London Drugs Commission The Cannabis Conundrum March 2025

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THE CANNABIS 
CONUNDRUM: 
a way forward for London 
A report by the London Drugs 
Commission, March 2025 

   
 
2 
 
FOREWORD  
 
Our Terms of Reference – to investigate implications of the non-medical 
use of cannabis in London and the impact of the current laws which govern 
it, and to make associated recommendations – poses a readily 
comprehensible task but one which has proved significant and challenging.   
 
We have been presented with a vast amount of evidence both in person 
and on paper. We have conducted a more wide-ranging and detailed study 
of the best policy options in respect of cannabis than any other, in the UK 
or abroad, in recent times. The scale of our investigation is revealed by the 
very substantial list of people from whom we received evidence - over 200. 
In particular, we heard extensively from other countries and jurisdictions 
which have changed the legal position of cannabis in recent years. 
 
We came to this investigation from different backgrounds and from different 
perspectives. Our Chair, Lord Falconer, has extensive experience of 
government responsibility for the administration of justice. He has 
previously called drugs prohibition a failure for working class communities. 
One Deputy Chair, Janet Hills MBE, had spent 30 years in the Metropolitan 
Police Service, providing strong leadership to the Black Police Association, 
and has spoken out about the detrimental impact of cannabis stop and 
search within the black community at both a local and national level. Our 
other Deputy Chair, Professor Virginia Berridge, is an academic historian 
who has written widely on the forces which position substance use as legal 
or illegal and what drives change in policy for different drugs. We did not 
start from the same positions or outlook. But we have had no trouble in 
reaching a consensus about what our conclusions in this report should be. 
 
It is commonplace for legalisation to be seen as the panacea for all the 
problems associated with the prohibition of cannabis use. We have not 
come to that conclusion, but we do not make the case for retaining the 
status quo. We recommend instead moving the drug from the Misuse of 
Drugs Act to the newer Psychoactive Substances Act. This makes it 
possible to continue to police the production and supply of cannabis while 
not penalising its possession. In retaining the criminalisation of importation, 
production and supply we have paid strong regard to the evidence of those 
people dealing with the adverse effects of cannabis – educators, youth 
workers, medical practitioners and police. They strongly urged us not to 
legalise those aspects of the trade, because it would likely worsen the 

   
 
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position of those whose use is already problematic, and potentially increase 
their number. 
 
The legalisation of possession however goes some way to addressing the 
racial disproportionality in the operation of stop and search, which 
particularly affects London’s black communities. We have also put forward 
workable proposals which will help policing in London; bring some order to 
schemes which aim to divert people out of the criminal justice system; 
further develop coordination across parts of the health system and improve 
education on the risks and uses of cannabis. 
 
Having considered all the evidence, we do not think the case can be made 
at the current time for legalisation beyond the extent accepted in the 
Psychoactive Substances Act. The arguments are rehearsed in detail in 
this report, but international evidence shows that legalisation does not have 
the effects often assumed. It does not eradicate the illicit market. The 
commercial model adopted in some jurisdictions has meant the 
replacement of ‘Big Tobacco’ by ‘Big Cannabis’. The health implications of 
widely available cannabis, in particular modern high-strength skunk, and its 
use in the UK with tobacco, would be amplified by expanded availability. 
There are too many imponderables in terms of the evidence on legal 
change as it currently exists; and once the leap to legalisation is made it is 
difficult to row back. 
 
But regulation need not be set in stone. Cannabis first came under legal 
regulation in the UK in 1928, nearly a century ago – not because of 
problems with use in Britain, but because of colonial power politics in Egypt 
which led to laws being applied to all countries. The drug was always an 
outlier in what was then called dangerous drugs legislation, an uneasy add-
on to heroin and cocaine. That situation needs change. In this report we 
put forward what we consider to be achievable legal and practical 
proposals which will benefit both the population of London and the wider 
community.  
 
 
 
 
 
 
 

   
 
4 
 
The Commission wishes to express their profound thanks to everyone who 
submitted evidence to our inquiry. Their time, effort and contributions 
formed the invaluable foundation of this report. 
 
We also wish to thank each member of our Expert Reference Group, 
namely Dr Arun Dhandayudham, Dr Marta Di Forti, Niamh Eastwood, David 
Gauke, Jason Harwin, Iona Lidington, Junior Smart OBE and Professor 
Adam Winstock. All of them are truly experts, all of them gave their time 
freely and without restraint, and all of them provided us with insight, lines of 
enquiry and true assistance. Responsibility for the report lies with the three 
members of the Commission, but we have been tremendously supported 
by this Group. 
 
Finally, we have been hugely assisted by our secretariat. Jenny Cann, the 
Commission’s head of secretariat, has been the person who has done the 
organisation, arranging and co-ordination of the evidence. She has guided 
and made possible all that we have done. Her deft and tactful skills lie 
behind the report; she brought the very best of civil servant expertise to the 
task. Our debt to her is incalculable. Our admiration and respect for all that 
she has done is huge. 
 
 
          
         
       
 
Lord Falconer Janet Hills, MBE  Professor Virginia Berridge   
Chair Deputy Chair    Deputy Chair      
 
 
 
The London Drugs Commission, March 2025  

   
 
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ACKNOWLEDGEMENTS 
 
In addition to those we have thanked in our Foreword, we would also like to express our 
gratitude to colleagues from University College London (UCL). Professor Ben Bradford 
and Professor Toby Seddon oversaw and guided the gathering and reviewing of a wide 
range of existing evidence regarding the control of cannabis in the UK and across the 
world. The outputs from this substantial exercise helped to inform and shape our focus 
and lines of inquiry.  
 
We are similarly grateful to all those who undertook or otherwise supported these 
evidence reviews, namely Hannah Barnett (Imperial College London), Dr Nicola Bennett 
(UCL), Angus Chan (UCL), Dr Gonzalo Croci (UCL & Universidad ORT Uruguay), Dr 
Simon Flacks (University of Sussex), Gonzalo Garcia-Campo Almendros (University of 
Oxford), Dr Lucy Harry (University of Oxford), Dr Arabella Kyprianides (UCL), Dr Anna 
Ross (University of Edinburgh), Isabella Ross (Crest Advisory) and Dr Julia Yesberg 
(Victoria University of Wellington). 
 
Finally, we would like to thank the Mayor of London for providing us with the opportunity 
to conduct this inquiry, and those staff from the Mayor’s Office for Policing & Crime who 
provided support throughout the process.  
 
     
 
  

   
 
6 
 
ABBREVIATIONS 
 
ACMD   Advisory Council on the Misuse of Drugs 
ADPH   Association of Directors of Public Health 
ASH   Action on Smoking & Health 
BCU   Basic Command Unit  
BMA    British Medical Association 
BTP   British Transport Police 
BWV   Body-Worn Video 
CBD   Cannabidiol 
CBPM   Cannabis-Based Product for Medicinal use 
CoLP   City of London Police 
CoP   College of Policing 
CJS   Criminal Justice System 
CPS   Crown Prosecution Service 
DBS   Disclosure & Barring Service 
DfE   Department for Education 
DHSC   Department of Health & Social Care 
EMCDDA  European Monitoring Centre for Drugs and Drug Addiction 
FSA Food Standards Agency 
GPhC General Pharmaceutical Council 
HHC  Hexahydrocannabinol 
HMICFRS His Majesty’s Inspectorate of Constabulary and Fire & Rescue 
Services 
ICS   Integrated Care System 
HAC   Home Affairs Committee 
HO   Home Office 
MDA 1971  Misuse of Drugs Act 1971 
MDR 2001  Misuse of Drugs Regulations 2001 
MHA 1983  Mental Health Act 1983 
MPS   Metropolitan Police Service 
MoJ   Ministry of Justice 
MOPAC   Mayor’s Office for Policing & Crime 
MSHT   Modern Slavery & Human Trafficking 
NCA   National Crime Agency 
NICE   National Institute for Health & Care Excellence 
NPCC   National Police Chiefs Council 
OCG   Organised Crime Group 
OHID   Office for Health Improvement & Disparities 
ONS   Office for National Statistics 
PCC   Police & Crime Commissioner 
PSA 2016  Psychoactive Substances Act 2016 
RCP   Royal College of Physicians 
S&S   Stop and Search  
THC   Delta-9-tetrahydrocannabinol 
UNODC  United Nations Office on Drugs & Crime 
WHO   World Health Organization 

   
 
7 
 
GLOSSARY & EXPLANATORY NOTES 
 
We rely on a variety of specific terms and concepts related to cannabis and its use 
throughout this report. We explain these, and how we have used them, here. 
 
Cannabis  
• Refers to botanical cannabis used for non-medical purposes, unless otherwise 
specified. There are several other terms for the plant, including marijuana, but 
cannabis is the most commonly used across medical and non-medical settings, 
in the UK and around the world. Unless otherwise specified, when we refer to 
‘cannabis’ we mean the drug in its herbal or ‘flower’ form. 
 
Cannabidiol (CBD)  
• A non-psychoactive component of cannabis that is associated with particular 
effects on the brain and the body. It can ameliorate some of the effects of delta-
9-tetrahydrocannabinol (THC) and is increasingly used in products offered by the 
expanding health and wellness market. 
 
Cannabinoids  
• Are chemical compounds present in cannabis that, when consumed, bind to 
cannabinoid receptors on the surface of cells in the brain and immune tissue. 
There are more than 100 cannabinoids but the two most abundant are CBD and 
THC.  
 
Concentrate  
• Refers to cannabis flower that has been processed, resulting in a reduced 
concentrated mass that contains a far greater proportion of cannabinoids and 
terpenes (see below). Concentrates may be referred to as ‘dabs’ because 
‘dabbing’ (see below) is a common way to consume forms of concentrated 
cannabis.  
 
Dabbing  
• Is the term given to heating a cannabis concentrate or extract (usually high-THC 
but can be high-CBD) using a device known as a dab rig, to produce a highly 
potent vapour for inhalation.  
 
Delta-9-tetrahydrocannabinol (THC)  
• Is the psychoactive component of cannabis that causes the consumer to feel 
‘high’. It exerts effects on the brain and the nervous system. While there are 
several forms of THC, such as delta-8-tetrahydrocannabinol, when we refer to 
the compound, we use the term to mean delta-9-tetrahydracannabinol.  
 
Endocannabinoid System (ECS) 
• Regulates the brain signals responsible for bodily functions including learning 
and memory, mood, sleep, appetite, pain control and inflammatory and immune 

   
 
8 
 
responses. Endocannabinoids become active when they bind with, or stimulate, 
a cannabinoid receptor.  
 
Ethnicity  
• We refer to people from different ethnic backgrounds throughout our report, as 
we have explored how the impacts of cannabis use and its legal status can vary 
according to ethnicity. We have adopted the government’s preferred style, which 
is not to capitalise ethnic group (such as ‘black’ or ‘white’) unless that group’s 
name includes a geographic place (for example, ’Asian’, ‘Indian’ or ‘black 
Caribbean’).1 Many of the statistics we have drawn on are produced using 
reference to people from a white, black, Asian or mixed ethnic background and 
for ease of reading we have replicated this approach. We recognise, however, 
that these terms aggregate many different groups; for example, included in the 
‘black’ category are people of black Caribbean and black African origin, as well 
as those from any other black or black British background. 
 
Illicit/illegal market 
• Refers to cannabis produced, distributed, supplied and purchased in any non-
legal setting. The terms are used interchangeably throughout this report. 
 
Legal regulation  
• Refers to a legal framework governing non-medical cannabis use by adults, in 
which regulations allow for the lawful possession, supply, transit and production 
of the drug. This is commonly referred to as ‘legalisation’. The term ‘legalisation’ 
is used interchangeably with ‘legal regulation’ for ease of reading throughout this 
report.  
 
Opiates and opioids  
• Are used interchangeably in this report. Both can be used for medical treatment, 
both can also be used illicitly, but the difference lies in how they are made. 
Opiates are chemical compounds extracted or refined from natural sources and 
include opium, morphine, codeine and heroin. Opioids are largely designed and 
manufactured in laboratories and include fentanyl, oxycodone and hydrocodone.  
 
Potency  
• Is used to mean the strength of cannabis with respect to its psychoactive, or 
THC, content.  
 
Terpenes  
• Are organic compounds found in the cannabis plant. Over 400 terpenes have 
been identified and these are responsible for making strains of cannabis smell or 
taste different from others and influence how a person experiences their 
consumption of the drug. 
 
 
1 Writing about ethnicity – GOV.UK (ethnicity-facts-figures.service.gov.uk) 

   
 
   
 
CONTENTS 
 
Executive Summary            11  
 
Recommendations             20 
 
1. Introduction                                                                                         26  
     
2. A history of cannabis regulation in the UK                                      32  
     
3. Non-medical cannabis, UK law & alternative legal  
approaches  
44  
    
4. Cannabis use in the UK                                                                     50  
  Figure 1: Proportion of 16–59-year-olds reporting past-year 
cannabis use in England & Wales and London, 2001–2023 
Figure 2: Proportion of adults (aged 16+ / 18+ and over) 
reporting past-year non-medical cannabis use in selected 
jurisdictions, 2016–2023 
Figure 3: Proportion of 16–59-year-olds reporting past-year 
cannabis use in England & Wales, by age group, 2001–
2023 
 
  
5. The UK cannabis market                                                                    73  
     
6. Public attitudes 87  
  Figure 4: Cannabis mindsets among Londoners   
    
7. International approaches to cannabis regulation  93  
7.a Alternatives to prohibition in regulating non-medical cannabis   
  Table 1: Legal regulation of non-medical cannabis in the 
US  
 
  
7.b The impact of alternatives to prohibition   
  Figure 5: Understanding the impacts of cannabis 
legalisation 
Table 2: Canadian retail sales of adult-use non-medical 
cannabis, 2018–2023 
Table 3: Cannabis retail stores across Canadian regions, 
September 2022 
  

   
 
   
 
Table 4: Cannabis-related charges in Canada, 2017 and 
2022 
    
8. The effects of non-medical cannabis on physical and mental 
health 
160  
    
9. The health policy response to non-medical cannabis use 
 
188  
10. Cannabis, policing and the criminal justice system 206  
  Figure 6: Outcomes from MPS-led drug-related stops and 
searches in 2023 
Table 5: Ethnic disproportionality in drug-related stop & 
searches, by London borough, 2023 
Table 6: Outcomes from MPS-led drug-related stop and 
searches, 2023  
Table 7: Outcomes of MPS-led arrests for cannabis by 
ethnicity, 2021 
Table 8: Outcomes of convictions for cannabis offences at 
all courts in England & Wales, 2022 
Table 9: Prosecutions and convictions for cannabis 
offences in London by ethnicity, 2022 
 
  
11. Cannabis for medical purposes 267  
  Table 10: Number of prescriptions issued in England for 
licensed cannabis-based medicines, 2020–2023 
  
 
12. 
 
Education and cannabis 
 
288 
 
 
13. 
 
Cannabis Social Clubs 
 
 
300 
 
 
Appendices                      306 
 
 

   
 
11 
 
EXECUTIVE SUMMARY 
 
Our comprehensive examination of the nature and effectiveness of UK cannabis law 
involved taking evidence from over 200 witnesses from national and international settings, 
who brought significant knowledge and lived experience. Many are well-known, highly 
regarded experts in their respective fields. We also considered a substantial amount of 
wider data and research. Collectively, this led us to the following position and principal 
recommendation, with several underpinning conclusions and associated further 
recommendations set out subsequently:  
 
The current law criminalises importation, exportation, production and supply of cannabis, 
with the possibility of severe associated punishments. It also criminalises cannabis 
possession and, in this, we find it not fit for purpose. The law therefore requires some 
modification.  
 
• While use of cannabis can cause considerable harm to a minority of those who 
consume the drug, the severity of penalties for related offences, particularly 
possession, is, in our view, disproportionately high. This is relative both to risks posed 
by cannabis itself and to those posed by drugs classed alongside cannabis in the 
Misuse of Drugs Act (MDA).  
 
• Moreover, the law with respect to cannabis possession is experienced 
disproportionately by those from ethnic minority (excluding white minority) groups, 
particularly London’s black communities. While more likely to be stopped and 
searched by police on suspicion of cannabis possession than white people, black 
Londoners are no more likely to be found carrying the drug. 
 
• In addition, evidence of any criminality, however serious (drugs-related or otherwise), 
is evidenced in only around one-third of stops overall. Taken together, these realities, 
in our view, mean that continuation of the law as it currently stands cannot be justified. 
 
That said, we do not think wholesale change, whereby all (non-medical) cannabis-related 
activities become legal, either in a for-profit or non-profit framework, is the answer.  
 
• We heard several times that legalisation has not been calamitous. While (at least so 
far) this seems to be the case, neither has it been a panacea in solving issues 
associated with prohibition, and those who have studied the experience of early 
adopters of legalisation urge caution. Risks remain and evidence does not suggest 
these, at least currently, are outweighed by benefits such as tax revenue rises (in 
commercial models) or reductions in pressures on criminal justice systems. Moreover, 
legalisation by no means abolishes the illicit cannabis market. Overall, in our view 
there remain too many unknowns about the longer-term impacts of legalising 
cannabis, particularly those relating to public health.   
 
• Cannabis use is falling though it remains – as across the world – the most widely used 
illegal drug in England & Wales, and its market value is significant. Around 2.5 million 

   
 
12 
 
people aged between 16 and 59 reportedly consumed the drug at least once during 
2022–2023. Prohibition thus seemingly does little to prevent access to the drug so, at 
the most basic level, legalisation simply changes how a person purchases cannabis 
(as well as the type and quality available).  
 
• Most people who use cannabis suffer no adverse or life-limiting consequences. 
Evidence suggests however that at least 10% risk developing associated difficulties of 
some kind. While not always severe, in some cases very significant psychiatric, 
physical and/or societal problems (including a failure to engage productively or at all 
with education or work, or to sustain interpersonal relationships) can manifest. The 
increase in cannabis potency over recent decades has heightened the risk of 
problems developing. While that risk depends on several factors (including age at 
onset of use, frequency of use and genetic predisposition to certain health conditions), 
the number of users overall means the number of problematic users is not 
inconsequential.  
 
• Drug treatment services are overwhelmed, in no position to deal with any rise in 
demand that legalising cannabis may create following an almost inevitable rise in the 
number of users. This is probably exacerbated in profit-based models, where 
encouragement of widespread, frequent consumption is incentivised.  
 
• Moreover, in the UK cannabis is mainly co-consumed with tobacco. So, unless habits 
were to significantly shift, legalisation risks a wholly unwelcome reversal in the current 
declining rates of smoking. It would represent a somewhat illogical move, in light of 
wider plans to restrict use of cigarettes and e-cigarettes, and the intention for future 
generations never to be legally permitted to purchase them. 
 
• Polling suggests a majority of the public do not support wholesale prohibition of 
production, supply and possession of cannabis. While people do not want to see lives 
ruined through cannabis addiction, nor do they wish to see lives ruined as a result of 
engagement with the criminal justice system for use of the drug. That said, for some 
there is considerable disquiet around its consumption in public spaces, with fears that 
a more permissive legal framework would worsen this.  
 
While not a perfect solution, we therefore recommend natural (but not synthetic) cannabis 
be removed from the Misuse of Drugs Act (MDA). This will bring it under the Psychoactive 
Substances Act (PSA). We think this represents the best way of addressing key harms of 
the current law, without risking others that further relaxation, or legalisation, at least at the 
moment, would likely entail. It would mean: 
 
• Cannabis possession for personal use will no longer be a criminal offence and stop 
and search (S&S) could not be deployed solely on suspicion of such. Use of the power 
remains where police suspect other offences, including those related to more serious 
cannabis offending, including trafficking offences.  
 

   
 
13 
 
• Importation, exportation, production and distribution of cannabis (including street 
dealing, or supply) remain illegal, but maximum sanctions are reduced (prison custody 
remains an option).  
 
Two further outcomes may follow removal of natural cannabis from the MDA, namely: 
 
• Concern regarding consumption of cannabis in public spaces may rise (although we 
think, as some evidence suggests, that consumption itself is unlikely to materially 
increase). This should be addressed through clear application of local anti-social 
behaviour regulations.  
 
• Disparities in risk of criminal sanction faced by those who can and cannot afford 
privately prescribed medical cannabis – which in many cases resembles illicit forms of 
the drug – should ease. People who find the drug alleviates symptoms of ill health and 
who have a cannabis prescription are not at risk of such sanction. Those who rely on 
illegal cannabis to ease the same symptoms are, however, liable to be so – even 
where medical records evidence their ill health. This seems unjust: removing sanctions 
for possession of cannabis for personal use, irrespective of source, offers a solution.   
 
Scope of our inquiry 
 
Our terms of reference (see Appendix A) broadly guided our inquiries and our overall 
approach is laid out in our introduction (ch.1). We have explored not only how non-
medical cannabis is dealt with in the UK’s legal system (ch.3) but the historical origins of 
that approach (ch.2). We considered current and past patterns of cannabis use (ch. 4), 
the illicit cannabis market (ch.5), and public attitudes towards both use of the drug and its 
prohibition (ch.6).  
 
How cannabis interacts with the human body and mind (ch.8) and implications for health 
services (ch.9) comprised a substantial element of our work. This led us also to consider 
the recently established UK market in, and demand for, medical cannabis products 
(ch.11).    
 
The implications of cannabis prohibition for those who use the drug regardless formed a 
key plank of our inquiries: in ch.10 we set out our findings with respect to the policing of 
cannabis use and the way related offences are treated within the criminal justice system. 
 
We refer throughout our report to evidence from jurisdictions across the world that have 
moved away from wholesale prohibition, with details set out in ch.7. Those considerations 
also led us to consider the advent of Cannabis Social Clubs (ch.13).  
 
Finally, matters related to education – principally of children and young people but also of 
relevant healthcare professionals and others – are touched on throughout our report but 
ch.12 focuses on the specifics.  
 
 
 
 

   
 
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Conclusions  
 
Our overarching conclusions speak broadly to public health, policing and the justice 
system, and education. The 42 recommendations (R#) to which these gave rise are set 
out at the close of this Executive Summary and largely follow suit. Some focus on London 
and are aimed at the Mayor and City Hall, others have broader application. 
 
Conclusion 1: Cannabis can be addictive: irrespective of the current or future legal 
position, more explicit provision of services focused on problematic use of and addiction 
to the drug is needed, alongside greater join-up between relevant health services.  
 
The majority of people who use cannabis experience few if any long-term adverse health 
consequences. But frequent use of high-potency cannabis, particularly from a young age, 
elevates risk. For some, this can be significant, especially where difficulties related to 
health, deprivation and poverty, trauma, education, interpersonal relationships and/or 
compliance with criminal justice sanctions feature heavily in a person’s life. Synthetic 
cannabinoid receptor agonists (SCRAs), which often closely resemble natural cannabis 
and mimic the effects of its psychoactive component (THC)2 but are many times more 
potent, are thought to pose substantially greater risk.  
 
We heard time and again from practitioners across the justice, health and education 
sectors that increasing availability, choice and access to cannabis could worsen 
challenges faced by people already struggling to cope. While less concerned about a 
relaxation of the law regarding possession for personal use, they expressed significant 
concern at the prospect of any wider easing.  
 
While less so than alcohol and opioids, cannabis (and the nicotine in tobacco with which it 
is commonly co-consumed) is addictive and regular use builds tolerance, meaning a 
person requires more and more to achieve the desired effect. The emergence of 
Cannabis Use Disorder (CUD), thought to affect at least 10% of those who use the drug 
(and possibly more in jurisdictions where it is legal, though evidence is mixed and reasons 
for both rises and falls remain unclear), is testimony to these properties. There is, too, 
increasingly clear evidence of a causal link between development of severe mental health 
disorders (namely psychosis and schizophrenia) and cannabis use, particularly heavy use 
of highly potent forms of the drug from an early age (generally conceived of as being 
before 15 or 16).  
 
Cannabis-related problems, however, receive relatively short shrift in the underfunded 
and understaffed reality of drug treatment services. Posing as they do a greater risk of 
harm, opioids and alcohol tend to be prioritised. Not only can this leave parallel cannabis 
use unaddressed, those who use neither opioids nor alcohol but exhibit cannabis-related 
problems risk falling between the gaps: specialist care is very limited.  
 
Inadequate join-up between services and poor understanding across wider health 
provision, including GPs and tobacco cessation providers, intensifies this and is further 
 
2 Delta-9-tetrahydrocannabinol (THC) is the psychoactive component of cannabis that causes a user to feel ‘high’. While 
there are several forms of THC, in this report the term refers to delta-9-tetrahydracannabinol.  

   
 
15 
 
heightened in London by fragmentation of healthcare across boroughs. This means that 
cannabis is not identified as a factor in poor health as often as it might be. Compounding 
these challenges is a lack of detailed evidence regarding what works in addressing issues 
related specifically to cannabis addiction.  
 
Legalisation could encourage help-seeking before problems become entrenched and 
more difficult and costly to treat. There is so far, however, inadequate evidence of such 
behaviour being encouraged. Thus, a change that risks increasing demand on already 
stretched services – because it increases numbers in need, or numbers willing to admit 
they are in need, or both – will be neither welcome nor achievable at the current time. 
 
While legal for use to treat a number of specified medical conditions since 2018, cannabis 
remains on the fringe of modern medicine in the UK – although CBD-based3 products in 
the wellness industry are now mainstream. This means the market is taking some time to 
become established and until relatively recently has relied on importation of the drug to 
meet demand, which in itself has brought challenges.  
 
Use by the NHS is limited, in part due to evidence of medical impacts of the whole plant 
(therapeutic and side effects) so far failing to meet standards required for licensed 
medicines. Unlicensed cannabis-based products for medicinal use (CBPMs) are available 
via the private sector to treat a wider range of conditions, but costs can be prohibitive for 
many who claim cannabis offers relief of their symptoms.  
 
Our recommendations regarding cannabis and healthcare (see R4–13, 15, 34 and 37) 
seek to:  
 
• Reduce inadvertent consumption of more dangerous synthetic cannabis products.  
• Expand awareness among health professionals of how cannabis affects the body 
and brain.  
• Develop the evidence base regarding: 
- How cannabis users understand potency and risks, and the impact of this on 
consumption choices. 
- Interplay between consumption of legal CBD products and illegal cannabis. 
- Treatment of addiction to non-medical cannabis and other symptoms of ill 
health related to its use, including any possible therapeutic role for medical 
cannabis. 
- The efficacy of unlicensed CBPMs in treating physical and mental health 
conditions, including side effects.  
• Improve join-up between healthcare providers, including pharmacists, tobacco 
cessation and drug treatment services, to better identify and care for those whose 
symptoms of ill health might be associated with, or worsened by, use of cannabis.  
• Ensure law enforcement officers understand the law surrounding use and 
possession of cannabis for medical purposes and are familiar with its prescription. 
 
 
3 Cannabidiol (CBD) is a non-psychoactive component of cannabis that is associated with particular effects on the brain 
and the body. It can ameliorate some of the effects of delta-9-tetrahydrocannabinol (THC). 
 

   
 
16 
 
Conclusion 2: Any model of legalisation involves challenging trade-offs. But while 
undoubtably it is possible for gains to be realised fairly swiftly, including tax takes and 
reductions in criminalisation, the extent and nature of harms, principally (but not limited) 
to public health, with associated personal and societal costs, are yet to be fully 
understood.  
 
While we see opportunities to reap benefits, we also see potential for harms, and are 
unconvinced that current knowledge is sufficient to manage those adequately. Until the 
picture is clearer, wholesale change to the legal framework in the UK – which similarly is 
not without associated harms – would be unjustifiable and irresponsible. It is too great a 
risk and – as demonstrated by the alcohol and tobacco industries – tightening regulations 
and governance to respond to emerging risk once markets are in place is difficult. Once 
the law changes, the genie cannot easily be put back into the bottle.  
  
No jurisdiction that has adopted a more liberal position than the UK considers they have 
achieved the perfect balance, and it remains unclear as to what the optimal regulatory 
model might be. While, as is broadly accepted, cannabis is not a harmless drug, 
wholesale prohibition does not, in our view, present the best, or least problematic, option. 
But we are not persuaded that a balance between policy aims to raise tax revenue, shrink 
the illegal market and reduce criminalisation can be achieved in such a way that does not, 
for example, unduly threaten public health through making cannabis consumption as 
commonplace as coffee drinking.  
 
In our view, the case cannot currently be made that legalising cannabis for non-medical 
use brings a net gain across society, and we are not convinced that any current model 
adequately safeguards risks to health. Whether such a model exists or can ever exist 
remains, to our mind, unclear. We do not rule out the possibility of such in the future, 
though equally accept it may never be a realistic prospect for this country, bearing in 
mind, too, our unique social, political and cultural context.   
 
As legalisation becomes more established elsewhere and more jurisdictions embrace 
different models, however, evidence will expand and solidify: consequences will become 
clearer in time. The Mayor, or government, might wish to undertake a further review in five 
years to explore whether a more convincing case for legalisation has emerged (see R3). 
Such a review would be usefully informed by parallel work to fill various associated 
evidence gaps we also recommend be addressed (see R1, 2, 33, 41 and 42).  
 
It should consider how to prioritise aims of any alternative to prohibition, and whether 
some form of commercial or non-profit model offers the best way of ensuring benefits 
relative to those priorities outweigh risks, or costs. The evidence base is currently 
dominated by early indications of the impact of commercial approaches: in time, we 
expect more research will emerge from jurisdictions that have adopted more limited or 
non-commercial models, offering a more comparative picture of relative costs and 
benefits. 
 
Conclusion 3: Wholesale prohibition under the Misuse of Drugs Act (MDA) treats 
cannabis in a manner that is disproportionate to its harms, particularly in the case of 
possession for personal use. While use carries risks, particularly for some people in some 

   
 
17 
 
circumstances, we consider those to be insufficiently widespread to justify the sentencing 
options available while it remains governed by the MDA.  
 
The possibility of a custodial prison sentence of any length, but certainly up to the current 
maximum of five years, for possession of cannabis for personal use feels excessive. While 
in reality those sentenced to custody for such serve only a matter of weeks, the negative 
consequences of serving any time in prison are significant.  
 
Moreover, cannabis possession is very often identified by police through use of S&S, a 
practice that continues to be utilised in a racially disproportionate way. This means people 
from ethnic minorities (excluding white minorities), particularly those of black heritage, are 
not only at greater risk of being subjected to what can be an intrusive, traumatic process, 
they end up over-represented throughout the justice system for cannabis possession 
offences.    
 
The potential to receive a custodial sentence for up to 14 years for possessing enough 
cannabis to supply others similarly feels extreme, relative to the dangers of cannabis itself 
(as compared to other drugs alongside which it is classed in the MDA).  
 
Our recommendation that, as a psychoactive substance, cannabis should fall under the 
auspices of the Psychoactive Substances Act (PSA, see R30–32, 36), seeks to: 
 
• Expose fewer people to S&S (suspicion of cannabis possession alone will no 
longer be legitimate cause to deploy the power).  
• Help tackle the persistent racial disproportionality seen in use of the power.  
• Ensure that, where illegal cannabis activity is proven, sanctions are commensurate 
with the risks posed relative to other controlled drugs.  
• Ease the risk of criminal sanction for those who find cannabis addresses symptoms 
of ill health but who cannot afford to purchase it via legal prescription. 
 
We recognise that changing how the law treats possession of cannabis for personal use 
does not address the fact that those who use the drug depend on the illicit market to 
access it, with all the inherent risks that entails. Close attention should be paid to 
jurisdictions that permit limited home cultivation, to understand whether this measure 
reduces demand for product offered by illegal dealers (see R33). In future, the legal 
definition of cannabis production could be amended to exclude limited home cultivation.  
 
Conclusion 4: Cannabis policing, particularly via Stop & Search (S&S), continues to focus 
on particular groups with damaging, long-lasting consequences for individuals, wider 
society and police–community relations. Grounds are often poorly justified and, in 
London, the risks of criminalisation and harsher outcomes where possession of small 
quantities of the drug are found are borne unfairly by black communities.  
 
The risk of criminal sanction associated with (suspected) possession of cannabis can be 
greater than risks associated with use of the drug and is one of the most widely felt 
consequences of prohibition. Criminalising those who choose to use cannabis neither 
makes communities safer nor, in our view, meaningfully discourages use.    
 

   
 
18 
 
The possession of cannabis is not, as far as we understand, a stated priority for S&S (the 
power is asserted to be one which targets those suspected of carrying knives and other 
weapons). We recognise, however, the somewhat invidious position into which 
criminalising possession of the drug puts the police. Duty bound to maintain law and order 
and prevent crime, where police have evidence to suggest a person is breaking the law, 
or reasonable grounds to suspect they are doing so, they are expected to investigate. 
With respect to possession of cannabis, it is difficult to see how else they might do this, 
other than through exercising their power to S&S. Given the ubiquitous nature of cannabis 
use, this – perhaps inevitably – means significant numbers of people risk criminalisation.   
 
With that risk borne disproportionately by people from ethnic (excluding white ethnic) 
backgrounds. In London, this is felt particularly by those of black heritage, who are more 
likely to be S&S on suspicion of cannabis possession than white people despite little clear 
evidence of any parallel disparity in use of the drug. Moreover, the practice of S&S does 
not result, in our view, in a high enough cannabis find rate to justify the extent of its use – 
even were it to represent a proportionate response to a police priority (which cannabis 
possession is not). More importantly still, that find rate appears to be no different for black 
suspects than white.  
     
Racial disparities in use of S&S persist despite much attention over the years, many 
recommendations for change and relatively widespread public acknowledgement – and 
dislike – of unjust practices. The issue affects not only individuals but wider police–
community relations: trust and confidence in police show worrying declines, particularly 
among black communities across London.  
 
Ensuring a person can no longer be stopped solely on suspicion of cannabis possession is 
no magic bullet and is not the solution to root causes of disproportionality. Indeed, while 
legalisation undoubtably reduces the number of people criminalised for cannabis-related 
activities, evidence shows that racial disproportionality remains with respect to those 
which remain illegal.  
 
Similarly, while we expect bringing cannabis under the PSA will reduce the number of 
people subjected to S&S for possession, it will not put an end to racial disparities in the 
justice process. We hope, however, it will be a meaningful start.  
 
We do not intend the removal of possession of cannabis for personal use from criminal 
law to interfere with wider S&S practice. We recognise the power plays an important role 
in, for example, police endeavours to find and remove dangerous weapons, including 
knives, from the streets of London and elsewhere. But it must be deployed responsibly, 
and we make several recommendations intended to support this, as well as to inform and 
progress other aspects of cannabis policing (see R16–29), in particular to: 
 
• Clarify how S&S should be used with respect to suspicion of cannabis offences. 
• Ensure the power is used fairly and in line with guidance. 
• Better understand police practices and outcomes regarding drug-related 
offending. 
• Improve access to and delivery of criminal justice drug diversion schemes. 

   
 
19 
 
• Improve police–community relationships.  
 
The impact of these measures, along with the consequences of removing criminal 
sanctions from possession of cannabis for personal use, should be monitored.  
 
Conclusion 5: The content and timing of education about cannabis are inadequate. 
Provision largely fails to acknowledge the realities of drivers of use and is delivered too 
late, if at all, in both medical and statutory education settings. In the latter, it is often led 
by providers who lack sufficient credibility and insight.  
 
School guidance focuses on illegality and risks to health, with material often delivered by 
teachers perceived to have little relevant or credible lived experience. Failure to explicitly 
acknowledge the many drivers of cannabis use (including as self-medication for mental 
health issues), or its widespread availability, probably does little to help those who will try 
(or have already tried) the drug to make safer choices, or to convey the very real health 
risks cannabis can bring.   
  
Indeed, by the time children and young people are educated about cannabis, many have 
tried it, or are at least familiar with it through family and friends. Some will have become 
regular users. This is concerning particularly because the earlier regular use begins, the 
greater the impact on brain development and risk of long-term consequences.  
 
While not a palatable subject for many parents and guardians, the system as it stands is 
not serving children well in equipping them to make informed decisions, as and when 
confronted with cannabis. We recognise the inherent tensions in proactively educating 
young people about use of an illegal drug, but consider the risks of not providing them 
with tools to make more informed decisions to outweigh those tensions.  
 
Among the mainstream medical community, knowledge of the health consequences 
(positive and adverse) of cannabis use is low – not surprising as the endocannabinoid 
system does not systematically feature in training. This means opportunities risk being 
missed in healthcare practice to confidently ask about and identify problematic cannabis 
use, and conversely to accept that in some cases cannabis may offer relief of symptoms.  
 
Alongside our recommendations aimed at healthcare professionals (R14, 35) we make 
several more designed to improve education for schoolchildren in partnership with a 
range of stakeholders (R38–41), specifically to: 
 
• Evaluate existing drug education programmes to better understand their impact 
and inform future offers, in primary, secondary and post-16 settings.  
• Involving key stakeholders (including parents, schools, police, substance use and 
youth services), explore what and how to communicate cannabis education in 
meaningful, age-appropriate ways that reflect modern realities of exposure to the 
drug for many children and young people.  
 
 
 
 

   
 
20 
 
 
RECOMMENDATIONS  
 
Our recommendations are presented in context throughout our report, but we bring them 
together here for ease of reference. Numbers in parentheses indicate the paragraph in 
the main body of the report in which the recommendation is presented. 
 
Chapter 4: Cannabis use in the UK  
 
Recommendation 1: The Home Office (HO), together with the Office for National Statistics 
(ONS) and the Mayor’s Office for Policing & Crime (MOPAC), should consider how data 
collections could be boosted to facilitate more nuanced understanding of cannabis use 
among different ethnic groups in London and other regions. (para.4.46) 
 
Chapter 5: The UK cannabis market 
 
Recommendation 2: The government should commission an updated assessment of 
costs and benefits that could be realised through a legal market for non-medical 
cannabis. This needs to be a net benefit assessment and include potential for additional 
public health and other costs associated with different models of legalisation. (para.5.72)  
 
Chapter 7: International approaches to cannabis regulation: Part a – Alternatives to 
prohibition in regulating non-medical cannabis  
 
Recommendation 3: Changing international practice and associated outcomes, including 
those related to public health, levels of wider crime, size of the illegal market, burdens on 
criminal justice systems and economic considerations, [should] be monitored, ideally by 
an independent body that reports into either City Hall or central government or both. 
(para.7.128) 
 
Chapter 8: The effects of non-medical cannabis on physical and mental health 
 
Recommendation 4: The Mayor of London should expedite considerations to introduce a 
drug testing service in London, which includes the capability to test cannabis, as soon as 
practicable. (para.8.126) 
 
Recommendation 5: The Home Office (HO) and Department for Health & Social Care 
(DHSC) should consider commissioning independent research to explore how those who 
use cannabis view potency and do or do not adapt their consumption accordingly. 
(para.8.133) 
 
Recommendation 6: The Department for Education, in partnership with the DHSC, HO 
and Food Standards Agency (FSA), should consider the issue of consumption of legal 
CBD alongside illegal cannabis further, with thought given to how educational materials 
regarding cannabis use might raise awareness of the potential risks of CBD consumption. 
(para.8.144) 
 

   
 
21 
 
Chapter 9: The health policy response to non-medical cannabis use 
 
Recommendation 7: The DHSC should explore what works in cannabis treatment, for 
whom and under what circumstances, to support development of guidance and ultimately 
services to meet specific needs of this group. (para.9.25) 
 
Recommendation 8: [The] National Institute for Health & Care Excellence (NICE) [should] 
review the content of both guides covering drug misuse prevention and treatment. They 
should account for changes in the nature of modern-day cannabis and its use and have 
regard to evidence that relates specifically to the treatment of problematic use of 
cannabis. (para.9.29) 
 
Recommendation 9: The DHSC should consult with the medical cannabis industry to 
explore potential to utilise cannabis produced for prescription products, where levels of 
THC and CBD are strictly controlled, in treating those with problems associated with non-
medical use. (para.9.31) 
 
Recommendation 10: A programme of work [should] be developed to explore how 
physical and mental health services could better join up with treatment and addiction 
services, irrespective of which borough they operate within. This should consider 
mechanisms of delivery, commissioning practices and how to reduce inequalities in 
service access and be jointly led by the London Health Board and London Drugs Forum 
(LDF). (para.9.71) 
 
Recommendation 11: The Association of Directors of Public Health (ADPH), together with 
NHS England, those responsible for healthcare within prison and probation, and local 
government (including Integrated Care Services’), should investigate creation of a ‘single 
point of contact’ advisory service. (para.9.82) 
 
Recommendation 12: We recommend the ADPH, in partnership with the DHSC and the 
Office for Health Improvement & Disparities (OHID), should consider how tobacco 
cessation practitioners can be supported to explore clients’ cannabis use. A requirement 
for them to do so should in due course be built into commissioning of such services. 
Assessment and recording systems should be duly adapted, with training developed on 
how to establish appropriate treatment plans for co-users. (para.9.88) 
 
Recommendation 13: The OHID, in partnership with the ADPH, Action on Smoking & 
Health (ASH) and providers of tobacco cessation and drug treatment services, should 
explore the barriers to more integrated provision and how these could be overcome to 
better meet the needs of co-users and improve the chances of successful treatment 
outcome(s). (para.9.90) 
 
Recommendation 14: The General Pharmaceutical Council (GPhC) should explore the 
feasibility of including in their syllabus content that covers the endocannabinoid system 
and the way in which cannabis exerts effects on the body. (para.9.97) 
 
Recommendation 15: The Mayor should consider, in partnership with the GPhC and local 
drug treatment services, implementing a small-scale pilot of this nature in one or more 

   
 
22 
 
London boroughs, whereby pharmacists provide a link into services for those struggling 
with cannabis use. (para.9.99) 
 
Chapter 10: Cannabis, policing and the criminal justice system 
 
Recommendation 16: i) All relevant guidance should explicitly set out that the smell of 
cannabis alone cannot ever lawfully be used to justify a stop and search: ii) A clause be 
inserted into PACE Code A to state the smell of cannabis alone cannot be used to lawfully 
justify a stop and search. (para.10.37) 
 
Recommendation 17: The Home Office, in partnership with the College of Policing (CoP) 
and National Police Chiefs Council (NPCC), should seek to update data recording 
systems nationwide to allow officers to record:  
• The suspected nature of drugs seized via S&S. 
• The ethnicity of persons found in possession of broad drug types. 
• The outcome of an S&S when it results in finds of i) illegal drugs excluding 
cannabis, ii) those including cannabis and iii) illegal items excluding drugs. This 
must be linked to the ethnicity record. (para.10.56) 
 
Recommendation 18: The Metropolitan Police Service (MPS), in partnership with 
MOPAC, should ensure evaluation of the Precision S&S pilot includes recording: 
• When an officer is directed to undertake S&S using the Precision approach.  
• Reason for S&S and, where drug-related, the type of drug suspected.  
• The type of drug found. 
• Number of drug-related S&S that end in no further action (NFA) as well as positive 
outcomes.  
• Driver for each stop (self-generated, third-party information or intelligence). 
• Views of those subject to S&S by officers receiving enhanced training, alongside 
views of the wider community. (para.10.79)   
 
Recommendation 19: MOPAC should ensure the MPS engage with the City of London 
Police (CoLP) to explore the possibility of trialling a similar approach to involve and build 
trust among young communities. (para.10.123)   
 
Recommendation 20: MOPAC should explore how the MPS can record the specific type 
of S&S about which a complaint is made, and link the ethnicity of the complainant to that 
record. (para.10.129) 
 
Recommendation 21: The MPS [should] work with the HO and MOPAC to make better 
use of data concerning cannabis-related demand where these exist, and to start collating 
such where they currently do not. In all cases, the ethnicity of the persons reporting or 
being subject to police action should be recorded, and areas of demand include: 
• Intelligence submissions linked to both public reporting and officer generation. 
• Number of calls for service from the public linked to cannabis, as well as 
complaints related to local cannabis activity.  
• Enforcement action following execution of warrants, including the number of 
closure orders issued.  

   
 
23 
 
• Drug driving. 
• Volume of police seizures of cannabis. (para.10.131) 
 
Recommendation 22: MOPAC should mandate those charged with scrutiny of the MPS 
and CoLP to review a random sample of body-worn video (BWV) of drug-related S&S at 
least quarterly and report any concerns to the force and MOPAC. (para.10.148) 
 
Recommendation 23: The HO, in partnership with the CoP and NPCC, should ensure use 
of outcome 22 is recorded in such a way that allows for i) it to be counted as a positive 
outcome and ii) full analysis of use across forces. This must be implemented in such a 
way that records do not show up in a basic or enhanced Disclosure & Barring Service 
(DBS) check, given there is no admission of guilt. (para.10.177)   
 
Recommendation 24: MOPAC, in partnership with the MPS and Turning Point, should 
explore how this [diversion] pilot has operated for people referred for cannabis offences, 
including any identified via S&S. (para.10.208) 
 
Recommendation 25: All service providers contracted to support deferred prosecution 
referrals should be mandated to inform the police as to whether associated conditions 
have been met. Alternatively, a third party should be appointed to manage the process. 
(para.10.212) 
 
Recommendation 26: MOPAC should ensure ADDER evaluators collect data on 
characteristics of those diverted (including ethnicity), the route of referral (whether via 
S&S, for example) and the nature of offending (where drug-related, which drugs). The 
impact on provision of services for those who use drugs more widely should be 
monitored. (para.10.215) 
 
Recommendation 27: MOPAC and the London Drugs Forum (LDF), together with the 
MPS and CoLP, should consider expanding this planned pilot for young adults across 
London, and across age groups. This should be in partnership with ADDER to ensure join-
up and learning, and to reduce the risk of duplication. (para.10.219)  
Recommendation 28: MOPAC [should] publish a list of schemes currently in place, and 
the LDF explore whether a city-wide model would be more effective. As a minimum the 
LDF, in partnership with MOPAC and the MPS, should draw up clear guidance regarding 
eligibility for diversion schemes. (para.10.220)   
Recommendation 29: Requiring police to specify why they choose not to refer an eligible 
individual to a diversion scheme would shed light on the use and efficacy of these 
schemes, and MOPAC should work with the MPS to ensure this happens. (para.10.223) 
Recommendation 30: Natural cannabis should be removed from the MDA, meaning as a 
psychoactive substance it would fall under the auspices of the PSA. (para.10.306) 
 

   
 
24 
 
Recommendation 31: Local regulations (byelaws) should be deployed to prohibit and 
therefore prevent consumption of cannabis in public spaces, including parks, squares, 
beaches and pedestrian pavements. (para.10.315)    
 
Recommendation 32: The regime governing disclosure of criminal convictions should be 
amended so that cannabis possession offences are protected from disclosure, regardless 
of the date of offence. (para.10.324) 
 
Recommendation 33: Central government [should] explore the possibility of permitting 
limited home cultivation, drawing on evidence from jurisdictions elsewhere that allow it 
(such as Washington D.C.). But home cultivation should not be legalised until such time 
as there is clear evidence it significantly reduces connection with illegal suppliers, and has 
public health benefits. (para.10.334) 
 
Chapter 11: Cannabis for medical purposes 
 
Recommendation 34: Research programmes such as the T21 and Cannabis & Me 
studies should be funded to explore the effectiveness of CBPMs in treating a wider range 
of conditions, including but not limited to chronic pain. These must be funded and led by 
independent, objective bodies such as the Medical Research Council. (para.11.25) 
 
Recommendation 35: Health bodies should consider how recommendations in the 
Canadian Review to provide information and evidence on the use of cannabis for medical 
purposes could be drawn on and actioned in England. This should include use of both 
licensed and unlicensed CBPMs. (para.11.38) 
 
Recommendation 36: Forces across England & Wales, including the MPS, should 
routinely ensure officers are aware of the law surrounding use and possession of cannabis 
for medical purposes, and are familiar with its prescription. (para.11.75) 
 
Recommendation 37: We therefore recommend, if sufficiently robust, favourable 
conclusions emerge from research recommended in R34, further research be undertaken 
into training and cost implications of equipping the NHS to provide unlicensed CBPM 
product scripts more widely, where (initially) sanctioned by a doctor on the Specialist 
Register. This should consider the potential burden on those doctors in the context of 
their overall burden as front line practitioners, as well as the opportunity costs of 
prescribing traditional medicines (including opiates) over unlicensed CBPMs. Findings 
should inform decisions as to whether the current system should be changed and the 
implications of doing so for medical cannabis supply chains should be considered. 
(para.11.82) 
 
Chapter 12: Education and cannabis 
 
Recommendation 38: The City of London Corporation should commission independent 
evaluation of DART and, if appropriate, the Mayor should explore potential for it to be 
delivered in primary schools across London boroughs. (para.12.37) 
 

   
 
25 
 
Recommendation 39: The Mayor should consult with parents, schools, youth workers, 
substance use services and other organisations such as Cranstoun to consider how more 
comprehensive content focusing on risks of cannabis use could be systematically 
introduced to younger children, and revisited during post-16 education, in meaningful, 
age-appropriate ways. Existing resources, including the DART material, should be 
considered, as should the efficacy and appropriateness of police involvement in delivery. 
(para.12.40) 
 
Recommendation 40: The Mayor should consider ensuring all establishments across 
London that provide education post-18 are aware of and have access to such [harm 
reduction] materials, and signpost this to all students at the point of entry. (para.12.62) 
 
Recommendation 41: Representatives of schools, parent bodies, substance use services 
and other organisations involved in localised endeavours, as well as developers of 
material designed for post-18 students, [should] form a working party. This should aim to 
produce detailed, age-appropriate guidance for use across London’s schools, to help 
young people better understand the risks and make more informed choices. (para.12.71) 
 
Chapter 13: Cannabis Social Clubs 
 
Recommendation 42: Given the central role played by Cannabis Social Clubs in 
approaches being developed in Malta and Germany, City Hall should maintain a watching 
brief on how those proceed. Consideration should be paid to any indications of a 
subsequent rise in prevalence of cannabis use and adverse health outcomes, as well as 
any reduction in demand or burdens on criminal justice systems and changes in take-up 
of other illegal substances and alcohol. (para.13.14) 
 
 
 

   
 
26 
 
1. INTRODUCTION  
 
Background 
 
1.1 In his 2021 London Mayoral campaign manifesto,4 Sadiq Khan committed to 
establishing a panel of independent experts to explore the nature and 
effectiveness of the UK’s drug laws, focusing on cannabis used for recreational, or 
non-medical, purposes. With an emphasis on harm reduction, leading figures from 
public health and criminal justice, alongside experts from the third sector, politics 
and academia, were brought together to form the London Drugs Commission 
(LDC).5 
 
1.2 The Mayor is not empowered to change drug laws: this responsibility rests with 
central government. It is our intention, however, for this report to inform and 
further the debate regarding those laws which govern production, supply and 
possession of non-medical cannabis in London and across the UK.  
 
1.3 Our inquiries were guided by our terms of reference (Appendix A), which, briefly, 
tasked us to explore the impact of current laws governing non-medical cannabis. 
We focused particularly on health and criminal justice-related outcomes 
associated with use of cannabis, and considered evidence from London, the UK 
and across the world. 
  
Our approach 
 
1.4 Our aim has been to determine, based on the best available evidence, whether 
prohibition of cannabis for non-medical purposes represents the most effective 
way to minimise individual and societal harms. To draw on terminology rooted in 
economics, we explored whether prohibition achieves the best balance of 
‘benefits’ set against ‘costs’, or disbenefits, in comparison to alternatives, namely 
decriminalisation (de facto and de jure) and legalisation (see chapter 3 for fuller 
descriptions). 
 
1.5 We adopted a broad definition of ‘harm’, with regard principally to health and 
interactions with the criminal justice system following suspected involvement with 
cannabis. We also considered public attitudes, the size and nature of the illegal 
cannabis market and implications for public services in responding to cannabis 
use. 
 
1.6 We explored these matters as they manifest in the UK and within other 
jurisdictions that have adopted (or are considering adopting) different legal 
frameworks to govern production, supply and possession of non-medical 
cannabis. As part of this, we also examined the economic implications of non-
prohibitive approaches. 
 
4 Sadiq-for-London-Manifesto-.pdf 
5 The London Drugs Commission | London City Hall 

   
 
27 
 
 
1.7 The scope and focus of our enquiries were guided by our terms of reference. We 
have, however, been led by the evidence presented to us, meaning we necessarily 
explored associated matters such as the role of medical cannabis, made legal in 
the UK in 2018 and which we consider in chapter 11. Similarly, while we 
concentrated on botanical cannabis, we considered synthetic forms of the drug 
where relevant. We describe cannabis, and how it is consumed, in chapter 4. 
 
1.8 As per our task, we sought to focus where possible on the London context, 
particularly with regard to policing and public opinion. Recognising, however, that 
laws governing cannabis reach nationwide and many issues apply irrespective of 
geography, much of our thinking and many of our recommendations apply UK 
wide. Where helpful we have drawn on evidence from across the country and, in 
our recommendations, sought to clarify those which have broader applicability 
beyond London.  
 
1.9 We have taken neither a moral nor a philosophical perspective (though have brief 
regard below) but one of public policy: what are the positive and adverse 
consequences of the current position and can, or should, the balance of these be 
altered by changing the legal framework. 
 
What have morals got to do with it?  
 
1.10 It was put to us that, like cannabis, alcohol and tobacco are drugs that can cause 
harm, incite addiction and lead to forms of intoxication. Yet both are legal. We 
reflect on this in chapter 2 in a brief history of the UK’s approach to cannabis, 
considering the role of the Misuse of Drugs Act 1971 (MDA)6 and how views about 
cannabis influenced, at least in part, the way the drug was legislated. Concerns 
about its effects (positive or harmful, individually or societally), alongside a 
perspective that it was somehow morally objectionable irrespective of whether it 
caused harm, were important.  
 
1.11 We consider public attitudes in chapter 6 but polling shows more liberal 
approaches to cannabis are gathering support, highlighting one of the challenges 
of any morality-based approach to law and public policy. Namely, that public views 
tend to change over time, as, for example, with respect to abortion, homosexuality 
and capital punishment.  
 
1.12 And of course, moral opposition to drug use, or any other behaviour, does not 
mean it should be criminalised. Libertarians would likely argue the only reason to 
limit a person’s freedom (prohibit their ability to use cannabis) is to prevent harm 
to others. Paternalists on the other hand would probably argue that if something 
(cannabis) harms a person then state interference, i.e. prohibition, is justified 
because it is in their best interests.  
 
 
6 Misuse of Drugs Act 1971 (legislation.gov.uk) 

   
 
28 
 
1.13 But cannabis-related ‘harm’ can be difficult to define and may manifest differently 
for different groups. And not all behaviours or drugs that risk harm to an individual 
or others are prohibited. As we note, alcohol undeniably causes health harms and 
is a consistent factor in public disorder and violence, yet is legal in the UK and 
large parts of the world. The ‘right’ to consume it remains intrinsic to many 
societies and cultures. 
 
1.14 The notion of rights is similarly relevant to cannabis. Protected under an array of 
legal instruments and treaties, many have argued the right to privacy7 means 
those who choose to use any illicit drugs should be protected from interference in 
what is their private decision to do so. 
 
1.15 It is not, however, an absolute right, meaning it is subject to qualification. Article 8 
in the European Convention on Human Rights (ECHR), for example, sets out 
‘…the right to respect for his private and family life, his home and his 
correspondence’ can be subject to interference ‘…in the interests of natural 
security, public safety or the economic wellbeing of the country, for the prevention 
of disorder or crime, for the protection of health or morals, or for the protection of 
the rights and freedoms of others.’  
 
1.16 This raises questions such as what constitutes a risk to health, how can morals be 
defined and protected, and how might the rights and freedoms of others be 
threatened by a person’s use of cannabis. Some would almost certainly argue that 
given its role in disorder, detrimental impact on health, and in some cases adverse 
effect on others, the right to consume alcohol should be subject to ‘interference’. 
 
1.17 Whether prohibition of cannabis or adoption of some other approach represents 
the most appropriate way of protecting the human rights of all persons is fraught 
with complexity and, in our view, there is no clear right or wrong solution.  
 
1.18 The right to freedom of religion (protected by Article 9 of the ECHR) is also 
relevant. For Rastafarians, of whom there are at least 6,000 in England & Wales,8 
cannabis is part of their practice, an important part of spiritual expression. Several 
have attempted to challenge criminal charges of cannabis possession or supply by 
invoking their right to religious freedom, but have thus far failed because of a 
similar qualifier under Article 9(2).9 Rastafarians who use and supply cannabis may 
have associated sentences reduced, but they will not avoid prosecution or 
conviction.10  
 
1.19 We touch on the interplay between a decision to use, or grow, cannabis and the 
law in our description of the legal position in Mexico (chapter 7). The notion of 
human rights has played a central role in development of the current situation.   
 
 
7 Set out, for example, in Article 8 of the European Convention on Human Rights, Article 12 of the Universal 
Declaration of Human Rights and Article 17 of the International Covenant on Civil and Political Rights.   
8 Religion, England and Wales – Office for National Statistics (ons.gov.uk) Accessed 10th August 2023. 
9 See for example R v Taylor [2001] EWCA Crim 2263.  
10 See for example R v John-Lewis [2013] EWCA Crim 2085.  

   
 
29 
 
Our methodology 
 
1.20 In attempting to unpick the many complex and varied matters relevant to our task, 
we deployed a multi-methods approach to gathering evidence: 
 
• Oral evidence sessions with over 200 experts and other stakeholders from 
London, around the UK and across the world, and receipt of written submissions 
from several more (Appendix B).  
• An independent qualitative research study11 to explore lived experiences of 
cannabis among a small sample of Londoners. 
• An opt-in survey available to those living or working in London to investigate 
perspectives on cannabis use and views of legal approaches (Appendix C). 
• Questions in the quarterly survey run by the Mayor’s Office for Policing and 
Crime to canvass Londoners’ views of approaches to cannabis (Appendix D).  
• In partnership with University College London, a series of desk-based literature 
reviews summarising evidence from the UK and elsewhere. These informed our 
evidence sessions and focused on: 
i. Cannabis markets (legal and illegal). 
ii. Health impacts of cannabis use. 
iii. Legal approaches to non-medical cannabis use. 
iv. Patterns of non-medical cannabis use. 
v. Philosophical positions relating to cannabis.  
vi. Policing of cannabis. 
vii. Public attitudes towards cannabis.  
 
Constraints in understanding the impact of changes in legal frameworks  
 
1.21 We heard directly, or otherwise received, a vast amount of evidence and our 
inquiries led us to consider even more. This enabled us to undertake substantial 
exposition of a wide range of issues, which we discuss throughout this report.  
 
1.22 Despite the amount of evidence, however, we must acknowledge the difficulties in 
drawing firm conclusions, particularly with respect to the precise impact of 
changes to legal frameworks elsewhere. The limitations of research and real-world 
contexts merit setting out, and we do so below.    
 
1.23 In exploring whether prohibition of cannabis is the most effective way to reduce 
associated harms, we needed to first understand the nature and extent of those 
harms. The causal impacts of cannabis, however, particularly on health (both 
positive and adverse), are in some cases difficult to reliably determine (and to 
distinguish from reverse causation, where use is a consequence of a health 
condition rather than a cause).  
 
1.24 Similarly, the impact of alternatives to prohibition on such things as prevalence of 
cannabis use, public health and the size of the illegal cannabis market are difficult 
 
11 Thinks Insight & Strategy (2023). Lived experiences of cannabis among Londoners. MOPAC. Available at MOPAC 
academic research | London City Hall 

   
 
30 
 
to causally attribute. Different approaches across US states, and variability in the 
way legalisation was implemented in Canadian provinces and territories (see 
chapter 7), arguably form a series of ‘natural experiments’ enabling some 
comparison of outcomes under different models. Inherent contextual and 
situational variance, however, means attribution of cause and effect is no less 
challenging.  
 
1.25 We cannot be confident that reported outcomes are caused by the particular legal 
approach to cannabis rather than other things, nor which element of an approach 
caused which effect, nor indeed whether that effect might have happened anyway 
without legislative change.  
 
1.26 We are mindful, too of national context and culture. While we learnt a great deal 
from examining approaches adopted elsewhere, what is deemed successful in 
other jurisdictions may not translate as such in the UK. Indeed, outcomes may not 
manifest in the same way. Despite similarities, the UK is neither culturally nor 
economically equivalent to those international jurisdictions with which we 
engaged. And while geographically closer to our European neighbours, 
distinctions between societal structures and broader legal frameworks remain. 
These include current use of medical cannabis and public acceptance of such, the 
history of cannabis use and governance, and approaches to wider permissions, 
regulation and compliance.  
 
1.27 These realities are compounded by limited methodologies and small samples 
characteristic of many studies, which restrict scope to draw inferences for 
application in a wider context. Furthermore, some of the work we were directed 
towards was funded by backers with a vested interest in a particular outcome, so 
their findings cannot be considered truly independent or objective. 
 
1.28 This means that, while there are several learnings that offer important guiding 
principles and on which we relied in drawing our conclusions and 
recommendations, we cannot translate wholesale the evidence regarding impacts 
of non-prohibitive policies and laws implemented in other parts of the world.   
 
1.29 Moreover, legal markets for non-medical cannabis have existed only for a little 
over ten years. The earliest adopters were Washington State and Colorado in the 
US – both voted to legalise cannabis for non-medical adult use in 2012. While in 
many policy areas this would be ample time in which to reliably evaluate impact of 
any change, effects on some outcomes of interest to us (particularly health) take 
time to materialise and require collection of comprehensive data from the outset. 
 
1.30 And it takes time to effect behaviour change. People who use cannabis do not, for 
example, switch from illegal dealers to legal suppliers overnight. Several eminent 

   
 
31 
 
researchers in the field note the importance of longer-term evaluation in 
determining the impact of moves away from prohibition.12 
 
1.31 Pre-legislative trends are important. For example, cannabis use in Canada had 
been rising before legalisation in 2018 (see chapter 7), so growth post-legalisation 
cannot necessarily be attributed (entirely) to the new approach. Not only does this 
highlight the limits of a pre-post design in outcome evaluation, it is also testimony 
to the need for baseline data to understand and accurately interpret those which 
are gathered subsequent to legislative change.  
 
1.32 Finally, much evidence on the impact of legislative change on prevalence of 
cannabis use, important particularly from a public health perspective, derives from 
survey data. As pointed out by many experts in the field, any apparent increase 
post-legalisation may also simply reflect a greater willingness to report use of a 
now legal substance. 
 
1.33 Consequently, robust evidence of the impact of more liberal approaches to 
cannabis use is in its infancy. As a result of our inquiries, however, we consider 
there to be several reasonably strong indications of likely results were a change to 
be made in this country, to which we have had regard in reaching our own 
conclusions and recommendations. 
 
 
 
12 See for example Manthey, J., Armstrong, M.J., Hayer, T., Myran, D.T., Pacula, R.L., Queirolo, R. … & Zobel, F. 
(2023). How to interpret studies on the impact of legalizing cannabis. Addiction, 118(11). doi.org/10.1111/add.16314 
Accessed 16th August 2023. 

   
 
32 
 
2. A HISTORY OF CANNABIS 
REGULATION IN THE UK 
 
With its roots in Central Asia, cannabis and its derivatives have been in use around the 
world for millennia, harnessed for rope and textiles, food and a range of medicinal 
purposes in addition to psychoactive properties. Evidence suggests it played a role in 
religious practices and ceremonies, as well as general recreation, as early as 3000 
BCE,13 and of course it continues today to be associated with both Rastafarianism and 
Hinduism.  
 
Regulation of cannabis is, therefore, comparatively recent. In this chapter we examine 
how the drug first came to be regulated through drug control laws, at both the 
international and national level. This had little to do with any inherent dangerousness of 
the substance but was rather the outcome of colonial power politics played out in the 
international sphere.  
 
Prohibition, which tied cannabis to opiates and cocaine firstly under international and 
subsequently national UK legislation, was more an ‘accident of history’ than the rational 
process based on assessments of harm that has sometimes been assumed. This history 
has led to the uneasy association between cannabis and other ‘dangerous drugs’ which 
persists to the present day – becoming of particular significance in the 1960s. To 
understand how this came about, we need first to look at the colonial politics of 
cannabis. 
 
Regulation of cannabis in the colonial world 
 
2.1 Colonial states in the nineteenth century derived income from cannabis cultivation 
and trade. Between the 1790s and 1850s in India, for example, the East India 
Company raised significant revenue from the drug, although without direct 
intervention: cannabis retailers were required to buy a Company licence before 
they could purchase from a producer and sell on.  
 
2.2 Mid-nineteenth century the system changed, meaning wholesalers located in the 
place of business rather than production or sale became liable for taxation. In 
addition, licences also became required for cultivation. Cannabis duties duly 
became a significant source of revenue for the Indian government, in particular in 
Bengal where one-fifth of overall revenue was raised from these internal 
customs.14 
 
2.3 Other colonial states acted similarly and found it quite acceptable to derive 
revenue from cannabis. Indeed, the principal issue for some became how to 
 
13 Lawler, A. (2018). Cannabis, opium use, part of ancient Near Eastern cultures. Science, 360 (6386). 
doi.org/10.1126/science.360.6386.249  
14 Mills, J. (2003). Cannabis Britannica. Empire, Trade and Prohibition. Oxford University Press. 

   
 
33 
 
protect the then legal trade from smugglers and abolitionists in order to maintain 
that revenue. 
 
2.4 The UK government, however, became concerned about the effects of cannabis in 
Bengal, and the Indian Hemp Commission of 1893–4 was convened to look into 
the matter. They concluded that moderate consumption of the drug was not 
unduly harmful (noting excessive use could result in harm but suggesting this was 
confined to the user rather than society) and proposed four main planks of 
cannabis-related policy, namely: i) adequate taxation; ii) licenced-only cultivation; 
iii) limits on the number of retail outlets and iv) limits on the extent of legal 
possession.  
 
2.5 Those conclusions, however, have to be seen in light of the prevailing climate at 
the time, i.e. one in which cannabis was an important revenue source. The report 
had been heavily influenced by the Indian government’s need to maintain the 
cannabis trade, with objections of some members of the Commission swept aside. 
 
2.6 Despite the report’s findings and proposed policy of regulation rather than 
prohibition, attempts at eradication of the trade began in some Indian states. 
Behind these lay international labour market migration patterns, which saw 5.5 
million Indians emigrate as labourers between 1834 and 1938, principally to 12 
colonies within the Empire including Natal,15 Jamaica, Trinidad, British Guiana,16 
Fiji and French Réunion. These migrations were stimulated by both the British 
authorities in receiving nations and by India itself, in order to meet labour demands 
of the imperial economy.17 
 
2.7 The migrant labourers took their cannabis habits with them, leading the Union of 
South Africa,18 soon to become important in terms of international restrictions, to 
develop controls over the drug from the 1880s. State governments were 
concerned about perceived efficiency of their Indian labourers, their obedience as 
subjects and their relationships with African neighbours, who often supplied 
cannabis to the incoming migrants. 
 
2.8 In the early twentieth century, cannabis prohibition ultimately contributed to 
strategies of white nation-building, racial rule and imperatives of segregation.19 
Colonial and post-colonial elites effectively wielded and gained power in attempts 
to control cannabis, whether with intent to eradicate the trade or gain profit from it.  
 
 
 
 
 
15 A former province of South Africa. 
16 A former British colony, since 1966 it has been known as the independent nation of Guyana. 
17 Mills, J. (2007). ‘Colonial Africa and the International Politics of Cannabis: Egypt, South Africa and the Origins of 
Global Control’. In J. Mills & P. Barton (Eds). Drugs and Empires. Essays in Modern Imperialism and Intoxication, 
c1500–c.1930. Palgrave, pp.165–84. 
18 Established in 1910 to unify the provinces of the Cape, Natal, Transvaal and Orange River. 
19 Waetjen, T. (2021). Dagga: How South Africa Made a Dangerous Drug, 1902–1928. In L. Richert & J. Mills (Eds). 
Cannabis: Global Histories. The MIT Press. doi.org/10.7551/mitpress/12102.001.0001 

   
 
34 
 
Medical usage and the origins of the connection between cannabis and insanity 
 
2.9 The overall medical as well as recreational (non-medical) use of cannabis was part 
of ongoing colonial discussions about the drug. Although used widely for both 
purposes in non-Western societies, its medical use in the West was non-existent in 
the early nineteenth century. It was not until the late 1830s in Calcutta, when the 
physician W.B. O’Shaughnessy praised the drug as a painkiller and anti-
convulsive, that the West was alerted to its medical properties.  
 
2.10 Cannabis was not embraced equally across Western nations, however. In France, 
for example, it had fallen from favour as a medicine by the mid-nineteenth 
century.20 Conversely, it enjoyed a vogue of sorts in British medicine, being used 
to treat labour pains, combat tetanus and even to treat symptoms of insanity. 
There is, however, no evidence that Queen Victoria used the drug during 
childbirth, as is often claimed.21  
 
2.11 Alongside a partial medicalisation in some parts of the West came an opposite 
reaction, namely a connection between cannabis use and insanity, or mental 
illness. On the basis of scant evidence and a great deal of cultural stereotyping, 
British doctors in India identified what they termed ‘cannabis with insanity’, 
claiming a large proportion of asylum inmates were cannabis users and that their 
poor mental health was directly related to its use. 
 
2.12 Other colonial nations followed a similar path. For example, use of hashish, or 
hash, (compressed cannabis resin) among the Muslim population in French North 
Africa had, it was argued, produced a wide range of behaviours that were 
irrationally violent and threatened the social order, epitomised in the history of the 
Hachichins (Assassins).22 
 
2.13 It was this twin-track background – the significance of cannabis to the colonial 
economy and concerns about its use and perceived link to insanity in native 
populations – that ultimately led to the belated arrival of cannabis on the 
international drug regulation scene.  
 
The arrival of cannabis in the international control system 
 
2.14 The origins of widespread international control lay in US power politics and moral 
entrepreneurship (namely a desire to expand US influence in South East Asia), as 
well as in the concerns of American missionaries in China about the opium trade. 
Britain, already in the throes of bringing the Indo-Chinese opium trade to an end, 
was – at least initially – a reluctant participant.  
 
2.15 Cannabis was not originally part of the system of international drug control, which 
arose in the early twentieth century and led to a raft of domestic drug control 
 
20 Guba, D. (2020). Taming Cannabis. Montreal: McGill-Queen’s. 
21 Berridge, V. (2003). 'Queen Victoria's cannabis use…' Addiction Research and Theory, 11(4), pp.213–15. 
22 See footnote #20. 

   
 
35 
 
legislation across the globe. The focus at this stage was opium, with the 1912 
Hague International Opium Convention the initial vehicle of control – although this 
did not apply internationally until three years later when it entered into force in five 
countries.23 
 
2.16 Focus soon widened to include cocaine, which became part of international 
control concerns during World War I due to its use by troops (with cocaine 
smuggling a principal driver of later domestic controls in the UK). International 
control of both opiates and cocaine subsequently became a global system when 
the Hague treaty was adopted as part of the peace settlement after the War, in the 
Treaty of Versailles. This led to worldwide implementation of laws covering 
dangerous drugs and, in Britain, the first Dangerous Drugs Act of 1920, with the 
Home Office (HO) the lead government department. 
 
2.17 Thus, cannabis played little part in the early history of international drug control. It 
had featured briefly in 1912 at The Hague, introduced by the Italians, but did not 
appear in international discussions again until 1923. By then drug control was 
under the aegis of the League of Nations, which had appointed an Advisory 
Committee on Traffic in Opium. A letter to that Committee from South Africa drew 
attention to cannabis.  
 
2.18 From there, the issue transferred to the Second Opium Conference, which met in 
1924. This was intended to deal with administrative matters related to control of 
opiates and cocaine. But Dr Mohamed El Guindy, head of the Egyptian delegation, 
successfully forced cannabis into the deliberations of the meeting and 
subsequently into a new agreement made at that time. 
 
2.19 El Guindy may have been genuinely concerned about the effects of cannabis. But 
much of his agenda came from a British report on cannabis and insanity in the 
Cairo asylum system, and his enthusiasm was bolstered by the fact that the 
subject would embarrass the British, his former colonial masters.  
 
2.20 British representatives at the 1924 conference had tried to keep cannabis off the 
agenda, as did the British Indian delegation, because of the financial importance of 
cannabis to the colonial economy. Their opposition, however, proved fruitless, and 
cannabis became part of the system of international control.24 
 
Cannabis in UK drug laws from the 1920s 
 
2.21 The extension of international control legislation to cannabis led automatically to 
domestic control and the UK’s Pharmaceutical Society included the drug on the 
Poisons Schedule in 1924. After the League of Nations incorporated cannabis in 
1925, obligations were finally implemented in the UK under the Coca Leaves and 
Indian Hemp Drug Regulations of 1928. 
 
 
23 See The 1912 Hague International Opium Convention (unodc.org) Accessed 15th May 2024. 
24 See footnote #14. 

   
 
36 
 
2.22 There was no public discussion about the legislation. The HO concluded there was 
no evidence of abusive use of Indian hemp among the UK population, and only 
perhaps occasional use among ‘Oriental seamen’. The only group to voice 
opposition were corn plaster manufacturers, who used it in their product.25 
 
2.23 This, then, was the state of play regarding cannabis on the domestic scene in the 
interwar years. The US and UK remained the core actors in international drug 
diplomacy and represented the two main policy strands within the system: 
prohibition and regulation respectively.  
 
2.24 During this time the international system was as much about regulation as 
prohibition and those advocating the latter were rarely allowed a substantial 
platform before the 1960s. The system was run in the interwar years in the 
interests of the colonial drug-producing powers anxious to protect their 
monopolies.26  
 
2.25 So, despite now being subject to (some) regulation, cannabis was of relatively little 
importance in terms of control at both national and international levels. But the 
colonial politics of the 1920s meant it was inextricably linked to opiates and 
cocaine through the system of international control and required domestic 
legislation. 
 
World War II and beyond: a time of international system change. 
 
2.26 In the decades after World War II, much changed. The League of Nations opium 
control apparatus moved to New York during the war and American influence 
became strong. Pressure was brought to bear on the colonial powers to drop their 
drug monopolies.  
 
2.27 The United Nations (UN) 1961 Single Convention on Narcotic Drugs27 (amended 
by a 1972 protocol and hereafter ‘the Convention’) limited 'exclusively to medical 
and scientific purposes the production, manufacture, export, import, distribution 
of, trade in, use and possession of drugs' (Art. 4c). Cannabis was listed in 
Schedule I, alongside substances with addictive properties considered to present 
a serious risk of abuse.  
 
2.28 It was also listed in Schedule IV. This contains a subset of Schedule 1 substances 
that were thought to be particularly harmful and to offer extremely limited or no 
medical or therapeutic value. Drugs included under Schedule IV were subject to a 
number of additional control measures. 
 
2.29 The UK ratified the Single Convention in 1964, leading to further amendments to 
the Dangerous Drugs Act that same year – and the banning of cannabis 
cultivation. Like most eventual signatories, the UK introduced associated criminal 
 
25 Mills, J. (2013). Cannabis Nation. Control and Consumption in Britain, 1928–2008. Oxford University Press. 
26 Collins, John. (2021). Legalising the Drug Wars. A Regulatory History of UN Drug Control. Cambridge University 
Press. 
27 FINAL ACT OF THE UNITED NATIONS CONFERENCE (unodc.org)  

   
 
37 
 
sanctions for possession or use of those drugs it now prohibited, including 
cannabis.  
 
2.30 The US, on the other hand, did not ratify until 1967, advocating the 1953 Opium 
Protocol in its stead. The Convention, it has been suggested, developed as a 
hybrid regulatory system underpinned with prohibitionist aspects – arguably it 
represented a victory for the UK-led regulatory strand over the US-led 
prohibitionist strand.28  
 
Cannabis in the UK in the 1950s and 60s: the Wootton Report 
 
2.31 Meanwhile, in the UK, the cultural significance of cannabis was changing. With the 
wave of migration from the British Empire in the 1950s came new music and 
cultural habits, including cannabis smoking. Increasingly adopted particularly by 
young people and students, cannabis became associated with the emergence of 
1960s youth subculture and wider counterculture (with its challenge to social and 
political order) as well as with the colonised citizens of the British Empire.29  
 
2.32 These subcultures built up significant pressure for the liberalisation of drugs laws 
after ratification of the Convention criminalised drug-related activity. Support for 
the cause came from several high-profile public figures including the Beatles, Mick 
Jagger and Keith Richards (the latter two were both convicted – later overturned – 
in 1967 for drug offences).30  
 
2.33 In 1967, responding to increasing calls for a rethink including those from the 
Advisory Committee on Drugs (ACD),31 the government set up a separate 
committee, chaired by Lady Wootton, to review the laws on cannabis. Use of the 
drug continued to attract significant public and media attention, with the 
curtailment of civil liberties inherent in prohibition, the sentences received by 
Jagger and Richards (largely seen as excessively harsh) and the way cannabis 
laws were enforced of particular focus. 
 
