Attachment 9: Referral comments – Island Health

MEDICAL HEALTH OFFICERS

Office of the Chief Medical Health Officer

COWICHAN AREA 250.331.8591 Shannon Waters MD MHSc FRCPC 601-222 Cowichan Way Duncan, BC V9L 6P4

NORTH ISLAND 250.331.8591 Charmaine Enns MD, MHSc, FRCPC 355-11th Street Courtenay, BC V9N 1S4

CENTRAL ISLAND 250.739.6304 Paul Hasselback MD, MSc, FRCPC 3rd Floor 6475 Metral Drive Nanaimo, BC V9T 2L9

SOUTH ISLAND 250.519.3406 Richard Stanwick, CMHO MD, MSc, FRCPC, FAAP Murray Fyfe MD, MSc, FRCPC Dee Hoyano MD, FRCPC 430 – 1900 Richmond Ave. Victoria, BC V8R 4R2

After Hours On Call 1.800.204.6166

September 10, 2018

Dear: Mayor and Council – Municipal Governments, Chair and Directors – Regional Districts Chief and Council – First Nations

Re: A Public Health Approach to Non-Medical Cannabis

Dried cannabis, cannabis oils and seeds will be legalized in Canada on October 17, 2018. Evidence suggests that the prohibition of cannabis has not achieved the intended objective of reducing use and associated harms. Legalization with regulation has been recommended as likely more effective.¹ In implementing these changes, a balance between the intended benefits and expected harms must be achieved. Island Health Medical Health Officers (MHOs), in addition to other MHOs provincially, support a public health approach to cannabis access and use²³. Such an approach includes legalization with market regulation aimed at protecting and promoting health while allowing access at levels that reduce the negative outcomes associated with illicit distribution.

Multiple sectors of society, and all levels of government, have roles to play in a comprehensive public health approach to cannabis legalization. Local governments, in particular, can adopt regulations aimed at 1) reducing youth exposure to non-medical cannabis, 2) reducing high risk use in general (e.g., heavy or frequent use, use with other substances), and 3) unwanted exposure to second-hand cannabis smoke and vapour. Local governments can also support increasing public knowledge and awareness, to support risk reduction and de-stigmatization, without normalization or promotion.

Local governments' jurisdiction in zoning, land use, business licensing, building codes, nuisance and clean air by-laws, and enforcement, as well as their ability to advocate to higher levels of government, can all be leveraged to promote a public health approach to cannabis.⁴ Some specific areas of best practice⁵ where local governments can support a public health approach include:

1. Restrict public consumption of cannabis and exposure to environmental cannabis products. By limiting where cannabis can be consumed, local governments can reduce unwanted exposure to second-hand cannabis smoke or vapour, and can reduce the visibility of cannabis consumption for youth, making it less normative, and more likely that youth delay initiation or never start:

   • Prohibit public cannabis consumption wherever tobacco or alcohol consumption is already prohibited. This should include areas not covered by provincial legislation including enclosed public spaces, transit shelters, common areas of apartment buildings and community care facilities, and areas frequented by children and youth, such as parks, beaches, pools, playgrounds, and sports fields; and,
   • Prohibit smoking/vaping lounges, including mobile units; and,
   • Facilitate multi-unit dwelling policies that limit unwanted exposure to environmental cannabis emissions.

2. Ensure local retail sales of non-medical cannabis should be limited to reduce the unintended exposure by youth and harmful patterns of consumption in the general population:

   • Restrict marketing of cannabis such as sandwich boards, exterior signage, flyers, and sign spinners;
   • Establish a minimum separation of 300 metres between cannabis retail outlets, to limit overall density of cannabis availability in the community;
   • Establish a minimum buffer zone of 300 metres and preferably 600 metres between cannabis retail outlets and schools, recreation centres, and other areas where children and youth frequent;
   • Ensure any site specific siting within 600 metres of schools and on major school transportation routes should actively involve the school community and school districts in ensuring impact on students is negligible, and,
   • Limit hours of sale to at least correspond with alcohol sale policy, while greater restriction would provide additional health and safety benefits.

3. Include public messaging on safer use and potential risks in local government communications to residents.

4. Limit personal use growth and small grow operations to reduce nuisance odour concerns in residential settings.

5. Be cognizant of and prepared to revise local restrictions and limitations on cannabis when and if edible cannabis products for consumption are approved for sale. Exclusion of on-premise edible consumption is likely to be recommended as peak effects will be delayed in most circumstances to after the departure of consumers from the premises. The concurrent consumption of cannabis and alcohol is known to increase risk and zoning and approval decisions should dissuade co-consumption opportunities.

