Submission to Health Select Committee on Cannabis Inquiry

Submission to the Health Select Committee on the Cannabis Inquiry 2001
(please note: publication of this submission on our website was done after consulting the NZ Ministry of Health)

February 2001.
Copyright: Health Action Te Mana Taki Hauora
PO Box 691, Nelson. 03 548 2798
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Health Action Te Mana Taki Hauora is a community-based health promotion group and has been operating since 1982 in the Nelson region.
Our organisation carries several contracts via the Ministry of Health and is involved in additional collaborative community projects. The organisation is governed by a Board of Trustees and currently employs three fieldworkers and a projects' manager.

Health Action's work is guided by the principles of the Ottawa Charter (1986). In particular our organisation uses a community action approach. These kinds of approaches to health promotion are steadily gaining recognition as effective methods for addressing drug-related problems. Fundamentally they move away from placing responsibility on individuals and their families and instead promote community ownership of problems and solutions.

For the last six years Health Action's focus has been almost exclusively on youth health promotion initiatives. Our particular interests include alcohol and other drug use, safer partying and youth mental health. Our current projects are focused on mental health and the well being of young people within the Nelson region. We work with schools, with other youth and community agencies and statutory organisations in collaborative projects. We have developed resources with young people - for young people - particularly in the field of safer partying and reducing harm with any use of alcohol and drugs.

For the past 4 years Health Action has been involved as a project partner in the Community Action on Youth and Drugs Project (CAYAD), initially funded by the Ministry of Education and currently by the Ministry of Health. The project is a community action initiative between six communities, the Alcohol and Public Health Research Unit (APHRU) and Whariki, its indigenous research partner.

The projects were located in Opotiki, Whangaruru, Te Runanga o Te Rarawa, Hokianga, West Auckland and Nelson, areas that are familiar with high unemployment, high levels of cannabis growing, high cannabis use and high drug suspensions in schools. The overall aim of the project is to reduce drug-related harms to young people, their families and the community.

Health Action's submission to this inquiry is informed by our involvement in the CAYAD project both locally, in our community, and nationally with the other project partners.

Summary of recommendations

That cannabis policy is considered in terms of harms as a public health issue.
That the Health Select Committee consider moving to a policy option based on prohibition with civil penalties informed by the Australian experience.
That any policy change would be implemented gradually with an initial focus on health promotion and preparation of referral and treatment services.
That prevention and intervention efforts aim to reduce cannabis use and reduce drug-related harm.
That education for both target groups and wider populations be central, with a focus on developing appropriate programmes that are geared towards specific needs and groups, considering gender, ethnicity, geographic location and age.
That any campaigns avoid strategies that provide inaccurate information, use scare tactics and/or emotional and moral appeals, or those that actively marginalise drug users.
That community-level strategies are employed which involve parents, whanau, caregivers, whole schools, communities and the media in coherent pro-health messages and activities, reinforcing commitment to responsible drug use within a wider health enhancing context.
That schools are encouraged to avoid employing "zero tolerance" drug responses and instead follow the Ministry of Educations' Drug Education: A Guide for Principals and Boards of Trustees (2000) using pastoral student-centred approaches.
That multi-agency contributions are harnessed as part of a planned, coherent approach.
That approaches are cohesive at a national level and consider social, political and economic forces involved. Cannabis harm prevention efforts should be tied to programmes addressing areas such as employment opportunities, community support systems, institutionalised racism, housing, and other structural forces that marginalise at-risk communities from the rest of society (Ministry of Health, 1996).
That systems are put in place to monitor and evaluate changes in cannabis use, preventions, interventions and policing.

Introduction

Health Action supports the National Drug Policy's approach of harm minimisation that focuses on achieving a net reduction in drug-related harm rather than reducing drug use per se. It is our firm position that any public health response, and the future legal status of cannabis should aim to minimise cannabis-related harms both to the individual and to society. In doing so it is vital to consider the harms of cannabis use against the potential harm of the policy itself.

Specific Comments

The following matters are discussed in response to the terms of reference for this inquiry:

To inquire into the most effective public health and health promotion strategies to minimise the use of and harm associated with cannabis and consequently the most appropriate legal status of cannabis.