2.34 A ‘Legalise Pot’ rally was held in London later that year, shortly after which a group 
of 64 high-profile musicians, artists, writers and academics (including the Beatles, 
David Dimbleby, Graham Greene and Dr R.D. Laing), alongside two sitting 
Members of Parliament (MPs) took out a full-page advert in The Times. Entitled 
‘The law against marijuana is immoral in principle and unworkable in practice’, it 
urged the government to reform cannabis laws and control, rather than prohibit, 
the drug.32  
 
2.35 The arguments put forward in the advert were ones which have become familiar 
since. Cannabis use had become ubiquitous, was less risky than alcohol and 
 
28 See footnote #26. 
29 Seddon, T. (2020). Immoral in Principle, Unworkable in Practice: Cannabis Law Reform, the Beatles and the 
Wootton Report. British Journal of Criminology, 60 (6), pp.1567–84. doi.org/10.1093/bjc/azaa042  
30 Green, J. (1999). All Dressed Up: The Sixties and the Counterculture. Pimlico. Cited in ibid. 
31 Set up to offer independent, evidence-based advice to government on drug dependence, misuse and policy. 
32 See footnote #29. 

   
 
38 
 
contained properties thought to be of medicinal benefit. It also addressed what it 
saw as the misconceived ‘gateway theory’ (those who become addicted to more 
serious drugs are said to begin with cannabis; see chapter 4), pointing out that, by 
prohibiting cannabis, users had to access the illicit market, which in itself could 
expose them to harder drugs to which they would otherwise have no access. 
Finally, it drew attention to the threat to civil liberties and the harms of 
criminalisation of large numbers of people.  
 
2.36 The Wootton Report33 was published in early 1969. It recognised cannabis as a 
dangerous drug but considered that: ‘The association in legislation of cannabis 
with heroin and the other opiates is inappropriate and new legislation to deal 
specially and separately with cannabis and its synthetic derivatives should be 
introduced as soon as possible.’ (para.81).   
 
2.37 Moreover, in essence the report also called for de-penalisation, suggesting that 
‘Possession of a small amount of cannabis should not normally be regarded as a 
serious crime to be punished by imprisonment.’ (paras.87, 90). It recommended a 
general review of police powers of search and arrest in relation to all drugs 
offences, especially cannabis, but recognised that the law alone could not deal 
with the problem. Education also had a part to play.34 
 
2.38 The Labour Home Secretary at the time, James Callaghan, rejected the 
conclusions of the Report in a Commons debate, through a speech focusing 
principally on opposition to the rising tide of perceived permissiveness. Little of 
that debate was about cannabis itself or the work of the sub-committee: with just 
over a year to go until a general election, his response has been characterised as 
‘playing to the gallery’ about the counterculture for which cannabis had become a 
symbol.35 
 
2.39 The related Bill introduced by the Labour government in 1970, however, in fact 
contained several recommendations from the Wootton Report. These included the 
separation of cannabis from other more dangerous drugs, and the differentiation 
of possession from supply offences.  
 
The Misuse of Drugs Act 1971 
 
2.40 The Conservative Party came to power following the 1970 general election and 
quickly took the Labour-initiated Bill through Parliament, resulting in the Misuse of 
Drugs Act 1971 (MDA). Based in part on the UK’s treaty obligations under 
international conventions on drug control, the MDA regulated the production, 
supply, possession, importation and exportation of controlled drugs.  
 
2.41 Drugs were classified according to the harm they were considered to cause, with 
Class A (which included cocaine and heroin) the most harmful. The severity of 
 
33 The Wootton Report Table of Contents (druglibrary.net) Accessed 1st September 2023. 
34 See footnote #25. 
35 Ibid. 

   
 
39 
 
criminal penalties followed the classification system, with those attached to 
offences involving Class A drugs being the harshest. Cannabis was placed in 
Class B, along with some amphetamines. 
 
2.42 Alongside the classification system, the MDA placed into law several 
recommendations of the Wootton Report, including reduced maximum sentences 
for cannabis offences and the differentiation between possession for personal use 
and possession with intent to supply.  
 
2.43 The Act also increased penalties for trafficking and supply, and established what is 
known today as the Advisory Council on the Misuse of Drugs (ACMD). A non-
departmental advisory public body (sponsored by the HO), like its predecessor the 
ACD, the ACMD is charged with advising and making recommendations to 
government on the control of dangerous or harmful drugs, including classification 
and scheduling under the MDA. The government may choose to accept or reject 
that advice as it sees fit.  
 
The end and the beginning of medical use 
 
2.44 Medical use of cannabis in the West was undermined by the new drug control 
system. In the UK, the MDA meant it could no longer be prescribed by doctors or 
dispensed by pharmacists (though could be used for research purposes under an 
HO licence). This put cannabis in a more restrictive position than, for example, 
morphine (a strong opiate), which had established and widespread use in Western 
medicine. 
 
2.45 The prohibition of cannabis for medical use ironically took place at a time when the 
possibilities for such began to expand in Western medicine, in particular through 
the discovery of THC (the principal psychoactive component of the drug) by 
Raphael Mechoulam at the Hebrew University in Jerusalem in 1964.  
 
2.46 This belatedly brought cannabis into a potentially more significant role in Western 
medicine. By contrast, the alkaloids of opium (including morphine and codeine) 
had been isolated in the nineteenth century and so were already well established 
in medical practice.36 
 
The ‘British compromise’: 1971–1990s 
 
2.47 What one historian has called the ‘British compromise’37 was implemented after 
the MDA. Possession of cannabis remained illegal but maximum sentences were 
reduced and a less than severe application of the laws was openly advocated. 
Indeed, Lord Hailsham, the Conservative Lord Chancellor who had attacked the 
Wootton Report in the Commons in 1968, advised magistrates to adopt 
moderation in sentencing cannabis offenders found guilty of simple possession. 
 
 
36 Taylor, Suzanne. (2022). Remedicalising Cannabis. Montreal: McGill-Queens.  
37 See footnote #25. 

   
 
40 
 
2.48 Cannabis dropped from legislative attention during the 1980s as greater 
consideration was paid to heroin and cocaine. By the end of the decade, the vast 
majority (75%) of cannabis offenders in the UK received nothing more serious than 
a police caution. However, there was considerable regional variation across police 
forces. The Metropolitan Police Service (MPS) in London, for example, issued 
cautions in 88% of cases, whereas Avon and Somerset did so in only 20%.38 
 
2.49 What was also noticeable by the end of the decade was the increasing number of 
drugs offences being dealt with by the police, and the significant proportion that 
involved cannabis. The rise was driven principally by concern about other, harder 
drugs, meaning people who used cannabis ended up in a net designed really for 
people using those other substances. This led to the re-emergence of cannabis on 
the political agenda in the 1990s, but it proved difficult to wrest power back from 
enforcers of the law.  
 
Reclassification (and reclassification) in the twenty-first century 
 
2.50 Under the MDA, cannabis remained a Class B drug until 2004. This meant 
conviction for possession could lead to a maximum custodial sentence of five 
years with an unlimited fine. A conviction for trafficking, growing or knowingly 
operating premises in which cannabis is consumed could attract up to 14 years in 
custody. 
 
2.51 In 2004, however, in line with recommendations set out in the Runciman Report39 
and advice from the ACMD,40 the government reclassified cannabis as a Class C 
drug. Supported by a majority of the public, the move was designed to 
enable police forces to concentrate resources on other (more serious) offences, 
including those involving ‘harder drugs’.  
 
2.52 Both Runciman and the ACMD recognised cannabis can pose a risk of harm in 
several respects. Their recommendations for a lower classification, however, 
reflected their conclusions that placing cannabis on a par with amphetamines and 
similar in Class B was disproportionate in relation to that harm. Reclassification to 
Class C would also mean possession of cannabis would no longer be an 
arrestable offence.  
 
2.53 However, senior police officers intervened in the HO position, in favour of the right 
for police to decide when and how the law should be enforced. The meaning of 
Class C was redefined: possession of drugs in that category was made an 
arrestable offence and the maximum sentence for supply was increased. 
Nonetheless, arrests for cannabis possession reportedly fell by one-third in the first 
 
38 See footnote #25. 
39 An independent inquiry commissioned by the Police Foundation (a UK policing think tank), and chaired by 
Viscountess Runciman, this investigated whether revisions to the MDA were necessary in light of changes that had 
taken place in society since it was passed. Drugs and the Law: Report of the Independent Inquiry into the Misuse of 
Drugs Act 1971 (2000). The Police Foundation. 
40 ACMD (2002). The Classification of Cannabis under the Misuse of Drugs Act 1971. Home Office Crown Copyright. 

   
 
41 
 
year following reclassification, saving an estimated 199,000 police hours41 – 
although some of those savings were likely offset by a parallel rise in the number of 
police-issued cannabis warnings. 
 
2.54 Three years later, the government asked the ACMD to review cannabis 
classification once again. They recommended it be retained as a Class C drug, on 
the grounds that it more closely equated with other substances in that class than 
with those in Class B.42 The government, however, rejected this and proceeded to 
reclassify cannabis as a Class B drug with effect from early 2009. The decision to 
do so was, it has been argued, not about the advice of experts, but rather 
because a failure to reclassify carried too great a perceived political cost.43   
 
2.55 Then in 2012, the Home Affairs Committee (HAC) reported on the UK’s drugs 
policies.44 They once again revisited the classification of cannabis, explicitly stating 
their position to be one of regret that government had reclassified the drug. They 
agreed with recommendations elsewhere that it should be Class C.   
 
2.56 It remains, however, a Class B drug to this day, with calls (so far resisted by 
government) in the latter part of 2022 for it to be upgraded still further. This would 
place it in Class A, i.e. the same category as heroin, cocaine and ecstasy, with 
consequently harsher penalties for production, supply and possession.  
 
2.57 The most recent HAC inquiry into drugs45 did not consider cannabis classification. 
We note, though, its concerns regarding the risk of harm caused by use of the 
drug for non-medical purposes (particularly in relation to young people) and 
subsequent conclusion that cannabis should not be legalised and regulated for 
such use. These are matters that have been a significant focus of our own 
inquiries.  
 
2.58 No brief journey through the history of cannabis law in the UK would be complete 
without reference to the comprehensive review recently led by Dame Carol 
Black.46 While this covered illegal drugs more widely, its considerations with 
respect to use of cannabis and associated markets, harms and medical treatment 
are relevant to our inquiries, and we return to these in chapters 5, 8 and 9. Suffice 
to say here that the government’s current drug strategy47 draws heavily on findings 
from the Black Review, which advocated widespread investment in drug- and 
alcohol-related services – although cannabis tends to have little place within 
mainstream treatment provision. 
 
2.59 Finally, we return once more to modern-day obligations upon signatories to the 
1961 Single Convention on Narcotic Drugs. In 2018 the World Health 
 
41 Cannabis Reclassification | Home Office (archive.org) 
42 ACMD (2008). Cannabis: Classification and Public Health. Home Office Crown Copyright. 
43 See footnote #25. 
44 Microsoft Word - HC 184 Drugs Report CRC v8 - FINAL.docx (parliament.uk) Accessed 4th September 2023. 
45 Home Affairs Committee (2023). Drugs: Third Report of Session 2022–23. House of Commons. Available at Drugs 
- Committees - UK Parliament Accessed 4th September 2023. 
46 Available at Independent review of drugs by Professor Dame Carol Black – GOV.UK (www.gov.uk) 
47 From harm to hope: A 10-year drugs plan to cut crime and save lives – GOV.UK (www.gov.uk) 

   
 
42 
 
Organization (WHO) Expert Committee on Drug Dependence (ECDD), responding 
to direction from the Commission on Narcotic Drugs (CND, the United Nation’s 
central drug policy-making body), undertook a scientific review of the health 
effects of cannabis.48  
 
2.60 The evidence they considered did not, in their view, suggest that cannabis (plant 
or resin) was liable to cause ill effects akin to those produced by other substances 
listed in Schedule IV of the Convention, reserved for substances with the highest 
potential for abuse and limited if any therapeutic value. Akin (although not directly 
equivalent) to substances listed in Class A in the MDA, those in Schedule IV 
attract the very strictest controls.  
 
2.61 The ECDD concluded that listing cannabis and cannabis resin in Schedule IV may 
not be consistent with the category’s inclusion criteria and recommended they be 
removed. And in 2020, CND member states subsequently voted (by a narrow 
margin of 27 to 25, with one abstention) to do so. The UK voted in favour.  
 
2.62 The drug has since been removed from Schedule IV – although it remains in 
Schedule I and thus subject to all wider controls exercised by the Convention. This 
means production, distribution and possession of cannabis are highly restricted 
activities and, while medical and scientific uses are permitted, they are subject to 
very strict regulation.  
 
2.63 Opinions are mixed as to whether removal from Schedule IV makes much material 
difference to the lawful use of cannabis with respect to compliance with 
international obligations. Some argue it has little consequence because Schedule I 
drugs remain so highly controlled. Others suggest it will help facilitate access to 
and availability of medical cannabis through removal of barriers in domestic 
frameworks to research and development.  
 
2.64 Arguably it has had little effect in the UK because as a Class B drug under the 
MDA cannabis is not considered among the most dangerous of drugs and medical 
use is permitted in some (limited) circumstances. We explore the medical use of 
cannabis in chapter 11.  
 
2.65 Either way, both before and since the removal of cannabis from Schedule IV, an 
increasing number of jurisdictions around the world have legalised cannabis for 
non-medical purposes. None have withdrawn from the Single Convention to do so, 
despite cannabis effectively remaining under prohibitive control, and none are 
considered to be in overt violation of international law. We explore the position in 
some of those jurisdictions further in chapter 7. 
  
 
 
 
 
48 WHO Expert Committee on Drug Dependence: Fortieth Report. Geneva: World Health Organization; 2018 (WHO 
Technical Report Series, No. 1013). Licence: CC BY-NC-SA 3.0 IGO.  

   
 
43 
 
Cannabis, alcohol and tobacco  
 
2.66 The question is often raised as to why some drugs are illegal while others – with 
alcohol and tobacco most commonly cited – are governed via far less stringent 
systems of legal control. This apparent conundrum has led some scientists and 
others working in the area to call for more ‘rational’ systems of drug control 
overall.49 If tobacco or alcohol were to be discovered now, so the argument goes, 
on the basis of their potential for harm and abuse there is no way they would be 
legal substances. 
 
2.67 The point we have sought to make in this chapter is that the legal pathways taken 
by drugs of all types have been historically determined, affected by a range of 
interests such as the role of the state, vested economic industries (including those 
of tobacco and alcohol), activism of different groups, varying professional interests 
and the role of international obligations, networks and treaties. 
 
2.68 Culture too has been bound up in the process. Substances with widespread 
cultural legitimacy such as alcohol and tobacco are not easily made the subject of 
stringent systems of control.50 Cannabis, originally and chiefly a drug of Eastern 
medicine and culture, became bound up in a system of Western-led international 
control primarily designed for the opiates and cocaine. 
 
2.69 But legitimacy can change in either direction. Back in the 1950s no one would 
have countenanced a ban on tobacco smoking on public transport, in offices, 
shops and other public venues. Now in 2024, the end of the legal sale of tobacco 
to certain age groups in the UK is in sight. Substances can decline and they can 
also rise in terms of public and legal legitimacy, but rationality arguably often has 
little part to play in the process.
 
49 Nutt, D., King., L.A., Saulsbury, W. & Blakemore, C. (2007). Development of a rational scale to assess the harm of 
drugs of potential misuse. Lancet, 369, pp.1047–53. 
50 Berridge, V. (2016). Demons. Our changing attitudes to alcohol, tobacco and drugs. Oxford University Press. 

   
 
44 
 
3. NON-MEDICAL CANNABIS, UK LAW & 
ALTERNATIVE LEGAL APPROACHES 
 
The starting point for our exploration of whether prohibition of non-medical cannabis is 
the most effective way to minimise individual and societal harm was the current legal 
framework.  
 
This chapter summarises the law governing cannabis production, supply and 
possession in the UK (the relevant legislation applies to all four nations, thus non-
medical cannabis is prohibited across the UK). It also briefly describes non-prohibitive 
alternative legal frameworks adopted in a variety of other jurisdictions (illustrated in 
chapter 7). 
 
UK legislation and penalties for cannabis-related offences 
 
3.1 Since 2018, it has been legal for a limited number of cannabis-based products to 
be medically prescribed to treat a range of physical and mental health symptoms 
(see chapter 11). But using cannabis for non-medical, or recreational, purposes 
remains illegal in the UK.  
 
3.2 As we introduced in the previous chapter, the prevailing legislative instrument 
covering non-medical cannabis in the UK is the Misuse of Drugs Act (MDA) 1971, 
which governs activities associated with prohibited drugs. 
 
3.3 Under the MDA 1971, non-medical cannabis is a Class B drug. This means for 
unlicenced dealing, unlicenced production (including home cultivation) and 
unlicenced trafficking of cannabis, an individual could face up to 14 years in 
prison, an unlimited fine, or both. The maximum penalty for possession of 
cannabis is five years in prison and/or an unlimited fine.  
 
3.4 Custodial sentences for possession of cannabis are, however, rare. Between 2007 
and 2017, 3,861 people received a prison sentence in England & Wales for the 
offence51 and on 30th June 2024, 33 people were held in prison custody for 
possession of cannabis.52  
 
3.5 Very many thousands more, of course, have been prosecuted or given a police 
caution. We go into more detail regarding the criminal justice system response to 
cannabis offences in chapter 10, from police activity through to sentencing and 
conviction. We also consider the implications for individuals who come into contact 
with police on suspicion of cannabis-related offending.     
 
 
51 Garius, L. & Ali, A. (2022). Regulating Right, Repairing Wrongs: Exploring Equity and Social Justice Initiatives within 
UK Cannabis Reform. London: Release.  
52 Ministry of Justice & HM Prison and Probation Service. (2024). Offender Management statistics quarterly: January 
to March 2024. Annual Prison Population: 2015 to 2024. Table 1.A.11 Available at Offender management statistics 
quarterly: January to March 2024 - GOV.UK (www.gov.uk) Accessed 29th August 2024. 

   
 
45 
 
Dealing with cannabis possession: the current law (in England & Wales) 
 
3.6 Possession of cannabis (non-medical, see para.3.13 for the law in relation to 
medical) is by far the most common cannabis related offence. Having caught a 
person in possession, police have a degree of discretion (dependant on the 
circumstances) with respect to whether they pursue prosecution or deal with the 
offence without recourse to the courts.  
 
3.7 In 2017, the National Strategy on Charging and Out of Court Disposals was 
introduced, which enabled police to deal quickly with low-level offending of this 
nature using one of six disposals, namely: Simple Cautions; Conditional Cautions; 
Penalty Notices for Disorder (PND); Community Resolutions, and Cannabis and 
Khat53 Warnings.  
 
3.8 A cannabis (or khat) warning, introduced in 2004, can be issued under the 
following circumstances: 
 
‘A cannabis or khat warning may be given where the offender is found in 
possession of a small amount of cannabis or khat consistent with personal use 
and the offender admits the elements of the offence. The drug is confiscated and 
a record of the warning will be made on local systems. The warning is not a 
conviction and should not be regarded as an aggravating factor when 
sentencing for subsequent offences.’  
(Sentencing Council, 2023).54  
 
3.9 A warning can only be issued for a first-time possession offence, when the 
individual has no prior convictions, is not known as a persistent offender and has 
complied with the police process. While a record of the warning is made locally, 
this would not be revealed by a standard criminal records check (but could be 
disclosed as part of an enhanced check, which can be necessary for employment 
in particular organisations or roles). 
  
3.10 On a second occasion, police may issue an on-the-spot fine (Penalty Notice for 
Disorder, PND) to someone found in possession of a small amount of cannabis. 
Notably, however, and in line with the guidance regarding cannabis warnings, 
there is no maximum amount that legally constitutes a ‘small amount… consistent 
with personal use’: guidelines state only that ‘Police can issue a warning or an on-
the-spot fine of £90 if you’re found with cannabis’.55 
 
3.11 This lack of legal definition is contrary to common belief. Several participants in our 
research (see chapter 6 and full report56) thought being found in possession of up 
to one ounce (around 25 grams) of cannabis would be unlikely to attract sanction 
beyond a fine and/or a formal warning.  
 
 
53 A stimulant that is illegal in the UK and a Class C drug in the Misuse of Drugs Act 1971. 
54 2. Cannabis or khat warning – Sentencing (sentencingcouncil.org.uk) Accessed 5th October 2023. 
55 Drugs penalties – GOV.UK (www.gov.uk) Accessed 4th October 2023. 
56 See footnote #11. 

   
 
46 
 
3.12 While this may be the case in practice – at least in some circumstances (we 
discuss the matter in more detail in chapter 10) – it is not a legal position, although 
inaccurate media reporting may serve to strengthen such misperceptions among 
the public.57  
 
3.13 Under current law, there is one exception to application of sanctions for cannabis 
possession. Where procured via proven medical prescription, the law allows a 
person to possess the drug in the form of a licensed cannabis-based medicine or 
an unlicensed cannabis-based product for medicinal use (CBPM).  
 
3.14 Those unable to afford such prescriptions but who find cannabis alleviates their 
symptoms of ill health may turn instead to the illicit market. We discuss the legal 
implications of doing so in chapters 10 and 11, and explore the difference 
between CBPMs and licensed cannabis-based medicines. 
 
Dealing with cannabis possession: forthcoming changes (for England & Wales)  
 
3.15 The Police, Crime, Sentencing and Courts Act 2022 (PCSC) introduced changes 
to the way in which cannabis possession and other lower-level offences committed 
by those aged 18 and over will be dealt with. These centre around a simplified 
statutory framework for Out of Court Disposals (OOCDs) which, if enacted as 
designed,58 are expected to replace five of the six disposals detailed above with 
just two, namely an upper tier Diversionary Caution and lower tier Community 
Caution. The existing Community Resolution will be retained alongside the new 
cautions framework. 
 
3.16 As with the current system, an offender will have to admit their offence in order to 
be eligible for a caution of either type. A key change, however, is that whichever 
the police administer, one or more ‘conditions’ must be issued alongside it. These 
will focus on rehabilitative and reparative activity aimed at tackling the underlying 
causes of the offence (which could include treatment to help with substance use) 
or providing restitution to any victim(s) or the local community. Financial penalties 
will also be available where an officer considers such to be appropriate.  
 
3.17 This approach clearly hinges on availability of appropriate rehabilitative and 
reparative services. Fulfilment of a caution for cannabis possession that depends 
on, for example, attending an educational and/or treatment programme requires 
that programme to be available (locally) and have capacity. This is an important 
consideration and one to which we return briefly in chapters 9 and 10. 
 
3.18 Low-level offences will be eligible for either type of caution (or the Community 
Resolution). Breaches, however, will be dealt with differently. Breach of a 
Community Caution could result in a fine, whereas breach of a Diversionary 
 
57 See for example Is cannabis illegal in UK and where is weed legal to smoke and buy? – The Sun | The Sun 
Accessed 4th October 2023. 
58 At time of writing, the Ministry of Justice had issued a public consultation on the details. A response is expected in 
2024; see Diversionary and Community Cautions – Code of Practice (publishing.service.gov.uk) Accessed 4th 
October 2023.  

   
 
47 
 
Caution may result in prosecution for the original offence. If convicted (highly likely 
given admission of guilt is a criterion for deployment of the original caution), an 
individual will be left with a criminal record and its associated consequences. We 
discuss this further in chapter 10.  
 
3.19 Importantly, neither type of caution will be considered appropriate for street 
administration (unlike a Community Resolution). This means an offender will need 
to attend a police station, court building or other suitable location, with implications 
for their wider experiences of the police and the justice process.   
 
3.20 In terms of formal record and disclosure, the Community Caution will be 
considered spent immediately upon being given. This means it would not be 
disclosed through a basic criminal record check and an individual would not have 
to disclose (to a potential employer, for example) that they had received it. A 
Diversionary Caution will be spent a maximum of three months after the date of 
issue, or earlier if attached conditions are fulfilled. However, it would require 
disclosure under any basic check during that period.  
 
3.21 Both types of caution would, however, show up in an enhanced criminal record 
check for six years after issue. This means that, for employment requiring checks 
above basic level, the caution would need to be disclosed during that period. As 
both types represent a formal criminal justice disposal, they will be recorded on 
the Police National Computer.  
 
3.22 There are therefore obvious implications for anyone issued with a caution under 
the new framework, namely that offending must be disclosed in some 
circumstances. Those caught with cannabis may therefore feel the consequences 
for a longer period than under the current system. 
 
Alternative legal approaches to cannabis for non-medical use 
 
3.23 At time of writing, around 30 countries and over 50 jurisdictions have adopted an 
alternative approach to non-medical cannabis.59 Notable examples that we 
consider in chapter 7 include Uruguay, Portugal, many US states and Canada.   
 
3.24 Broadly speaking there are four different models or legal frameworks that can 
govern non-medical cannabis use. All are technically forms of market regulation 
and we briefly describe each below. Our inquiries led us to consider all four with 
respect to the most effective way to minimise individual and societal harm related 
to cannabis use. 
 
i. Prohibition: the model of control across the UK, until recently this represented 
the global status quo. It means the production or cultivation, transit, supply and 
possession of cannabis for non-medical or non-scientific purposes is illegal, thus 
 
59 https://idpc.net/themes/decriminalisation Accessed 4th Oct 2023.  
 

   
 
48 
 
associated activities are subject to punitive sanctions including criminal 
penalties. In effect, the criminal law is used to ‘regulate’ the cannabis market. 
 
ii. De-penalisation: also known as ‘de facto decriminalisation’, under a de-
penalisation model, activities related to production or cultivation, transit, supply 
and possession of cannabis for non-medical or non-scientific purposes remain 
illegal and liable to criminal sanction. The penalties, however, for possession of 
small quantities of cannabis are no longer applied (though remain in law) or are 
very substantially reduced in severity and police are usually guided to treat the 
offence as low priority and not suitable for proactive policing. Alternatively, police 
may divert an individual to an education or treatment programme, instead of 
proceeding with a charge of possession. 
 
iii. Decriminalisation: also referred to as ‘de jure decriminalisation’, this means 
(usually) possession of small quantities of cannabis is no longer a criminal 
offence, so criminal sanctions are removed. They may (or may not) be replaced 
with administrative sanctions (e.g. a civil fine or therapeutic response) – in some 
jurisdictions these will be mandatory, in others they will be advisory only.  
 
iv. Legal regulation: commonly referred to as ‘legalisation’ but more accurately legal 
regulation, under this framework cannabis can be legally produced, supplied and 
purchased. The term ‘describes the way in which government authorities 
intervene to control a particular legal drug product, or activities related to it. This 
control can take the form of regulations on, for example, a drug’s price, potency 
and packaging, as well as various aspects of its production, transit, availability, 
marketing and use’.60  
 
3.25 Within these models there is substantial variation with respect to the breadth of 
prohibited activities, the nature and severity of criminal sanction and the existence 
and nature of civil penalties. Regulatory frameworks differ in terms of permissions 
regarding marketing, advertising and product availability, as well as minimum age 
limits, whether the industry is profit-making or designed as not-for-profit, and the 
extent of state involvement in production, supply and retail. We consider several 
examples in chapter 7.   
  
3.26 We note, though, that models based on a ‘de facto’ rather than ‘de jure’ approach 
(i.e. what happens ‘in practice’ compared to what is set out in law) can (and do) 
lead to inequities in how the guidance for sanctioning any offence is applied. That 
said, any model where possession of cannabis for personal use leads to diversion 
into education or treatment rather than entry into the criminal justice system is, to 
our mind, positive.  
 
3.27 In our view, where cannabis possession remains a criminal behaviour, diversion is 
far more commensurate with the nature of the offence. It may, too, serve to 
highlight the existence of support services to those who might be in need (we 
 
60 Rolles, S. (2017) Legalizing Drugs: The key to ending the drug war. New Internationalist, p.52. 
 

   
 
49 
 
discuss treatment for people who have developed problematic use of cannabis in 
chapter 9). 
 
3.28 On the other hand, diversion not only requires services to be available, a one-size-
fits-all approach risks those not in need being required to access them in order to 
avoid formal criminal sanction. Not only does this mean such individuals are likely 
to get little from whatever programme they attend, it will increase pressure on 
access and delivery to those with greater need.  
 
3.29 De jure approaches, however, shift the societal lens through which cannabis 
possession (in this case) is treated. Because they require formal legislative 
change, those who use cannabis for personal use are no longer treated as 
criminals, with potential implications for the stigma commonly associated with use, 
treatment-seeking behaviour and harms that can result from a criminal conviction. 
We discuss these considerations in more detail elsewhere. 
 

   
 
50 
 
4. CANNABIS USE IN THE UK 
 
In this chapter we consider prevalence of cannabis use in the UK. It is abundantly clear, 
from available statistics and evidence put to us directly, that those who wish to consume 
the drug for non-medical purposes, including children, can access it without difficulty 
despite its illegal status. We set out what statistics tell us about the demographics of 
those who choose to use cannabis and explore some of the drivers behind that use.  
 
We consider what can happen when the drug is used to excess and explore the 
implications of co-consumption with tobacco. Finally, we touch briefly on the ‘gateway 
theory’, which suggests that cannabis use increases the likelihood of use of more 
serious drugs such as heroin and cocaine (though evidence remains scant).  
 
We begin, however with a description of cannabis and how it can be consumed. 
 
What is cannabis?  
 
4.1 In simple terms, cannabis is a botanical plant known by a myriad of names 
including marijuana, ganja, weed, pot, hash, dope, grass and herb (hereafter 
referred to as cannabis). The two most widespread species, or strains, are 
cannabis sativa and cannabis indica and it is these with which we are principally 
concerned, given their propensity to be cultivated to produce variants higher in 
psychoactive components (see below).61 While sativa plants are also the source of 
hemp (cultivated for both oilseed and fibres), variants used for this purpose 
contain little to no psychoactive properties. 
 
4.2  Cannabis contains over 100 different chemical compounds known as 
cannabinoids (or more accurately, phytocannabinoids, to distinguish them from 
cannabinoids produced by non-plant living organisms). When consumed, they 
bind to receptors (CB1 and CB2) in the human endocannabinoid system62 to 
produce a range of effects.  
 
4.3 The two most abundant cannabinoids are the most well understood and the cause 
of much of the contention surrounding cannabis: namely delta-9-
tetrahydrocannabinol (delta-9-THC, hereafter THC) and cannabidiol (CBD). 
 
4.4 CBD is non-psychoactive so on its own will not cause a user to become ‘high’. In 
other words, it will not cause any significant alteration in perception or senses. 
Usually present in higher proportions in medical than non-medical cannabis, it also 
 
61 Cannabis ruderalis is a variety of cannabis with low levels of psychoactive compounds, so tends not to be used for 
non-medical purposes.   
62 Discovered during the late 1980s, the endocannabinoid system (ECS) regulates the brain signals responsible for 
bodily functions including learning and memory, mood, sleep, appetite, pain control and inflammatory and immune 
responses. Endocannabinoids, or endogenous cannabinoids, are produced within the body, phytocannabinoids 
derive from plants and synthetic cannabinoids are produced in laboratories. Experts are still trying to fully understand 
the ECS and its interaction with cannabinoids of all types.  

   
 
51 
 
features in a wide range of CBD-based products sold legally in the UK (see 
chapter 8).  
 
4.5 It is the psychoactive THC that causes the ‘high’ commonly associated with 
recreational, or non-medical cannabis use – although like CBD it is also thought to 
possess some medicinal properties (e.g. pain relief). THC can, however, be 
addictive and is associated (particularly at higher concentrations) with a range of 
adverse effects on mental health, which we discuss in chapter 8.  
  
4.6 Levels of THC in cannabis have been steadily increasing over recent decades. 
While varying according to the particular strain and method of consumption, on 
the whole cannabis available today is substantially stronger in terms of THC than 
that available in the latter decades of the twentieth century.  
 
4.7 Concentrates (see below) have seen a particularly marked rise (now 40–90% 
THC63) and levels in herbal cannabis, the most common form of the drug, have 
risen from around 4% to around 15–20% THC on average,64 with some strains 
claiming nearer 30%. 
 
4.8 Working synergistically with cannabinoids are terpenes, which are organic 
compounds found in plants.65 Cannabis contains over 400 terpenes, which are 
responsible for making strains smell or taste different from others. While not 
intoxicating in themselves, they likely interact with CBD and THC in what is known 
as the ‘entourage effect’,66 which influences how a person experiences their 
consumption of cannabis.  
 
How is cannabis consumed?  
 
4.9 The method of consumption depends on the form of cannabis used. Smoking the 
herbal dried flower/bud, or hash, (compressed cannabis resin) in cigarette-like 
joints/spliffs or cigar-like blunts is the most common. When consuming cannabis 
this way, it is usual – though not necessary – to combine it with tobacco. Cannabis 
can also be smoked, or inhaled, via a bong (a water pipe that acts as a filtration 
device).  
 
4.10 The drug is also increasingly being ingested. The market for cannabis edibles 
(foodstuffs and drinks) is growing rapidly as legalisation is increasingly being 
adopted in many parts of the world and includes baked goods, sweets, butters 
and oils alongside cannabis-infused coffees, teas and carbonated drinks. 
 
63 If you use cannabis, do it safely - Harvard Health Accessed 23rd August 2023. 
64 See for example Cannabis Potency Data | National Institute on Drug Abuse (NIDA) (nih.gov); Freeman, T.P., Craft. 
S., Wilson, J., Stylianou, S., ElSohly, M., Di Forti, M. & Lynskey, M.T. (2021). Changes in delta-9-
tetrahydrocannabinol (THC) and cannabidiol (CBD) concentrations in cannabis over time: systematic review and 
meta-analysis. Addiction, 116(5). doi.org/10.1111/add.15253 Accessed 23rd August 2023. 
65 Responsible for the aromas, flavours and colours associated with various types of vegetation, terpenes are the 
primary constituents of essential oils such as peppermint or lavender and many are thought to possess a range of 
biological and pharmacological functions (including anti-inflammatory, anti-viral and antioxidant properties).  
66 See for example Hanuš, L.O & Hod, Y. (2020). Terpenes/Terpenoids in Cannabis: Are They Important? Med 
Cannabis Cannabinoids, 3(1). doi.org/10.1159/000509733 Accessed 23rd August 2023. 

   
 
52 
 
 
4.11 With the advent of e-cigarettes, or vaporisers/vape pens, in recent years, vaping 
has become an increasingly popular way to consume cannabis. Flower or extract 
is heated to a high temperature (but below the point of combustion) in a dry herb 
vape, and then inhaled. This is also the principal method by which cannabis used 
for medical purposes is consumed. 
 
4.12 Then there is concentrated resin produced for ‘dabbing’ (as opposed to hash, 
which is smoked). This involves vaporising the resin to a high temperature and the 
user inhaling the vapour, emitted as it cools, using what is known as a ‘dab rig’ (a 
form of water pipe). Alternatively, vape pens can be used to consume 
concentrates, with a small amount – a ‘dab’ – heated using the device and the 
vapour inhaled.   
 
4.13 Finally, cannabis extract can be infused with some other liquid (such as alcohol, 
glycerin or oil) to form a tincture. Usually consumed orally, it can also be applied to 
the skin.  
 
Overall use in the twenty-first century 
 
4.14 Cannabis is the most used drug worldwide; the United Nations Office for Drugs 
and Crime (UNODC)67 estimated the global number of past-year cannabis users in 
2022 aged 15–64 years to be 228 million (around 4% of the world’s population). 
This represents a 34% rise on the 170 million users estimated in 2010, likely due 
in part to an increase in the global population and the Covid-19 pandemic (many 
countries reported a rise in use during that period).  
 
4.15 While increases are observed regardless of race, income or ethnicity,68 the 
UNODC notes significant variation in rates of use across the world. That said, 
much of these data derive from self-report surveys, which may lead to artificially 
small prevalence rates, particularly in countries with more punitive repercussions 
for drug use. Broadly, though, irrespective of region, cannabis use tends to be 
higher in adolescents and young adults.  
 
4.16 In line with the global picture, reported use of cannabis in England & Wales is 
almost three times that of the next most common illegal drug (cocaine). It remains, 
however, far less widespread than use of tobacco or alcohol (see paras. 4.28–
4.29) – though we acknowledge that measures of illegal drug use almost inevitably 
underestimate consumption.69  
 
 
67 WDR24_Key_findings_and_conclusions.pdf (unodc.org) Accessed 23rd July 2024. 
68 Hasin, D. & Walsh, C. (2021). Trends over time in adult cannabis use: A review of recent findings. Current Opinions 
in Psychology, 38, pp.80–85. doi.org/10.1016/j.copsyc.2021.03.005  
69 See for example European Monitoring Centre for Drugs and Drug Addiction & Europol (2024). EU Drug Market: 
Cannabis — Retail markets. EU Drug Market: Cannabis — Retail markets | www.emcdda.europa.eu Accessed 9th 
April 2024 

   
 
53 
 
4.17 Almost one-third of 16–59-year-olds in England & Wales reported cannabis use at 
least once in their lifetime,70 and over 7% reported consumption during the year to 
March 2023.71 While statistics suggest use is falling (from a 20-year high of almost 
11% in the year to March 2003,72 see Figure 1, and even more so in London 
where it dropped by over half from the beginning of the century), estimated 
prevalence equates to an estimated 2.5 million people73 (aged between 16 and 
59).  
 
Figure 1: Proportion of 16–59-year-olds reporting past-year cannabis use in England 
& Wales and London, 2001–2023 
 
 
 
 
4.18 The position is similar across Great Britain (GB),74 with around 7% of those aged 
over 18 (around 3.7 million adults) reporting past-year cannabis use in early 
2023.75  
 
70 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.01: 31.1%. 
Accessed 16th January 2024.  
71 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.02: 7.6% of 
those aged between 16 and 59 in England & Wales used cannabis in the year ending March 2023. Accessed 16th 
January 2024.  
72 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.02. 
Accessed 16th January 2024.  
73 See Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.05. 
Accessed 16th January 2024. 
74 Data collections differ with respect to geographical coverage, reporting periods, age parameters and sampling 
strategies, so care must be taken when comparing figures. 
75 Action on Smoking and Heath (ASH) (2024). Available at committees.parliament.uk/writtenevidence/129570/pdf/ 
Accessed 24th July 2024. 
10.7
7.6
14.3
6.2
0
2
4
6
8
10
12
14
16
Proportion reporting use (%)
Annual periods March–April (2001–2023)
England & Wales London
Source: Drug misuse in England and Wales – Appendix table – Office for National Statistics (ons.gov.uk) Table 1.02. 

   
 
54 
 
 
4.19 Comparing levels of cannabis use in this country with other jurisdictions is 
complex. A lack of systematic data, variations in measurement, age groups, 
reporting years and periods, distinctions between medical and non-medical use of 
cannabis (or not), price and legal status of the drug all affect the statistics 
available. This means comparisons often likely compare apples with pears, which 
limits our ability to predict what might happen to levels of use if the legal 
framework here were to be changed.   
 
4.20 Acknowledging these limitations, we note prevalence rates across the European 
Union (EU) are similar to those in this country. Almost 30% (29.3%) of those aged 
15–64 are estimated to have used cannabis at least once in their lifetime,76 
broadly in line with England & Wales (31.1% among 16–59-year-olds in the year to 
March 2023.)77  
 
4.21 Based on data reported up to 2019, 7.7% of those aged 15–64 in the EU had 
reportedly used the drug in the past year, also in line with England & Wales (7.6% 
in 2018–19 for those aged 16–59, see Figure 3). 
 
4.22 While direct comparisons are difficult due to variation in reporting year, prevalence 
of cannabis use is reportedly higher across younger Europeans (15–34 years) 
than those in England & Wales, with average past-year rates estimated at 15.4% 
and 13.4% respectively.78 The difference is likely to be driven at least to some 
extent by higher-than-average rates in a handful of European countries, namely 
Spain, France, Italy, Germany, Croatia and Czechia.  
 
4.23 Indeed, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) 
reported that Europe’s two largest illicit cannabis retail markets are France and 
Italy, followed by Germany and Spain. They note too that, while central and 
eastern EU countries tend to report lower levels of past-year use, prevalence rates 
in Croatia and Czechia are among Europe’s highest.79  
 
4.24 Overall, the prevalence of cannabis use in Europe has remained relatively stable 
over the past decade, as in England & Wales (see Figure 1), although, based on 
data from countries that have conducted surveys since 2019, the EMCDDA noted 
a rise in four with decreases in a further five. 
 
4.25 Looking to the US and Canada, prevalence has risen over the past five years or 
so. Figure 2 shows average past-year rates of use in Colorado and Washington 
state, which both legalised non-medical cannabis in 2012, in California, which 
 
76 See footnote #69. Accessed 13th May 2024. 
77 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.01: 31.1%. 
Accessed 16th January 2024. 
78 European Monitoring Centre for Drugs and Drug Addiction (2021). European Drug Report 2021: Trends and 
Developments. Publications Office of the European Union, Luxembourg. See Table A5. 
79 See footnote #69. Accessed 10th April 2024. 
 

   
 
55 
 
legalised its use in 2016, and Canada, which followed suit in 2018. Average past-
year prevalence across the US is presented by way of comparison.  
 
4.26 We consider these jurisdictions in more depth in chapter 7, where we explore 
evidence about the impact of legalising non-medical cannabis on levels of use. 
 
Figure 2: Proportion of adults (aged 16+ / 18+) reporting past-year non-medical 
cannabis use in selected jurisdictions, 2016–2023 (where data permits*)   
 
 
*2020 data collection affected by the Covid-19 pandemic and 2021 figures to be treated with caution due to 
change in methodology. 
Sources: See annual US state tables at National Survey on Drug Use and Health (samhsa.gov) National Survey 
on Drug Use and Health (samhsa.gov); https://www.canada.ca/en/health-canada/services/publications/drugs-
health-products/canadian-cannabis-survey-2017-summary.html; https://health-infobase.canada.ca/cannabis/  
 
4.27 After cannabis, the next most commonly taken illicit drug in England & Wales is 
cocaine, though it is used by far fewer people. In the year to March 2023, 2.5% of 
individuals aged 16–59 reported some use of the drug.80  
 
4.28 Conversely, cannabis users are outnumbered by users of tobacco and alcohol. 
Across the UK in 2022, almost 13% of those aged 18 years and over (around 6.4 
million people) smoked cigarettes (though numbers are in decline),81 with alcohol 
consumption higher still.  
 
 
80 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 1.02. 
Accessed 13th November. 
81 Adult smoking habits in the UK - Office for National Statistics (ons.gov.uk) Accessed 13th November. 
0
5
10
15
20
25
30
35
2016 2017 2018 2019 2020 2021 2022 2023
Proportion reporting use (%)
US (18+) Canada (16+)
Colorado (18+) California (18+)
Washington state (18+)

   
 
56 
 
4.29 The Health Survey for England reported that in 2021, over three-quarters (79%) of 
those aged 16 and over reported drinking alcohol at least once in the past 12 
months, and around half (49%) drank at least once a week.82 In comparison, in 
2023 18% of adult cannabis users across GB reported consuming the drug at 
least once a week.83 
 
Characteristics of cannabis users in the UK 
 
Age 
 
4.30 Cannabis is used predominantly by youth and young adults. While reported use 
overall has fallen in England & Wales over the past 20 years (except among older 
age groups, where it has risen slightly recently), it is consistently more common 
among younger people. Around one-sixth of those aged 20–24 and one-seventh of 
16–19-year-olds are reportedly recent users – see Figure 3.  
 
Figure 3: Proportion of 16–59-year-olds reporting past-year cannabis use in England 
& Wales by age group, 2001–2023 
 
 
Source: Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk)  Table 
3.03. 
 
4.31 While cannabis is used by school-aged children, as with adults it is less prevalent 
than alcohol or tobacco. In 2021, seven per cent of 11–15-year-olds in England 
reported having tried the drug, compared with 12% who had tried tobacco and 
 
82 Part 3: Drinking alcohol - NHS Digital Accessed 13th November. 
83 See footnote #75. Accessed 24th July 2024. 
14.3
16.1
0
5
10
15
20
25
30
Proportion reporting use (%)
Annual periods March–April (2001–2023) 
16–19 20–24 25–29
30–34 35–44 45–54
55–59 16–59

   
 
57 
 
40% alcohol. While use rose among older children, with one-fifth (19.2%) of 15-
year-olds reportedly having tried cannabis, more (25%) had tried tobacco and 
almost two-thirds (65%) alcohol.84 A similar pattern has been reported elsewhere 
for 16–17-year-olds.85 
 
Gender 
 
4.32 Cannabis use is higher among men than women: among those aged 16–59, over 
9% reported use in the year to March 2023, compared with a third fewer women 
(6%). The difference is less marked among young adults with around one-sixth of 
men (17%) aged 16–24 reporting use, compared with around one-seventh of 
women (14%) of the same age.86 
 
4.33 Among children, slightly more girls reported trying cannabis in 2021 than boys 
(7.1% vs 6.8% in 2021). As smoking cannabis with tobacco is the most common 
means of consumption, higher rates of cigarette smoking among girls than boys 
(13% vs 10% reported having ever smoked)87 may be partly responsible. We 
discuss school-based cannabis education in chapter 12 and cannabis sources in 
chapter 5, but note the role of both peers and dealers in providing cannabis to 
children (around three-fifths got it from a friend on the first occasion, and around 
one-fifth from a dealer88).  
 
Ethnicity 
 
4.34 Various surveys report differences in prevalence of cannabis use between ethnic 
groups. However, there is little convergence in patterns, meaning we cannot be 
confident in drawing conclusions with respect to genuine variation in use 
according to ethnicity. This is compounded by methodological limitations (e.g. 
small samples of respondents from ethnic backgrounds other than white mean 
confidence intervals around those estimates are larger89).  
 
4.35 One survey reported cannabis use in the year to March 2023 in England & Wales 
to have been highest among those of mixed ethnicity (11.2%), followed by those 
from a white background (8.6%). Among those of black ethnicity, use was 
recorded at 4.6% and at just over 2% it was lowest among those of Asian origin.90  
 
 
84 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Tables 1.2, 5.2 
and 8.7c. Accessed 13th November 2023. 
85 See footnote #75. Accessed 24th July 2024. 
86 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 3.04. 
Accessed 16th January 2024. 
87 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Tables 1.2 and 
8.8. Accessed 13th November 2023. 
88 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Tables, Table 
9.4. Accessed 14th November 2023. 
89 The larger the confidence interval around an estimate of cannabis prevalence, the less precise the estimate, and 
the true prevalence of cannabis use among one group may be more similar (or indeed equal) to another than 
estimates suggest. 
90 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 3.01. 
Accessed 15th January 2024. 

   
 
58 
 
4.36 Elsewhere, however, past-year prevalence was reportedly highest among black 
populations in England when compared to white British and other ethnic groups, 
with higher rates too among those from Asian and Arab backgrounds.91,92  
 
4.37 The relationship between ethnicity and cannabis use is no doubt complex. And 
there is some evidence, too, that apparent variation might be explained by factors 
other than ethnicity,93 namely age94 and deprivation. After controlling for both, one 
analysis reported levels of past-year drug use among black and mixed/other ethnic 
groups to be statistically no different from the white British group.95 
 
4.38 Given a potential link with deprivation, it is not surprising that prevalence of 
cannabis use varies by socio-economic status. While used across society, both 
prevalence and frequency of use96 tend to rise as income falls.97 Cannabis users 
overall, as well as those using frequently (daily), are also more likely to live in 
rented housing than their own home, and to be unemployed or otherwise not in 
work.98  
 
Cannabis in London   
 
4.39 Reported cannabis use in London has fallen substantially over the past 20 years, 
with just over 6% of Londoners claiming to have used the drug during the year 
ending March 2023 – below the national average across England & Wales of 
7.6%99 (see Figure 1). Estimates from Action on Smoking & Health (ASH), 
however, put the figure in London higher at almost 10% – the highest of all regions 
across England, Scotland and Wales.100 
 
4.40 Among London’s schoolchildren, use of cannabis and/or exposure in the home 
was thought relatively commonplace among those we heard from who worked 
with young people. Use was described as having become a social norm to a much 
greater extent than for older generations, almost a rite of passage or a milestone 
in youth, with consumption among peers and in wider social settings reportedly 
 
91 McManus, S., Bebbington, P., Jenkins, R. & Brugha, T. (eds.) (2016). Mental health and wellbeing in England: 
Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Table 11.3. Note: this survey runs every seven years, at 
time of writing the next iteration was in preparation.  
92 Bespoke analysis undertaken by Action on Smoking and Health (ASH) for the London Drugs Commission, which 
aggregated data on cannabis use reported in the 2020/21, 2021/22 and 2022/23 waves of a survey of adults aged 
18+ across GB. 
93 Pinto, C., Yates, K., Weston-Stanley, P., D'Arcy, A., Bennetto, R., Sawdon, E., Lau, R. & Khambhaita, P. (2024). 
Non-opiate and cannabis drug use in minority ethnic groups. National Centre for Social Research. 
94 See also Shiner, M., Carre, Z., Delson, R. & Eastwood, N. (2018). The Colour of Injustice: ‘Race’, drugs and law 
enforcement in England and Wales. StopWatch & Release. 
95 See footnote #93. 
96 See footnote #75. Accessed 24th July 2024. 
97 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 3.02. 
Accessed 11th April 2024. 
98 See footnote #75. Accessed 24th July 2024. 
99 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 3.07. 
Accessed 15th January 2024. 
100 Action on Smoking and Heath (ASH) (2023). Unpublished written submission to the London Drugs Commission: 
9.8% of those aged 18+ in London reported past-year cannabis use. Figures from the Smokefree GB Adult survey. 

   
 
59 
 
sometimes continuing for several years. Family members of a number of young 
people were also known to be users of cannabis and other illicit drugs. 
 
4.41 The difficulties with comparing levels of cannabis use across different ethnic 
groups are compounded at regional level because prohibitively small sample sizes 
mean data is not published at this granularity. Bespoke analysis of ASH data, 
however, showed rates of past-year use to be highest among Londoners of mixed 
ethnicity or from another ethnic group (18%). It was next highest among black 
Londoners – of whom 11% had used the drug in the past year, mirroring the rate 
found by the same survey in black populations across England. Among the white 
ethnic group, 8.5% reported past-year cannabis use, with use among Asian/Arab 
ethnic groups the lowest at 7.7%.  
 
4.42 In terms of lifetime prevalence, however, the pattern was slightly different. Among 
Londoners of mixed ethnicity or from another ethnic group, it stood at 42%, with 
the next highest rate reported for those from a white background (36%). Among 
black Londoners, 27% reported ever having used cannabis, as did 18% of those 
from an Asian/Arab background.101 
 
4.43 As our own research indicated (see Appendix C and research report)102 and as we 
heard in testimony from MPs, Council Leaders, senior council officials and other 
stakeholders across London, cannabis use is widespread, even normalised, in 
some areas. Among some communities it is considered part of cultural practice103 
and we heard about intergenerational use where families share knowledge of 
different cannabis strains and products, advising others on safer consumption. 
 
4.44  While we heard about hotspots, and characteristics of local cannabis markets and 
users do vary across boroughs, public dealing and consumption is consistent and 
commonplace. It was put to us by several witnesses, however, that the police 
response is less consistent. While identifiable in wealthier boroughs as well as 
more deprived parts of London, there is a perception (borne out by statistics; see 
chapter 10) that police action regarding cannabis, including stop and search 
(S&S), is more likely in the latter.  
 
4.45 London’s more deprived neighbourhoods tend to be home to higher proportions of 
residents from ethnic minority (excluding white ethnic) backgrounds than its less 
deprived areas.104 Together with the finding that deprivation might explain at least 
some of the variability in cannabis use among ethnic groups, this suggests to us 
the potential for some ethnic disparity in the policing of cannabis.      
 
4.46 We return to the issue in chapter 10 but consider the lack of routinely collated data 
showing use of individual drugs by ethnicity below national level to be unhelpful. 
The Home Office (HO), together with the Office for National Statistics (ONS) and 
 
101 Action on Smoking and Heath (ASH) (2023). Unpublished written submission to the London Drugs Commission.  
102 See footnote #11. 
103 See also footnote #93, p.22. 
104 See Census 2021 deep dive: ethnicity and deprivation in London | Trust for London Accessed 30th November 
2023. 

   
 
60 
 
the Mayor’s Office for Policing & Crime (MOPAC), should consider how data 
collections could be boosted to facilitate more nuanced understanding of cannabis 
use among different ethnic groups in London and other regions (R1). 
 
4.47 While experiences of cannabis being consumed in public are widespread, this 
does not mean the public are accepting of it (although whether levels of concern 
are as high or extensive as authorities and some parts of the media believe is not 
clear; see chapter 6 for discussion of public views).  
 
4.48 We heard overt cannabis use can be associated with wider indications of anti-
social behaviour, which can act to compound feelings of general lawlessness. It 
was, however, also put to us that smoking cigarettes, or vaping, or being drunk in 
public, are behaviours that many would prefer did not happen but often accept are 
part of life – although smoking is increasingly seen as less acceptable.  
 
4.49 Law enforcement officers from the UK and US told us that anti-social or violent 
behaviour resulting from excessive cannabis use is relatively minor compared with 
that driven by use of alcohol and other types of illegal drugs. Lawbreakers high 
from cannabis at the point of arrest, for example, pose less risk of violence than 
those who are high on crack cocaine, or drunk. Indeed, one officer described 
alcohol as the worst drug he had ever experienced in several decades of policing 
in terms of its propensity to incite violence.   
 
4.50 That said, there is some evidence that persistent use of cannabis, particularly 
when begun at an early age, can be associated with an increased risk of physical 
violence, although the role played by factors including potency and pre-existing 
mental health factors is unclear.105 While we did not consider the mechanisms 
involved, frequent cannabis use may cause a user to process emotional stimuli 
differently in comparison to non-users, which might lead to negative interpretations 
of otherwise neutral events and potentially a heightened risk of an aggressive 
response.106  
 
4.51 And while they act very differently to organic cannabis, which makes direct 
comparison difficult, the use of synthetic or adulterated forms of cannabis (see 
chapter 8) may also raise the risk of violent behaviour. While adverse 
consequences are largely physical in nature (including extreme dizziness, nausea 
and vomiting), we heard reports of increased paranoia in consumers of synthetic 
cannabis, which can manifest in erratic and unpredictable behaviour and 
responses to those around them. 
 
 
 
 
 
 
105 See discussion in University of West London & ARCS Ltd (2024). Cannabis, violence and policing in London – 
assessing current practice, modelling future approaches. Available at MOPAC academic research | London City Hall.  
106 Ibid. 

   
 
61 
 
The ‘Lambeth experiment’ 
 
4.52 For one year, beginning in July 2001, the Lambeth Cannabis Warning Scheme 
(LCWS) operated in the London Borough of Lambeth.107 This de-penalised 
possession of ‘small quantities’ of cannabis (what constituted a small amount was 
police officer-determined), meaning that, while still recorded, it was no longer a 
prosecutable offence, and the individual was not arrested. Instead, they were 
given a warning and their cannabis confiscated. All other boroughs retained their 
usual policing policy towards cannabis. 
 
4.53 Overall, around 80% of residents supported the scheme (although backing was 
higher among white than black or Asian residents)108 and evaluations suggested 
the policy led police to reallocate effort towards non-drug related crimes. This saw 
a reduction of over 9% in those crimes (and a consequent fall in total crime)109 with 
improvements in overall effectiveness as measured through arrest and clear-up 
rates – including for cannabis supply offences (which rose during and after the 
experiment).  
 
4.54 Arrests for possession not surprisingly fell substantially, although the number of 
recorded possession offences rose during the experiment and remained elevated 
for some time following its cessation.110 The role played in this rise by ‘drugs 
tourism’ into Lambeth from neighbouring London boroughs, a concern for many at 
the time, is unclear. Some analysis suggests it was a significant factor,111 evidence 
elsewhere reports it played no role.112  
 
4.55 Concerns that the experiment would lead to a rise in the dealing and use of 
cannabis in Lambeth’s schools were unfounded.113 There is some evidence, 
however, that the experiment was associated with both a fall in local house prices, 
particularly in areas where the illicit drug market was most active,114 and a rise in 
harder drug-related hospital admissions among young men.115  
 
4.56 While the drivers of this are unclear, some witnesses told us the illegality of 
cannabis can increase its appeal among young people because it is perceived as 
‘risky’: using, sourcing and supplying it can attract a certain social status, affording 
a badge of honour. If de-penalisation removed some of that status, this may have 
 
107 For background, see Crowther-Dowey, C. The Police and Community Justice: The Lambeth Policing Experiment. 
Available at 7970 BJCJ Insides.qxd (mmuperu.co.uk) Accessed 15th November 2023. 
108 Lambeth Cannabis Policing Experiment | Ipsos Accessed 15th November 2023. 
109 Adda, J & Rasul, I. (2011). Crime and the Depenalization of Cannabis Possession: Evidence from a Policing 
Experiment. London: IFS. https://ifs.org.uk/publications/crime -and-depenalization -cannabis -possession -
evidence -policing -experiment  Accessed 15th November 2023 . 
110 Adda, J., McConnell, B. & Rasul, I. (2014). Crime and the Depenalization of Cannabis Possession: Evidence from 
a Policing Experiment. Journal of Political Economy, 122(5), pp.1130–1202. 
111 See footnote #109. 
112 See footnote #107. 
113 Ibid. 
114 See footnote #109. 
115 Kelly, E. & Rasul, I. (2014). Policing Cannabis and Drug Related Hospital Admissions: Evidence from 
Administrative Records. Journal of Public Economics, 112, pp.89–114. doi.org/10.1016/j.jpubeco.2014.01.008 

   
 
62 
 
encouraged some to look to other, harder drugs, to push boundaries and elevate 
their peer standing.   
 
4.57 If nothing else, outcomes from the Lambeth experiment demonstrate the 
complexity of understanding the effects of changes in the application of criminal 
law. Improvements in one measure (e.g. reduction in some crime types) may be 
unintentionally countered by deterioration in another (e.g. measures of wider 
social functioning such as house prices.) 
 
4.58 Whether the net outcome was one of overall reduced harm, with neither creation 
nor exacerbation of existing disproportionality or inequalities, is a thorny question 
with, in our view, no clear answer. That said, during the period in which cannabis 
was de-penalised Lambeth did not descend into the chaos and lawlessness that 
some had predicted.  
 
Drivers of cannabis use 
 
4.59 We did not set out to explore drivers of cannabis use in depth, thus did not seek to 
hear from users directly.116 That said, the issue arose several times and indeed, 
the top reasons for use cited by Londoners responding to our survey (Appendix C) 
were thought to be relaxation, management of stress and anxiety, and pain relief. 
While not necessarily users of cannabis themselves, it is striking that only a quarter 
(26%) thought having fun was a driver. Even fewer cited being sociable or getting 
‘stoned’ (high) as a reason to take the drug.   
 
4.60 We heard from several witnesses about the role of peer pressure in initiating and 
sustaining use. And both young people and professionals who work with young 
people in a range of settings told us self-medicating through cannabis to soothe 
symptoms of anxiety and stress, often linked to deprivation, trauma, neglect and 
violence, is common.  
 
4.61 For many, it forms a coping mechanism, a means of emotional self-regulation, and 
it was put to us by several experts that this is more likely where wider community 
services to support young people with mental health conditions and other 
significant life challenges are absent, or very limited. We heard cannabis can 
become a crutch – one which is vastly more accessible than professionally 
administered support.  
 
4.62 Indeed, it was put to us that significantly more investment has been made in 
cannabis policing than in wider support services, particularly in the wake of the 
global pandemic. And that this has served to compound a range of issues, 
particularly among young people.  
 
4.63 We heard levels of anxiety have risen substantially in recent years, with increased 
nervousness attached to interacting with others, particularly for LGBTQ+ youth 
 
116 Reasons for cannabis use have been thoroughly explored in many previous government and non-governmental 
reviews and a wide range of research.  

   
 
63 
 
who have not yet, or have only recently, come out. Cannabis has become, for 
some, an easy tool in the box for young people to draw on to ease tensions, as 
well as deal with feelings of loneliness and isolation:  
 
‘It [cannabis] is a huge coping mechanism… [young people say] ‘it will help me 
be calm in social settings’… maybe they use because they have an underlying 
chronic anxiety disorder that arises from trauma in early childhood…’.  
 
‘…they continue to live in a horrible home environment, surrounded by poverty 
and deprivation. And they’re constantly living in fear because they're actually in a 
community where they do feel at risk, then they're not going to stop because it's 
what makes life tolerable’. 
 
4.64 As reported by, among others, the British Medical Association (BMA), rates of 
mental illness have been rising for some time, particularly among children and 
young people – a trend exacerbated by the Covid-19 pandemic. In 2017 around 
one in eight young people aged 7–16 suffered with a probable mental illness, 
increasing to more than one in six by 2022. For those aged 17–19, rates rose from 
one in ten to one in four.117  
 
4.65 Overall, the number of people seeking treatment has grown rapidly. Services in 
England received a record 5 million referrals in 2023 (a rise of 33% from 2019)118 
– more people than ever are asking for help. But the sector is not resourced to 
meet demand.  
 
4.66 Long waiting lists mean sufferers can remain undiagnosed for long periods of time, 
and once diagnosed can face exceptionally long waiting lists to be seen by a 
health practitioner. Thresholds for treatment can be high119 and, where not met, or 
where waiting times leave someone suffering, it is not inconceivable for them to 
turn to alternative ways of achieving relief. For some, this might be cannabis. 
 
4.67 The dynamic between cannabis and adverse mental health more widely is 
extremely complex, as we set out in chapter 8. While there is certainly some 
association, it is by no means consistent across all users and, as we heard, many 
people turn to cannabis to alleviate existing symptoms of poor mental health, 
which can result from a wide range of traumatic life experiences. For others, 
cannabis use might bring on symptoms of mental ill health that may not otherwise 
have materialised. 
 
4.68 We also heard that underfunding and in some cases closure of young people’s 
services across London more broadly (i.e. not just in the health sector) has meant 
a fall in community provision of meaningful activities. These typically help reduce 
the risk of children and young people being drawn into drug use and other criminal 
or anti-social behaviour. Reducing or ceasing provision has, it was argued, left 
 
117 Mental health pressures data analysis (bma.org.uk) Accessed 16th November 2023. 
118 Ibid. Accessed 23rd July 2024. 
119 Ibid. Accessed 16th November 2023. 

   
 
64 
 
young communities vulnerable, with the risk of becoming involved in drug use, or 
increasing existing use, rising.  
 
4.69 Many of those who work with young people described a process of considered 
cost–benefit analysis. The risks and costs of getting caught for using cannabis 
(related to parents, schools and the police) are weighed up against the benefits – 
a calculation that often comes out in favour of the latter, meaning there is little 
motivation not to start using, or to desist. Cannabis can help those who choose to 
use it feel life is tolerable; for some it can ease a boredom associated with a lack of 
employment or education opportunities. 
 
4.70 But it is of course used not just to help people cope, but for enjoyment. We heard 
about it heightening feelings, aiding creativity and, especially for young people, 
oiling social wheels and breaking down barriers that they otherwise struggle to 
overcome. Indeed, the Global Drugs Survey reported maximising pleasure to be 
the most important aspect of cannabis consumption reported by respondents who 
used the drug, followed by avoiding harm and having fun with others.120 (Which 
contrasts with findings from our survey in which respondents – not necessarily 
users of cannabis – cited relaxation as a primary reason to consume the drug, see 
para.4.59.) 
 
4.71  This means (as we discuss in chapter 12 on education) focusing communications 
around cannabis on harm can disenfranchise many whose experiences do not 
chime with that message. Indeed, we heard of some who, in seeking to 
understand the risks, had disregarded information from sources including the 
NHS, which were described as unbalanced with no recognition of the broader 
drivers and positive effects of the drug.121 
 
4.72 And as we heard from experts across sectors, a large number of people who use 
cannabis experience no adverse or life-limiting consequences. They are able to 
study, work and socialise as effectively as those who do not use the drug. While 
difficult to estimate the proportion who remain wholly unaffected by negative 
effects, evidence suggests at least 10%122 and possibly up to around 20%123 might 
develop symptoms of Cannabis Use Disorder (CUD) and/or other symptoms of 
adverse mental health that can be associated with use of cannabis (see chapter 
8).  
 
 
120 Winstock, A.R., Maier, L.J., Zhuparris, A., Davies, E., Puljevic, C., Kuypers, K.P.C. … & Barratt, M.J. (2021). 
Global Drug Survey (GDS) 2021 Key Findings Report. Report2021_global.pdf (globaldrugsurvey.com) Accessed 27th 
November 2023. Note this surveyed 32,022 people who use drugs from 22 countries so findings cited are not 
specific to the UK unless stated.  
121 Walsh, H. (2023). Unpublished PhD findings shared with the London Drugs Commission. 
122 Connor, J.P., Stjepanović, D., Le Foll, B., Hoch, E., Budney, A.J. & Hall, W.D. (2021). Cannabis use and cannabis 
use disorder. Nature Reviews Disease Primers 7(16). doi.org/10.1038/s41572-021-00247-4 
123 Leung, J., Chan, G.C.K., Hides, H. & Hall, W.D. (2020). What is the prevalence and risk of cannabis use disorders 
among people who use cannabis? a systematic review and meta-analysis. Addictive Behaviours, 109. 
doi.org/10.1016/j.addbeh.2020.106479 
 

   
 
65 
 
4.73 While these are certainly not insignificant proportions, the fact remains that the 
majority of people who use cannabis are unlikely to end up with poorer health or a 
lower quality of life as a result. That said, those who use highly potent forms of the 
drug on a very regular basis almost certainly run a much greater risk of adverse 
consequences, as we discuss below and further in chapter 8. 
 
Excessive use of cannabis 
 
4.74 We heard powerful stories from a small number of people who had become 
addicted to cannabis and developed symptoms of psychosis that were highly likely 
to be associated with their use of the drug. We heard, too, exceptionally moving 
accounts about the impact of extreme cannabis consumption, particularly from 
parents who tragically lost children to drug overdoses, or who watched a loved 
one’s mental health deteriorate while using cannabis and/or other drugs to the 
point where they tried, sometimes successfully, to take their own life.  
  
4.75 We heard from representatives of charities that support those who use drugs and 
their families, who spoke poignantly of the challenges experienced by the people 
they work with, of difficulties in securing treatment, and of dealing with increasing 
demand. 
 
4.76 Cannabis is among the top four substances causing concern for those reaching 
out (alongside alcohol, cocaine and heroin) – both as a primary drug of choice 
and, often, alongside alcohol. But while these charities provide a lifeline – 
sometimes literally – to those who use drugs and their loved ones, they cannot 
take the place of properly funded treatment and rehabilitation services. We return 
to this matter in chapter 9.  
 
4.77 Equally, the support that charities provide to those wishing to reduce or stop 
cannabis use, and to put in place alternative activities in response to triggers that 
drive it, cannot succeed without such activities being available. Employment, for 
example, or other forms of structured activity, were cited as crucial. Purposeful 
activity fills time that would otherwise be spent consuming cannabis.  
 
4.78 But we heard how the illegal status of the drug can prohibit opportunities. For 
example, many industries now require applicants to employment and training 
schemes to undergo a drug test. For users of cannabis, including those weaning 
themselves off the drug, this can present a problem because of the length of time 
the drug remains identifiable in the body. It remains detectable in urine for up to a 
month (depending on strength and frequency of use) whereas heroin and cocaine 
are not identifiable beyond around four days post-use. 
 
4.79 As described to us by those who had experienced cannabis dependency, the drug 
was the only thing they cared about, wholly normalised in their lives. Indeed, one 
former user of cannabis described how growing up with parents who used the 
drug not only meant exposure from an early age but instillation of a belief that it 
posed no harm. This chimes with some of the concerns expressed to us from 

   
 
66 
 
experts in jurisdictions that have legally regulated non-medical cannabis, i.e. the 
act of doing so can suggest its use is risk-free.   
 
4.80 There were mixed views with respect to whether the illegal status of cannabis 
does more to hinder than help those who develop problematic use. Broadly 
speaking, those working to support people who use cannabis and their families 
tended to feel that illegality deters both groups from acknowledging a problem and 
seeking help, often until it is too late. And that without a legal market, people who 
choose to use the drug are subject to elevated risks from unknowingly consuming 
contaminated product.  
 
4.81 From a harm-reduction perspective, some thought legal products might 
encourage safer practices because health professionals might be better informed 
about what people are actually taking. That said, it was acknowledged that many 
would likely still source cannabis from the illicit market, driven by personal 
preferences and allegiances to dealers.  
 
4.82 But some who have been problematic users are more nervous, describing the 
risks of unwittingly ending up addicted and unable to motivate oneself to engage in 
life or reap reward from anything that does not involve cannabis. ‘The world 
doesn’t come into existence until one’s had a joint’ was how one person described 
his former life to us. Engaging with others and the world around him became 
impossible without cannabis, until he sought treatment and stopped using the 
drug. Another told us, ‘When you think you have no choice but to take your own 
life, things have got out of hand.’  
 
4.83 The personal stories of the dangers of becoming cannabis-dependent, and those 
of families who have lost loved ones, are a profound reminder that this is not a 
harmless drug. But those we spoke with acknowledged, too, that cannabis 
prohibition is not harm-free and suggested legal regulation might remove at least 
some of the negative judgement and stigma associated with its use, and with 
associated help-seeking.  
 
4.84 Accusatory fingers are pointed at people who use and sell cannabis; society 
denotes them as bad people. But as was pointed out to us time and again, that 
this judgement is not levelled at those who use, sell and manufacture tobacco or 
alcohol is arguably, at least to some degree, hypocritical. The fact that tobacco 
and alcohol are perfectly legal, however, despite the well-documented huge health 
risks, led many we heard from to question how likely it is that non-medical 
cannabis could ever be made legal in a responsible way. 
 
4.85 The perceived failure of education and information campaigns to focus on 
messages about safer consumption and how to manage health risks was cited as 
a roadblock to helping those who try cannabis to do so in a way that limits the risk 
of harm. The principle of ‘conversation not confrontation’ to support people to stop 
or reduce use was considered fundamental – but one which is doomed to fail if 
cannabis continues to be dealt with primarily through the lens of criminal 
enforcement rather than public health.  

   
 
67 
 
 
4.86 We explore the importance of trusted, credible voices in chapter 12. But it was put 
to us that celebrities and other influencers who routinely endorse cannabis across 
social media platforms and other mediums (despite the illicit status of the drug in 
this country, such material is perfectly accessible) could be drawn on to 
encourage safer use.  
 
Cannabis use and perceptions among young people 
 
4.87 We heard from young people and those who work with them that cannabis is 
normalised among large swathes of the youth population. Musical references are 
commonplace, use is openly discussed across social media channels and 
influencers, and, alongside the range of usage statistics, we were pointed to 
surveys of schoolchildren, nightclub and festival-goers that routinely show 
cannabis to be the most commonly reported illicit drug. If young people wish to 
access cannabis they can, and there is a general feeling that very many have tried 
it or are frequently around others who use it. 
 
4.88 Some young people are also involved in selling cannabis, often known as ‘grinding’ 
or ‘hustling’. It was put to us that the culturally popular idea of ‘being your own 
boss’ has effectively encouraged some to become entrepreneurs through growing, 
sourcing and dealing cannabis. Those involved in growing are very aware that 
producing popular strains, swiftly, can offer a substantial source of income. As a 
result, some will actively study how to maximise yields through the most effective 
horticultural practices. 
 
4.89 The reality is that the cannabis trade can earn someone far more than legitimate 
work, and far more easily – notwithstanding the inherent risks. For some young 
people, dealing leads to consuming, while others begin dealing to fund their use. 
Still others take on elements of the ‘business’ from older siblings who, we heard, 
will sometimes pass down responsibilities – especially where they are involved in 
county lines activity (see chapter 5) and are unable to fulfil their commitments.  
 
4.90 Cannabis use is a topic of conversation with which, it was suggested to us, young 
people across London are largely familiar. Those we heard from directly were 
knowledgeable and all knew someone who used the drug, whether among their 
friendship circles or family or both.  
 
4.91 Many (though by no means all) were aware of at least some of the risks in 
sourcing illegal cannabis – whether related to the product (unknown substances 
being mixed or sprayed on), the purchase (visiting unsafe areas) or criminalisation 
(after being caught by police). Moreover, cannabis dealers often sell other drugs 
and we heard about young people being offered harder substances when picking 
up cannabis. 
 
4.92 As a result, some young people would like to see cannabis for non-medical use 
made legal, to help reduce these risks. We also heard from several youth workers 
who highlighted how the risk of criminalisation is heightened for those young 

   
 
68 
 
people who use cannabis whose home life is challenging, who are often living in 
houses of multiple occupancy and who as a result frequently spend much of their 
lives outside. This means they are more likely to use cannabis in public, with the 
associated heightened risk of coming to the attention of police.  
 
4.93 Then there are the overlaps between race and deprivation. As referred previously, 
London’s most deprived neighbourhoods house disproportionately more people 
from a minority ethnic background than their wealthier counterparts. We explore 
the relationship between criminalisation, wealth and ethnicity further in chapter 10. 
 
4.94 Youth workers also told us they were seeing rising numbers of children and young 
people experiencing cannabis-induced psychosis. Increasing consumption of 
edibles may be partly responsible – we heard about young people, unaware of the 
strength and delayed onset of effect (as compared to smoking cannabis), taking 
far more than they might intend in the mistaken belief that nothing is happening. 
The increase in potency (levels of THC) of street cannabis is also likely to be a 
factor (which we discuss further in chapter 8).  
 
4.95 With their American-style packaging designed to mimic that of typical sweets and 
chocolates, edibles (which, like other cannabis products, are available via the 
internet despite their illegality in the UK) are becoming increasingly popular among 
young people. Attractively and professionally packaged, they are easier to carry 
and use than herbal cannabis and emit no smell, meaning they are less likely to 
attract police attention.  
 
4.96 But it was put to us that such illegal products, which of course undergo no quality 
assurance processes, often contain little or inaccurate information about potency 
levels. The THC content can, we heard, often be much higher than labelled, 
meaning dose regulation is difficult and adverse effects more likely as a result. 
 
4.97 Clearly, a legal market would facilitate sale of regulated, quality-assured products 
with accurate labelling and use instructions. And over time, as we heard from 
jurisdictions that have legalised non-medical cannabis, the reduction in stigma 
associated with the drug can encourage help-seeking behaviours among those 
with problematic use. 
 
4.98 The counter, of course, is that not everyone who uses cannabis switches to legal 
products. Added to this is the fact that more easily available cannabis in a legal 
market probably increases the number of users (see chapter 7). Even if the 
proportion who develop problematic use, or wider symptoms of poor health 
including psychosis, remained the same, the number suffering from such would 
rise in line with a rise in prevalence of use.  
  
Co-use of cannabis with tobacco 
 
4.99 As in other European nations, in the UK smoking cannabis in a joint alongside 
tobacco (co-use) is by some significant margin the most common method of 
consumption among all age groups. Herbal cannabis tends to be cheaper and 

   
 
69 
 
more readily available than other forms of cannabis available in the illegal market, 
and co-use enables the drug to go further.  
 
4.100 For those conscious of harm reduction, co-use may also be deployed to dilute the 
psychoactive effects of cannabis – although of course consumption of tobacco 
brings its own health-related collateral damage. 
 
4.101 Whatever the driver, a majority of UK cannabis users mix their cannabis with 
tobacco, although the proportion has fallen in recent years from around three-
quarters in 2019124 to under 60% in 2023.125 While substantially lower than the 
almost 90% of users co-consuming in Italy, the figure is significantly higher than in 
countries with the lowest rates of co-consumption, namely Canada (around 10%), 
parts of South America, and the US – where fewer than 5% of users in 2022 
reportedly consumed their cannabis with tobacco.126 
 
4.102 Co-consumption is particularly high among daily cannabis users – in 2023, almost 
three-quarters reported smoking the drug with tobacco. And while those who use 
cannabis who are also cigarette smokers are more likely to co-consume (78%), 
over a third (36%) of daily users who do not smoke cigarettes do the same.127 
Culturally, for very many cannabis users in the UK, tobacco features heavily in 
their use of the drug.  
 
4.103 Evidence on the nature and extent of harm caused by co-consumption compared 
to smoking cannabis in isolation is relatively limited. It is reasonable to assume, 
however, given incontrovertible evidence of adverse health impacts of tobacco, 
that smoking both substances together will compound the risk of health harms. 
And tobacco smokers, too, are far more likely to be past-year cannabis users than 
ex-smokers (25% and 6% respectively), with those who have never smoked 
tobacco the least likely to have used cannabis (3%).128  
 
4.104 In considering which legal framework could best minimise cannabis-related harm 
in the UK context, the high rate of co-consumption with tobacco is a significant 
consideration. Cannabis use tends to rise following legalisation (see chapter 7), so 
it is reasonable to assume the same would happen – at least to some extent – 
here.  
 
4.105 While some users, particularly those who are not already tobacco smokers, might 
well limit their intake to edibles and other non-smoking means of consumption, 
there is at least some risk of a rise in tobacco use. Reliably estimating by how 
much, however, is difficult. Currently, those jurisdictions which have implemented 
 
124 Lisbon Addictions Conference paper (2022). Winstock, A., Strating, T., Ferris, J., Barratt, M. & Puljevi, C. What 
would it take to get you to stop skinning up your joints with tobacco? PowerPoint Presentation (lisbonaddictions.eu) 
The Global Drugs Survey reported around 55% of UK cannabis users co-consuming cannabis with tobacco in 2022, 
down from around 75% in 2019. Accessed 27th November 2023. 
125 Ibid. And see footnote #75: 57% of past-year cannabis users aged 18+ in GB in 2023 smoked cannabis with 
tobacco. 
126 See footnote #124.  
127 See footnote #75. Accessed 24th July 2024. 
128 Ibid. 

