questions to its National Household Survey.
The questions measured attitudes about marijuana harms by young people in AZ and CA, which were then compared to attitudes in other states. The findings: In 1997 Californians and Arizonans were less likely than other Americans to perceive great risk in using marijuana.
Perceived risk has been demonstrated to be a leading indicator of change in drug use in that when perceived risk decreases, drug use increases. The inverse has also been demonstrated. An individual's perception of the risks of substance use has been shown to be related to whether he or she actually uses the substance (e.g., Bachman, Johnston, & O'Malley, 1998).
Alaska: Following the 1975 state Supreme Court ruling [Ravin v. State, 537 P;.2d 494 (Alaska 1975)] which stated that personal marijuana possession and use was part of a fundamental state constitutional right to privacy, and subsequent legislation establishing a 4 ounce possession limit, marijuana use among adolescents rose rapidly and the age of first use moved lower until in 1988, the number of 12- to 17-year-olds in the state that were smoking marijuana stood at more than twice the national average. In 1990, an Alaskan grass-roots parents movement successfully recriminalized marijuana use through the ballot initiative process.
Arizona: Several ballot initiatives 1996, 1998. This state is the only one that requires a physician's prescription. To date, physicians have not been willing to write a prescription. According to the most recent bi-annual youth survey data, the current usage rates for marijuana are higher than the national rates for 8th and 12th graders. Rates of lifetime use are also higher in Arizona than for the national sample. The executive summary for the report offers an explanation: "When students were asked how much of a risk (health and otherwise) there was in using marijuana, students in Arizona generally believed that it was less harmful to try marijuana once or twice and to smoke marijuana regularly than students nationwide. The greatest difference is seen in the perceived harm of smoking marijuana regularly. For all grades of the Arizona students surveyed, there was a perception that marijuana was less harmful than was the perception of their national counterparts. For the 8th grade, there was an 11.8% difference in perceived harmfulness, in the 10th grade there was an 11.3% difference in perceived harmfulness, and in the 12th grade there was an 8.8% difference in perceived harmfulness. Such results could potentially explain the higher experimental and lifetime marijuana use rate for Arizona youth, since (generally) students who are not afraid of using substances, and who believe they will not be harmed by using substances, tend to use substances more than students who perceive harm in using a substance."[emphasis added]
California: As was the case in Arizona, California has been subjected to ballot initiatives supporting the medical use of marijuana beginning in 1996. There have been aggressive media campaigns exposing the state's population to messages that marijuana is medicine and not a harmful, addictive drug. There have been highly publicised court cases and much publicity surrounding the use of marijuana as a medicine.
California conducts surveys on drug use by 7th, 9th, and 11th grade-level students every two years.
According to the most recent CA survey data available (2003/2004) on current (past 30 days) use of marijuana by students, it was found that for 7th graders there was no change from the 1999-2000 levels; for 9th graders there was only a slight decrease (2.4% to 2.2%) in current use of marijuana; and for 11th graders there was an increase (4.4% to 4.8%) over the 1999-2000 percentages but a decrease from a spike (to 5.3%) in current marijuana use found in the 2001-02 survey.
These biennial surveys also contain questions as to the perception of harms in marijuana use. For many years, California students have demonstrated a softening in the perceptions of marijuana harms and the survey data presented in the 2003/04 report continues that trend of a lessening of the perception that occasional use of marijuana is harmful for all three grade levels surveyed. In fact, California students in all three grade levels perceived the occasional use of cigarettes to be more harmful than the occasional use of marijuana.
Oregon: Initiative was passed in 1998 and has a cardholder program. Since enactment, more than 10,000 people in the state have obtained official cards allowing use of marijuana for alleged medical reasons. This is about 20 times the number of people that officials had predicted. According to Pam Salsbury, manager of the state's medical marijuana office, the number of cardholders has doubled in less than two years and about 80 to 100 new or renewal applications arrive on a typical day. The most commonly reported debilitating condition in applications to the OMMP, is severe pain.
