Risks of Legalising Cannabis Underestimated

A comparison of Dutch and Swedish drug policy

February 2002

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 debate. 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, i.e. 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 rare³. 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 ecstasy and hard drug use doubled.” ²

Following the de facto legalisation prevalence of cannabis has increased sharply. In the age group 18-20 an increase in the past year use of cannabis from 15% in 1984 to 44% in 1996 was observed. The increase in the past month use over the same period was from 8.5% to 18.5%.

The increase in Dutch prevalence from 1984 to 1992 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 approach⁷. 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 70s 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 countries⁵. (Table 1):

Table 1: Life-time prevalence of drug abuse (all drugs) among 15-16 year olds in Sweden ^{5  [8]}

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% in the Netherlands and 8% 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 1999 ⁸

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.

Table 4: Percentage of Cannabis use among 15-16 year olds. ESPAD 1999 survey. Source[9] 

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% and 25.9%. The figure for Sweden is 2.6% ⁸.

The prevalence of ‘problem drug users’ is possibly higher in Sweden (4.0-5.4 per 1000 population) than in the Netherlands (2.5-2.9 per 1000) 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 ¾ of ‘problem users’) whereas only ¼ 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 (i.e. younger) users are entering the treatment system. This is usually a positive sign. This trend has also been observed in the almost every other European country in the late 1990s apart from Holland and Luxembourg, where the mean age has decreased, i.e. 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 deaths⁸. This would translate into a drug-related mortality of approximately 5 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 Netherlands³. Also, there is a far higher autopsy rate with toxicological analysis for suspected drug-related deaths in Sweden (up to 90%) than in the Netherlands (30-40%) which would make the detection of drug-related deaths more likely in Sweden than in the Netherlands³ .

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 used⁸ . 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, 118122 kg of Cannabis were seized in Holland compared to 496 kg in Sweden. Dutch seizures of cocaine significantly increased from 3433 kg in 1992 to 11452 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 Netherlands³.

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% 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 use³. 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, i.e. 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 realized.”[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.

Footnotes