   
 
70 
 
full-scale legalisation are those where cannabis, when smoked, tends not to be 
mixed with tobacco, or at least is less likely to be so. 
 
4.106 And we note that introduction of any policy that carries a risk of increasing 
tobacco use, however small, is completely at odds with wider public health 
attempts to limit tobacco consumption, with plans to phase it out completely 
currently in train. Proposed legislation (covering England) will, if passed, make it 
an offence for anyone born on or after 1st January 2009 to be sold tobacco 
products. 
 
4.107 There is also rising interest in vaping cannabis (as well as consumption via 
edibles). THC vapes are increasingly available through the illicit market (including 
through social media – see chapter 8) and of course are used, in combination with 
CBD, in the medical cannabis market (see chapter 11).  
 
4.108 A key driver, particularly for younger users, is reportedly the enhanced discretion 
that vaping permits. Not only is the practice increasingly normalised and the range 
of ‘flavours’ an attraction, but it also allows consumption of cannabis more 
discreetly when out in public or in social settings because the smell emitted is less 
pungent than that associated with smoking the drug alongside tobacco.  
 
Cannabis: a ‘gateway drug’? 
 
4.109 The view that use of non-medical cannabis increases the likelihood of use of drugs 
such as heroin and cocaine was expressed to us by a number of those we heard 
from. Equally, we heard from just as many witnesses who believed there is no 
robust evidence in support of the so-called ‘gateway theory’.  
 
4.110 The theory is discussed at length within the wider literature and was not a specific 
line of inquiry for us, but we cover it briefly because it is important. The theory is 
founded on several principles, chiefly that:  
 
i) Most users of other drugs are also users, or have been users, of 
cannabis.  
ii) Cannabis dealers encourage users to try other drugs to increase profits. 
iii) The pharmacological action of cannabis predisposes users to try other 
drugs. 
 
4.111 While true that use of heroin, cocaine and other serious drugs is almost always 
preceded by cannabis use, it is also true that the vast majority of cannabis users 
do not become users of those other drugs. Were there a significant causal 
relationship then, as the Runciman Report points out,129 the population of those 
who use heroin and other more serious drugs would be far higher than it is.  
 
 
129 Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971 (2000). The Police 
Foundation. 

   
 
71 
 
4.112 While a heroin user is highly likely to have been a cannabis user, the same does 
not hold the other way around: cannabis users are not highly likely to become 
heroin users. In our view, the conclusion reached by the Runciman Report on this 
remains valid – namely that, as concluded by the Advisory Committee on Drug 
Dependence130 some 50 years ago, convincing evidence that cannabis use in itself 
leads to use of more serious drugs has yet to emerge.  
 
4.113 With respect to increased exposure to other drugs through cannabis dealers, this 
is plausible. As the WHO suggested, engagement of those who use cannabis in 
what is, by definition in the UK given the status of non-medical cannabis, an illegal 
subculture, increases opportunity and encouragement to try other illicit drugs.131 
That said, not all cannabis dealers will offer other drugs, and those who source 
their cannabis online may be less likely to face active encouragement to try other 
substances.  
 
4.114 In terms of cannabis activating some pharmacological driver towards harder 
drugs, this notion has largely been discounted.132 We consider, though, it is not 
unreasonable to assume that users of non-medical cannabis who enjoy its 
psychoactive effects are perhaps more likely to be willing to try other mood-
altering drugs than those who do not choose to try cannabis, or who dislike its 
effects. So rather than any inherent property of cannabis, it may be that factors 
associated with a willingness to use cannabis may also be associated with a 
willingness to use other drugs.133 
 
4.115 What is somewhat clearer in terms of pharmacological impact is the existence of 
an association, in some users, between cannabis use and psychiatric disorders 
(although, as we discuss in chapter 8, the nature of this association is complex). 
And there is some evidence to suggest presence of a psychiatric disorder may 
increase the risk of progression in drug use from less risky to more risky 
substances.  
 
4.116 The same also seems to be true for intense use of an individual drug.134 But while 
heavy use of cannabis and the presence of psychiatric disorder may increase the 
likelihood of subsequent use of other drugs, the presence of one or both factors by 
no means guarantees an individual will do so.  
 
4.117 Alongside individual factors, social elements also likely play a role in any 
progression from cannabis use, including the influence of friends (and dealers 
offering additional drugs) and other factors associated with problematic drug use, 
such as poverty and unemployment.135 While true that cannabis use does tend to 
 
130 The Wootton Report Table of Contents (druglibrary.net) para.51, section 4. Accessed 29th November 2023. 
131 World Health Organization (1997). Cannabis: a health perspective and research agenda. Geneva, World Health 
Organization. 
132 See for example Institute of Medicine (1999). Marijuana and medicine: assessing the science base. Washington 
D.C., National Academy Press. Available at First, Do No Harm: Consequences of Marijuana Use and Abuse - 
Marijuana and Medicine - NCBI Bookshelf (nih.gov) chapter 3. Accessed 29th November 2023. 
133 Ibid. 
134 Ibid. 
135 See footnote #129. 

   
 
72 
 
precede that of other illicit drugs, this may simply reflect the fact that opportunities 
to access cannabis present themselves earlier in life (as with alcohol and tobacco) 
than do opportunities to access more harmful drugs such as heroin.136 
 
4.118 Overall, we are not convinced that cannabis use itself increases the chance of 
progression to use of other illicit drugs. We do consider it likely, however, that 
sourcing cannabis from dealers raises the chance of exposure both to 
opportunities to purchase those drugs and to sell drugs (the ‘supply gateway’.)137 
This is a facet of the illegal status of cannabis rather than the drug itself and one 
which, arguably, a legally regulated model would diminish – at least for those who 
transition to a legal market.  
 
4.119 As several experts put it to us, cannabis use is in effect a gateway to 
criminalisation (and possibly to becoming engaged in dealing drugs),138 rather than 
a gateway to other drugs. Although that said, as evidence from international 
jurisdictions suggests, the existence of a legal market does not necessarily mean 
people who use cannabis eschew the illegal.   
 
4.120 Moreover, the culture of co-consumption in the UK means that, for some, their first 
exposure to tobacco is via smoking cannabis.139,140 Cannabis can therefore in 
some instances present a gateway to tobacco, and, while not all will continue to 
smoke tobacco independently, a number almost certainly will.  
 
4.121 Under a different legal framework for non-medical cannabis, very substantial 
public health campaigns would be required to dissuade particularly first-time 
cannabis users from smoking cannabis in conjunction with tobacco. Indeed, for 
any future users barred from the legal tobacco market because of their age (see 
para.4.106), they would be in the reverse position to now, whereby they would be 
able legally to purchase cannabis but not tobacco. 
 
136 Morral, A.R., McCaffrey, D.F. & Paddock, S.M. (2002). Research Brief – Using Marijuana May Not Raise the Risk 
of Using Harder Drugs. RAND Drug Policy Centre. Available at Using Marijuana May Not Raise the Risk of Using 
Harder Drugs | RAND Accessed 29th November 2023. 
137 Bryan, M., Del Bono, E. & Pudney, S. (2013). Licensing and Regulation of the Cannabis Market in England & 
Wales: Towards a Cost–Benefit Analysis. The Beckley Foundation and the Institute for Social and Economic 
Research, University of Essex. 
138 Ibid. 
139 Walsh, H. (2023). Unpublished PhD findings shared with the London Drugs Commission. 
140 See footnote #75. Accessed 24th July 2024. 

   
 
73 
 
5. THE UK CANNABIS MARKET 
 
In this chapter we set out our understanding of the market for non-medical cannabis in 
London and the UK (for details of the legal medical cannabis sector, see chapter 11). 
This includes demand, price, availability of and access to the drug, as well as common 
sources.  
 
We have explored the operation of supply chains, including the role of organised crime 
and so-called ‘county lines’, focusing particularly on the involvement of children and 
young people. Efforts to tackle supply chains are ongoing and we set out recent 
statistics showing the scale of endeavours by both law enforcement and Border Force. 
 
The chapter concludes with brief consideration of the economic case for legalising non-
medical cannabis: who might benefit and to what extent, the nature of associated 
uncertainties and the interplay between illicit and licit markets.     
 
Cannabis demand and availability  
 
5.1 Demand for non-medical cannabis in the UK is high. In England & Wales alone, 
recent figures indicate sales equate to around 240 tonnes per annum, with 
approximately 2.6 million users and a total value of £2.4 billion.141  
 
5.2 That said, the market is shrinking. Levels of reported use across England & Wales 
are falling (more markedly so in London; see chapter 4), and overall sales have 
dropped by one-third over the past 20 years. While estimates vary, in 2003/04 
around 360 tonnes of cannabis were sold in England & Wales, valued at £900 
million142 (though later revisions put the value at over £1.4 billion).143  
 
5.3 By 2010, sales had fallen to an estimated 216 tonnes144 – although at between 
£1.1145 and £1.4 billion,146 the market value did not decline to the same extent. The 
reason for this is thought to lie in the fact that, by 2010, a majority of the market 
comprised higher-strength product (commonly known as ‘skunk’, which contains 
higher levels of THC – see chapter 4 and para.5.7). As it commands a higher 
 
141 Unpublished data shared with the London Drugs Commission by the National Crime Agency. 
142 Pudney, S., Badillo, C., Bryan, M., Burton, J., Conti, G. & Iacovou, M. (2006) Estimating the size of the UK illicit 
drug market. In Measuring different aspects of problem drug use: methodological developments (2nd edition). Home 
Office.  
143 Vincent, I., Mills, H. & Blyth, P. (2013) The scale of the illicit drugs market. (Annex 2 in Understanding organised 
crime: estimating the scale and the social and economic costs. Research Report 73. Mills, H., Skodbo, S. & Blyth, P. 
Home Office. Crown Copyright. Available at Understanding organised crime: estimating the scale and the social and 
economic costs (publishing.service.gov.uk)) 
144 Bryan, M., Del Bono, E. & Pudney, S. (2013). Licensing and Regulation of the Cannabis Market in England & 
Wales: Towards a Cost–Benefit Analysis. The Beckley Foundation and the Institute for Social and Economic 
Research, University of Essex. 
145 See footnote #143.  
146 See footnote #144. 

   
 
74 
 
price, this meant that, while overall demand fell, the value of the market remained 
buoyant.147 
 
5.4 During 2016/17, (at least) 255 tonnes of non-medical cannabis were estimated to 
have been consumed across the entire of the UK, with an estimated value of £2.6 
billion.148 If consumption in England & Wales only was 216 tonnes in 2010, 255 
tonnes across the UK some years later suggests demand stabilised somewhat, 
falling only slightly in ensuing years to the current 240 tonnes (at a value of £2.4 
billion) reported above for England & Wales.  
 
5.5 The illicit market for non-medical cannabis thus remains both buoyant and 
substantial, despite some falls in levels of use. This has understandably led to 
significant and continued debate as to the value of that market were use of non-
medical cannabis to be legal.  
 
5.6 As we describe in chapter 4, despite its illegality non-medical cannabis is widely 
available across the country. London is no exception. Prices vary according to the 
type of product (herbal, resin, edible etc) and strength, as well as geographical 
region, but we heard that herbal cannabis currently retails in the capital for an 
average of £10 per gram (with reductions for bulk purchase).   
 
5.7 Unlike cannabis of previous decades, strains that now dominate the market are 
substantially more potent. These come under the umbrella term of ‘skunk’ and 
were described to us as having flooded the market. Relatively easily to cultivate in 
indoor environments, there are countless variants available at different price 
points. One of the more expensive, it was put to us, is known as ‘Cali’, short for 
California Skunk. We heard this can fetch up to £20 or more a gram in London, 
and, as its name suggests, it originates in California.149 Like all varieties of skunk, 
and again as the term suggests, it has a particularly pungent aroma.    
 
5.8  ‘It’s everywhere’ was a common refrain across our witnesses – many of whom 
lived or worked in London. It is ubiquitous across boroughs; it was put to us that 
increasing numbers of young people are involved both in growing and supplying 
cannabis (and using). While an active choice for some, for others it is a coerced 
activity.  
 
5.9 As we set out elsewhere, we heard public dealing of cannabis in London is 
commonplace and statistics, albeit national rather than specific to the capital, bear 
this out. In 2021, half (52%) of children aged 11–15 who had taken drugs reported 
buying or being given cannabis in the street, in a park or other outdoor area,150 
 
147 See Snowdon, C. (2018). Joint Venture: Estimating the Size and Potential of the UK Cannabis Market. IEA 
Discussion Paper No.90. Available at iea.org.uk   
148 Ibid.   
149 Although some Cali product is imported into the UK, much of it is grown here from imported seeds or is 
misbranded as Cali when it is in fact a different strain.   
150 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Table 9.12. 
Accessed 1st December 2023. 

   
 
75 
 
and we have no reason to believe the situation is different in London, where during 
2022/23, 6.2% of 16–59-year-olds reported using the drug.151 
 
Sourcing cannabis  
 
5.10 Testimony to its widespread use is the perceived ease of sourcing cannabis – 
indeed, it was put to us by many witnesses that those who wish to use it know 
exactly where and how to get it. Again, statistics bear this out. While the 
proportion of children claiming accessing cannabis is easy has fallen from one-
third in the past 20 years, around a quarter (26%) continue to report such, and 
this rises to around half of 15-year-olds.152   
 
5.11 Among young people and adults aged 16–59, during the year to March 2023 
almost two-fifths (38%) reported it being easy to source illegal drugs of any kind 
within 24 hours, rising to over 44% of those aged 20–29. Less than 30% reported 
it would be difficult or impossible.153  
 
5.12 Consumers purchase primarily from known sources. Over half (57%) of 16–59-
year-olds who bought illegal drugs in the year to March 2023 sourced their most 
recent purchase from a family member, friend, neighbour, colleague or other 
acquaintance, and just over 12% from a known dealer. In comparison, around 
10% reported purchasing from a stranger or a dealer not known to them 
personally. Just over 1% purchased via the internet (excluding social media sites), 
with a further 1% using the dark web.154 
 
5.13 Similarly, around two-thirds of children aged under 16 who reported trying 
cannabis in 2021 got it from a friend or sibling on the first occasion, and around 
one-fifth from a dealer.155 Just over one in ten purchased cannabis from someone 
they knew of but did not know personally, but none reported buying from a 
stranger. 
 
5.14 While internet-based cannabis purchases are less common overall than in-person 
routes,156 in 2021, 16% of children in England aged 11–15 reported making at 
least one purchase of (unspecified) illegal drugs via the internet.157 While based on 
a survey with a small sub-sample, and purchases were not necessarily cannabis, 
 
151 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 3.07. 
Accessed 15th January 2024. 
152 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Table 9.17. 
Accessed 1st December 2023. 
153 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 5.04. 
Accessed 16th January 2024. 
154 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 5.01. 
Accessed 16th January 2024. 
155 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital, Table 9.4. 
Accessed 14th November 2023. 
156 See also European Monitoring Centre for Drugs and Drug Addiction & Europol (2023). EU Drug Market: Cannabis 
— Retail markets. Available at EU Drug Market: Cannabis — Retail markets | www.emcdda.europa.eu Accessed 
13th May 2024. 
157 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Table 9.21. 
Accessed 1st December 2023. 

   
 
76 
 
our enquiries suggest that in 2023 its purchase is increasingly likely to be made 
online (although products may not always be delivered, meaning buyers collect 
and sometimes pay in person). 
 
5.15 Online outlets selling cannabis (some also offer other drugs including powder 
cocaine and ecstasy) are proliferating. Online purchasing offers a level of 
convenience and safety as it removes, at least when goods are posted rather than 
collected, any risks associated with meeting sellers offline (although arguably it 
creates new risks associated with a user’s details being recorded in a database 
and is open to interception by authorities).  
 
5.16 Legitimate businesses may offer supplementary cannabis services – we heard, for 
example, about a dog-walking app being used as a means of enabling ordering 
and delivery. A checkout code indicates cannabis rather than a dog-walking 
service is requested, and the product is paid for and delivered to the home. 
 
5.17 Alongside word of mouth, online sales are facilitated chiefly though social media, 
with Instagram and particularly Snapchat dominant in the UK. Both platforms have 
a relatively young user base. Around one-quarter of Instagram users in the UK are 
aged between 18 and 24,158 and almost half (48%) of Snapchat users are under 
24, with almost one-fifth (18%) aged 12–17.159 Snapchat’s ‘Quick Add’ function, 
which suggests users who may be known to an individual or in whom they may be 
interested, allows cannabis sellers to connect with and offer products to hundreds 
of people at once.  
 
5.18 Research in 2019160 found a quarter of young people aged 16–24 had seen illicit 
drugs advertised for sale on social media (predominantly Snapchat and 
Instagram), with cannabis the most common. Sellers (not always UK-based) will 
often highlight a link to a closed Telegram account, acceptance to which affords 
access to what in some cases can be tens or even hundreds of different strains 
and types of cannabis, set out in ‘weed menus’. Notably, there are no age limits – 
proof of identification, social media platform profile and/or ability to pay is usually 
sufficient.  
 
5.19 Products are posted (routinely via Royal Mail) and some sellers permit collection if 
a purchaser agrees to various conditions. The functionality of social media 
platforms and closed groups not only allows sophisticated, user-friendly 
mechanisms for purchase, it also permits those who in past decades would be 
known as ‘dealers’ to effectively become ‘pushers’: sellers can ‘push out’ details of 
products they have in stock and advertise forthcoming items and strains.  
 
5.20 The legality of non-medical cannabis elsewhere and the largely unfettered nature 
of the internet means people in the UK can access an inordinate number of 
 
158 UK Instagram users by age group 2023 | Statista Accessed 4th December 2023. 
159 UK data watchdog issues Snapchat enforcement notice over AI chatbot | Snapchat | The Guardian Accessed 4th 
December 2023. 
160 McCulloch, L. & Furlong, S. (2019). DM for Details: Selling Drugs in the Age of Social Media. Volteface. Volteface-
_-Social-Media-report-DM-for-Details.pdf Accessed 6th December 2023.    

   
 
77 
 
legitimate websites registered in parts of the world where the drug is legal, which 
are selling perfectly legitimate products.  
 
5.21 While illegal for sellers to ship to the UK,161 there is nothing to stop individuals 
based in the UK seeking out websites and gaining a huge amount of information 
about different strains, tastes and effects, and how to approach growing cannabis. 
All of this serves further to normalise the drug across our society and affects 
market dynamics. The different elements of cannabis (smell, taste, look, effects) 
are important and those who use it often seek new strains: knowing they are 
available elsewhere likely creates demand in the UK market.  
 
The supply chain and the role of county lines 
 
5.22 Somewhat at odds with the law prohibiting production, supply and possession of 
non-medical cannabis, cannabis seeds are widely available in the UK through 
online and offline outlets. While sellers stipulate they are for collectable or souvenir 
purposes only because to germinate them is illegal, inevitably many purchasers 
will aim to do just that. Certainly, the large number of small-scale seizures of 
cannabis plants suggests, as noted in the Black Review, that many individuals and 
small groups are cultivating the drug.162 
 
5.23 On a larger scale, supply chains for cannabis consumed in London and across the 
UK are both domestic and international in nature, and often controlled by 
organised crime groups (OCGs, i.e. groups of people working together to plan and 
conduct criminal behaviour on a continuing basis).  
 
5.24 Cultivation happens across the country although, where growers struggle to 
produce enough cannabis, or sufficient varieties at scale, we heard they may 
import product to meet demand for well-known, high-profile strains. Often 
produced in the US, these are regularly promoted by cannabis influencers and 
other well-known celebrity users of the drug.  
 
5.25 The National Crime Agency (NCA, the UK’s national specialist function with 
respect to tackling serious and organised crime) confirmed to us that cannabis is 
imported to the UK via three main routes: bulk shipments arrive via 
unaccompanied air and sea freight containers (destined for warehouses or large 
garages, often on remote industrial estates), products are posted to individual 
purchasers through standard international postal providers, and air passengers 
bring in tens of kilos at a time in checked baggage. 
 
5.26 Whether imported or grown in the UK, we heard that bulk cannabis is sold 
primarily to national wholesalers who sell to local operators in cities and regions 
around the country. They sell to dealers, who in turn sell the drug to end users 
 
161 And in the US, while non-medical cannabis remains illegal at the federal level it similarly remains illegal to ship 
products using the US Postal Service or private carriers, domestically or internationally. 
162 Black, C. (2020). Review of Drugs – evidence relating to drug use, supply and effects, including current trends 
and future risks PowerPoint Presentation (publishing.service.gov.uk) Accessed 4th December 2023. 

   
 
78 
 
including regular customers and, as we heard happens regularly in parts of 
London, street-level strangers. 
 
5.27 So called ‘county lines’ have become a significant part of the drug supply chain, 
with cannabis no exception. These are used to move drugs around the country, 
typically from major cities into smaller towns and rural areas – meaning the 
majority of activity originates in London, followed by Merseyside, the West 
Midlands and Greater Manchester. The term ‘lines’ refers to the networks of 
mobile phone lines used to run supply operations. It was put to us that these are 
an incredibly cost-effective method of drug distribution, generating more income in 
one day than the annual budget of the Metropolitan Police Service (MPS) 
ringfenced to combat the activity. 
 
5.28  Children and young people, particularly those from deprived backgrounds where 
families struggle to make ends meet, are at heightened risk of being drawn into 
county lines. As described to us by those who work with young people, 
involvement offers tantalising opportunities to make a lot of money very quickly 
and cannabis, we were told, is the most common gateway into this world.  
  
5.29 It was put to us that as cannabis is a cheap drug that is widely accepted – even 
normalised – among young people, OCGs and local gangs will target young 
people, often those living in deprived areas and/or suffering troubled, chaotic 
home lives. They offer cannabis ‘to try’ and in accepting, not only is a drug debt 
unwittingly created, but young people become exposed to sought-after trappings 
of wealth associated with the drugs trade, namely expensive clothes, trainers, 
jewellery and cars. Such material gains are reportedly often evident to those 
working with children and young people, in education and wider youth settings.  
 
5.30 A gang will demand ‘payment’ for the cannabis, with young recipients offered the 
chance to work off their ‘debt’ through supplying drugs. This can mean they are 
expected to travel some distance from home and where family life is chaotic or 
neglectful, it may be less likely that the alarm will be raised following their 
disappearance.  
 
5.31 The Black Review discusses the emergence of the hugely exploitative county lines 
model in depth.163 It examines why young people from deprived backgrounds or 
troubled homes are particularly vulnerable to being targeted – although it points 
out that children from seemingly stable families with no prior police or care service 
contact are not immune from being approached.  
 
5.32 Factors to which the Black Review points chime with evidence we heard from 
those working with young Londoners. Both sources emphasised that cuts to youth 
services, alongside parental absence or inadequate parenting, school exclusion, 
living in poverty, family breakdown and, for some, entering the care system, leave 
 
163 Black, C. (2020). Review of Drugs: Executive Summary. Department of Health and Social Care and Home Office, 
Crown Copyright. Microsoft Word - SummaryPhaseOne+foreword200219 (publishing.service.gov.uk) Accessed 6th 
December 2023. 

   
 
79 
 
many increasingly vulnerable to county lines exploitation. Ongoing consequences 
of the Covid-19 pandemic have likely exacerbated or compounded many of these 
issues.  
 
5.33 Involvement in a county line offers opportunity to make what in some cases is a 
substantial amount of money, particularly to those raised and living in poverty. It 
can provide a chance to own things that would never otherwise be affordable. We 
heard from those working in London’s education sector about young people 
suddenly arriving in school wearing or possessing expensive items, often having 
developed a certain ‘swagger’ – visible signs of involvement in county lines activity.  
 
5.34 We heard it is common for a handful of young people in mainstream education, at 
least in some parts of London, to be arrested several times over the course of a 
year due to cannabis use and/or selling. Moreover, students in alternative 
education provision, who struggle with learning and behaviour in mainstream 
school, tend to be disproportionately involved with the criminal justice system 
(CJS). It was put to us that a substantial driver of that involvement is use, 
possession and dealing of cannabis.  
 
5.35 For some, involvement in county lines activity causes them to start carrying a 
weapon, and it is this which often initiates contact with the CJS. Ostensibly to 
protect against the risk of being targeted by other actors in the drug trade, 
including those working in conflicting lines who bring cannabis and other drugs 
into the local area, it is also one of the principal ways in which drug-related 
violence manifests.164  
 
Breaking the supply chain 
 
5.36  It was put to us that main routes of cannabis importation (air and sea freight, air 
passenger luggage and postal packages) have all seen substantial increases in 
traffic over the past three years.165 The US and Canada are the main countries of 
export, possibly due to over-production of cannabis seen there in recent years 
(see chapter 7). In previous years, other countries such as Morocco tended to 
dominate the imported cannabis market.  
 
5.37 Indeed, the NCA recently reported that during the first eight months of 2024, 378 
people were arrested in connection with cannabis smuggling by air passengers.166 
The vast majority were arrested in relation to cannabis originating in Canada and 
the US, and now also Thailand. Around 15 tonnes of cannabis were detected and 
seized at UK airports in the same period. This is around three times more than in 
the whole of 2023, when approximately five tonnes of cannabis were seized and 
136 people arrested, and more than seven times the two tonnes seized in 2022.  
 
164 See Black, C. (2020). Review of Drugs – evidence relating to drug use, supply and effects, including current 
trends and future risks PowerPoint Presentation (publishing.service.gov.uk) Slides 54, 58. Accessed 4th December 
2023. 
165 Unpublished data shared with the London Drugs Commission by the National Crime Agency. 
166 See It’s not worth the risk – jail warning for passengers flying to the UK after increase in cannabis arrests - National 
Crime Agency Accessed 28th August 2024. 

   
 
80 
 
 
5.38 Wider domestic and import data similarly point to increases in the amount of 
cannabis being traded. The total quantity of herbal cannabis seized by the police 
and Border Force in England & Wales during the year ending March 2023 
represented a rise of 96% on the previous year, i.e. from 35,436 kilograms (kgs) in 
the year to March 2022 to 69,302 kgs (the rise from 2020/21 to 2021/22 was over 
100%, from 17,155 to 35,436 kgs).167 
 
5.39 Amounts of seized cannabis resin rose even more dramatically, from 611 kgs to 
1,467 kgs – a rise of 140%, though the number of seized cannabis plants fell by 
34% (from 785,955 to 515,884 plants).168 
 
5.40 The number of seizures made by police and Border Force (as opposed to quantity) 
of herbal cannabis and resin also rose between 2021/22 and 2022/23, by 4% and 
60% respectively. Seizures of plants fell 3%. This means overall the number of 
seizures of any form of cannabis rose by 7% (from 131,668 in the year to March 
22 to 140,370 in the year to March 2023). In comparison, between 2020/21 and 
2021/22, overall cannabis seizures fell by 16%.169 
 
5.41 While it is difficult to know whether year-on-year changes represent Border Force 
and police (de-)prioritisation of related activity, the amounts that continue to be 
seized suggest supply chains remain resilient.  
 
5.42 Seizures of illicit Synthetic Cannabinoid Receptor Agonists (SCRAs, which fall 
under the definition of proscribed compounds in the MDA and as such are 
prohibited through the Misuse of Drugs Regulations 2001; see chapter 8),170 
however, fell.  
 
5.43 In the year ending March 2023, a total of 637 seizures were made by Border 
Force and police forces in England & Wales, a fall of 63% from 1,731 seizures the 
previous year171 (compared with a decrease of 24% between 2020/21, when 
2,271 seizures were made, and 2021/22).172 
 
 
167 Seizures of drugs in England and Wales, financial year ending 2023 - GOV.UK (www.gov.uk) Data tables: 
Summary Table 2. Accessed 24th May 2024. 
168 Ibid. 
169 Seizures of drugs in England and Wales, financial year ending 2023 - GOV.UK (www.gov.uk) Data tables: 
Summary Table 1. Accessed 24th May 2024. 
170 Synthetic Cannabinoid Receptor Agonists (SCRAs) are classified as Class B drugs under the Misuse of Drugs Act 
1971 (amended). 
171 Seizures of drugs in England and Wales, financial year ending 2023 - GOV.UK (www.gov.uk) Data tables: 
Appendix Table 1. Accessed 24th May 2024. 
172 Seizures of drugs in England and Wales, financial year ending 2022 - GOV.UK (www.gov.uk) Data tables: 
Appendix Table 1. Accessed 24th May 2024. 

   
 
81 
 
5.44 The quantity of doses of synthetic cannabinoids seized by Border Force and 
police, however, rose by 64% from 2,198 in 2021/22 to 3,597 in 2022/23.173 
(compared to a dramatic previous fall from 15,139 in 2020/21).174  
 
5.45 Due to the very high strength of SCRAs (they can be very many times more potent 
than THC), they can be shipped or posted in smaller quantities that are more 
difficult to detect. Falls in the numbers of seizures may not, therefore, accurately 
reflect the extent of use or market penetration – although statistics suggest their 
use to be lower than use of herbal cannabis.175 We consider SCRAs and their 
potential for harm in more detail in chapter 8. 
 
The role of organised crime 
 
5.46 As noted by the Black Review and as we heard from law enforcement, OCGs are 
heavily involved in drug activity across the UK. As of December 2022, it was put to 
us by the NCA that over half (57%) of all active OCGs were linked to such activity, 
and just under one-fifth (18%) were directly involved in cannabis cultivation. This 
creates a significant challenge for law enforcement at local and national level.  
 
5.47 At least half of OCGs involved in cannabis are thought to be poly-criminal, and 
violence is associated with around one-fifth of those. Many involve firearms so 
present a substantial threat of very serious harm – although OCGs involved 
primarily or solely in wholesale supply and retail of cannabis are typically less 
violent than those supplying crack/powder cocaine and heroin.176 Where the 
ethnicity of those involved is known, British and Albanian nationals dominate.  
 
5.48 Modern Slavery and Human Trafficking (MSHT), often involving violence, is a 
particular concern associated with OCG-run cannabis operations. This involves 
trafficking vulnerable people – typically but not exclusively from Vietnam, as well as 
Albania and other parts of the Western Balkans – into the UK to work in large 
cultivation sites. During the year ending March 2023, 20% of all those referred to 
the National Referral Mechanism177 as potential victims of criminal exploitation 
(5,647 individuals in total) came from Albania and Vietnam (902 and 229 
respectively). Almost all were males aged over 18.178 
 
5.49 While many might intuitively expect that legally regulating production and sale of 
non-medical cannabis would eliminate the illegal market and thus the involvement 
of organised crime, this is not in fact the case. As we show in chapter 7, legal 
 
173 Seizures of drugs in England and Wales, financial year ending 2023 - GOV.UK (www.gov.uk) Data tables: 
Appendix Table 2. Accessed 24th May 2024. 
174 Seizures of drugs in England and Wales, financial year ending 2022 - GOV.UK (www.gov.uk) Data tables: 
Appendix Table 2. Accessed 24th May 2024. 
175 Drug misuse in England and Wales - Appendix table - Office for National Statistics (ons.gov.uk) Table 4.01. 
Accessed 10th May 2024. 
176 See Black, C. (2020). Review of Drugs – evidence relating to drug use, supply and effects, including current 
trends and future risks PowerPoint Presentation (publishing.service.gov.uk) Slide 11. Accessed 4th December 2023. 
177 The National Referral Mechanism is a framework for identifying and referring potential victims of modern slavery 
and ensuring they receive appropriate support. 
178 Data provided to the LDC by the National Crime Agency. 

   
 
82 
 
regulation does not eradicate demand for illicit cannabis, meaning the illicit market 
continues to play a role – albeit to varying degrees in different jurisdictions.  
 
5.50 It was put to us that, for example, at least 50 gangs continue to be involved in 
what remains of the Canadian illicit cannabis market post-regulation. They seek 
principally to meet demand for cannabis among those below the minimum age 
limit for legal purchase, and desires for high-strength, cheaper product than that 
which is now available legally. 
 
5.51 This suggests that a more permissive approach to non-medical cannabis in the UK 
would be unlikely to cause OCGs to withdraw from its production, distribution and 
sale. While it seems reasonable to assume that over time the illicit market would 
become less profitable, which might deter OCG involvement, at the same time we 
heard that perceived risks associated with cannabis activity would also likely fall. 
This could well counter any drop in profitability. 
 
The economic possibilities of a legally regulated non-medical cannabis market 
 
5.52 A for-profit legal regime for non-medical cannabis has long been advocated by 
stakeholders across a wide range of UK sectors and we heard from many who 
called passionately for its introduction. A key plank of the case lies in forecasts 
about the potential for a legal market to raise significant amounts of tax revenue. 
This, it is argued, can be ploughed back into public coffers to support, for 
example, drug-related health, treatment and education services.  
 
5.53 Canada and some US states that have legalised cannabis via for-profit models 
have explicitly made such reinvestment a part of their approach. Undoubtably this 
has led to significant increases in public services funding – particularly healthcare. 
For example, close to 60% of $1 billion cannabis-related tax revenue projected to 
be raised in Washington state in 2021–23 was earmarked for healthcare 
services.179  
 
5.54 Simply increasing funding, however, does not necessarily improve health services 
and outcomes. The importance of infrastructure and governance should not be 
underestimated, as illustrated in Oregon where non-medical cannabis has been 
legal since 2014. Assessment of the state’s wider move in 2020 to decriminalise 
possession of all controlled drugs180 found the approach to provision of treatment 
services (the principal recipient of cannabis-related revenue)181 remained siloed 
 
179 Figures sourced from Washington State Office of Financial Management and cited in How $1 billion in pot taxes 
gets spent in Washington state | Cascade PBS News (crosscut.com) Accessed 10th May 2024. 
180 This decision was overturned in early 2024. Repeal of Measure 110, which decriminalised possession of small 
amounts of all controlled drugs, is due to take effect in September 2024. Cannabis will remain legal. 
181 See Figure 7, Oregon Liquor and Cannabis Commission (2023). Oregon Needs to Modernize Cannabis Laws to 
Help Grow the State’s Economy and to Ensure Equitable Opportunities and Benefits for all Communities. Report 
2023-15: Oregon Audits Division. Oregon Liquor and Cannabis Commission Oregon Needs to Modernize Cannabis 
Laws to Help Grow the State's Economy and to Ensure Equitable Opportunities and Benefits for all Communities 
Accessed 10th May 2024. 

   
 
83 
 
and fragmented.182 Lack of infrastructure to distribute funds, alongside challenges 
to scaling up posed by the Covid-19 pandemic, have not helped.  
 
5.55 On the face of it, considering the level of demand for non-medical cannabis and its 
estimated market value in England & Wales, the attractiveness of the economic 
argument for legalisation is evident. Our examination of associated consequences 
of for-profit models, however, leads us to believe the situation is less 
straightforward than the basic premise suggests, notwithstanding impressive sales 
revenue figures. 
 
5.56 As we note in chapter 7, there is little doubt that a legally regulated, for-profit 
market in non-medical cannabis generates economic opportunities for investors 
and governments alike. But those opportunities seem often to have been 
overestimated and the hotly anticipated ‘green rush’ has largely, in our view at 
least, so far failed to materialise to any great extent.  
 
5.57 While it has likely made a relatively small number of cultivators, investors, sellers 
and influencers very wealthy, widespread profitability seems to be more limited 
and we are not convinced that, so far, there is reliable and consistent evidence of 
net fiscal benefit.       
 
5.58 As we demonstrate in chapter 7, understanding the costs and benefits of different 
models of legalisation is complex. The interplay and trade-offs between taxation, 
regulation, revenue, public health and the illegal market are challenging to unpick. 
This is the case for jurisdictions that have implemented a legal market and where 
hard data is emerging: it is inevitably even more so for the UK, where possibilities 
and calculations remain assumption-dependent. 
 
5.59 The potential for a legally regulated market to generate economic gain cannot be 
considered in isolation from its potential to generate parallel costs. Whether overall 
the former offset the latter to elicit net gain is a question that, in our view, is too 
early to answer.  
 
5.60 There is certainly, for example, emerging indication of adverse consequences to 
public health, but their extent and severity remain as yet unclear. More broadly, it 
seems reasonable to suggest that potential frictions between economic and other 
aims of legal regulation (such as protecting public health) are likely to be 
significant.  
 
5.61 Set taxes or prices too high and the illegal market likely continues to flourish. Set 
them too low and public health objectives are at risk through potential for higher 
levels of use, which is, of course, fundamental to any for-profit model: increased 
demand means increased profit.  
 
 
182 Oregon Health Authority (2023). Too Early to Tell: The Challenging Implementation of Measure 110 Has Increased 
Risks, but the Effectiveness of the Program Has Yet to Be Determined. Report 2023-03: Oregon Audits Division. 
Oregon Health Authority: Too Early to Tell: The Challenging Implementation of Measure 110 Has Increased Risks, but 
the Effectiveness of the Program has Yet to Be Determined Accessed 10th May 2024. 

   
 
84 
 
5.62 So far, the international picture remains mixed and, to our mind, inconclusive. 
Billions of dollars have been generated through sales of legal non-medical 
cannabis and reductions in CJS system costs allied with hitherto criminal offences. 
But whether associated rises in use ultimately drive up public health costs 
(monetised and non-monetised) to an extent that outweighs those benefits 
remains to be seen.   
 
Estimating the economic return of a legal cannabis market in the UK 
 
5.63 The most recent estimate of which we are aware put the potential tax revenue 
from cannabis products in the UK, were legal regulation in place, at £690 million 
per annum. This is based on 2018 prices, tax at 30% plus VAT and an illegal 
market value of £2.6 billion.183 Together with direct and indirect taxes on those 
working in the legal industry, that analysis estimated total annual tax revenues 
would exceed £1 billion. The same analysis estimated parallel savings to the NHS 
and other public services, principally the CJS, of at least £300 million per annum. 
Analysis elsewhere estimates savings to be even higher.184 
 
5.64 Clearly, and notwithstanding the caveats that accompany them, these figures are 
considerable. They, are, however, based by necessity on a series of assumptions. 
In our view, and with the luxury of more recent evidence, including that drawn from 
several jurisdictions that have now been operating legal regulation for some years, 
we consider those assumptions somewhat optimistic.  
 
5.65 One of the most crucial relates to transition from illegal to legal markets. The 
evidence with which we have been presented suggests this has been neither swift 
nor wholesale in any jurisdiction that has implemented legalisation – and certainly 
nowhere near the 95% assumed in the UK market analysis. While that is not to say 
the UK could not achieve a greater level of movement, a 95% switch seems, to us, 
unlikely. 
 
5.66 Similarly, evidence put to us suggests assumptions regarding levels of THC and 
legal availability might also be overly favourable. We agree both are important with 
respect to diminishing the illegal market. But from what we heard, it is only really 
when legal outlets proliferate, with long opening hours, that they offer a consumer-
friendly alternative to the swift, often doorstep delivery of illegally sourced 
cannabis. Not only do legal markets struggle to sustain those levels of service, but 
the public tend not to welcome high streets dominated by cannabis retail shops 
that are open all hours.  
 
5.67 Capping THC levels in legal products seems to us to be important. Not only are 
the health risks associated with cannabis consumption exacerbated with 
increased potency (see chapter 8), evidence from Canada suggests that following 
legalisation, there has been some shift towards consumption of higher strength 
 
183 See footnote #147.   
184 Ramanauskas, B. (2018). Potential savings from the legalisation of cannabis. Taxpayers’ Alliance. Available at 
Cannabis_Legalisation.pdf (d3n8a8pro7vhmx.cloudfront.net) Accessed 13th May 2024. 

   
 
85 
 
cannabis products. Parallel increases in cannabis-related healthcare presentations 
have also been reported.185 
 
5.68 Caps on THC are adopted to varying extents by all jurisdictions that have legalised 
non-medical cannabis. But the 15% cap proposed in the UK market analysis from 
2018 is, we think, unlikely to be sufficient to encourage substantial numbers of 
users to switch to legal products: we heard time and again about increasing 
demand for higher-strength cannabis.  
 
5.69 What the cap should be, i.e. where the right balance lies between facilitating 
market transition and protecting public health, is not clear. What is clear, however, 
is the recommendation from the Canadian Review of the first five years of non-
medical cannabis legalisation that tax regimes should effectively discourage 
consumption of higher-strength products.186  
 
5.70 More is beginning to be known about the ways in which legal cannabis markets 
operate, with evidence emerging from Canada and elsewhere of the nature of 
impacts on, among other things, public health and criminal justice systems. 
Monetised and non-monetised costs and benefits in these sectors must be 
considered, alongside the considerable revenues raised through taxes, to 
understand how they offset or complement net economic gain.  
 
5.71 The economic case for legalising use of non-medical cannabis in the UK should be 
reconsidered in light of this evidence and the latest data on health consequences 
(positive and adverse) of consumption, which more accurately reflect the realities 
of the strength of modern-day cannabis. 
 
5.72 The government should commission an updated assessment of costs and benefits 
that could be realised through a legal market for non-medical cannabis. This 
needs to be a net benefit assessment and include potential for additional public 
health and other costs associated with different models of legalisation (R2). It 
should also consider non-monetisable aspects, including benefits derived (or 
perceived to be derived) by different groups of people who consume cannabis.187  
 
5.73 We recognise the shortcomings and frustrations inherent in a ‘more research is 
needed’ recommendation. But effects of factors including advertising and 
marketing strictures, number and location of retail outlets, permitted THC levels 
and tax structures, as well as the set-up and running costs of regulatory and 
enforcement regimes, are critical considerations.  
 
5.74 From the evidence we have considered, we have been unable to identify any 
jurisdiction in which the overall economic position following legalisation of non-
medical cannabis has been improved wholesale. That is to say, while it unarguably 
and relatively quickly raises tax revenue, and some savings are realised similarly 
 
185 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.3.  
186 Ibid, recommendation 27, p.12. 
187 See footnote #144. 
 

   
 
86 
 
quickly to policing once cannabis-related activities are no longer illegal, initial net 
benefit may not be sustained in the longer term.  

   
 
87 
 
6. PUBLIC ATTITUDES 
 
Public attitudes towards non-medical cannabis can play a role in the approach adopted 
by different jurisdictions, and the issue has long drawn heated debate. Indeed, public 
opinion arguably influenced to some degree the UK governments decision in 2018 to 
legalise cannabis-based products for medicinal use (CBPMs, see chapter 11), and 
similarly helped drive the political decision to legalise non-medical cannabis in Canada 
(chapter 7). 
 
In this chapter, we draw on publicly available data from the UK/Great Britain and 
London, as well as results from our bespoke research (all cited quotes are drawn from 
here)188 and survey findings (Appendices C and D) to explore public feeling about issues 
we have considered throughout our inquiries. 
 
The nationwide perspective 
 
6.1 Overall, the public increasingly favour more liberal approaches to cannabis. 
Surveys show that over half support decriminalisation (possession of small 
quantities of cannabis is no longer criminal) or legalisation (cannabis may be 
legally produced, supplied and purchased), with the latter often more popular. 
Recent YouGov data, for example, showed 32% of those polled backed 
legalisation compared with 24% in favour of decriminalisation.189  
 
6.2 When asked simply whether they would support or oppose cannabis legalisation, 
around half the public in recent years have supported the measure.190,191 Indeed, 
one survey reported more support for legalisation of cannabis (49%) than tobacco 
(40%, although 27% opposed the measure against 22% for tobacco).192 And while 
support tends to be highest among younger age groups, half of those aged over 
40 are also in favour.193  
 
6.3 That said, around one-third remain in favour of prohibition of some kind, and 
YouGov’s tracker suggests support has in fact increased, rising from 30% in 2019 
to 40% in 2021, falling back slightly to stabilise since at around 37% (May 2024.194 
Whether driven by active desire for prohibition, however, or from a (real or 
perceived) rise in cannabis being traded and consumed openly in public spaces – 
which as we heard attracts substantial concern – is difficult to say. 
 
 
188 See footnote #11.  
189 Criminalisation of soft drugs e.g. cannabis (yougov.co.uk) Accessed 1st August 2024. 
190 See (2023) https://yougov.co.uk/topics/health/survey-results/daily/2023/04/20/8d0a4/1; (2021) 
https://yougov.co.uk/topics/politics/survey-results/daily/2021/04/06/fcf4a/3; (2019) YouGov | What the world thinks 
Accessed 17th August 2023.  
191 VI-28 Corbyn, Anti-Social Laughing Gas and Do we need Radical Policies? | Omnisis Table 28. Accessed 17th 
August 2023. 
192 220810+APPG+polling+results+Great+Britain.pdf (squarespace.com) Accessed 17th August 2023 
193 See footnote #191. 
194 See footnote #189. Accessed 1st August 2024. 

   
 
88 
 
6.4 Nevertheless, a more liberal approach would likely find favour among around half 
the public, meaning it is perhaps unsurprising that faith in current UK drug policy is 
low. Over one-third (38%) consider it unsuccessful in reducing the supply and use 
of harmful drugs, compared to one-fifth who think it a success.195  
 
6.5 In terms of harm, many of those we heard from, particularly among the health 
sector, emphasised that use of cannabis is not without risk (whether related to 
health or, where illegal, criminal sanction). The only guaranteed safe way to 
consume the drug is not to consume it at all. Similarly, the public tend not to view 
it as risk-free – although other substances, including alcohol, tobacco and Class A 
drugs, are considered to pose greater health and societal harm.196ʼ197ʼ198  
 
6.6 In local communities, cannabis use and dealing are perceived as commonplace. 
Almost two-thirds (65%) considered the supply and use of cannabis to be 
widespread in their area199 (after tobacco at 76% and alcohol at 68%), which 
suggests criminalisation is little barrier to access and use, at least in some parts of 
the country, is ubiquitous.  
 
The London perspective 
 
Prohibition and alternatives 
 
6.7 Overall, a majority of Londoners support a more liberal approach. Around six in 
ten are in favour,200ʼ201 with fewer directly opposed to legalisation compared to the 
public nationwide (25% of Londoners compared to 32% nationally).202  
 
6.8 That said, the nature of support does vary, and our research identified six distinct 
‘mindsets’, ranging from those open to cannabis use and legalisation to those 
mostly against both:  
 
Figure 4: Cannabis mindsets among Londoners* 
  
*For detailed descriptions, see Thinks Insight & Strategy (2023). Lived experiences of cannabis among Londoners. 
MOPAC  
 
 
195 See footnote #192. Accessed 16th August 2023. 
196 See footnote #191. Accessed 17th August 2023. 
197 See: How harmful is cannibus to people who regularly use it? (yougov.co.uk); How harmful is cocaine to people 
who regularly use it? (yougov.co.uk); How harmful is ecstacy to people who regularly take it? (yougov.co.uk); How 
harmful is tobacco to people who regularly use it? (yougov.co.uk); How harmful is alcohol to people who regularly 
drink it? (yougov.co.uk)  Accessed 2nd August 2024. 
198 See footnote #192. Accessed 17th August 2023. 
199 Ibid. 
200 See footnote #189. Accessed 17th August 2023. 
201 See Appendix D. 
202 See footnote #191. Accessed 17th August 2023. 

   
 
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6.9 Irrespective of mindset, though, the possibility of a five-year custodial sentence on 
conviction of cannabis possession felt overly harsh (and was surprising to many). 
More widely, surveys suggest around half of Londoners (and 42% of the public 
nationwide) believe cannabis laws should be less tough.203 
 
6.10 While Londoners largely understand cannabis is an illegal Class B drug, many in 
our research assumed there would be few if any consequences if caught 
consuming or carrying small amounts. This is based partly on seeing cannabis 
openly supplied and consumed with no perceived police response. A number of 
participants were also surprised to learn it is illegal to use cannabis at home, with a 
broad view that such use is not – and should not be – policed. 
 
6.11 Across mindsets, and among respondents to our online survey (N=153, Appendix 
C), there was a perception that the current legal system is failing. And for many, 
attempts by police to uphold cannabis laws are seen to be inconsistent, a poor 
use of resource and frequently resulting in unfair outcomes, particularly for those 
from ethnic minority (excluding white minority) backgrounds.  
 
6.12 We explore issues related to policing practice and disproportionality in chapter 10, 
but the public sense of unfairness being baked into the legal and enforcement 
system is important. This holds regardless of attitudes towards cannabis per se 
and the nature of personal experiences of cannabis policing (which vary from 
amicable to acrimonious).  
 
6.13 Police use of Stop & Search (S&S) showcases this perceived unfairness. Many 
want an end to the practice with respect to suspicion of cannabis possession for 
personal use, which is largely felt to be inappropriately and disproportionately 
applied to black Londoners. A majority of those responding to our online survey 
felt it was ineffective.  
 
6.14 Flagrant consumption in parks and other public areas, and overt sale of cannabis 
within communities, is considered a more appropriate focus for enforcement of the 
law. Accordingly, dislike of cannabis consumption in public spaces was a common 
theme and people openly using the drug and impacting upon the personal space 
of others was raised with us throughout the course of our inquiries.  
 
6.15 Indeed, when asked about police activity to control cannabis use in the local 
community as part of our inquiries, almost half of Londoners asked felt they should 
do more. One-third agreed what they do now is about right, and around one-fifth 
considered they should do less (see Appendix D).    
 
6.16 The smell produced when cannabis is smoked (usually with tobacco as is common 
in the UK and Europe, unlike in the US where it tends to be smoked with no 
supplement) can be pervasive and intrusive. Consequently, it prompts complaint, 
 
203 See for example Do you think the current cannabis laws should be tougher, less tough, or are about right? | Daily 
Question (yougov.co.uk) accessed 18th August 2023. 

   
 
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particularly when consumed in spaces frequented by children (e.g. parks, high 
streets).  
 
6.17 There is frustration with the way cannabis is dealt with in law. Its illegality drives an 
expectation of enforcement for some (regardless of whether they agree with the 
law) but at the moment there is a sense that no one wins. Those who use 
cannabis face criminalisation (with risk seen to be unfairly shouldered by black 
Londoners), and those who do not, or who object to its use in public spaces, feel 
the law is not being upheld in their interests: 
 
‘You can smell cannabis smoke even if you go for a small walk. On top of that, police 
reluctance to do nothing about it – pretty much like vehicle crime. They just ignore 
it.’ 
 
6.18 For others, the perceived failures of prohibition outweigh any desire for an 
upholding of the law: 
 
‘With over a third of 16–25 [-year-olds] having tried cannabis in their life, it seems 
that policing the supply and demand of the drug has failed.’ 
 
‘The illegality of cannabis production, sale and possession has done nothing to 
inhibit the potential harms.’ 
 
‘Criminalising people over the drug wastes tax, ruins lives and incarcerates people, 
as well as reducing the labour force.’ 
 
6.19 Decriminalisation of personal use was largely supported by participants in our 
research. Some considered it to be the de facto position – though with concerns 
regarding how, when and to whom the law is applied. And while several would not 
wish production and supply to also become legal, they recognised the challenges 
inherent in a model where personal use is permitted but enabling activities are not.  
 
6.20 Having considered evidence and heard from experts in jurisdictions that have gone 
beyond decriminalisation and fully legalised non-medical cannabis, it is clear that 
frameworks grapple with a range of issues and trade-offs. Many of these were 
identified by Londoners in our research, including: 
 
• The protection of young people from harmful substances in general (including 
alcohol, e-cigarettes/vapes and tobacco, as well as cannabis). 
• Age and marketing restrictions. 
• Need for quality-assured products to be sold by trained and qualified staff.  
• Desire for a mixed economy to facilitate small business participation and 
support transition for dealers to reduce risk of displacement to other illicit 
markets.  
• Risk of increasing the number of users. 
• Balancing individual freedoms or rights of those who choose to use cannabis 
against those of non-users. 

   
 
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• How to manage the risk of those who use cannabis working or driving while 
intoxicated. 
• How to ensure the (likely inevitable) remnants of the illegal market do not 
simply undercut prices of legal products.    
 
6.21 The potential for a legal market to end – at least to some extent – involvement of 
criminal gangs in cannabis supply, and to deliver safer, quality-assured products, 
was acknowledged. However, there was also distrust of corporate entities and a 
dislike of for-profit models of regulation, seen by some to pose a risk of harm 
through financial incentives to increase sales and therefore probably the numbers 
of people who use cannabis. That said, there was also recognition of the potential 
for tax revenue and reinvestment of profit into communities.  
 
Awareness of the impacts of cannabis 
 
6.22 Most Londoners in our research considered cannabis use, especially in one’s 
home, to be acceptable – as long as no harm is done to others. The risk to oneself 
was thought minimal – or at least no worse than smoking cigarettes or consuming 
alcohol.  
 
6.23 That said, more Londoners believed cannabis to be the substance most damaging 
to a person’s health and wider society (13%) than the national average (8%),204 
suggesting broad support in the capital for a more liberal approach is tempered by 
some degree of concern about impact of the drug itself. 
 
6.24 And while our research participants who used cannabis cited positive 
consequences including relaxation, sociability and pain relief, they acknowledged 
negative effects such as hallucinations, paranoia and a sense of feeling unwell 
(though tended to attribute such to a ‘bad batch’ or irresponsible use). They did 
not, however, see it as down to legal strictures to help people avoid such effects, 
rather it was an individual’s responsibility to manage (through weaker strains, 
abstaining or using when in the right frame of mind). 
 
6.25 Respondents to our online survey (Appendix C) considered the top drivers of non-
medical cannabis use to be relaxation, the management of stress and anxiety, and 
pain relief. Relatively few cited the desire to get ‘stoned’ (high), or to be sociable. 
Taken together with findings from our qualitative research and evidence from 
witnesses, the adjective ‘recreational’ to describe use of non-medical cannabis 
seems for some to be misleading, suggesting a level of active enjoyment that may 
not always be the case.  
 
6.26 This is borne out in evidence we heard from young people and those working with 
young Londoners in a range of sectors. The view that cannabis use was driven in 
many cases by a desire to manage distress resulting from traumatic or otherwise 
adverse life experiences rooted in childhood and the present day (including as a 
 
204 See footnote #192. Accessed 18th August 2023. 

   
 
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result of anxieties stemming from the Covid-19 pandemic) was relatively widely 
held.   
 
6.27 The risk of use cited most frequently by respondents to our online survey was 
damage to the lungs, with over half (59%) reporting this to be a common harm 
(although associated with co-consumption of tobacco rather than perception of 
any inherent harm posed by combustion of the drug itself). A criminal record was 
the second most cited harm (47%), followed by paranoia (cited by 28% of 
respondents).  
 
6.28 We discuss the impact of cannabis on physical and mental health in chapter 8, 
including its effects on young people. While our survey suggested high public 
awareness about the risks to children (70% cited those aged under 16 as 
vulnerable) there was less awareness of vulnerabilities of young adults. This is 
concerning for two reasons. Firstly, because of the risks posed by cannabis use to 
brain development, a process that continues until a person reaches their mid-
twenties. And secondly, the fact that cannabis use is particularly prevalent among 
16–24-year-olds (see chapter 4).  
 
6.29 More hearteningly, over half (52%) of respondents identified those with a family 
history of mental illness (including psychosis) to be particularly vulnerable to risks 
of cannabis, and 43% felt those with a current mental illness to be similarly at risk.  
 
6.30 Given evidence of the impacts and who may be more at risk of harmful effects, in 
our view there is scope for greater education about cannabis use. While numbers 
seem to be falling (see chapter 4), very many people still choose to consume the 
drug and we heard throughout our enquiries how easily available it is. Better 
education is a theme to which we return throughout this report and is the focus of 
chapter 12. 
 
6.31 We heard, too, of public desire for more information. In the absence of accessible, 
credible and objective evidence, views and decisions tend to rely on anecdote and 
personal judgement. Helping those who choose to use non-medical cannabis 
regardless of its il(legal) status do so with less risk to health seems to us to be 
sensible.  
 

   
 
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7. INTERNATIONAL APPROACHES TO 
CANNABIS REGULATION 
 
In exploring the UK’s approach, we sought evidence from jurisdictions around the world 
who have adopted, or are in the process of adopting, alternatives to prohibition. Our 
enquiries were not exhaustive, and we acknowledge there are several countries where 
non-medical cannabis is decriminalised or legally regulated but with whom we did not 
engage (e.g. South Africa, Thailand, the Czech Republic).  
 
That said, we heard from experts hailing from several US states, Australia, Canada, 
Catalonia, Denmark, Germany, Luxembourg, Malta, Mexico, Portugal, Switzerland and 
Uruguay. These experts occupied roles within policing and criminal justice, health, 
policy, not-for-profit and other third sector organisations, academia and government. 
We have also considered the positions in the Netherlands, Spain and New Zealand. 
 
This chapter is in two parts: the first describes regulatory models in place in those 
countries considered, the second considers evidence of effects on public health, crime 
and policing and economic considerations. Due to earlier adoption of non-prohibitive 
approaches, the majority of evidence originates in the US and Canada. 
 
While jurisdictions differ in precise drivers of regulation, grappling as they are with 
specific challenges brought by different domestic contexts, broadly speaking they aim 
to: 
• Protect public health and safety through provision of quality-assured products 
and education regarding the risks and effects of cannabis consumption. 
• Combat the illicit market through transitioning purchases to a legal market, 
ensuring state and citizens, not criminal enterprises, benefit from profits. 
• Combat cannabis use particularly among young people.  
• Address disproportionate harms caused by the war on drugs, whereby people of 
colour are more likely to be arrested, charged and convicted of cannabis 
offences.  
 
It is clear to us, however, that, even where non-medical cannabis has been legally 
regulated for some years, robust evidence of the extent to which these aims have been 
met is limited. We find it hard, therefore, to disagree with the conclusion of the 
International Narcotics Control Board in its Annual Report 2022 that: 
 
‘It is difficult to assess the impact of the ongoing legalization initiatives on society 
and individuals. In many States, the time since these laws have come into effect 
is too short to produce valid data and to judge the full effects of legalization. The 
consequences do not appear immediately after enactment or implementation of 
the relevant law and regulations… The impact of legalization on public health, 

   
 
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public safety and the economy is difficult to measure and varies according to the 
different legalization model.’205 
 
7a: Alternatives to prohibition in regulating non-medical cannabis 
 
Details were accurate at time of writing. Positions with respect to use, purchase and 
supply of non-medical cannabis may have since changed. We consider the frameworks 
adopted in the US and Canada first because we consider them to represent the most 
extensive alternatives to wholesale prohibition. Uruguay, the first country in the world to 
legalise use of non-medical cannabis, follows, and we then explore the positions of 
various European countries. The section concludes by describing the situation in 
Australia, New Zealand and finally Mexico.     
 
The US 
 
7.1 Cannabis in the US is illegal at federal level. This means it remains prohibited by 
the Controlled Substances Act and is, at time of writing, classed as a Schedule 1 
narcotic. However, the Biden Administration initiated investigation of rescheduling 
the drug in 2022. The Health & Human Services Department duly recommended it 
be moved to Schedule 3 in 2023, and the Drug Enforcement Administration 
concurred with that recommendation the following year. 
 
7.2 This means that, while remaining illegal for non-medical use at federal level, 
cannabis will sit alongside other substances seen as posing a low to moderate risk 
of abuse and harm with some potential for medicinal purpose, such as ketamine 
and anabolic steroids. It will no longer be classed alongside those substances 
considered to pose a much higher risk with no medicinal value, including ecstasy, 
LSD and heroin. (Although note that while the US considers heroin to hold no 
medical value, the UK position differs. Here, it may be prescribed under the 
generic name diamorphine for use as a powerful painkiller to treat acute or chronic 
pain, including during terminal illness).  
 
7.3 The move follows the Presidential pardon issued in 2022 to all Americans 
convicted at the federal level of possessing small amounts of cannabis. While this 
had little immediate impact as no individual was serving a custodial sentence at 
the federal level solely for possession of cannabis (most such convictions occur at 
state level), it was also intended to support those with prior convictions for 
possession to secure employment, housing and education opportunities.  
 
7.4 Despite federal prohibition, many states have made their own laws in relation to 
both medical and non-medical cannabis – although anyone involved in the industry 
is technically engaging in illegal activity under federal law, which can make 
traditional methods of banking and investment (and interstate commerce) difficult. 
Sales are regulated and taxed at state level and provisions regarding public 
 
205 unis.unvienna.org/unis/uploads/documents/2023-INCB/INCB_annual_report-English.pdf pp.17–18. Accessed 5th 
October 2023. 

   
 
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consumption, the amount that adults (over 21) can possess, and permissions to 
grow plants at home vary from state to state. 
 
7.5 As at November 2023, 38 states, four territories and Washington D.C. had passed 
laws allowing cannabis to be used for medical purposes and 24 states, three 
territories and Washington D.C. permitted non-medical use (although not all permit 
commercial sales), as shown in Table 1. (Note sales do not begin until sometime 
after legislation for use is passed). States where non-medical use remains illegal all 
share at least one border with a state where its’ use is now legal. 
 
Table 1: Legal regulation of non-medical cannabis in the US206 
 
Date of legalisation* US State/territory  
2023 Delaware, Minnesota, Ohio, US Virgin Islands 
2022 Missouri, Maryland, Rhode Island 
2021 Connecticut, New York, New Mexico, Virginia** 
2020 Arizona, New Jersey, Montana  
2019 Guam, Illinois 
2018 Michigan, Northern Mariana Islands, Vermont 
2017 - 
2016 California, Maine, Massachusetts, Nevada  
2015 - 
2014 Alaska, Oregon, Washington D.C.** 
2013 - 
2012 Colorado, Washington (state) 
*  Date when legislation approved. Date legislation takes practical effect follows in due course. 
** 207 
 
7.6 In US states where cannabis is legalised, the ‘for-profit’, or commercialised model 
dominates. This means entities that have rights to cultivate, process, distribute 
and sell products do so in a manner which maximises profits, not necessarily 
public health or safety. While the practice is restricted in some states, many 
industry players operate on a ‘seed-to-sale’ basis whereby all associated 
processes are vertically integrated within one company. 
 
7.7 Levels of taxation, along with mechanisms of licensing and regulation, are set by 
individual states and differ accordingly. Most, if not all, stipulate how much of the 
revenue raised through cannabis taxes goes back into drug treatment, healthcare, 
education and research and for many there is overt intent to focus on communities 
most harmed by the ‘war on drugs’ (usually communities of colour). Several states 
were suggested as good models of such reinvestment programmes, including 
California, Illinois and New York, all of which include specific programmes and 
 
206 As at time of writing, based on State Medical Cannabis Laws (ncsl.org), Table 1. Accessed 8th August 2024. 
207 In Virginia, a bill allowing legal recreational sales to commence in 2025 has passed but remains vetoed by the 
state Governor. Limited home grow, possession, and gifting is permitted. In Washington D.C., while the measure 
technically allows for commercial sales of cannabis by licensed retailers, Congressional opposition means no 
regulatory system has been implemented to allow for this. Limited home grow and gifting of up to one ounce is 
permitted.  

   
 
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policies funded at grass-roots levels to support community-wide, community-led 
development. 
 
7.8 States also differ with respect to public use of cannabis. In some, such as 
Washington state and Colorado, this remains a civil offence punishable by a fine or 
some form of community service order. This can help limit exposure of non-users 
in public spaces to the distinctive smell of smoked or vaped cannabis – which is an 
important consideration for us. Our enquiries have highlighted widespread dislike 
of public consumption of cannabis in London and the issue is recognised by the 
public and local government leaders as a concern across the capital.  
 
7.9 Making public consumption a civil offence, however, is not without challenge. It 
effectively discriminates against those unable to consume the drug at home for a 
range of reasons, including because to do so would infringe private or social 
rented housing policy. This can further exacerbate discrimination against 
communities of colour, who are more likely to live in rented housing and who have 
already been particularly harmed by the war on drugs through disproportionate 
criminalisation.  
 
7.10 This is principally why New York, for example, which legalised cannabis for non-
medical purposes in 2021 (first shops operational from late 2022), permits the 
smoking of cannabis wherever smoking cigarettes is permitted. While this means, 
for example, it cannot be consumed in vehicles, restaurant patios and public 
parks, early indications suggest the approach is also not without difficulty. We 
heard anecdotally that the smell of cannabis is pervasive across large areas of 
New York City and, indeed, the issue was highlighted in media coverage of the 
2023 US Open tennis championship, where several players complained of a smell 
of cannabis on the court.208  
 
7.11 Free speech laws in the US mean commercial advertising of cannabis, like 
tobacco, is permitted in all states, although some have limited what products may 
be marketed, where and how. That said, we heard anecdotally of a proliferation of 
advertising in some states, particularly on large billboards alongside highways (in 
California, for example).  
 
7.12 Many states also place limits on product packaging, not permitting, for example, 
edibles to be sold in shapes and wrapping that might appeal to children or 
otherwise be confused with standard food products. It was put to us that such 
rules are frequently violated, however, due to lack of clear enforcement and 
sufficient civil penalties for businesses who choose to violate these laws.  
 
7.13 We heard about the crucial importance of having licensing and regulatory 
frameworks not only agreed but in place and operational from the moment legal 
regulation is passed into statute, with clear guidance to support applicants. 
California, which was the earliest adopter of legalised medical cannabis in 1996, 
 
208 Weed at the U.S. Open? Some Players Swear They Can Smell It – The New York Times (nytimes.com) Accessed 
6th October 2023. 

   
 
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failed to introduce a regulatory framework until almost 20 years later in 2015, 
when it became apparent that a vote on legal regulation for non-medical cannabis 
was inevitable.  
 
7.14 It was put to us that this effectively created a chaotic and piecemeal approach to 
cannabis regulation whether for medical or non-medical use, and that ‘birthing’ a 
marketplace and subsequently trying to wrap a regulatory framework around it 
had made it more difficult to achieve associated legislative aims.  
 
7.15 Learning from California’s experiences, the states that followed in legalising 
medical and/or non-medical cannabis have adopted a more proactive approach, 
attempting to ensure frameworks and licensing regimes were designed and 
agreed before being implemented.   
 
7.16 Having such plans agreed on paper, however, is not the same as having systems 
fully operational and properly resourced. Several witnesses commented that 
despite a well-considered system in New York, with social equity principles at its 
heart (see part 7b of this chapter), insufficient thought and resource was 
committed to its roll out and subsequent operation.  
 
7.17 This meant that, when non-medical cannabis became legal, the responsible office 
was overwhelmed, and applicants seeking a licence to cultivate, distribute and/or 
sell cannabis have reportedly struggled to access and navigate the system. This is 
particularly challenging for those whom the system is designed to prioritise – 
notably people from communities most harmed by the war on drugs of recent 
decades.  
 
7.18 We heard, too, that delays in implementation of the regulatory framework have 
allowed, particularly in New York City, illicit operators to gain a firm foothold in the 
emerging non-medical marketplace. 
 
Canada 
 
7.19 In 2016, the Canadian government acknowledged its prohibitive approach to non-
medical cannabis had failed, highlighting that thousands of citizens had sustained 
criminal records for (non-violent) cannabis offences, cannabis use among young 
people was among the highest worldwide and organized crime was reaping 
billions of dollars in profits from cannabis sales. 
 
7.20 The government was thus persuaded to pursue legal regulation for non-medical 
use, following legalisation of medical use in 2001. Legal regulation had been a 
campaign issue prior to the election of the government, and enjoyed high levels of 
support – certainly a majority of the public felt cannabis possession should not be 
subject to harsh criminal sanctions. 
 

   
 
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7.21 A specialist Task Force209 considered the most effective means of meeting the 
government’s desire to address the social and health harms associated with 
cannabis, and its findings informed the Cannabis Act of 2018. Canada became 
the second country in the world after Uruguay (see below) to legalise non-medical 
cannabis for adults.  
 
7.22 In line with recommendations from the Task Force, and given experiences in the 
US, efforts were made to ensure capacity for a legal cannabis industry was 
developed in key areas prior to the start of the regulatory regime (including 
laboratory testing, licensing and inspection). The government also committed $46 
million for cannabis education and awareness, and its legislation required an 
evaluation be conducted after three years to determine whether and how legal 
regulation is meeting its objectives.210 This review was recently completed211 and 
its considerations are highly relevant to our work. They include: 
 
i. Health and consumption habits of young people. 
ii. Impact of the cultivation of cannabis plants in a housing context.  
iii. Economic, social and environmental impacts. 
iv. Access to regulated, lower-risk, legal cannabis products.  
v. Deterrence of criminal activity and displacement of the illicit market. 
vi. Impact on access to medical cannabis. 
vii. Impacts on Indigenous peoples, minority communities and women – including 
whether they face greater barriers to participation in the legal industry. 
 
7.23 Today, non-medical cannabis is permitted in all ten Canadian provinces and its 
three territories. While the federal government controls production licences (as of 
31st March 2023, it had issued 913 – a ninefold rise from the 100 licensed at the 
point of legalisation), retail is the responsibility of each province/territory. Some 
chose a state-owned model that follows the way alcohol is regulated in many 
areas (i.e. state monopolies for distributors and retailers); the remainder operate 
commercial models.  
 
7.24 Despite the number of production licences (913), and original intent to prioritise 
smaller producers, the market has become somewhat monopolised by a handful 
of large companies: according to the Competition Bureau of Canada, the six 
largest cannabis producers have an overall industry market share in excess of 
40%.212  
 
7.25 Prices are variable by province/territory (as in the US). In 2019, legal cannabis 
was cheapest in Quebec ($7.88 per gram) and most expensive in New Brunswick 
($11.36 per gram), which at the same time also hosted the cheapest illegally 
sourced cannabis at $4.90 per gram (followed by Quebec at $5.08 per gram).213  
 
209 A Framework for the Legalization and Regulation of Cannabis in Canada - Canada.ca 
210 S.151(1)(2) of the Act Cannabis Act (justice.gc.ca)  
211 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca 
212 Competition Bureau submission to Health Canada and the Expert Panel to support the  Cannabis Act legislative 
review. Available at Planting the seeds for competition (canada.ca) 
213 Average price of cannabis, by province, 2019 (statcan.gc.ca) Accessed 9th October 2023. 

   
 
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7.26 The Cannabis Act sets out restrictions on production, sales and marketing, with 
responsibilities shared across federal and provincial governments. The latter, for 
example, set minimum age limits for purchase (if higher than the federal minimum 
age of 18), maximum amounts permissible to possess in public or share with 
others (up to a federal maximum of 30 grams for both) and how many plants (up 
to a maximum of four) can be grown per residence.  
 
7.27 While cannabis edibles and concentrates have been legal since 2019, not all 
provincial governments adopted the permission wholesale. Quebec, for example, 
has explicitly limited the type of edible products available throughout the province, 
banning sweets, confectionery, desserts and cannabis-infused chocolates. As a 
result, the types of edible products currently available in the Quebec market 
include beef jerky, fruit-based bites, dried figs, infused beets and beverages. 
 
Uruguay 
 
7.28 In 2013, Uruguay became the first country in the world to legalise adult-use 
cannabis, principally to combat violent crime associated with the illegal drug trade 
and deal with rising pressures on the criminal justice system, alongside a desire to 
improve public health through access to quality-assured product. Notably, 
personal possession of all drugs had been decriminalised since 1974, and there 
was relatively widespread social acceptance of cannabis use,214 although this did 
not necessarily translate into majority support among the public for its legal 
regulation. 
 
7.24 The country adopted a non-profit, state-run model. This means the government 
controls prices, which products can be sold (and their potency), who can 
purchase and how much they may purchase. It also issues multi-purpose licences 
for cultivation, processing and packaging of unbranded cannabis and for 
distribution to pharmacies (five companies are currently licensed).215 Retail sales 
are permitted through for-profit pharmacies, although within the parameters set by 
the government’s price controls.216 
 
7.25 Consumers have three options for accessing legal cannabis, all of which require 
registration with the government via the Instituto de Regulación y Control del 
Cannabis (Institute for the Regulation and Control of Cannabis). They cannot 
combine sources, so must decide which one of the routes they wish to use:  
 
i. Home grow, where up to six (female) plants may be grown for personal use. 
Sales are prohibited – if surplus is produced, the grower must call the 
regulator to collect it, or otherwise throw it away. 
 
214 Magson, J. (2014). Drugs, Crime and Decriminalisation: Assessing the Impact of Drug Decriminalisation Policies 
on the Efficiency and Integrity of the Criminal Justice System. Winston Churchill Memorial Trust.  
215 Seddon, T. & Floodgate, W. (2020) Regulating Cannabis: A Global Review and Future Directions. Palgrave 
Macmillan.  
216 Pardal, M., Kilmer, B., d’Auria, S., Strabel, T., Galimberti, S., Hoorens, S., Decorte, T. & Senator, B. (2023). 
Alternatives to profit-maximising commercial models of cannabis supply for non-medical use. RAND Corporation.  

   
 
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ii. Join a not-for-profit cannabis social club217 (CSC – see section on Spain and 
Catalonia) where members cultivate cannabis collectively for their own 
consumption with no profit motivation.218 Membership is capped at 45 
members with a 40-gram monthly consumption limit per member. 
iii. Purchase one of six types of dried flower (edibles, oils etc are not permitted) 
from a pharmacy, with purchases limited to 40 grams per month or 10 grams 
per week. THC levels in pharmacy products are lower than those in home-
grown cannabis and in that available in CSCs, and prices are capped at 
$1.82 per gram.  
 
7.26 Indoor smoking of cannabis is prohibited in all places where tobacco smoking is 
banned, and it is not permitted on school or hospital premises. Driving following 
consumption is banned. 
 
7.27 We were told that the number of registered cannabis users in Uruguay represents 
an estimated one-third of all those in the country who use the drug. It was put to 
us that the requirement to register with the government is likely to deter many 
given levels of public mistrust, although those who have done so consume quality-
assured product. This is likely to be less potent (and therefore less risky) than that 
available from the illegal market (though they may of course dual-purchase from 
both legal and illegal markets).     
 
Portugal 
 
7.28 In 2001 Portugal decriminalised possession of all drugs for personal use in an 
attempt to stem rising drug use and associated health and social issues, arguing 
that criminal punishment does not deter people from using illicit drugs. Possession 
of relatively small quantities of cannabis for personal use is therefore dealt with as 
an administrative rather than a criminal offence. Possession of larger quantities, 
however, and involvement in sale, distribution or production of cannabis, remain 
activities that are dealt with under criminal law. 
 
7.29 In parallel, Portugal invested in welfare, social support and treatment services 
(partly through repurposing parts of criminal justice budgets), which were seen as 
vital elements of a public health approach to drug use. In line with this, ‘Dissuasion 
Commissions’ (DCs), established as de facto replacements for criminal courts 
where possession of drugs is concerned, were set up under the Ministry of Health 
rather than Justice.  
 
7.30 DCs were created in each of Portugal’s 18 Districts and on both its islands, and 
typically comprise a legal expert, health professional and social worker. Those 
appearing before them (following police referral) undergo a risk assessment that 
explores reasons for drug use alongside a range of health and socio-economic 
 
217 Clubs are tightly regulated and must first obtain approval to run as a non-profit organisation, then register with the 
Ministry of Education and Culture, and finally with the Instituto de Regulación y Control del Cannabis. 
218 Queirolo, R., Boidi M.F. & Cruz, J.M. (2016) Cannabis clubs in Uruguay: The challenges of regulation. 
International Journal of Drug Policy, (34), pp.41–8.  

   
 
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factors. Conclusions from that assessment inform the DC’s decision regarding 
whether to issue any sanction(s) and what it/they should be.  
 
7.31 As the name suggests, DCs aim to discourage drug use and they have several 
administrative penalties at their disposal, including fines,219 community work, 
regular reporting to the commission, withholding of social benefits and group 
therapy. They may also refer a person to treatment and can execute further 
sanctions following non-compliance with any condition imposed, including referral 
to the criminal court. We heard, however, that non-compliance is low – in part 
because sanctions are negotiated to ensure they take the form of something that 
works with an individual’s personal capabilities and capacities.  
 
7.32 The majority of referrals to DCs are due to cannabis possession (we were told they 
make up around 80% in Lisbon). Most do not, however, demonstrate problematic 
use220 and thus attract no, or minimal, sanction. Proceedings are commonly 
suspended,221 with less than 10% routed into significant intervention. Referral to 
drug treatment or addiction services tends to be reserved for those with current or 
previous symptoms of psychosis, although the aim is reduction of, or abstinence 
from, cannabis use. Signposting to employment centres is common as many risk 
assessments identify long-term unemployment as a factor in cannabis use.  
 
