APPENDIX 14
Memorandum submitted by Dr H C Raabe and
Dr Linda Stalley
RISKS OF LEGALISING CANNABIS UNDERESTIMATED
A COMPARISON OF
DUTCH AND
SWEDISH DRUG
POLICY
SUMMARY
Introduction
The aim of any drug policy should be to minimise
harm caused by the drug to individuals and society.
Whether drugs such as cannabis should be decriminalised
is now the subject of intense debate.
We are concerned that the discussion on this
issue often neglects the important roles of drug prevention, education
and treatment.
Comparison Netherlands—Sweden
Two European countries, the Netherlands and
Sweden adopted completely different drug policies about 25 years
ago.
In the Netherlands the use of cannabis has essentially
been legalised: the drug policy has been based on the harm-reduction
approach, aiming at a reduction of health risks, not necessarily
at abstinence.2
In contrast, Sweden's drug policy is based on
the goal to create a drug free society: drug prevention, education
and the criminal justice system are aimed towards limiting any
use of illicit drugs.4
The assessment of the Dutch policy by the United
Nations Office for Drug Control and Crime Prevention finds that:
"the liberal attitude towards cannabis went parallel with
relatively high levels of cannabis consumption . . . Abuse of
almost all other drugs was increasing stongly in Amsterdam over
the last decade. Hard drug use doubled. The strongest growth was
observed for ecstasy."2
Following the de facto legalisation cannabis
use has increased sharply in the Netherlands: in the age group
18-20 an increase in the past year cannabis use from 15 per cent
in 1984 to 44 per cent in 1996 was observed. In this period, its
use did not increase in countries such as Denmark, Germany, Canada,
Australia and the USA.7
A 1999 European School survey found that cannabis
is used far more frequently in Holland than in Sweden: 14 per
cent of Dutch pupils aged 15-16 have used cannabis over the past
month versus 2 per cent in Sweden. 5 per cent of 15-16 year olds
have used it more than six times in the past month in Holland
as compared to 0 per cent in Sweden.9
The use of other illicit drugs including cocaine,
amphetamines and ecstasy is far higher in the Netherlands than
in Sweden.8
The United Nations Office for Drug Control and
Crime Prevention states that: the Netherlands "is one of
the main entry points of drugs into Europe and the centre of synthetic
drug manufacture in Europe, notably ecstasy and amphetamines.
Cannabis cultivation in the Netherlands is among the largest in
Europe."2
In 1998, 118,122 kg of cannabis were seized
in Holland compared to 496 kg in Sweden. Dutch seizures of cocaine
were 11,452 kg in comparison with 19 kg in Sweden.3
It is estimated that 80 per cent of the heroin
seized in the UK and France has passed through Holland since it
is considered to be "relatively trouble-free from a criminal's
point of view."11
Conclusion
The outcome of the Swedish drug policy aimed
at creating a drug-free society has, after a quarter of a century,
been far more successful than the liberal "harm-reduction
approach" utilised in the Netherlands.
Associated with its "harm-reduction"
policy, the Netherlands has seen a significant rise in drug abuse
and trafficking of cannabis, cocaine, amphetamines and ecstasy.
This exceeds, by far, abuse and trafficking in Sweden.
If the UK followed the Dutch approach, it is
likely that this would substantially increase cannabis and hard
drug abuse as well as drug trafficking.
RISKS OF LEGALISING CANNABIS UNDERESTIMATED
A COMPARISON OF
DUTCH AND
SWEDISH DRUG
POLICY
1. An issue of public health
The starting point of drug policy should be
public health. How can we reduce the harms caused to individuals
and society by drugs in general and cannabis in particular? To
abuse drugs is not primarily an issue of individual rights since
drug taking has adverse consequences for the individual and society,
for example car accidents due to the influence of alcohol and/or
cannabis.1 From a public health point of view the aim of any drug
policy should be to minimise harm caused by the drug. Legislation
and the criminal justice system play a role in this and whether
drugs such as cannabis should be decriminalised is currently the
subject of intense debates. We are concerned that—over this
issue—the current discussion on drugs perhaps neglects the
important roles of prevention, education and treatment.