1. Weighing the harms

The current legislation around cannabis in New Zealand involves significant social and economic costs to individuals and to society.

1.1. Between 1990 and 1998 there was an average of 6,622 convictions for cannabis offences (cited Field and Casswell, 2000). Health Action is concerned that many of these convictions cause significant harm to individuals that may outweigh the harms of using cannabis itself.

1.2. Financially there are vast economic costs incurred by enforcing the current legislation. Twenty two million dollars were spent in 1998/99 in relation to cannabis enforcement (Field and Casswell, 2000). This money may be better spent on providing better education and treatment to address cannabis use.

1.3. Current legislation does seem to undermine effective drug education. Health Action's experience has shown that many school staff and agencies delivering messages regarding cannabis find it difficult to offer a harm minimisation perspective given that cannabis is illegal and they do not want to be seen to be advocating illegal drug use.

1.4. There are increasing reports that cannabis is creating learning problems in school age young people (Field and Casswell, 2000). School staff in the Nelson region are consistently concerned that young peoples' cannabis use is affecting their school performance. Some schools are responding to cannabis use with "zero tolerance" policies that often result in exclusion. While proving to be popular with parents and community members, these approaches do very little to address students' well being or the issues involved. Schools that enforce strict suspension or exclusion policies are at risk of compounding the harms experienced by students.

Health Action's key concern is that every effort is made to focus on pastoral rather than punitive approaches and to make every attempt to keep young people in school. This is emphasised in the Ministry of Education's Drug Education: A Guide for Principals and Boards of Trustees, which strongly recommends that school drug intervention policies should focus primarily on keeping young people in school (2000).

1.5. The current legislation may be a deterrent to seeking information or treatment. (Field and Casswell, 1999). There are already many barriers preventing people from accessing primary health services, e.g. costs, waiting lists and the location of services. Fear of prosecution may be compounding this (National drug survey, 1999).

1.6. The current prohibition policy may increase cannabis users' contact with, and financial contribution to, the black market. This may increase their exposure to other drugs (Field and Casswell, 2000).

1.7. While potentially a symbolic deterrent to use, the current legislation appears to have done little to reduce cannabis use. The Drugs in New Zealand survey (1999) indicates that half of the national sample of people aged between 15-45 years have at some time tried cannabis, and for most of these people their use was occasional rather than regular. Research has shown that the attitudes of family and friends tend to be more significant than the threat of conviction (ARF, 1997). Evidence also shows that most people convicted for cannabis use continue to use the drug (cited Field and Casswell, 2000). In addition to this, it does not appear that reducing criminal penalties for cannabis use leads to increased use of the drug.

1.8. Health Actions supports the Ministry of Health's assertions that the overall relative health risk of occasional cannabis use appears to be minor with most of the negative effects associated with long-term heavy use (Ministry of Health, 1996). Currently in New Zealand 3% of people use heavily (on 10 or more occasions in the last month), and 1% of people are daily users of cannabis. (Field and Casswell, 1998).

2. The legal status of cannabis

Health Action is familiar with the potential options for cannabis policies and is aware that there are advantages and disadvantages to each in terms of addressing cannabis-related harm. We are also aware that attitudes towards cannabis and its use differ significantly between countries, making it very difficult to translate the impact of any policies that are in place elsewhere. However, the current legislation around cannabis in New Zealand involves significant costs to individuals and to society. Given these costs, Health Action recommends that changing the current legislation be thoroughly considered.

Cannabis policy is a very complex issue and our organisation has struggled to find a comfortable position in the debate. After much research and discussion, Health Action favours a policy similar to the prohibition with civil penalties approach that has been operating in three Australian States for over ten years. We propose that based on the Australian National Drug Research Institute (2000) suggestions, some alterations are made to the existing models of this policy to address problematic aspects.

Under this policy, cannabis use, possession and cultivation are considered civil, rather than criminal offences. This would function to prevent low-level offenders' contact with the criminal justice system. Drawing on the Australian experience, we propose that "convictions" for small amounts of cannabis possession or cultivation are subject to a health-oriented system of referrals. Ideally, for an initial "conviction" individuals would be referred to an education session geared to increase their awareness around cannabis-related harm with the aim of potentially changing their attitudes and behaviour. Non-attendance would incur a fine. For a second "conviction" individuals would be referred for assessment and treatment. Again, non-attendance would incur a fine. Any further convictions would be treated as criminal prosecutions.