Experience of Other Countries
Colombia: In 1994, a court ruling legalised possession of 20 grams of marijuana and one gram of cocaine and heroin for private use. Drug use increased 40% over a 10-year period according to Dr. Camilo Uribe (no relation to Colombian President Alvaro Uribe), a toxicologist and the president's adviser on drug matters. Dr. Uribe blames legalisation for part of the increase, saying it made drugs more acceptable. "The court decision sent the completely wrong message -- that it's OK to do drugs," he has stated. The rational for the 1994 Constitutional Court ruling for legalisation: force the government to find more effective methods than law enforcement for combating drug abuse.
Today, the country is experiencing addiction problems and the president is moving to restore total prohibition. The sale of drugs remains illegal but suspected dealers can only be arrested if caught with more than the legal limit.
Denmark: Christiania, an area of Copenhagen, 'founded' in September of 1971 by a group of squatters who took over a military-barracks complex in the centre of Copenhagen, has been the centre for much of the Scandinavian trade in cannabis, as well as other drugs even though "Christianites" officially banned so-called hard drugs in 1980. A study conducted by Denmark's Board of Public Health (2003) reveals that the number of drug users in the country, already at high levels, had increased noticeably 1998-2003. During that period, numbers rose by 25%, or 5000 people. As of 2003, there were an estimated 25,500 people suffering from physical, psychological and/or social damage from their drug abuse. Hashish is illegal in Denmark, but people who are caught for the first time in possession of a small amount of the drug are only cautioned. Brian Mikkelsen, the country's Justice Minister says that the cautioning has been interpreted by youth as a form of legalisation of cannabis. In 2003, statistics from the Danish Institute of Public Health show that some 200,000 people in Denmark, aged 16 and over, smoke hashish at least once a year and an increasing number of youths are admitted into rehab every year because of cannabis abuse. As of mid-2004, Denmark began to tighten its cannabis law and to stop the drug sales and criminal elements in Christiania - described as a "derelict drug haven". In 2004, parliamentary bill L 205, an attempt to normalise Christiania, was introduced. The end was beginning for Denmark's drug liberalisation experiment.
Great Britain: In January of 2003, the UK government, upon recommendation of drug legalises well-placed in the UK government , downgraded the classification of marijuana (similar to the US method of 'scheduling' drugs), leading its citizens to the perception that marijuana was not a harmful or addictive drug. Since that action: The UK Department of Health, in 2004, found that drug centres were reporting growing numbers of marijuana addicts, many of them still in their teens. It also reported figures showing that drug centres are reporting growing numbers of marijuana users coming to the centres with problems related to the drug. Nine percent of those attending clinics cited cannabis as the main reason they were attending, twice as many as a decade ago.
Italy: In April 1993, by referendum, Italians voted to decriminalise the use of drugs, including marijuana for personal use. Sellers and traffickers were still subject to punishment, but users were not. According to Prime Minister Gianfranco Fini in 2003, it was virtually impossible for law enforcement to distinguish between personal use and trafficking. Italy has decriminalised all drugs. In November 2003, Italy's government adopted a proposal making it an offence to possess and use even the smallest quantities of narcotics and abolished any so-called distinction between what drug legalises like to think of as "soft"(marijuana) and "hard" (cocaine, heroin, etc.) drugs. It also virtually reverses existing Italian law by starting from the principle that it is drug use, rather than drug abuse, that must be stamped out. The vote reflected the social reality of a country in which consumption of mild drugs has become increasingly common. According to a 2001 study by the European Monitoring Centre for Drugs and Drug Addiction, the EU's official body for analysing trends in drugs use, 9.4 per cent of Italians between the ages of 15 and 34 had used cannabis in the previous year.