The success of any policy regarding cannabis
and other illicit drugs can be measured by many factors. We suggest
that the main criterion should be how good this policy is at "producing"
a low usage of illicit drugs.
2. Background
We have the advantage of being able to examine
two European countries, which, 25 years ago, adopted completely
different drug policies:
In the Netherlands—while officially still
illegal—the use of cannabis has essentially been decriminalised
in 1976. Dealing in small quantities of cannabis has been legalised
through coffee shops. The drug policy has been based on the harm-reduction
approach, aiming at a reduction of health risks, not necessarily
at abstinence.2 This is reflected for example by easy access to
needle exchange and methadone maintenance programmes. A strong
distinction is made between "hard drugs" and "soft
drugs". This is based on the assumption that "hard drugs"
such as heroin, cocaine, LSD and amphetamines pose an unacceptable
risk while the risks of cannabis are considered to be not so great.3
Another goal of the Dutch policy is to separate the markets for
"soft" and "hard" drugs.
In contrast, Sweden's drug policy is based on
the goal to create a drug free society. Drug prevention
and education is aimed towards limiting experimental and occasional
use. Public opinion strongly supports this approach.4 Interestingly
enough, Sweden's drug policy used to be liberal in the 1960s,
basically reflecting a harm reduction approach.5 However, with
the 1968 Narcotic Drugs Act Swedish drug legislation became restrictive
until the goal of a drug free society was officially adopted in
1978. In Sweden all non-medical use of drugs is regarded as drug
abuse and no distinction is made between soft and hard drugs.
The Swedish drug policy is formulated around the gateway hypothesis,
ie cannabis use is associated with "harder" drug use.
Efforts are focussed on preventing cannabis use since this is
frequently the first illicit drug experimented with. The dangers
of cannabis are strongly emphasised in education. Possession of
any illicit drug is punishable, depending on the amount and the
substance by a fine or imprisonment. The prosecution is essentially
bound to prosecute drug offences and abstaining from prosecution
is rare.3 The Police have the power to enforce drug testing if
they suspect abuse.6
3. Trends in cannabis use in the two countries
Has the liberal drug policy of the Netherlands
led to an increased use of cannabis? The assessment of the Dutch
policy by the United Nations Office for Drug Control and Crime
Prevention finds that:
"the liberal attitude towards cannabis
went parallel with relatively high levels of cannabis consumption
. . . Abuse of almost all other drugs was increasing strongly
in Amsterdam over the last decade. The strongest growth was observed
for ectasy and hard drug use doubled."2
Following the de facto legislation prevalence
of cannabis has increased sharply. In the age group 18-20 an increase
in the past year use of cannabis from 15 per cent in 1984 to 44
per cent in 1996 was observed. The increase in the past month
use over the same period was from 8.5 per cent to 18.5 per cent.
The increase in Dutch prevalence from 1984-92
provide the strongest evidence that Dutch regime might have increased
cannabis use among the young: In this period, use levels were
quite flat or declining in cities such as Oslo, Stockholm, Hamburg,
and countries such as Denmark, Germany, Canada, Australia and
the USA.7
A comparison with the trends of drug abuse for
all drugs in Sweden reveals the following pattern: During the
mid 1960s up to the early 1970s a strong rise of drug abuse was
observed among 15-16 year olds. It may be relevant to note that
Sweden's drug policy used to be liberal in the 1960s, reflecting
a harm reduction approach.7 However, with the 1968 Narcotic Drugs
Act Swedish drug legislation became restrictive3 until in 1978
the goal of a drug free society was officially adopted. Drug abuse
fell in the 1970s and up to until 1990. In the 1990s, drug abuse
has been once again on the rise in Sweden as in other European
countries, though levels seem to be still lower than in the early
1970s and—apart from solvents—lower than in most European
countries.5 (Table 1)
Table 1
LIFE-TIME PREVALENCE OF DRUG ABUSE (ALL DRUGS)
AMONG 15-16 YEAR OLDS IN SWEDEN5, 8
| Early 1960s | 1967
| 1970-71 | 1975
| 1983 | 1990
| 1993 | 1996
| 1999 |
| Very low | <4%
| 13% | 7.5%
| 5.0% | 3.5%
| 5% | 7.6%
| 8.0% |
| Although data is not directly comparable in methodologies, the main trends indicated are clear.
|
4. A comparison of current cannabis use
How do the Netherlands and Sweden compare regarding cannabis
use?