Casswell and Field (2000) discuss "net-widening" in South Australia where fines are issued to people who formerly would have been warned. This could potentially be a positive outcome if the emphasis is firmly on education and treatment.

We propose that possession or cultivation of larger amounts of cannabis would result in a criminal conviction, as would supplying to minors (probably under 18 years).

Similar offences by minors may be able to be managed by the existing youth justice system, although this would require substantial discussion and planning.

Such a system would allow for the grower-user population to increase somewhat undermining the black market. Currently 90% of New Zealand cannabis users do not grow their own supply (Field and Casswell, 2000). In Western and Southern Australia less than 30% are grower users.

However, Health Action believes that prior to any policy change there is a need to establish the systems to support its implementation. We believe that public education is the key to successfully reducing cannabis-related harm. The area of health promotion is neglected in relation to cannabis. While there is an abundance of existing preventative information, there is very little for those resistant to cessation messages. Prior to any policy change, we suggest that resources go into developing and delivering appropriate materials for these populations. The New Zealand Drug Foundation would be an ideal agency to oversee any developments.

We are also concerned that treatment services would need a period of induction to prepare for any referral system. In order to do this it may be useful to gradually withdraw criminal sanctions in relation to cannabis.

3. Recommendations for effective public health and health promotion strategies to reduce cannabis-related harm.

3.1 . Effective drug education

What constitutes "effective" drug education depends on the goal of the education programme. If most drug education aims to prevent use, it is clearly ineffective - most drug education does not prevent young people from using drugs (Cohen, 1996; Erickson, 1997; O'Connor and Saunders, 1992; Perry, 1996, Roker and Coleman, 1997).

In the past the majority of programmes have been based on primary prevention that usually promotes abstinence and aims to stop people from using drugs. Educational programmes have used combinations of scare tactics, hard facts, self-empowerment, resistance to peer pressure and alternative risk taking (O'Connor et al, 1997; Perry, 1996; New Zealand Ministry of Health, 1996). While often well intentioned, many of these approaches are fundamentally flawed in their assumptions about people's social development, motivation for using drugs and the cultural context in which they are used.

3.2. Providing a cohesive approach

Public health strategies should focus on both harm minimisation and reducing cannabis use. While there is much debate about whether it is possible to combine these seemingly disparate approaches, Health Action believes that this is consistent with "best practice" drug policy that caters to a broad range of individuals' needs.

Health Action's experience in working with a range of drug education providers, both within schools and the community, has shown that there is a lot of confusion and misunderstanding around the concurrent provision of preventative messages for some individuals and harm minimisation messages for others.

The Ministry of Health's 1996 report on Cannabis claims that abstinence is a reasonable approach to employ with regard to those who have not used drugs, and to delay the onset of potential use, but it may not be so effective for those already using. Instead, it appears to be more beneficial to promote responsible use and informed choice and to concentrate on reducing drug related harm.

"While not encouraging drug use, there is little value in perpetuating a perspective that emphasizes don't but persuades few not to, while simultaneously ignoring those that do". (O'Connor and Saunders, 1992, p178).

Given that there is enough evidence showing that people are still using drugs in the face of "say no" messages, Health Action advocates an increased shift in focus to provision of harm minimisation education for people resistant to preventative messages. This should include providing accurate and credible information that promotes responsible behaviour and aims to reduce drug related harm rather than prevent use per se.

However, Health Action is concerned that preventative approaches are still more acceptable to the community than education approaches based on informed choice. Teaching staff, parents and drug education providers and the wider community may require general education to raise awareness regarding the key concepts around harm minimisation approaches.

3.3. Health education messages

Community education about cannabis should focus on the adverse health effects of use and abuse. Any information should be accurate, factual and non-judgemental. Emphasis should be placed on the risks of driving after using cannabis, particularly in combination with alcohol; the risks of operating machinery; the adverse respiratory effects of smoking cannabis and the negative social and interpersonal effects of chronic cannabis use (Ministry of Health, 1996). It is also important to provide positive messages focusing on alternative attitudes and behaviours.