Spain & Catalonia 
 
7.33 While production, importation and sale of non-medical cannabis are criminal 
offences, possession and home cultivation for personal use are decriminalised, up 
to a certain limit (typically around 100 grams, or 3.5 oz). Any plant visible from a 
public space, however, is not permitted and can lead to a fine of between €601 
and €30,000, as can public possession or consumption of cannabis.222  
 
7.34 Law enforcement is prolific in this regard: in 2020, Spain recorded around four in 
ten (n=258,379) of all sanctions across Europe for cannabis use or possession,223 
although past-year prevalence of adult use was higher in both France and the 
Czech Republic.224 
 
 
219 The law stipulates that a financial penalty cannot be levied to a drug-dependent person due to a risk that it may 
lead to further offences to obtain the money. For non-dependent users, amounts levied can be increased with any 
successive appearance before the DC. 
220 Up to 90% of individual cases in 2018 were reported as not demonstrating problematic use; 
see https://transformdrugs.org/assets/files/PDFs/Drug-decriminalisation-in-Portugal-setting-the-record-
straight.pdf and footnote 26: SICAD (2020). Statistical Bulletin 2018: Illicit Substances. p.7. 
http://www.sicad.pt/BK/EstatisticaInvestigacao/ Documents/2020/sinopses/SinopseEstatistica18_ 
substanciasIlicitas_EN.pdf 
221 Eastwood, N., Fox, E. & Rosmarin, A. (2016). A Quiet Revolution: Drug Decriminalisation Across the Globe. 
Release. pp.28–9. 
222 Spain, Country Drug Report 2019 | www.emcdda.europa.eu Accessed 10th October 2023. 
223 Statistical Bulletin 2022 — drug law offences | www.emcdda.europa.eu Accessed 10th October 2023. 
224 Cannabis use in Europe 2020 | Statista Accessed 10th October 2023. 

   
 
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7.35 The introduction of administrative sanctions for public use of cannabis was partly 
what led to emergence of the not-for-profit Cannabis Social Club (CSC),225 as 
users protested against perceived interference in their private lives.226 The first 
CSC emerged in 2001 in Barcelona (Catalonia), and they have since proliferated 
across the region and Spain as a whole (and are central to Uruguay’s not-for-profit 
model of legal regulation). It is not clear how many there are in total, but in 2017 
estimates ranged from ~800 to over 1,000,227 with several hundred in Barcelona 
alone. It was put to us that numbers have since increased, with the total number 
somewhere between 1,500 and 2,000. 
 
7.36 Existing in something of a legal grey space, the model took advantage of a 
loophole created by a Supreme Court jurisprudence that ‘distinguished between 
possession for personal consumption and possession for distribution’ and 
permitted ‘shared consumption among those dependent on drugs’.228  
 
7.37 This meant no criminal offence was deemed to have occurred where drugs were 
purchased for immediate consumption among a closed group of users and no 
profit was made from their distribution.229  
 
7.38 However, a subsequent Supreme Court judgment concluded CSC activity creates 
a risk of distribution to, and use of, cannabis by non-members, and thus clubs 
should be considered criminal endeavours.230 A statement in 2015 set this out: 
‘…organised, institutionalised and persistent cultivation and distribution of 
cannabis among an association [i.e. CSCs] open to new members is considered 
drug trafficking’.231  
 
7.39 This left clubs in a precarious position. While not a police priority (indeed, it was 
put to us that some feel clubs reduce public consumption and dealing), they 
remain at risk of closure and the owners risk prosecution.  
 
7.40 A number of regions have attempted to introduce their own regulatory frameworks 
to legitimise clubs, but so far all have been declared unconstitutional by the 
national government. The Basque Country is the exception, although while it is the 
 
225 The history behind the CSC model, its operation and impacts are too complex to cover here in detail but are set 
out in many sources, including: Marks, A. (2019). Defining ‘Personal Consumption’ in Drug Legislation and Spanish 
Cannabis Clubs. International and Comparative Law Quarterly (68), 193–223: Pardal, M., Decorte, T., Bone, M., 
Parés, Ò. & Johansson, J. (2020). Mapping Cannabis Social Clubs in Europe. European Journal of Criminology, 
pp.1–24. doi.org/10.1177/1477370820941392: M. Pardal, Ed. (2022). The Cannabis Social Club. Routledge.  
226 See Sánchez, C. & Collins, M. (2018). Better to Ask Forgiveness Than Permission: Spain’s Sub-national Approach 
to Drug Policy. Policy Brief 12, Global Drug Policy Observatory, Swansea University. 
227 Decorte, T., Pardal, M., Queirolo, R., Boidi, M.F., Avilés & Franquero, O.P. (2017). Regulating Cannabis Social 
Clubs: A comparative analysis of legal and self-regulatory practices in Spain, Belgium and Uruguay. International 
Journal of Drug Policy, (43) pp.44–56.  
228 Franquero, O.P. & Bouso Saiz, J.C. (2015). Innovation Born of Necessity: Pioneering Drug Policy in Catalonia. 
Open Society Foundations.  
229 This has its origins in the 1980s when the system was overwhelmed with heroin users purchasing small amounts 
for peer distribution. The law meant they were charged with trafficking, resulting in very many people being given 
prison sentences.   
230 See footnote #226. 
231 Spain, Country Drug Report 2019 | www.emcdda.europa.eu Accessed 10th October 2023. 

   
 
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only region whose regulations have not been suspended by the Constitutional 
Court the law has not been developed further, leaving the legal position in limbo.   
   
7.41 In keeping with their origins, CSCs are largely non-profit associations, whose 
members are adult users of cannabis. An existing member must verify any 
prospective member as a cannabis consumer, to help ensure clubs do not 
encourage people to begin taking the drug. Membership fees cover cultivation and 
operating costs, with revenue reinvested into the club. Clubs provide information 
on the CBD, THC and terpenes specific to strains offered, and daily limits on 
individual consumption help growers know how much cannabis to cultivate. These 
also reduce the chance of product being diverted for sale through the illegal 
market.  
 
7.42 Clubs provide space for members to relax and consume cannabis with other 
members, although not all do so, preferring to consume at home (small amounts 
are permitted for off-site consumption). Many also provide opportunities to listen to 
music and watch sport or other entertainment and may offer a range of (non-
alcoholic) drinks and snacks, adopting more of a café environment. Consumption 
of other types of drugs is prohibited and any member caught attempting to do so 
is ejected – although it was put to us that this is not a common occurrence. 
 
7.43 Many clubs employ harm reduction strategies,232 with staff trained to provide 
advice on safer methods of consumption (e.g. vaping rather than smoking) and 
less potent strains, and to offer general information about cannabis and risks of 
use. Seen as trusted, credible voices, where they detect signs of problematic 
consumption staff are encouraged to signpost a member into treatment services.  
 
7.44 In recent years, however, the original ethos and model of the CSC has been 
somewhat reinterpreted, with some now much bigger than originally intended. 
Many are aimed at tourists, with touts used to approach visitors in key tourist 
areas (particularly in Barcelona) to encourage them to sign up.  
 
7.45 A majority of these larger clubs are thought to be run by organised crime groups 
(OCGs), which often control large cultivation sites and sell the product through a 
CSC. Because criminal players are much larger than locally based operators, they 
can better afford to take the risks of operating without legal cover.  
 
7.46 This development is shifting the dynamic: clubs run by criminal enterprises are 
remaining open at the expense of smaller non-profit associations. It was put to us 
that the Supreme Court judgment several years ago that effectively prevented 
formal regulation of CSCs (although a number of Cannabis Social Club 
Federations provide guidance and codes of practice to members) has helped 
facilitate the entry of organised crime into the market. 
 
 
232 See for example RdRCannabis, which in partnership with the Health Department of Catalonia seeks to support and 
complement risk and harm reduction endeavours undertaken by clubs. Home - rdrcannabis.cat Accessed 2nd August 
2024. 

   
 
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7.47 More widely, the original non-profit ethos of CSCs has been adopted by recently 
introduced legislation in Malta and is a core part of endeavours in Germany and 
Switzerland to introduce limited forms of legal regulation for non-medical cannabis. 
 
Malta 
  
7.48 Malta de-penalised cannabis possession in 2015, meaning individuals caught by 
police with small amounts of the drug (up to 3.5 grams) are diverted to the 
Commissioner for Justice and given a fine instead of facing criminal 
consequences. The country legalised the medical use of cannabis in 2018.  
 
7.49 In 2021, it partially decriminalised cannabis for personal use and became the first 
country in Europe to legally regulate a limited number of activities related to 
collective cultivation and distribution of the drug, though in a much more limited 
fashion than Canada and the US. It was emphasised to us that the change centres 
on individual rights and public health, allowing those who consume cannabis to do 
so more safely without fear of prosecution or exposure to adulterated and 
synthetic cannabis. 
  
7.50 Cannabis has not been legalised wholesale. The legislation permits use and 
possession, with a limited framework for cultivation – so is more akin to a 
‘decriminalisation plus’ model. From the age of 18, adults may carry up to seven 
grams of cannabis in public, grow up to four plants per household (if they remain 
out of sight to third parties), store up to 50 grams of dried cannabis flowers at 
home and consume the drug in a private setting. Public consumption, however, 
remains illegal and carries a fine.  
 
7.51 Notably the model does not explicitly seek to shrink the illegal cannabis market 
from the outset, acknowledging that it will take time for legal regulation to grow 
and consolidate sufficiently to meet demand. In order to sustain focus on public 
health and harm reduction, the approach is not-for-profit because, as it was put to 
us, for-profit models are diametrically opposed to public health. The alcohol and 
tobacco industries were cited as examples that gain from increases in both the 
number of users and high-risk use – in contravention to notions of public health.  
 
7.52 As befits its non-profit approach, Malta does not permit marketing or advertising of 
cannabis, and there is no traditional retail market. Those unable or unwilling to 
pursue home grow can join a non-profit (collectively owned) Cannabis Harm 
Reduction Association (CHRA). These offer several services, among them access 
to cannabis flowers. They are modelled on core principles of the peer-led CSCs 
established in Spain, although consumption is not currently permitted on site and 
staff must engage in harm-reduction activity (such as encouraging users to adopt 
less risky methods of consumption). Each association will cultivate, process and 
distribute cannabis among its own membership base.  
 
7.53 CHRAs must register with and be licensed to operate by the newly created 
regulator, the Authority for the Responsible Use of Cannabis (ARUC). They must 
have a minimum of two founders, both aged 18 or over and resident in Malta for at 

   
 
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least five consecutive years. Cultivation must be undertaken away from the CHRA, 
which is then used as the distribution mechanism. 
 
7.54 Clubs are permitted a maximum of 500 members, in part to discourage larger 
corporate operators and retain the ethos of ensuring safer ways for those who 
choose to do so to consume cannabis. As of time of writing, applications had been 
made by a mix of associations, some seeking a licence for around 100 members, 
with others planning for up to 500. The ARUC currently charges €1,000 for a 
licence that accommodates up to 50 members, €13,000 for a licence that 
accommodates up to 250 members, and €26,000 for a licence that permits up to 
500 members. 
 
7.55 We understood that ARUC does not expect to grant licences to all applicants. 
Plans will be carefully scrutinised and those deemed not to be genuinely not-for-
profit, or which do not set out clear harm-reduction strategies, will fail. Similarly, 
applicants are subject to rigorous checks including criminal and financial histories, 
and funds flowing into and out of associations will be regulated, with wages 
expected to be in line with average market rates. 
 
7.56 ARUC neither fixes prices for cannabis nor levies taxes, in an attempt to allow 
CHRAs to compete with the illegal market more easily. Nor have they placed a cap 
on the number of licences they will issue, on the basis that the more there are, the 
greater the capability to provide a safer way for users to consume cannabis. 
Members will be permitted a maximum of 50 grams per month and the intention is 
that, in time, the quality and assured nature of the product available through 
CHRAs or home grow will encourage a permanent shift from illegal sources. 
 
7.57 Some criticism has been levelled at the decision to bring in a form of legal 
regulation, notably from Malta’s National Addictions Advisory Board, which is 
concerned about the potential for motor vehicle accidents resulting from cannabis 
intoxicated drivers. However, and as we discuss elsewhere, this issue is complex 
as there is currently no reliable technology or other form of test to distinguish 
cannabis as present in the bloodstream (which could be a consequence of 
consumption several days or even weeks previously) from cannabis intoxication, 
which evidence suggests impairs motor skills and judgement.  
 
7.58 Expungement of criminal convictions sustained for cannabis possession is 
permitted under the new law, acknowledging that those previously convicted of 
such should not continue to suffer the consequences of behaviour no longer 
considered criminal. The process however is not without complication, and is not 
automatic: it must be undertaken via court decree, meaning applicants require 
legal support to navigate the requirements. This leaves open the possibility that 
expungement will only ever be an option for those who can afford to engage with 
the demands of the process. 
 
 
 
 

   
 
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Luxembourg 
 
7.59 Luxembourg is embarking on a two-stage journey towards a fully regulated market 
for non-medical cannabis, following a commitment in 2018 by the former coalition 
government and the legalisation of cannabis for medical use that year. The 
commitment recognised that demand for cannabis across Luxembourg is not 
abating, with increasing numbers of both users and high consumption users, 
particularly among the youth population.  
 
7.60 Moreover, there was growing concern about risks associated with the 
consumption of illicit cannabis of unknown quality and constitution. The cautious 
view of the former government was that on balance, some form of regulated 
market would not risk more harm than prohibition, and that public health would, in 
the longer-term, benefit.  
 
7.61 A concept paper set out the plan in detail233 and from July 2023, as per stage one 
of implementation, it became legal for a household to grow up to four cannabis 
plants and for cannabis to be consumed within the home. Criminal proceedings 
remain in place with respect to possession, transport or purchase of cannabis, 
though the new legislation reduces the range of fines available. Public 
consumption of cannabis remains illegal.  
 
7.62 Implementation of stage two depends on the political will and priorities of the new 
coalition government, which following elections in October 2023 has been in place 
since November of that year. Public health considerations lie at the heart of this 
second stage, including safeguarding consumer health more effectively via access 
to quality assured cannabis, diverting people from adulterated or synthetic 
products procured via the illegal market. Over time, the wider strategy hopes, too, 
to reduce organised crime through shifting cannabis purchases from the illegal to 
the legally regulated market.  
 
7.63 Under the plans, vendors would be trained to signpost customers to CBD-
dominant strains first, thus encouraging purchase of lower-potency products, and 
to introduce alternative methods of consumption that do not involve co-
consumption of tobacco (e.g. vaping). Legal regulation also aims to reduce the 
stigma surrounding cannabis use, which architects of the policy believe is limiting 
treatment-seeking behaviour among those who develop associated problems.  
 
7.64 The approach draws heavily on that adopted in Canada, in particular the model 
developed in Quebec. Here, legal retail of cannabis is limited to state-owned 
outlets, meaning the provincial government retains control over pricing as well as 
the number and location of stores. If it proceeds, Luxembourg plans to open 14 
cannabis retail outlets across the country, which would similarly be state-owned 
and -run. Seeking to maximise profit is thought to undermine public health aims, 
 
233 See Non-medical use - Health Portal - Luxembourg (public.lu) and Report of the “Cannabis for Non-Medical 
Purposes” Working Group: Pilot Project for Legal Access to Cannabis for Non-Medical Purpose. (2023). Ministry of 
Health, Ministry of Justice (Luxembourg). Accessed 11th October 2023. 

   
 
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so will not be a priority. Instead, outlets will focus on promoting safer use of 
cannabis and signposting treatment services where necessary.  
 
7.65 Production and distribution will not be state-owned, but fee-based licences will be 
issued to private cultivators and operators. There is currently no intention to cap 
the THC content in flower-based products on the basis, we were told, of research 
which purportedly found no evidence that such a cap would support public health 
aims. It was put to us that people choosing to use cannabis would simply consume 
twice as much in order to achieve the desired effect (known as ‘compensatory 
smoking’ in the tobacco field) and that it would increase the risk of consumers 
shifting to the illicit market. 
 
7.66 The position in Luxembourg underlines the importance of agreement regarding the 
primary purpose of any legally regulated market. Raising taxes is not a priority in 
the model; likewise in Malta, because financial aims arguably undermine their 
principal aims of improving public health. This is obviously the case with any 
industry selling a product with potential to damage health: rising consumption can 
raise health risks in tandem with profits – as is the case, of course, with alcohol, 
tobacco and sugar. It is easy to see, therefore, how tension between health and 
economic considerations within government makes for a challenging legislative 
process.  
 
7.67 With this in mind, Luxembourg’s strategy decouples health outcomes from 
cannabis sales. It recognises that commitments to use sales-generated revenue to 
support treatment services, for example, automatically create a vested interest in 
increasing sales of what is, after all, a drug with potential to lead to addiction and 
other health problems for some who choose to consume it. 
 
7.68 Education is a key plank of the strategy and in partnership with the National 
Addiction Prevention Centre, the Ministry of Education has developed a range of 
materials related to cannabis use. The intention is for these to be delivered 
uniformly across schools to all year groups from around age 12 upwards. 
Messaging will include the potential for cannabis to lead to addiction and 
associated risks, and how to use cannabis in a less risky fashion should young 
people choose to do so.    
 
7.69 Wider public campaigns are also planned, focusing on how to engage in lower-risk 
consumption of cannabis (including consuming without tobacco). Expectations 
regarding public cut-through and impact are however low to moderate, in 
recognition of the fact that there is relatively limited evidence of such campaigns 
affecting significant behaviour change.  
 
Germany  
 
7.70 In its 2021 coalition agreement the German government set out its intention to 
pass a Cannabis Act, creating a legally regulated retail market for non-medical 
cannabis which, it intended, would be available in shops nationwide. Drivers 
included the desire to, as elsewhere, curb the illegal cannabis market, protect 

   
 
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consumers from adulterated product and improve public health outcomes, and 
reduce drug-related crime. 
 
7.71 However, the proposals risked breaching both UN international drug control 
treaties and EU regulations (which currently do not allow commercial production 
and retailing of cannabis for non-medical use). The latter were a particular 
concern given the risk of direct political consequences as well as the possibility of 
serious sanctions and tensions with Germany’s EU neighbours. 
 
7.72 As a result, the country scaled back its original plan, proceeding with a more 
restricted two-phase strategy that was passed by parliament in early 2024. The 
approach was informed by a government-sponsored systematic literature review 
of impacts of legal regulation elsewhere (predominantly the US and Canada),234 on 
which we draw later in this chapter. 
 
7.73 From 1st April 2024, phase one decriminalised non-medical cannabis possession 
and domestic cultivation. German residents aged 18 and over are now permitted 
to possess up to 25g of cannabis in public and store up to 50g at home. They may 
consume the drug in public (though it is illegal to do so near premises including 
schools, playgrounds and sports grounds) and each household can grow up to 
three cannabis plants for personal consumption. 
 
7.74 Alternatively, users may register with a non-profit association to procure cannabis. 
Operational from July 2024, each association, or club, is permitted a maximum of 
500 members. Cannabis consumption on the premises is prohibited (similar to the 
Maltese approach) and all running costs are covered by membership fees.  
 
7.75 Phase two will pilot a time limited ‘experiment’ where specialist shops in 
participating cities and municipalities will be licensed for retail sales of non-medical 
cannabis (similar to Switzerland, see below). Evaluation will consider how public 
health, youth protection and the illegal market are impacted, as well as how supply 
chains cope and might scale up for any future roll-out nationwide.  
 
7.76 As an experiment with an associated research strategy rather than a formal 
change in the law, the expectation is that the plan will not breach EU regulations. 
This has, however, yet to be tested and at time of writing there remains no further 
detail or timescale for phase two of the country’s approach. 
 
7.77 Medical doctors and the police are reportedly largely opposed to the reforms. As, 
too, are the political opposition who have committed to scrapping the law if they 
win power in the next general election in 2025, which serves to highlight how 
politically controversial the issue of cannabis legalisation remains. 
 
 
234 Manthey, J., Hayer, T., Jacobsen. B., Kalke, J., Klinger S., Rehm, J. … & Zobel, F. (2023). Technical Report – 
Effects of legalizing cannabis. ECaLe_Technical_Report.pdf (bundesgesundheitsministerium.de). As a systematic 
review, this represents a methodologically robust assessment of available literature, encompassing only those studies 
which met stringent inclusion criteria. Studies we reference that are sourced from this paper we therefore considered 
to be robust and reliable. 

   
 
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Switzerland  
 
7.78 Cannabis for (limited) medical use has been legal in Switzerland since 2022 with a 
doctor’s prescription (before then, it was possible to obtain but patients were 
required to apply to the Federal Office of Public Health). The new law allows for 
easier access with a doctor's prescription, although the use of medical cannabis is 
not typically covered by compulsory health insurance unless in exceptional cases
235.  
 
7.79  While it remains illegal at the federal level, under a recently launched pilot 
programme participating cantons may provide non-medical cannabis through 
regulated, non-profit pharmacies, Drug Information Centres’ and social clubs 
(which allow consumption on site). Participating cantons include Basel, Bern, 
Geneva, Lausanne and Zurich, each of which is permitted to register a maximum 
of 5,000 participants who must meet a set of specific criteria236.  
 
7.80 Participants must prove themselves to be existing cannabis users, Swiss citizens, 
able to speak the principal language of the canton, and must undergo a range of 
health tests and questions before entering the pilot and at regular points 
throughout its term. ID cards are required to purchase cannabis and to 
demonstrate if stopped by law enforcement that the holder is legally permitted to 
possess the drug, making them immune from criminal sanction. These measures 
are intended to ensure scientific rigour and safeguard participant heath237.  
 
7.81 Irrespective of the canton, all cannabis available through the pilots will be 
produced organically in Switzerland by pre-approved cultivators. Available in dried 
flower, edible and hash form, THC levels are capped at 20% for dried flower and 
10mg per unit of edibles. Sale prices are set to reflect the current rate in the illegal 
market. All products must be sold in separate units of five grams with neutral, 
childproof packaging containing health warnings. Public consumption is 
prohibited, and violating this rule could result in a person having their cannabis 
confiscated238.  
 
7.82 The different cantons will lead independent evaluations of their project, conducted 
in partnership with universities (Basel’s pilot, for example, is known as Weed Care, 
and in Zurich it is the ZüriCan project). Each will examine the impact of regulated 
cannabis sales on consumption patterns and the health of users over the lifetime 
of the pilot239.  
 
The Netherlands 
 
7.83 One of the most well-known examples of de-penalisation of cannabis for personal 
possession and consumption, the current iteration of Dutch policy dates back to 
 
235 https://practiceguides.chambers.com/practice-guides/medical-cannabis-cannabinoid-regulation-2024/switzerland 
236 https://www.bag.admin.ch/bag/en/home/gesund-leben/sucht-und-gesundheit/cannabis/pilotprojekte/faqs.html 
237 Ibid. 
238 See footnote #235. 
239 https://cannactiva.com/en/cannabis-in-switzerland/ 

   
 
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the 1970s when the first coffee shops selling small amounts of cannabis for 
consumption on- and off-premise were established and tolerated.240 
 
7.84 A principal driver was the notion of ‘separation of markets’. It was thought that, by 
separating cannabis from other ‘harder’ drugs such as cocaine and heroin, limited 
access to the former could be facilitated in such a way that does not expose a 
user to other, riskier drugs that might be offered by an illegal source.241 The 
subsequent amendment to the relevant legislation in 1976 did not technically 
decriminalise cannabis, but rather implemented written guidelines that instructed 
prosecutors to consider prosecution of sale and possession of small amounts of 
cannabis as their lowest priority.242 
 
7.85 Following this, in 1977 further legislative changes gave localities across the 
Netherlands the power to decide whether to prosecute small-scale sales of 
cannabis, effectively introducing a policy of de-penalisation. This relates to the 
Dutch concept of gedogen, which ‘refers to activities that are not legal, but are not 
treated as illegal unless they cause other harms’.243 It also reflects the values 
placed by the Dutch on individual freedoms.244  
 
7.86 The coffee shop phenomenon that emerged in the 1970s expanded throughout 
the 1980s, leading the government to issue official guidelines for regulation in the 
early 1990s. Referred to as the ‘AHOJ-G’ criteria and enacted in 1994, these 
included limits on both the daily amount that can be sold to individuals and on 
advertising, which can amount to no more than very low-profile signposting of the 
coffee shop. Neither alcohol nor harder drugs can be sold or held on the premises 
(though up to 500 grams of cannabis is permitted) and cannabis sales are 
prohibited to under-age patrons.245  
 
7.87 Failure to comply with regulations led to the closure of many coffee shops from 
1997 onwards and further restrictions followed in an attempt to address ensuing 
concerns about public disturbances related to some shops, as well as the 
emergence of cannabis tourism. While these restrictions did not, in the main, last 
very long, as a consequence of regulations more broadly the number of coffee 
shops has continued to reduce over time and at the time of writing stands at c.570 
across the Netherlands.246 
 
7.88 The de-penalisation approach, or ‘toleration policy’, highlights the ‘back door 
problem’, whereby Dutch coffee shops selling cannabis are exempt from 
prosecution for the sale of small quantities (the front door), but still liable to 
 
240 See footnote #215.  
241 Grund, J-P. & Breeksema, J. (2013) Coffee Shops and Compromise: Separated Illicit Drug Markets in the 
Netherlands. Open Society Foundations.  
242 Stevens, A. (2010) Drugs, Crime and Public Health: The Political Economy of Drug Policy. Taylor and Francis 
Group.  
243 Ibid.  
244 See footnote #241. 
245 Ibid. 
246 Background and design of the controlled cannabis supply chain experiment | Drugs | Government.nl Accessed 
12th October 2023. 

   
 
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criminal prosecution for the purchase of large quantities to facilitate those sales 
(the back door).247 This legal uncertainty is one of the principal challenges of the 
model, and indeed was identified by many participants in our own research248 
when asked to consider the advantages and disadvantages of a range of 
approaches to cannabis regulation. The fact that consumers cannot be certain as 
to the provenance and constitution of the cannabis they purchase is a further 
difficulty.  
 
7.89 The government has recently come under increasing pressure to address these, 
and other problems caused by the toleration policy. As a result, they are preparing 
to launch a four-year experiment249 in ten regions, to explore the impacts of 
formally decriminalising cultivation, permitting provision (and regulation) of a 
quality-controlled supply of cannabis to coffee shops. Growers and coffee shops 
across participating regions will agree on the strains of cannabis to be provided, 
and within the framework of the experiment it will no longer be a criminal offence 
to grow, distribute or sell cannabis.  
 
7.90 Independent researchers have been appointed to monitor and evaluate the impact 
of the experiment, focusing on public order, crime and public health. While the 
government acknowledge there may be some economic benefits resulting from 
the trial, they stress these are not the focus. Key aims are to shrink the illegal 
market and improve public health, with coffee shop staff trained to provide 
information about the risks of cannabis and ways to reduce them. Staff will refer 
customers to sources of further information as well as support and treatment if 
they see signs of problematic use and shops must display a range of material 
setting out the risks of cannabis use. 
 
Denmark 
 
7.91 The Danish model for dealing with non-medical cannabis use is one of prohibition, 
although those found in possession of the drug for personal use are mostly fined 
rather than arrested. If they show signs of dependency or limited financial means, 
the police have discretion to issue a caution or divert into treatment.  
 
7.92 The approach was strengthened in the early 2000s, when fine levels were raised 
and the policing of low-level drug crime intensified, in an attempt to reinforce the 
deterrence approach and signal zero tolerance to drug use more widely. Surveys 
assessing consumption and treatment, however, suggest little effect with respect 
to cannabis.   
 
7.93 It was suggested to us that, as in other jurisdictions, those from marginalised and 
ethnic minority communities (which, of course, often overlap) are over-policed. 
That said, in some districts the police are purportedly becoming increasingly 
resistant to the zero-tolerance approach and are making more of their discretion 
 
247 Ibid.  
248 See footnote #11. 
249 Controlled cannabis supply chain experiment | Drugs | Government.nl Accessed 12th October 2023. 

   
 
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to divert people into treatment. The aim of this approach is ultimately to stop drug 
use, motivated by the fact police often encounter the same people using cannabis 
time and again. Which not only suggests the financial penalty approach has limited 
effect at best, it requires significant police resource to manage.  
 
7.94 Medical cannabis was legalised in Denmark in 2018, so prescription-based 
cannabis is now possible. As in the UK, however (see chapter 11), there are 
ongoing issues with implementation, with some doctors reluctant to prescribe and 
THC in medical cannabis capped at a low level. This means the illegal market 
continues to thrive – even for those able to access a prescription, it was put to us 
that the cannabis permitted may not always be of sufficient strength to address 
symptoms (particularly with respect to pain).  
 
7.95 Denmark is similar in many ways to other countries where non-medical use 
remains criminalised to some extent. But the country is also notable for its 
Freetown Christiania district. A commune comprising 15 local areas and situated 
in Copenhagen’s Christianshavn district, it dates back to the countercultural 
movement of the late 1960s and early 1970s. Legally recognised by the Danish 
government in 1989, it is very much a community-led enterprise with matters 
including finances, business operations, construction, and social and public 
services discussed and agreed at local level.  
 
7.96 An open, illegal cannabis trade has historically been a central element of the 
district’s culture and community. The drug has long been widely sold and used 
within Christiania and, until around two decades ago, the trade was supplied by 
small-scale dealers and sales managed through pop-up stalls situated 
predominantly on Pusher Street. Those involved were largely residents and/or 
employees of the community (although the district has always attracted a 
substantial tourist presence). While the police did on occasion raid Pusher Street 
and its environs, they largely left it alone.   
 
7.97 However, two decades or so ago organised crime gangs, whose members were 
neither resident in nor employed by Christiania, began to take over the trade, 
leading to a hardened police approach. Small-scale participants in the trade were 
largely forced out, unable to afford to take the necessary risks to remain involved. 
In 2016 two police officers and a civilian were shot and seriously injured by a 
Danish citizen known to be involved in cannabis sales, which led Christiania 
residents to remove the cannabis stalls in Pusher Street.  
 
7.98 The stalls ultimately returned, accompanied by regular police raids. But a fatal 
shooting in 2023, thought to be linked to the criminal cannabis enterprise, 
prompted residents to call for an end to the district’s illegal cannabis trade. A 
press release issued by Christiania called for it to be replaced by a state-regulated 
legal market, seen as a more effective way of dealing with the violence through 
lessening the grip of organised crime over trade of illegal cannabis. 
 
7.99 No such regulation has emerged. Indeed, quite the opposite, demonstrating that 
cannabis policies globally are not all moving in one direction, namely from 

   
 
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prohibition to liberalisation. In an attempt to end the organised cannabis trade in 
Christiania, a legal change in early 2024 designated the area an ‘enhanced 
penalty zone’. Those caught in possession of cannabis within the designated area 
face increased fines for first time offences and imprisonment for subsequent 
offences. While this is considered likely to reduce the cannabis trade in Christiania, 
experts have voiced concerns that it will merely relocate to other parts of 
Copenhagen. 
 
7.100 In terms of the district more widely, it is seeking to lose its former reputation and 
association. Based on collaborative agreement between Christiania residents, the 
police and the municipality of Copenhagen, in April 2024 the infamous ‘Pusher 
Street’ was dug up with the intention of turning it into a recreational area 
comprising playgrounds, gardens and creative art shops. 
 
Australia 
 
7.101 Non-medical cannabis is prohibited in Australian federal law, although in practice a 
majority of states and territories operate a cautioning scheme for minor cannabis 
and most other minor drug offences. Two, however, have in place some type of de 
jure (i.e. in law) decriminalisation, namely South Australia and the Northern 
Territory. Decriminalisation was also in place throughout the Australian Capital 
Territory (ACT) until 2020, when a limited legalisation scheme was introduced: 
 
i. ACT: Possession of all illegal drugs for personal use has been decriminalised 
(effective since October 2023, and since 1993 for cannabis). However, since 
31st January 2020 it has been legal for people over the age of 18 to possess, 
grow, and use small amounts of cannabis at home, in line with specified 
limits, namely: up to 50 grams of dry, or 150 grams of fresh, cannabis, and 
up to 2 plants per person and not more than 4 per household. Those who 
exceed the limits incur a Simple Cannabis Offence – a civil penalty (i.e.: fine). 
Using cannabis in a public place, growing it hydroponically or where it is 
accessible to the public, storing it where children can access it, and using it 
where children could be affected by cannabis smoke, remain illegal. 
ii. South Australia: Since 1987, police have issued a Cannabis Expiation Notice 
(CEN) for minor cannabis possession and cultivation offences. Over time the 
scheme has been tightened so that at present it is limited to those caught 
possessing up to 100 grams of cannabis, or 20 grams of resin, or cultivating 
no more than one plant for personal use.250. A fine of up to AU$400 must be 
paid within 28 days, after which no record is made. If the individual fails to 
pay, they receive a reminder, which attracts an additional fee. If they still do 
not pay, they are referred to court, leading to an enforcement fee, automatic 
criminal conviction and enforcement of the outstanding fine(s). 
iii. Northern Territory: Cannabis has been decriminalised since 1996251 and 
possession of up to 50 grams of cannabis, 1 gram of hash oil, 10 grams of 
 
250 See footnote #221.  
251 Ibid. 

   
 
114 
 
hash or 2 non-hydroponic cannabis plants results in an infringement notice 
requiring payment of a fine of up to AU$200. Failure to pay results in a debt 
owed to the state but there is no criminal conviction or formal record.  
 
7.102 While medical cannabis (including herbal cannabis flower) has been legal across 
the country since 2018, the position in some states and territories with respect to 
non-medical cannabis has shifted around following changes in government.  
 
7.103 Thus, under the Gallop Labor Government , Western Australia introduced a 
‘prohibition with civil penalties’ scheme in 2004. This meant personal possession (of 
not more than 30 grams of cannabis or a used smoking implement, or cultivation of 
not more than 2 non -hydroponic plants) was not legal but if apprehended, citizens 
were issued with an infringement notice . If they cleared this by paying a fine or 
completing an approved education session , they  would not receive a criminal 
record. This resulted in many thousands of people avoiding criminal penalties and 
the adverse consequences for employment, housing and travel that follow criminal 
conviction. 
 
7.104 The reform was, however, formally repealed in 2011 a s part of a ‘tough on crime’ 
approach adopted by the then Liberal state government, despite no evidence of a 
rise in cannabis use. Police may now issue a ‘Cannabis Intervention Requirement’ 
(CIR) to anyone found in possession of small amounts of the drug f or the first time, 
but this is at their discretion and users may still end up being prosecuted through 
the criminal courts. Anyone caught on a subsequent occasion having once been 
issued with a CIR is automatically prosecuted.  
 
7.105 This recriminalisation took place despite widespread public support, which has been 
growing steadily since the 1980s, for some form of legal regulation of non -medical 
cannabis – particularly among young people. Latest data at time of writing showed 
78% of Australians supported the removal of criminal penalties for cannabis (an 
increase from 74% in 2016)  and over 40% agreed it should be legalised (up from 
35% in 2016 ).252 The groundswell of public support for legal regulation remains 
difficult, however, for politicians who agree. Often labelled ‘Soft on Drugs’, they can 
become easy targets for the media and opposition parties , as indeed they are in 
other parts of the world. 
 
7.106 It was put to us that decriminalisation of possession both reduces the costs of law 
enforcement (around 76,000 arrests were made in 2019 –20 for cannabis 
possession across Australia)253 and helps address what can be very severe social 
consequences for those convicted of a minor cannabis -related offence (as we 
discuss elsewhere).  
 
7.107 However, because cannabis production and  supply remain criminal where 
possession is decriminalised, users must continue to access the illegal market 
 
252 See tables 9.15 and 9.23: National Drug Strategy Household Survey 2019, Data - Australian Institute of Health 
and Welfare (aihw.gov.au) Accessed 16th October 2023. 
253 Australian Crime Commission (2021). Illicit Drug Data Report 2019–20. 

   
 
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(where unable or unwilling to grow plants at home if this is also decriminalised) with 
all the risks inherent in doing so. Moreover, decriminalisat ion does little to address 
the stigma associated with using what remains an illegal drug , which, it was 
suggested to us  by experts across jurisdictions, does nothing to encourage 
problematic users to seek help (where drug treatment services exist).   
 
New Zealand 
 
7.108 Cannabis for non-medical use is prohibited in New Zealand. All associated 
activities remain illegal and the maximum sentence for personal possession is 3 
months' imprisonment (though this is rare) or a $500 fine. However, in 2019 the 
country passed into law a Misuse of Drugs Amendment which gave police greater 
discretion in terms of arresting and prosecuting those found in possession of illicit 
drugs. 
 
7.109 The amendment encouraged a health-centred approach, with prosecution 
reserved for more serious cases where the police considered it to be in the public 
interest. In practice though, at least for possession of cannabis, police have been 
increasingly exercising discretion not to prosecute for several years, with 
associated charges falling quite considerably as a result.  
 
7.110 Cannabis for medical purposes has been legal since 2018 and in 2020, the 
Misuse of Drugs (Medicinal Cannabis) Regulations 2019 came into force. This 
enabled implementation of the Medicinal Cannabis Scheme, intended to improve 
hitherto very limited access to medicinal cannabis products. In practice, however, 
many argue the Scheme has had little impact with those who find the drug 
alleviates symptoms of ill health still struggling with access.  
  
7.111 In the same year (2020), in a public referendum held during the general election, 
New Zealand’s voters narrowly rejected a Bill which would have legalised non-
medical cannabis for commercial (but regulated) production and distribution, as 
well as home-growing. Just over half (50.7%) voted against the proposal, with 
48.4% in support.  
 
Mexico 
 
7.112 There has been long-standing desire for drug policy reform in Mexico, where from 
1920 until recently cannabis was illegal for any purpose. A turning point came in the 
mid-2000s following various government crackdowns on OCGs trafficking drugs; 
many thousands of Mexicans were imprisoned following convictions for drug 
possession, in particular cannabis. 
 
7.113 This led to the establishment of thresholds for possession of certain substances, 
including cannabis, without danger of prosecution. In 2011, a series of reforms 
followed that placed human rights at the centre of Mexico’s constitution. These 
made laws compatible with human rights treaties to which Mexico was a signatory, 
cementing human rights into the country’s international obligations. The scene was 
set for renewed emphasis on drug policy reform and the judiciary were effectively 

   
 
116 
 
permitted to accept that  such reform was not out of line with human rights and 
international treaties designed to protect them.  
 
7.114 These reforms paved the way for several cases to be brought to the Supreme Court 
challenging laws on use of non -medical cannabis. In 2015, the Court r uled that 
prohibiting people from growing cannabis for personal consumption was 
unconstitutional as it ‘… violated the human right to the free development of one’s 
personality’,254 and this was followed by four further cases in which similar rulings 
were passed, the fifth of which took place in 2018.  
 
7.115 During this period (in 2017), the government also passed a bill permitting use of 
medical cannabis, although this is limited to pharmaceutical derivatives only, which 
are imported into the country. The barriers  to import can be substantial, meaning 
products are expensive. 
 
7.116 Under Mexican law, it was necessary for the Supreme Court to rule in five 
consecutive cases that the law on non -medical cannabis was unconstitutional, in 
order for legal jurisprudence to be re ached. Having done so, the Supreme Court 
cannot, however, then rewrite the law to enable non -medical cannabis to be fully 
legally regulated; this must be done by Congress. The necessary bill was drafted 
and by March 2021 had passed in both parliamentary ch ambers (Senate of the 
Republic and the Chamber of Deputies) – but is not yet enacted in full due to 
ongoing disagreement on several articles.  
 
7.117 This has created something of a halfway house. As a result of the Federal 
Congress’s inability to regulate, the Supreme Court issued a general declaration of 
unconstitutionality regarding the administrative prohibition system surrounding non-
medical cannabis. To operationalise this in the absence of a law in statute, those 
aged 18 and over may apply for a free -of-charge permit to cultivate and consume 
their own cannabis. This includes permission to carry up to 28 grams of cannabis 
(without a permit, over five grams is a criminal offence). As with tobacco, smoking 
cannabis in public and in front of children is banned. 
 
7.118 If a permit holder is stopped by police, they must articulate their protection in law 
and show their permit. While not necessarily sufficient to avoid arrest, the permit will 
protect its holder from subsequent criminal prosecution. Until, however, the co urt 
ruling is signed into federal law and a legal structure allowing cultivation, supply and 
sale of non -medical cannabis is created, cultivation beyond home grow, and 
transportation of amounts over 28 grams, remain illegal.  
 
7.119 Those unable or unwilling to grow cannabis or apply for a permit remain unable to 
legally access and consume non -medical cannabis, and those incarcerated for 
cannabis offences (many of whom have remained unsentenced for many years in 
 
254 Article 22 in the Universal Declaration of Human Rights Article states that: ‘Everyone, as a member of society, has 
the right to social security and is entitled to realization, through national effort and international co-operation and in 
accordance with the organization and resources of each State, of the economic, social and cultural rights 
indispensable for his dignity and the free development of his personality.’ 

   
 
117 
 
one of the largest prison populations in the world )255 continue in limbo with no path 
to release.  
 
7.120 Differences between criteria attached to permits issued at different times creates a 
confusing landscape and has effectively created different laws for different people. 
Permits issued more recently, for example, stipulate the maximum number of plants 
that an individual can grow, whereas earlier permits did not. 
 
7.121 It was put to us that without a change in the law police will continue to arrest people 
for possession of cannabis, although following the court ruli ng some judges are 
increasingly dropping cases and routing people away from incarceration on the 
grounds that it is unconstitutional. But because the law technically permits it, others 
continue to imprison people for cannabis possession.  
 
7.122 As we heard elsewhere, people from particular communities are disproportionately 
more likely to end up being arrested, charged and incarcerated – namely young 
men from poor households. And it was put to us that women in Mexico can be liable 
to particularly harsh treatment, attracting more serious charges and lengthier 
custodial sentences.  
 
7.123 We also heard that since the Supreme Court  ruling, several  large Canadian 
cannabis growers have been pressing to access the Mexican market, anticipating 
the time when the law is fully enacted. As relatively experienced operators (Canada 
regulated non -medical cannabis in 2018) they are well placed to set up quickl y, 
meet market entry criteria and comply with regulations. This provides them with a 
significant advantage as it risks undermining the position of local Mexican growers 
– often operating in entrenched poverty, they are forced to sell their product to 
criminal gangs who distribute it domestically and internationally.  
 
7.124 One aim of proposed legal regulation is to address the increased harms caused by 
a security-focused strategy aimed at ending Mexico’s ‘war on drugs’ . In the mid -
2000s increased fighting between rival drug gangs for control of territory and 
markets, including shipment routes, brought widespread and increasing use of the 
military in response.  
 
7.125 The strategy has arguably failed to stem the violence. Homi cide rates rose 256 
(despite a slight fall in recent years, over 360,000 people have been killed since 
2006)257 and over 100,000 Mexicans are currently registered in the interior 
ministry’s official database as ‘disappeared’: the vast majority, mostly thought to be 
victims of organised crime, have disappeared since inception of the military -based 
strategy. Moreover, the number of OCGs dedicated to drugs has increased very 
substantially, from a handful of big cartels to, we were told, over 300. 
 
 
255 Mexico was ninth at the time of writing, with 220,866 people in custody – Incarceration Rates by Country 2023 
(worldpopulationreview.com) Accessed 18th October 2023. 
256 See Mexico Murder/Homicide Rate 1990-2023 | MacroTrends Accessed 18th October 2023. 
257 https://www.cfr.org/backgrounder/mexicos-long-war-drugs-crime-and-cartels Accessed 30th July 2024.  

   
 
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7.126 While legal regulation is by no means expected to end the violence any time soon, 
it is hoped it will, as and when it comes, decrease the resources to which criminal 
organisations have access. This means they would be less able to effect harm and 
it should be easier for law enforcement to target and shut them down. 
 
In summary 
  
7.127 Clearly the global position with respect to legal frameworks governing non-medical 
cannabis is changing rapidly. The contents of this report are accurate at time of 
writing, but will inevitably become out of date as more countries seek alternatives 
to prohibition and evidence continues to emerge on the impact of doing so.  
 
7.128 While we set out evidence of those impacts to date in the next part of this chapter, 
it is important that the Mayor and UK government remain appraised of future 
developments in order to further review the position in this country when 
appropriate. We recommend, therefore, that changing international practice and 
associated outcomes, including those related to public health, levels of wider 
crime, size of the illegal market, burdens on criminal justice systems and 
economic considerations, be monitored, ideally by an independent body that 
reports into either City Hall or central government or both (R3).   
 
  

   
 
119 
 
7b: The impact of alternatives to prohibition 
 
The UNODC focuses on eight impacts of legal regulation (see Figure 5). All are broadly 
encompassed within our principal considerations, namely public health, crime and 
policing, and economic implications. After a brief introduction to contextual factors, in 
this second half of chapter 7 we explore what the evidence shows so far, considering: 
 
• Public health: including what happens to the prevalence of cannabis use and 
methods of consumption, parallel use of alcohol and tobacco, and rates of 
mental health disorder, poisonings, suicide and self-harm. Evidence on cannabis-
related road traffic incidents and use of the drug in pregnancy concludes this 
section.   
• Crime and policing: we cover what happens to volumes of arrests and charges 
for cannabis-related offences, the impact on law enforcement (principally police) 
expenditure and how expungement of criminal convictions for cannabis offences 
has operated. We also look at what happens to crime levels – including 
organised crime activities – and implications for the illicit cannabis market.  
• Economics of legalisation: here, we look at tax revenues, employment and the 
price of cannabis. Economic impacts vary as a function partly of the type of 
legalisation model, and we touch on this. We also look at the licit/illicit market 
interplay and the role of social equity – an explicit driver of regulatory change in 
some jurisdictions. 
• Other considerations: we close this chapter by looking briefly at how perceptions 
of cannabis use and associated risks change following legalisation, the role of 
public messaging, and concerns about public consumption of cannabis. 
 
Figure 5: Understanding the impacts of cannabis legalisation  
 
 
Source: United Nations Office on Drugs and Crime: WDR 2022_Booklet 3 (unodc.org)  
 
 
 

   
 
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Interpreting the evidence base  
 
7.129 Evaluation of regulatory change is both complex and in its infancy.258 The first 
markets for non-medical cannabis have existed for a little over ten years and plans 
for consistent, independent evaluation were not always in place from the outset.  
 
7.130 In addition, public policy that depends to a large extent on behaviour change to 
meet its objectives requires time to take effect (in the case of cannabis regulation 
this includes behaviour of users and law enforcement). Behavioural patterns do 
not change overnight, so expectations about the extent to which consequences 
can be reliably determined just a few years post-implementation must be realistic.  
 
7.131 Disentangling trends in cannabis consumption driven by regulatory changes from 
those related to the Covid-19 pandemic (some studies suggest consumption may 
have increased in response to changed daily routines and related stress) will also 
take time. 
 
7.132 Moreover, much of the evidence on the nature and extent of impacts lacks clear 
consensus. And as noted by the UNODC, different regulatory models operate in 
different social, legal and economic contexts , which mean trends in indicators 
monitored following p olicy change may be, to some extent at least, independent 
from the change itself and therefore not evidence of genuine cause and effect.  
 
7.133 Added to which is the fact that, reflecting both the complexity of the issues and the 
relative infancy of evaluation of legal regulation, there are , so far , few 
methodologically robust, wholly independent studies affording conclusions that offer 
little room for interpretation.  
 
7.134 For example, one review exploring the impact of legalisation on health screened 
6,253 relevant studies , of which 136 were eligible for review.259 Of those, only 13 
met the inclusion criteria for analysis. While these included data from a substantial 
number of participants (N=333,550), all were conducted in North America, meaning 
findings cannot be extrapolated wholesale to other contexts where different cultures 
and policy regimes will inevitably play a role in outcomes.     
 
7.135 We also note that most studies evaluating the impact of non -prohibitive models of 
regulation focus on full (commercial) legal regulation, particularly in the US. There 
are even fewer examinations of the impact of decriminalisation policies, for example, 
despite the fact that these are currently (globally) more common and widespread 
than legal regulation. 
 
 
258 Key issues summarised in: WDR22_Booklet_3.pdf (unodc.org) p.30. Accessed 24th October 2023. 
259 Manthey, J., Jacobson, B., Hayer, T., Kalke, J., López-Pelayo, Pons-Cabrera, M.T., Verthein, U. & Rosenkrantz, 
M. (2023). The impact of legal cannabis availability on cannabis use and health outcomes: A systematic review. 
International Journal of Drug Policy, 116. doi:10.1016/j.drugpo.2023.104039 
 

   
 
121 
 
7.136 All this being the case, we do, however, consider there to be some important early 
indications that we have understood from both the views put to us and wider data 
and research, which we set out in the remainder of this chapter.  
 
Public Health 
 
7.137 Changes in indicators of health harms are a crucial part of considering whether 
prohibition of non-medical cannabis is more or less harmful overall than alternative 
approaches. We have therefore explored whether adverse consequences for 
mental and physical health which can result from cannabis use (see chapter 8) 
rise in jurisdictions where it is legally permitted.  
 
7.138 We acknowledge once again the comparative newness of legislative changes. 
Health indicators will likely be affected by prevalence of cannabis use that broadly 
rises following relaxation in laws governing non-medical cannabis. But it will take 
time for the extent of any associated health consequences to become fully 
apparent. 
 
7.139 We are mindful, too, that, even where a legal cannabis industry has been in place 
for several years, it continues to adapt to meet demand and comply with 
regulatory frameworks. This means a steady-state scenario is unlikely to emerge 
for some time, and arguably, where it is beginning to do so, namely in early-
adopting US states, it will still be some while before longer-term trends are clear.  
 
7.140 Moreover, industry efforts to lobby for relaxations on limits designed to reduce 
health harms (for example, advertising, THC caps and levels of tax),260ʹ261 may 
bring as yet unknown further consequences for public health that complicate the 
picture.  
 
7.141 And alongside rising global trends in cannabis use there have been parallel rises in 
related health problems. These pre-date regulatory changes, meaning that, while 
several reviews point to increases in adverse health outcomes post- legalisation, 
the extent to which these are a direct effect is not yet wholly clear.  
 
Prevalence and frequency of cannabis use  
 
7.142 Whether legal regulation leads to a rise in cannabis use, particularly among the 
young given evidence of the adverse impact of use of the drug on brain maturation 
and cognitive function (see chapter 8), is a critical consideration.  
 
7.143 As above, attributing any rise to regulatory change is challenging because 
prevalence has been rising globally for some time, often for some years before 
non-medical use was introduced.262 In US states where it is permitted and those 
where it is not, as well as those where medical cannabis only is allowed, overall 
 
260 Hall, W., Stjepanović, D., Dawson, D. & Leung, J. (2023). The implementation and public health impacts of 
cannabis legalization in Canada: a systematic review. Addiction. doi:10.1111/add.16274 
261 See footnote #259. 
262 See for example footnote #215, pp.62–3. 

   
 
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prevalence rose between 2018 and 2021. Past-year use was higher in states 
where non-medical use is legal, but not substantially so (36% in 2021 compared 
with 33% in illegal states).263  
 
7.144 The UNODC, however, has concluded that, notwithstanding historical trends, 
legal regulation in the US, Canada and Uruguay has increased cannabis use (at 
least among adults),264 with similar conclusions reached by other studies and 
reviews.265ʹ266ʹ267 Recent research has reported an average increase in frequency 
of use in the US of around 20% or more following legalisation of non-medical 
cannabis.268 
 
7.145 While much evidence relies on self-report data, which tend to be confounded by 
the fact that people are more willing to disclose cannabis use once it is legal 
(meaning regulation does not change use, simply the likelihood of reporting it), 
several studies are based on comparative analysis of data from regions that have 
and have not introduced the measure. These are supported by a handful of 
(mainly US-based) wastewater analysis and workplace drug tests, which 
corroborate findings on prevalence.269   
 
7.146 Further evidence of a link between legalisation and increased use comes from 
Canadian sales data, which shows spending on legal non-medical cannabis has 
steadily increased since introduction of the Cannabis Act in 2018 – see Table 2: 
 
Table 2: Canadian retail sales of adult-use non-medical cannabis, 2018–2023 
 
Month ending December Sales ($billion) 
2018 0.16 
2019 1.2 
2020 2.6 
2021 3.8 
2022 4.5 
2023 5.1 
 
263 Hammond, D., Corsetti, D., Goodman, S., Iraniparast, M., Danh Hong, D. & Burkhalter, R. on behalf of the ICPS 
Research Team. (2022). International Cannabis Policy Study – United States 2021 Summary. Sept 2022. 
264 See WDR 2022_Booklet 3 (unodc.org) Accessed 20th October 2023.  
265 See footnote #234.  
266 See for example Lalam, N., Weinberger, D., Alimi, D., Obradovic, I. & Gandilhon, M. (2017). Executive summary of 
the Cannalex study results. 
267 See footnote #260.  
268 See Zellers, S.M., Ross, J.M., Saunders, G.R.B., Ellingson, J.M., Anderson, J.E., Corley, R.P. … & Vrieze, S. 
(2023). Impacts of recreational cannabis legalization on cannabis use: a longitudinal discordant twin study. Addiction, 
118(1), pp.110–118. doi.org/10.1111/add.16016. See also Pessar, S.C., Smart, R., Naimi, T., Lira, 
M., Blanchette, J., Boustead, A. & Pacula, R.L. (2024). The association between state cannabis policies and 
cannabis use among adults and youth, United States, 2002–2019. Addiction. doi.org/10.1111/add.16663  
269 Hollingsworth, A., Wing, C. & Bradford, A.C. (2022). Comparative Effects of Recreational and Medical Marijuana 
Laws on Drug Use among Adults and Adolescents. The Journal of Law and Economics, 65(3), 515–54: Burgard, 
D.A., Williams, J., Westerman, D., Rushing, R., Carpenter, R., LaRock, A. … & Banta-Green, C.J. (2019). Using 
wastewater-based analysis to monitor the effects of legalized retail sales on cannabis consumption in Washington 
State, USA. Addiction, 114(9), pp.1582–90. Both cited in ECaLe_Technical_Report.pdf 
(bundesgesundheitsministerium.de). 

   
 
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Source: Statistics Canada 2023270 
 
7.147 As in the US, cannabis use in Canada had been increasing pre-legal regulation.271 
But legal sales data, combined with the fact that these outpaced decreasing sales 
in the illegal market, equates to a net rise in estimated overall spend on the drug 
(combining non-medical, medical and illegal sales) of around 40% between 2018 
and 2022.272  
 
7.148 In addition, the growth in reported use noted by the Expert Review Panel 
responsible for the legislative review of the Cannabis Act 2018273 is marked. 
Almost seven million Canadians (22% of those aged 15 and over) reported past-
year use of cannabis in 2020–2021.274 This is an increase of over two million 
people, or 56%, compared with data from pre-legalisation in 2017.275 Similarly, the 
International Cannabis Policy Study (ICPS)276 reported prevalence of past-year use 
in 2018 among Canadians aged 16–65 to be 28%, rising to 35% in 2022. Monthly 
and daily/near daily consumption followed a similar pattern (19% to 25% and 9% 
to 12% respectively).  
  
7.149 Whether cannabis use specifically among young people changes following legal 
regulation is unclear. While some reviews report there is little evidence that 
frequency of use among existing young users is affected,277 analyses report mixed 
findings with respect to overall prevalence. It is, however, still early days. As 
pointed out by authors of the review undertaken for the German government, 
youth use is likely to change over time as cannabis becomes more normalised 
among adults following legal regulation (as has been the case for cigarettes and 
alcohol). Inevitably this will take time.  
 
7.150 We heard from several witnesses that levels of use have remained largely stable 
among young people in the US and Canada, and several academic reviews 
agree278 (with similar evidence from Uruguay).279 Indeed, one recent study found 
no evidence that legalisation was associated with encouraging cannabis use 
among a large national sample of young people (aged around 16) across the 
US.280  
 
270 Statistics Canada. Table 20-10-0056-01  Monthly retail trade sales by province and territory (x 1,000). 
doi.org/10.25318/2010005601-eng Accessed 15th April 2024. 
271 Health Canada. Canadian Alcohol and Drugs Survey (CADS): summary of results for 2019. Canadian Alcohol and 
Drugs Survey (CADS): summary of results for 2019 - Canada.ca. Accessed 20th October 2023. 
272 See footnote #234, p.50. 
273 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca 
274 Statistics Canada, Canadian Community Health Survey 2021. (2022). Table 13-10-0096-01  Health 
characteristics, annual estimates https://doi.org/10.25318/1310009601-eng Accessed 20th October 2023.  
275 Health Canada. (2018). Canadian Tobacco, Alcohol and Drugs Survey (CTADS): summary of results for 2017. 
Canadian Tobacco Alcohol and Drugs (CTADS) Survey: 2017 summary - Canada.ca Accessed 20th October 2023. 
276 Hammond, D., Corsetti, D., Fataar, F., Iraniparast, M., Danh H.D. & Burkhalter, R. (2023). International Cannabis 
Policy Study – Canada 2022 Summary. 
277 See footnotes #234, p.37 and #258. Accessed 24th October 2023. 
278 See for example footnote #260. 
279 Rivera-Aguirre, A., Castillo-Carniglia, A., Laqueur H.S., Rudolph, K.E., Martins, S.S. & Cerdá, M. (2021). Does 
recreational cannabis legalization change cannabis use patterns? Evidence from secondary school students in 
Uruguay. Addiction (117), pp.2866–77. 
280 Anderson, D.M., Fe, H.T., Liang, Y. & Sabia, J.J. (2024). Recreational Marijuana Laws and Teen Marijuana Use. 
JAMA Psychiatry, pp.1993–2021. doi:10.1001/jamapsychiatry.2024.0698 

   
 
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7.151 Several other studies report a rise in prevalence of cannabis use, with still others 
suggesting it has fallen following legalisation. Concentrating on those with longer 
follow-up periods, however, it seems likely that in the longer-term youth use 
rises.281 Some of this is probably due to non-users initiating consumption – 
certainly, there are some data from the US and Canada which suggest legalisation 
increases the likelihood of this happening.282 
 
7.152 The same is true for adults, i.e. at least some of the rise in prevalence is probably 
driven by previous non-users entering now legal markets,283ʹ284 possibly no longer 
deterred by the risk of criminal sanction. Where overt marketing, wide product 
ranges and a high density of retail outlets are permitted, it seems intuitive that the 
likelihood of non-users trying cannabis is heightened, even if use is not sustained. 
We discuss implications of different elements of commercialisation later in this 
chapter.  
 
7.153 Among young people (aged both up to and over 18), at least in Canada, use has 
almost certainly risen post-legalisation.285 While difficult to causally attribute given 
prior rising trends, the rate of increase among young adults aged 20–24, between 
the months preceding and subsequent to legal regulation, was greater than 
among other age groups.286 Notably, while use of cannabis at least once in the 
preceding year was highest among those aged 26–35 (47%), over one-third 
(34%) of those aged 16–25 reported doing so.  
 
7.154 We must also have regard to an important health-related side effect of any rise in 
prevalence of cannabis. Namely, that where the drug is co-consumed with 
tobacco, use of the latter likely rises. As the primary method of cannabis 
consumption in the UK, this would represent a very unwelcome consequence of a 
move away from prohibition of the drug for non-medical use.  
 
7.155 If increased prevalence were driven by use of cannabis without tobacco (whether 
smoked in isolation, vaped or consumed via edibles) this might be less of a 
concern: evidence from Canada suggests this is feasible (see para.7.160) but it is 
difficult to know whether the pattern would replicate in the UK, where co-
consumption is so dominant. 
 
281 See footnote #234, p.35.  
282 Ibid, pp.35–6. 
283 Gunadi, C., Zhu, B & Shi, Y. (2022). Recreational cannabis legalization and transitions in cannabis use: findings 
from a nationally representative longitudinal cohort in the United States. Addiction, 117(10), pp.2651–9: 
Hollingsworth, A., Wing, C. & Bradford, A.C. (2022). Comparative Effects of Recreational and Medical Marijuana 
Laws on Drug Use among Adults and Adolescents. The Journal of Law and Economics, 65(3), pp.515–54. Cited in 
ECaLe_Technical_Report.pdf (bundesgesundheitsministerium.de). 
284 See footnote #259. 
285 See footnote #234, p.51 for data on those aged over 18. For data on 12–18 year olds, see Imtiaz, S., Nigatu, Y.T., 
Sanches, M., Ali, F., Boak, A., Douglas, L. … & Elton-Marshall, T. (2024). Effects of cannabis legalisation on patterns 
of cannabis consumption among adolescents in Ontario, Canada (2001–2019). Drug Alcohol Rev, 43(3), pp.764–
774. doi.org/10.1111/dar.13786. Legalisation was not associated with increased cannabis initiation during the first 
year, but was associated with an increased likelihood of any cannabis use, daily use and cannabis dependence. 
286 Health Canada. Canadian Alcohol and Drugs Survey (CADS): summary of results for 2019. Available at Canadian 
Alcohol and Drugs Survey (CADS): summary of results for 2019 - Canada.ca. Accessed 20th October 2023. 

   
 
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7.156 Associated, too, with any rise in prevalence of cannabis use is the risk of a 
consequent rise in problematic use, which might increase the prevalence of 
symptoms of poor mental or physical health. 
 
7.157 In terms of less punitive approaches to non-medical cannabis that fall short of legal 
regulation, namely decriminalisation or de-penalisation, and their impact on 
cannabis use, it is again difficult to disentangle effects from prior trends. One 
recent review, however, drawn from studies in Australia, the Czech Republic, 
Denmark, Germany, Jamaica, the Netherlands, Portugal, the UK and the US, 
found no strong evidence for a link between reduced sanctions for drug 
possession and increased drug use.287  
 
7.158 And one European review reported an increase in cannabis use (as well as in 
potency and treatment rates) across most countries and age groups, irrespective 
of the legal framework in place. While reported daily use among past-month users 
was highest in Portugal, followed by Luxembourg and Spain – in all three, 
possession of cannabis is effectively decriminalised – overall past-month use rates 
were higher in several other countries where it is not, including France.288  
 
Cannabis products and methods of consumption 
  
7.159 Legal regulation typically diversifies the range of cannabis products available. 
While some jurisdictions such as Uruguay and Malta have acted to limit this, 
others permit sales of a wide variety of products with equally wide variation in 
levels of THC. More potent products, particularly dabs and other forms of 
concentrate that can be up to 90% THC, have become available in many 
markets289 and, it was put to us, demand increases to match. This is perhaps 
inevitable as more users are exposed to such products, but is nonetheless of 
concern given the generally accepted increased risk to health of consuming very 
high-strength cannabis. 
 
7.160 While dried cannabis flower remains the most popular, use is falling against rising 
use of other products. The Canadian ICPS290 reported falls among users of both 
flower and hash (81% consumed flower in 2018, down to 68% in 2022, with hash 
falling from 25% to 21%), with rises in use of all other product types including 
edibles, vapes and tinctures. Perhaps unsurprisingly given the fall in use of flower, 
the Legislative Review of the Canadian Cannabis Act reported a decline in 
smoking of cannabis between 2018 and 2022 (from 89% to 70% among past-year 
 
287 Stevens, A., Hughes, C.A., Hulme, S. & Cassidy, R. (2022). De-penalization, diversion and decriminalization: A 
realist review and programme theory of alternatives to criminalization for simple drug possession. European Journal of 
Criminology, (19), pp.29–54. 
288 Manthey, J., Freeman, T.P., Kilian, C., López-Pelayo, H. & Rehm, J. (2021). Public health monitoring of cannabis 
use in Europe: prevalence of use, cannabis potency, and treatment rates. The Lancet Regional Health – Europe. 
doi.org/10.1016/j.lanepe.2021.100227 
289 See for example footnote #260. 
290 See footnote #276. 

   
 
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users), with a concurrent rise in consumption of edibles (41% to 53%) and vape 
pens (16% to 33%).291 
 
7.161 Consumption patterns across Canadian provinces and territories vary little with 
respect to different products, with the exception of Québec, where consumers are 
less likely to report using edibles, vape oils, topicals and concentrates. Notably, 
Québec remains the only province to cap THC at 30% and to implement 
restrictions on edibles and vape oils, and has fewer stores per capita than other 
regions, as shown in Table 3.  
 
Table 3: Cannabis retail stores across Canadian regions, September 2022 
 
Sales 
regulatory 
model 
Region Cannabis stores per 
100,000 population 
Public 
Nova Scotia 5.11 
New Brunswick 3.73 
Prince Edward Island 2.75 
Québec 1.24 
Private 
Alberta 20.38 
Yukon 16.41 
Northwest Territories 16.29 
Saskatchewan 15.46 
Manitoba 14.12 
Ontario 12.10 
British Columbia 10.13 
Newfoundland & Labrador 8.96 
Nunavut 3.56 
 Canada (all regions) 10.6 
Source: Myran et al. (2023)292 
 
7.162 Table 3 shows clear differences in access to cannabis outlets between Canadian 
jurisdictions operating private retail models and those with public, or state-run, 
models. The former had on average 6.98 times more stores per capita than public 
systems (13.19 vs. 1.83 stores per 100,000 individuals aged 15+ years). Not 
surprisingly, therefore, neighbourhoods in private retail regions are closer to their 
nearest cannabis store (2.55 mins drive vs. 5.63 min).  
 
7.163 Regions operating private retail models also, however, experienced eight times 
more permanent store closures than those with public models (7.8% vs. 0.6%) – 
although they sold on average 1.82 times more ($13.53 vs. $7.43 CAD per 
individual aged 15+ years) before doing so.  
 
 
291 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.22. 
292 Myran, D.T., Friesen, E.L., Dickson, S., Konikoff, L., Arora, G. & Tanuseputro, P. (2023). Access to legal cannabis 
market in Canada over the four years following non-medical cannabis legalisation. Drug and Alcohol Review, 42(5), 
pp.1114–9. doi.org/10.1111/dar.13650 

   
 
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7.164 We consider the economic consequences and sustainability of legal regulation in 
more detail later in this chapter but, importantly, evidence suggests that greater 
retail availability is associated with increases in both use293 and related healthcare 
visits.294 
 
Cannabis as replacement for alcohol and tobacco 
 
7.165 Levels of consumption of alcohol and tobacco continue to cause alarm among 
public health officials across the world, and there is some suggestion that, once 
legally available, non-medical cannabis can help stem use of both through 
substitution.  
 
7.166 This depends, however, on cannabis being consumed without tobacco. As we set 
out previously, the dominance of co-consumption in the UK means there may be 
more risk of tobacco use in fact rising following any change to the legal framework 
governing non-medical cannabis than is the case in jurisdictions where cannabis 
tends to be smoked in isolation. Unless, that is, tobacco-smoking behaviour could 
be shifted. 
 
7.167 Use of tobacco overall is declining: the WHO reported 1.30 billion global users in 
2020, down from 1.32 billion in 2015, and estimates a further fall to 1.27 billion by 
2025.295 Legal regulation of non-medical cannabis coincides: between 2002/03 
and 2019/20, falls in tobacco use were observed in US states both with and 
without access to legal non-medical cannabis.296   
 
7.168 Alcohol consumption, however, remained stable over the same period regardless 
of the legal status of non-medical cannabis. While cannabis use rose across US 
states, it began to do so several years earlier where non-medical use was 
legalised, and there is some indication that binge drinking was also slightly higher 
in those states. The UNODC conclude that, while there is no evidence that 
legalisation of non-medical cannabis impacts on alcohol sales, there is a positive 
association between regular cannabis and alcohol use in US and Canada.297 
 
7.169 More recently in Canada, sales of both alcohol and non-medical cannabis have 
been steadily rising following legal regulation of the latter.298 It was also suggested 
to us that players in the alcohol and tobacco industries, here and elsewhere, are 
increasingly seeking to enter the legal cannabis market, perceiving future 
opportunities in light of risk of declining sales (despite there being little evidence of 
 
293 Young-Wolff, K., Pacula, R.L. & Silver, L.D. (2022). California Cannabis Markets – Why Industry-Friendly 
Regulation Is Not Good Public Health. JAMA Health Forum, 3(7) doi:10.1001/jamahealthforum.2022.2018 
294 See footnote #292. 
295 See 9789240039322-eng.pdf (who.int) Accessed 24th October 2023. 
296 See footnote #264. Accessed 24th October 2023. 
297 Ibid. Accessed 24th October 2023. 
298 See chart 6, Research to Insights: Cannabis in Canada (statcan.gc.ca) Accessed 25th October 2023. 

   
 
128 
 
this so far). This also, of course, opens up the future possibility of the infusion of 
cannabis products with alcohol or tobacco.299  
 
Psychiatric disorders and Cannabis Use Disorder (CUD)300 
 
7.170 Evidence on whether legalisation of cannabis for non-medical purposes directly 
increases the prevalence of mental health disorders, at least in the short term, is 
so far mixed. As with other measures of impact, research often fails to account for 
the fact that cannabis-related hospital admissions were increasing in many places 
before regulatory change.  
 
7.171 That said, experts largely agree the lack of clear evidence of a causal relationship 
between legally available non-medical cannabis and increasing rates of mental 
health disorder overall does not preclude the emergence of such over the longer 
term. In our view, and that of many health experts, an increasing body of evidence 
suggests some relationship between access to legal cannabis and increased rates 
of both psychosis and Cannabis Use Disorder (CUD) – although there may well be 
other factors involved. 
 
7.172 There has been a modest rise overall in the number of adults and young people 
across the US and Canada showing symptoms of, or being admitted to hospital 
with, signs of CUD.301ʹ302 Rises in US jurisdictions permitting non-medical cannabis 
tend, however, to be greater than in those which have not.303 
 
7.173 It is possible of course that, rather than a genuine increase, such rises simply 
reflect a greater willingness to self-disclose symptoms post-legal regulation. 
Several experts from whom we heard were, however, sceptical of this suggestion 
and, on balance, we consider that the possibility of legalisation leading to a rise in 
CUD cannot be ruled out.  
 
7.174 Indeed, in one US state where non-medical cannabis use is legal, around one-fifth 
of a recent sample of healthcare patients who reported using the drug showed 
signs of CUD. Moreover, moderate to severe symptoms were more prevalent 
among those reporting non-medical use, either alone or alongside medical use 
cannabis.304 Which suggests use of the drug for medical purposes is also not 
 
299 Kilmer B. (2019). How will cannabis legalization affect health, safety, and social equity outcomes? It largely 
depends on the 14 Ps. The American Journal of Drug and Alcohol Abuse, 45(6). 
doi:10.1080/00952990.2019.1611841 
300 Cannabis dependence, also known as cannabis use disorder, refers to a problematic pattern of cannabis use 
characterised by the development of tolerance, withdrawal symptoms upon cessation, unsuccessful attempts to cut 
down or control use, and continued use despite negative consequences. American Psychiatric Association, DSM-5 
Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric 
Publishing, Inc. doi.org/10.1176/appi.books.9780890425596  
301 See footnote #234, p.70. 
302 See footnote #260. 
303 See for example Cerdá, M., Mauro, C., Hamilton, A., Levy, N.S., Santaella-Tenorio, J., Hasin, D. …. & Martins, 
S.S. (2020). Association between recreational marijuana legalization in the United States and changes in marijuana 
use and cannabis use disorder from 2008 to 2016. JAMA Psychiatry, 77, pp.165–71. 
304 Lapham, G.T., Matson, T.E., Bobb, J.F., Luce, C., Oliver, M.M., Hamilton, L.K. & Bradley, K.A. (2024). Prevalence 
of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is 
Legal. JAMA Network Open, 6(8). doi:10.1001/jamanetworkopen.2023.28934 

   
 
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without risk – although whether that risk is outweighed by benefits in terms of 
alleviating other symptoms of ill health is unclear.  
 
7.175 This is supported by diagnoses of CUD among US veteran populations. While 
rates increased overall between 2005 and 2019, the rise was slightly higher both 
in states that had legalised cannabis for medical use only and those where non-
medical use was also permitted (although the role of other factors could not be 
ruled out).305  
 
7.176 In terms of psychiatric disorders and the impact of legalisation (for medical or non-
medical use), the picture is more mixed. Some US data suggest state cannabis 
policies have not been associated with a statistically significant increase overall in 
rates of psychosis-related health outcomes, or in prescribed anti-psychotic 
medication, although there is some indication of a rise among particular groups.306  
 
7.177 Conversely, in Colorado, one of the first US states to legalise non-medical 
cannabis, the prevalence of mental health conditions in emergency department 
visits has been shown to be higher among those reporting cannabis exposure than 
those without.307 Direct causality, however, remains elusive as other factors 
alongside legalisation remain possible drivers. 
 
7.178 Canadian evidence so far is relatively limited, with no conclusive evidence that 
non-medical cannabis legalisation is responsible for significant rises in visits to 
emergency departments involving symptoms of psychosis or schizophrenia. While 
presentations have been rising, the trend pre-dates legalisation in 2018 (tripling 
between 2006 and 2016). 308 Which once again serves to highlight the difficulty in 
extrapolating precise impacts of regulatory change. 
 
7.179 What seems clearer, however, is a link between commercial expansion of the legal 
cannabis industry and increased risk of mental health disorder. Health 
administration records from several Canadian provinces showed emergency 
department visits for cannabis-induced psychosis rose following implementation of 
 
305 Hasin, D.S., Wall, M.M., Choi, C.J., Alschuler, D.M., Malte, C., Olfson, M. & Saxon, A.J. (2023). State Cannabis 
Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019. JAMA Psychiatry, 
80(4), pp.380–8.   doi:10.1001/jamapsychiatry.2023.0019 
306 Elser, H., Humphreys, K., Kiang M.V., Mehta, S., Yoon, J.H., Faustman, W.O. & Matthay, E.C. (2023). State 
Cannabis Legalization and Psychosis-Related Health Care Utilization. doi:10.1001/jamanetworkopen.2022.52689 
Accessed 26th October 2023. 
307 Hall, K.E., Monte, A.A., Chang, T., Fox, J., Breivik, C., Vigil, D.I. … & James, K.A. (2018). Mental Health–related 
Emergency Department Visits Associated With Cannabis in Colorado. Academic Emergency Medicine, 25(5), 
pp.477–608. doi.org/10.1111/acem.1339 
308 Callaghan, R.C., Sanches, M., Murray, R.M., Konefal, S., Maloney-Hall, B. & Kish, S.J. (2022). Associations 
Between Canada’s Cannabis Legalization and Emergency Department Presentations for Transient Cannabis-Induced 
Psychosis and Schizophrenia Conditions: Ontario and Alberta, 2015–2019. The Canadian Journal of Psychiatry, 
67(8), pp.616–25. doi:10.1177/07067437211070650 

   
 
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full commercialisation of non-medical cannabis.309,310 In contrast, no such rise was 
observed during the initial period of legalisation, when restrictions were in place on 
the number of stores and range of cannabis products permitted.  
 
7.180 Moreover, the number of retail outlets per capita and proximity to a retailer has 
been associated with higher use of health services for the treatment of psychosis 
in both Canada311 (specifically Ontario) and Colorado.312 Which suggests the 
burden of psychosis on mental health services may rise in line with greater 
numbers of cannabis outlets, particularly in areas where populations are at higher 
risk of onset of cannabis use and/or a greater predisposition to psychosis. 
 
7.181 As a result, the Canadian Legislative Review panel recommended health warning 
messages that pertain to cannabis-related mental health risks, including psychosis 
and schizophrenia, should be (re)instated across cannabis products.313  
 
7.182 We have not only considered fully legalised settings. Following decriminalisation of 
all drugs in 2001 and a corresponding rise in (reported) cannabis consumption, 
Portugal saw a substantial rise in hospitalisations for psychotic disorders. Between 
2000 and 2015, the number of hospitalisations for psychotic disorders or 
schizophrenia associated with cannabis use increased by around 30 times 
(although how much of this was due to increased propensity to seek help following 
decriminalisation is unclear), and the proportion of cases with a secondary 
diagnosis of cannabis use or dependence rose from 0.87% to 10.6%.314 
 
7.183 That said, the impact of the policy on overall use of cannabis is debatable.315 
Evidence is mixed but does not indicate any dramatic effect either way – as above 
(para.7.158), Portugal does not appear to have become a particular outlier in 
comparison with other European nations.     
 
7.184 Cannabis strength is also relevant to consideration of psychotic disorders and 
CUD as higher potency is linked to increased risk of both.316 As legally regulated 
 
309 Myran, D.T., Pugliese, M., Roberts, R.L., Solmi, M., Perlman, C.M., Fiedorowicz, J. … & Anderson, K.K. (2023). 
Association between non-medical cannabis legalization and emergency department visits for cannabis-induced 
psychosis. Molecular Psychiatry. doi.org/10.1038/s41380-023-02185-x  
310 Myran, D.T., Gaudreault, A., Konikoff, L., Talarico, R. & Pacula, R. L. (2023). Changes in Cannabis-Attributable 
Hospitalizations Following Nonmedical Cannabis Legalization in Canada. JAMA Netw Open, 6 (10). 
doi:10.1001/jamanetworkopen 
311 Wootten, J.C., Rodrigues, R., Gilliland, J., Carter, B., Shariff, S.Z., Zhong, S. … & Anderson, K.K. (2023). The 
effect of non-medical cannabis retailer proximity on use of mental health services for psychotic disorders in Ontario, 
Canada. International Journal of Social Psychiatry, pp.1–11. doi:10.1177/00207640231206053 
312  Wang, G.S., Buttorff, C., Wilks, A., Schwam, D., Tung, G. & Pacula, R.L. (2022). Impact of cannabis legalization 
on healthcare utilization for psychosis and schizophrenia in Colorado. Int J Drug Policy. 
doi:10.1016/j.drugpo.2022.103685 
313 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.33, recommendation 9. 
Accessed 17th April 2024. 
314 Gonçalves-Pinho, M., Bragança, M. & Freitas, A. (2020). Psychotic disorders hospitalizations associated with 
cannabis abuse or dependence: a nationwide big data analysis. International Journal of Methods in Psychiatric 
Research. doi.org/10.1002/mpr.1813 
315 See discussion in footnote #218, p.29.  
316 Petrilli, K., Ofori, S., Hines, L., Taylor, G., Adams, S. & Freeman, T.P. (2022). Association of cannabis potency with 
mental ill health and addiction: a systematic review. The Lancet Psychiatry Review, 9(9), pp.736–50. 
doi.org/10.1016/S2215-0366(22)00161-4 Accessed 26th October 2023. 