Netherlands: The revised Dutch drug policy, often held up as an example by U.S. drug legalisation organisations, is based upon Parliament's 1976 acceptance of the recommendation of a commission headed by Pieter A. H. Baan, a psychiatrist and expert in rehabilitating drug addicts. The Baan Commission's report proposed distinguishing between so-called List One drugs-- those that present "an unacceptable risk (heroin, cocaine and LSD)"--and List 2 drugs--cannabis products, such as hashish and marijuana--seen as less dangerous and "softer." Essentially, Parliament de-penalised the possession of 30 grams of marijuana or hashish--enough, legislators calculated, to meet an average smoker's needs for three months. The Dutch legalised the public sale, under certain restraints, of cannabis products and adopted a much more lenient policy toward all forms of drug use and abuse based on a philosophy of harm reduction. The country also (in 2003) authorised the use of marijuana for medical purposes.
As a direct result, it is now considered Europe's drug supermarket and the drug capital of Western Europe. "Our liberal drug policy has been a failure, but its advocates are so rooted to their convictions they cannot bring themselves to admit it," says Dr. Franz Koopman, director of De Hoop (The Hope) drug rehabilitation centre in Dordecht and an open opponent of the Dutch policy. "First, we banalized cannabis use. We have left our kids with the idea that it's perfectly all right to smoke it, and from there it was an easy step for them to move to the notion that it's also okay to use mind-altering substances like ecstasy. It is that mentality that is behind the explosion in the use of these synthetics we've seen in the last three years, and [it] is a grave peril to this country just as it is to the rest of Europe." Since importing cannabis was still illegal, the Dutch began to grow their own and produced a high-THC content marijuana.
As the coffee shops boomed between 1984 and 1996, marijuana use among Dutch youths aged 18 to 25 leapt by well over 200 percent. In 1997, there was a 25 percent increase in the number of registered cannabis addicts receiving treatment for their habit, as compared to a mere 3 percent rise in cases of alcohol abuse. In 1995, public Ministry of Justice studies estimated that 700,000 to 750,000 of Holland's 15 million people--about 5 percent of the population--were regular cannabis users. A 1998 study by Professor Pieter Cohen of the University of Amsterdam, disputes those figures, claiming that only 325,000 to 350,000 Dutch men and women are regular cannabis users. Unfortunately, however,his survey discovered that those smokers are particularly concentrated among the young in densely populated areas of Amsterdam, Utrecht, and Rotterdam. 1995-1999 data shows that these same areas have witnessed a skyrocketing growth in juvenile crime and the number of youths involved in acts of violence associated by many Dutch law enforcement officers with the abuse of 'soft' drugs.
Former Amsterdam Police Commissioner Jelle Kuiper declared more than 18 months ago, "As long as our political class tries to pretend that soft drugs do not create dependence, we are going to go on being confronted daily with problems that officially do not exist. We are aware of an enormous number of young people strongly dependent on soft drugs, with all the consequences that has." A few months later, his counterpart in The Hague, the de facto Dutch capital, echoed his views: "Sixty-five percent of the persistent rise we are seeing in criminality is due to juveniles, and above all juvenile drug users."
The Attorney General for The Netherlands severely criticised the cannabis policy as "an ineffective form of law enforcement". He further stated that "law enforcement struggles with an unworkable mandate." In an as yet unpublished report prepared for The Netherland's Supreme Court of Justice, J. Wortel, Director of Public Prosecutions and a career-long prosecutor states that even The Netherlands' official policy of tolerating small-scale sales and personal possession of cannabis is an "unworkable" policy that undermines other law enforcement activities and public health. The pot crop--a direct outgrowth of Holland's drug policy--comes from some 25,000 to 30,000 small to medium scale producers, most of them indoor growers. Under Dutch law, anyone may possess five plants for personal use, which can yield 64.46 joints per day . One ounce of leaves will yield 40-50 joints. Cannabis grows fast; indoor growers can reap four crops a year.