Other restrictions are already required under provincial and/or federal law, but local government can reinforce and strengthen these restrictions through setting higher standards, imposing additional penalties, and of course enforcement actions. The Municipal Guide to Cannabis Legalization, published by the Federation of Canadian Municipalities, which provides extensive practical guidance on these matters is a good resource to consult.

Certain specific recommendations may not be feasible in very small communities, e.g. relating to the physical separation of cannabis retail from areas where youth congregate. We still encourage local governments to follow the spirit, if not the letter, of the recommendations, e.g. striving for whatever physical separation is possible.

Island Health Medical Health Officers and colleagues across the province strongly caution against pursuing economic gain from the legalization of non-medical cannabis use. When cannabis production and sales are significantly motivated by revenue generation, this creates an incentive to encourage greater cannabis consumption by the public, and a disincentive to establishing appropriate restrictions on cannabis availability. The recommendation to legalize cannabis for non-medical purposes was driven in part by reducing the ongoing violence and negative health impacts caused by the illicit drug trade. Promoting and protecting health should remain the primary concern within a legalized environment.⁶ Revenue generated should be used to fund education, health promotion activities, and/or data collection and analyses that support the overall public health-related goals of cannabis legalization⁷.

Alcohol, tobacco, and opioids continue to cause a greater overall burden of disease and injury than cannabis. Local governments are encouraged to take the opportunity from the upcoming legislative changes to cannabis, to review how the harms associated with other substances, might also be reduced through local government action. For example, restrictions on public consumption should include cannabis, tobacco, e-cigarettes, and other combustible products; and many of the strategies we recommend to reduce harm from cannabis consumption through limits on access and buffer zones, should also apply to alcohol and tobacco retail.

Cannabis legalization represents both an opportunity and a challenge for local governments to foster the development of healthy, vibrant communities across BC. The above public health recommendations can be integral to local cannabis policy development. For more information, or to further discuss your community's approach to non-medical cannabis or other substances, feel welcome to connect with your local Medical Health Officer.

Paul Hasselback, MD, MSc, FRCPC Medical Health Officer

Charmaine Enns, MD, MHSc, FRCPC Medical Health Officer

Shannon Waters, MD, MHSc, FRCPC Medical Health Officer

Dee Hoyano, MD FRCPC Medical Health Officer

Murray Fyfe, MD, MSc, FRCPC Medical Health Officer

Richard S. Stanwick, MD, MSc, FRCPC, FAAP Chief Medical Health Officer

Key Resources:

• Canadian Public Health Association: A Public Health Approach to the Legalization, Regulation, and Restriction of Access to Cannabis (available online: https://www.cpha.ca/sites/default/files/uploads/policy/positionstatements/cannabis-positionstatement-e.pdf)
• Centre for Addiction and Mental Health: Canada's Lower Risk Cannabis Use Guidelines (available online: https://www.camh.ca/-/media/files/lrcug_professional-pdf.pdf)
• Federation of Canadian Municipalities: Municipal Guide to Cannabis Legalization (available online: https://fcm.ca/Documents/issues/Cannabis-Guide-EN.pdf)

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¹ Haden, M., Emerson, B. (2014). "A vision for cannabis regulation: a public health approach based on lessons learned from the regulation of tobacco and alcohol." Open Medicine 8(2)e73. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085088/

² Canadian Public Health Association's position statement on Legalization, Regulation, and Restriction of Access to Cannabis. Available online: https://www.cpha.ca/sites/default/files/uploads/policy/positionstatements/cannabis-positionstatement-e.pdf

³ Canadian Chief Medical Officers and Urban Public Health Network. (2016). Public health perspectives on cannabis policy and regulation. Available online: http://uphn.ca/wo-content/uploads/2016/10/Chief-MOH-UPHN-Cannabis-Perspectives-Final-Sept-26-2016.pdf

⁴ Federation of Canadian Municipalities. (2018). Municipal Guide to Cannabis Legalization: A Roadmap for Canadian Governments. Ottawa, ON: Federation of Canadian Municipalities.

⁵ Recommendations are derived from Peloquin R, Scarr J. (2017). Cannabis Regulation and Youth: A Jurisdictional Review. Vancouver: Child Health BC, and Tyler, I., Schwandt, M.. Padhi, S. (2018). Recommendations to support municipal bylaw development regulating cannabis access and use. Surrey, BC: Fraser Health Authority.

⁶ Canadian Chief Medical Officers and Urban Public Health Network. (2016). Public health perspectives on cannabis policy and regulation. Available online: http://uphn.ca/wo-content/uploads/2016/10/Chief-MOH-UPHN-Cannabis-Perspectives-Final-Sept-26-2016.pdf

⁷ Peloquin R, Scarr J. Cannabis Regulation and Youth: A Jurisdictional Review. Vancouver: Child Health BC 2017.