Overall lifetime prevalence of drug abuse among 15-16 year
olds in 1999 is about 29 per cent in the Netherlands and 8 per
cent in Sweden. The lifetime prevalence of drug use for cannabis,
amphetamines, ecstasy and cocaine among Swedes is only a fraction
of the Dutch prevalence (Table 2). In the European Monitoring
Centre for Drugs and Drug Addiction (EMCDDA) comparison, Sweden
has also far lower 12-month prevalence rates than almost all other
European countries surveyed regarding use of cocaine, amphetamines
and ecstasy but not solvents (Table 3).8 Furthermore, Cannabis
use among 15-16 year olds appears to be far heavier in the Netherlands
than in Sweden with one in 20 using cannabis six times or more
in the last month (Table 4).
Table 2
LIFE-TIME PREVALENCE OF USE OF DIFFERENT ILLEGAL DRUGS
AMONG 15-16 YEAR OLD STUDENTS IN 19998
| | All illegal drugs
| Cannabis | Amphetamines
| Ecstasy | Cocaine
| Heroin |
| Netherlands | 28.8%
| 28.6% | 4.0%
| 5.0% | 4.2%
| 1.3% |
| Sweden | 8.0%
| 7.0% | 1.0%
| 1.0% | 1.0%
| 1.0% |
Table 3
LAST 12-MONTH PREVALENCE OF DRUG USE IN POPULATION AGED
15-34 IN THE NETHERLANDS (1997-98) AND SWEDEN (2000), LATEST YEARS
FOR WHICH 12 MONTH PREVALENCE DATA AVAILABLE8
| | Cannabis
| Cocaine | Amphetamines
| Ectasy |
| Netherlands | 9.8%
| 1.4% | 0.8%
| 1.8% |
| Sweden | 1.0%
| 0.0% | 0.0%
| <0.5% |
Table 4
PERCENTAGE OF CANNABIS USE AMONG 15-16 YEAR OLDS. ESPAD
1999 SURVEY. SOURCE9
| | Ever use
| Last month use |
Six times or more last month
|
| Netherlands | 28%
| 14% | 5%
|
| Sweden | 8%
| 2% | 0%
|
5. Measures of health statistics in both countries
The AIDS incidence related to drug users is low both for
Holland (0.6 per million population) and Sweden (0.9 per million
population). The prevalence of HIV infection among injecting drug
abusers in the Netherlands is in the range between 0.5 per cent
and 25.9 per cent. The figure for Sweden is 2.6 per cent.8
The prevalence of "problem drug users" is possibly
higher in Sweden (4.0-5.4 per 1,000 population) than in the Netherlands
(2.5-2.9 per 1,000).8 However, due to the methodology used there
appears to be some fluctuation of these figures and the figures
only a few years ago were lower in Sweden than in the Netherlands.
In the past, problem users in Sweden mainly injected amphetamines
(roughly three-quarters of "problem users") whereas
only a quarter of "problem users" injected heroin. Heroin
use has increased recently. In the Netherlands, almost all problem
drug users use heroin.
An increase in the mean age for people in drug treatment—as
observed in Sweden—indicates a flattening or possible downward
trend as less new (ie younger) users are entering the treatment
system. This is usually a positive sign. This trend has also been
observed in almost every other European country in the late 1990s
apart from Holland and Luxembourg, where the mean age has decreased,
ie younger users enter the treatment system.10
6. Drug related deaths
Drug-related deaths do not necessarily support the Dutch
drug policy:
The low numbers of drug-related deaths in the Netherlands
has been put forward as vindicating the Dutch approach. Indeed,
in 1998, the last year for which figures are available for Sweden
by the European Monitoring Centre, there were 85 acute drug-related
deaths. In 1999, the last year for which figures are available
for the Netherlands (which has nearly twice the population of
Sweden) there were 76 drug-related deaths.8 This would translate
into a drug-related mortality of approximately five per million
population for the Netherlands and 10 per million for Sweden using
national definitions.