A 1997 report on drug use in the Netherlands by the government-financed Trimbos Institute acknowledged that "drug use is considered to be the primary motivation behind crimes against property"-[more than] 23 years after the Dutch policy was intended to stop such crimes. Furthermore, the Trimbos report put the number of heroin addicts in Holland at 25,000, a figure so low that critics of the
government say it "Promotes a policy, not a reality." That statistic is based, the sceptics note, on the number of heroin addicts who actually come into contact one way or another with the nation's social or justice departments. The real figure, they maintain, is far closer to 35,000. But even if the Trimbos figures are correct, they represent almost a tripling of the number of Dutch addicts since the country liberalised its drug policies. The numbers also mean that Holland has twice as many heroin addicts per capita as Britain, which is known for having one of the most serious heroin problems in Europe. Furthermore, the number of heroin addicts being treated in the methadone maintenance programs run by the Ministry of Public Health went from 6,511 in 1988 to 9,838 in 1997, an increase of just over 50 percent. After coffee shops started selling marijuana and the normalisation of drug use set in, use of marijuana nearly tripled (from 15 percent to 44 percent) among 18-20 year old Dutch youth between 1984 and 1996.
According to the 2004 National Drugs Monitor report on outpatient treatment data, the proportion of cocaine and cannabis clients among all drug clients has strongly increased in the past ten years, amounting to 38% and 20% in 2003, respectively. The proportion of new cocaine and cannabis clients among all drug clients applying for help for the first time (first treatments) is even more
Pronounced (41% and 32% in 2003, respectively) which would appear to indicate a rising popularity of marijuana or hash and increasing numbers of cannabis users who are seeking medical help. The Monitor also reported that both the lifetime and current (monthly) prevalence of cannabis use among students 12-18 years of age, in 2003, stands at more than double the number of students using cannabis in 1988.
Top government officials are considering the tightening of Holland's current policy on cannabis.
Switzerland: The Swiss have been experimenting for a number of years with various drug liberalisation policies that have been well publicised within the country. In June of 2004, the Swiss Parliament declined to decriminalise cannabis production and consumption for personal use. As a result, the drug-legalisation supporters (a committee called "Pro Jugendschutz gegen Drogenkriminalita't" ["For Protection of Children and Young People, against Drug Crime"]) proposed an initiative entitled "For a rational cannabis policy with effective protection of young people." If they collect 100,000 signatures by January 20, 2006, the initiative will be put to a nationwide vote.
According to a survey from the Swiss Institute for the Prevention of Alcohol and Drug Addiction, using figures collected by the Federal Statistics Office between 1997 and 2002, cannabis consumption has dramatically increased over the past few years, with an estimated 250,000 people regularly smoking cannabis-which is nearly twice as many as a decade ago. More than one-half of young adults (aged 20-24 years) interviewed for the study said they had tried cannabis at least once.
In another survey, conducted for the Swiss Federal Office of Public Health in 2003, 10% of 13 year-olds and 25% of 16 year-olds said they had smoked cannabis at least once in the preceding month. Around twice those percentages for each age group affirmed contact with cannabis at least once. This was a sharp increase over the rates found in a poll released in 2000, where 31.2 % of
15-16 year-olds said they had smoked cannabis at least once.
Switzerland also has a growing problem with people driving while under the influence of marijuana. Driver urine tests show marijuana use rose 20% in 2003.
European Union Attitudes and Perception of Harm:
Cannabis prevalence rates correspond with attitudes as to how dangerous the drug is. The average number of young people in the EU who say they perceive cannabis as very dangerous is 20.6 percent. The number is much higher in northern Europe, in countries with tighter policies: in Sweden 45 percent perceive the drug as very dangerous and in Finland percent do so. In the United Kingdom the number is 17 percent, in Belgium 14 and in the Netherlands 7.2 percent. A similar relationship between attitudes and prevalence of use exists in American data as referenced previously in this paper. When attitudes to the harmfulness of cannabis declines, prevalence estimates increase.
Additional considerations when liberalising public policy on marijuana use:
- Physicians who recommend marijuana may find they have no insurance coverage for the liability exposure and potential claims by patients or third parties harmed by a patient's use of marijuana as recommended by a physician.
- "Most discussants of legalisation or government distribution of addictive substances do not take account of predictable long-term growth in the population of addicted persons and/or the long-term addiction costs associated with this policy choice."