3.4. Targeted approaches

Certain populations of people are considered at greater risk of incurring cannabis-related harm. In particular youth, Maori, women of childbearing age, persons with mental illness, and people with a pre-existing disease (Ministry of Health, 1996). Public health and health promotion strategies should distinguish between the wider population and groups considered at-risk. At-risk groups should be targeted with strategies tailored to address cannabis-related harms.

In order to be more effective it is important that preventions and interventions are based on the targeted groups' experience, knowledge and needs. People require drug education and programmes that are relevant to their environment, and their development (O'Connor et al, 1997).

It is important that target groups are consulted as to what they want and need from drug education. This will increase the likelihood of designing and delivering cannabis education programmes that may have a much greater positive impact on these people's attitudes and behaviour.

3.5. Existing cannabis education resources

Health Action is concerned that currently there are not enough quality health promotion resources available concerning cannabis harm minimisation.

Our staff were particularly impressed by the Australian publication "Mulling It Over", a resource designed to reduce harm (appendix 1). In 1998 Health Action produced two pamphlets, Dope Tips l and ll, based on this resource designed to give tips to young cannabis smokers about practical ways to reduce the harms incurred from their use. (appendix 2). We have also seen several other good quality New Zealand educative resources.

3.6. Community-based approaches

Numerous research papers conclude that drug use and related problems are engendered by actions that occur at different levels of overall societal systems (O'Connor and Saunders, 1992), for example, families, whanau, peers, the wider community, the media, local and national government, and popular culture. If the messages that are being conveyed in these wider contexts are significantly different to those delivered by drug education then programmes cannot be as effective (Erickson, 1997).

There is strong evidence which recommends that community-wide, coordinated strategies are needed to effectively address drug use (Chavis et al, 1993; Goodstadt, 1996; Perry, 1996). Because people's families and peer groups are their closest and most potent social systems, education without the support of these influential groups will be less effective (Perry, 1996; Goodstadt, 1996). Approaches and strategies for changing attitudes and behaviour regarding drug use will be strengthened if embedded in schools, communities and cultures which reinforce similar values and norms (Perry, 1996).

The key to creating this cohesion is through community action based projects. These approaches work to strengthen social and institutional relations between groups in the community (Chavis et al, 1993). Research has shown that working collaboratively involving various sectors is more effective than working in isolation (Perry, 1996). Increased responsibility for programme planning should be placed at this community level, providing opportunities to develop community-driven tailored strategies and responses (Ministry of Health, 1996).

3.7. The wider context

Health Action supports the Ministry of Health's recommendation that public health policy and practice should address "the overall social, political, and economic forces putting communities at cannabis-related risk. Cannabis harm prevention efforts should be tied to programmes addressing areas such as employment opportunities, community support systems, institutionalised racism, housing, and other structural forces that marginalise at-risk communities from the rest of society." (1996, p34).

In particular Health Action is concerned about the impact that public health policy, health promotion strategies and legislative changes may have within Maori populations.

"Patterns of Maori cannabis use are likely to be strongly related to the social, economic, political and cultural standing of Maori in NZ. Maori face a major challenge in changing lifestyle and behaviour which places them at greater risk of cannabis use." (Ministry of Health, 1996, p32)

3.8. Service provision

It is crucial that services are available to provide effective cannabis-related treatments where necessary. Health promotion programmes and messages should be linked to primary care and treatment services. It is crucial that if there is any further liberalisation of the current legal status of cannabis that incorporates referral systems to education and/or treatment sessions, that agencies are equipped to offer a well-managed, cohesive service.

It is also important that these services are integrated with mental health services and are focused on recruiting and retaining well-trained staff.

3.9. Evaluation

Health Action is concerned that terms be developed for monitoring and evaluating any policy change. In particular we are concerned that monitoring should:

· indicate any changes in cannabis use,

· illustrate changes in public knowledge and learning regarding accurate cannabis information,

· show any changes in convictions,

· Show any changes in police and justice system resources devoted to cannabis offences, and

· monitor activity in the black market.