A higher death rate may reflect a higher age of the drug
using population in Sweden. However, there is the obvious concern
that drug addicts may not seek treatment for fear of criminal
charges. This would certainly be a serious shortcoming of the
Swedish drug policy.
It is, however important to note that the above mentioned
figures are based on national definitions which are not identical
in both countries: for example, if a person dies following an
accident and the toxicological analysis reveals the presence of
an illicit drug, the death would be classified as drug-related
in Sweden but not in the Netherlands.3
Furthermore, there is a huge variation between death rates
for the same country according to the definition used. For the
year 1995 the number of drug-related deaths in the Netherlands
was 33 according to the national definition, however 70 when using
a definition using a European standard. For the same year, the
figures for Sweden range between 41 and 134, depending on the
definition or standard used.8 For this reason, the claimed low
number of deaths per population which has been used to defend
the "Dutch model" may not reflect the real situation.
It may be more relevant to note that there has been an increase
in the number of drug-related deaths in the Netherlands over the
past five years. This is mainly due to an increase in cocaine-related
deaths. During the same period, a decrease was observed in Sweden.
7. Drug trafficking and manufacture of drugs
In the assessment by the United Nations Office for Drug Control
and Crime Prevention the Netherlands continue to be the centre
of synthetic drug manufacture in Europe, notably ecstasy and amphetamines.
Cannabis cultivation in the Netherlands is among the largest in
Europe. In terms of trafficking, the Netherlands—notably
due to its port of Rotterdam—is one of the main entry points
of drugs into Europe2: In 1998, 118,122 kg of Cannabis were seized
in Holland compared to 496 kg in Sweden. Dutch seizures of cocaine
significantly increased from 3,433 kg in 1992 to 11,452 kg in
1998. In contrast, the Swedish cocaine seizures in 1998 were 19
kg. Also, there are significantly higher seizures for heroin,
amphetamines, ecstasy and LSD in the Netherlands.3
Holland—in the words of senior customs and police officers
in the UK, France and Belgium has become "the drugs capital
of Western Europe"—and not just of cannabis, but also
of heroin, cocaine and now ecstasy. It is estimated that 80 per
cent of the Heroin seized in the UK and France has passed through
Holland since it is considered to be "relatively trouble-free
from a criminal's point of view."11
8. Policy
The Dutch official view is that cannabis use is by no means
risk free, but certainly no more harmful than alcohol and tobacco
use.3 This view is outdated: According to recent research, smoking
marijuana—as compared with smoking cigarettes—is associated
with nearly fivefold increase in blood carboxyhaemoglobin level,
a threefold increase in the amount of tar inhaled and retention
of one-third more tar.12 This is likely to lead to an increase
in cancer promotion. In fact, there have been case reports of
cancer in the aerodigestive tract in young adults with a history
of heavy cannabis use. Such cancers are unusual in this age group,
even among those who smoke tobacco and drink alcohol.13
The assumptions of the Dutch drug policy, ie that the harms
of cannabis are not considered to be great and that cannabis has
a low potential for dependency are not borne out by recent thorough
reviews on the subject.14, 15 In a 1995 conference on Marijuana
use organised by the US National Institute of Drug Abuse one of
the experts stated that "Studies show that [marijuana]
is more harmful than any of us realised."16
One of the bases of the Swedish drug policy is the "gateway"
hypothesis. While discounted by some researchers, there has been
recent pharmacological support for this hypothesis indicating
that both cannabis and heroin may act on the same receptors in
the brain.17 Data from New Zealand also supports this hypothesis.
After adjustment for confounding factors, a 60-fold increased
risk of other illicit drug use among those who used cannabis on
more than 50 occasions a year was observed.18 Adolescents who
use marijuana are 104 times more likely to use cocaine compared
with peers who never smoked cannabis.19 The data on drug prevalence
in both countries appears to vindicate the Swedish approach based
on the gateway hypothesis: infrequent cannabis use in Sweden is
associated with a low use of "hard" drugs whereas a
high prevalence of cannabis use in Holland is associated with
higher prevalence of "hard" drug abuse.