   
 
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markets emerge, expand and seek to meet demand for product variety, potency is 
likely to be of increasing concern to those seeking to minimise adverse 
consequences for public health. As one witness put it to us, cannabis in the 1980s 
was generally no higher than 5% THC. Cannabis in the 2020s, however, averages 
around 20% THC, with daily use also more likely.  
 
7.185 With more people using cannabis than pre-legal regulation, and very high-strength 
products available in many markets, the expectation among several of those we 
heard from is that mental health problems associated with cannabis use will 
increase over the next generation. We heard too that the extent of cannabis use 
among patients in psychosis clinics is very high, and demand for such services is 
thought likely to increase. 
 
Poisonings 
 
7.186 Cannabis-related poisonings have increased following legal regulation. Related 
calls by adults and young adults to US poison centres rose following retail sales 
beginning in nine states (by 77% and 61% respectively) and emergency 
department data in several US states (including Colorado and California)317 and 
Canadian provinces/territories318 shows this followed through to admissions. 
 
7.187 Poisonings, some of which have resulted in hospitalisation, have also risen among 
children.319,320,321 This is thought to be largely down to unintentional ingestion of 
cannabis edibles in the home,322 and data from Canada suggests the more 
commercial the approach to regulation and the greater the variety of products 
permitted to be sold, the greater the rise in accidental intoxication.  
 
7.188 The rise in Canada is notable given strict regulations in place aimed to minimise 
childhood poisonings, including a maximum of ten mg THC per package of edibles 
(which is ten times less than some US states permit), plain and child-resistant 
packaging, and education campaigns to raise awareness of how to store edibles 
safely at home.323  
 
7.189 It was put to us that the nature of edibles, however clear the labelling around dose 
and strength, means they can lend themselves to over-consumption. We heard 
how one serving size could equate to, for example, one or two gummies out of a 
larger pack, or one-tenth of a cookie. Arguably, expecting a user to restrict 
consumption to such a small proportion of available product, particularly when the 
 
317 See footnote #264. Accessed 30th October 2023. 
318 See footnote #234, pp.27, 39. 
319 Ibid, p.39. 
320 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca 
321 Myran, D.T., Tanesuptro, P., Auger, N., Konikoff, L., Talarico, R. & Finkelstein, Y. (2023). Pediatric hospitalizations 
for unintentional cannabis poisonings and all-cause poisonings associated with edible cannabis product legalization 
and sales in Canada. JAMA Health Forum. doi:10.1001/jamahealthforum.2022.5041 
322 See footnote #234. 
323 Myran, D.T., Tanuseputro, P., Auger, N., Konikoff, L., Talarico, R. & Finkelstein Y. (2022). Edible cannabis 
legalization and unintentional poisonings in children. New England Journal of Medicine: Research, 387, pp.757–9.  

   
 
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effects take some time to materialise (certainly longer than when cannabis is 
smoked or vaped), is to misunderstand human behaviour.  
 
7.190 Access to legal, quality-assured cannabis may, however, at least reduce use of 
synthetic cannabinoids, thought to pose a greater danger to health (see chapter 
8) than botanical cannabis. There is some limited evidence of a fall in emergency 
admissions caused by synthetics,324 but the extent to which this offsets rises in 
legal cannabis-related poisonings and other adverse health consequences is 
unclear. 
 
7.191 And quality assurance is dependent on quality of the testing process. In Canada 
this is overseen by the state, but in the US the system is more fragmented. While 
federal prohibition remains in place, national services to oversee and deliver 
testing have not been possible, leading to inconsistency within and across states 
that permit non-medical cannabis. We heard that in California, for example, 
cannabis producers choose who assures their products, which has led to some 
degree of gaming and a lack of clarity over relative equivalence of cannabis from 
different producers. 
 
Suicide and self-harm  
 
7.192 So far, evidence of association between self-harm and cannabis consumption is 
limited. And while mental health disorders, particularly depression, can raise the 
risk of suicide, and depression can be associated with cannabis use (especially 
more frequent use),325 it is difficult to unpick the relationship. Whether poor mental 
health is a cause or result of cannabis use is a complex question.  
 
7.193 This means conclusions as to whether legal regulation of cannabis causes suicide 
rates to rise are difficult to reach. And the relatively few robust studies that have 
explored the issue have reported mixed findings. The evidence review 
commissioned by the German government (see para.7.72) found little evidence of 
regulation increasing self-harm (including non-suicidal and suicidal attempts) 
among adults, although reported a tentative suggestion of association with a rise 
among men aged between 21 and 39 years in the US.326  
 
7.194 While the UNODC has reported higher suicide rates in US states that allow non-
medical cannabis compared with those where it remains illegal,327 the quality of 
studies in this area more broadly has been characterised as low.328  
 
 
324 Klein, T.A., Dilley, J.A., Graves, J.M. & Liebelt, E.L. (2022). Synthetic cannabinoid poisonings and access to the 
legal cannabis market: findings form US national poison centre data 2016–2019. Clinical Toxicology, 60(9), pp.1024–
8. doi:10.1080/15563650.2022.2099887 
325 See footnote #264. Accessed 30th October 2023. 
326 Matthay, E.C., Kiang, M.V., Elser, H., Schmidt, L. & Humphreys, K. (2021). Evaluation of State Cannabis Laws and 
Rates of Self-harm and Assault. JAMA Network Open. doi:10.1001/jamanetworkopen.2021.1955   
327 See footnote #264. Accessed 30th October 2023. 
328 Shamabadi, A., Ahmadzade, A., Pirahesh, K., Hasanzadeh, A. & Asadigandomani, H. (2023).  Suicidality risk after 
using cannabis and cannabinoids: An umbrella review. Dialogues Clin Neurosci. 25(1), pp.50–63. 
doi:10.1080/19585969.2023.2231466  

   
 
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7.195 For example, toxicology reports from Colorado have shown a rise in the proportion 
of suicides testing positive for cannabis following legal regulation.329 Figures had 
been rising pre-regulation but rose more rapidly after the change took effect – 
although conclusions are not clear-cut as they are based on cases where 
toxicology data was available rather than all suicides. As there may be bias in 
those cases where testing was undertaken, it is unclear whether the rise reflects a 
real increase or is an artefact of the base data. 
 
Driving  
 
7.196 Evidence is similarly inconclusive with respect to the role of cannabis in vehicle 
crashes (with and without fatalities). One of the challenges is in isolating the effect 
of cannabis on driving: if a driver has cannabis present in his or her bloodstream, 
this may not indicate intoxication to an extent that impairs driving (with respect to 
motor skills, reaction times, cognitive and spatial judgement etc). We heard from 
several experts about the need for technology to support law enforcement in this 
regard, as the inability to accurately detect intoxication means it is difficult to 
enforce prohibitions related to cannabis consumption and driving. 
 
7.197 Moreover, cannabis remains detectable in the human body for up to 30 days 
(though this depends on a range of factors including THC levels, frequency of use 
and physiological characteristics such as body fat and metabolism). Detection in a 
driver’s bloodstream following an accident does not automatically mean 
consumption played a causal role.    
 
7.198 Reviews have reached different conclusions with respect to the role of legal 
regulation of non-medical cannabis on motor vehicle crashes and fatalities. The 
UNODC found little difference in cannabis-related traffic fatalities between US 
states that have and those that have not legalised non-medical cannabis.330 More 
specifically, evaluation in Colorado and Washington found limited evidence that 
fatalities rose significantly following regulation331 (despite rises in the number of 
accidents where the driver tested positive for cannabis, again this trend was 
apparent pre-regulation).    
 
7.199  In Canada’s British Columbia, however, the prevalence of moderately injured 
drivers with a THC level of at least the legal limit (i.e. 2 nanograms per millilitre) 
more than doubled following legal regulation in 2018332 (although this may be due 
at least in part to increasingly accurate recording instruments). And wider reviews 
have reached similar conclusions, namely that legalisation is associated with 
increased prevalence of THC in drivers involved in motor vehicle crashes.333 
 
329 Rocky Mountain HIDTA Investigative Support Center (2021). The Legalization of Marijuana in Colorado: The 
Impact. Volume 8. RMHIDTA-Marijuana-Report-2021.pdf (dfaf.org) Accessed 30th October 2023.  
330 See footnote #264. Accessed 30th October 2023. 
331 Hansen, B., Miller, K. & Weber, C. (2019). Early evidence on recreational marijuana legalization and traffic 
fatalities. Economic Inquiry, 58(2), pp.547–68. 
332 Brubacher, J.R., Chan, H., Erdelyi, S., Staples, J.A., Asbridge, M. & Mann, R.E. (2022). Cannabis Legalization and 
Detection of Tetrahydrocannabinol in Injured Drivers. New England Journal of Medicine, 386, pp.148–56. 
doi.org/10.1056/nejmsa2109371 
333 See for example footnote #234, pp.29–32. 

   
 
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7.200 Research among law enforcement officers in the US state of Washington reported 
a firm belief that following legal regulation, there are many more cannabis-impaired 
drivers on the road.334 They too noted they were inadequately equipped to detect 
cannabis impairment and thus enforce related laws.  
 
7.201 On balance it seems reasonable to us that following legal regulation, a rise in the 
number of drivers found with THC present in their bloodstream is likely, resulting 
from probable rises in both the numbers of drivers who use cannabis and in 
increased testing. Among those drivers, some will have sufficient THC present to 
impair driving, increasing the risk of accident. But whether the actual number of 
such impaired drivers increases as a direct result of legal regulation so far remains 
unclear.  
 
Cannabis use during pregnancy 
 
7.202 The impact of cannabis during pregnancy on child outcomes (including low birth 
weight and neurocognitive functioning) is unclear, largely due to methodological 
limitations of studies such as the failure to control for tobacco exposure. That said, 
given THC is capable of crossing the placenta, and is present in the milk of 
cannabis-using breastfeeding mothers, health experts advise against its use if 
trying to get pregnant, while pregnant and during breastfeeding. 
 
7.203  The overall trend of increased cannabis use post-legal regulation has also been 
observed in pregnant women. Data from the US Pregnancy Risk Assessment 
Monitoring System suggests residing in a state with legalised non-medical use of 
cannabis is associated with higher prevalence of cannabis use prior to, during and 
after pregnancy.335  
 
7.204 A rise in the number of pregnant women presenting at Ontario emergency 
departments following cannabis use has also been reported.336 While based on 
small samples and limited to one province, this suggests a similar pattern to the 
US may be emerging in Canada. It may also point to the impact of 
commercialisation – an earlier Ontario study that took place less than two years 
post-legal regulation (i.e. before market expansion in the province) reported no 
change in cannabis use among pregnant women.337  
 
 
334 Stanton Sr, D.L., Makin, D., Stohr, M., Lovrich, N.P., Willits, D. & Snyder, J. (2022). Law enforcement perceptions 
of cannabis legalization effects on policing: Challenges of major policy change implementation at the street 
level. Contemporary Drug Problems, 49(1), pp.20–45. 
335 Taylor, D.L., Bell, J.F., Adams, S.L. & Drake, C. (2021). Factors Associated With Cannabis Use During the 
Reproductive Cycle: A Retrospective Cross-Sectional Study of Women in States With Recreational and Medical 
Cannabis Legalization. Maternal and Child Health, 25, pp.1491–1500. doi.org/10.1007/s10995-021-03197-1  
336 Myran, D. T., Roberts, R., Pugliese, M., Corsi, D., Walker, M., El-Chaâr, D., Tanuseputro, P. & Simpson, A. (2023). 
Acute care related to cannabis use during pregnancy after the legalization of nonmedical cannabis in Ontario. 
Canadian Medical Association Journal, 195(20). doi.org/10.1503/cmaj.230045  
337 Drabkin, M., Pudwell, J. & Smith, G.N. (2022). Before and After Legalization: Cannabis Use Among Pregnant 
Patients at a Tertiary Care Centre in Ontario. Journal of Obstetrics and Gynaecology Canada, 44(7), pp.808–12. 
doi.org/10.1016/j.jogc.2022.03.014  

   
 
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7.205 While we acknowledge there has been no evidence of a rise in adverse birth 
outcomes in the US or Canada,338 the lack of clear evidence of the effects of using 
cannabis in pregnancy and the difficulties inherent in reliably testing in this area 
means a cautious approach is warranted with respect to any use at all of cannabis 
in pregnancy. 
 
7.206 Post-legal regulation, dispensaries in some jurisdictions have in fact recommended 
cannabis-based products to pregnant women (primarily to treat nausea).339 Given 
the general agreement among health professionals that cannabis should be 
avoided by pregnant women, this suggests a need for greater education among 
both women of child-bearing age and cannabis retailers.  
 
Crime and policing 
 
7.207 Arguably the most dramatic impact of any framework that at the very least 
decriminalises use of non-medical cannabis has been with respect to the criminal 
justice system (CJS). Arrests for cannabis possession fall substantially, as we 
heard from very many of the experts we have spoken with, and observed in 
available statistics.  
 
7.208 This is an important outcome. A criminal record, no matter how minor the offence, 
can limit an individual’s prospects (albeit to varying degrees depending on 
individual jurisdictional policy). It can hamper employment and restrict travel 
opportunities, render social housing inaccessible and in some cases threaten 
access to children. Those given a custodial sentence are at particular risk of 
suffering mental and physical ill health and of losing protective ties with family and 
friends.   
 
7.209 But the chances of incurring such a conviction for a cannabis-related offence do 
not fall equally. We found or heard evidence of racial disproportionality in cannabis 
policing in most if not all the jurisdictions we examined – both before regulatory 
change and after. We return to this issue when we briefly consider social equity 
drivers of legal regulation later in this chapter. 
 
Arrests and charges 
 
7.210 Not surprisingly, jurisdictions that have decriminalised or de-penalised cannabis 
possession see falls in arrests,340 though the position is not without complication. 
South Australia, for example, which operates a de jure decriminalisation approach 
to cannabis possession (see para.7.101ii), initially saw more people ending up 
with a criminal conviction – as a result of unpaid fines issued where they were 
found in possession of more than the legal limit.341  
 
338 See report in footnote #234, p.41. 
339 Dickson, B., Mansfield, C., Guiahi, M., Allshouse, A.A., Borgelt, L.M., Sheeder, J., Silver, R.M. & Metz, T.D. 
(2018). Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. Obstetrics and 
Gynecology, 131(6), pp.1031–8. doi:10.1097/AOG.0000000000002619 
340 See footnote #264. 
341 See footnote #221.  

   
 
136 
 
 
7.211 Subsequent government action (namely permitting fine payment by instalments, 
substituting community service for payment and clarifying fine requirements) did 
lead to a substantial fall in convictions for cannabis possession – but the example 
serves as a cautionary tale in terms of unintended consequences of policy 
change.  
 
7.212 More positively, there is very clear evidence that adverse social impacts of a 
criminal conviction for cannabis possession far outweigh those resulting from a 
civil sanction,342 so the reduction in the former that South Australia ultimately 
achieved is compelling evidence for the approach. 
 
7.213 Jurisdictions going further and fully legalising non-medical cannabis have seen 
additional reductions in arrests (including, unsurprisingly, for production, trafficking 
and importation, distribution and sales).  
 
7.214 While previously falling trends (due largely to reduced law enforcement attention 
rather than any fall in use of cannabis) mean the extent to which falls in cannabis-
related arrests are due to regulatory change is unclear, any reduction is to be 
welcomed given the widely acknowledged harm caused to those convicted of 
even minor offences.  
 
7.215 By way of example, in two of the earliest adopters of legal regulation in the US – 
Colorado and Washington states – cannabis-related arrests fell substantially after 
implementation in 2012. Seven years after Colorado’s regulatory change, the total 
number had fallen by 68% (possession arrests dropped by 71% and sales by 
56%),343 and in Washington cannabis offences fell by 38% by 2018.344 Elsewhere it 
is a similar picture. In Oregon, for example, arrest rates decreased from 35 per 
100,000 adults in 2011 to three per 100,000 in 2016,345 and in Uruguay, too, legal 
regulation has been associated with a reduction in cannabis possession 
offences.346 
 
7.216 A comparable effect has been observed in US states that decriminalised 
possession (before later implementing legal regulation). Overall, the change in 
Massachusetts, Connecticut, Rhode Island, Vermont and Maryland resulted in 
large decreases (around 75%) in cannabis possession arrests among both youth 
and adults.347  
 
 
342 Lenton, S., Humeniuk, R., Heale, P. & Christie, P. (2000). Infringement versus conviction: the social impact of a 
minor cannabis offence in South Australia and Western Australia. Drug and Alcohol Review 19(3), pp.257–64. 
343 Impacts of Marijuana Legalization in Colorado: A Report Pursuant to C.R.S. 24-33.4-516 (July 2021) (state.co.us) 
Accessed 1st November 2023. 
344 See footnote #334. 
345 Marijuana Consequences - Oregon 2019 Accessed 1st November 2023. 
346 Cited in Barata, P.C., Ferreira, F. & Oliveira, C. (2022). Non-medical cannabis use: International policies and 
outcomes overview. An outline for Portugal. Trends in Psychiatry and Psychotherapy.  
doi.org/10.47626/2237-6089-2021-0239 
347 Grucza, R.A., Vuolo, M., Krauss, M.J., Plunk. A.D., Agrawal, A., Chaloupka, F.J. & Bierut, L.J. (2018). Cannabis 
decriminalization: A study of recent policy change in five U.S. states. International Journal of Drug Policy, 59, pp.67–
75. doi:10.1016/j.drugpo.2018.06.016 

   
 
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7.217 And in Canada, legal regulation of cannabis in 2018 seems to have further 
intensified the pre-existing falling trend in related charges, particularly possession 
offences; see Table 4:  
 
Table 4: Cannabis-related charges in Canada, 2017 and 2022 
 
Offence Charges % change 2017 2022 
Possession 13,715 624  ↓ 95 
Trafficking 3,973 825 ↓ 79 
Import/export 30 18 ↓ 40 
Production 837 248 ↓ 70 
Source: Adapted from Table 2: Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca 
 
7.218 These falls apply to Canadian adults and young people, suggesting that legal 
regulation met at least one of the original aims of the policy, namely, to protect 
youth. Not surprisingly, however, falls are less substantial for those below the age 
minimum for consumption of legally regulated cannabis in US states348 and 
Canada,349 for whom possession remains a criminal offence.  
 
7.219 Moreover, and somewhat concerningly, Canadian data from 2015–2019 suggest 
that, where young people are charged with cannabis possession post-legal 
regulation, they are dealt with more harshly than previously.350 Legal regulation for 
adults has perhaps led to renewed police attention on enforcing the law for youths. 
 
7.220 And while absolute numbers and rates have fallen for all racial groups following 
adoption of legal regulation or decriminalisation, racial disproportionality persists in 
remaining cannabis-related arrests and charges. We discuss this in chapter 10 
with respect to interactions with the police and the wider CJS in the UK but, 
globally, people of colour are more likely than white people to be stopped and 
searched by police on suspicion of a cannabis offence, and more likely to be 
subsequently proceeded against.  
 
7.221 Given they are broadly no more likely to be users of cannabis than white people 
(see chapter 4), a certain degree of racial bias within justice systems, particularly 
within policing, is widely agreed to be largely responsible for this over-
representation.  
 
7.222 It was put to us that in Canada legal regulation of non-medical cannabis has 
resulted in little difference in policing practices. People of colour remain more likely 
to experience interaction with the police, but for something other than cannabis 
possession. It is difficult to support this assertion with statistics because Canadian 
data are not broken down by race, but provincial figures cited in the review of the 
 
348 See footnote #264. 
349 Impact of Cannabis Legalization on Youth Contact with the Criminal Justice System (ccsa.ca) 
350 Ibid. 

   
 
138 
 
Cannabis Act351 showed black and Indigenous Canadians continue to be over-
represented in the justice system with respect to cannabis offences, relative to 
other ethnicities.  
 
7.223 In the US, arrest statistics tell a similar story, namely that white Americans remain 
less likely to be arrested for cannabis-related offences than Americans of colour. 
In Colorado, for example, the greatest fall in the number of cannabis related 
arrests between 2012 and 2019 was observed for those from a white background 
(72%), followed by black (63%) and Hispanic (55%). Arrest rates show the extent 
to which racial disparity remains even more starkly: 76 per 100,000 white 
individuals, 107 per 100,000 Hispanics and 160 per 100,000 black individuals in 
the state in 2019.352 Similar patterns have been observed elsewhere.353,354  
 
7.224 In Australia, it is a comparable story. With the exception of Tasmania, the three 
states that have introduced some form of de jure decriminalisation or de-
penalisation recorded the lowest number of arrests for cannabis offences during 
2020–21, and the Australian Capital Territory, which decriminalised possession in 
2020, issued zero Simple Cannabis Offence Notices.355 But racially 
disproportionate policing has not been eliminated, particularly so, it was put to us, 
where police retain discretion over whether to apply a civil or criminal sanction.  
 
7.225 In New South Wales, for example, the use, supply and possession of cannabis 
remain illegal but first-time offenders caught with less than 15 grams may be 
issued with a caution instead of being prosecuted – at police discretion. But 
substantial racial disparity exists in who is cautioned instead of prosecuted: among 
eligible Aboriginal offenders, 40% were issued a caution, compared to 74% of 
eligible non-Aboriginal offenders.356  
 
7.226 And we heard from experts across jurisdictions about the very significant harms 
caused to communities of colour as a result of over-policing of cannabis and 
subsequent over-representation in the justice system. While legal regulation of 
cannabis does much to reduce the volume of people caught up in the justice 
system, racial bias evidently remains with respect to those who continue to be 
arrested and charged.   
 
Law enforcement expenditure 
 
7.227 One of the arguments in favour of a legally regulated market for non-medical 
cannabis is that it frees up law enforcement to focus on bigger, more serious 
criminal enterprise. But this has largely not been the case so far, as far as we can 
tell.  
 
351 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.72. 
352 Impacts of Marijuana Legalization in Colorado: A Report Pursuant to C.R.S. 24-33.4-516 (July 2021) (state.co.us) 
Accessed 3rd November 2023. 
353 For a brief summary see Garius, L. & Ali, A. (2022) Regulating Right, Repairing Wrongs: Exploring Equity and 
Social Justice Initiatives within UK Cannabis Reform. London: Release. 
354 Marijuana Consequences - Oregon 2019  
355 cannabis_iddr_2020-21_forweb.pdf (acic.gov.au) Accessed 9th November 2023. 
356 Why are Aboriginal adults less likely to receive cannabis cautions? (nsw.gov.au) Accessed 9th November 2023. 

   
 
139 
 
 
7.228 Data from US states that have adopted legal regulation show no clear change in 
expenditure relative to national trends.357 Indeed, law enforcement officers in 
Washington state reported an increase in time spent on cannabis-related matters 
since regulatory change in 2012, including identifying and dealing with illegal 
cannabis growers, i.e. those who fail to comply with licensing and regulatory 
requirements.358  
 
7.229 That said, they welcomed the reduction in demand for resources previously 
directed at arresting, prosecuting and in some cases incarcerating low-level 
cannabis consumers. But rather than a reduction in overall cannabis-related law 
enforcement, there seems simply to have been a shift in focus.   
 
7.230 In Portugal, where all drugs have been decriminalised for over 20 years, 
processing individuals for possession through Dissuasion Commissions has, it was 
put to us, demonstrably reduced costs and simplified procedures relative to 
equivalent court processes – though it is unclear whether police resources have 
similarly reduced. Findings from one study359 support the view that court costs, as 
well as prison expenditure related to drug offending, have indeed fallen, although 
police costs appear on average to have seen little change. (Note this is based on a 
series of assumptions because data on drug-related police costs were largely 
unavailable). 
 
Expungement of cannabis-related criminal convictions 
 
7.231 Most if not all experts agree that criminalisation of drug possession has not only 
failed to stem drug use, it has led to a great many people sustaining criminal 
convictions, which can not only stigmatise but cause long-standing problems in 
terms of participation in and access to wider society and services. Moreover, the 
act of arrest itself can be extremely distressing and, as we discuss in chapter 10, 
have a detrimental impact not only on the arrestee but on how they and others 
view the police and engage with them in the future.  
 
7.232 In recent years, the UN, the WHO and the International Narcotics Control Board 
(INCB) have all acknowledged that criminalisation of drug possession is largely 
disproportionate to the behaviour and can deter help-seeking among those in 
need of treatment. Their collective position is beginning to lead to a global shift in 
how drug possession is viewed, and in 2019 the Chief Executives Board of the 
UN, representing 31 UN agencies, adopted a common position that endorses 
decriminalisation of drug possession and use.360 We have had regard to this in 
 
357 Dills, A. Goffard, S., Miron, J. & Partin, Erin. (2021). The Effect of State Marijuana Legalizations: 2021 Update. 
Cato Institute, Policy Analysis No. 908. https://ssrn.com/abstract=3780276 Accessed 2nd November 2023. 
358 See footnote #334. 
359 Gonçalves, R, Lourenço, A. & Nogueira da Silva, S. (2015). A social cost perspective in the wake of the 
Portuguese strategy for the fight against drugs. International Journal of Drug Policy, 26(2), pp.199–209. 
doi.org/10.1016/j.drugpo.2014.08.017 
360 CEB-2018-2-SoD.pdf (unsceb.org) Accessed 3rd November 2023. 

   
 
140 
 
making our recommendation in chapter 10 regarding the treatment of cannabis 
possession in England & Wales.  
 
7.233 Legal regulation has been used to try to redress some of the adverse 
consequences resulting from the criminalisation of cannabis possession: pardons, 
and/or expungements of convictions, are a key element of regulatory change in 
some jurisdictions.  
 
7.234 In the US, mass pardons have been issued, officially ‘forgiving’ those convicted of 
what is now considered legal behaviour in many states. Most notably, President 
Biden declared in 2022 that all US citizens with a federal record solely for 
cannabis possession would be pardoned. This has since been applied to around 
6,500 citizens.361 At state level, similar action has been taken where non-medical 
cannabis is now permitted, pardoning residents of low-level possession offences.  
 
7.235 Pardons are not, however, equivalent to expungement, which effectively seals a 
conviction from view or otherwise deletes it from the record. In some states, the 
expungement process is automatic, meaning the conviction is automatically struck 
from the record, or otherwise made permanently unavailable for access. 
Elsewhere, the onus is on the individual to apply, which not surprisingly tends to 
limit take-up. 
 
7.236 In Canada, expungement has not so far been automatic and the opportunity has 
not been taken up as widely as expected. The process is reportedly cumbersome 
and, while now free for applicants, remains difficult to access and requires 
documentation that some may not have. Moreover, those perhaps most in need of 
expungement, due to a variety of compounding social challenges and deprivation 
from which they are already more likely to suffer, are often the least able to access 
the process (including First Nations, Inuit and Métis peoples, black and other 
minority ethnic Canadians).362  
 
7.237 Even where records are expunged, they may not be deleted in their entirety, 
meaning some US authorities, for example, remain able to view a record even 
where a Canadian agency can no longer do so. Opportunities for travel or 
emigration, for example, may therefore remain limited for those with prior 
convictions for minor cannabis activity previously considered illegal. So, while the 
intention behind pardons and expungements is positive, procedural challenges 
means that intent has yet, for many, to be realised.    
 
Crime  
 
7.238 As we discuss in our consideration of economic impacts, legal markets for non-
medical cannabis do not eradicate illegal markets. Demand for cheaper product 
remains, as does demand among those unable to purchase legal cannabis 
 
361 News Advisory: Updated Analysis Relating to Executive Action to Pardon Federal Convictions for Simple 
Possession of Marijuana (ussc.gov) Accessed 3rd November 2023. 
362 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.9. 

   
 
141 
 
(namely those under the minimum age). This means the market for illegal cannabis 
remains and associated opportunities for organised crime continue. Indeed, 
Uruguay saw a rise in homicides connected with disputes between cannabis 
dealers following implementation of its legal model in 2013 – though more 
positively, authorities have estimated a fivefold reduction in their activities more 
generally.363 
 
7.239 Whether regulating non-medical cannabis reduces organised crime to any great 
extent is unclear and, based on what we have heard, seems unlikely. While we are 
not aware of any independent study that has examined the matter, we heard there 
is little anecdotal evidence of legalisation having materially changed the extent of 
organised crime or its operations in the US or Canada. Indeed, according to UK 
intelligence assessments, almost one-third of organised crime gangs operating in 
Canada remain involved in the production and distribution of illicit cannabis. 
 
7.240  The police themselves report little impact on organised crime activity and, where 
a substantial illegal market in cannabis remains despite legalisation, organised 
crime continues to be heavily involved. And while Spain, for example, continues to 
operate a prohibitive model, unofficial tolerance of Cannabis Social Clubs without 
the oversight and regulation brought by legalised models has effectively increased 
involvement of organised crime (see para.7.45). 
 
7.241 And it was put to us that, while organised crime continues to play a role in illegal 
cannabis markets, both online and offline, law enforcement functions are largely 
under-resourced to tackle the issue. This in turn increases the challenge of 
reducing illicit market share in favour of legal markets.  
 
7.242 On more localised criminal activity, evidence is mixed. Some US states show a 
rise in property crime following legalisation, others report no impact – although 
where related to cannabis dispensaries, the increase may be driven by the fact 
that cannabis currently remains illegal at the federal level.364  
 
7.243 Retailers are thus dependent on cash as they cannot use banking mechanisms to 
process their activities, meaning premises can be an attractive target for burglary 
(which sometimes involves violence). Possibly for this reason, there has been no 
evidence of a similar rise in Canada or Uruguay, where proceeds can be banked 
in the usual manner. 
 
7.244 More broadly though, we could find no evidence of any clear association between 
regulatory change and rates of violent or other types of crime in any jurisdiction 
that has legalised non-medical cannabis.   
 
7.245 One facet of legal regulation at the US state level, and which may in due course 
become an issue on the European mainland as and when individual countries 
 
363 Cited in Barata, P. C., Ferreira, F. & Oliveira, C. (2022). Non-medical cannabis use: International policies and 
outcomes overview. An outline for Portugal. Trends in Psychiatry and Psychotherapy. doi:10.47626/2237-6089-
2021-0239 
364 See for example footnote #264. 

   
 
142 
 
legalise non-medical cannabis, is cross-border transference of legal cannabis to 
states or countries in which it is prohibited but which share a land border.  
 
7.246 This is not only an issue for shared borders. As we discuss in consideration of the 
economics of legal non-medical cannabis, over-production can fuel trafficking to 
countries where it remains illegal. UK law enforcement suggested that since 
regulatory changes, Canada and the US (and more recently Thailand) have 
become source countries of cannabis entering the UK, displacing countries like 
Morocco, which previously featured more heavily.  
 
The economics of legal regulation 
 
7.247 The economics of different regulatory models for non-medical cannabis are 
complex and the interplay between regulation, taxation, revenue, public health and 
the illegal market even more so. And while there is no doubt that a legally 
regulated, for-profit market generates economic opportunities for investors and 
governments, the anticipated so-called ‘green rush’ may not have been the 
panacea originally hoped for.  
    
7.248 Creating a model that shrinks the illegal market, reduces criminalisation and 
therefore police enforcement and associated (predominantly racial) disparities, but 
does not unduly threaten public health by making cannabis consumption as 
commonplace as coffee drinking, is fraught with complexity and trade-offs.  
 
7.249 Grasping the net economic position is complicated by the emergence of benefits 
and costs at varying paces. Monetised benefits, specifically rises in tax revenue 
and falls in the number of prosecutions for what had been criminal offences, can 
be seen relatively quickly (where data collections are in place).  
 
7.250 But shifts from illegal to legal markets take longer to emerge, reliant as they are on 
consumer behaviour change which does not happen overnight. Understanding the 
extent and long-term sustainability of such shifts takes time. The same is true for 
impacts on public health. While likely to be a mixed picture of benefits and costs 
(given cannabis may have some therapeutic effects in addition to heightening the 
risk of adverse consequences), they likely do not emerge for some time.  
 
7.251 As a result, and despite the number of jurisdictions that now have some form of 
legalised model in place for non-medical cannabis, we find it difficult to reach clear 
conclusions as to whether, overall, the benefits of legalising use of non-medical 
cannabis outweigh the costs. It is, we think, simply too early to tell – and reliable 
answers will be forthcoming in due course only where data collection practices 
permit.  
 
7.252 Considering the evidence available so far, it seems to us that no jurisdiction has 
achieved the ideal balance between costs and benefits. There is an inherent 
friction between economic and other aims of legal regulation. If taxes and/or prices 
are set too high, the illegal market continues to flourish and investment in the legal 
market can be disincentivised. Set them too low and user entry to the legal market 

   
 
143 
 
is more effectively facilitated, threatening public health objectives through 
encouraging take-up and higher levels of use. And where taxes are set as a 
function of price, lower prices mean lower tax revenue – unless there is a parallel 
increase in consumption.365  
 
7.253 Any for-profit commercial model is incentivised to increase consumption to 
maximise revenue, enticing non-users of cannabis into the market and 
encouraging higher consumption among users. It was put to us that 20% of 
cannabis users consume about 80% of cannabis,366 meaning the health 
implications for a minority of users of increased access to cheaper and more 
varied products in a legally regulated market are likely to be significant.   
 
7.254 As one recent review noted, lower prices and reduced profit margins have a 
significant impact on the nature of the market. It becomes harder for smaller 
businesses to compete, meaning that, over time, larger corporations will almost 
inevitably end up controlling much of the market.367 Not only is this likely to be at 
odds with aims of social equity, a key driver of legalisation in several jurisdictions 
as we cover below, it may disincentivise some users from transitioning from illegal 
to legal markets due to preferences for, and loyalty to, smaller craft growers who 
cannot afford to enter, or to remain in, the latter. 
 
7.255 Overall, the longer-term picture is unknown. While it is certainly the case that 
billions of dollars have been generated through legal non-medical cannabis, as we 
illustrate in the next section, it is unclear whether associated rises in prevalence of 
use will in the longer-term lead to increased public health-related costs (monetised 
and non-monetised) that outweigh those economic benefits.   
 
Revenue, taxes and costs 
 
7.256 The picture with respect to the overall value of the for-profit market is complex and 
mixed. While sales of legal non-medical cannabis have raised billions, discernible 
impact on overall gross domestic product (GDP) so far seems uncertain. States 
that had implemented legal sales by early 2021 had not, at that time, shown 
marked increases in GDP compared with the national average.368 
 
7.257 As yet, there has been little impact on employment rates (though there is some 
variation by state)369 – with the exception of the agricultural sector in early 
adopters of the legal non-medical market, namely Colorado, Washington, 
California and Oregon.370 With most US states moving to legal regulation only 
 
365 See footnote #299. 
366 See discussion of Pareto’s Law in Kilmer B. (2019). How will cannabis legalization affect health, safety, and social 
equity outcomes? It largely depends on the 14 Ps. The American Journal of Drug and Alcohol Abuse, 45(6). 
doi:10.1080/00952990.2019.1611841 
367 Pardal, M., Kilmer, B., d’Auria, S., Strabel, T., Galimberti, S., Hoorens, S., Decorte, T. & Senator, B. (2023). 
Alternatives to profit-maximising commercial models of cannabis supply for non-medical use. RAND Corporation.  
368 See footnote #357. Accessed 2nd November 2023. 
369 Ibid. 
370 Dave, D.M., Liang, Y., Muratori, C. & Sabia, J.J. (2022). The Effects of Recreational Marijuana Legalization on 
Employment and Earnings. National Bureau of Economic Research Working Paper, 30813.  

   
 
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within the past five years, it is too early for more significant workforce impacts to 
show. 
 
7.258 Demand forecasts for non-medical cannabis may have been overly optimistic. 
Over-production in the US and Canada has flooded the market with surplus 
product and several cultivators have closed, with resultant job losses – which may 
help explain the relatively minimal impact on job markets.  
 
7.259 The extent to which that surplus makes its way into illegal markets is unclear but, 
as we discuss (see para.7.246), a certain amount seems likely to be doing so. 
Similarly, what happens to surplus produced by home growers is also unclear (as 
is the amount of such surplus), but it is likely to impact on users transitioning to the 
legal market. Some, too, is likely to find its way to the illegal market for distribution 
domestically and overseas. 
 
7.260 All that said, state revenues have undoubtably risen following legalisation of non-
medical cannabis (though as we have noted, the extent to which these are offset 
by associated increases in public expenditure elsewhere, most notably in 
healthcare, is, as far as we can tell, so far unclear). And the market continues to 
be valuable.  
 
7.261 The general pattern, perhaps unsurprisingly, is for initial growth as measured by 
tax revenue to slow down some years after legalisation, as seen among early 
adopters such as Washington state and Colorado. Peaks in 2021,371 likely driven 
by increased use of cannabis during the Covid-19 pandemic, have tended to be 
followed by some drop-off in more established markets, although they remain 
relatively buoyant.  
 
7.262 The extent of future growth, however, is difficult to predict – certainly in the US. As 
the number of states legalising non-medical cannabis continues to rise, revenues 
in states with more established markets may be affected in various ways. There is 
evidence, for example, that sales by dispensaries along state borders fall 
substantially once neighbouring states introduce legal regulation.372 
 
7.263 Moreover, it is difficult to accurately compare revenue raised through cannabis 
sales because the precise level and nature of sales and excise taxes vary between 
jurisdictions, as do licensing and other fees. Not all US states, for example, impose 
a general sales tax in addition to excise taxes, and few so far impose taxes related 
to potency (i.e. levels of THC). While a potency-based measure could help nudge 
consumers towards lower-strength products,373 it also risks nudging them towards 
the illicit market. 
 
 
371 See examples in How much revenue do states make from marijuana taxes? (usafacts.org). Accessed 2nd May 
2024. 
372 Hansen, B., Miller, K. & Weber, C. (2020). Federalism, Partial Prohibition, and Cross-Border Sales: Evidence from 
Recreational Marijuana. National Bureau of Economic Research, Working Paper 23762. 
http://www.nber.org/papers/w23762 Accessed 5th November 2023.  
373 See footnote #299. 

   
 
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7.264 The regulatory model in place, restrictions around usage and product availability, 
and the level of government control on pricing all act to place different burdens on 
producers, retailers and consumers (the UNODC sets outs details for each US 
and Canadian state/territory, and Uruguay.)374  
 
7.265 Levels of taxes are important, however, not just because of overall cost to the 
consumer and revenue raised for public coffers, but because they are thought to 
offer one way of moderating public consumption. Higher taxes mean higher overall 
costs, which in turn should drive down demand for cannabis products.  
 
7.266 At least, so the theory goes. Despite taxes in the earliest adopters of non-medical 
cannabis legalisation in the US, Washington state and Colorado, being markedly 
different (37% compared with around 18%),375 latest data show little difference in 
the overall value of cannabis sales. In 2023, Washington reported sales valued at 
$1.2 billion,376 with Colorado’s figures totalling around $1.3 billion.377 
 
7.267 Tax revenue, however, was significantly higher in Washington ($465million,378 
compared with $274 million in Colorado.)379 While it is not clear how sales break 
down (types of product, average value of sales, numbers of purchasers etc), the 
fact that cannabis products are now reportedly less expensive in Washington than 
Colorado380 suggests retailers are not passing on the cost of taxes to consumers.   
 
7.268 Which highlights the importance of the interplay between tax and retail price, and 
the challenge of using tax as a strategy to protect public health. Canada’s recent 
review found similar, reporting cannabis licence holders to be largely bearing 
taxation costs rather than passing them on to consumers,381 which in the longer 
term may threaten their sustained presence in the market.  
 
7.269 More generally, however, whatever the level of taxation, there seems little doubt 
that legalisation of non-medical cannabis allows governments/governing bodies to 
collect considerable additional revenue.382 Even accounting for declines seen 
post-pandemic, both Colorado and Washington collected more from state 
cannabis taxes than from state alcohol and cigarette taxes in 2022.383  
 
7.270 Which suggests the value of the cannabis market not only seems here to stay 
(albeit subject to fluctuation) but may prove more lucrative in terms of so-called 
‘sin taxes’ than its predecessors. While perhaps reflecting some shift in consumer 
 
374 See footnote #264. 
375 How much revenue do states make from marijuana taxes? (usafacts.org). Accessed 2nd May 2024. 
376 Washington State: $465 Million in Marijuana Taxes Made in FY 2023, Over 5,000 Approved Products 
(themarijuanaherald.com) Accessed 2nd May 2024. 
377 Marijuana Sales Reports | Department of Revenue (colorado.gov) Accessed 2nd May 2024. 
378 See footnote #376. Accessed 2nd May 2024 
379 Marijuana Tax Reports | Department of Revenue (colorado.gov) Accessed 2nd May 2024. 
380 Adlin, B. (2020). Where’s the Cheapest Cannabis? A State-by-State Comparison. Leafly. Available at 
https://www.leafly.com/news/strains-products/wheres-the-cheapest-cost-cannabis-a-state-by-state-comparison  
381 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.49. 
382 How do state and local cannabis (marijuana) taxes work? | Tax Policy Center Accessed 2nd May 2024. 
383 Auxier, R. & Airi, N. (2022). The Pros and Cons of Cannabis Taxes. Tax Policy Centre, Urban Institute & Brookings 
Institution. Pros and Cons of Cannabis Taxes_0.pdf (urban.org) Accessed 2nd May 2024. 

   
 
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behaviour from one product to another, and certainly tobacco consumption is 
falling, there is little evidence that legalisation of non-medical cannabis has much 
impact on alcohol sales (see para.7.168).  
 
7.271 US states that have more recently entered the market also report increasing tax 
revenue. California, for example, registered steadily rising figures quarter on 
quarter since 2018.384 There, too, revenue peaked in 2021 with $1.5 billion raised 
(from $5.1 billion of sales). While it fell in 2022 to just over $1.1 billion, there are 
early signs of stabilisation, with tax revenue in 2023 equating to just under $1.1 
billion.385 
 
7.272 While we have been unable to source comparative figures for the world’s first 
country to legalise non-medical cannabis, Uruguay, which of course adopted a 
very different model to those taking hold in the US, in Canada the value of the 
emerging legal cannabis market is similarly not insignificant.  
 
7.273 In 2022, more than C$5 billion ($3.7 billion) was spent on non-medical 
cannabis,386 and 2021–2022 saw over C$1.5 billion ($1.1 billion) raised in taxes 
and other duties387 (although the proportion attributable to non-medical rather than 
medical is unclear). This rose to C$1.9 billion ($1.4 billion) in 2022–2023, and, 
between legalisation taking effect in 2018 and the end of 2021, the sector created 
an estimated 150,000 jobs.388  
 
7.274 Despite this, however, the picture is not entirely rosy in Canada’s burgeoning non-
medical cannabis market. While dwarfed by costs associated with the alcohol and 
tobacco industries (which accounted for over 62% of the C$49 billion ($36 billion) 
in economic costs associated with substance use), those related to cannabis use 
in 2020 still amounted to C$2.4 billion ($1.8 billion). These included costs 
connected with lost productivity, healthcare and criminal justice.389  
 
7.275 While criminal justice costs fell by around 3% between 2019 and 2020 (driven by 
fewer incidents, charges and admissions for cannabis possession), healthcare 
costs rose from C$360 million to C$381 million ($264 to $279 million), and lost 
productivity from C$468 million to C$491 million ($343 to $360 million).390 Costs 
had been increasing for some years before the Cannabis Act 2018, so it is difficult 
to directly associate continued rises directly with legalisation, but those related 
particularly to healthcare rose more sharply than had been seen for some time.  
 
384 Cannabis Tax Revenues, Grid View Accessed 2nd May 2024. 
385 Ibid. Accessed 2nd May 2024. 
386 Statistics Canada. (2023). Table 36-10-0124-01: Detailed household final consumption expenditure, Canada, 
quarterly (x 1,000,000). https://doi.org/10.25318/3610012401-eng Accessed 6th November 2023. 
387 Statistics Canada. Table 10-10-0165-01  Net income of cannabis authorities and government revenue from the 
sale of cannabis (x 1,000) doi.org/10.25318/1010016501-eng Accessed 2nd May 2024. 
388 Deloitte and Ontario Cannabis Store. (2021). An industry makes its mark: The economic and social impact of 
Canada’s cannabis sector. An industry makes its mark - The economic and social impact of Canada’s cannabis 
sector (deloitte.com) Accessed 6th November 2023. 
389 Canadian Substance Use Costs and Harms Scientific Working Group. (2023). Canadian Substance Use Costs 
and Harms, 2007–2020. Canadian Institute for Substance Use Research & the Canadian Centre on Substance Use 
and Addiction. Canadian Substance Use Costs and Harms 2007–2020 (csuch.ca) Accessed 6th November 2023. 
390 Ibid. 

   
 
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7.276 And we heard Canada is struggling to maintain the initial success of its non-
medical cannabis sector. Despite early issues meaning supply struggled to match 
demand, several years on the country is seeing oversupply and challenges 
achieving profitability. In many provinces/territories, a proliferation of cultivators 
and dispensaries has meant substantial competition in a sector arguably still in its 
infancy – the lack of caps on retail licences has meant a flooding of the 
marketplace in many areas, in a similar fashion to parts of the US.  
 
7.277 Since 2018, several producers have reportedly exited the Canadian market. 
Among those remaining in 2023, around half owed excise duties and over 12% of 
regulatory fees (c.C$7.6 million) remained unpaid.391 Perhaps indicative of the gap 
between demand forecasting and reality, almost 200 licensed cultivators reported 
no production during 2022 and a further 599 licensed retailers reported no sales.  
 
7.278 Despite the intention for a mixed economy comprising larger and smaller players, 
enabling hitherto illegal or ‘legacy’ craft growers such as those cultivating the 
renowned British Columbia (BC) Bud to enter the legal market, the sector is 
increasingly dominated by corporate players. Costs of entry are high and 
economies of scale mean larger, corporate producers are of more interest to 
distributors (where not part of a vertically integrated model.)392 Craft growers 
produce too little to be a maximally economically viable option and, we heard, 
struggle to meet the costs of taxation and regulatory compliance.  
 
7.279 The recent Legislative Review makes a number of recommendations with respect 
to the administrative burden of legal compliance, the excise tax model (including 
proposing that higher-potency products attract larger duties) and distribution 
processes, while also cautioning that changes should not compromise public 
health and public safety objectives of the legislation. This illustrates the 
fundamental challenge of balancing economic success with other 
considerations.393  
 
7.280 Further market consolidation, it was suggested to us, risks increasing prices and 
reducing product diversity. We heard that where small growers have been forced 
to exit the sector, in some cases following bankruptcy, they may well have 
returned to the illegal market – taking their customers with them – which in turn will 
threaten some of the gains made in shifting custom from illegal to legal markets 
(see below).  
 
7.281 Regardless, interest in the cannabis sector is growing, including from the alcohol 
and tobacco industries394 – at least in the US. This means the influence of large 
corporations, with their power to shape regulatory frameworks to their own benefit, 
represents a further threat to the interests of and engagement from smaller 
businesses and artisanal cannabis producers. 
 
391 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.55. 
392 i.e. An individual company has direct ownership of all elements of its operation, from seed (cultivation) to sale.   
393 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca pp.12–13. 
394 See footnote #264. 

   
 
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7.282 There is also arguably tension between the interests of those who use cannabis 
and those of public administration. Users want variety in brands and products, and 
many are loyal towards smaller, craft growers, who can be renowned for long-
standing skill and expertise in growing particular strains of cannabis, like BC Bud. 
However, overseeing and regulating a mixed market comprising a number of large 
corporate entities alongside very many smaller elements is a complex 
administrative challenge.  
 
7.283 As was put to us by several experts, large producers, distributors and retailers 
have more to lose through non-compliance with licencing and other regulatory 
requirements. They are thus more likely to invest in and demonstrate high levels of 
compliance and it is likely to be easier for governing bodies to oversee a handful of 
large operators than to manage compliance across a much greater number of 
micro/small/medium-sized enterprises.   
 
7.284 And as we heard, levels of taxation have led many in the industry to claim it is 
prohibitively difficult to compete with prices in the illegal market. Taxes and fees, 
and in Canada the suite of regulations regarding advertising, product packaging 
and labelling, have been blamed for claimed issues with profitability and 
sustainability.395  
 
7.285 Perhaps more worryingly, those regulations restricting labelling and promotions 
have reportedly, and presumably inadvertently, led cannabis consumers to fixate 
on THC content (which must be clearly shown) as a marker of quality, or value. 
Meaning, as the Canadian Review396 found, more consumers are purchasing 
higher-potency products – which, given the link between consumption of stronger 
cannabis and adverse mental health consequences, is troubling from a public 
health perspective.    
 
Price 
 
7.286 Where the illegal market remains the only source of non-medical cannabis, price 
tends to remain relatively fixed. The significant risks associated with producing, 
distributing and selling cannabis due to consequences of being caught, and the 
need to ensure product security, resist illegal competitors and potentially retaliate 
against takeover, means prices must reflect those risks, even if demand rises.  
 
7.287 That said, while prices of illegal cannabis can and do shift up and down, they will 
almost always remain lower than prices in legal markets, where the two exist side 
by side. The impact of taxes and regulatory compliance costs in the latter will 
almost always outweigh risk-related pricing in their illegal counterparts.  
 
7.288 There are, however, two almost universal inevitabilities of a legally regulated 
market for non-medical cannabis: a fall in price (though an initial spike is common) 
 
395 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.59. 
396 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.50. 

   
 
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and product diversification. The risks inherent in illegal markets are largely 
eliminated in legal supply chains, and participants can overtly take advantage of 
economies of scale, which translate into lower marginal costs and reduced retail 
prices. Cultivators, for example, can purchase huge plots of land to grow large 
quantities of cannabis, with no fear of penalty and no costs associated with 
clandestine operation. 
 
7.289 Since passage of the Cannabis Act in 2018, prices in Canada have fallen across 
both legal and illegal markets to an all-time low. On average (notwithstanding 
provincial variation), the cost of one gram of legal dried flower fell by 43% from 
C$10.70 in 2019 to C$6.12 in 2020, with illegal prices dropping 36% from C$7.22 
to C$4.62.397  
 
7.290 In the US, prices vary significantly by state, reflecting factors including the 
newness of the market, levels of competition and tax structures. But across states 
with legal non-medical cannabis, retail prices fell by around 20% between 2021 
and 2022, and by even more in mature markets such as Colorado and Oregon.398 
Indeed, in Colorado the wholesale price of a pound of cannabis flower fell from 
$1,876 in 2014 to $649 in 2023, and in Oregon the average cost per gram 
dropped from $10.50 in 2016 to $4.17 by 2022.399  
 
7.291 Overall, the price per gram of non-medical dried flower averaged $8.99 across US 
legal markets in 2021, compared with $8.48 for the same from illegal sources. 
And average prices across US legal markets (inclusive of product sourced from 
legal and illegal sources) was lower than in states where it remained illegal: $8.75 
compared with $9.94.400 
 
7.292 Prices may also vary as a result of level of harm. In a handful of jurisdictions, 
cannabis intended to be co-consumed with tobacco and/or containing high levels 
of THC, is more expensive. While consistent with attempts to safeguard public 
health, this strategy likely risks pushing those seeking higher-potency products 
towards the illegal market and probable cheaper product. 
 
Impact of different commercialised models 
 
7.293 Legal regulation of non-medical cannabis use is not a binary yes/no choice. There 
are different models and, where a commercial marketplace is introduced, a range 
of policy choices to be made in terms of, for example: under what conditions (if 
any), products may be advertised and marketed; what products are permitted for 
sale, in what packaging with what labelling; whether the number of retail stores is 
capped (according to location and/or population density); whether potency and 
prices are capped; whether retail is state or privately controlled, and whether 
public campaigns are implemented with respect to safer use of cannabis.  
 
397 See footnote #276. 
398 Cannabis Industry Statistics for 2023 (flowhub.com) Accessed 6th November 2023. 
399 Cited in Kilmer, B. & Pérez-Dávila, S. (2023). Nine Insights from 10 Years of Legal Cannabis for Nonmedical 
Purposes. Clinical Therapeutics, 45(6), pp.496–505. Elsevier Inc. 
400 See footnote #263. 

   
 
150 
 
 
7.294 As we set out in part a) of this chapter, different jurisdictions have implemented a 
range of approaches and it is important to consider their relative impact on 
outcomes of interest. While the evidence is so far too limited to reach conclusive 
views, we heard about some emerging indications.  
 
7.295 Academic assessment of early US policies concluded the models that are most 
effective in reducing, or limiting, excessive cannabis use in adults and young 
people (where desired) are those which target business practices rather than 
consumers. This means using, for example, tax levers and limitations on retail 
operations and advertising to help control use, rather than relying on possession 
limits and associated penalties.401  
 
7.296 With respect to adverse health consequences, evidence – albeit limited so far – 
suggests greater access to cannabis stores is associated with increases in both 
use and related healthcare visits. Limits on retail outlet densities and locations 
have been proposed as one of several measures to safeguard public health while 
the evidence base regarding impacts on health indicators builds (others include 
labelling and packaging requirements, potency and price controls, public health 
messaging about safer use, and investments in mental health services).402  
 
7.297 That said, restricting the number of outlets may simply help sustain the illegal 
market, or at least limit transition to new legal markets. Canadian research found 
provinces with fewer stores had more illegal compared to legal sales, but overall 
prevalence of use was similar to that in provinces with more stores.403    
 
7.298 Comparison of Canadian provinces and territories sheds some tentative light on 
links between aspects of commercialisation and cannabis use. Québec, for 
example, has fewer retail outlets per capita than any other province/territory (see 
Table 3), a limit of 30% THC on products and additional restrictions on edibles and 
vapes. Consumers are less likely to report use of edibles, vape oils, topical 
cannabis products and solid concentrates than elsewhere in the country,404 and 
prevalence rates in Québec are below both the national average and those 
recorded in other provinces/territories.  
 
7.299 However, a less commercialised model and lower levels of reported use do not 
equate to an obsolete illegal market: it remains unclear to what extent the 
approach has shrunk in Québec as compared to provinces that adopted a more 
commercialised model. It is possible that Québec contains a disproportionate 
amount of Canada’s total remaining illegal market, but it is not clear how legal and 
illegal market shares break down across different provinces. 
 
401 Blanchette, J.G., Pacula, R.L, Smart, R., Lira, M.C., Boustead, A.E., Caulkins, J.P. … & Naimi, T.S. (2022). Rating 
the comparative efficacy of state-level cannabis policies on recreational cannabis markets in the United States. 
International Journal of Drug Policy, 106. doi:10.1016/j.drugpo.2022.103744 
402 See footnote #326. 
403 Armstrong, M.J. (2021). Relationships Between Increases in Canadian Cannabis Stores, Sales and Prevalence. 
Drug and Alcohol Dependence. doi:10.1016/j.drugalcdep.2021.109071 
404 See footnote #276. 

   
 
151 
 
 
7.300 As different approaches become more embedded, data and research should 
increasingly begin to paint a clearer picture of the interplay between varying 
conditions of commercialisation and outcomes. We explore the impact of 
legalisation on illegal markets in the next section. 
 
Impacts on the illegal cannabis market 
 
7.301 As we have set out, the illegal market does not disappear in the face of a legally 
regulated market. It adapts and survives – indeed, both Canada and the US (as 
well as the UK) retain illegal markets in tobacco and alcohol despite their legality. 
Alternatives to non-medical cannabis prohibition will never completely eradicate 
the illegal market: a (convenient) legal supply is a necessary but not sufficient 
condition for its reduction.405 
  
7.302 Legalisation does, however, shrink the illegal market to some degree, albeit not 
overnight. In 2022, several years on from enactment of its Cannabis Act in 2018, 
almost C$8 billion was spent on cannabis in Canada overall: at C$5.1 billion, the 
majority was in the legal market and, while a further C$2.4 billion was spent in the 
illegal market (the remainder went into the medical sector), this was about half the 
estimated spend of C$4.9 billion on illegally sourced cannabis in 2017.406  
 
7.303 Findings from the ICPS407 also suggest legal sales now dominate the non-medical 
sector in Canada. Past-year consumers reportedly purchased 82% of their 
cannabis from legal outlets (online and offline) – a substantial increase from 61% 
in 2019. Purchases from family or friends and dealers declined to 41% and 15% 
respectively (from 61% and 36% in 2018) – although we note the risk of over-
reporting legal purchases due to wariness about admitting illegal market sources 
within a legal structure.  
 
7.304 The market for illegal cannabis in the US is similarly shrinking as users increasingly 
report purchasing exclusively from licenced retailers, with corroboration from 
(albeit so far limited) wastewater analysis. In Washington, for example, legal sales 
grew much faster than THC levels measured in wastewater, suggesting some 
displacement from the illegal market rather than an overall rise in sales.408  
 
7.305 While very limited, evidence from Uruguay suggests that, while legal regulation 
has equally elicited shift from the illegal market, legal market share remains well 
 
405 Goodman S., Wadsworth, E. & Hammond, D. (2022). Reasons for Purchasing Cannabis From Illegal Sources in 
Legal Markets: Findings Among Cannabis Consumers in Canada and U.S. States, 2019–2020. Journal of Studies on 
Alcohol and Drugs, 83 (3), pp.392–401.  
406 Statistics Canada (2023). Table 36-10-0124-01: Detailed household final consumption expenditure, Canada, 
quarterly (x 1,000,000). doi.org/10.25318/3610012401-eng Accessed 6th November 2023. 
407 See footnote #276. 
408 Burgard, D.A., Williams, J., Westerman, D., Rushing, R., Carpenter, R., LaRock, A. … & Banta-Green. C.J. 
(2019). Using wastewater-based analysis to monitor the effects of legalized retail sales on cannabis consumption in 
Washington State, USA. Addiction, 114(9), pp.1582–90. 

   
 
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below 50% and there has been a considerable move to the grey market (i.e. 
legally sourced but illegally distributed cannabis).409  
 
7.306 Low retail prices set by government have done little to reduce illegal market share 
(and therefore operations of organised crime and drug-related gangs), principally 
because price is relevant mainly for lower-income users who are often not 
registered with the government and therefore ineligible, under Uruguay’s model, 
for legal access.410  
 
7.307 More positively, reported use of adulterated cannabis in Uruguay has fallen since 
legal regulation in 2013. That said, this is less likely to be the case among poorer, 
more marginalised communities given their lower likelihood of registration, which 
acts as the gateway to legal access to quality-assured product. Uruguay’s model 
does not, it seems, reach or affect everyone in the same way.  
 
7.308 Irrespective of jurisdiction, however, the main drivers for illegal purchases remain 
price, convenience and quality, and, for some, a desire to remain anonymous, 
which suggests stigma associated with cannabis use remains, to some extent, in a 
legal market.  
 
7.309 And as above, difficulties faced by craft growers in sustaining a presence in the 
legal market can discourage user transition from the illegal market. Many 
reportedly prefer to support independent, non-corporate producers with whom 
they often have a long-standing relationship. Loyalty, and a desire to benefit those 
who have spent years fighting against prohibition rather than ‘corporate cannabis’, 
transcends desire to shift to the legal market – particularly in Canada.  
 
7.310 Moreover, it was suggested to us that loyalty is likely to be felt particularly strongly 
among more frequent cannabis users, in part because illegal dealers allow large 
bulk purchase. This means that, at the individual level, economies of scale are 
possible in the illegal market in a way the legal market will often not permit.  
 
7.311 So while reduced to varying degrees, the illegal market continues to exist and 
indeed, as it was put to us, thrive in some states despite legal regulation. This is 
partly because of higher prices of legal product relative to illegal (due to 
production and regulation costs, as well as taxation) but also issues of 
accessibility.  
 
7.312 California, for example, is a vast state with large areas that are effectively legal 
cannabis deserts. Illegal cannabis is easier to access – and there are plenty of 
opportunities to do so. Unlicenced farms reportedly proliferate across the state 
and produce huge amounts of cannabis, impacting legal wholesale prices and 
livelihoods of legitimate cultivators. They are also allegedly causing environmental 
damage, forcing labourers to work in dangerous conditions and, due to the need 
 
409 Queirolo, R., Álvarez, E., Sotto, B. & Cruz, J.M. (2022). How High-Frequency Users Embraced Cannabis 
Regulation in Uruguay. Journal of Drug Issues, 53(4). doi.org/10.1177/00220426221134902  
410 See footnote #234, pp.55–7. 

   
 
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to protect grows from rivals, are introducing armed guards and exacerbating 
cannabis-related violence.411   
 
7.313 Their continued existence underlines the view among law enforcement that the 
illegal market continues to flourish despite access to licensed cannabis products. 
In 2019, Washington state legislature allocated $3 million to the Washington State 
Patrol to address the persistence of the illegal market and associated involvement 
of organised crime412 – indication that, several years on from legalisation, there 
remain significant problems despite hopes that implementation would render them 
much diminished.  
 
7.314 Reduced criminal penalties associated with illegal cannabis activity following legal 
regulation, alongside a reduced focus among some law enforcement, inevitably 
lower perceived risk. It is therefore hard to see criminal enterprises ever 
completely eschewing involvement, especially as opportunities to set up illegal 
retail outlets (offline and online) that mirror legal counterparts seemingly abound.  
 
7.315 This is problematic for users, many of whom struggle to distinguish legal from 
illegal413 product despite official guidance414 (and risk buying adulterated product 
as a result). It also causes difficulties for law enforcement, who struggle to identify 
and shut down illegal outlets (especially given reduced focus on illegal cannabis 
activity following legalisation). New unlicensed outlets continue to open on a 
regular basis – in Los Angeles County, for example, in the state of California, one 
study reported that almost half of such stores open in 2020 were not recorded as 
existing in 2019.415  
 
7.316 And despite seed-to-sale tracking systems, intended to prevent diversion of legal 
product to the illegal market, there is evidence of market leakage. In 2022, 25% of 
cannabis purchased from an illegal or unauthorised source in Canada was 
originally made for legal sale, which is not perhaps surprising given reports of 
surplus product.416  
 
7.317 Overall, the degree to which legal regulation shrinks the illegal market is 
dependent on several factors. Switching is more likely where legal markets are 
cheaper, highly competitive and less regulated, allowing wide choice – particularly 
with respect to higher-potency products. This scenario, however, is also likely to 
drive up the number of hitherto non-users seeking to try cannabis. 
 
7.318 In effect, the more regulated the legal market, the more slowly the illegal market 
will reduce. While higher prices and inconvenience of legal sources of cannabis 
 
411 Reality of legal weed in California: Illegal grows, deaths - Los Angeles Times (latimes.com) Accessed 7th 
November 2023. 
412 See footnote #334. 
413 See footnote #276. 
414 See for example Reduce your risk: Choose legal cannabis - Canada.ca Accessed 7th November 2023. 
415 Firth, C.L., Warren, K.M., Perez, L., Kilmer, B., Shih, R.A., Tucker, J.S. ... & Pedersen, E.R. (2022). Licensed and 
unlicensed cannabis outlets in Los Angeles County: the potential implications of location for social equity. Journal of 
Cannabis Research, 4(18). doi.org/10.1186/s42238-022-00120-5 
416 See footnote #276. 

   
 
154 
 
are common barriers to legal transition,417 when legal markets expand sufficiently 
to address those difficulties, use of the drug and related health problems are likely 
to increase.418  
 
7.319 Which demonstrates the tension at the heart of setting policy objectives in this 
area: reducing the illegal market is arguably, at least to some extent, incompatible 
with safeguarding public health. Diminishing market share captured by dealers 
and organised crime is positive but, at the same time, seemingly somewhat of a 
mixed blessing. 
 
Social equity 
 
7.320 Principles of social equity are an important part of the global movement to legalise 
production, supply, sale and use of non-medical cannabis. That said, for cultural 
and historical reasons they hold more importance in some jurisdictions than 
others. 
  
7.321 They have been a particular focus in the US, where harms caused by cannabis 
prohibition are felt particularly unevenly. Rates of arrest and incarceration for 
simple cannabis possession, as we set out above, have been many times higher 
among black citizens than white, reflecting the extent to which the so-called ‘war 
on drugs’ has been felt most keenly by communities of colour.  
 
7.322 While not an explicit aim of Canada’s Cannabis Act, its recent Review reported 
calls for an expansion of its objectives to include measures to improve equity. 
Recommendations duly included reconsidering the regulatory fee structures 
applicable to ‘equity-deserving groups’ and working to ensure those eligible for 
support to enter the legal market are aware of what is available.419  
 
7.323 Broadly speaking, social equity approaches proactively support actors in the illegal 
cannabis industry to transition into legal markets. At their heart are intentions for 
profits to be realised first and foremost by those most harmed by the war on drugs 
(as opposed to corporate endeavours), with a variety of models in place to try and 
prioritise entry to markets for qualifying applicants. 
 
7.324 Some US states, for example, license one equity then one non-equity applicant for 
production, supply and retail licences. Others prioritise equity applicants for a 
certain period of time before opening out the process to others. Elsewhere, a 
lottery model guides the awarding of licences. The process is often complemented 
by commitments to reinvest a proportion of revenue generated by the legal non-
medical industry into communities disproportionately harmed by prohibition.  
 
7.325 However, it was put to us that intent behind equity programmes has not been 
matched by resource, meaning that, while good in theory, in practice – so far at 
 
417 See footnote #405.  
418 See footnote #234. 
419 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca pp.51–4, recommendations 
30, 31, 33, 34, 35. Accessed 18th April 2024. 

   
 
155 
 
least – they have not been as effective as hoped. Inadequate resource has been 
compounded by operational challenges: we heard processes can be too easy to 
game or circumvent, and eligibility criteria can inadvertently act as barriers to 
those they seek to encourage. 
 
7.326 Wider structural inequalities in the US also mean business knowledge and access 
to capital funding is lacking among communities eligible for equity programmes. 
And access to alternative banking (allowing legal cannabis businesses to operate 
in spite of the industry remaining illegal at federal level) has hampered sustained 
entry to the market among marginalised communities.  
 
7.327 The need for longer-term resources and funding has also, it was suggested, been 
underestimated. This has meant that, once corporate players are permitted to 
enter the market, equity applicants must compete against long-standing 
businesses who often have a legit footprint in the medical cannabis market. Their 
existing infrastructure affords easy transition to, and dominance of, the non-
medical sector.  
  
7.328 Legal frameworks that prohibit smoking or vaping of cannabis in public have also 
served to entrench rather than improve social inequities. Those who own their own 
homes or whose rental agreements permit smoking, or who otherwise have 
access to private outside space, are lawfully able to consume at home. But those 
whose living conditions do not permit this but whose consumption preference is 
smoking or vaping can struggle to find space to do so without risking a penalty 
(such as a civil fine).  
 
7.329 Because those from more deprived or disadvantaged socio-economic 
backgrounds are less likely to own their home, and people of colour are more 
likely to come from such backgrounds, public bans on cannabis consumption 
arguably generate discriminatory effects in contravention of wider social equity 
objectives that legal regulation has sought to meet. 
 
7.330 There is no simple solution. New York City has sought to address the issue by 
permitting cannabis to be smoked wherever tobacco is permitted (see para.7.10). 
This is not, however, ideal from the perspective particularly of those who do not 
consume cannabis: we discuss throughout our report the challenges faced by 
local lawmakers and officials in London in addressing disquiet about public 
cannabis consumption. 
 
7.331 Progress is also slow in improving diversity within the sector. As put to us, those 
who were over-represented in prohibitive frameworks in terms of harms are under-
represented in legal markets in terms of opportunities. White men continue to 
dominate the US and Canadian420 industries, particularly in senior positions: in 
 
420 See for example Deloitte and Ontario Cannabis Store. (2021). An industry makes its mark: The economic and 
social impact of Canada’s cannabis sector. An industry makes its mark - The economic and social impact of 
Canada’s cannabis sector (deloitte.com) Accessed 10th November 2023. 

   
 
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2020, they comprised 73% of executives and directors across legal cannabis 
producers and parent companies in Canada.421 
 
Other considerations  
 
Perceived risk and education regarding cannabis use 
 
7.332 Level of perceived risk is important as the less risky an individual considers 
cannabis to be, unsurprisingly the more likely they are to use it.422 But evidence is 
mixed regarding the effect of legal regulation on risk perception, both within and 
across jurisdictions.  
 
7.333 According to one large study, it has had little impact in US states and Canada.423 
Elsewhere, however, evidence suggests perceptions of risk are generally below 
the national average in US states where non-medical cannabis is permitted 
(although the overall trend is one of declining perceived risk),424 whereas in 
Canada the reverse seems to be the case. Here, there is some evidence that 
perceptions of risk and addiction potential resulting from cannabis use rose 
following legalisation, with a similar trend emerging in Uruguay.425   
 
7.334 One explanation for national differences may lie in levels of commercialisation: US 
states have largely allowed models that permit advertising and marketing, with few 
restrictions on packaging. Canada, however, set more stringent regulations at 
federal level so states have less flexibility in terms of commercial possibility, and 
Uruguay opted for a much more limited model overall.  
 
7.335 Public campaigns warning of risks of non-medical cannabis use may also play a 
role. Uruguayan authorities produced a range of materials that launched following 
regulation in 2013, and Canada too invested in public education following passage 
of the Cannabis Act 2018, as have several US states. Campaigns have sought to 
raise awareness of health and safety risks associated with cannabis, prevent 
problematic use, including with respect to driving under the influence of cannabis, 
and promote informed choices. 
 
7.336 We heard how legalisation has certainly facilitated more informed public 
conversations about safer consumption. Greater awareness of how different forms 
of the drug exert effects, with better understanding of potency (and how it is 
 
421 See Maghsoudi, N., Rammohan, I., Bowra, A., Sniderman, R., Tanguay, J., Bouck, Z. … & Owusu-Bempah, A. 
(2020). How Diverse is Canada’s Legal Cannabis Industry? Examining Race and Gender of its Executives and 
Directors. Centre on Drug Policy Evaluation. How-Diverse-is-Canada’s-Legal-Cannabis-Industry_CDPE-UofT-Policy-
Brief_Final.pdf Accessed 10th November 2023. 
422 Schleimer, J.P., Rivera-Aguirre, A.E., Castillo-Carniglia, A., Laqueur, H.S., Rudolph, K.E., Suárez, H. …. & Cerdá, 
M. (2019). Investigating how perceived risk and availability of marijuana relate to marijuana use among adolescents in 
Argentina, Chile and Uruguay over time. Drug and Alcohol Dependence, 201, pp.115–126. 
423 Lemos, M.K., Taylor, E., Wadsworth, E., Reid, J.L., Hammond, D. & East, K. (2023). Perceptions of cannabis use 
risk to mental health among youth in Canada, England and the United States from 2017 to 2021. Drug and Alcohol 
Dependence, 250. doi.org/10.1016/j.drugalcdep.2023.110904 
424 See footnote #357. 
425 See footnote #264. Accessed 8th November 2023. 

   
 
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measured) and risks of adulteration associated with illegal product, are arguably 
positive in terms of encouraging safer use and informed choices. 
 
7.337 That said, it was put to us that more could be done, certainly in Canada, where 
message cut-through seems to be falling (unlike in the US, where it reportedly 
increased slightly between 2018 and 2021).426 While numbers vary, overall the 
proportion of Canadians recalling a cannabis education campaign or public health 
message fell between 2019 and 2022427,428 – although it is unclear whether this 
reflects genuine reduction in message cut-through or in the frequency of 
campaigns. 
 
7.338 The review of the Cannabis Act highlighted frustration with the pace of progress 
on public campaigns (and aligned research activity). Moreover, it found better 
attenuation of messages to meet needs of different groups was warranted, and 
suggested health warnings be tailored to product format (generic messages about 
smoking should not be applied to edible products, for example).429 
 
7.339 Cannabis literacy more widely, it was put to us, is not yet sufficiently widespread 
among Canadian families, education providers, law enforcement or health 
professionals. The Review found certain risks (for example, cannabis-related 
psychosis) and specific populations (including those with a family or personal 
history of mental health disorders) have received inadequate attention in terms of 
education and awareness. It makes a range of associated recommendations in 
this space.430 
 
7.340 We heard that messages focusing on less harmful ways of consuming cannabis 
are valuable, akin to those around (e-)cigarette and alcohol consumption, and 
messenger as well as content is key. As the Covid-19 pandemic highlighted, 
credible, trusted voices are crucial – perhaps including people with experience of 
using cannabis rather than physicians or government. Pharmacists too could play 
a role given their presence within communities (we explore this within the UK 
context in chapter 9).  
 
7.341 In legalised settings, supporting people who use cannabis to identify legal and 
illegal sources of the drug – offline and online – is also important. The latter 
particularly so for communities with no nearby dispensary who are more likely to 
purchase online. Cannabis bought remotely means there is little or no opportunity 
to enquire about products, effects and strength (unlike in retail stores where staff, 
known as ‘budtenders’, can advise) – highlighting the importance of ensuring an 
educated customer. 
 
 
426 See footnote #263. 
427 Health Canada. (2023). The Canadian Cannabis Survey 2022 and 2019. https://epe.lac-
bac.gc.ca/100/200/301/pwgsc-tpsgc/por-ef/health/2022/124-21-e/index.html and https://epe.lac-
bac.gc.ca/100/200/301/pwgsc-tpsgc/por-ef/health/2019/130-18-e/index.html 
428 See footnote #276. 
429 See Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca and Legislative Review of the 
Cannabis Act: Final Report of the Expert Panel - Canada.ca 
430 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.28.  

   
 
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7.342 Driving under the influence of cannabis was highlighted by several of those we 
heard from, with some desire for deterrence campaigns similar to those designed 
to prevent drink driving. These are largely accepted to be relatively successful, 
perhaps in part because of the risk of police stops. That said, the challenge of 
distinguishing intoxicating levels of cannabis (as distinct from mere presence) 
remains. 
 
7.343 Public education strategies alone, however, are unlikely to achieve harm reduction 
objectives, particularly where these depend on behaviour change. Specific 
programmes focusing on drivers of cannabis use, mental health and wider skills 
development are important and require adequate investment and ongoing funding. 
We discuss education about cannabis use in more detail in chapters 8, 9 and 12. 
 
7.344 Most of those from whom we heard accepted that the non-medical cannabis 
industry is still nascent, and that expectations for more substantial shifts in 
attitudes, practice and resources after, for example, only five years since Canada 
passed its Cannabis Act in 2018 following 100 years of prohibition, were overly 
optimistic.  
 
7.345 On the other hand, regulatory changes were widely recognised to have brought 
welcome opportunities for more open, informed conversations about cannabis 
use. Along with associated education and awareness raising which legalisation 
has facilitated – albeit fairly limited thus far – such opportunities were accepted as 
important components of legislative aims to improve public health. 
 
Use of cannabis in public 
 
7.346 Following legal regulation, we heard that people tend to feel more comfortable 
using cannabis in public. That said, a certain stigma remains, meaning some feel 
self-conscious among a prevailing view, at least in some places, that consumption 
should happen in private.  
 
7.347 While we heard it is not generally the norm for cannabis to be smoked in public 
spaces in Canada, and byelaws enacted in many provinces and territories in an 
effort to counter public concerns about odour mean it is illegal to do so (as in 
many US states), there remains a strong likelihood, particularly in some areas, of 
encountering the smell of cannabis. And even where a person smokes cannabis in 
their home, if they do so in gardens or on balconies, in reality the smell is likely to 
drift – particularly in built-up areas and high-density housing. 
 
7.348 It was put to us that smell of cannabis (and tobacco) smoke, risk of passive 
inhaling and anxieties related to children witnessing cannabis being smoked are 
the primary concerns with public consumption in jurisdictions that permit its use. 
Whether these rise following legalisation, however, is unclear. Certainly, concerns 
exist in London despite continued prohibition of non-medical cannabis, as we 
heard many times from elected leaders and other senior officials, as well as 
members of the public. Concerns around public dealing, however – a worry for 
many Londoners – seem to diminish following legal regulation (although it was put 

   
 
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to us that some hotspots remain, which is not surprising given the persistence of 
the illegal market).  
 
7.349 It was also suggested that legal regulation tends to shift cannabis use down the 
public, political and media agenda more broadly. In Canada, for example, it was put 
to us that concerns around alcohol and hard (illicit) drugs now take prima cy, with 
cannabis largely considered a relatively non-controversial issue.  

   
 
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8. THE EFFECTS OF NON-MEDICAL 
CANNABIS ON PHYSICAL AND 
MENTAL HEALTH  
 
While the biological mechanisms through which cannabis exerts its effects are beyond 
the scope of our inquiry, we have considered the nature and extent of those effects. 
Isolating the precise causal effects of cannabis (beyond immediate impacts) is 
challenged by methodological and other limitations of research, but nonetheless an 
increasing body of evidence points to some risk of harm, particularly in certain 
circumstances.  
  
In this chapter, we summarise our understanding of the evidence and explore health-
related harms as well as potential therapeutic benefits of non-medical cannabis. We 
look at the impact of the drug on the body and brain, particularly its relationship with 
serious psychiatric disorders and potential for dependency and addiction. We then 
consider the extent to which cannabis is implicated in wider injury and death, as well as 
associations with physical diseases.   
 