The harms of marijuana to seriously or terminally ill persons must be considered. Dr. Donald P. Tashkin stated the consideration well when he said, "The most potent argument against the use of marijuana to treat medical disorders is that marijuana may cause the acceleration or aggravation of the very disorders it is being used to treat."
A 2001 report by Dr. Tashkin showed that the use of marijuana as a medical therapy can and does have a very serious negative effect on patients with pre-existing immune deficits resulting from AIDS, organ transplantation, or cancer chemotherapy -- the very conditions for which marijuana has most often been touted and suggested as a treatment. "In view of the immuno-suppressive effect of THC, the possibility that regular marijuana use could enhance progression of HIV infection itself needs to be considered, although this possibility remains unexplored to date." ,
Habitual marijuana smoking may cause a number of potentially harmful effects on the lung, including the following: (1) acute and chronic bronchitis; (2) extensive histopathologic alterations in the cells lining the bronchial passages that could impair mucociliary clearance or predispose to malignancy; (3) increased accumulation of inflammatory cells (alveolar macrophages) in the lung; and (4) impairment in the function of these important immune-effector cells, including their ability to kill microorganisms and to produce protective pro-inflammatory cytokines. The major potential pulmonary consequences of regular [defined as an average of one 'joint' per day] marijuana use are pulmonary infection and respiratory cancer.
"Infections of the lung are more likely in marijuana users due to a combination of smoking-related damage to the ciliated cells in the bronchial passages (the lung's first line of defence against inhaled microorganisms) and marijuana-related impairment in the function of alveolar macrophages (the principal immune cells in the lung responsible for defending it against infection). Patients with pre-existing immune deficits due to AIDS or cancer chemotherapy might be expected to be particularly vulnerable to marijuana-related pulmonary infections".
- The link between schizophrenia and psychosis and the use of marijuana began to become evident in the early 1980s. Research in recent years, including long-term studies, have begun to prove the links observed over the past several decades. According to Thomas Edward Radecki, M.D., J.D., who has compiled a list of studies examining this link, "the research evidence is extremely strong, proving beyond a doubt that marijuana causes a large number of cases of schizophrenia in the modern world. Indeed, a number of studies have found marijuana has a stronger link to causing schizophrenia than other drugs."
A sampling of studies:
- "Schizophrenia Increased in US Army After Marijuana". Schizophrenia in US Army in Europe jumped from 1/1000 to 38/1000 over the 5-year period from 1967-1971. Tennant and Groesbeck, Arch Gen Psyc 27:133-6, 1972;
- Dutch Prospective Study Found Causal Link with Major Increase in Schizophrenia from Marijuana: A three-year follow up of a Dutch cohort of 4045 people free of psychosis and 59 with a baseline diagnosis of psychotic disorder showed a strong association between use of cannabis and psychosis. Am J Epidemiol 2002; 156:319-327;
- New Zealand Study Finds Marijuana Triples Schizophreniform Disorder: A birth cohort of 1037 individuals born in Dunedin, New Zealand, in 1972-3 and studied for 26 years.
- Cannabis use is associated with an increased risk of experiencing schizophrenia symptoms, even after psychotic symptoms preceding the onset of cannabis use are controlled for, indicating that cannabis use is not secondary to a pre-existing psychosis. Secondly, early cannabis use (by age 15) confers greater risk for schizophrenia outcomes than later cannabis use (by age 18). British Medical Journal 23 November 2002;325:1212-1213
For community leaders, government officials and others to consider promoting a public policy that marijuana is medicine, leading to a natural conclusion that it is not a harmful and addictive drug, creates an obligation to perform due diligence before promoting or endorsing such a public policy.
This paper has presented only a small sampling of available information to encourage further study and research. There is an abundance of research and historical data available to meet the due diligence responsibility. There are conflicting interpretations of what certain data represent. However, having the benefit of historical experience over a long period of time allows for the observation of long-term trends which are often more significant than specific data that is limited to just a year or two.
C. E. Edwards
Arizona H.I.D.T.A. Demand-Reduction Office