9. Conclusion
Having implemented their different policies for a quarter
of a century, the outcome of the Swedish drug policy aimed at
creating a drug-free society has been far more successful than
the liberal "harm-reduction approach" utilised in the
Netherlands. The use of cannabis and of other illicit drugs including
cocaine, amphetamines and ecstasy is far lower in Sweden than
in the Netherlands. Associated with its "harm-reduction"
policy, the Netherlands has seen a significant rise in cannabis,
cocaine, amphetamines and ecstasy use. Furthermore, it has become
one of the main drug trafficking countries in Europe for heroin,
cocaine and cannabis and the centre of synthetic drug manufacture,
notably ecstasy and amphetamines. Far more harm-reduction for
the Netherlands and other European countries would ensue if the
Netherlands adopted drug regulations aimed at reducing drug use.
The available evidence therefore strongly favours the Swedish
approach.
10. Lessons to be learnt
The Swedish and Dutch experiences points to the following
lessons:
— A clear message that drugs in general and cannabis
in particular are harmful is associated with a low abuse of cannabis
and other drugs.
— A strong consensus in politics, education and
public opinion to aim at a drug-free society leads to significantly
lower drug abuse than legalising drugs.
— The criminal justice system can play a role—together
with education and treatment—in reducing drug abuse by consequently
enforcing drug laws.
— Legalising cannabis sends the message that it
is "ok to take cannabis". This is associated with a
high use of cannabis.
— Low use of cannabis is associated with a low use
of other illicit drugs whereas high use of cannabis is associated
with a high use of other illicit drugs including cocaine, amphetamines
and ecstasy.
— Legalising cannabis is likely to lead not only
to an increased abuse of cannabis, but also to a steep rise in
abuse of other illicit drugs such as cocaine, amphetamines and
ecstasy.
— Legalisation of cannabis is associated with increasing
drug trafficking in other illicit drugs such as heroin, cocaine,
amphetamines and ecstasy.
February 2002
REFERENCES
1 Tutt D et al. Cannabis and road death: an emerging injury
prevention concern. Health Promotion Journal of Australia 2001;
12: 159-62.
2 United Nations Office for Drug Control and Crime Prevention
2000: The Netherlands—Country profile on drugs.
3 European Parliament, Directorate General for Research 2001:
The drug policies of the Netherlands and Sweden: How do they compare?
4 Report to the EMCDDA by the Reitox national focal point
in Sweden, Folkhalsoinstitutet. Sweden, Drug Situation 2000.
5 United Nations Office for Drug Control and Crime Prevention
1998: Country Drug Profile Sweden.
6 Boekhout van Solinge T. The Swedish Drug Control System.
Cedro, Amsterdam 1997. Please note that the more negative conclusion
of this Dutch assessment of the Swedish drug policy are not supported
by EMCDDA data.
7 MacCoun R and Reuter P. Evaluating alternative cannabis
regimes. British Journal of Psychiatry 2001. 178: 123-8.
8 European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA) 2001: Annual report on the state of the drugs problem
in the European Union.
9 Trimbos Institute Utrecht, quoting European School Survey
Project on Alcohol and Other Drugs ESPAD 1999.
10 United Nations Office for Drug Control and Crime Prevention.
World Drug Report 2000; p 96-7.
11 Collins L. Holland's half-baked drug experiment. Foreign
Affairs 1999; 78: 82-98.
12 Wu TC et al. New England Journal of Medicine 1998; 318:
347-51.
13 Hall W, Solowij N. Adverse effects of cannabis. Lancet
1998; 35: 1611-16.
14 Ashton CH. Adverse effects of cannabis and cannabinoids.
British Journal of Anaesthesia 1999; 83: 637-49.
15 Johns A. Psychiatric effects of cannabis. British Journal
of Psychiatry 2001; 178: 116-22.
16 National Institute on Drug Abuse (NIDA), National Institutes
of Health 1995. National Conference on Marijuana Use. p 38.
17 Tanda G et al. Cannabinoid and Heroin activation of mesolimbic
dopamine transmission by a common mu1 opioid receptor. Science
1997; 276: 2048-50.
18 Fergusson DM, Horwood LJ. Does Cannabis use encourage
other forms of illicit drug use? Addiction 2000: 95: 505-20.
19 The American Academy of Pediatrics. Marijuana: A continuing
concern for Pediatricians. Pediatrics 1999.
| 