As cannabis is typically co-consumed in this country with tobacco, we examine related 
concerns. Use, too, of cannabidiol (CBD), a non-psychoactive component of cannabis 
contained in products designed for the wellness market, also merited consideration. We 
briefly explore the risks of synthetic cannabinoid receptor agonists (SCRAs) as well as 
the relationship between cannabis potency and health. 
 
We conclude by reflecting on public messaging and education, considering 
opportunities to inform and help those who choose to use the drug do so with less risk.  
 
The starting point  
 
8.1 Despite the use of cannabis going back millennia, findings from the vast evidence 
base investigating its effects on the human body and mind remain largely mixed. 
While in some areas the evidence seems to be converging, there is no universally 
held view among the medical community with respect to the precise nature or 
extent of either harmful or beneficial effects of cannabis on physical and mental 
health. Inconsistencies are in part due to the heterogeneity of populations 
assessed, the aims of research and the different patterns and preparations of 
cannabis studied. 
 
8.2 Most agree cannabis is not a harmless drug, irrespective of whether they are in 
favour of relaxing the legal framework governing its use for non-medical purposes. 
Views differ, however, on the relative risk of harm versus pleasurable or beneficial 
effects, who is at most risk of harm, to what degree and in what circumstances.  
 
8.3 Whether cannabis plays a causal role in the onset of specific mental health 
conditions, including psychosis as well as anxiety and depression, is the subject of 

   
 
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some debate. Most research, however, supports the notion of some association, 
particularly in the case of psychosis and, too, schizophrenia, and that risks are 
greatest among those who commence use at an early age, those who use heavily 
and frequently, and those with co-morbid mental health conditions. 
 
8.4 We recognise upfront some of the limitations of study in this area because they 
have a bearing on the strength or surety of conclusions we feel able to draw in 
some respects. While the quality and strength of evidence is improving all the time, 
key challenges facing health-related research, particularly in some areas, have 
included: 
 
• Inconsistent and relatively small, or unrepresentative, sample sizes, meaning 
it is difficult to generalise research findings in some areas to wider 
populations. Increased use of systematic reviews, meta-analyses and cross-
border population studies are helping to address this.   
• Risk of bias, which can result from sample selections being drawn too 
narrowly, or from partiality in funders of research exploring the effects of 
cannabis use. 
• Lack of adequate control groups or access to information on all potential 
confounding factors, meaning, in some areas, clear evidence of causality 
between cannabis use and observed effects is difficult to establish 
conclusively.   
• Lack of standardised procedures or measures making it difficult to compare 
findings across studies to build up a reliable picture of effects (this includes 
the lack of a standard ‘unit’ of THC, the main psychoactive component of 
cannabis).431 
• Failure to account for confounding factors, particularly use of alcohol, 
tobacco and/or other drugs as well as variations in personal vulnerability. This 
means in some cases physical or mental health markers following cannabis 
use cannot easily be isolated from effects of other substances or pre-existing 
conditions.  
• Changes in potency, meaning cannabis available today tends to be stronger 
(higher in THC, lower in CBD) than ten or even five years ago. Findings from 
studies undertaken some time ago may hold up less well in the current 
context. 
• Knowledge of the impact of edible cannabis and vaping remains under-
developed as the majority of studies have historically focused on the 
relationship between smoking the drug (often with tobacco) and symptoms of 
ill health. Those who use cannabis are now increasingly adopting other 
methods of consumption.  
 
8.5 Despite these limitations, however, recent studies and reviews have reached well-
supported conclusions regarding a number of health risks associated with 
 
431 Freeman, T. P. & Lorenzetti, V. (2020). Standard THC units: a proposal to standardize dose across all cannabis 
products and methods of administration. Addiction, 115(7), pp.1207–16. 

   
 
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cannabis use.432 These chime with much of the evidence put to us directly from 
experts working in academic and policy settings as well as frontline health delivery 
services. 
 
8.6 It is, though, important to consider those risks in the broader context as a 
substantial proportion of (adult) users of the world’s most widely consumed illicit 
drug suffer no adverse health consequences – even where use is regular.433  
 
8.7 The sheer number of total users means in volume terms, though, many will 
experience some transient or longer-lasting ill effects (of the estimated 193 million 
users worldwide, at least 10% are thought to be affected by cannabis use disorder 
(CUD),434 for example, and the figure could be higher, see para.4.72). But the 
overall risk of adverse impact is somewhat smaller than, say, among those who 
use opiates, or alcohol. Over one-fifth (23%) of adults in England aged over 16 
report drinking more than the recommended maximum units per week.435   
 
8.8 In 2021, 9,641 deaths in the UK were recorded as due to alcohol-specific 
causes,436 whereas cannabis-related fatal poisonings equated to less than 1% 
(n=32) of drug-poisoning deaths in England & Wales in 2022. The risk of death 
due to cannabis toxicity is reportedly negligible.437 That said, cannabis use is 
implicated in other fatal outcomes (resulting, for example, from cardiac failure, 
suicide, non-intentional self-inflicted injury and road traffic collisions), which we 
discuss in subsequent sections.  
 
8.9 And the principal risk posed by cannabis use is of course not death but rather, as 
we set out in this chapter, development or exacerbation of a severe mental health 
disorder, or other life-worsening conditions such as increased anxiety. Not only 
can these cause huge distress to an individual and their loved ones but such 
disorders place significant pressure on heavily oversubscribed treatment services. 
They also risk wider costs to society through, for example, incapacity to work or 
participate fully in wider life. 
 
8.10 So, while cannabis use unquestionably raises some health risks, as we have 
commented elsewhere so too does consumption of other perfectly legal 
substances, notably alcohol and nicotine (tobacco), but also caffeine, sugar and 
 
432 Solmi, M., De Toffol, M., Yeob Kim, J., Je Choi, M., Stubbs, B., Thompson, T. … & Dragioti, E. (2023). Balancing 
risks and benefits of cannabis use: umbrella review of meta-analyses of randomised controlled trials and 
observational studies. The BMJ, 2023; 382:e072348. doi.org/10.1136/bmj-2022-072348 Accessed 12th February 
2024. 
433 Fergusson, D.M., Boden, J.M. & Horwood, L.J. (2015). Psychosocial sequelae of cannabis use and implications 
for policy: findings from the Christchurch Health and Development Study. Soc Psychiatry Psychiatr Epidemiol, 50, 
pp.1317–26. doi:10.1007/s00127-015-1070-x Accessed 11th March 2024. 
434 Connor, J.P., Stjepanović, D., Le Foll, B., Hoch, E., Budney, A.J. & Hall, W.D. (2021). Cannabis use and cannabis 
use disorder. Nature Reviews Disease Primers 7(16). doi.org/10.1038/s41572-021-00247-4 Accessed 11th March 
2024. 
435 Health Survey for England 2019: Adults' health-related behaviours data tables, Table 10. Health Survey for 
England, 2019: Data tables - NHS England Digital 
436 Alcohol-specific deaths in the UK - Office for National Statistics (ons.gov.uk) 
437 Rock, K.L., Englund, A., Morley, S., Rice, K. & Copeland, C.S. (2022). Can cannabis kill? Characteristics of deaths 
following cannabis use in England (1998–2020). Journal of Psychopharmacology, 36(12). 
doi.org/10.1177/02698811221115760 

   
 
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fat. All have addictive properties and, if consumed to excess, risk harmful 
consequences for physical and mental health.  
 
8.11 As we explore in this chapter in relation to cannabis, some people are at greater 
risk of health harms than others (because of genetics, pre-existing mental health 
conditions or other lifestyle factors). Education and honest conversations between 
health services and the patients they serve may, however, help individuals make 
more informed choices and moderate those risks. Arguably, in much the same 
way that public health information is offered regarding consumption of alcohol, 
cigarettes and processed foods, the same could be offered for cannabis. 
 
Impacts of cannabis use on the human brain and body 
 
8.12 Just because cannabis is a plant does not mean it contains no harmful properties 
– indeed, plant extracts are used not only in medicines but also poisons. And it is 
perfectly possible to develop an addiction to cannabis, although the chances are 
slightly lower than for alcohol and substantially lower than for opioids or 
psychostimulants.438  
 
8.13 As the Runciman Report points out, when cannabis is compared to other illicit 
drugs, as well as alcohol and tobacco, using the main criteria of harm (mortality, 
morbidity, toxicity, addictiveness and relationship with crime), it is less damaging 
to individuals and wider society.439 Certainly, the majority of experts who 
contributed to our inquiries considered the health risks from tobacco to be greater 
than those linked to cannabis. That said, we note these criteria do not include 
mental health morbidity, a significant consideration with respect to cannabis use.  
 
8.14 Consideration of such relative harms partly underpinned the Runciman conclusion 
that cannabis is wrongly designated a Class B drug. We have had significant 
regard to this in our considerations, over two decades later, about the most 
appropriate legal framework to govern its non-medical use.  
 
8.15 In the following sections we summarise our understanding of evidence on health-
related consequences associated with cannabis. We consider first what are widely 
thought of as detrimental, or harmful, effects, then touch on potential therapeutic 
benefits (covered in more detail in chapter 11 on medical cannabis).  
 
8.16 But before doing so, we must first acknowledge the perspective put forward by 
those frontline experts who participated in our inquiries from health, criminal 
justice and educational settings. While almost universally among those witnesses 
there was little active support for maintenance of the criminalisation of use of non-
medical cannabis (widely accepted to cause significant harms), this tended not to 
equate to support for outright legalisation.  
 
 
438 Curran, H.V., Lawn, W. & Freeman, T.P. (2023). Cannabis and Addiction. In D.C. D’Souza, D. Castle & R. Murray 
(Eds.), Marijuana and Madness. (pp.299–310). Cambridge University Press.  
439 Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971 (2000). The Police 
Foundation. Police Doc. (police-foundation.org.uk) chapter 7, para.21. Accessed 12th February 2024. 

   
 
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8.17  We recognise many of those we heard from occupy roles that mean they spend 
their days with patients struggling with drug addiction and abuse, or offenders for 
whom drugs form part of a wider range of needs. They likely have less exposure to 
the very much greater number of people whose use of cannabis does not become 
problematic. However, in considering our position with respect to legalisation, we 
must have regard to implications for those struggling with cannabis use. Because 
the user population is so large, the number who go on to develop significant 
health-related harms can arguably be relatively high.  
 
8.18 Whether these harms (as distinct from harms associated with criminalisation; see 
chapter 10) would be exacerbated or moderated through an alternative legal 
framework is very difficult to predict. On the one hand, legalising use of non-
medical cannabis might encourage help-seeking behaviours among those at risk 
of, or suffering from, adverse consequences. On the other, it might increase the 
number of users in need of such help. 
 
Brain structure and cognitive function 
 
8.19 The effect of cannabis on the brain has received much attention. While the picture 
is mixed, there is a degree of convergence on the suggestion that acute effects 
(transient and seen during the period of intoxication)440 can include memory 
impairment and behavioural inhibition, which can in turn increase impulsivity. The 
extent of such effects is likely to be moderated by the strength of cannabis 
consumed (strains high in THC and low in CBD are widely accepted to cause 
greater memory loss) and acute impacts on judgement, cognition and motor skills 
are relevant particularly for consideration of driving, studying and operation of 
machinery.  
 
8.20 Longer-term, heavy use may impact more significantly on brain structure and 
composition, with changes to, or reduction in, some cognitive functions including 
learning, memory (both working and episodic) and decision-making. This is of 
particular note because the human brain continues to develop and mature until a 
person reaches their mid-twenties. As use of (non-medical) cannabis is particularly 
common among young people (see chapter 4), this raises obvious concerns about 
the potential for alterations to the process of brain development and maturation of 
neural pathways.  
 
8.21 The earlier in life a person begins using cannabis regularly, the greater the risk of 
dependence, the more significant the impact on development of the 
endocannabinoid system and brain development, and the greater the risk of 
poorer cognitive outcomes.  
 
8.22 The role of other factors, including adverse childhood experiences and mental 
health disorders (which are associated with earlier onset of use and can 
 
440 Curran, H.V., Freeman, T.P., Mokrysz, C., Lewis, D.A., Morgan, C.J.A. & Parsons, L.H. (2016). Keep off the 
grass? Cannabis, cognition and addiction. Nature Reviews – Neuroscience, 17, pp.293–306. Macmillan Publishers 
Limited. 

   
 
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independently affect brain structure) is not always clear, but at least one large 
birth cohort study441 has reported a greater decline in neuropsychological 
functioning when cannabis use began in adolescence. More persistent use was 
also associated with greater decline.  
 
8.23 This so-called neurotoxic effect of cannabis on the adolescent brain is accepted 
by the majority of experts regardless of their position on legalising non-medical 
cannabis use. Most if not all of those we heard from agreed that use among young 
people should not be supported, and one recent review of 101 meta-analyses 
concluded that adolescents and young adults should avoid using it.442 
 
8.24 The possibility of reverse causation cannot be entirely discounted, at least in some 
cases. This means that pre-existing conditions, patterns of mental ill health or 
genetic predispositions may pre-date or even drive cannabis use in some cases, 
rather than be a consequence of it. Even where not the case, isolating causal 
effects of cannabis use from other factors implicated in the emergence of poor 
mental health (significant life stressors, trauma etc) means conclusively 
determining causality remains a challenge (though less so in the case of 
psychosis, which we discuss further in this chapter). 
 
8.25 There is some evidence to suggest, for example, that young people with poor 
cognitive performance are more likely to become regular cannabis users, and 
poorer cognition and education outcomes have been reported to pre-date the 
onset of cannabis use among some. That said, its use, particularly where heavy 
and frequent, is likely to further exacerbate those poor outcomes.  
 
8.26 Sustained abstinence from cannabis following regular, heavy use may, however, 
lead to cognitive recovery (although not among adolescent-onset cannabis users, 
or at least not complete recovery)443 and, where present, improvement of 
psychotic symptoms. Which suggests detrimental effects on brain function may 
not always be long-lasting or indeed permanent.  
 
8.27 The fact that cannabis use is, as was put to us, very common among the Child 
and Adolescent Mental Health Services (CAMHS)444 caseload reinforces our 
position on the need for balanced education about the effects of cannabis use, 
which we summarise at the end of this chapter and cover, too, in chapter 12. 
Whether legal for non-medical purposes or not, realistically young people do and 
will continue to use cannabis.  
 
8.28 The view that, rather than seeking to stop them using cannabis completely, they 
should be encouraged to desist from use for as long as possible and be educated 
 
441 Meir, H., Caspi, A., Ambler, A., Harrington, H., Houts, R., Keefe, R.S.E. … & Moffit, T.E. (2012). Persistent 
cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of 
Sciences (PNAS). doi.org/10.1073/pnas.1206820109  
442 See footnote #432. 
443 See footnote # 441.  
444 The NHS services that assess and treat children and young people with emotional, behavioural or mental health 
difficulties. 

   
 
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about means of safer consumption, was echoed time and again across our 
witnesses. This should, as we discuss in chapter 12, begin very much earlier than 
at present, if there is to be hope of lessening the chances of children and young 
people turning to cannabis as a solution to the pressures and harms of current 
and future life challenges, including the inequalities faced by many.  
 
8.29 As the aforementioned review of meta-analyses concluded, negative effects on 
academic or wider scholastic performance are to be ‘reasonably expected’, 
particularly where use commences at an early age and is heavy. The risk of 
underachievement and any number of well-documented consequences 
associated with poor school outcomes are heightened.   
 
8.30 We note the challenge presented by the timing of the natural process of brain 
maturation set against the legal minimum purchase age for cannabis in 
jurisdictions where non-medical use has been legalised. In some this is 18 years, 
in others 21 – but even in cases of the latter, brain development is not complete by 
the time would-be users reach the minimum purchase age.  
 
8.31 Prohibiting people from buying cannabis products until they reach 25 or 26 is 
clearly neither practicable nor credible, given parallel age limits for alcohol and 
tobacco purchase. Given many young people in the UK are no doubt well aware 
that cannabis is legal for non-medical use elsewhere in the world, this makes the 
need for clear and balanced information about the risks that substantial 
consumption may pose to their brain maturation even more critical.  
 
Mental health 
  
8.32 The debate around whether cannabis use directly causes mental health problems 
is particularly polarised. That said, evidence at least with respect to its role as a 
risk factor in development of psychosis and schizophrenia is now relatively well 
established, particularly where there is existing predisposition to develop those 
illnesses.    
 
8.33 The nature of the association between other forms of mental illness and cannabis 
use is less clear and debate continues to rage in medical and academic circles, as 
well as among those who feel strongly that the drug should remain illegal or, 
conversely, subject to regulation and legally available through choice.  
 
8.34 Knowledge should be substantially furthered in coming years as the largest 
scientific study of its kind into the effects of cannabis on mental health bears fruit. 
The ‘Cannabis & Me’ study, launched in 2023 by King’s College London, will 
explore why a minority of those who use the drug experience paranoia and/or full-
blown clinical psychosis. It aims to examine whether and how biological make-up 
(DNA) interacts with socio-economic and other factors to modify effects of the 
drug, and how this may change across different strains and potency.  
 
8.35 We consider different disorders separately because evidence varies accordingly, 
but acknowledge upfront an important conclusion from the previously referred 

   
 
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review of meta-analyses. Namely that those prone to, or who have a mental health 
disorder, should refrain from using cannabis. Risk of adverse reaction to its main 
psychoactive component, THC, which is more dominant in cannabis strains of 
recent years, is considerably heightened. And conversely, relative levels of CBD – 
whose properties, some evidence suggests, may alleviate or mitigate wider 
symptoms of poor mental health – have diminished.  
 
Psychosis and schizophrenia 
 
8.36 A person suffering from psychosis has lost at least some contact with reality, and 
neutral events or stimuli can become intensely meaningful. They can experience 
changes in perceptions, hearing and seeing things which other people cannot see 
or hear (hallucinations). They may hold unshakeable beliefs against evidence to 
the contrary, which are not supported by their social or cultural background 
(delusions). Such beliefs can seem bizarre or paranoid in nature: sufferers can 
often, for example, believe they are the target of conspiracy. A sufferer may also 
present with disorganised thinking and speech445.  
 
8.37 A person diagnosed with schizophrenia, a mental health condition affecting 
thought processes, emotions and behaviour, can experience symptoms of 
psychosis – but not all those experiencing psychosis have schizophrenia.  
 
8.38 While multiple factors are widely recognised to be involved in the onset of both 
psychosis and schizophrenia, and cannabis use is neither necessary nor sufficient 
to cause either446, evidence increasingly shows an association between 
development of the illnesses and use of the drug447. Incidence rates are higher and 
age of onset lower where cannabis use, particularly heavy use, is reportedly more 
prevalent448. 
 
8.39 More specifically, evidence is converging around the notion of risk thresholds449. In 
other words, frequent, heavy use of high potency cannabis450, when no disorder 
has already occurred, can raise the risk of onset - particularly in those with a 
hitherto dormant genetic predisposition451.  
 
 
445 Overview - Psychosis - NHS (www.nhs.uk) Accessed 9th February 2024. 
446 D’Souza, D.C., Di Forti, M., Ganesh, S., George, T.P., Hall, W., Hjorthøj, C. & Spinazzola, E. (2022). Consensus 
paper of the WFSBP task force on cannabis, cannabinoids and psychosis. The World Journal of Biological Psychiatry, 
23(10), pp.719–42. doi.org/10.1080/15622975.2022.2038797 
447 See footnote #433. 
448 Pow, J.L., Donald, C., Di Forti, M. Roberts, T., Weiss, H.A., Ayinde, O. & Hutchinson, G. (2023). Cannabis use 
and psychotic disorders in diverse settings in the Global South: findings from INTREPID II. Psychological Medicine, 
pp.1–8. doi.org/10.1017/S0033291723000399 
449 Robinson, T., Ali, M. U., Easterbrook, B., Hall, W., Jutras-Aswad, D. & Fischer, B. (2023). Risk-thresholds for the 
association between frequency of cannabis use and the development of psychosis: a systematic review and meta-
analysis. Psychological Medicine, 53(9), pp.3858–68. doi:10.1017/S0033291722000502 
450 Marconi, A., Di Forti, M., Lewis, C. M., Murray, R. M. & Vassos, E. (2016). Meta-analysis of the association 
between the level of cannabis use and risk of psychosis. Schizophrenia Bulletin, 42(5), pp.1262–9. 
doi.org/10.1093/schbul/sbw003 
451 Patel, S., Khan, S., M, S. & Hamid, P. (2020). The Association Between Cannabis Use and Schizophrenia: 
Causative or Curative? A Systematic Review. Cureus, 21;12(7). doi:10.7759/cureus.9309 

   
 
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8.40 Adults and adolescents who use cannabis are likely to be at greater risk of 
developing psychosis and/or schizophrenia in such circumstances than non-users, 
or those who use lower-strength product less regularly.452ʹ453 Indeed, meta-
analyses suggest that the odds of frequent users of cannabis developing a 
psychotic disorder specifically are four times greater compared to non-users 
(cannabis users overall have twice the odds).454 
 
8.41 Among those diagnosed with a psychotic disorder or schizophrenia, cannabis use 
is likely to exacerbate symptoms,455 worsen clinical outcomes and raise the 
chance of relapse and hospitalisation – even among patients responding well to 
antipsychotic medication.456,457  
 
8.42 It remains difficult to pin down the precise impact of cannabis use as distinct from 
unknown predisposition to schizophrenia or psychosis – here too, the possibility of 
reverse causality cannot conclusively be ruled out. Nevertheless, longitudinal 
studies show that after statistically controlling for those who began using cannabis 
to ameliorate psychological distress and sub-clinical psychotic symptoms, and 
those with a family history of psychosis, heavy cannabis use – particularly if started 
in adolescence – increases the risk of psychosis.  
 
8.43 While it seems likely the relationship operates in both directions, evidence 
suggests the pathway from cannabis use to development of psychotic symptoms 
is stronger than that from development of symptoms to use of cannabis.458  
 
8.44 The fact that evidence suggests regular (daily or near daily) users of cannabis are 
more likely than non-users to be diagnosed with schizophrenia or psychosis459 is 
clearly cause for concern. Regardless of the direction of association, there is a 
raised likelihood of adverse consequence from cannabis use for those at 
heightened risk or suffering from either disorder. Indeed, we heard the extent of 
cannabis use among patients under the care of mental health services treating 
psychosis is very high, in some cases up to 80%.  
 
8.45 Furthermore, it was put to us that, if high-potency cannabis strains (THC=>10%) 
were no longer available, 30% of cases of first-episode psychosis in south London 
could be prevented (and 50% in Amsterdam, where cannabis possession is 
 
452 See footnote #432. 
453 Petrilli, K., Shelan, O., Hines, L., Taylor, G., Adams, S. & Freeman T. (2022). Association of cannabis potency with 
mental ill health and addiction: a systematic review. The Lancet Psychiatry Review, 9(9), pp.736–50. 
doi.org/10.1016/S2215-0366(22)00161-4. 
454 See footnote #450. 
455 Hamilton, I. (2017). Cannabis, psychosis and schizophrenia: unravelling a complex interaction. Addiction, 112(9), 
pp.1653–7. doi:10.1111/add.13826 
456 See footnote #432. 
457 See footnote #453. 
458 See footnote #433. 
459 See summary in Wang, G.S., Buttorff, C., Wilks, A., Schwam, D., Tung, G. & Pacula, R.L. (2022). Impact of 
cannabis legalization on healthcare utilization for psychosis and schizophrenia in Colorado. Int J Drug Policy. 
doi:10.1016/j.drugpo.2022.103685 

   
 
169 
 
effectively de-penalised, see chapter 7).460 This has obvious and powerful 
implications for London’s oversubscribed psychiatric services (the city has a 
higher incidence rate for psychosis than elsewhere):461 removal of one-third of the 
caseload would significantly lessen the pressure.  
 
8.46 While common among psychiatric populations, forensic psychiatric services 
reported very high rates of cannabis use among offenders – in excess of 90% (see 
chapter 10). Practitioners here were similarly agreed on a clear link between 
psychosis and cannabis – particularly with use of high-potency products.  
 
8.47 Research has also attempted to quantify the extent of the burden of cannabis use 
with respect to schizophrenia: one estimate suggests around 14% of people with 
the disorder might never have developed the condition had they not begun to use 
the drug.462 While less stark than the association with psychosis, it seems 
incontrovertible that regular use particularly of high-potency cannabis likely 
increases the burden on public health services.  
 
8.48 We recognise most cannabis users do not develop psychosis or disorders such as 
schizophrenia, and many of those diagnosed with such conditions have never 
used cannabis.463 But several health experts told us they expect to see a rise in 
the number of users presenting psychotic symptoms over the next decade or so, 
due to increasingly potent products now being the norm rather than the 
exception.464  
 
8.49 While difficult to predict the extent of any rise until research has opportunity to 
investigate the link over the longer term in large samples of people who use 
modern-day cannabis, it is likely to be felt unequally across different regions of the 
country.  
 
8.50 Differences in exposure to risk factors for psychosis and schizophrenia, including 
socio-economic factors (measured by, for example, levels of owner-occupied 
housing) and elevated risk among some groups, particularly young people, 
migrant populations and men from black ethnic backgrounds465ˏ466 mean large 
urban areas tend to show higher rates of both disorders. This is particularly 
evident in London.467  
 
460 Di Forti, M., Quattrone, D., Freeman, T.P., Tripoli, G., Gayer-Anderson, C., Quigley, H. … & the EU-GEI WP2 
Group. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe 
(EU-GEI): a multicentre case-control study. Lancet Psychiatry, 6, pp.427–36.  
doi.org/10.1016/S2215-0366(19)30048-3 
461 Ibid. 
462 Medical Research Foundation | Spreading the word about harmful ‘skunk’. Accessed 27th March 2024. 
463 See footnote #440. 
464 See also Freeman, T.P. & Winstock, A.R. (2015). Examining the profile of high-potency cannabis and its 
association with severity of cannabis dependence. Psychol Med, 45(15), pp.3181–9.  
doi:10.1017/S0033291715001178 
465 See for example Psychosis data report (publishing.service.gov.uk) 
466 Bebbington, P., Rai, D., Strydom, A., Brugha, T., McManus, S. & Morgan, Z. (2016). Psychotic Disorder. Chapter 
5 – Adult Psychiatric Morbidity Survey 2014. adult_psychiatric_study_ch5_web.pdf (digital.nhs.uk) 
467 Jongsma, H.E., Gayer-Anderson, C., Lasalvia, A., Quattrone, D., Mulè, A., Szöke, A. … & Kirkbride, J.B. (2018). 
Treated Incidence of Psychotic Disorders in the Multinational EU-GEI Study. JAMA Psychiatry, 75(1), pp.36–46. 
doi:10.1001/jamapsychiatry.2017.3554 

   
 
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8.51 And of course, the risk of developing CUD among those who use cannabis more 
generally is somewhat higher than the likely risk of developing either psychosis or 
schizophrenia as a result of use of the drug. 
 
8.52 Underpinning views from experts, we heard powerful testimonies from patients at 
London’s Cannabis Clinic for Patients with Psychosis (CCP, see chapter 9), who 
were, or who had been, users of high-strength cannabis. We heard how vital the 
clinic has become for its patients, who are routed into the service primarily through 
community-based psychosis teams or following time in a psychosis ward, and how 
valuable its support and tools are to reduce dependence on cannabis. 
 
8.53 These testimonies highlighted how much of a role the wider environment can play 
in a patient’s decision to use cannabis. Similar to drivers among non -psychotic 
users, use is often precipitated by a desire to avoid dealing with a particular issue(s), 
feelings or life circumstances. It was described by one patient, for whom extreme 
paranoia had featured among his symptoms, as ‘a form of socialising with no  one 
there’. The importance of wider wraparound services in helping psychotic cannabis 
users address needs related to other areas of their lives was highlighted to us 
several times.  
 
8.54 The role of wider life inequalities featured in much of the evidence put to us. While 
consumed across socio -economic groups, high levels of cannabis use are 
particularly common among young people, especially m ales,468 (which perhaps 
goes some way to explaining why y oung men tend to be over -represented in 
psychiatric and drug-dependent populations). They are often living in poverty with 
poor family support,  a past engagement with the criminal justice system, low 
educational attainment and a history of school exclusion. And as was put to us, the 
latter is likely to be a precipitant as much as a consequence of cannabis use.  
 
8.55 We discuss these issues throughout ou r report and note the challenges in 
determining whether cannabis use is a driver or a consequence of wider inequalities. 
Irrespective of that relationship, however, is the fact that cannabis use is widely 
considered to risk worsening social inequalities still further.  
 
8.56 It was also suggested, however, that more is known about poor than middle class 
people who use drugs. Much research and therefore evidence tends to be gathered 
from patients involved in treatment services. Lengthy wait times and a lack of lo cal 
NHS services drive those who can afford to do so to private healthcare, meaning 
associated data about their characteristics and drug use are less accessible. This 
means data about the poor may come to dominate in health and drug statistics and 
research.  
 
 
468 See for example European Monitoring Centre for Drugs and Drug Addiction (2023). Cannabis – the current 
situation in Europe (European Drug Report 2023). Available at European Drug Report 2023: Trends and 
Developments | www.emcdda.europa.eu 

   
 
171 
 
8.57 Built-in data bias may also be at least partly responsible for the observed gender 
imbalance: young men are over -represented in psychiatric populations compared 
to young women, but they are also more likely to be caught up in the criminal justice 
system (CJS) and excluded or suspended from school .469 It is thus perhaps easier 
for clinicians and researchers to explore drivers and consequences of drug use, 
alongside contextual factors, for men , as they are more likely to come to the 
attention of authorities more generally. 
 
Mood disorders (depression and bipolar disorder) and anxiety 
 
8.58 Evidence with respect to association between use of cannabis and mood 
disorders is mixed. Several studies report a link particularly, again, between 
regular use of high-potency cannabis and depression (although research 
elsewhere reports no such association).470 The same is true for bipolar disorder, 
where continued use is associated with recurrence of manic episodes and 
reduced response to treatment.  
 
8.59 Consumption of higher-potency cannabis may be particularly associated with the 
development of anxiety disorders. Certainly, for some users THC can heighten 
feelings of anxiety while intoxicated. Dependence on cannabis (see below) has 
also been linked with symptoms of anxiety and depression,471 although we note 
some sufferers report cannabis to be helpful in reducing these. 
 
8.60 The possibility of reverse causation once again cannot be discounted. As with 
other conditions, symptoms of depression, bipolar disorder or anxiety might cause 
a person to initiate (and in some cases become dependent on) cannabis use, at 
least in part by way of self-medication (as we discuss elsewhere).  
 
Cannabis dependence, addiction and Cannabis Use Disorder 
 
8.61 Cannabis dependence is defined in the International Classification of Diseases 
(ICD)472 as a disorder of regulation of cannabis use arising from repeated or 
continuous use of cannabis, characterised by a strong drive to use the drug. This 
is manifested by impaired ability to control use, increasing priority given to use 
over other activities, and persistent use despite harm or negative consequences.  
 
8.62 Tolerance and withdrawal symptoms following cessation or reduction are 
physiological indicators of dependence, with mental dependence indicated by a 
strong desire to use cannabis, which can become a conditioned response to an 
event or feeling (triggers). It is possible to be dependent on cannabis without 
being addicted. 
 
469 Suspensions and permanent exclusions in England, Autumn term 2022/23 – Explore education statistics – 
GOV.UK (explore-education-statistics.service.gov.uk) Accessed 21st February 2024. 
470 See footnote #453. 
471 See discussion in Curran, H.V., Lawn, W. & Freeman, T.P. (2023). Cannabis and Addiction. In D.C. D’Souza, D. 
Castle & R. Murray (Eds.), Marijuana and Madness. (pp.299–310). Cambridge University Press.  
472 World Health Organization (2018). International classification of diseases for mortality and morbidity statistics 
(11th Revision). World Health Organization. 

   
 
172 
 
 
8.63 While often used interchangeably with dependence, addiction is a separate 
concern and refers principally to behavioural changes in a user. The main priority 
of a person addicted to cannabis (or any substance) becomes the use of cannabis 
come what may, irrespective of any harm caused to themselves or others in the 
process. Addiction to cannabis is likely to mean a user is dependent on the drug.  
 
8.64 CUD arguably combines elements of both addiction and dependence. It is defined 
by the Diagnostic and Statistical Manual of Mental Disorders as ‘a problematic 
pattern of cannabis use characterized by the development of tolerance, 
withdrawal symptoms upon cessation, unsuccessful attempts to cut down or 
control use, and continued use despite negative consequences.’473  
 
8.65 Despite a common belief among those who use it that cannabis neither leads to 
dependence nor incurs withdrawal symptoms, that these definitions are included 
in the principal guides to mental disorders used across the world suggests 
otherwise. Estimates of the prevalence of CUD worldwide vary but evidence 
suggests at least around 10% of global users474 would meet the criteria for the 
disorder.  
 
8.66 And this figure may well be higher, likely because of the increasing dominance of 
high-potency cannabis:475 one review reported double that prevalence with an 
average of over 20% of users across several studies showing symptoms of CUD. 
As with other mental health disorders, risk increased with early onset and frequent 
use.476  
 
8.67 Moreover, risk is not confined to non-medical use. The disorder is reported among 
medical users too (although there are challenges in reliably distinguishing this 
group from those who also, or solely, use cannabis for non-medical purposes). 
One recent review found up to 25% reported symptoms, most commonly 
withdrawal and tolerance.477 
 
8.68 While debatable whether such symptoms should be specified for CUD when they 
are not applied in DSM-5 criteria of, for example, Opiate Use Disorder,478 the fact 
remains that cannabis is seemingly not without risk even when used to alleviate 
symptoms of poor physical and/or mental health.  
 
 
473 American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental 
disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. doi.org/10.1176/appi.books.9780890425596  
474 See footnote #434. 
475 See discussion in Hall, W. & Hoch, E. (2023). Minimizing double standards in assessing the adverse and beneficial 
effects of cannabis. Addiction, 118(9), pp.1606–8. doi.org/10.1111/add.16267 
476 Leung, J., Chan, G.C.K., Hides, H. & Hall, W.D. (2020). What is the prevalence and risk of cannabis use disorders 
among people who use cannabis? a systematic review and meta-analysis. Addictive Behaviours, 109. 
doi.org/10.1016/j.addbeh.2020.106479 
477 Dawson, D., Stjepanović, D., Lorenzetti, V., Cheung, C., Hall, W. & Leung, J. (2024). The prevalence of cannabis 
use disorders in people who use medicinal cannabis: A systematic review and meta-analysis. Drug and Alcohol 
Dependence, 257. Elsevier. 
478 Ibid. 

   
 
173 
 
8.69 Cannabis use in jurisdictions where it is legal for non-medical purposes may be 
driving up overall reported prevalence of CUD – although whether due to 
increased numbers of those using the drug or more frequent use by existing users 
is unknown. A recent report from Washington state in the US, where non-medical 
cannabis has been legal since 2012, found just over one-fifth of primary care 
patients who were also cannabis users – including those who used it only for 
medical purposes – showed signs of CUD.  
 
8.70 While symptoms were reported among medical and non-medical users, moderate 
to severe symptoms were particularly prevalent among those reporting non-
medical use (alone or alongside medical use).479 This group were also more likely 
than medical users to report use of cannabis in hazardous circumstances, 
uncontrolled escalation of use, cravings and interference with wider obligations. 
 
8.71 In the UK, clinicians told us around 25,000 people a year present in clinics with 
symptoms of cannabis addiction – or around 1% of those in England & Wales who 
report using the drug (see chapter 4). This represents a fraction of those who 
might potentially be experiencing CUD – the global prevalence rates above 
suggest they could number at least 250,000 and possibly be as many as half a 
million users of cannabis.  
 
8.72 While individual and public health burdens associated with CUD may well be lower 
than those associated with use of, for example, heroin or other opioids, they are 
certainly not nothing. Given that frequent use of high-potency cannabis480 
heightens the risk of developing symptoms (as with psychosis, schizophrenia and 
other disorders), the fact that this now dominates the market suggests there is 
potential for the burden posed by CUD to rise.  
 
8.73 Environmental factors, including living alone and negative life events such as a 
major financial crisis or parental death, can also raise the risk of cannabis 
addiction. Personality traits including impulsivity, novelty-seeking and behavioural 
inhibition (common in those with ADHD) have equally been associated with more 
problematic cannabis use. 
 
8.74 And as we have discussed, earlier onset of cannabis use increases risk. One 
estimate suggests those aged under 18 are three times more likely to become 
addicted compared to people over 18: there is some evidence that adolescents 
may be more resilient to cannabis effects, which might contribute to escalated use 
and thus increased risk of dependence and addiction.481 
 
 
479 Lapham, G.T., Matson, T.E., Bobb, J.F., Luce, C., Oliver, M.M. … & Bradley, K.A. (2024). Prevalence of Cannabis 
Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal. JAMA 
Network Open, 6(8). doi:10.1001/jamanetworkopen.2023.28934 
480 See footnote #464. 
481 See discussion of risk factors in Curran, H.V., Lawn, W. & Freeman, T.P. (2023). Cannabis and Addiction. In D.C. 
D’Souza, D. Castle & R. Murray (Eds.), Marijuana and Madness. (pp.299–310). Cambridge University Press. 

   
 
174 
 
8.75 Indeed, recent research482 found an increased risk of CUD symptoms in 
adolescents aged 16–17 who currently use cannabis regularly, compared with 
adults aged 26–29 who use the drug similarly. This risk persisted over the course 
of the year-long study (though symptoms reduced over time in both groups). 
 
Injury and death 
 
8.76 Evidence of a link between cannabis and self-harm or suicide/suicidal ideation is 
conflicting. Several studies show an association, but others suggest this is 
explained by factors including use of other drugs and diagnoses of poor mental 
health (including depression and psychosis). Of the 32 drug-related poisonings 
recorded in England & Wales during 2022 in which cannabis was mentioned on 
the death certificate, only one was recorded as suicide483 (the remainder were 
classified as non-suicides).  
 
8.77 While some evidence from other jurisdictions suggests suicide rates rise following 
legalisation of non-medical cannabis (see chapter 7), it is difficult to unpick 
whether these are ‘real’ rises or simply a result of improved or more 
comprehensive toxicology testing. More broadly, and certainly compared to 
alcohol dependence, any direct association between cannabis use and suicide 
seems likely to be small.484  
 
8.78 But given that risk of suicide ideation is particularly pronounced in those who begin 
consuming cannabis in adolescence, as well as heavy users,485 and as it seems 
likely these factors (especially where cannabis is high-potency) can raise the risk 
of addiction as well as psychosis, we think a cautious approach is warranted. The 
possibility of a causative link between cannabis use and suicide ideation should 
not be ruled out until more robust evidence can cast a more conclusive light.   
 
8.79 There is also evidence that cannabis consumption during pregnancy may 
adversely affect offspring,486 though we note once again that findings are mixed 
and largely unable to account for confounding factors such as concurrent tobacco 
use. Use is likely motivated in some cases by a desire to treat pregnancy-related 
nausea but, as we acknowledge in chapter 7, there is general agreement among 
most health professionals that cannabis should be avoided by pregnant women. 
Such a cautionary approach seems sensible in the absence of clear evidence that 
it does not cause prenatal harm.  
 
482 Lees, R., Lawn, W., Petrilli, K., Brown, A., Trinci, K., Borissova, A. … & Freeman, T.P. (2024). Persistent increased 
severity of cannabis use disorder symptoms in adolescents compared to adults: a one-year longitudinal study. Eur 
Arch Psychiatry Clin Neurosci. doi.org/10.1007/s00406-024-01806-y 
483 Using the ICD-10 code for suicide. Deaths related to drug poisoning, England and Wales, 2022 (2023): Table 3. 
Deaths related to drug poisoning, England and Wales - Office for National Statistics (ons.gov.uk) And Table ‘Deaths 
related to drug poisoning by selected substances, England and Wales 1993–2022’. Deaths related to drug poisoning 
by selected substances, England and Wales - Office for National Statistics (ons.gov.uk) Accessed 2nd September 
2024. 
484 See for example Inskip, H.M., Harris, E.C. & Barraclough, B. (1998). Lifetime risk of suicide for affective disorder, 
alcoholism and schizophrenia. The British Journal of Psychiatry: the Journal of Mental Science, 172, pp.35–7. 
doi:10.1192/bjp.172.1.35 
485 See footnote #432. 
486 Ibid.  

   
 
175 
 
 
8.80 The acknowledged stigma associated with cannabis use means, however, the 
subject may not arise when pregnant women are seen by their GP and other 
health services, so opportunities to flag the risks are missed. 
 
8.81 Driving following cannabis consumption likely raises the risk of both fatal and non-
fatal road traffic accidents,487ʹ488 though it is difficult to isolate precise effects 
because cannabis presence in the bloodstream does not necessarily equate to 
intoxication sufficient to impair driving (due to the length of time it remains 
detectable, see chapter 7). The drug is also often consumed alongside alcohol 
which confounds isolation of effects. That said, when regular users smoked 
cannabis before partaking in a simulated driving experiment, performance 
remained impaired for four to five hours489.  
 
8.82 Consumption – particularly of higher-potency cannabis – affects cognition and can 
loosen behavioural inhibition, at least in the short term and particularly with parallel 
alcohol consumption. We therefore consider the conclusion drawn in the recent 
review of meta-analyses that cannabis should be avoided before and while driving 
(i.e. while impaired, as per DVLA guidance for medical cannabis users)490 to be 
intuitive and sensible. 
 
Cancer, respiratory and cardiovascular diseases  
 
8.83 As far as we are aware, there is little conclusive evidence of a causal relationship 
between cannabis and a range of cancers. Evidence is strongest for an 
association between chronic use and testicular cancer but the nature of that 
association remains unclear. Studies are confounded by the impact of parallel 
tobacco use (either mixed with cannabis or in separate cigarettes), particularly so 
with respect to lung and other cancers that are widely accepted to be causally 
linked to tobacco.  
 
8.84 The confounding effects of tobacco also beset attempts to determine the nature of 
any association between cannabis use and respiratory diseases (such as chronic 
bronchitis and chronic obstructive pulmonary disease, COPD). Frequent use has 
been associated with respiratory problems491 but separating such effects from 
those caused by tobacco remains a significant challenge, meaning evidence 
regarding the impact of cannabis remains inconclusive.  
 
487 See footnote #437. 
488 See for example Asbridge, A., Hayden, J.A. & Cartwright, J.L. (2012). Acute cannabis consumption and motor 
vehicle collision risk: systematic review of observational studies and meta-analysis. The BMJ. 
doi.org/10.1136/bmj.e536   
489 Marcotte, T.D, Umlauf, A., Grelotti, D.J., Sones, E.G., Sobolesky, P.M., Smith, B.E. & Fitzgerald, R.L. (2022). 
Driving Performance and Cannabis Users' Perception of Safety: A Randomized Clinical Trial. JAMA Psychiatry, 79(3), 
pp.201–9. doi:10.1001/jamapsychiatry.2021.4037 
490 Grollman, C., Pinto, C., Ismail, F. & Roberts, E. (2021). Medical cannabis and road safety. A research report for 
the Department for Transport. NatCen Social Research. Medical cannabis and road safety - GOV.UK (www.gov.uk) 
Accessed 15th February 2024. 
491 As cited in McManus, S., Bebbington, P., Jenkins, R. & Brugha, T. (Eds.) (2016). Mental health and wellbeing in 
England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Note: this survey runs every seven years, the 
next iteration is currently in preparation. 

   
 
176 
 
 
8.85 Current wisdom seems to be that, while smoking cannabis without tobacco is not 
without harm, and is associated with heightened rates of symptoms of chronic 
bronchitis,492 it does not increase the risk of COPD, or of lung or airway cancers 
(at least where consumption is light to moderate). Evidence suggests the risks of 
pulmonary complications from cannabis smoking – even regularly and heavily – 
are far outweighed by those resulting from smoking tobacco.493 
 
8.86 With respect to cardiovascular disease, there is increasing evidence of an 
association between cannabis use and adverse outcomes. A recent large US 
study, which in controlling for tobacco use and other demographic factors 
addressed many of the methodological limitations of earlier research, found use of 
the drug to be associated with increased risk of heart attack and stroke, with more 
frequent use raising the odds of these outcomes.494  
 
8.87 Notably, similar increases in risk were also found in cannabis users who do not 
smoke tobacco, meaning that, while there may be little evidence of risk to 
pulmonary functions among this group, they may nevertheless be at increased risk 
of other serious disease.  
 
8.88 Research drawing on UK Biobank data495 suggests similar. Those who smoke 
cannabis more than once a month were significantly more likely than those who do 
so less frequently or not at all to suffer a heart attack. This finding remained once 
some other relevant factors (such as age, sex and body mass index) were 
controlled for.496 Crucially, however, the analysis did not control for tobacco use, 
which of course is also a risk factor for cardiovascular disease. Moreover, reliance 
on Biobank data means findings cannot be considered representative of the UK 
population more generally.497  
 
8.89 Further suggestion of a causal link, though, comes from analysis of 3,455 deaths 
reported to England’s National Programme on Substance Abuse Deaths (NPSAD) 
between 1998 and 2020, in which post-mortems detected the presence of 
cannabinoids.498  
 
8.90 Cardiac failure immediately following cannabis use was recorded in 9 of the 14 
cases where cannabis itself (as opposed to alongside other drugs and/or alcohol) 
 
492 See discussion in Ware, M. (2013) Cannabis and the Lung: No More Smoking Gun? Annals of the American 
Thoracic Society, 10(3), p.248. doi.org/10.1513/AnnalsATS.201302-034ED 
493 Tashkin, D.P. (2013). Effects of Marijuana Smoking on the Lung. Annals of the American Thoracic Society, 
10(3),pp.239–47. doi.org/10.1513/AnnalsATS.201212-127FR 
494 Jeffers, A.M., Glantz, S., Byers, A.L. & Keyhani, S. (2024). Association of Cannabis Use With Cardiovascular 
Outcomes Among US Adults. Journal of the American Heart Association, 13(5). doi.org/10.1161/JAHA.123.030178 
495 A biomedical database and research resource containing genetic and health information from half a million UK 
participants. UK Biobank - UK Biobank 
496 Wei, T., Chandy, M., Nishiga, M., Zhang, A., Kumar, K.K., Thomas, D. ... & Wu, J.C. (2022). Cannabinoid receptor 
1 antagonist genistein attenuates marijuana-induced vascular inflammation. Cell, 185, pp.1676–93, Elsevier Inc. 
doi.org/10.1016/j.cell.2022.04.005 
497 See Keyes, K.M. & Westreich, D. (2019). UK Biobank, big data, and the consequences of non-representativeness. 
The Lancet Correspondence, 393(10178), p.1297. doi.org/10.1016/S0140-6736(18)33067-8 
498 See footnote #430. 

   
 
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was considered the underlying cause of death. Death following use of cannabis 
alone was rare (136 cases, or 4% of the total 3,455) with traumatic injury the most 
common underlying cause in such instances (the vast majority of which resulted 
from self-inflicted injuries or a road traffic collision). 
 
8.91 We consider the evidence so far suggests a need to pay close attention to the 
incidence of both cardiovascular disease and road traffic accidents in jurisdictions 
where cannabis for non-medical purposes is legal, particularly given indications 
that THC increases inflammation of blood vessels, which can be an important 
antecedent of a heart attack.499  
 
8.92 Those at greater risk more generally of cardiovascular disease would, we think, be 
wise to consider desisting from using cannabis – once again, this points to a need 
for better education about the health risks of the drug.  
 
8.93  However, the focus on smoking cannabis or, where other forms of consumption 
are considered, a failure to distinguish effects according to mechanism of 
consumption, means a better understanding of the cardiovascular impact of 
cannabis ingested in other ways (via edible products or vaping, for example) 
remains a gap. 
 
Co-consumption with tobacco 
 
8.94 One of the most potentially harmful and possibly under-appreciated effects of 
cannabis is the ‘reverse gateway’: by smoking tobacco together with cannabis, 
individuals risk becoming addicted to nicotine, especially where they were not 
previously smokers. Consuming cannabis in this way is the most common form of 
administration across the UK and Europe, in contrast to the US and Canada, 
where if the drug is smoked, it tends to be without tobacco.  
 
8.95 Those jurisdictions which have moved to legalising non-medical cannabis also, of 
course, offer a variety of other means of consuming the drug that do not involve 
tobacco, most notably edibles and vapes. While inhalation of a vaporised liquid 
extracted from cannabis is not without risk, particularly to respiratory health (and 
the consequences of long-term vaping remain unknown), it does at least allow the 
effects of cannabis to be experienced without parallel exposure to tobacco-related 
harms. 
 
8.96 Availability of legal, regulated and quality-tested cannabis for consumption without 
tobacco is one benefit of a legally regulated framework. Edibles and vapes 
allegedly containing THC are accessible via the illegal market in the UK (primarily 
via the internet, as we discuss in para.8.148 with respect to cannabis foodstuffs 
more widely). As we have raised elsewhere, however, and touch on in this chapter 
with respect to SCRAs, there are no guarantees of composition or potency and no 
comeback for users against suppliers of adulterated goods. 
 
 
499 Marijuana and heart health: What you need to know - Harvard Health Accessed 22nd February 2024. 

   
 
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8.97 We heard of some (albeit limited) evidence that consideration of the 
consequences of cannabis use among the public tend to focus on potential health 
benefits rather than risks, even when consumed with tobacco. This is possibly at 
least in part a result of narratives emerging from the expanding wellness industry, 
in which cannabis-derived products based around CBD extracts from the 
cannabis plant are a significant and growing element (see para.8.136).  
 
8.98 Any optimism bias, albeit one rooted in confusion of health benefits potentially 
conferred by CBD with consequences of consuming THC, likely increases 
chances of both initial uptake and continued use. This reinforces the need for 
better, more comprehensive education about cannabis, highlighting that co-
consumption with tobacco almost certainly outweighs the potential for any positive 
health effects resulting from parallel consumption of CBD.  
 
Therapeutic effects 
 
8.99 We have focused up until now on the adverse risks to health of cannabis use, 
particularly heavy and sustained use of high-potency cannabis, which, compared 
with what was commonly available in the last century, is now the norm.  
 
8.100 There are, however, several potential benefits of cannabis and cannabinoids, but 
these have received relatively little research attention compared with that given to 
their harms. Cannabis is used for a range of pleasurable psychological and social 
effects that are highly valued by users,500 as well as for medicinal, or therapeutic, 
purposes, which we discuss in more detail in chapter 11. 
 
8.101 We note that evidence of the therapeutic effect of cannabis with respect to severe, 
rare forms of epilepsy, vomiting or nausea caused by chemotherapy, and muscle 
stiffness and spasms related to multiple sclerosis (MS), is considered sufficiently 
strong that licensed cannabis-based medicines to treat those conditions are 
available on NHS prescription.     
 
8.102 Symptoms associated with a much wider range of conditions, such as Alzheimer’s 
disease, Crohn’s disease, glaucoma, endometriosis, pain and nausea as well as a 
range of mental health conditions including anxiety, depression and PTSD, are 
considered by many to also be treatable with cannabis-based medicines, although 
there are as yet no licensed products to do so. Those we spoke to who prescribe 
and dispense such unlicensed cannabis-based products for medicinal use 
(CBPMs) were optimistic about their capacity to improve quality of life for users – 
although clinical evidence of the precise nature and extent of effects is in its 
infancy.  
 
8.103 There is some (albeit limited) support for the use of cannabis to improve mental 
health from elsewhere, including US research501 that noted falls in mental health 
 
500 See footnote #440. 
501 Ortega, A. (2023). The highs and the lows: Recreational marijuana laws and mental health treatment. Health 
Economics, 32(10), pp.2173–2919. doi.org/10.1002/hec.4726  

   
 
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treatment admissions across states that had legalised non-medical cannabis by 
2019. The authors suggest this might be explained by individuals who would 
otherwise seek treatment turning to cannabis instead, alleviating symptoms 
sufficiently to deter them from health services.  
 
8.104 Given, however, that evidence remains unable to reach a conclusive position on 
the causal nature of the effect of cannabis on mental health overall, the use of 
(unlicensed) CBPMs is not currently endorsed by the National Institute for Health 
and Care Excellence (NICE) or the Royal College of Physicians (RCP). This means 
they remain unlicensed and as such are very difficult indeed to secure through the 
NHS: the vast majority of prescriptions are dispensed through private (paid-for) 
healthcare (see chapter 11).   
 
8.105 We are aware, too, that many cannabis users enjoy the feeling of being high or 
‘stoned’, the sense of relaxation that the drug can induce, and its often facilitative 
effects on wider social interactions. While by no means the case for all those who 
use cannabis, many report positive effects on creativity and associated activities, 
with enhanced enjoyment of music, art or film. Like any drug, including alcohol and 
tobacco, it can make those who use it feel good.  
 
Synthetic cannabinoid receptor agonists (SCRAs) 
 
8.106 Consideration of SCRAs falls outside the scope of our inquiries. However, several 
witnesses felt they represented a much greater risk to health than that posed by 
natural cannabis. Classed as a ‘novel psychoactive substance’, SCRAs are, as the 
name suggests, synthetic chemicals that stimulate the cannabinoid receptors in 
the body and mimic the effects of natural psychoactive THC found in herbal 
cannabis.  
 
8.107 First created in the 1980s to enhance understanding of the endocannabinoid 
system and explore therapeutic potential of drugs that interact with it,502 they were 
not at the time covered by the Misuse of Drugs Act 1971 (MDA), so began to be 
commercialised a decade or so later, appearing for sale in the UK as ‘legal highs’.  
 
8.108 Typically comprising an herbal mixture, paper or clothing infused or sprayed with 
SCRA and designed to be smoked (although other methods of consumption 
included vaping and ingestion of pills or powders), they came to be known under 
the umbrella term of ‘spice’, although Spice was originally a brand name along 
with several others including Black Mamba, Annihilation, Crazy Monkey and K2.  
 
8.109 While mimicking the effects of THC, SCRAs are much more potent than natural 
cannabis: some variants can be up to several hundred times stronger. While 
cannabis only partially stimulates cannabinoid receptors, SCRAs are capable of 
fully stimulating them. 
 
502 Advisory Council on the Misuse of Drugs (2020). Synthetic cannabinoid receptor agonists (SCRA): An updated 
harms assessment and a review of classification and scheduling under the Misuse of Drugs Act 1971 and its 
Regulations. ACMD Synthetic cannabinoid receptor agonists (SCRA) report (publishing.service.gov.uk) 

   
 
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8.110 The range of adverse effects of SCRAs (the causal relationship is much less 
contested than for natural cannabis) is extensive. They include loss of 
consciousness (though arguably this is for some, see para.8.115, a desired 
effect), raised heart rate and blood pressure, nausea and vomiting, seizures and 
psychosis. Behavioural effects include aggression and violence.  
 
8.111 Cardiac dysrhythmias, cardiac arrest, heart attacks, stroke and acute kidney 
failure have also been reported,503 and in extreme cases SCRAs can kill. Synthetic 
cannabinoids were listed on the death certificate in 48 fatal drug-related 
poisonings in 2022 (cannabis was mentioned in 32),504 though this is probably an 
underestimate as SCRAs may not be routinely tested for.505 
 
8.112 The relative risk of health-related harms posed by SCRAs compared with natural 
cannabis has been quantified through pursual of emergency medical treatment. 
The risk associated with use of the former was 30 times higher than that 
associated with the latter. Moreover, significantly more symptoms were reported 
by those seeking treatment for synthetic cannabinoid use than for cannabis.506 
 
8.113 Longer-term effects linked with use of SCRAs include mood disorders, anxiety, 
depression and suicidal thoughts. More recent evidence suggests they can 
adversely impact memory and cognition, with tolerance, swift dependence and 
withdrawal effects also associated with use.507ʹ508 
 
8.114 All SCRAs became illegal to sell, make, import and export under the Psychoactive 
Substances Act (PSA) 2016, although possession (unless a person was in prison) 
remained legal. However, following amendment to the MDA that same year, most 
known SCRAs, including those commonly found in Spice, became Class B drugs 
classified under that legislation, meaning possession became illegal. 
 
8.115 While use of SCRAs has declined among the general population, it remains 
prevalent particularly among the homeless and those in prisons. This is likely 
driven by the strength of effect (often allowing a user to lose consciousness for 
several hours), lower costs relative to other illicit drugs and low likelihood of 
detection via drug testing. 
 
8.116 Legislation now specifies and outlaws the vast majority of SCRAs, although as 
manufactured, synthetic (or semi-synthetic) compounds they are subject to 
 
503 Ibid. 
504 Deaths related to drug poisoning by selected substances, England and Wales, 2022 (2023). Table ‘Number of 
drug-related poisonings where new psychoactive substances were mentioned on the death certificate, England and 
Wales, deaths registered between 1993 and 2022’. Deaths related to drug poisoning by selected substances, 
England and Wales - Office for National Statistics (ons.gov.uk) Accessed 2nd September 2024. 
505 See footnote #502. 
506 Winstock, A., Lynskey, M., Borschmann, R. & Waldron, J. (2015). Risk of seeking emergency medical treatment 
following consumption of cannabis or synthetic cannabinoids in a large global sample. Journal of 
Psychopharmacology 29(6), pp.698–703. doi:10.1177/0269881115574493 
507 See footnote #502. 
508 Spice-info-sheetv1.3-Interactive-national.pdf (drugwise.org.uk) Accessed 19th February 2024. 

   
 
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constant evolution, meaning it is difficult for the law to keep pace. The European 
Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has, for example, 
recently pointed to the emergence of hexahydrocannabinol (HHC) and two related 
substances known as HHC acetate and hexahydrocannabiphorol, which are semi-
synthetic compounds synthesised from cannabis.509  
 
8.117 While the effects of HHC in humans have not yet been formally studied, animal 
studies show it activates the same cannabinoid receptors as THC. This means it 
has psychoactive properties which, while reportedly less intense than those 
associated with delta-9-THC in herbal cannabis, as the EMCDDA notes means it 
may have potential for abuse and dependence in humans. 
 
8.118 As well as being sprayed or mixed into herbal (low-THC) cannabis, resin and 
edibles, HHC is also available in vape pens and cartridges. Not currently a 
specified controlled drug in the UK or EU (it remains under monitoring by the 
EMCDDA), in the UK its psychoactive properties mean that under the PSA it is 
technically illegal to produce, sell or supply HHC products. Possession for 
personal use, however, is not criminalised (although remains illegal in prison).  
 
8.119 This means the legal risk associated with use is lower than that associated with 
cannabis. That said, if caught in possession, UK police are liable to consider it 
cannabis until forensic tests prove otherwise. Moreover, HHC-based flowers/bud 
and edible products can easily be purchased from online marketplaces selling 
CBD products, marketed as ‘non-psychoactive’ or ‘THC-free’ but very similar in 
look to illicit cannabis. In our view, there is something of a legal grey status when it 
comes to the status of HHC. 
 
8.120 And the similarity to illicit cannabis of products containing HHC means there is a 
risk, as with prohibited SCRAs, that it may be mis-sold, or used to further 
adulterate cannabis and CBD products and produce effects that users are not 
expecting.    
 
8.121 This is a growing challenge with herbal cannabis and related CBD- and THC-
based products, in particular vapes, as reported by the UK’s nationwide drug 
testing facility. The Welsh Emerging Drugs and Identification of Novel Substances 
(WEDINOS)510 service reported almost 40% of liquids tested during 2023 that 
were purchased in the belief they were cannabis, CBD or THC e-liquids for use in 
vapes in fact contained one or more SCRAs.  
 
8.122 Inadvertent consumption of SCRAs is a concern. Arguably it is potentially also, at 
least in part, one of the consequences of prohibiting use of cannabis for non-
medical use, because users cannot be confident in what they are purchasing. 
What looks and smells like cannabis (or derivatives), sold in packages which look 
 
509 European Monitoring Centre for Drugs and Drug Addiction (2023). TECHNICAL REPORT Hexahydrocannabinol 
(HHC) and related substances. Luxembourg: Publications Office of the European Union. Hexahydrocannabinol 
(HHC) and related substances | www.emcdda.europa.eu Accessed 20th February 2024. 
510 WEDINOS - Welsh Emerging Drugs & Identification of Novel Substances Project 

   
 
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to all intents and purposes like those which house legitimate product from 
jurisdictions where non-medical cannabis is legal511, is not necessarily cannabis. 
 
8.123 Testing services like the WEDINOS are an important part of furthering 
understanding about how cannabis is adulterated. As a postal submission service, 
though, it is not designed to provide would-be users with near real-time 
information about the make-up of cannabis (or any other illicit drug) they intend to 
consume. We were therefore pleased to note the recent expansion of a user-
centred drug testing service run by The Loop, which is now live in Bristol.512  
 
8.124 This builds on the service already provided by the organisation at festivals, where 
confiscated drugs or those left in amnesty bins are tested and, if found to be 
stronger than usual, contaminated or sold as something they are not, a warning is 
issued to festival-goers. The Bristol service focuses on enabling would-be users to 
make an informed decision whether to take a drug they have purchased: they 
leave a sample of the product and return around an hour later to receive the 
results. 
 
8.125 Crucially, a health consultation is offered along with the results, providing 
opportunity to discuss drug use and risks. Focused on dependent, frequent and 
problematic drug use, the service aims to reduce consumption of adulterated and 
contaminated drugs and thus reduce the risk of poisoning and overdose, while 
signposting users to support services. 
 
8.126 Understandably, due to limited capacity and high risk of harm, the service is 
focused on Class A drugs. It is also currently limited to Bristol, although we 
understand the introduction of a similar service in London is being explored. The 
Mayor of London should expedite considerations to introduce a drug testing 
service in London, which includes the capability to test cannabis, as soon as 
practicable (R4).  
 
Cannabis potency 
 
8.127 The proportion of THC relative to CBD is what determines the strength, or 
potency, of cannabis. As noted at the beginning of this chapter, the lack of a 
standard ‘unit’ of THC means it is not yet possible to understand what a ‘safer’ 
dose of cannabis might amount to.  
 
8.128 The lack of what constitutes a ‘standard dose’, as well as an appropriate definition 
of ‘high potency’, has implications for public health messaging and education 
about cannabis use more widely, as alluded to in the Legislative Review of 
Canada’s Cannabis Act and associated recommendation.513  
 
 
511 Empty packaging, printed with known names, images and brands of cannabis strains, are available online and 
offline.  
512 What We Do — The Loop (wearetheloop.org) 
513 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca pp.31–5, recommendation 
14. Accessed 26th March 2024. 

   
 
183 
 
8.129 Strength of alcoholic beverages, in contrast, is measured in standard units of 
alcohol. This permits different types of alcoholic drink to be compared so users 
know, for example, that one large glass of wine (250ml) equates to around three 
units, approximately equal to three single measures of spirits (25ml each) or one 
pint (568ml) of strong lager. The measurement of one standard alcoholic unit has 
enabled development of safer consumption guidelines and permits a person’s 
consumption to be objectively counted. This is not currently possible with 
cannabis.  
 
8.130 Severe intoxication could result from consumption of just one joint if the cannabis 
is very high in THC, or from several joints if potency is lower. One person who 
consumes two joints in 24 hours might consume far more THC than another who 
consumes 6 edible gummies: there is simply no way of measuring this, meaning 
assessing consumption and any associated treatment needs is difficult.  
 
8.131 We were pleased to hear about work currently underway in the UK to develop a 
standard measure of one unit of THC, which would apply irrespective of method of 
administration and product (i.e. across cannabis flower/bud, resin, concentrated 
extracts and dabs, vape oils and edibles). This could in future support education 
and guidance about the number of units, or milligrams, of THC, which is generally 
sufficient for an intoxicating effect but poses less risk of adverse side effects. 
 
8.132 While cannabis for non-medical use remains illegal, however, the concept of units 
of THC remains to some extent academic. Dealers are unlikely to label their goods 
in the way of alcoholic drinks, indicating the number of THC units per 
serving/entire product. Indeed, even if they wished to, they would have little way of 
knowing what the correct number was.    
 
8.133 The likely behavioural response of users is also unknown: would knowing how 
many units of THC units were contained in a cannabis product mean they would 
moderate consumption? Or would it drive risk-taking and competitiveness? This is 
a concern perhaps particularly relevant for young people. It would be helpful to 
better understand these issues. The Home Office (HO) and Department for Health 
& Social Care (DHSC) should consider commissioning independent research to 
explore how those who use cannabis view potency and do or do not adapt their 
consumption accordingly (R5).  
 
Cannabidiol (CBD) based edible products 
 
8.134 While not within our terms of reference, our inquiries inevitably touched on the 
relatively recent emergence of a legal (under the MDA) market for cannabis-
derived extracts as the basis of a vast array of goods for human consumption. 
 
8.135 As we discuss in chapter 2, cannabis has long been cultivated for hemp (i.e. those 
plants which contain tiny amounts of THC so are not considered to have 
psychoactive properties). Hemp cultivation, principally for oilseed and fibres, has 
long been a legal practice.  
 

   
 
184 
 
8.136 More recently, however, a market for edible and non-edible products (such as 
body creams and lotions) based on CBD has emerged. Sold predominantly as 
health supplements and other wellbeing products, their history, particularly that of 
edible consumables, in terms of authorisation and licencing is somewhat 
chequered.  
 
8.137 Over tens of thousands of different edible products containing varying amounts of 
CBD have entered the market since the mid–late 2000s. Their status as ‘edible’ 
remained unchallenged until a European assessment in 2019 deemed them to be 
‘new’ products, which therefore required authorisation for manufacture, sale and 
consumption. 
 
8.138 This led the UK’s Food Standards Agency (FSA, the UK regulator responsible for 
authorising new foods as safe for consumption) to take steps to ensure the 
industry was compliant with standards set for the novel foods market in this 
country. (EU Exit meant the agency was taking over relevant authorising 
processes from the European Commission.) As they had little or no history of 
consumption before May 1997, when the EU brought in its original laws defining 
‘novel foods’, FSA authorisation was required for CBD edible products to remain 
on the market in the UK. In 2021, the FSA permitted the industry to retrospectively 
apply for permissions to sell products that had been available for sale prior to 
February 2020.  
 
8.139 The FSA told us around 90 applications for authorisation are currently being 
considered, covering many hundreds of different companies and listing many 
thousands of edible products, including gummies, chocolates and baked goods as 
well as coffee, tea and other soft drinks. Listed products remain legal while 
authorisation is pending.  
 
8.140 Where retrospective authorisation is refused, the product will be deemed as non-
compliant, meaning it must be removed from sale. Any products developed since 
2021 must apply for FSA authorisation before entering the market. 
 
8.141 While there is no cap on permitted quantities of CBD in edible products, recent 
reviews concluded that long-term use could risk liver, thyroid and other health 
problems. This led the FSA, towards the end of 2023, to update its guidance514 on 
CBD intake from food and recommend an acceptable daily intake (ADI), i.e. 10mg 
(around four or five drops of 5% CBD oil). 
 
8.142 As this is a recommendation only, any products that contain more than the 
suggested daily limit can remain on sale. Consumers will, however, need to pay 
attention to labelling and serving size to ensure they are aware of how much CBD 
they are consuming. Any future authorisations granted will place legal limits on 
quantities of CBD in edible products. 
 
 
514 Cannabidiol (CBD) | Food Standards Agency Accessed 20th February 2024. 

   
 
185 
 
8.143 Arguably this is no different to consumption of other foodstuffs that, when 
consumed in quantity, pose a risk of adverse health effects (notably sugar, 
caffeine and alcohol): consumers here may make their own decisions with respect 
to what and how much they consume.  
 
8.144 There is a question, however, in terms of the interplay with consumption of illegal 
cannabis that also contains THC. People consuming cannabis alongside ‘CBD-
only’ products, even where use of the latter does not exceed the recommended 
daily limit, will clearly be ingesting more CBD than may be safe in the long term. 
The Department for Education, in partnership with the DHSC, HO and FSA, 
should consider the issue of consumption of legal CBD alongside illegal cannabis 
further, with thought given to how educational materials regarding cannabis use 
might raise awareness of the potential risks of CBD consumption (R6).   
 
8.145 FSA-authorised products must comply with limits on permitted levels of THC 
(specifically delta-9-THC), which must be sufficiently low so as not to induce a 
psychoactive ‘high’ and thus contravene the MDA. Following advice from the 
Advisory Council on the Misuse of Drugs (ACMD), forthcoming legislation intends 
to cap the total amount of THC in one single serving of a CBD edible product to 50 
micrograms (mcg).  
 
8.146 Widely available in larger retailers including supermarkets, as well as health shops 
and pharmacies, CBD ‘infused’ products are, like it or not, rapidly becoming 
normalised within wider food and drink choices (and other non-edible product 
ranges) and are swiftly growing in popularity. Indeed, Trip, a CBD-infused drink 
sold in major retail outlets, became the UK’s fastest growing soft drinks brand in 
2023.515  
 
8.147 Availability in outlets associated with health and wellbeing is likely to further 
strengthen any association in the mind of the public between cannabis and health 
benefits. Indeed, young people are increasingly turning to infused drinks as an 
alternative to alcohol: a lucrative market is developing that, as was put to us, is of 
huge interest to both the alcohol and tobacco industries. Seeing declining revenue 
from future purchasing generations, they are seeking to diversity their interests. 
 
8.148 Widespread availability of CBD-derived products within a wider landscape in which 
edibles containing more than trace amounts of THC remain illegal is, in our view, 
confusing. Moreover, it is perfectly possible to order edibles containing significant 
amounts of THC through online outlets. As they are likely shipped from 
jurisdictions where they are legal, with payment usually required via digital 
currency (e.g. bitcoin), there is nothing on sale sites to suggest such products are 
in fact illegal in the UK.  
 
8.149 Once again, we return to education, which has seemingly not kept up with the 
reality of a rapidly expanding marketplace for cannabis and cannabis-derived 
 
515 CBD brand Trip becomes ‘fastest-growing’ soft drink in the UK | News | The Grocer Accessed 22nd February 
2024. 

   
 
186 
 
products. Attention of policy makers and health service providers with respect to 
illegal drug use tends, it was put to us, to be directed towards synthetic opioids,516 
chemsex,517 overdose prevention and needle-sharing prevention – as we heard is 
also the case with forensic (offender) populations.  
 
8.150 In a world of limited resource, focusing on drug use that risks the most immediate 
harm and, in some cases, death, is understandable. But cannabis use is not risk-
free, particularly in today’s world of wider choice in method of consumption and 
higher-potency products.  
 
8.151 Providing neither education to explain risks and encourage safer use among those 
who choose to use it anyway (as many do), nor accessible treatment and support 
services (as we cover in chapter 9), may well serve simply, over time, to increase 
the number of users suffering harm. Who begin as ill-informed and end up ill-
served by services inadequately equipped to prioritise their needs. 
 
Education about the risks of cannabis and health 
 
8.152 As we set out in this chapter, there are a range of medical or otherwise 
therapeutic uses for the cannabis plant, as well as several pleasurable benefits 
afforded by the drug, and we do not disregard the importance of these.  
 
8.153 We also recognise that, despite the risks (related not just to health but to 
procuring and using an illegal substance), non-medical use of cannabis is plainly 
not going away despite continued prohibition, ‘just say no’ public messaging and 
criminalisation of those involved in production, supply and possession. 
  
8.154 It is important to acknowledge this. Without accepting the reality of use, 
opportunities for meaningful, credible policy and education strategies with 
potential to reduce the risk of health-related harms are lost. We recognise the 
challenge inherent in discussing safer or more responsible consumption of what 
remains an illegal drug – but the reality of widespread cannabis use cannot be 
ignored.  
 
8.155 We discuss the matter in more detail (as it relates to children and young people 
specifically) in chapter 12 but believe public policy and education practices should 
support those who choose to use cannabis, as well as would-be users, to make 
informed choices, similar to campaigns focusing on the health risks associated with 
alcohol and tobacco. Key messages include: 
 
• Heavy, regular consumption from an early age can affect brain development 
and cognitive function at a crucial time in a young person’s life. This can 
substantially harm their prospects for education and employment in addition to 
the success of interpersonal relationships. 
 
516 Following advice from the ACMD, the UK government banned 11 synthetic opioids in 2023.  
517 Sexual activity, mostly between men, undertaken while under the influence of illegal stimulant drugs such as 
methamphetamine or mephedrone. 

   
 
187 
 
• For some, particularly those with genetic predisposition to serious mental or 
physical health disorders or who already suffer such, cannabis acts similarly to 
an allergen. They are, simply put, allergic and cannot use or enjoy it in the same 
way others are able to – the risks are too great and are greatest if someone is 
already acutely unwell. 
• Cannabis may in some cases limit rather than create opportunities to achieve, 
find employment, build and maintain relationships, or to find and enjoy activities 
that do not revolve around use of the drug.  
• The drug does not universally aid imagination, flair and creativity (indeed, we 
heard how some CCP patients reported such abilities to be significantly 
heightened once they stopped using cannabis). 
• Different types of cannabis, levels of potency and methods of consumption 
deliver different levels of intoxication and pose different health risks, similar in 
some respects to alcohol and the differences between beer, wine and spirits.  
• Smoking cannabis produces toxicants that are harmful to health (recognised 
in Canada and legalising US states through higher taxes on combusted forms 
of cannabis). This is compounded by co-consumption with tobacco, which also 
undermines attempts to quit either substance.  
 
8.156 A focus on safer use strategies and the benefits of reducing use are likely to be 
more successful in effecting behaviour change than messages urging complete 
desistance. Outright health warnings may have less impact, particularly on those 
who are already regular users.518  
 
8.157 Which highlights the importance of timing. Harm-reduction messaging should 
ideally target young people and other groups at heightened risk before the 
opportunity to use cannabis emerges, with a focus on the importance of delaying 
onset. It should be in place before use risks becoming regular and sustained. 
 
8.158 It is important, however, to be realistic about the extent of behaviour change and 
priorities of cannabis users. It was pointed out to us that many heavy users, 
despite being fully aware of the harms of smoking cannabis (either alone or with 
tobacco), may well not switch to, for example, consuming edibles instead.  
 
8.159 Principally because they value the control that smoking cannabis affords: once the 
desired effects are reached, or a person might begin to feel unwell, they can 
immediately stop smoking. Once an edible has been consumed, however, the 
individual must simply wait out any effects – good or bad. Because they do not 
take effect immediately, it is also more difficult to moderate consumption relative to 
desired effect.  
 
 
 
518 Winstock, A.R., Lynskey, M.T., Maier, L.J., Ferris, J.A. and Davies, E.L. (2021). Perceptions of cannabis health 
information labels among people who use cannabis in the U.S. and Canada. Int J Drug Policy, May; 91:102789. 
doi:10.1016/j.drugpo.2020.102789 

   
 
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9. THE HEALTH POLICY RESPONSE TO 
NON-MEDICAL CANNABIS USE 
 
Our inquires did not demand a detailed exploration of drug and other treatment services 
that (non-medical) cannabis use might cause a person to need. Understanding possible 
implications for those services of any change in the legal framework governing non-
medical cannabis use, however, is important. 
 
In this chapter we set out our high-level understanding of the current drug treatment 
landscape in London, before considering the demand placed on the system by those 
with cannabis-related needs, particularly with respect to mental health. We have 
explored barriers to seeking help, which can include fear of judgement and criminal 
sanction as well as mistrust in wider authorities, and considered whether these can 
affect different groups in different ways. 
 
We briefly considered the extent of the evidence base regarding ‘what works’ in treating 
symptoms of poor health related to cannabis use, and what more is needed. We go on 
to look at the way in which treatment services are structured across London and 
implications for those working in the sector – including those working with offenders 
presenting with drug-related needs.  
 
Specific challenges posed by the typical separation of mental health, drug treatment 
and tobacco cessation services stood out and we consider the need for further join-up. 
This includes the potential for pharmacists to play a greater role in identifying symptoms 
of cannabis-related ill health and supporting help-seeking.  
 
We conclude this chapter by briefly considering the implications of legalising non-
medical cannabis for drug treatment and other health services, considering the likely 
rise in prevalence of use and probable accompanying rise in tobacco use.   
 
The wider landscape 
 
9.1 The comprehensive and highly regarded two-part review undertaken by Professor 
Dame Carol Black (the Black Review), which considered firstly drug supply and 
demand and secondly, treatment, recovery and prevention,519 provides valuable 
current context. We do not wish to revisit ground so ably and thoroughly covered 
by that review, though note among its conclusions the judgement that provision of 
drug treatment and recovery services was not fit for purpose and required urgent 
repair. 
 
9.2 The government’s subsequent 10-year drug strategy,520 underpinned by the 
findings and recommendations of the Black Review, committed to delivering a 
 
519 See Independent review of drugs by Professor Dame Carol Black - GOV.UK (www.gov.uk) for related reports. 
520 See From harm to hope: A 10-year drugs plan to cut crime and save lives - GOV.UK (www.gov.uk) 

   
 
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world-class treatment and recovery system in England. It pledged an additional 
£780 million to fund measures to meet that commitment. 
 
9.3 While this investment was welcomed by the sector, we note it followed a period of 
several years in which treatment funding was very significantly reduced, leaving 
many local authorities able to offer only the bare minimum of provision. Against a 
backdrop of rising overall prevalence of drug use (particularly of opiates and crack 
cocaine) but falling numbers in treatment following shrinking of capacity, levels of 
unmet need rose substantially.521 The extent to which the £780 million has served 
or will serve simply to return funding back to levels not seen since the mid-2000s 
remains to be seen.   
 