It is also vital that any health promotion strategies are effectively planned with evaluation built into development and delivery. It is also important that existing programmes are assessed in terms of their effectiveness in achieving the intended aims. National populations and at-risk groups must be monitored to assess the efficacy of any policy change. Health Action recommends that the Alcohol and Public Health Research Unit's national drug survey is carried out more frequently and adapted to yield more specific information (for example: of those young people who are using cannabis, how much are they using per "session"?).

If there is any change made to cannabis legislation, it is vital that a plan is put in place that can ascertain the outcomes (Drug Policy Forum Trust, 1998).

References

Addiction Research Foundation (1997) ARF Best Advice: Cannabis and Public Policy. Sourced from the Addiction Research Foundation website: www.arf.org.nz

Bleeker, A. and Malcolm, A. (1998) Mulling It Over: Health information for people who use cannabis. Manly Drug Education and Counselling Centre, Manly, Australia.

Cachemaille, J. (1998) Health Action discussion paper: Reducing drug related harm (unpublished).

Cohen, J. (1996) Drug education: politics, propaganda, and censorship, The International Journal of Drug Policy, 7:3, 153-157.

Erickson, P.G. (1997) Reducing the harm of adolescent substance use, Canadian Medical Association Journal, 156:10, 1397-1399.

Field, A. and Casswell, S. (1999) Drugs in New Zealand: A National Survey 1998, Alcohol and Public Health Research Unit, University of Auckland, New Zealand.

Field, A. and Casswell, S. (1999) Drugs in New Zealand: comparison Surveys 1990 and 1998, Alcohol and Public Health Research Unit, University of Auckland, New Zealand.

Field, A. and Casswell, S. (2000) Options for Cannabis Policy in New Zealand, Social Policy Journal of New Zealand, 14, 49-64.

Goodstadt, M. (1996) Education and policy in prevention, The Prevention Researcher, 3:1,1-5.

Health Action Community Health Promotion and Nelson Alcohol and Drug Services. (1998) Dope Tips l and ll. Health Action, Nelson.

Ministry of Education (1999) Health and Physical Education in the New Zealand Curriculum. Learning Media Limited, Wellington, New Zealand.

Ministry of Education (2000) Drug Education: A Guide for Principals and Boards of Trustees. Learning Media Limited, Wellington, New Zealand.

Ministry of Health (1996) Cannabis: The Public Health Issues 1995-1996. Public Health Group, Wellington, New Zealand.

Ministry of Health (1998) National Drug Policy: A National Drug Policy for New Zealand 1998-2003, Ministry of Health, Wellington, New Zealand.

New Zealand Drug Foundation (2000) Cannabis ifs and butts, Matters of Substance, 9:4, 1-2.

New Zealand Drug Foundation (2000) Foundation calls for unbiased information on cannabis, Matters of Substance, 10:3, 1-4.

New Zealand Drug Foundation (2000) Forum on cannabis law reform and harm reduction, Matters of Substance, 10:4, 1-2.

O'Connor, J. and Saunders, B. (1992) Drug education: an appraisal of a popular preventive, The International Journal of the Addictions, 27:2, 165-185

O'Connor, L., Best, D., Best, R. and Rowley, J. (1997) Young people, drugs and drugs education: missed opportunities. (source available through ALAC).

Perry, C.L. (1996) Models for effective prevention, The Prevention Researcher, 3:1, 1-5.

Roker, D. and Coleman, J. (1997) Education and advice about illegal drugs: what do young people want? Drugs: education, prevention and policy, 4:1,53-64.

The Drug Policy Forum Trust (1998) New Zealand Should Regulate and Tax Cannabis Commerce: Final report, Sourced on the New Zealand Drug Foundation website: www.nzdf.org.nz

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Submission to the Health Select Committee on the Cannabis Inquiry 2001(please note: publication of this submission on our website was done after consulting the NZ Ministry of Health)

Introduction

Specific Comments

1. Weighing the harms

Submission to the Health Select Committee on the Cannabis Inquiry 2001
(please note: publication of this submission on our website was done after consulting the NZ Ministry of Health)