Need for treatment among those who use cannabis  
 
9.4 Statistics suggest around 10% of people who use cannabis worldwide will develop 
symptoms of Cannabis Use Disorder (CUD),522 although the figure could be as 
high as 20% or more.523 While not all those who develop symptoms of CUD (or 
other health issues potentially related to cannabis use) seek treatment, cannabis is 
the most cited problematic substance after opiates (excluding alcohol) in 
England.524 This is perhaps not surprising given it is the most widely used illicit 
drug (see chapter 4). 
 
9.5 During 2022/23, a total of 290,635 adults across England were undergoing some 
form of drug and/or alcohol treatment. Of those, 57,181 (one-fifth) cited problems 
related to cannabis (either alone or alongside problems with other drugs and/or 
alcohol). By comparison, just under half had problems with opiates, used with or 
without crack cocaine (n = 138,604). The most commonly cited problematic 
substance, however, was alcohol, cited by half (n = 145,202) of all adults in 
treatment.525 
 
9.6 Of all those in treatment for cannabis use (n=57,181), almost two-fifths (n=22,124, 
38.7%) also had problems with opiates. Almost one-third (29.7%, n=17,011) were 
in treatment solely for non-opiate use (including those who only used cannabis as 
well as those using cannabis alongside non-opiates such as crack or ecstasy). A 
similar number (31.6%, n=18,046) were using both cannabis and alcohol.526    
 
521 Black, C. (2020). Review of Drugs – evidence relating to drug use, supply and effects, including current trends 
and future risks, pp.84–5. Available at Review of drugs: phase one report - GOV.UK (www.gov.uk) Accessed 23rd 
February 2024. 
522 Connor, J.P., Stjepanović, D., Le Foll, B., Hoch, E., Budney, A.J. & Hall, W.D. (2021). Cannabis use and cannabis 
use disorder. Nature Reviews Disease Primers 7(16). doi.org/10.1038/s41572-021-00247-4 Accessed 11th March 
2024. 
523 Leung, J., Chan, G.C.K., Hides, H. & Hall, W.D. (2020). What is the prevalence and risk of cannabis use disorders 
among people who use cannabis? a systematic review and meta-analysis. Addictive Behaviours, 109. 
doi.org/10.1016/j.addbeh.2020.106479 
524 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Tables 10_3 & 10_4. 
Accessed 4th April 2024. 
525 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Table 10_4. Accessed 
4th April 2024. 
526 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Table 1_2. Accessed 4th 
April 2024.  

   
 
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9.7 While the number of new entrants to treatment with a primary dependence on 
cannabis remains lower than those for whom alcohol or opiates are the principal 
dependence, the figure has been slowly rising since 2018/19, with a 2% rise 
recorded in the last year (from 28,263 in 2021/22 to 28,845 in 2022/23). This 
follows a steady decline seen in years prior to 2018/19, down from an 18-year 
high in 2013/14 of 30,422.527  
 
9.8 It is difficult to know whether this rise indicates growing numbers of problematic 
users, improved identification of those with symptoms, and/or increased 
propensity to seek help. Nevertheless, the number in treatment is likely to be a 
fraction of the number of people who use cannabis who may need help, given the 
total number of users in England & Wales is estimated to be around 2.5 million 
(see chapter 4) and, as above, at least 10% of those (i.e. 250,000) may have 
symptoms of CUD.  
 
9.9 Compared to the 10% rise in new entrants to treatment citing problems with the 
next most widely used illicit drug, powder cocaine (from 21,298 in 2021/22 to 
23,529 in 2022/23, see chapter 4), the 2% increase related to cannabis is 
arguably relatively modest.528  
 
9.10 That said, it was put to us by some of those we heard from that, among young 
people accessing drug treatment, the proportion for whom cannabis is their 
primary dependence is higher than among adults. This is certainly the case for 
young adults – over 50% of new entrants to treatment in England in 2022/23 aged 
between 18 and 24 cited cannabis. Ten per cent of that age group cited opiate 
use (with or without crack cocaine). For those aged 25–29, 35% cited cannabis 
use, and 18% opiates.529  
 
9.11 As with any form of substance dependence, cannabis dependence can lead to 
adverse consequences for other aspects of a person’s life, including finances, 
employment and relationships. The process of trying to cut down or stop is also 
not straightforward and dealing with symptoms of withdrawal can pose similar 
challenges. 
 
9.12 But most people dependent on alcohol or other drugs do not seek treatment. 
Stigma, fear of judgement and lack of awareness of the link between their 
substance use and other issues can be compounded by inconsistent, or 
inaccessible, treatment. Provision also tends to prioritise alcohol and opiates, with 
many of those presenting problems related to cannabis use, it was put to us, being 
seen instead by psychiatric services, which are often unable to address underlying 
issues.  
 
527 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Table 10_3. Accessed 
4th April 2024. 
528 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Table 10_3. Accessed 
4th April 2024.   
529 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Tables 2_2. Accessed 4th 
April 2024. 

   
 
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9.13 We heard too that parents can be wary of seeking help for children suffering with 
their mental health who also use cannabis, due to fear of recrimination related to 
the criminal status of the drug, as well as the stigma. Young people themselves 
can be particularly anxious about raising questions with health professionals 
because of fear of judgement.530  
 
9.14 Cannabis use is not restricted to any demographic (see chapter 4). Data on 
characteristics of those in treatment, however, may not reflect the spread of need 
but rather propensities of different groups to seek help and engage with services.  
 
9.15 One London-based service provider, for example, told us the majority of their 
caseload comprised middle-aged white men, and over 80% of adults in treatment 
in England in 2022/23 were from a white background (68% were male).531 
Treatment and harm-reduction services therefore need to be cognisant of the 
potential for different levels of inclination of those in need to seek help, to ensure 
equity of access. 
 
9.16 Differences in propensity to seek help are likely due in part to levels of fear felt in 
different communities about admitting use of an illegal drug. We heard that 
mistrust and wariness of the police among some communities in London, resulting 
from a range of negative experiences (see chapter 10), can often extend to wider 
authority. This can include healthcare services, where similarly poor experiences, 
personally or second hand, might deter help seeking.  
 
9.17 Those experiences can be compounded where service providers are not 
representative of communities they serve, in terms of demographics or experience 
of drug use. This latter speaks to the discomfort that we heard is often articulated 
by young people when asked to discuss cannabis use with healthcare, education 
or other professionals whom they perceive to have little relevant experience.  
 
9.18 It was also put to us that sweeping funding cuts to youth services in recent years 
have reduced access, not only to recreational activities but to sources of trusted 
advice and routes into support services of all kinds, including drug treatment.  
 
9.19 We discuss the importance of credible voices in chapter 12, but the peer mentor 
element of London’s Cannabis Clinic for Patients with Psychosis (CCP, see 
para.9.46), seen by its patients as a vital part of the service, is a good example. 
The importance of integrating similar networks of peer-based support into drug 
treatment and recovery services was highlighted by the Black Review532 and 
reiterated in the recent review by the Home Affairs Committee (HAC). They noted 
 
530 Walsh, H. (2023). Unpublished PhD findings shared with the London Drugs Commission. 
531 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Tables 1_1 and 1_6. 
Accessed 4th April 2024. 
532 Black, C. (2021). Review of drugs part two: prevention, treatment and recovery. Available at Independent review 
of drugs by Professor Dame Carol Black - GOV.UK (www.gov.uk) 

   
 
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the positive role played by informal, peer-run organisations that seek to promote 
and support recovery from drug and alcohol dependency.533   
 
Treating problematic cannabis use   
 
9.20 Evidence regarding treatment of cannabis dependence is limited compared to that 
for alcohol and opioids, though it suggests approaches including cognitive 
behavioural therapy (CBT), motivational interviewing and contingency 
management techniques534 are the most effective.535 There is no consistent 
approach to managing withdrawal, however, and relapse following detoxification is 
common. Difficulties in assessing and treating co-morbid conditions that may 
contribute to relapse are additional barriers to successful outcomes.  
 
9.21 The focus on alcohol and opioids can also mean people who use cannabis 
perceive drug treatment services to be aimed at those who use Class A drugs and 
consequently feel uncomfortable attending assessments or treatment, which in 
turn reduces their likelihood of doing so. Services for this group can, it seems, be 
presented as somewhat of an ‘add-on’ to those aimed at people with problems 
related to more serious drugs: cannabis treatment does not feel to us to be a well-
developed or integrated part of the wider system, especially in mental health 
(among child and adolescent services as well as those for adults). 
 
9.22 For poly-drug users where cannabis use is identified (which is not a given as not all 
services routinely test for it), the latter risks being ignored as treating problems 
with more serious substances takes precedence. If a person succeeds in dealing 
with a heroin addiction, for example, outstanding problems with cannabis may 
remain unaddressed. 
 
9.23 As one expert pointed out, dependence on heroin is treated with a drug substitute 
(commonly methadone or buprenorphine), but a similar approach to helping a 
person addicted to cannabis appears so far to be elusive. While there are largely 
accepted methods of reducing the risks of health harm from cannabis use 
(including not smoking the drug, not mixing it with tobacco or co-consuming it with 
alcohol, and reducing potency), evidence for the efficacy of medicinal drugs to 
treat cannabis dependence is less well developed.  
 
9.24 There is some limited indication that Sativex® (a cannabis-based medicine 
containing THC and CBD that is licensed for use in the UK, see chapter 11) may 
 
533 Home Affairs Committee (2023). Drugs: Third Report of Session 2022–23. House of Commons, p.388. Available 
at Drugs - Committees - UK Parliament Accessed 28th February 2024. 
534 CBT helps a person recognise patterns in how they think and behave to help break out of negative cycles. 
Motivational interviewing helps people to identify and resolve ambivalent feelings, in order to find the internal 
motivation necessary to change behaviour. Contingency management provides those who are substance-dependent 
with rewards for both engaging in treatment and providing evidence (usually via a urine drug screen) of desisting from 
substance use. 
535 Winstock, A.R. & Ford, C. (2010). Assessment and management of cannabis use disorders in primary care. The 
BMJ, Clinical Review. doi.org/10.1136/bmj.c1571 

   
 
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help with symptoms of both withdrawal and dependence.536 Overall, however, 
robust evidence of which medicinal drugs might help with cannabis withdrawal, or 
promote cessation or reduction in use, remains limited.537  
 
9.25 A focus on opiates is understandable given limited resources and levels of harm 
caused not only to user health but through associated criminality (see chapter 10). 
Given the growing prevalence of cannabis dependence reported by clinicians, 
however (in isolation or as part of poly-drug addiction), the DHSC should explore 
what works in cannabis treatment, for whom and under what circumstances, to 
support development of guidance and ultimately services to meet specific needs 
of this group (R7).  
 
9.26 This should have regard to the work of the CCP (see below) and should also 
consider that the common model of drug treatment, which tends to approach all 
illegal drugs together, may not be the most appropriate for supporting cannabis 
users. Other models should be tested (for example, provision of support or 
cessation services that include alcohol, tobacco and cannabis but not opiates). 
Given the dominance in London and across the UK, as elsewhere in Europe, of 
co-consumption of cannabis with tobacco, nicotine addiction should be central to 
considerations. 
 
9.27 Aligned with this, the current guidance developed and maintained by NICE 
regarding interventions to address problematic use of, or dependence on, 
cannabis, was last reviewed in 2016.538 Its parallel guidance related to drug 
misuse prevention through targeted interventions was published in 2017.539  
 
9.28 Not only does neither document explicitly decouple use of cannabis from use of 
opioids or stimulants, the form, potency and means of access to non-medical 
cannabis products have changed quite considerably in the past seven or eight 
years. At the same time, the wellness market drawing on cannabis extracts 
(notably CBD, see chapter 8) has firmly established itself. All of which arguably 
renders the guidance somewhat out of date. 
 
9.29 We therefore recommend that NICE review the content of both guides covering 
drug misuse prevention and treatment. They should account for changes in the 
nature of modern-day cannabis and its use and have regard to evidence that 
relates specifically to the treatment of problematic use of cannabis (R8). The 
process should also take account of findings emerging from any future work led by 
the DHSC to further understanding of what works in this space (R7).   
 
 
536 See for example Trigo, J.M., Lagzdins, D., Rehm, J., Selby, P., Gamaleddin, I., Fischer, B. … & Le Foll, B. (2016). 
Effects of fixed or self-titrated dosages of Sativex® on cannabis withdrawal and cravings. Drug and Alcohol 
Dependence, 161, pp.298–306. doi:10.1016/j.drugalcdep.2016.02.020 
537 Nielsen, S., Gowing, L., Sabioni, P. & Le Foll, B. (2019). Pharmacotherapies for cannabis dependence. Cochrane 
Database of Systematic Reviews, 1 (CD008940). doi:10.1002/14651858.CD008940.pub3  
538 Overview | Drug misuse in over 16s: psychosocial interventions | Guidance | NICE Accessed 25th July 2024. 
539 Overview | Drug misuse prevention: targeted interventions | Guidance | NICE Accessed 25th July 2024. 

   
 
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9.30 ‘What works’ should also consider the content of existing resources aimed 
specifically at those considering or already using cannabis.540 Such material often 
seeks to support and inform safer use as well as provide advice to those seeking 
to reduce or cease their use of the drug. Aimed at cannabis consumers in general, 
such resources can contain evidence-based messages designed to promote 
understanding of levels of use and associated risks, and resonate in terms of 
drivers of use and effects of the drug (both positive and negative). 
 
9.31 It was also put to us that the inability of non-medical cannabis users to be sure 
what they are consuming also makes attempts at harm reduction (lowering THC 
consumption for example) difficult. The DHSC should consult with the medical 
cannabis industry to explore potential to utilise cannabis produced for prescription 
products, where levels of THC and CBD are strictly controlled, in treating those 
with problems associated with non-medical use (R9). The use of edibles, for 
example, could offer a means of reducing use without co-consumption with 
tobacco, although they too, of course, are not without associated risks.  
 
Cannabis treatment services in London 
 
9.32 The commitment to increased funding set out in the government’s strategy is 
clearly welcome and crucial to rebuilding drug treatment services across the 
capital. However, it will take time for entrenched issues with recruitment and 
retention of qualified staff to be addressed, as funding cuts over many years have 
inevitably led to challenges in maintaining sufficient human resources.  
 
9.33 This in turn has meant, as elsewhere in the country, a rise in thresholds for access 
to London’s drug treatment services. Unless cannabis users co-present with other 
needs, related to opiates for example, or with symptoms of severe mental health 
disorder, we heard they have been and remain unlikely to be prioritised by 
services that continue to be stretched.  
 
9.34 The way in which those services are structured in London is complex, which 
further compounds challenges with access. It can be difficult for those who come 
into contact with people who use drugs, whether through health, education, police 
or the wider justice system, and who have a responsibility to refer into relevant 
services, to know where and how to do so. The situation is no different for an 
individual wishing to self-refer. 
 
9.35 The capital’s 33 local authority areas (i.e. 32 boroughs and the City of London) are 
individual commissioners of drug treatment services provided by a range of 
organisations. The NHS is one such provider (though they too commission 
services); others are based in the voluntary and community sector. Turning Point 
and Via, for example, operate in several (but not all) of London’s local authorities.  
 
9.36 Because local authorities act as individual commissioners, one provider may be 
governed by several different contracts across a number of boroughs. Moreover, 
 
540 See for example Safer Use Limits Accessed 3rd April 2024. 

   
 
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they may function as a principal provider, as sub-contractor to another provider, or 
both, which further complicates the system for those working within or alongside it, 
as well as those seeking support. 
 
9.37 The system does permit a local authority a degree of flexibility and autonomy in the 
treatment services it chooses to commission, meaning in theory they can better 
take account of needs across the populations they serve. In practice, though, the 
system is likely to contribute to what was described as a postcode lottery faced by 
those requiring services. It also, we heard, makes economies of scale difficult 
because local authorities act independently from others in their role as service 
commissioners. 
 
9.38 Reflecting its lesser potential for harm relative to more serious drugs (for most 
people who use it), as we set out above cannabis is not the principal issue of 
concern for the majority of those referred to London’s treatment services. One 
provider told us that of their c.2,000 daily caseload, cannabis is the main issue for 
around 40 people. Many more use the drug but are referred (or self-refer) for 
support with other issues that they do not perceive to be related to cannabis use.  
 
9.39 This speaks to a wider need for accurate, accessible information about the harms 
and dependence potential of cannabis for both consumers and their families, 
including the impact of use on wider aspects of life as well as health. CCP patients 
reported having previously received little from education, mental health or youth 
services about the potential effects of cannabis on mental health or its addictive 
qualities. This chimes with our understanding about the nature of statutory 
education (see chapter 12).  
 
9.40 We heard a number of people who use cannabis first come to treatment services 
because of wider support on offer, including programmes focusing on 
Employment, Training and Education (ETE), or health and fitness. Many do not 
realise the challenges they face in those spheres may be due at least in part to 
their persistent use of cannabis.  
 
9.41 Once identified, a service can help someone understand whether their use is 
problematic, what the potential harms might be, how to minimise these and how to 
reduce the risk of progression. For those with dependence or other issues, 
services can help identify the function of their cannabis use and provide support to 
reduce it, exploring alternative ways to achieve things that are important to the 
individual. 
 
9.42 But getting someone through the door can, despite the number of people affected 
by drug use in London, be a challenge for providers. This means some are 
struggling to meet a key condition attached to additional funding, namely an uplift 
in the number of service users on their caseload.541 Since 2009–10, the number of 
new entrants each year into drug and alcohol services has fallen by around 
 
541 See From harm to hope: A 10-year drugs plan to cut crime and save lives - GOV.UK (www.gov.uk) p.34. 

   
 
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10,000 (from 147,046 to 137,749 in 2022–23), reaching a low in 2017–18 of 
127,307.542 
 
9.43  This is puzzling, given need has not gone down – particularly so among offenders 
exiting prison and serving community sentences. As we heard elsewhere, a 
majority of offenders have drug-related needs and many are serving sentences 
where attending drug treatment is a mandated condition, which suggests a failure 
somewhere along the way to ensure users are referred into, and attend, 
treatment.  
 
9.44 The widespread lack of specialist cannabis treatment across London was flagged 
by most health specialists we heard from. Development of a coherent, widespread 
and accessible response to problematic cannabis use is compounded not only by 
limited evidence about the most effective approach but by structural barriers 
within existing treatment services, including the skills and expertise of clinical staff. 
Once again, this tends to mean alcohol- and opiate-related issues are prioritised.  
 
9.45 Moreover, while there are commonalities in some of the behavioural and other 
approaches utilised in both mental health and drug treatment, the lack of join-up 
between services makes a holistic approach difficult. Years of ever-reducing 
funding in both have, it was suggested to us, resulted in deterioration in capacity 
for joint working. 
 
 The Cannabis Clinic for Psychosis 
 
9.46 London’s Cannabis Clinic for Patients with Psychosis (CCP) was established in 
2019 on a trial basis. Positive early evaluation543 led the South London and Maudsley 
NHS Foundation Trust (SLaM), in 2022, to commission the CCP to continue to 
deliver clinical services. The first of its kind in the UK, the clinic provides s pecialist 
support for adults with psychosis who are seeking support related to (current or 
previous) cannabis use.  
 
9.47 Its approach is one of dual diagnosis, meaning patients have both a mental health 
condition (psychosis) and a parallel substance use disord er (related to cannabis). 
Open to SLaM patients who are motivated to change their cannabis use (which 
could mean abstinence, a reduction in or more controlled use, or harm reduction) 
the clinic offers various types of support adapted to the needs of people  suffering 
from psychosis.  
 
9.48 These include 1:1 weekly sessions with a keyworker, psychoeducation, craving 
management (including help with withdrawal symptoms), relapse prevention 
strategies and an innovative weekly online ‘Peer Group’ (PEER), open to both 
patients and staff. This provides peer -to-peer support, access to expert guest 
speakers and practical tools and advice. 
 
542 Substance misuse treatment for adults: statistics 2022 to 2023 - GOV.UK (www.gov.uk) Tables 10_3 & 10_4. 
Accessed 5th May 2024. 
543 Cannabis Clinic for Patients with Psychosis - Maudsley Charity Accessed 21st February 2024. 

   
 
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9.49 The CCP also facilitates referrals to Nicotine Replacement Therapy (NRT) services. 
Given the health risks posed by co-consumption of cannabis with tobacco, this is in 
our view a notable benefit.  
 
9.50 Current resources allow the clinic to see around 100 patients per year, in addition 
to supporting several people who are not/no longer patients but attend weekly PEER 
sessions. The majority are current users of cannabis (89%) and 95% of patients 
began using around the age of 16. Some are referred through community mental 
health teams that operate across the SLaM  catchment area (namely Lambeth, 
Lewisham, Croydon and Southwark), others following admission to an in -patient 
psychiatric unit.  
 
9.51 A minority reach the clinic following involvement with the police, through powers set 
out in sections 135 and 136 of the Mental Health Act 1983 (MHA). These enable a 
police officer to seek assessment and treatment for a person suffering from a mental 
health disorder. Sometimes, at the time of police intervention, they may be exhibiting 
behaviours that represent a risk of harm to themselves or to others. 
 
9.52 CCP clinicians told us that , among their patients, managed withdrawal is vital to 
reduce the risk of potentially harmful or violent behaviour and , in their experience, 
aggression is common among cannabis users detained under the MHA. 
 
9.53 Indeed, the widely accepted belief that cannabis universally relaxes and ‘chills out’ 
users is, it was put to us, not  always the case. It is not everyone’s experience and 
we heard that in some cases it can lower a person’s threshold for aggressive 
behaviour. Where a psychosis patient uses cannabis, several clinicians told us their 
risk of violence was heightened: those who stopped using the drug or who had never 
used it demonstrated much lower scores on clinical assessments of violent 
behaviour.  
 
9.54 Cannabis was, in the experience of a number of our witnesses, associated with a 
worsening of symptoms in psychosis patients, and reportedly risked an increasing 
sense of paranoia even among general users. While for most such users this does 
not reach the thre shold of psychotic illness, it can nevertheless be a debilitating 
adverse side effect.  
 
9.55 Abstaining from cannabis or controlling its use was considered as important as 
taking anti-psychotic medication in terms of managing symptoms of psychosis. This 
is an important part of what was described as patient –clinician ‘negotiations’ 
regarding cannabis  use: most do not like taking anti -psychotics so the fact that 
abstinence or reduced use of cannabis could lower their dose can be a powerful 
lever.  
 
9.56 It was put to us that non-compliance with anti-psychotic medication, combined with 
cannabis use, presents the most significant risk factor for relapse and hospital 
readmission: both behaviours are however potentially amenable to tailored 

   
 
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psychological and behavioural in terventions, such as contingency management  
(see para.9.20). 
 
9.57 Where CCP patients access services from an in -patient psychiatric unit and their 
cannabis use is actively managed down, psychotic symptoms largely subside. The 
challenge comes, however, after discharge. As with offenders released from prison, 
the risk is high of returning to previous friendship circles in which cannabis is 
common, and of lapsing back into use , w hich highlights the importance of 
continuation of care into the community . The role played by the CCP through its 
PEER group plays a vital role here. 
 
9.58 Psychotic cannabis users outside of the SLaM catchment area are not eligible to 
be seen by the CCP. Neither is the service equipped to treat users presenting with 
non-psychotic mental health disorders, or those dependent on cannabis but who 
do not present acute symptoms of mental health distress (in other words, the 
majority of problematic cannabis users).  
 
9.59 And while all mental health services in theory can treat acute psychosis related to 
cannabis use, the joint specialist mental health/drug treatment model deployed by 
the CCP may help reduce the chance of relapse to a greater degree. 
 
9.60 We acknowledge there are services that cater to those cannabis users not 
exhibiting symptoms of mental ill health: the global Marijuana Anonymous peer-
support programme, for example, has a presence in London and provides support 
to those wishing to stop using the drug, irrespective of any other health conditions.  
 
9.61 There are, too, a range of general addiction services such as those provided 
under the auspices of the charity Humankind. Among other facilities, Humankind 
supports residents of Lambeth who are seeking help with recovery from drug and 
alcohol addiction. Like others, the organisation also offers interventions to 
offenders issued with drug or alcohol treatment requirements as part of a criminal 
justice sentence (see chapter 10). Whether such general services are optimally 
equipped to address issues and challenges specifically related to cannabis use is, 
however, unclear. 
 
Navigating drug services alongside mental health services  
 
9.62 Despite some overlap in treatment needs related to drug use and mental ill health, 
services for the latter are commissioned not by individual local authorities but 
through London’s five Integrated Care Systems (ICS’).544 The view among health 
professionals and policy makers with respect to mental health provision in London, 
particularly for young people, was universal: similar to drug treatment, it was 
described as patchy, heavily oversubscribed and substantially underfunded. 
 
 
544 Partnerships that bring together providers and commissioners of NHS services across each of five areas of 
London with local authorities and other local partners to plan health and care services.  

   
 
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9.63 Given the role that poor mental health can play in driving drug use, it is difficult to 
disagree with suggestions that more comprehensive, accessible mental health 
services could reduce the risk of some sufferers turning to cannabis to try to 
alleviate immediate symptoms. That said, it is unclear to us how many might 
refrain or desist, given the range of factors involved in the decision to use 
cannabis (or any drug).  
 
9.64 It feels more sensible to us to simply accept the reality of the need for dual 
diagnosis teams to identify, treat and manage those presenting with symptoms of 
mental health disorder alongside drug use disorders. This means embedding 
substance use specialists within mental health services. 
 
9.65 With respect specifically to mental health for young people, we understand the 
creation of Mental Health Support Teams, designed to integrate mental health 
care across London’s schools and the NHS, has been largely welcomed by the 
sector – but implementation is slow. Less than 50% coverage across each ICS is 
expected by the end of 2024, meaning what was often referred to as a postcode 
lottery will remain for some time in terms of access to mental health services for 
children and young people.   
 
9.66 Moreover, in some boroughs, cannabis use automatically excludes a young 
person or adult from mental health services, even where they are using 
prescription-issued medical cannabis (see chapter 11) to help manage symptoms 
of mental ill health. In some respects this is indicative of a wider lack of service 
integration and poor understanding of cannabis use among parts of the sector. 
 
9.67 Given relatively high rates of mental health disorders among those with cannabis 
use related disorders, failure to assess and manage the former will inevitably 
increase the risk of relapse where an individual tries to reduce or abstain from their 
cannabis use – with or without the help of treatment services.  
 
9.68 It was put to us that treating underlying mental health conditions to reduce the risk 
of relapse into substance use is a well-understood narrative in psychiatry, yet the 
current system does not support its delivery. Indeed, it almost incentivises people 
who use cannabis to conceal the fact from mental health services. This means 
clinicians and drug workers do not always have a complete picture of a service 
user’s history, which can threaten the appropriateness of any treatment plan and, 
ultimately, its success. 
 
9.69 Experts across the sector impressed on us an increasing urgency for greater join-
up between mental health services (in community and hospital settings) and drug 
treatment and addiction services. Greater knowledge within both about the 
interplay between cannabis use and symptoms of mental health would help. The 
model deployed by the CCP is, to our mind, an example of best practice, bringing 
together as it does specialists who understand both mental (ill) health and the 
ways in which cannabis affects bodily and brain functions.  
 

   
 
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9.70 Similarly, we heard evidence from some local authorities that primary care 
physicians are often unaware of a patient’s cannabis use (or lack confidence to 
ask due to inadequate knowledge about the physiology of its effects). Stigma, and 
concern about access to other services, can prevent a patient from being open – 
which again poses implications for treatment and likelihood of successful 
outcomes.  
 
9.71 We therefore recommend a programme of work be developed to explore how 
physical and mental health services could better join up with treatment and 
addiction services, irrespective of which borough they operate within. This should 
consider mechanisms of delivery, commissioning practices and how to reduce 
inequalities in service access and be jointly led by the London Health Board and 
London Drugs Forum (R10).545 Involvement of the latter will ensure other relevant 
agencies are aware and have opportunity to contribute (including those within the 
criminal justice sector; see next section).  
 
9.72 This programme should also play a key role in testing and piloting findings 
emerging from the work we recommend be led by the DHSC with respect to 
developing the evidence base focused on what works in treating problematic use 
of cannabis effectively (R7).  
 
9.73 Of wider relevance is the fact that medical students currently receive little, if any, 
education on cannabis use and its effects, both adverse as well as therapeutic or 
medicinal. We discuss this further with respect to use of cannabis for medical 
purposes in chapter 11. 
 
Treatment for offenders  
 
9.74 As we discuss in chapter 10, drug use features heavily among offender populations 
and drugs, particularly synthetic cannabinoids (SCRAs, see chapter 8) are rife in 
prison establishments. HM Prison Service has estimated that around 60% of the 
prison population use SCRAs, and prisoners themselves suggest the figure is closer 
to 90%.546 
 
9.75 We heard, too, that the performance framework for prison -based drug services is 
led by the number of prisoners treated in drug wings. These are wings reserved for 
those with more serious needs (related to opioid addiction, for example) – meaning 
offenders who enter prison with problems related to cannabis are less likely to be 
prioritised and often end up leaving custody having had no opportunity to address 
those issues. 
 
9.76 Overall, we heard only around 20%  of offenders and ex-offenders referred to drug 
treatment services in London attend, often because finding housing and 
employment take priority. Moreover, almost two -thirds of prison leavers fall out of 
 
545 The London Drugs Forum | London City Hall 
546 Cited in Abbott, M.J., Dunnett, J., Wheeler, J. & Davidson, A. (2023). The identification of synthetic cannabinoids 
in English prisons. Forensic Science International, p.348. doi.org/10.1016/j.forsciint.2023.111613 

   
 
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treatment upon release .547 This is likely due in no sm all part to lack of resources, 
leaving community-based services unable to meet would -be clients at the prison 
gate on release. Previously, such engagement would help build relationships and 
offer opportunity to explain how treatment can support ambitions to reintegrate into 
society.  
 
9.77  Failure to engage in treatment is likely to jeopardise compliance with requirements 
of a sentence or terms of release from custody. This is compounded by continued 
use of drugs and , as we heard from representatives of the Youth Justice and 
Probation Services, heavy use of highly potent cannabis is rife among those they 
supervise.  
 
9.78 Offender managers reportedly struggle to identify the most appropriate service into 
which they should r efer an individual whose drug -related issues relate primarily to 
cannabis. More broadly, and as noted by HM Inspectorate of Probation three years 
ago, treatment providers and probation often work in silos, which does little to help 
identify and source provision appropriate to meet an offender’s needs. We heard no 
evidence that the position has changed, at least in London.  
 
9.79 We heard too that sentencers lack confidence in the probation service to identify 
and refer offenders into appropriate treatment. Concerns are linked, at least in part, 
to consequences of the very significant structural reforms of the past decade, with 
the part-privatisation of the service introduced in 2014 subsequently reversed in 
2019.  
 
9.80 Sentencers, also, it was put to us, lack confidence in the capacity of drug treatment 
services to meet offenders’ needs, due in part to aforementioned funding cuts. It 
will, we heard, take some time to rebuild that confidence despite the recent increase 
in government funding.   
 
9.81 In London, the situation is compounded by the complex, somewhat fragmented 
nature of drug treatment provision and mental health services. With inadequate join-
up between commissioning authorities, it is perhaps no wonder the probation 
service can struggle to navigate both systems, nor that those systems struggle to 
accommodate the needs of offenders.    
 
9.82 A dedicated triage function to join up local  treatment services with offender 
management might help improve confidence and provide a practical solution to 
match need with provision. The ADPH, together with NHS England, those 
responsible for healthcare within prison and probation  and local government  
(including ICS’) should investigate creation of a ‘single point of contact’ advisory 
service (R11). This should support staff responsible for managing releases from 
prison and for supervision within the community, offering advice regarding 
substance use services available in the locale within which an offender will reside. 
 
547 HM Inspectorate of Probation & Care Quality Commission (2021). A joint thematic inspection of community-based 
drug treatment and recovery work with people on probation. His Majesty’s Inspectorate of Probation, Manchester. A 
joint thematic inspection of community-based drug treatment and recovery work with people on probation 
(justiceinspectorates.gov.uk)  

   
 
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Co-use of cannabis and tobacco  
 
9.83 Smoking cannabis combined with tobacco not only exacerbates the risk of harm, it 
also increases the risk of dependence and makes it harder to quit. While the offer of 
tobacco cessation treatment is a requirement of drug misuse services,548 we heard 
the two are not well integrated.  
 
9.84 Only 2% of substance use treatment recipients across England were offered a 
tobacco cessation referral in the year ending March 2021, despite over half (56%) 
identifying as recent smokers .549 The CCP is an exception. Working in close 
collaboration with local (SLaM) in-patient and community smoking cessation 
providers, the clinic offers Nicotine Replacement Therapy (NRT) alongside support 
for reduction or cessation of cannabis use.  
 
9.85 The situation is no better the other way around. From what we heard, referrals from 
tobacco cessation services into drug treatment are likely to be low – though 
precisely how low is unclear d ue to a lack of data. The illegal status of cannabis 
reportedly deters practitioners from asking about co-use, so data on the number of 
people who seek tobacco cessation services and also use cannabis is not routinely 
collected. 
 
9.86 Moreover, we heard how, as  elsewhere in frontline healthcare, smoking cessation 
advisors are poorly equipped to raise cannabis use with clients. Their lack of 
knowledge and often confidence means many do not broach the subject, although 
there is appetite to do so. A recent survey r eported almost all (94%) smoking 
cessation respondents would welcome training on cannabis use, yet two-thirds had 
received none. Fewer than half of services operated a database that recorded 
cannabis use and not much more than one-third had any internal guidance relating 
to use of the drug.550 
 
9.87 It is easy to see how efforts at tobacco cessation for co -users are likely to be 
undermined unless concurrent cannabis consumption features in the discussion. In 
our view, tobacco cessation practitioners should be equipped to identify and talk 
with their clients’ about the role of cannabis consumption in tobacco cessation.  
 
9.88 We recommend the Association of Directors of Public Health (ADPH), in partnership 
with the Department for Health & Social Care (DHSC) and the Office for Health 
Improvement & Disparities (OHID) , should consider how tobacco cessation 
practitioners can be supported to explore clients ’ cannabis use. A requirement for 
them to do so  should in due course be built into commissioning of such services. 
 
548 Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group (2017). 
Drug misuse and dependence: UK guidelines on clinical management. Public Health England. 
549 Office for Health Improvement and Disparities (2021). Adult substance misuse treatment statistics 2020 to 2021: 
report. Adult substance misuse treatment statistics 2020 to 2021: report - GOV.UK (www.gov.uk) Accessed 28th 
February 2024. 
550 Sumodhee, D., Walsh, H., Brose, L., McNeill, A., McEwen, A., & Duaso, M.J. (2024). Support Provided by Stop-
Smoking Practitioners to Co-users of Tobacco and Cannabis: A Qualitative Study. Nicotine & Tobacco Research, 
26(1), 23–30. doi:10.1093/ntr/ntad115 

   
 
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Assessment and recording systems  should be duly adapted , with training 
developed on how to establish appropriate treatment plans for co-users (R12).  
 
9.89 Pathways between drug treatment and t obacco cessation provision should be 
clearer for practitioners and users, and much better integrated. In actively referring 
psychosis patients to NRT services, as well as working with local drug and alcohol 
services to identify patients who might benefit f rom the dual diagnosis treatment it 
provides, the CCP offers a good example of how this can operate.  
 
9.90 The Office for Health Improvement & Disparities (OHID), in partnership with 
providers of tobacco cessation and drug treatment services, should e xplore th e 
barriers to more integrated provision and how these could be overcome to better 
meet the needs of co -users and improve the chances of successful treatment 
outcome(s) (R13). 
 
The role of pharmacists 
 
9.91 Pharmacists and pharmacies advise and dispense, or sell, medical and non-medical 
cannabis in several jurisdictions around the world. Indeed, in Uruguay, the first 
country to legalise non -medical cannabis for adult use, it can only be purchased 
through pharmacies (see chapter 7). No other retail outlets are permitted to sell the 
drug.  
 
9.92 The HAC has noted the potential role of community pharmacists in supplying, 
distributing and administering naloxone as part of efforts to counteract opioid -
related overdose.551 Based on evidence put to us, we agree that pharmacies can 
occupy a unique role within communities. While other authorities can often be 
viewed with a degree of wariness, particularly by some communities  (see para 
9.16), pharmacists tend to attract relatively high levels of public trust.552 
 
9.93 Pharmacies can dispense prescriptions for licensed cannabis -based medicines 
(Sativex®, Epidyolex® and Nabilone, see chapter 11). Since the law changed in 
2018 to allow the prescribing of unlicensed cannabis-based products for medicinal 
purposes (CBPMs), in Great B ritain pharmacies registered with the General 
Pharmaceutical Council (GPhC)  (usually offering online/distance selling) may 
dispense these products too. 
 
9.94 However, it was put to us that , as among other healthcare practitioners, there is 
little awareness or k nowledge among the pharmaceutical profession of the 
cannabinoid system and the way in which cannabinoids affect the body (with the 
exception of those licenced to supply specialist prescriptions for CBPMs). Certainly, 
the subject is not routinely covered in education and training for pharmacists.  
 
 
551 See footnote #533, p.58. 
552 Maidment, I., Young, E., MacPhee., M., Booth, A., Zaman, H., Breen, J … & Wong, G. (2021). Rapid realist review 
of the role of community pharmacy in the public health response to COVID-19. BMJ Open. doi:10.1136/bmjopen-
2021-050043 

   
 
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9.95 Moreover, while the number of NHS prescriptions for licensed cannabis -based 
medicines is slowly rising, overall numbers remain low (a total of 5,873 were issued 
in England in 2022/23 ).553. This means  most pharmacists (of whom there were 
64,384 registered with the GPhC in June 202 4)554 are unlikely to be very familiar 
with use of cannabis-based products in the medical management of ill health.  
 
9.96 We heard, though, there is appetite for more information about the effects of 
cannabis and cannabis -based medicine (including unlicensed CBPMs) . This is 
important because if, as we recommend in chapter 11, consideration is given to 
expanding prescribing capabilities for unlicensed CBPMS , the number of 
prescriptions coming to pharmacies may rise.  
 
9.97 Our observations regarding content on the endocan nabinoid system in wider 
medical training can equally be applied to pharmacists and other health 
professionals. The GPhC should explore the feasibility of including in their syllabus 
content that covers the endocannabinoid system and the way in which canna bis 
exerts effects on the body  (R14). They should also consider R 35 regarding 
expansion of provision of information on the use of cannabis for medical purposes 
(chapter 11). 
 
9.98 Finally, public trust in pharmacies, which are often more representative of 
communities they serve than other public -service providers, offers a wid er 
opportunity. They may, for example,  be well placed to identify what problematic 
cannabis use can look like and , where appropriate, offer to coordinate with, or 
connect a person into, local treatment services.  
 
9.99 This might help increase engagement with g roups whom services can otherwise 
struggle to reach because of wider mistrust in authority. The Mayor should consider, 
in partnership with the GPhC  and local drug treatment services, implementing a 
small-scale pilot of this nature  in one or more London boroughs , whereby 
pharmacists provide a link into services for those struggling with cannabis use  
(R15). 
 
Brief implications for drug treatment and he alth services of legalising non -medical 
cannabis 
 
9.100 Evidence suggests that post -legalisation, the number of people choosing to use 
cannabis rises (see chapter 7). While difficult to conclusively disentangle 
contributing factors, it seems likely (and intuitiv e) that , without fear of criminal 
sanction, more people will try the drug. In the UK, this means  that, unless 
mechanisms of consumption shifted away from co-consumption with tobacco 
(wider mechanisms of ingestion become available within a legally regulated model), 
this would be cause for concern given the indisputable health harms associated with 
the latter.  
 
553 Issued in England and dispensed in England, Wales, Scotland, Guernsey, Alderney, Jersey and the Isle of Man, 
based on figures provided to the LDC by the NHS Business Services Authority (NHSBSA). 
554 Registers | General Pharmaceutical Council (pharmacyregulation.org) Accessed 23rd July 2024. 

   
 
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9.101 Evidence on whether legalisation directly incre ases the prevalence of CUD, 
psychosis and other mental health disorders is more mixed. It often fails to account 
for the fact that rates (at least as measured by hospital admissions) were rising in 
many jurisdictions before regulation (see chapter 7).  
 
9.102 It is also possible that a more permissive legal framework encourages reporting of 
cannabis use among those seeking help for symptoms of ill health more widely, and 
may increase the likelihood of those experiencing problematic cannabis use to seek 
help. Both phenomena would drive up the number of people recorded as presenting 
with cannabis-associated difficulties, but neither reflect a genuine increase in the 
prevalence of such difficulties. 
 
9.103 By and large, most of those we heard from accept it is too early to  tell with any 
certainty whether legalising non -medical cannabis drives a real increase in the 
number of people developing symptoms of addiction or other health -related 
problems (as distinct from a rise in the numbers reporting such).  
 
9.104 Given that legalisa tion likely  drives up the number of people who use cannabis 
overall, and possibly the extent of use among existing users  of the drug, it  is not 
unreasonable to expect a rise in the number who develop associated problems 
(particularly where use becomes more  frequent). There is, however, currently no 
clear evidence to suggest, relative to the total number of users, that the proportion 
of problematic users materially increases.  
 
9.105 All that being so, the reason for any increase in demand for drug treatment and 
mental health services following legalisation is in some ways immaterial from a 
service provision perspective. Whether due to a genuine rise in numbers of people 
developing problems or an artefact of increased help-seeking behaviour and better 
recording, or both, the bottom line is demand for support would probably go up. 
 
9.106 Arguably, it is no bad thing if problematic cannabis users feel more able to seek 
help, p articularly if they do so before symptoms become entrenched and more 
difficult and costly to treat, with less chance of success. This could represent a step 
forward in improving public health and is one potential benefit of removing, or at 
least lessening, the stigma associated with illicit cannabis use.  
 
9.107 The extent to which that benefit would be realised, however, is unclear as there are 
other barriers to help -seeking behaviour that legalisation does not necessarily 
resolve. There are plenty of people with problematic use of alcohol and tobacco, for 
example, who choose not to seek support or otherwise engage with relevant 
services, despite neither substance being illegal.   
 
  

   
 
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10. CANNABIS, POLICING AND THE 
CRIMINAL JUSTICE SYSTEM 
 
Data availability and the experiences of many of those we spoke to about the 
enforcement and consequences of cannabis laws mean we focus in parts of this 
chapter on London. But several of the issues we consider, particularly with respect to 
racial disproportionality in the criminal justice system (CJS), have relevance for 
communities and police forces around the UK, especially larger towns and cities with 
more ethnically diverse populations.  
 
We consider the dominance of cannabis offences – particularly possession – in 
recorded crime, and the significance of Stop & Search (S&S) in drugs policing. We 
explore the nature and basis of cannabis-related S&S, including its accuracy and wider 
value, evidence of racially disproportionate deployment, and the experience and impact 
of use of the power on individuals and communities.   
 
We briefly consider the use of strip searching, and how police deploy the discretion 
available to them when imposing sanctions short of arrest for cannabis offences. As part 
of this we discuss the role of police-led diversion schemes, before looking at how 
cannabis possession offences progress through the justice system, from arrest and 
prosecution to court sentencing.   
 
We then consider the extent of cannabis use among those convicted of a criminal 
offence, and the level of demand that the illegal status of the drug places on police and 
justice system resources. We finish this chapter by comparing how the Misuse of Drugs 
Act (MDA) 1971 treats non-medical cannabis with how it would be dealt with were it 
subject instead to the Psychoactive Substances Act (PSA) 2016. We set out our 
rationale for proposing the drug be governed by the latter and discuss the likely 
consequences.   
 
Note: Data sourced from the MPS Stop & Search Dashboard may have been slightly 
revised since extracted for this report during January – May 2024, reflecting ongoing 
operational updates to data collections.  
 
Policing cannabis  
 
10.1 The importation, exportation, production, supply and possession of non-medical 
cannabis, which is categorised as a Class B drug and controlled under the MDA, 
are criminal offences in the UK.555  
 
10.2 Enforcement of the law enshrining those offences rests initially with the police. In 
the case of less serious offending, depending on the circumstances they have the 
 
555 For unlicenced dealing, production (including home cultivation) and trafficking of cannabis, an individual could face 
up to 14 years in prison, an unlimited fine, or both. The maximum penalty for possession of cannabis is five years in 
prison and/or an unlimited fine.  

   
 
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power to choose to apply sanctions without recourse to the criminal courts. For 
more serious offences, an individual is usually liable to prosecution and, if found 
guilty, sentenced by a magistrate or a judge. 
 
10.3 The police therefore play a crucial role in determining who enters the criminal 
justice system (CJS) for cannabis offending. Stop and Search (S&S), considered 
a critical tool in proactively combatting drug possession and supply, is a key part 
of this. In this chapter we consider evidence regarding deployment and efficacy 
of the S&S power, as well as statistics regarding its use by the Metropolitan 
Police Service (MPS) and City of London Police (CoLP), who together with the 
British Transport Police (BTP)556 are responsible for policing the capital.  
 
10.4 We focus on the MPS in many aspects because they police the vast majority of 
the capital, namely all of its 32 boroughs. The CoLP are responsible for policing 
the City of London, also known as the Square Mile, and are a very considerably 
smaller force than the MPS (comprising around 1,000 full-time equivalent police 
officers compared to over 34,000 serving officers in the MPS). 
 
Prevalence of cannabis offences  
 
10.5 During the year ending September 2023, police across England & Wales 
recorded 181,810 drug-related offences, a rise of 2% on the previous year. Just 
under three-quarters (n=130,831) were for drug possession, the majority of 
which (74%, n=96,628) involved cannabis. Thus, 53% of all recorded drug 
offences in this period were for cannabis possession.557  
 
10.6 While 9% lower than in the previous year (when 105,639 such offences were 
recorded), cannabis possession is a significant part of the drug-related police and 
wider CJS workload. This has been the case for the past 20 years. Since 2004 
(when possession of controlled drugs was split into i) cannabis and ii) drugs other 
than cannabis), cannabis possession has been the most commonly recorded 
drug offence by a substantial margin.  
 
10.7 As alluded to in the Runciman Report,558 the dominance of cannabis (particularly 
possession) in crime statistics suggests its illegal status is little deterrent. The 
most widely used illicit drug across the world, it comprises the majority of police 
and Border Force drug seizures (see chapters 4 and 5). Indeed, Runciman found 
no indication that drugs laws in general act as a deterrent for the majority of the 
public. Health consequences of use reportedly play a more important role than 
legal controls, fear of being caught or punished, availability or price.559  
 
 
556 While the BTP are also responsible for policing London, and duly have the power to stop and search persons and 
vehicles, we have focused on the MPS and CoLP in our inquiries.  
557 Crime in England & Wales: Appendix tables - Office for National Statistics (ons.gov.uk) Year ending September 
2023, Table A4a. Accessed 6th February 2024. 
558 Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971 (2000). The Police 
Foundation. Overview, para.8.  
559 Ibid. Chapter 7, para.74. 

   
 
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10.8 This is no less the case in London, where we heard public dealing and 
consumption of cannabis are routine. Certainly, cannabis comprised the vast 
majority of all drug possession offences recorded in the capital during the year to 
March 2023 (and, at 87% for the MPS and 79% for the CoLP, it is higher than 
the national average of 74%).560  
 
10.9 There are, however, notable differences in the prevalence of offences recorded 
within individual boroughs. While overall in 2022/23 the MPS recorded 29,407 
cannabis possession offences561 (a fall from 35,354 the previous year), rates per 
1,000 population, as in previous years, varied considerably.  
 
10.10 As recorded at the time of our data extraction, during the year to 2023 Richmond 
upon Thames saw a low of 1.12, with Barnet next lowest at 1.39. While 
Westminster recorded the highest rate at 13.16, this likely reflects at least in part 
the high numbers of tourists and other visitors to the area, rather than a 
particularly high rate of offending by residents of the borough. Similarly, while the 
CoLP recorded 38.17, this is highly likely to be driven by behaviour among those 
visiting rather than resident in the Square Mile (City of London).  
 
10.11 Quite how much such statistics tell us about the true extent of the prevalence of 
cannabis, how much is really in circulation in London and elsewhere, and how 
much demand cannabis policing makes on resources is, however, to our mind 
debatable.  
 
10.12 The way in which police deal with offences of cannabis possession may affect 
how incidents are recorded, meaning the amount of cannabis found is likely 
higher than statistics suggest. And while the police unquestionably spend a lot of 
time dealing with cannabis offences, the numbers alone do not necessarily 
indicate that, relative to more serious offending, the drug takes up a hugely 
disproportionate amount of police time overall.  
 
10.13 Recorded crime figures are thus a function of police activity and recording as well 
as levels of offending. As a large proportion of cannabis possession offences are 
first identified via S&S, where police have a significant degree of discretion with 
respect to whether and who they stop, arguably at least some of the variation 
seen across boroughs is down to police behaviour rather than substantial 
geographical differences in prevalence of cannabis use.  
 
Stop & Search: background and practice 
 
10.14 Lord Scarman, in his inquiry into the riots of 1981 in Brixton, south London, 
concluded their origins lay in the breakdown of relations between police and – 
particularly black – communities across the borough. Against a backdrop of 
 
560 Figures from Police recorded crime and outcomes open data tables for year ending March 2023, table 2022_23. 
Outcomes open data year ending March 2023 https://www.gov.uk/government/statistics/police-recorded-crime-
open-data-tables The MPS recorded 33,868 drug possession offences during the period (CoLP recorded 527), of 
which 29,407 were for cannabis (414 for the CoLP). Accessed 6th February 2024. 
561 Ibid. 

   
 
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deprivation, racial disadvantage and inequality, alongside rising levels of street 
crime, he found clear evidence of disproportionate and indiscriminate use of S&S 
powers by the police against black Londoners.  
 
10.15 Over ensuing decades, S&S has continued to represent something of an ongoing 
sore for the police. The Lawrence inquiry,562 led by Sir Macpherson following the 
murder of Stephen Lawrence in London in 1993, found racial discrimination to be 
a major element in issues related to S&S.  
 
10.16 The Runciman Report, published the year after findings from the Macpherson 
inquiry, similarly highlighted the continuingly controversial nature of the 
practice.563 And there is no doubt that, more than 20 years on from then, the tool 
remains contentious,564 generating passionate views both against and in favour of 
its use.  
 
10.17 Our inquiries illustrated how highly the police value the power as part of their 
toolkit, but we also heard from many witnesses, including former senior police 
officers, who argued just as strongly that it does more harm than good.  
 
10.18 We make no comment on use of S&S conducted on grounds other than those 
related to drugs. But it was put to us that, at least in terms of cannabis, S&S 
serves, for many people, to isolate, antagonise and traumatise, as well as 
damage community relations – the very opposite of intent of recommendations 
from Scarman, Macpherson and others.  
 
10.19 Indeed, research led by the Mayor’s Office for Policing & Crime (MOPAC) found 
that of the one in ten Londoners surveyed who reported ever being subject to 
S&S, almost one-third (29%) had communicated negatively about their 
experience with family and friends. Just under one-quarter (24%) reported feeling 
negatively impacted or traumatised. Notably, black Londoners were far more 
likely than white Londoners to have reported such harmful consequences.565 
 
10.20 The history of S&S, its current use, guidance and reforms over past decades are 
set out comprehensively elsewhere,566 including by His Majesty’s Inspectorate for 
Constabulary and Fire & Rescue Services (HMICFRS), the College of Policing 
(CoP) and the Independent Office for Police Conduct (IOPC), as well as 
countless academic experts.  
 
 
562 Macpherson, W. (1999). The Stephen Lawrence Inquiry: Report of an Inquiry by Sir William Macpherson of Cluny. 
Home Office, p.360. Available at The Stephen Lawrence Inquiry - GOV.UK (www.gov.uk) 
563 See footnote #558. 
564 See also Home Affairs Committee (2021). The Macpherson Report: Twenty-two years on. Third Report of Session 
2021–22. Available at The Macpherson Report: twenty-one years on (parliament.uk) 
565 MOPAC (2023). Public Attitude Survey: Exploring the impact of Stop and Search on Londoners, and the role of 
the interaction between police and public. Slide 3 and 4. Available at https://data.london.gov.uk/download/mopac-
surveys/31726cff-01ec-4246-afc5-21eca3abeecd/PAS_In%20Focus_Stop%20and%20Search%20impact.pdf 
Accessed 14th August 2024.  
566 Summarised in, for example, Nickolls, L. & Allen, G. (2022). Police powers: stop and search. House of Commons 
Library Research Briefing, No. SN03878. Available at SN03878.pdf (parliament.uk)  

   
 
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10.21 There is no reason to repeat that material, except to say the impact of S&S on 
crime is at best mixed. There is little evidence it deters offending to any significant 
extent (and where it does, as we go on to discuss, in our view this may well be 
offset by detrimental impacts).567 The continued dominance of cannabis 
possession in crime statistics suggests this is no less true with respect to use of 
the drug. Indeed, following on from conclusions drawn elsewhere,568 HMICFRS 
have in recent years called for a national debate on the policing of controlled 
(illegal) drugs through S&S.569 
 
10.22 As the majority of S&S are, however, drug-related, and we think it a reasonable 
assumption that most are likely – at least on initiation – to relate to alleged 
suspicion of cannabis possession, our inquiries have inevitably strayed into 
associated issues. 
 
10.23  The power to S&S is set out in various legislation, principally: 
 
• Section 1, Police and Criminal Evidence Act 1984 (PACE). This allows a 
police officer to stop and search an individual or vehicle, in a public place, 
when they have objective and reasonable grounds to suspect that person 
has been involved in a crime and/or is carrying an unlawful item such as 
illegal/controlled drugs, a weapon or something else that could be used to 
commit a crime (e.g. a crowbar), or stolen goods. It means police can detain 
a person who is not under arrest in order to search them or their vehicle – 
though they must not do so simply because a person is known to the police 
or has been in trouble before. 
  
• Section 23, Misuse of Drugs Act (MDA) 1971. This enables police to stop 
and search a person or vehicle if they have reasonable grounds to suspect 
they are in possession of an illegal/controlled drug.  
 
• Sections 43 and 47A, Terrorism Act 2000. This relates specifically to 
searches for evidence or articles in connection with terrorism. 
 
10.24 The above powers are ‘suspicion-based’, meaning police must have a genuine 
suspicion they will find the object for which the power being used allows them to 
search before making a stop. Moreover, suspicion that an item will be found must 
be reasonable, based on facts, information and/or intelligence (this can include a 
person’s behaviour as witnessed by a police officer).570 It is these powers with 
which our inquiries are concerned, as they govern drug-related S&S.  
 
 
567 Weisburd, D., Petersen, K. & Fay, S. (2023). Does Scientific Evidence Support the Widespread Use of SQFs as a 
Proactive Policing Strategy? Policing: A Journal of Policy and Practice, 17. doi.org/10.1093/police/paac098 
568 See for example doubts expressed in the Runciman Report regarding efficacy of S&S, including regarding the 
extent to which dealers are arrested as a result of S&S and arrest of cannabis purchasers. See footnote #558. 
Chapter 5, para.34. 
569 His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (2021). Disproportionate use of police 
powers: A spotlight on stop and search and the use of force (justiceinspectorates.gov.uk) pp.2, 6. 
570 See PACE Code A (publishing.service.gov.uk), paras. 2.2, 2.6B. 

   
 
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10.25 There are also a limited number of ‘suspicion-less’ powers, which merit mention 
as they are part of the wider context – particularly those set out in Section 60 of 
the Criminal Justice and Public Order Act (CJPOA) 1994.571 This legislation 
enables officers to conduct ‘no-suspicion’ S&S for dangerous instruments or 
weapons. They may do so for a limited time within a specified area, in anticipation 
of violence occurring in that area or following an incident of serious violence 
involving a weapon.572 
 
10.26 As described by HMICFRS, suspicion-based stops can be self-generated (where 
an officer initiates the encounter as a result of their own observations), 
undertaken in response to information from a third party (the public or CCTV 
operators, for example), or intelligence-led.  
 
10.27 Their review of 9,304 S&S across England & Wales in 2019 showed the majority 
(55%) were self-generated. Over one-third (37%) were driven by third-party 
information and fewer than one in ten (9%) were intelligence-led. In London, over 
70% of MPS-led S&S were self-generated (third behind Nottinghamshire and 
Merseyside) and only around 5% were intelligence-led. Slightly more CoLP-led 
S&S were intelligence-led (although still less than 10%) with just over 60% self-
generated.573 
 
10.28 The low proportion of targeted S&S in London is notable not only because both 
the MPS and CoLP describe it as a power which is targeted and intelligence-
led574, but because stops based on accurate, current intelligence or information 
are considered more likely to be effective.575 Such stops also help to minimise 
inconvenience to law-abiding members of the public and to justify use of the 
power, both for those subjected to it and for the wider public.  
 
10.29 The analysis by HMICFRS found S&S was used mainly for self-generated, 
possession only drug searches (a majority of which were likely cannabis-related). 
The evidential basis for the vast majority of these (80%) was considered weak. 
By comparison, the evidential basis was thought weak in 15% of searches made 
in response to third-party information, and in only 5% of intelligence-led 
searches. Moreover, those subject to S&S are entitled to a record of the 
encounter: it was suggested to us that HMICFRS also found the quality of these 
to be lower when a search was self-generated. 
 
10.30 The low level of reliance on intelligence and other information in drug-related S&S 
means it is perhaps not surprising that so many find nothing and result in no 
 
571 Schedule 7 of the Terrorism Act 2000 also permits ‘suspicion-less’ stops, allowing police officers to examine 
people and goods who pass through the UK border to determine whether they may be involved or concerned in the 
commission, preparation or instigation of acts of terrorism. 
572 Legal basis | College of Policing Accessed 15th January 2024. Stops under this legislation must be authorised by a 
police officer of at least Inspector rank. 
573 See footnote #569, pp.33–4. 
574 See descriptions at Stop and search | Metropolitan Police and Stop and search | City of London Police Accessed 
28th August 2024. 
575 See PACE Code A (publishing.service.gov.uk), paras. 2.4, 2.4A. 

   
 
212 
 
further action (NFA),576 nor that use of the power is considered by many to be a 
risk to police–community relations. We consider these issues in more detail later 
in this chapter.  
 
10.31 With respect to drugs, an S&S should not be conducted where a person is 
suspected only of having used an illegal substance, or of having been around 
others who have done so. Nor is it good practice for a self-generated search to 
be based on a single factor such as the smell of cannabis, which various 
guidance stipulates is insufficient justification.577 The MPS told us this is 
reproduced in their local policy on cannabis related S&S.  
 
10.32 However, evidence put to us suggested that police claims of smelling cannabis 
continue to drive S&S across London, including in the high-profile incident 
involving athletes Bianca Williams and Ricardo dos Santos in 2020. In this case, 
officers originally sought to stop the vehicle in which the athletes were travelling 
on the grounds of suspicious driving and then a failure to stop when requested.  
 
10.33 Once stopped, officers then searched the vehicle and both individuals on 
suspicion of possession of drugs and weapons. The subjective nature of the 
grounds of S&S based on smell was laid bare when a misconduct panel found 
two of the officers involved had in fact lied when, in citing the grounds for the 
search, claimed they could smell cannabis.  
 
10.34 While the HMICFRS analysis found the number of stops across forces that were 
based on cannabis smell had reduced, they too concluded the practice was still 
taking place. Moreover, they considered that smell on its own offered only weak 
grounds for an S&S, meaning a higher likelihood that nothing is found.  
 
10.35 Where smell is not attributable to an individual (for instance when it comes from a 
car, area or group of people) HMICFRS considered the grounds for S&S to be 
even weaker, as it is even less likely a given person in that car, area or group is in 
possession of cannabis at that time. Without other compelling factors to justify a 
search, the grounds for doing so remain weak. 
 
10.36 It seems to us that previous recommendations and guidance from HMICFRS, the 
IOPC, CoP and others regarding the smell of cannabis alone as a basis for S&S 
have failed to change practice to any meaningful degree. Similarly, while the 
code of practice (Code A) that governs operation of the power to S&S clearly 
sets out legal grounds for its deployment, it makes no reference to whether and 
how smell may be used.  
 
10.37 Our view is this should no longer remain the case. We therefore recommend: 
i) All relevant guidance should explicitly set out that the smell of cannabis 
alone cannot ever lawfully be used to justify a stop and search.   
 
576 No further action (NFA) includes a number of scenarios, including words of advice being given to the person who 
has been S&S, or detention under section 136 of the Mental Health Act. 
577 Legal basis | College of Policing Accessed 9th January 2024. 

   
 
213 
 
ii) A clause be inserted into PACE Code A to state the smell of cannabis 
alone cannot be used to lawfully justify a stop and search.    
(R16). 
If a person is stopped on the grounds of smell alone, civil litigation should 
become an option for redress. 
 
10.38 Where police take further action following an S&S, this may not relate to the initial 
reason for the stop. An S&S on suspicion of cannabis possession may not yield 
the drug but instead, for example, may produce a weapon, for which the 
individual will likely be arrested. This is an important aspect of S&S practice to 
which we return later. 
 
Stop and Search in London: the numbers 
 
10.39 The MPS and City of London Police (CoLP) together account for more S&S 
under Section 1 of PACE (1984) each year than any other police force. During 
the year ending March 2023, they conducted a total of 178,936, equating to 
around one-third (33%) of all 542,722 S&S recorded that year in England & 
Wales. Unsurprisingly, the MPS were responsible for the vast majority (176,749, 
the CoLP force conducted 2,187).578 
 
10.40 In itself this is disproportionate, given around 15% of the population of England & 
Wales live in London, although we recognise the capital attracts high numbers of 
visitors for leisure and business purposes. Forces in the north west were the 
second most prolific users of the power, recording 111,221 S&S overall (with the 
majority made by Merseyside police).579  
 
10.41 While still responsible for more S&S than any other force, the number made by 
the MPS overall has, however, fallen over recent years. The force shared figures 
with us showing that between 1st August 2021 and 31st July 2024, the total 
number of S&S made by MPS officers fell by 39%. The number of drug-related 
S&S fell even more considerably, by 47% - and as a proportion of all S&S, from 
63% to 56%.580  
 
10.42 Suspicion of carrying drugs remains the most common reason for S&S across 
England & Wales, accounting for 61% (n=331,856) of all those undertaken under 
Section 1 of PACE (1984) and associated legislation in 2022/23. Despite the 
aforementioned recent falls in the number carried out by the MPS, London is no 
exception. As the two forces responsible for policing the capital, the MPS and 
CoLP undertook a combined total of 108,018 drug-related S&S in the year to 
March 2023, representing 60% of all S&S in London that year. The MPS were 
 
578 See Table SS_03, Stop and search and arrests, year ending March 2023 (second edition): 
https://assets.publishing.service.gov.uk/media/65ef2cd562ff4898bf87b2e3/stop-search-data-tables-summary-
mar23-second-edition.ods. Accessed 24th January 2024. 
579 Ibid. 
580 MPS. Unpublished written submission to the London Drugs Commission. 

   
 
214 
 
responsible for almost all of these (i.e. 106,822, the CoLP undertook a further 
1,196).581  
 
10.43 The continued dominance of drugs in S&S remains at odds with the assertion 
made by police leaders and others that use of the power targets those suspected 
of carrying knives and other weapons. HMICFRS have previously suggested the 
focus is, in fact, drug possession, of which cannabis is by some margin the most 
common, and that this potentially indicates frontline policing endeavours are not 
effectively focused on force priorities.582  
 
10.44 Moreover, while drug-related S&S’s take place across all London boroughs, as 
with offences there is wide variability. During 2023, Richmond upon Thames and 
Sutton recorded the fewest (455 and 793 respectively), with the highest numbers 
recorded in Westminster and Tower Hamlets (6,494 and 5,596).583 A further 9 
boroughs each recorded over 3,000 stops.584 
 
10.45 The variability is perhaps even more striking when considered on a per capita 
basis. Richmond upon Thames and Sutton saw 2.2 and 3.8 stops per 1,000 
population; Westminster and Tower Hamlets recorded 26.9 and 17.585  
 
10.46 That said, we must acknowledge that Westminster experiences particularly high 
levels of overall crime. This is likely due to the number of visitors – tourists, for 
example, or people gathering to protest – as well as concentration of the capital’s 
night-time economy in the borough.586 As a result, it is likely that proportionately 
more police officers are routinely deployed in Westminster, and greater levels of 
proactive policing such as S&S are perhaps to be expected. 
 
10.47 Nonetheless, Home Office (HO) analysis revealed that during the year to March 
2023, around 25% of all S&S in London took place in 2% of Lower layer Super 
Output Areas (LSOAs, small areas in which between around 1,000 and 3,000 
people live).587 Half took place in 9% of LSOAs. Alongside Westminster, parts of 
Croydon and Bromley also experienced very high levels of S&S.588 
 
10.48 The number of S&S undertaken specifically on the grounds of cannabis as 
distinct from other illegal drugs is difficult to ascertain from available data. While 
the MPS dashboard589 is a welcome and useful resource for exploring data at 
 
581 See footnote #578. Accessed 24th January 2024. 
582 See footnote #569, p.2. 
583 Based on analysis of 2023 data from MPS Stop and Search Dashboard Data - London Datastore Accessed 1st 
May 2024. 
584 Barking & Dagenham, Camden, Croydon, Ealing, Greenwich, Haringey, Lambeth, Newham and Southwark. 
585 Population data from 2020, available at Ethnic Groups by Borough - London Datastore Accessed 7th February 
2024. 
586 A total of 353 offences per 1,000 population were recorded in Westminster in 2023. Kensington & Chelsea 
recorded the next highest at 163. Richmond upon Thames and Sutton recorded the lowest at 69 and 74 per 1,000 
population respectively. Available at Stats and data | Metropolitan Police Accessed 27th April 2024. 
587 Census 2021 geographies - Office for National Statistics (ons.gov.uk) Accessed 15th March 2024. 
588 See A2 Stop and search hotspot areas, Police powers and procedures: Stop and search and arrests, England & 
Wales, year ending 31 March 2023 (second edition) - GOV.UK (www.gov.uk) (2024).  
589 MPS Stop and Search Monthly Report | Tableau Public 

   
 
215 
 
various levels, we were advised it was not possible to determine the number of 
drug-related S&S conducted during 2023 (in total or within each borough) that 
were initiated specifically on suspicion of cannabis (as opposed to other drugs).  
 
10.49 That said, bespoke analysis by the CoLP590 showed over half (54%, n=1,253) of 
all S&S conducted by the force within the Square Mile in the year to June 2023 
(n=2,326) were drugs-related, of which two-thirds (65%, n=809) involved 
cannabis.  
 
10.50 It is not possible to extrapolate from these figures to London more widely. The 
make-up of the population in the Square Mile compared to the capital as a whole 
is very different, comprising as it does vastly fewer residents compared to the 
numbers who travel into and out of the area each day for work or leisure 
purposes. However, they demonstrate the dominance of cannabis in drug-related 
S&S for the CoLP.  
 
10.51 Together with the dominance of drug-related stops in S&S, and of cannabis 
possession offences in recorded drug crime, we therefore consider it reasonable 
to assume cannabis dominates drug-related S&S conducted by the MPS. But 
without more precise data, a fuller understanding of the impact particularly on 
police resources of cannabis remaining illegal remains out of reach.  
 
10.52 This data gap also has implications for a fuller understanding of racial disparities 
in S&S (and the CJS).591 Across England & Wales, during the year to March 2023 
black people were 5.1 times more likely to be subject to S&S on suspicion of a 
drugs-related offence than white people. Those from an Asian background were 
1.9 times more likely to be stopped and searched for drugs than white people, 
and those from a mixed or other background were 1.6 times more likely.592  
 
10.53 Racial disparity in terms of the use of S&S is also evident in London, although we 
welcome recent figures which suggest it is lower in the capital than across 
England and Wales (see paras. 10.83-84). We also note, however, the finding 
reported by HMICFRS in their recent inspection of the force that officers do not 
always record the ethnicity of people subjected to S&S. This affected inspectors’ 
confidence in the disproportionality data and was deemed an area for 
improvement.593 
 
10.54 In our view, the inability to further unpick drug-related S&S statistics makes fully 
understanding the nature of disproportionality in this area of policing, and 
identifying potential solutions to what is clearly an endemic problem in London 
and elsewhere, more challenging. It also limits the ability to better understand the 
 
590 Undertaken for the London Drugs Commission, 2023. 
591 Ministry of Justice (2024). Statistics on Ethnicity and the Criminal Justice System 2022. A Ministry of Justice 
publication under Section 95 of the Criminal Justice Act 1991. Ministry of Justice: Crown Copyright. 
592 See Table 2.7, Police powers and procedures: Stop and search and arrests, England & Wales, year ending 31 
March 2023 - GOV.UK (www.gov.uk) Home Office. Accessed 2nd September 2024.  
593 His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (2024). PEEL 2023–25: Police 
effectiveness, efficiency and legitimacy – An inspection of the Metropolitan Police Service p.9. Accessed 27th August 
2024. 

   
 
216 
 
extent and nature of any links specifically between cannabis-related offending 
and other types of criminality, as well as serious and organised crime.  
 
10.55 We consider the lack of data clarifying the type of substance(s) a person is 
suspected of carrying when subject to a drugs-related S&S to be frustrating. In 
some cases, it will be obvious what an officer expects to find – where they have 
seen the drug or, in the case of cannabis, have smelled it. We recognise, 
however, this will not always be the case prior to conducting an S&S.  
 
10.56 As such, we acknowledge the operational challenges in recording the type(s) of 
drug on which an S&S is based. We do, however, consider it equally important 
that, where a drug is found, an officer should record what they suspect it to be 
(e.g. cannabis, cocaine, heroin). We accept that in some cases testing will be 
required to permit conclusive record. As such the Home Office, in partnership 
with the College of Policing and National Police Chiefs Council, should seek to 
update data recording systems nationwide to allow officers to routinely record 
(R17): 
• The suspected nature of drugs seized via S&S. 
• The ethnicity of persons found in possession of broad drug types (heroin, 
cocaine, cannabis etc). 
• The outcome of an S&S (arrest, Out of Court Disposal, diversion etc; see 
subsequent section) when it results in finds of i) illegal drugs excluding cannabis, 
ii) those including cannabis and iii) illegal items excluding drugs. This must be 
linked to the ethnicity record.    
 
10.57 Such a move will also support forces in responding to concerns that continue to 
be raised by watchdogs and others that they are not doing enough to analyse the 
use of their search powers.594  
 
Stop & Search: the outcomes  
 
10.58 The MPS told us that around one-third of S&S end in further action, or what is 
known as a ‘positive outcome’ (such as arrest). This means around two-thirds 
end in NFA – in other words, most people subject to S&S are not found in 
possession of any illegal or stolen item, or to be perpetrating offending behaviour, 
at the time of the stop. This is in line with NFA rates reported by forces across 
England & Wales (the average in 2022/23 was 71%).595  
  
10.59 The position is no different when it comes to drug-related S&S. Almost two-thirds 
of the 86,062 stops carried out by the MPS in 2023 (at time of data extraction) 
ended in NFA, with around one-third (31%, n=26,721)596 resulting in a positive 
outcome. Almost four in five of those outcomes (78%, n=20,716) related to 
 
594 See Nickolls, L. & Allen, G. (2022). Police powers: stop and search. House of Commons Library Research 
Briefing, No. SN03878. Available at SN03878.pdf (parliament.uk) 
595 See Table SS_010. Stop and search outcomes summary data tables: police powers and procedures, year ending 
31 March 2023 Home Office. Accessed 24th January 2024. 
596 MPS Stop and Search Dashboard Data - London Datastore 

   
 
217 
 
drugs, meaning just over one-fifth were unrelated to the original purpose of the 
search (22%, n=6,005), as shown in Figure 6: 
 
 
 
Figure 6: Outcomes from MPS-led drug-related stop and searches in 2023 
 
 
Source: MPS Stop and Search Dashboard Data - London Datastore 
 
10.60 Over half of drug-related outcomes took the form of a Community Resolution 
(52%, n=10,707). Currently, these can be used where an offender accepts 
responsibility for a lower-level crime (we describe forthcoming changes with 
respect to such disposals later in this chapter, and in chapter 3).  
 
10.61 A further 27% (n=5,666) ended in arrest, following which a person can be 
released, charged, or given a Community Resolution, fine, caution or summons. 
The remainder of the drug-related outcomes comprised cautions (n=121), 
penalty notices (fines, n=2,853) and summonses to the magistrates’ court 
(1,369). 
 
10.62 The remaining 22% of positive outcomes (n=6,005) followed identification of a 
non-drugs offence (such as carrying a weapon), or perpetration of an offence 
following the stop. It was put to us that the latter can and does result where a 
person challenges the grounds for a stop and can lead, for example, to arrest for 
public order or obstruction.  
 
10.63 The vast majority (80%, n=4,800) of the 6,005 non-drug related outcomes ended 
in arrest. This means that, of the 86,062 drug-related S&S carried out by the 
MPS in 2023, almost one-quarter (24%, n=20,716) ended in a criminal justice 
86,062 drug-
related S&S
69% NFA 
(59,341)
31% positive 
outcome (26,721
78% drug-related 
outcome (20,716)
27% arrest 
(5,666)
52% community 
resolution 
(10,707)
21% fine / caution 
/ magistrate 
summons (4,343)
22% non-drug-
related outcome 
(6,005)
80% arrest 
(4,800)
4% community 
resolution (223)
16% fine / caution 
/ magistrate 
summons (982)

   
 
218 
 
response for a drugs offence and a further 7% (n=6,005) in a response for a non-
drugs offence.  
 
10.64 One in eight drug-related S&S in 2023 (12%, n=10,466) therefore resulted in 
arrest. Drugs offences accounted for over half of these (n=5,666, 7% of all drug-
related S&S), and non-drugs offences comprised the remainder (n=4,800, 6% of 
all drug-related S&S). We consider arrests, prosecutions and convictions later in 
this chapter. 
 
10.65 As we describe earlier, police recording systems do not routinely enable the 
number of cannabis-related S&S to be split from the total number of drug-related 
S&S. Bespoke analysis by the CoLP, however, revealed that, during the year 
ending June 2023, 65% (n=809) of all their drug-related S&S pertained to 
cannabis. At 49% (n=400), the positive outcome rate for those stops was 
substantially higher than the England & Wales average (the rate for all S&S made 
by the CoLP was also higher than average, at 40%).  
 
10.66 Of those 400 cannabis-related S&S that ended in a positive outcome, almost half 
(49%, n=195) resulted in arrest. A further 28% (n=112) ended in a warning, and 
the remainder (23%, n=93) in some other type of disposal.  
 
10.67 Even allowing for the higher positive outcome rate recorded by the CoLP, the 
large majority of S&S conducted on suspicion of a drugs-related offence across 
London identify no criminality – drug-related or otherwise. This means tens of 
thousands of people are subjected to an intrusive police process when they have, 
on the occasion of the stop, committed no criminal offence. While we appreciate 
the power allows police to investigate suspicions without the need for arrest, it 
comes at some cost to individuals, particularly those who are law-abiding. And 
indeed, the process is likely to have been a negative experience for a substantial 
minority (see para.10.19).597 
 
10.68 As above, in some cases an arrest is made despite no illegal or stolen item being 
found. This can be because the person is wanted for another offence, or because 
they become aggrieved at the S&S and end up arrested for a public order or 
assault offence. We agree with HMICFRS, who concluded that such outcomes 
have potential to cause or reinforce negative attitudes toward the police and 
erode trust.  
 
10.69 Indeed, it was put to us by the oversight body that counting such outcomes as 
‘positive’ is somewhat disingenuous because they would probably not have 
happened had the S&S not taken place, meaning an individual would not have 
risked criminalisation at all. 
 
10.70 The MPS and CoLP told us S&S is a crucial aspect of proactive crime prevention 
and deterrence activity. We do not disagree (although we are not convinced 
there is strong evidence of either, at least with respect to cannabis offending, see 
 
597 See footnote #565. Slide 3. 

   
 
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para.10.100), and recognise the hugely complex nature of the policing landscape 
within which the tactic is deployed, particularly in London. As was also put to us 
by HMICFRS, S&S has potential to be a useful, positive element of the policing 
toolkit – when used well and appropriately, with officers setting out grounds in a 
non-threatening, polite and courteous fashion.  
 
10.71 We recognise, too, that S&S can be a tool in the fight against violent crime, 
allowing police a route to finding and removing weapons from London’s streets. 
That said, we think there is too much scope for the power to be misused in this 
respect, with suspicion of cannabis possession too often forming the primary 
mechanism.  
 
10.72 We heard that stops might sometimes happen when an officer suspects a 
weapon is being carried but with no hard evidence or factual basis for the 
suspicion. Unable to justify on weapons grounds, the smell of cannabis may in 
some circumstances instead be adopted as the sole or main reason for the stop. 
This speaks to what has been described elsewhere as ‘an often-held perception 
that the smell of cannabis is being used as an excuse to conduct a stop and 
search’.598  
 
10.73 As far as we can tell, this practice likely remains current. Indeed, our 
understanding of the view expressed by a very senior MPS officer was that, on 
occasion, S&S on the premise of suspicion of possession of cannabis may be 
used by the force as part of a wider strategy to identify weapons as part of 
tackling violence and knife crime. (A similar view was not expressed by the 
CoLP). 
 
10.74 We recognise the huge challenge faced particularly by the MPS in finding and 
removing weapons from the streets of London, and accept the reality that, in 
some cases, a person suspected of carrying cannabis who might otherwise not 
be subject to S&S ends up being so because they are also suspected of carrying 
a weapon.  
 
10.75 Undoubtably, drug-related S&S can result in finds of illegal items other than 
drugs. But statistics suggest these are relatively few and, ultimately, using S&S 
on drug-related grounds as a tactic to find and remove weapons feels to us to be 
against the spirit of PACE Code A and associated guidance, and an irresponsible 
use of an intrusive power. Research planned by MOPAC (see para.10.86-87) 
should shed further light on the practice, through matching the stated grounds 
for a stop (e.g.: drugs) to the outcome (e.g.: finding of a weapon). 
 
10.76 We heard from the MPS about their ‘Precision Stop & Search’ pilot in Lambeth 
and Barking & Dagenham. This seeks to increase the number of weapons 
 
598 Pearson, G. & Rowe, M. (2020). Police Street Powers and Criminal Justice: regulation and discretion in a time of 
change. Oxford: Hart Publishing. Cited in Independent Office for Police Conduct (2022). National stop and search 
learning report. IOPC, p.14. National stop and search learning report | Independent Office for Police Conduct (IOPC) 
Accessed 23rd January 2024. 

   
 
220 
 
removed from the streets via a targeted, data-driven approach that focuses 
policing efforts on where, according to data, they can have maximum impact.  
 
10.77 Principally designed to reduce the number of knife offences and improve public 
safety, it also seeks to improve the quality of S&S encounters. Focused training 
aims to, we were told, enhance officers’ understanding of the impact of S&S and 
raise awareness of potential for the encounter to create lasting trauma. 
 
10.78 We welcome the pilot but note its early stages. We consider, too, that officers 
dispatched to target areas may inadvertently be ‘primed to see’ crime, given the 
high-risk label attached to those areas. We think there is, therefore, some 
potential for this to result in less rather than more accurate S&S. 
 
10.79 The MPS, in partnership with the Mayor’s Office for Policing & Crime (MOPAC), 
should ensure evaluation of the Precision S&S pilot includes recording (R18): 
• When an officer is directed to undertake S&S using the Precision approach.  
• Reason for S&S and, where drug-related, the type of drug suspected (if 
known).  
• The type of drug found. 
• Number of drug-related S&S that end in NFA as well as positive outcomes.  
• Driver for each stop (self-generated, third-party information or intelligence). 
• Views of those subject to S&S by officers receiving enhanced training, 
alongside views of the wider community.   
 
10.80 The CoLP have introduced an enhanced supervision monitoring process to bring 
greater consistency to policing, alongside an Inclusivity Programme. Among 
other things, this provides officers from the force opportunity for insight into the 
experiences of young black Londoners when interacting with police, particularly 
with respect to S&S. Where not already taking place, we encourage the CoLP to 
share learning from these endeavours with the MPS, to support further 
development of their Precision pilot.       
  
10.81 An important outcome of visible policing like S&S can be community 
reassurance, particularly where obvious drug-related activity causes public 
concern. As we discuss elsewhere, we heard from officials and elected 
representatives across several London boroughs that such anxiety can be 
substantial. We have not, however, been presented with evidence that S&S 
reduces this to any meaningful extent and in some cases, among black 
communities in particular, it risks the opposite.   
 
Disproportionality in Stop and Search 
 
The numbers 
 
10.82 Several of those we heard from talked powerfully about the hugely detrimental 
effects of being stopped and searched. While true irrespective of ethnicity, racial 

   
 
221 
 
disparities in the likelihood of being subject to S&S means the extent of those 
detrimental effects is much greater among some communities.  
 
10.83 The racial disproportionality seen in S&S nationally (see para.10.52) is similarly 
evident in London. At time of writing, statistics showed that disparity rates were 
lower than the national average, which is to be very much welcomed and we 
commend the MPS and the CoLP forces for the steps they have taken to achieve 
this. That said, black Londoners were still 3.3 times more likely to be S&S by the 
MPS for any reason, and 3.1 times more likely to be subject to a drug-related 
S&S, than white Londoners (other ethnic minorities were 1.2 times more likely to 
be stopped for drugs).599  
 
10.84 In the City of London, black people were 2.2 times more likely to be S&S than 
white people (based on London’s population as a whole) although the CoLP told 
us the disproportionality rate was slightly lower for cannabis specific stops, at 1.8. 
The extent to which these figures tell us very much is, however, debatable given 
the unique demographics of the Square Mile and the fact that the resident 
population is fewer than 9,000 people.600  
 
10.85 For most other boroughs across the capital, the disparity for black Londoners is 
stark,601 as shown in Table 5: 
 
Table 5: Ethnic disproportionality in drug-related stop & searches, by London borough*, 
2023 
 
 Population by ethnicity  
(%) 
Drug-related S&S by ethnicity 
(%)** 
 White Black Asian Other White Black Asian Other 
Barking & Dagenham 45 23 25 7 51 26 21 1 
Barnet 64 7 20 9 42 38 11 9 
Bexley 74 11 8 7 68 23 7 1 
Brent 35 12 42 11 26 46 16 11 
Bromley 78 7 7 7 67 27 5 1 
Camden 59 11 13 17 49 37 8 4 
Croydon 57 16 20 8 35 40 10 13 
Ealing 47 8 26 18 27 30 35 6 
Enfield 64 17 13 7 56 31 7 4 
Greenwich 54 19 21 7 50 38 9 2 
Hackney 58 17 7 18 35 45 16 4 
Hammersmith & 
Fulham 68 8 8 16 36 44 7 12 
Haringey 74 13 5 8 46 41 7 5 
Harrow 41 3 42 14 37 29 24 8 
 
599 MOPAC Action Plan Data Dashboard | London City Hall Results from Q3 2023/24. Accessed 14th August 2024. 
600 City of London Resident Estimates and Projections Accessed 17th May 2024. 
601 Based on 2020 population data, available at Ethnic Groups by Borough - London Datastore and 2023 stop and 
search data, available at MPS Stop and Search Dashboard Data - London Datastore Both accessed 23rd January 
2024. 

   
 
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Havering 74 11 11 4 65 22 12 1 
Hillingdon 49 12 31 8 34 29 32 4 
Hounslow 45 13 37 4 42 25 25 5 
Islington 73 7 6 14 45 38 11 6 
Kensington and 
Chelsea 71 9 10 10 35 36 9 18 
Kingston upon Thames 75 4 14 8 58 20 16 5 
Lambeth 65 17 7 12 25 66 4 3 
Lewisham 62 20 8 11 38 52 6 3 
Merton 67 10 16 7 41 30 23 4 
Newham 46 16 33 6 37 32 29 2 
Redbridge 42 8 44 5 27 24 45 2 
Richmond upon 
Thames 82 2*** 7 9 56 22 12 6 
Southwark 57 25 8 10 36 52 8 3 
Sutton 66 8 16 10 62 23 12 2 
Tower Hamlets 49 5 38 8 33 19 45 2 
Waltham Forest 67 12 11 10 39 34 23 3 
Wandsworth 77 8 8 8 42 40 13 5 
Westminster 66 8 8 18 36 34 13 15 
* Population figures from 2020, S&S figures from 2023. For counts of populations and S&S, see sources: Ethnic 
Groups by Borough - London Datastore and MPS Stop and Search Dashboard Data - London Datastore  
** Percentages may not add up to 100% because table excludes S&S where ethnicity was not recorded.602 
*** Suppressed in published data due to small sample sizes but calculated for purposes of this table based on total 
population of borough and cited figures for white, Asian and other populations.   
 
10.86 A better understanding of what lies beneath these figures is important. We were 
therefore pleased to learn about a suite of MOPAC-led projects which seek to 
address key gaps in evidence related to S&S practice. Expected to deliver in mid-
2025, these will examine what drives disproportionality and, perhaps more 
importantly, what levels of disproportionality should be expected (if any) given 
London’s demographics alongside the distribution of deprivation and crime.  
 
10.87 The work will also explore officer decision-making when identifying grounds to 
warrant a S&S, and how those vary (if at all) by the ethnicity of those stopped. 
Additionally, it will consider how cited grounds for a stop compare to outcomes 
for that stop. We think these projects will add considerably to understanding of 
S&S practice in London and look forward to seeing their findings. 
 
10.88 There is also evidence of disparity across England & Wales in the proportion of 
S&S for any reason that are officer self-generated. Reportedly less likely to be 
effective or considered justifiable to the person searched or the wider public (see 
para.10.28), HMICFRS found 63% of all searches of those from a white ethnic 
group to be self-generated, compared with 67% of searches of black people and 
77% of those from an Asian background.  
 
 
602 See also footnote #593, p.9.  

   
 
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10.89 For drug searches overall, a higher proportion of weak recorded grounds was 
found where individuals were from a black ethnic group (29%) than white (24%), 
with a similar pattern in possession-only searches (29% compared with 23%).603 
 
10.90 While these data were not split by force, given ethnic disparities in the rate of 
drug-related S&S in London it is reasonable to assume a similar disparity with 
respect to the grounds of searches of people from different ethnic backgrounds 
in the capital.  
 
10.91 The broader context of drug-related S&S is important. Between July and 
September 2023, black Londoners were 6.2 times more likely than those from a 
white background to be searched for weapons, points or blades604. It is worth 
bearing this in mind when considering the experiences of drug-related S&S 
among black Londoners, and wider implications.  
 
10.92 That black Londoners are disproportionately more likely to be both victims and 
perpetrators of violent crime605 was, the MPS suggested to us, at least partly 
responsible for the disparity rate in those S&S’s led by the force. Certainly, and 
as Baroness Casey noted,606 between 2020 and 2023 black people in London 
were 70% more likely than white people to be a recorded victim of violence 
against the person (including knife crime), and nearly six times more likely to be 
murdered. However, the majority of S&S’s are drugs-related. In our view, the fact 
that both suspects and victims of knife, robbery and firearms offences are more 
likely to be black is therefore not an adequate explanation for racial 
disproportionality in drug-related S&S. 
 
10.93 We recognise the very significant challenges facing the police in tackling knife 
crime and other weapons-related offending, and the urgent need to remove 
weapons from the streets. In our view, however, S&S on suspicion of drugs – 
principally cannabis – is not the right tactic for the MPS (or any force for that 
matter) to use as part of endeavours to tackle weapons-related violence.  
 
10.94 Not only dubious in terms of legitimate use of the power, it results in what we 
consider to be a poor rate of return for drugs and an even lower return for 
weapons. Neither are the public wholly supportive of use of the power more 
broadly with respect to tackling knife crime – with differences by ethnic group 
once again apparent. White Britons are significantly more likely to consider S&S 
an effective measure against knife crime than those from ethnic minority 
backgrounds (62% against 48%).607 
 
 
603 See footnote #569, pp.35–6. 
604 MOPAC Action Plan Data Dashboard | London City Hall Results from Q3 2023/24. Accessed 14th August 2024. 
605 Calls for a commission on knife crime in the black community | London City Hall 
606 Baroness Casey of Blackstock, DBE CB (2023). Final Report An independent review into the standards of 
behaviour and internal culture of the Metropolitan Police Service. BARONESS CASEY REVIEW Final Report 
(met.police.uk), p.312. 
607 See How do white and ethnic minority views and experiences of knife crime differ? | YouGov Accessed 23rd August 
2024. 

   
 
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10.95 Moreover, there is some evidence that the rate of finding drugs following S&S of 
black people may be lower than it is for white people. In London, 11% of black 
adults surveyed who had been S&S reported a positive outcome, compared with 
16% of white respondents608. For adults outside London, figures were 12% and 
19% respectively.  
 
10.96 Coupled with somewhat mixed evidence regarding whether black people are 
more likely to use cannabis than white people, and to what extent (see chapter 4 
– some data suggests past-year use is higher among black people but lifetime 
prevalence is higher among white ethnic groups), it is not difficult to see how, as 
observed by Baroness Casey, the view that London’s communities of colour are 
both over-policed and under-protected might come about.609  
 
10.97 As above, we recognise S&S is an important element of proactive policing, 
although as far as we understand it the power is intended to be investigatory, to 
confirm whether a specific crime has taken place or not. While it may result in 
evidence of serious criminal behaviour or intent, thus prevention of crime 
(particularly where weapons are found) is a potential outcome, this should be a 
by-product of proper use of the power. 
 
10.98 The MPS told us that, in their view, S&S confers several benefits. They cited 
deterrence (see para.10.70), suggesting that individuals may be less likely to 
carry drugs and other illegal items if they know they may be subject to a search. 
Where drugs are found on an individual, confiscation prevents distribution and 
consumption, causing some disruption to the end of the supply chain.  
 
10.99 The MPS also suggested that S&S supports the gathering of intelligence with 
respect to drug-related activities, including identification of dealers and wider 
networks. They consider it contributes to keeping the public safe through 
reducing drug-related crime, and that it enables the targeting of individuals 
known or suspected of being involved in drug-related activities. 
 
10.100 In our view, however, evidence which clearly demonstrates these benefits is 
lacking. We acknowledge that some (albeit limited) findings suggest S&S may 
deter offending to a small extent,610 including that related to drugs.611 However, 
we also note the unclear nature of this effect. Rather than people who use drugs 
and dealers genuinely desisting due to heightened perceptions of the risk of 
being caught, they might simply change their behaviour to make it harder for 
police to uncover evidence through S&S.612  
 
 
608 Evans, E., Olajide, P. & Clements, J. (2022). Crime, policing and stop and search: Black perspectives in context. 
Crest Advisory. Crest Advisory Stop and search report 1 (usrfiles.com) p.78. 
609 See footnote #606, p.312. 
610 See footnote #567. 
611 Tiratello, M., Quinton, P. & Bradford, B. (2018). Does Stop and Search Deter Crime? Evidence From Ten Years of 
London-wide Data. The British Journal of Criminology, 58(5), pp.1212–31. doi.org/10.1093/bjc/azx085 
612 Ibid. 

   
 
225 
 
10.101 As we have discussed, most drug-related S&S are undertaken on suspicion of 
possession and not intent to supply,613 and the majority end in NFA. As a result, 
we consider any impact on wider drug supply chains is likely to be at best fairly 
minimal.   
 
10.102 Moreover, the changing nature of the drugs trade may mean S&S is now less 
likely to uncover drugs, at least in quantities that suggest dealing or supply. As 
we explore in chapter 5, drugs are increasingly purchased online or via dedicated 
phone lines, often with doorstep delivery (by post or dealers in person). This 
suggests the power is at risk of becoming outdated, a mechanism of addressing 
a problem that manifests in a very different way in 2024 than it did even five years 
ago. 
 
10.103 Overall, whether the benefits of S&S outweigh the costs is not clear to us. We 
consider monetised costs to police later in this chapter, but must not lose sight of 
non-monetised costs, most notably the risks of harm to individuals and to wider 
police–community relations. These are particularly pertinent to consideration of 
cannabis, given the majority of drug-related S&S are likely based on suspicion of 
related offences. 
 
10.104 While we acknowledge the role of S&S in legitimate maintenance of law and 
order, it must be a constrained power. To be justifiable, use must be transparent 
and verifiable – which to our mind demonstrates the challenge inherent in relying 
on the smell of cannabis as reason for a stop. 
 
The experience of S&S and implications 
 
10.105 While we acknowledge the role of S&S in appropriate circumstances, we must 
also acknowledge that experience of the process can, as was put to us and is 
well documented elsewhere, be shocking, distressing, humiliating and, in some 
cases, very traumatic. While this is true for people of all ethnicities, it is perhaps 
particularly so for those from black and mixed ethnicity backgrounds.614 Indeed, 
black Londoners who have been subject to S&S are less likely than those from a 
white background to agree police were polite, treated them with respect, and 
explained why they had been stopped.615  
 
10.106 Where an individual perceives a search as unjustified (perhaps because it follows 
one or more previous searches in which nothing was found), or feels officers 
were disrespectful during the process or otherwise behaved unprofessionally, 
negative effects are likely to be heightened. Indeed, such experiences can lead to 
 
613 See footnote #569, p.6. 
614 See footnote #608, pp. 65 & 79. 
615 See footnote #565, Slide 4. 

   
 
226 
 
measurable detrimental health consequences616ʹ617 particularly among young 
people, with future attitudes towards the police also negatively affected.  
 
10.107 Moreover, evidence suggests the experience of S&S in adolescence and young 
adulthood can in fact increase the likelihood of future cannabis use (as well as 
use of other illicit drugs, alcohol and tobacco).618 For young black men in 
particular, both direct and indirect exposure to perceived racially discriminatory 
police interactions have been shown to increase the chance of cannabis 
consumption.619  
 
10.108 The possibility for S&S to be counter-productive in tackling crime was raised with 
us several times. Use of the power – at least in London – was seen by some as 
serving principally to damage relationships between police and communities, 
leaving those with poor experiences less likely to engage with future intelligence 
gathering and crime investigation.620 This is likely to be magnified where a person 
has been subjected to S&S multiple times, which as we heard is common 
particularly among young black men. Certainly, trust in the police and faith in 
receiving fair treatment is consistently lower among black Londoners than those 
from white and other ethnic minority backgrounds.621 Poor experiences also raise 
the risk of wider detrimental personal consequences.   
 
10.109 The importance of quality interactions between police and communities cannot 
be overstated when it comes to public trust, confidence and willingness to 
engage with crime investigation and public safety endeavours. One recent HO 
review demonstrated the crucial role this plays in public opinions of, and 
cooperation with, police, noting that, if they are seen to lack legitimacy or work in 
ways perceived as procedurally unjust, then trust and confidence falls.622ʹ623  
 
10.110 That said, even when conducted with politeness and respect the experience of 
an S&S remains likely to be discomforting. After being subjected multiple times to 
the practice, it is not hard to imagine that discomfort becoming increasingly 
distressing, irrespective of how politely an officer conducts the search. 
 
10.111 With specific reference to S&S, the same HO review highlighted that negative 
experiences may reach beyond the individual, transmitting detrimental effects 
 
616 See footnote #567. 
617 McLeod, M.N., Heller, D., Manze, M.G., & Echeverria, S.E. (2020). Police Interactions and the Mental Health of 
Black Americans: A Systematic Review. Journal of Racial and Ethnic Health Disparities, 7(1), pp.10–27. 
doi.org/10.1007/s40615-019-00629-1 
618 Jackson, D.B., Testa, A. & Boccio, C.M. (2022). Police Stops and Adolescent Substance Use: Findings From the 
United Kingdom Millennium Cohort Study. Journal of Adolescent Health, 70(2), pp.305–12. 
doi.org/10.1016/j.jadohealth.2021.08.024 
619 Motley, R.O., Byansi, W., Siddiqi, R., Bills, K.L., & Salas-Wright, C.P. (2022). Perceived Racism-based police use 
of force and cannabis use among Black emerging adults. Addictive Behaviors Reports, 15, 100430. 
doi.org/10.1016/j.abrep.2022.100430 
620 See also Independent Office for Police Conduct (2023). National stop and search survey report. October 2023. 
IOPC. national-stop-and-search-survey-report-oct-2023.pdf (policeconduct.gov.uk) 
621 See footnote #565, Slide 2.  
622 Hanway, P. & Hambly, O. (2023). Public perceptions of policing: A review of research and literature. Home Office. 
Public perceptions of policing: A review of research and literature - GOV.UK (www.gov.uk)  
623 See footnote #565. 

   
 
227 
 
through social connections to a much broader network. It also found evidence 
that socio-demographic variables, including age and ethnicity, impacted 
perceptions of policing. Research elsewhere supports this: both first- and 
second-hand negative interactions with police reportedly detrimentally affect 
views among black people.624 
 
10.112 This has particular resonance in the capital, given that proportionally more 
Londoners come from a black background than elsewhere in the country (13.5%, 
with the West Midlands next highest at 4.5%).625 This means greater numbers of 
black people in London are likely to face S&S than elsewhere, particularly 
because, as was suggested to us, a range of cultural as well as economic factors 
(including unemployment and overcrowded housing) can mean they and those 
from other ethnic minority communities spend more of their lives in outside 
spaces. Which means, of course, they are more ‘available’ to police officers 
patrolling public spaces, and so arguably represent an easier target for proactive 
policing tactics. 
 
10.113 Overall, the MPS told us that almost nine in ten Londoners support the police 
having the power to S&S.626 This is substantially higher than levels of support 
cited by independent surveys, although those too report that a majority of 
Londoners627 and the public nationally are supportive – crucially, however, as 
long as there are reasonable grounds for suspicion and police are clear as to the 
reason for the stop.628  
 
10.114 Given that most S&S end in NFA, the extent to which the measure is effective is 
at best debatable. Certainly, the large majority of respondents to our online 
survey629 thought it was likely to be ineffective in helping manage or reduce any 
harmful effects associated specifically with the use of cannabis (see Appendix C).   
 
10.115 Moreover, several surveys show support for S&S is notably lower among black 
communities. Just over half (51%) of black Londoners polled in the latest (at time 
of writing) MOPAC survey supported use of the power, compared with over two-
thirds (71%) of both white Londoners and those from other ethnic minority 
groups.630ʼ 631 This is replicated at national level, with white Britons much more 
likely to support the power of the police to S&S than those from ethnic minority 
 
624 See research cited in Akintoye, B., Ali, A. & Stevens, A. (2022). The Ongoing Impact on the Racialised Policing of 
Black Communities. In I. Crome, D. Nutt & A. Stevens (Eds.), Drug Science and British Drug Policy (pp.198–203). 
Waterside Press. 
625 Regional ethnic diversity - GOV.UK Ethnicity facts and figures (ethnicity-facts-figures.service.gov.uk) Accessed 
19th January 2024. 
626 MPS. Unpublished written submission to the London Drugs Commission, MPS-sponsored survey of Londoners, 
n=7,592. Sampling criteria and sample demographics not cited meaning representativeness is unclear. 
627 MOPAC Action Plan Data Dashboard | London City Hall Results from Q3 2023/24. Accessed 14th August 2024. 
628 See for example Centre for Social Justice (2024). Serious Violence in London. Perceptions, Costs, and 
Recommendations. Centre for Social Justice. Serious Violence in London (centreforsocialjustice.org.uk). 63% of 
Londoners supported the power of the police to stop and search. Accessed 23rd August 2024. 
629 Results are not representative of Londoners’ views more broadly due to the methodology employed and the small 
sample. Findings were not weighted.  
630 MOPAC Action Plan Data Dashboard | London City Hall Results from Q3 2023/24. Accessed 14th August 2024. 
631 See also footnote #628, Chart 3: 67% of white Londoners surveyed supported S&S compared with 57% of black 
Londoners. 

   
 
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backgrounds (73% compared to 53% respectively). Among black Britons, 
support is even lower (44%).632 
 
10.116 Consistent with these figures, just over one-third (37%) of Londoners from black 
backgrounds feel S&S is conducted fairly, compared with 59% of Londoners from 
white ethnic groups and 63% from other ethnic minority groups633 Figures such 
as these highlight the point that S&S is not a ‘blank cheque’: it depends on stops 
being fair, proportionate and intelligence-led.634 
 
10.117 We accept S&S might play a role in wider community reassurance. But evidence 
put to us supports the notion that it can have the reverse effect in black 
communities, serving instead to entrench mistrust of the police and heighten 
perceptions of unjust and disproportionate policing tactics.  
 
10.118 Indeed, the public consultation that informed the Mayor of London’s 2020 Action 
Plan635 reported S&S to be the most frequently raised example of 
disproportionate policing of black Londoners. Perceptions of unwarranted, 
unprofessional S&S were reportedly damaging relations between the MPS and 
black communities: the Action Plan set out to address these concerns and 
improve wider trust and confidence in the police.  
 
10.119 Our inquiries three years later suggest there remains some way to go – although 
the recent assessment by HMICFRS that the MPS consistently involves 
communities in scrutiny of its use of S&S is welcome. Community Monitoring 
Groups operate across London and help hold the MPS to account636 - but the 
extent to which the feedback they provide leads to associated change in practice 
is unclear. Certainly, groups have previously raised concerns related to the clarity 
of grounds provided when conducting S&S.637 Such concerns sit against a 
current backdrop of continuing low levels of public trust in the MPS, particularly 
among women and ethnic minorities.638  
 
10.120 The scrutiny body also drew attention to measures the force is taking to improve 
its use of S&S.639 Inspectors highlighted a charter being developed in 
consultation with communities, particularly young people and those from ethnic 
minority groups, which will set out how police officers should interact with the 
community while using S&S. We are pleased this is in train and hope that in time, 
it will improve trust and confidence and the experience of S&S for those 
subjected to use of the power.  
 
 
632 Stop and search: how do ethnic minority Britons feel about police powers? | YouGov Accessed 23rd August 2024. 
633 MOPAC Action Plan Data Dashboard | London City Hall Results from Q3 2023/24. Accessed 14th August 2024. 
634 See footnote #608. p.94. 
635 action_plan_-_transparency_accountability_and_trust_in_policing.pdf (london.gov.uk) 
636 See footnote #593, p.10. Accessed 27th August 2024. 
637 See Stop and search based on the smell of cannabis (3) | London City Hall Accessed 27th April 2024. 
638 Pickering, S. Dorussen, H., Hansen. M.E., Reiflerd, J., Scottoe, T., Sunahara Y. & Yen, D. (2024). London, you 
have a problem with women: trust towards the police in England. Policing and Society. 
doi.org/10.1080/10439463.2024.2334009 
639 See footnote #593, p.12. Accessed 27th August 2024. 

   
 
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10.121 The CoLP is equally subject to challenges posed by S&S practice and public 
perceptions with respect to community relations. Similar to the MPS, they too 
operate community-led scrutiny mechanisms, and are soon to launch similar 
within the business communities operating in the Square Mile.  
 
10.122 In a partnership with Amazon, the force also works with sixth-form students to 
improve officers’ understanding of how young people view the police. They use 
this information to develop ways to better involve young communities and 
increase confidence and trust, particularly, it was put to us, with respect to S&S, 
which has emerged as an area of concern.  
 
10.123 We did not consider the initiative in detail but note its identification by HMICFRS 
as an example of innovative practice.640 If not in train, MOPAC should ensure the 
MPS engage with the CoLP to explore the possibility of trialling a similar 
approach to involve and build trust among young communities (R19).   
 
10.124 To further explore S&S-related concerns, we asked the CoLP and the MPS about 
the number of complaints they received regarding use of the power, specifically 
when related to cannabis. While not a wholly reliable measure of the scale of 
public disquiet, relying as it does on a person both feeling comfortable to raise a 
complaint and knowing how to do so, we nonetheless consider such data an 
important element of understanding police–community relations.  
 
10.125 The CoLP told us they had received three such complaints over the past ten 
years. The MPS provided us with a detailed report of all complaints received over 
the two-year period to July 2024, and we were pleased to see a fall in the number 
which related to S&S.  
 
10.126 On average, for the MPS, just over 3% of all complaints made between August 
2023 and July 2024 (398 out of a total of 11,675) related to S&S. Because 
multiple allegations may arise out of a single incident, the number of allegations 
made about S&S was higher, at 649 (although they too have fallen considerably 
from the previous year).  
 
10.127  Unfortunately, however, the MPS do not record the purpose of a S&S about 
which a complaint has been made. As a result, we are not clear as to how many 
complaints/allegations have been made following a cannabis-related stop. Given 
drugs – particularly cannabis - are, by some margin, the most likely cause of an 
S&S, this feels to be a gap which limits development of a more detailed 
understanding of aforementioned police-community relations.  
 
10.128 Moreover, black complainants are over-represented in the MPS S&S complaint 
statistics. They comprised 29% of those making a complaint related to the power 
in the year to July 2023, and the same proportion the following year. 
 
640 His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (2021). PEEL 2021/22: Police 
effectiveness, efficiency and legitimacy – An inspection of the City of London Police, p.14. Accessed 19th March 
2024. 

   
 
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Complainants from a white background made up 20% and 23% respectively. By 
comparison, black complainants made up 13% of those making a complaint 
about any matter in the last year (white complainants comprised 37%).  
 
10.129 We consider it important that the MPS better understands the extent not only to 
which cannabis-related S&S features among all S&S complaints, but also the 
characteristics of individuals making those specific complaints. As a result, we 
recommend MOPAC should explore how the MPS can record the specific type of 
S&S about which a complaint is made, and link the ethnicity of the complainant to 
that record (R20). In time, this data should inform the work of external scrutiny 
panels (see para.10.119). 
 
10.130 Moreover, it was also unclear to us how well the MPS understood the demand 
that (non-medical) cannabis-related activity places on policing in the capital. They 
were unable to provide sufficient insight in a number of areas, including 
intelligence, investigation and enforcement action. This made it difficult for us to 
properly understand the nature and scale of consequences associated with that 
demand.  
 
10.131 The force must better understand cannabis-related demand and its associated 
policing response. We recommend the MPS work with the HO and MOPAC to 
make better use of data concerning cannabis-related demand where these exist, 
and to start collating such where they currently do not. In all cases, the ethnicity 
of the persons reporting or being subject to police action should be recorded, 
and areas of demand include: 
• Intelligence submissions linked to both public reporting and officer generation. 
• Number of calls for service from the public linked to cannabis, as well as 
complaints related to local cannabis activity.  
• Enforcement action following execution of warrants, including the number of 
closure orders issued.  
• Drug driving. 
• Volume of police seizures of cannabis.  
(R21.) 
 
The CoLP, in partnership with the City Corporation (responsible for providing 
policing governance for the force) may also wish to consider whether such reporting 
is appropriate, although we appreciate the volume of drug-related offending dealt 
with by the force and the size of the resident population mean there may be less 
call. 
 
The impact of being stopped and searched multiple times 
 
10.132 It follows that, as black people are more likely to be subject to S&S, they are 
more likely to be S&S more than once. Over one-third (37%) of black participants 
in one survey reported having been S&S more than three times during their 

   
 
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lifetime, as had 39% of those with mixed ethnicity – compared with 24% of white 
participants.641   
 
10.133 The experience of multiple S&S deepens what can be enduring and harmful 
effects, which travel down the generations. Research among black Londoners 
found many had been subject to numerous stops, particularly as teenagers and 
young adults, and primarily on the basis of nothing more than the smell of 
cannabis.642 Those encounters routinely drove ‘the Talk’, whereby, as and when 
they become parents, black people who had experienced S&S or otherwise 
heard about the experiences of others discussed with their own children how 
best to approach interactions with the police.  
 
10.134 The MPS’ own review into its handling of the S&S of athletes Bianca Williams and 
Ricardo dos Santos, which included consultations with young black men, found 
searches of the same individual that consistently end in NFA to be ‘extremely 
corrosive to the person’s and wider communities’ trust and confidence in 
policing.’643 It was put to us that for some Londoners the police are seen as 
protagonists rather than protectors. 
 
10.135 Indeed, we heard from black Londoners who had experienced S&S many times, 
and from others who worked with or on behalf of black communities. We found a 
pervasive sense of persecution, particularly with respect to being young, black 
and from deprived communities, and perceptions of a distinction between the 
way in which Class A drug use among (predominantly white) middle-class 
Londoners is treated and experiences of cannabis policing: ‘…the police aren’t 
stopping people in Canary Wharf, are they?’.  
 
10.136 Similar views regarding differential treatment by the police with respect to 
ethnicity are reported elsewhere.644 And, as we previously describe, it is clear 
that, despite guidance regarding use S&S on the basis of smell of cannabis 
alone, the experiences of very many young black people in London suggest the 
extent of police adherence to this is questionable. 
 
10.137 We heard S&S was such a frequent part of daily life in one predominantly black 
community that ‘…we know every police officer by name… and not for any good 
reasons. We know each other too intimately and that’s problematic.’ The power 
was described as often being used en masse involving up to ten or more people, 
typically black, with the basis perceived as nothing more than an officer alleging 
they could smell cannabis.  
 
10.138 The practice, certainly for many black Londoners, was described to us as one 
which makes them feel unsafe, in which they have no choice, and which leaves 
 
641 See footnote #608, p.68. 
642 See research cited in Akintoye, B., Ali, A. & Stevens, A. (2022). The Ongoing Impact on the Racialised Policing of 
Black Communities. In I. Crome, D. Nutt & A. Stevens (Eds.). Drug Science and British Drug Policy (pp.198–203). 
Waterside Press. 
643 Police Professional | MPS officers must justify pre-arrest handcuffing following review 
644 See for example footnote #608, pp.65, 79. 

   
 
232 
 
them feeling powerless. This is exacerbated in designated ‘drug hotspots’ where 
we heard many young black people are arrested for cannabis possession 
following S&S, rather than receiving a (permissible in some circumstances) less 
serious Out of Court Disposal (OOCD) – even for a first offence. We discuss use 
of OOCDs later in this chapter.  
 
10.139 This practice, as described to us, effectively discriminates against children and 
young people growing up in those hotspots, which are likely to be the more 
deprived parts of London. Those affected children and young people are 
therefore more likely to be people of colour (see para.4.45).   
 
10.140 As our research645 among Londoners highlighted, the sense of disproportionate 
and unfair application of S&S to black Londoners is felt across ethnic groups. 
This underpinned a desire among some for an end to the practice with respect at 
least to possession of cannabis for personal use (see also chapter 6 on public 
attitudes towards cannabis and its legal status).  
 
10.141 Some participants from a white background described instances where black 
companions had been singled out in both body and vehicle S&S’s for cannabis, 
or had received what they felt to be a harsher punishment than that which a white 
person in possession of the drug would have (or had) received in a similar 
situation: 
‘Even though at the time [of the stop and search] myself and this other 
white friend were the ones holding the joints, it was my [black] 
boyfriend who was most aggressively spoken to, addressed, and body 
searched.’ 
‘Friends were driving and were stopped by a police car for no apparent 
reason other than they were black in a nice car. The police officers that 
stopped them said there was an issue with insurance and asked for car 
details. The officers started off aggressively and the driver reacted 
politely and provided all the documentation but the officer seemed 
unsatisfied. [The officer] asked whether anybody had been smoking 
cannabis because they could smell it from the car. This friend does not 
smoke cannabis nor has ever smoked cannabis and replied as such. 
The police officers vacated everyone from the car and searched the 
car thoroughly… They were eventually let go but this caused a lot of 
trauma to my friends. They were massively impacted and for a while 
they did not drive that car around and took public transport.’  
     
Source: Thinks Insight & Strategy (2023). Lived experiences of cannabis among Londoners. 
MOPAC. 
 
10.142 We heard, too, from one white former cannabis user who had frequently 
purchased the drug on London’s streets. Never subject to S&S himself, he 
 
645 See footnote #11. 

   
 
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described one instance when police stopped him along with several black people 
from whom he had just bought cannabis. He was permitted to walk away while 
those he was with were detained for S&S. Similarly, one young witness described 
seeing police S&S a white peer and find several bags of cannabis. Which they 
duly confiscated – before letting him go. 
 
10.143 Such anecdotes support perceptions among London’s black communities, 
arguably reinforced by the disparity rate, that the discretion available to police 
with respect to responding to cannabis possession (depending on the 
circumstances) is applied unequally. Data on outcomes from drug-related S&S 
do nothing to dispel this view – we consider these later in this chapter.  
 
10.144 Bias – unconscious or otherwise – may be partly responsible. We also heard of 
perceptions that young black people are treated differently to white counterparts 
in response to county lines activity (see chapter 5). The former, it was suggested, 
are more likely to be labelled criminals, the latter victims of modern slavery and 
exploitation.  
 
10.145 The use of body-worn video (BWV) offers one means to improve the way in which 
S&S is handled, and we welcome the fact that its use is now established within all 
forces in England & Wales (including the MPS and CoLP)646 – albeit with some 
inconsistency.647 It was put to us that it improves the behaviour of officers and 
those they S&S, although research (primarily from the US) suggests the measure 
tends not to affect the behaviour of either police or citizens in a clear or 
consistent manner.648 
 
10.146 Moreover, the technology is officer-activated, meaning recording begins only 
when an officer turns on the device – which may not always be at the very start of 
an encounter. Furthermore, part of the value of BWV lies in the review of footage 
by police supervisors to support learning and improvement.649 But we heard this 
is not as widespread as it could be, which causes us concern as there are almost 
certainly opportunities being missed to provide vital feedback to officers engaged 
in S&S.  
 
10.147 We welcome work which we heard is underway in the MPS to assess reviews of 
officers’ BWV for S&S, with results expected later this year: these should be 
passed to and discussed with MOPAC and Community Monitoring Groups as 
soon as practicable.  
 
 
646 National Police Chiefs Council (2022). Body-Worn Video V1.0. United Kingdon College of Policing: Body Worn 
Video Guidance 2014 
647 Race Disparity Unit (2022). Inclusive Britain: government response to the Commission on Race and Ethnic 
Disparities. Command paper number CP 625. Crown Copyright. Inclusive Britain: government response to the 
Commission on Race and Ethnic Disparities - GOV.UK (www.gov.uk) 
648 Lum, C., Koper, C.S., Wilson, D.B., Stoltz, M., Goodier, M., Eggins, E. … & Mazerolle L. (2020). Body-worn 
cameras' effects on police officers and citizen behavior: A systematic review. Campbell Syst Rev, 16(3). 
doi:10.1002/cl2.1112. 
649 See footnote #646.  

   
 
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10.148 It was also suggested to us that despite previous recommendations650ʹ651 and 
support from the National Police Chiefs Council (NPCC),652 sharing of BWV 
footage with external scrutiny groups continues to be patchy. MOPAC should 
mandate those charged with scrutiny of the MPS and CoLP to review a random 
sample of BWV of drug-related S&S at least quarterly and report any concerns to 
the force and MOPAC (R22).   
 
Strip searching 
 
10.149 Strip searches653  may take place in a police station or other appropriate location 
that is out of public view and is a suitable place in which to be partially naked.654 
While we did not explore the practice in detail, we heard how harrowing it is, 
particularly for young people, to be subjected to such a search. It was described 
as so traumatic that the end is completely unjustified by the means, and some 
witnesses felt it could never, in any circumstance, be considered a proportionate 
or appropriate response. 
 
10.150 This view was compounded by the low rate of positive outcomes. Over half the 
650 strip searches of children and young people carried out by the MPS between 
2018 and 2020 resulted in no further action.655 And the ethnic disproportionality 
seen in S&S more widely is also observed in strip searches, at least among 
children.  
 
10.151 The well-documented case of a young black girl, known as Child Q, was 
something of a pivotal moment in terms of highlighting both the nature of the 
practice and associated ethnic disparities. Suspected of carrying cannabis, Child 
Q was strip searched while at school in Hackney in north-east London in 2020. In 
contravention of the guidance no Appropriate Adult was present. No drugs were 
found.  
 
10.152 The case prompted examination of MPS practice by the IOPC and the Children’s 
Commissioner, as well as a local child safeguarding practice review. Notably, the 
latter reported that ‘…racism (whether deliberate or not) was likely to have been 
an influencing factor in the decision to undertake a strip search.’656 
 
 
650 See footnote #647, Action 12. 
651 Independent Office for Police Conduct (2022). National stop and search learning report, IOPC, pp.34–5. National 
stop and search learning report | Independent Office for Police Conduct (IOPC) Accessed 23rd January 2024. 
652 See footnote #646. 
653 A strip search involves a person removing more than their outer clothing. It can involve exposure of intimate body 
parts. 
654 London Policing Ethics Panel (2022). Report on conduct of searches exposing intimate parts by the Metropolitan 
Police Service. London Policing Ethics Panel. 
655 Children’s Commissioner (2022). Strip search of children by the Metropolitan Police Service – new analysis by the 
Children’s Commissioner for England. Children’s Commissioners Office. Available at Strip search of children by the 
Metropolitan Police Service - new analysis by the Children’s Commissioner for England | Children's Commissioner for 
England (childrenscommissioner.gov.uk) Accessed 22nd January 2024. 
656 Gamble, J. QPM & McCallum, R. (2022). Local Child Safeguarding Practice Review: Child Q. City & Hackney 
Safeguarding Children Partnership (CHSCP), p.6. Child-Q-PUBLISHED-14-March-22.pdf (chscp.org.uk) Accessed 
22nd January 2024. 

   
 
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10.153 Available statistics back this up. The vast majority of strip searches of 650 
children aged under 18 conducted by the MPS between 2018 and 2020 were of 
boys (over 95%, mostly aged 16–17). Well over half (58%) were black, a further 
one-fifth were white and 16% were Asian.657 Given the ethnic breakdown of 10–
17-year-olds across London (in 2021, 19% were black, 44% were white, 22% 
were Asian), racial disparity is in our view somewhat inarguable.  
 
10.154 More recent data published by the Children’s Commissioner, however, suggests 
a fall in the use of strip searching of children by police across England & Wales, 
and we welcome the fact this was particularly notable in London.658 Like the 
Children’s Commissioner, we too find this reassuring.659 In the year ending June 
2023, the MPS and CoLP conducted a combined total of 66 such searches, 
representing 14% of all strip searches of children undertaken across England and 
Wales that year.  
 
10.155 The latest report also found that while black children remain subject to a 
disproportionate number of strip searches, the disparity has reduced. Across 
England & Wales, black children are now four times more likely than white 
children to be strip searched rather than six times, as was previously reported. 
While figures are not broken down by individual police forces, we have no reason 
to believe the disparity is not similarly reducing in London. 
 
10.156 Moreover, following the case of Child Q, the MPS told us they have introduced 
several changes to the policy and procedure regarding the most intimate form of 
strip searching, known as a ‘More Thorough search involving Intimate Parts’ 
(MTIP). Effective since May 2022, among other things the new guidance, we 
were told, raises the authorisation level for conducting an MTIP to Inspector, and 
local Basic Command Unit (BCU)660 Inspectors now own all aspects of the 
procedures involving MTIPs of children.  
 
10.157 While we did not have opportunity to review this new guidance, we were told the 
MPS aim to have in place the highest possible threshold for authorisation of an 
MTIP, the strongest possible safeguards for children and the highest quality 
administration governing the procedure. These are welcome and laudable 
intentions, and we hope that future assessment and inspection can demonstrate 
positive associated outcomes.    
  
 
 
 
657 See footnote #655. Note: A further 5% of children strip searched between 2018 and 2020 were marked as ‘other’ 
ethnicity and, in 2% of cases, ethnicity was not recorded. 
658 Children’s Commissioner (2024). Strip searching of children in England and Wales: First complete dataset for 
2018–2023, including new data July 2022-June 2023. Children’s Commissioners Office. Strip searching of children in 
England and Wales: First complete dataset for 2018-2023, including new data July 2022-June 2023 
(childrenscommissioner.gov.uk) Accessed 27th August 2024. 
659 Child strip searched every 14 hours by police in England and Wales | Children's Commissioner for England 
(childrenscommissioner.gov.uk) Accessed 27th August 2024. 
660 For policing purposes, London is divided into 12 Basic Command Units (BCUs), each lead by a BCU Commander. 
The boundaries of each BCU incorporate up to four individual boroughs. 

   
 
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Options for the police on finding cannabis for personal use during stop and search  
 
10.158 On finding small amounts of cannabis during an S&S (i.e. not enough to 
constitute a supply offence, although what constitutes personal use versus 
supply is down to officer judgement), the police have some discretion in how they 
deal with the matter. Where a person admits guilt, an officer may apply an Out of 
Court Disposal (OOCD, some of which give rise to a criminal record), or proceed 
with arrest. 
 
10.159 A Community Resolution (CR) is a type of OOCD that can be applied for a first 
offence, or subsequent similar offences as long as 12 months have passed since 
an individual was last issued with a CR. It does not appear on a criminal record – 
though, importantly, can be referred to in any future legal proceedings and is 
eligible for disclosure under an enhanced Disclosure & Barring Service (DBS) 
check. This means it may show up in, for example, checks conducted as part of 
pre-employment processes for some job roles.  
 
10.160 Various types of CR are available, including cannabis warnings for those aged 
over 18 – although NPCC guidance issued some years ago means in practice 
these are no longer used by most forces. The simplified statutory framework for 
OOCDs, expected to come into force in 2025 (see chapter 3), will effectively 
abolish the cannabis warning. 
 
10.161 The issuing police force is responsible for any conditions imposed as part of a 
CR.661 These can include apologising or sending a letter of apology to any victim, 
making some form of reparation such as repairing or paying for any damage 
done, and/or attendance at services providing rehabilitative support for a range 
of issues including substance use. The latter can also be delivered via diversion 
schemes, which we discuss subsequently and which can also include 
educational courses. Failure to comply with conditions can lead to prosecution. 
 
10.162 The police may also consider a Penalty Notice for Disorder (PND) as an 
alternative to a CR. These similarly attract no criminal record (though can equally 
be disclosed under an enhanced DBS check), and are also due to be phased out 
under the forthcoming simplified OOCD framework.  
 
10.163 Where a person admits possession of cannabis but has recently been issued with 
a CR, or where police deem a CR inappropriate, they may under the current 
framework be offered a Simple or a Conditional Caution – both appear on a 
criminal record.  
 
10.164 The former equates to a formal warning and has no conditions attached, the 
latter imposes one or more conditions similar to a CR. Simple and Conditional 
Cautions will in due course be replaced by the Diversionary and the Community 
Caution under the new framework. 
 
661 The MPS told us that, typically, for a drug-related CR adults would be referred to drug treatment and young people 
to the local Youth Offending Team to be informed about the health risks associated with drug-taking. 

   
 
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10.165 Where a person has already been issued with a caution for cannabis possession 
or similar, or the police do not consider an OOCD appropriate, they may be 
arrested and then charged, or released under investigation. Prosecution could 
follow, especially where a person is caught in possession of more cannabis than 
that which could reasonably be deemed for personal use.  
 
10.166 College of Policing guidance stipulates that a person may only ever be issued 
with a cannabis warning once.662 A second possession offence should (currently) 
result in a PND or other community resolution, and a third in arrest. However, in 
reality police discretion means that, where they remain in use, more than one 
warning might be issued, or conversely a person may proceed immediately to 
arrest despite theirs being a first offence.  
 
10.167 Racial disparities in the likelihood of being S&S mean, while most will not be 
found in possession of drugs or anything else illegal, black Londoners who carry 
cannabis are more likely than their white counterparts to end up arrested for its 
possession, either as a result of multiple stops and progression through 
escalating options, or because, as it was put to us, officer discretion means they 
progress straight to arrest.   
 
10.168 Where police deem there to be no public interest in prosecution, a person may 
instead be mandated to attend a drug-related diversionary activity, which, unlike 
similar mandated via an OOCD, requires no admission of guilt (an educational 
intervention, for example). Effectively this is a ‘deferred prosecution’, as if the 
activity is completed then no criminal record is sustained.  
 
10.169 The case is then counted as one in which no further action (NFA) has been taken 
by police (i.e. it is not included as a ‘positive action’ in performance figures) and 
can be recorded in HO statistics as an ‘outcome 22’. If the activity is not 
completed, the police will consider subsequent prosecution.663 
 
10.170 The concept of outcome 22 is an important part of attempts to reduce wider 
disparities in outcomes. These result at least in part from the fact that people of 
colour are less likely to admit guilt, stemming from widespread lack of trust and 
confidence that they will be treated fairly by the police and justice system.  
 
10.171 However, a refusal to accept responsibility increases the likelihood of arrest and 
criminal charge because OOCD disposals (with the exception of PNDs, which will 
be abolished under the new framework) require admission of guilt. As we heard, 
police often face ‘no comment’ throughout an interview with someone found in 
possession of cannabis or some other illegal item, meaning the option of an 
OOCD is removed.  
 
 
662 Possible justice outcomes following investigation | College of Policing Accessed 14th March 2024. 
663 See Microsoft Word - Outcome 22 Updated Guidance V3.5 (npcc.police.uk) Accessed 24th January 2024. 

   
 
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10.172 Given documented issues with trust, this scenario is more likely among those 
suspected of cannabis possession from ethnic minority (excluding white minority) 
backgrounds. This exacerbates racial disparities, risking criminal records and 
harsher outcomes, despite the fact that evidence suggests any difference in rates 
of use between ethnic groups is marginal if it exists at all, and certainly does not 
equate to the disparity seen in rates of S&S. 
 
10.173 And a criminal record, no matter how minor the offence, can limit a person’s life 
prospects. It might restrict employment and travel opportunities, have 
implications for access to social housing, and in more serious cases threaten 
access to children. Those given a custodial sentence on conviction are at 
particular risk of suffering mental and physical ill health and of losing protective 
ties with family and friends.  
 
10.174 Detailed consideration of the consequences of criminalisation are beyond the 
scope of our inquiries, but there is a plethora of evidence on the issue.664 With 
respect to cannabis, its use is particularly prevalent among adolescents and 
young adults (chapter 4). A related conviction and ensuing criminal record – even 
for a relatively minor offence – could hold a person back during a pivotal time in 
their later working life. This is illustrated in the Lammy Review, which suggests 
that selling drugs as a teenager could prevent a person from becoming a 
plumber or licensed taxi driver in later life.665  
 
10.175 Arguably, a principal benefit of at least decriminalising possession of cannabis, if 
not permitting its production, sale and purchase, lies in the potential reduction in 
those sustaining a criminal record – a disproportionate number of whom come 
from ethnic minority (excluding white minority) backgrounds. And as was pointed 
out to us several times, a criminal record can in some cases be more harmful to 
an individual than use of the drug that led to it. 
 
10.176 Given the importance of outcome 22 in permitting sanction without formal 
criminal record, in our view its use should be recognised as a ‘positive outcome’ 
for the police and recorded as such. In terms of S&S, an NFA outcome suggests 
either that nothing was found on the person stopped or, if it was, the police took 
no proactive measure to help that individual desist from future related offending. 
It seems to us this is no incentive to route someone away from the CJS in 
appropriate cases of cannabis-related offending.   
 
10.177 It is important to better understand how frequently outcome 22 is used, in what 
circumstances, and with whom. We therefore recommend the Home Office, in 
partnership with the College of Policing and National Police Chiefs Council, 
should ensure use of outcome 22 is recorded in such a way that allows for i) it to 
 
664 Including as discussed in Black, C. (2020). Review of Drugs: Executive Summary. Department of Health and 
Social Care and Home Office, Crown Copyright. Microsoft Word - SummaryPhaseOne+foreword200219 
(publishing.service.gov.uk) 
665 Lammy, D. (2017). The Lammy Review: An independent review into the treatment of, and outcomes for, Black, 
Asian and Minority Ethnic individuals in the Criminal Justice System. Ministry of Justice, Crown Copyright. The 
Lammy Review (publishing.service.gov.uk) Accessed 25th January 2024.  

   
 
239 
 
be counted as a positive outcome and ii) full analysis of use across forces. This 
must be implemented in such a way that records do not show up in a basic or 
enhanced DBS check, given there is no admission of guilt (R23).    
 
10.178 A cannabis-related outcome is not the only possible consequence from S&S. As 
referred to previously, there is a risk that an individual subject to an S&S may 
challenge the police officer. This may be heightened where a person has been 
subject to multiple S&S and, especially when no evidence of wrongdoing has 
been found, experiences a sense of increasing frustration and injustice. The 
nature of the encounter may thus escalate, risking arrest for a public order 
offence or assault, despite there not necessarily being any evidence of the drug 
possession that first initiated the S&S.  
 
10.179 This is particularly so where there is a perceived lack of respect and 
professionalism from the officer(s). We heard how some people have been 
pushed and physically manhandled during an S&S, which can elicit similar in 
return – which of course raises the likelihood of an associated arrest.  
 
10.180 We have some sympathy, too, with the view that being subjected to multiple 
S&S’s – which, as discussed, is a more common experience among black than 
white Londoners (para.10.108) – might make a person more cautious and 
nervous around the police. This in itself risks being interpreted as suspicious and 
raises the chance of a further stop. 
 
10.181 Risk of escalation can be further heightened by a cannabis-induced state. The 
sense of paranoia that consumption of the drug can cause may be exacerbated 
by any prior negative interactions with police, leading to confrontational 
behaviour. Where interpreted as aggressive and violent rather than cannabis-
induced, this in turn risks a heavier-handed police response. While, 
encouragingly, we heard about instances where police had instead arranged for 
drug-related support, this was not considered to be common.  
 
10.182 We must acknowledge the challenge for police in accurately identifying, in an 
uncertain situation, the cause of what may appear to be confrontation. Officers 
face a risk of physical assault in the course of carrying out their duties and while 
this does not justify unnecessarily heavy-handed responses, we recognise it may 
affect how behaviour is interpreted, particularly by those who are less 
experienced. During the year ending March 2022, 6,172 assaults were recorded 
against MPS officers and 81 against CoLP officers.666  
 
10.183 Physical harm may also, however, be a risk of S&S for the person subjected to 
the power. While less likely than criminalisation, nonetheless the consequences 
can be severe, and we heard how the case of Jordan Walker-Brown has 
influenced recent attitudes to S&S among black communities. The black 
 
666 See Annex A: Annex: Statistics on the number of police officers assaulted in the year ending March 2022, England 
and Wales - GOV.UK (www.gov.uk) Accessed 4th September 2024. 

   
 
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Londoner, 23 years old at the time, was S&S by MPS officers in 2020. Found in 
possession of cannabis, he was arrested, charged and subsequently released.667  
 
10.184 The following day, he was spotted by police and, on seeing officers leave their 
vehicle and approach him, he ran away. Conscious of once again carrying a 
small amount of cannabis (which in itself is testimony to the widely referenced 
failure of S&S to deter the behaviour), he was fearful of what that would mean 
given the prior charge.  
 
10.185 Two of the nine officers drew Tasers (conducted energy devices that temporarily 
incapacitate a person). One discharged his weapon, saying he believed Mr 
Walker-Brown was carrying a knife. It hit him as he was jumping over a wall, 
causing him to fall backwards and break his back, leaving him paralysed. He 
believes he would not have been approached by police on either occasion had 
he not been a young black man.   
 
10.186 The incident was referred to the IOPC, who concluded that the officer who 
discharged his Taser may have committed grievous bodily harm. The case was 
passed to the Crown Prosecution Service (CPS) and the officer faced trial. 
Despite the not guilty verdict, incidents such as these are writ large in the minds 
of the public, particularly among black communities, and inevitably serve to 
further mistrust and fear of the police.  
 
10.187 We look at criminal justice outcomes for cannabis-related offending later in this 
chapter. But the importance of S&S in subsequent engagement with the CJS 
cannot be overestimated. The majority of recorded drug offences are for 
cannabis possession, and the majority of S&S are drug-related, so it is 
reasonable to assume that S&S is the gateway to the CJS for many of those who 
end up convicted of cannabis-related offending.   
 
10.188 Given the high rate of NFA following drug-related S&S across London, we find it 
difficult to disagree with the suggestion that, while there are some policing gains 
from the practice, these are offset by the risk of negative consequences, 
particularly for the large majority not found to have broken the law. The 
disproportionate nature of S&S means black people in London and across the 
country, many of whom experience drug policing as the norm,668 are more likely 
to suffer those consequences.  
 
Police-led diversion schemes for cannabis possession 
 
10.189 Diversion away from the CJS for lower-level offending is increasingly being used 
as understanding and evidence about the impact of criminalisation (especially of 
young people), costs to the system and failures of more traditional justice 
outcomes grows. With respect to drug offences, diversion tends to be utilised in 
 
667 It is not clear whether an OOCD disposal would have been an option or whether arrest and charge was the only 
appropriate avenue for the MPS to pursue. 
668 Akintoye, B., Ali, A. & Stevens, A. (2022). The Ongoing Impact on the Racialised Policing of Black Communities. In 
I. Crome, D. Nutt & A. Stevens (Eds.). Drug Science and British Drug Policy, p.201. Waterside Press. 

   
 
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response to possession for personal use, although more minor supply or 
cultivation offences can also be eligible. 
 
10.190 Usually police-led and often in partnership with specialist services, diversion 
schemes enable those caught committing minor offences to be routed away from 
prosecution (whether they admit responsibility or not). Schemes in place for drug 
offences usually require a person to, for example, attend a health assessment 
and a harm-reduction or drug treatment service, or drug education provision. 
 
10.191 The approach has its roots in US-led schemes known as Law Enforcement 
Assisted Diversion (LEAD), which are based on principles of harm reduction, 
health equity and racial justice. A growing body of evidence from the US, 
Canada, Australia and elsewhere, alongside emerging findings from UK 
schemes, suggests diversion may offer a more effective and less costly 
alternative to formal criminal justice disposals in terms of reducing reoffending, 
particularly for young people,669 perhaps in part because they can assist with 
wider related needs including access to housing and employment. 
 
10.192 It was put to us that currently, young people in London with problematic cannabis 
or other drug use struggle to find or access appropriate support. As a result, 
criminalisation following drugs possession can be the only way of triggering a 
referral for help – sustaining a Youth Offending Order, for example, was cited as 
one such route.  
 
10.193 But support is not guaranteed due to pressure from wider demands on the health 
system and related services. What was described as a ‘postcode lottery’ across 
the capital with respect to availability and capacity of services exacerbates this. 
By the time a young person is seen, their problems can have become very acute 
and require more intensive support.  
 
10.194 Or they reach the age of 18 before being seen and, because their problems may 
not be deemed sufficiently serious to warrant an appointment within the adult 
system, they fall between the cracks. The system ‘…means young people are set 
up to fail from the start’. Diversion schemes differ in approach and application, 
with some perhaps more successful in ensuring those referred are able to access 
the stipulated support in a timely way.  
 
10.195 One of the earliest schemes was developed by Durham Constabulary, which set 
up its Checkpoint programme in 2015.670 More recently, West Midlands police 
have partnered with Cranstoun, an organisation that supports adults and young 
people struggling with, among other things, alcohol and drugs, to implement a 
pre-arrest diversion model known as ‘DIVERT’ (originally piloted by Thames 
Valley Police, in conjunction with Cranstoun).  
 
669 Diversion (justiceinspectorates.gov.uk) Accessed 25th January 2024. 
670 See for example Weir, K., Kilili, S., Cooper, J., Crowe, A. & Routledge, G. (2021). Checkpoint: An innovative 
Programme to navigate people away from the cycle of reoffending – A randomised control trial evaluation. The Police 
Journal: Theory, Practice and Principles, pp.1–28. doi.org/10.1177/0032258X211018774 Accessed 25th January 
2024. 

   
 
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10.196 Since 2020, West Midlands police default to diverting adults and young people 
caught in possession of drugs to Cranstoun, who offer assessment, advice, 
information and referrals to wider drug treatment if appropriate. The pathway 
forms a community resolution. 
 
10.197 Early evaluation shows some encouraging results, namely:671 
• Recorded offences for possession of drugs increased by 30%. Initially 
counter-intuitive, this is likely due to officers not previously recording all such 
offences (it is now automatic upon referral), and means more people who 
choose to use drugs receive some kind of positive intervention. 
• While attendance is voluntary, 65% of referrals attended at least an initial 
assessment or harm reduction interview with a drug worker. They would 
previously have received no advice and may well have ended up with a 
criminal record, if not subject to prosecution. 
• Charges for eligible offences fell by 71%, formal cautions by 80%.  
• While formal criminal justice outcomes for drug possession offences fell for all 
groups, the drop was most marked for African-Caribbean males, from 46% to 
13%. Given wider racial disparities with respect to S&S, this is particularly 
encouraging.  
 
10.198 West Midlands police officers report the automatic referral takes some of the 
conflict out of S&S encounters, which now lead to arrest only on rare occasions. 
The scheme is popular with some as not only is referral straightforward, with 
handheld devices used to immediately divert anyone caught in possession of 
drugs, officers also save around 4.5 hours of processing time per individual. 
Others, however, reportedly feel the scheme does not represent a sufficiently 
legitimate outcome for criminal behaviour. 
 
10.199 We recognise drug-related diversion schemes are not a panacea. Not all those 
eligible are diverted (and there may be inequities in terms of those who are 
compared to those who are not), and schemes require appropriate services to be 
funded and available locally, ideally on a multi-year basis.  
 
10.200 As described to us by several witnesses, the fragmented nature of drug 
treatment and other services commissioned and provided across London (see 
chapter 9) mean these conditions are challenging. We heard there are several 
different schemes and associated funding streams in place across the capital, 
but lack of central ownership and governance compounds fragmentation of 
access and delivery.  
 
10.201 This means existing provision lacks consistency and common entry criteria, 
adding to the wider postcode lottery in terms of how those caught in possession 
of drugs, including cannabis, may be dealt with. The situation also means there is 
 
671 https://www.college.police.uk/support-forces/practices/drug-diversion-following-stop-and-search-and-custody-
divert-programme Accessed 25th January 2024. 

   
 
243 
 
a risk that some of those referred into services get little out of them, while in 
parallel adding to wider caseload pressure.  
 
10.202 However, we are nonetheless encouraged by evidence put to us with respect to 
the impact of diversion schemes running outside London. A way of avoiding 
criminalisation but ensuring some consequence for what remains a criminal 
offence, diversion offers a route to support for those with problematic drug use. 
Given our findings with respect to gaps in statutory education about cannabis 
(see chapter 12), schemes potentially offer a valuable way to help users 
understand risks about which they may otherwise be unaware, in a non-
judgemental and destigmatised setting.   
 
10.203 While we were encouraged to learn that a majority of police forces across 
England & Wales have adopted some form of diversion scheme for those found in 
possession of illegal drugs, it is disappointing that nothing consistent is yet in 
place across London. While we recognise several different projects exist, we 
were unable to reach a clear understanding of precisely what provision they offer, 
particularly for those caught with small quantities of cannabis.   
 
10.204 We heard the MPS and CoLP can refer those who are found in possession of 
drugs and subsequently arrested to Turning Point, a national organisation that 
supports those struggling with (among other things) drugs and alcohol. As we 
understand it, however, eligibility is dependent upon an offender’s home address. 
The CoLP told us they can refer residents of the City of London and the borough 
of Hackney only, which is problematic for the force because most of those they 
find in possession of drugs live in other parts of the capital. 
 
10.205 We were unclear whether the same residency limitations are in place for those 
found in possession of drugs by the MPS, nor whether there are any additional 
eligibility criteria governing referral. Whether those referred following S&S, for 
example, can access appropriate support quickly or whether there are lengthy 
waits (and what happens in the interim) was similarly not obvious to us.  
 
10.206 We understand evaluation of a separate pilot of a deferred prosecution model 
(see below), led by the MPS in partnership with Turning Point in north-west 
London, is also currently underway. Not solely for drug offenders, low-level 
offenders more widely were offered a four-month, police-supervised ‘contract’ 
following apprehension, instead of being formally cautioned or charged. The MPS 
told us the contract imposes restorative, rehabilitative and occasionally 
prohibitive conditions on those taking part.  
 
10.207 Initial analysis undertaken by the MPS672 showed the majority of those referred for 
a drug-related offence were referred for possession of cannabis (some were also 
in possession of Class A drugs), although we are unclear what or how any 
residency or other eligibility criteria for the scheme operated. So far, data suggest 
 
672 Harber, K, (2024). Unpublished analysis from initial evaluation of the Turning Point Programme. Shared with the 
London Drugs Commission by the MPS. 

   
 
244 
 
the scheme to be associated with reductions in subsequent criminal charges 
among participants aged under 22. This is positive and as the evaluation 
progresses, we think it would be useful, given the dominance of cannabis 
possession offenders in the cohort, to understand more about their experiences.   
 
10.208 Thus MOPAC, in partnership with the MPS and Turning Point, should explore 
how this pilot has operated for people referred for cannabis offences, including 
any identified via S&S (R24). Findings should inform preparations for roll-out of 
the new OOCD framework, to ensure treatment and support services across the 
capital are able to respond appropriately to those diverted into their provision 
from the CJS.  
 
10.209 One option is to build provision into the government’s Project ADDER (Addiction, 
Diversion, Disruption, Enforcement and Recovery).673 Extended in 2021 firstly to 
the London boroughs of Hackney and Tower Hamlets and now in place (since 
April 2024) across the remaining 30 boroughs, this facilitates a cross-system 
response to drug use. It aims to get more people into treatment (and supported 
with, for example, housing and employment) and includes the introduction or 
expansion of post-arrest criminal justice diversion programmes.  
 
10.210 Core to ADDER is the concept of (post-arrest) deferred prosecution, which 
means a person caught in possession of Class A or B drugs can, without 
admission of guilt, enter into a ‘contract’ whereby they agree to attend one or 
more sessions with a relevant service provider. Providers are usually contracted 
by the local authority and failure to engage means the individual is liable for 
subsequent prosecution. 
 
10.211 Key to deferred prosecution is accurately recording engagement with associated 
conditions. This means the police must have a record of attendance so they 
know whether an individual has complied with diversion requirements or should 
be subject to prosecution.  
 
10.212 It was put to us, however, that providers can be reluctant to disclose the 
necessary information because they view attendance as confidential – and their 
contracts may not mandate data sharing. This is, to our mind, unhelpful. We 
recommend all service providers contracted to support deferred prosecution 
referrals should be mandated to inform the police as to whether associated 
conditions have been met. Alternatively, a third party should be appointed to 
manage the process (R25).  
 
10.213 We note too that, while ADDER provides a diversion mechanism for drug 
offenders, its focus is more serious drug use. This leads us to question whether 
the extent to which those diverted following cannabis-related offending will have 
their needs met. More specifically, whether those sanctioned for possession 
might end up routed into treatment services despite their levels of use posing 
 
673 About Project ADDER - GOV.UK (www.gov.uk) Accessed 26th January 2024. 

   
 
245 
 
little risk from a health perspective – pointing once again to the risks of poor 
coordination of funding and service provision. 
 
10.214 For many such users of cannabis, a lighter-touch warning may be more 
appropriate – which would also lessen the risk of placing excessive burden on 
already limited services for those who use drugs more generally (see chapter 9).  
 
10.215 MOPAC should ensure ADDER evaluators collect data on characteristics of 
those diverted (including ethnicity), the route of referral (whether via S&S, for 
example) and the nature of offending (where drug-related, which drugs). The 
impact on provision of services for those who use drugs more widely should be 
monitored (R26). Findings must inform future decisions regarding the suitability of 
ADDER as a diversion mechanism for those found in possession of drugs.  
  
10.216 The lack of a consistent approach across the capital to route drug offenders 
away from the CJS, with or without admission of guilt, is concerning and we 
welcome desires across the MPS and MOPAC to ensure diversion schemes are 
London-wide.  
 
10.217 We also, however, recognise the challenges inherent in drawing on stretched 
health-led services to meet needs resulting from criminal justice-administered 
sanctions – which as we note may not be suitable when services are designed to 
meet needs of more serious drug offenders.  
 
10.218 We understand a separate diversionary pilot for young adults is planned in one 
part of the capital. This is welcome, but the exclusion of those aged over 25 is 
concerning given wider evidence of the positive impact of such schemes across 
age groups. Certainly, ADDER operates no such exclusion, and neither does the 
MPS pilot with Turning Point (para.10.206). We also appreciate the importance of 
piloting and evaluating new approaches but, arguably, diversion schemes for low-
level drug offenders are not new and there is evidence of what constitutes good 
practice.  
 
10.219 We recommend MOPAC and the London Drugs Forum (LDF), together with the 
MPS and CoLP, should consider expanding this planned pilot for young adults 
across London, and across age groups. This should be in partnership with 
ADDER to ensure join-up and learning, and to reduce the risk of duplication 
(R27).  
 
10.220 In addition, it would be useful for the LDF to consider whether a pan-London 
approach to diversion would be more appropriate than the current seemingly 
piecemeal model that arguably forms somewhat of a postcode lottery. To this 
end, we recommend MOPAC publish a list of schemes currently in place, and the 
LDF explore whether a city-wide model would be more effective. As a minimum 
the LDF, in partnership with MOPAC and the MPS, should draw up clear 
guidance regarding eligibility for diversion schemes (R28). Eligibility should allow 
for repeat opportunities for diversion: failure to do so essentially criminalises drug 

   
 
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dependency, given the likelihood that in many cases this drives repeated contact 
with police.   
 
10.221 We understand the model adopted by West Midlands police in partnership with 
Cranstoun has been considered by MOPAC and the MPS. In our view, its 
operation pre-arrest at street level, and the fact that it avoids the need for 
treatment providers to share information directly with police due to referrals being 
managed by a third party (i.e. Cranstoun), offer significant benefits. We strongly 
urge that both elements be given serious consideration as diversion provision in 
London is developed further.  
 
10.222 We accept, however, that the sheer volume of drug possession offences in 
London, as well as the way in which health service commissioning currently 
operates, would inevitably challenge implementation of any such model.  
 
10.223 We heard too about low rates of referrals from the police into diversion schemes 
(this is a wider issue across the CJS). Whether down to concerns about capacity 
of schemes, repeat offending or something else is unclear – but for any model to 
succeed, it requires police engagement alongside available and appropriate 
services into which eligible offenders may be referred. Requiring police to specify 
why they choose not to refer an eligible individual to a diversion scheme would 
shed light on the use and efficacy of these schemes, and MOPAC should work 
with the MPS to ensure this happens (R29).  
 
10.224 The level of treatment and ancillary services required to support those diverted 
from the CJS is significant and provision is currently patchy. We understand 
additional investment has been and continues to be provided by central 
government to bolster drug and alcohol treatment services,674 but it will take time 
for this to bear fruit.  
 
10.225 As we discuss in chapter 9, we heard from frontline practitioners and health 
policy experts how the sector more broadly, never mind those parts focusing on 
drug-related offending, has been hollowed out after many years of underfunding. 
It will take time to recruit, train and retain sufficient staff to provide the necessary 
levels of service, and the same will apply to realising the intention of the new 
OOCD framework when it goes live. 
 
10.226 The CoLP told us that availability of drug support services is a significant issue, 
compounded by the fact that each borough commissions services separately for 
its own residents. Many offenders do not offend in the borough within which they 
live, so it can be difficult for the force to offer a diversionary route because they 
do not have a contract in place with a provider in the necessary borough (see 
para 10.204).      
  
 
674 In line with recommendations made by the Independent review of drugs by Professor Dame Carol Black - GOV.UK 
(www.gov.uk) and the government’s subsequent drug strategy From harm to hope: A 10-year drugs plan to cut crime 
and save lives - GOV.UK (www.gov.uk) 

   
 
247 
 
10.227 As a result, the CoLP have, as part of their pilot in preparation for implementation 
of the new OOCD framework, secured a provider who will signpost eligible 
offenders to services available in the area in which they reside. These include 
online courses and e-learning for lower-level drug offenders, such as those found 
in possession of small quantities of cannabis. This is, however, based on an 
‘offender pays’ model, which may not always be ideal given the economic 
realities and potential issues with addiction experienced by many of those subject 
to S&S or otherwise arrested for drug-related offending. 
 
10.228 The force told us that a hardship fund to allow those without means to access the 
service will be available. While means to pay will be assessed as part of the 
associated needs assessment, we think there is at least some possibility that 
those expected to pay will fail to do so. In our view, this is likely to then risk a 
formal CJS disposal, although the CoLP plan to explore demand for a hardship 
fund and related issues as part of the pilot, to inform future considerations 
regarding funding sources and support longer-term solutions.  
 
 
10.229 Despite outstanding questions regarding the operation and funding of diversion 
schemes, the principle of diversion instead of criminal sanction for lower-level 
cannabis offences has a reasonable degree of public support (certainly more so 
than for offences involving Class A drugs). This would likely be further enhanced 
by educating communities about how schemes work, and their potential to 
reduce reoffending and support people to avoid harms associated with 
criminalisation.675  
 
10.230  Pointing out the potential for diversion schemes to route people into drug 
education and treatment is important as over half the public (54%) have agreed 
these form appropriate responses to drug possession. In comparison, one-fifth 
(20%) considered a custodial sentence suitable, with almost half (49%) seeing a 
fine as fitting punishment.  
 
Arrests for cannabis offences 
 
10.231 During the year to March 2023, 60,013 people in England & Wales were arrested 
on suspicion of a drug-related offence(s).676 The MPS were responsible for more 
than any other force or region (unsurprisingly, given the force comprises very 
many more police officers)677, making up 25% (n=15,424) of the total (the CoLP 
made 343, taking the London total to 15,767). The north-west recorded the 
second highest number at regional level (n=8,433) and Greater Manchester the 
next highest at force level (n=3,474). 
 
 
675 Crest Advisory (2022). Reducing flows into the criminal justice system: polling on out-of-court disposals and 
diversion. Crest. 
676 See Table A_07, Arrest summary data tables: police powers and procedures, year ending 31 March 2023 (second 
edition). Accessed 14th August 2024.  
677 See Table 1, Police Workforce, England and Wales: 30th September 2023 – Data Tables. Home Office. Available at 
Police workforce, England and Wales: 30 September 2023 - GOV.UK (www.gov.uk) Accessed 4th September 2024. 

   
 
248 
 
10.232 Because they are responsible for the majority of the drug-related S&S made in 
London, we concentrate in this section on arrests and other outcomes following 
stops made by the MPS. As the CoLP were able, however, to provide us with a 
bespoke breakdown of outcomes relating specifically to S&S made on the 
grounds of suspicion of cannabis-related offending, those figures merit repeating 
here (see also paras. 10.65–66).  
 
10.233 During the year to June 2023, the CoLP made 1,253 drug-related S&S. These 
represented 54% of the total number of S&S (n=2,326) made during that period. 
Of those drug-related S&S, bespoke analysis revealed 65% (n=809) related 
specifically to cannabis. 
 
10.234 For 16 of those 809 cannabis-related S&S’s, no outcome was recorded. In 
around half (49%, n=393), No Further Action (NFA) was taken. Of the remaining 
400 cases, almost half (n=195) resulted in arrest. A further 28% (n=112) ended 
in a drugs warning, and the remainder (23%, n=93) in some other type of 
disposal. Meaning of all 1,253 drug-related S&S made that year by the CoLP, 
16% ended in arrest specifically for cannabis   
 
10.235 Returning to the MPS, of the 86,062 drug-related S&S made by the force in the 
calendar year 2023 (as at time of writing), 12% ended in arrest, as shown in 
Table 6: 
 
Table 6: Outcomes from MPS-led drug-related stop and searches, 2023* 
 
Outcome n % 
Arrest 10,466 12 
Community Resolution 10,930 13 
Penalty Notice for Disorder (PND)/Fixed 
Penalty Notice (FPN) 3,428 4 
Postal Charge Requisition/Court 
Summons 1,769 2 
Caution 128 <1 
No Further Action (NFA) 59,341 69 
Total 86,062 100 
* Source: MOPAC Action Plan Data Dashboard | London City Hall 
 
10.236 These figures mask substantial variation by borough. In twelve boroughs, more 
than 12% of drug-related S&S in 2023 ended in arrest, with the highest 
proportion in Lewisham, followed by Lambeth (20% and 17% respectively). In 
contrast, Barking & Dagenham, Havering and Hillingdon made the fewest 
arrests, at 7%, 9% and 9%. 
 
10.237 Routinely available data do not show how many people are arrested for cannabis 
as opposed to Class A drug offences. But given its dominance in recorded drug 
offences overall, it is reasonable to assume the majority of drug-related arrests 
are associated with cannabis.  

   
 
249 
 
 
10.238 Data released to the Mayor of London678 by the MPS revealed cannabis was 
specifically cited in 5,825 arrests made by the force in 2023. While an increase 
on the 1,047 cannabis-related arrests made in 2022, it is significantly lower than 
the number of arrests for possession or possession with intent to supply cannabis 
made by the force in recent years, which in 2020 numbered 17,458 and in 2021, 
totalled 13,870.679  
 
10.239 That said, figures are likely to be an underestimate of the total number of 
cannabis-related arrests because data recording means the type of drug was not 
specified in an unknown number of cases. More broadly, the limited data mean 
determining longer-term trends in arrests (whether numbers of arrests made or 
numbers of people arrested) specifically for cannabis has not been possible. 
  
10.240 It is not clear how many arrests were initiated by an S&S, nor in 2023 how many 
were for cannabis possession compared to supply (in 2020, 2021 and 2022, 
possession accounted for, respectively, 37%, 41% and 46% of all MPS arrests 
for possession and supply). We think it reasonable to assume, however, based 
on wider S&S and recorded crime data, that a significant proportion across all 
years probably resulted from S&S.  
 
10.241 We note too that, during the year to March 2023, the MPS made 15,424 drug-
related arrests.680 Assuming a similar number were made during the calendar 
year 2023, then the 5,825 cannabis-related arrests conducted that year would 
comprise almost 40%, i.e. a considerable element of the drug arrest workload for 
the MPS.    
 
Disproportionality in arrests and subsequent outcomes 
 
10.242 Disparities in criminal justice outcomes begin with inequalities in relation to police 
contact, most notably through use of S&S.681 Unfortunately, available data limit 
the extent to which disparities can reliably be further explored with respect to 
drug, or cannabis, offending. Routinely published figures do not show how many 
people from different ethnic groups are arrested for drug offences, never mind for 
specific drugs, in individual police forces. 
 
10.243 Overall arrest rates, however, show that in England & Wales black people are 
disproportionately more likely to be arrested than people belonging to any other 
 
678 ‘Can you provide data on how many people were arrested for cannabis-related offences in 2023? Please break 
this down by borough and ethnicity.’ Reference 2024/0080. Cannabis (1) | London City Hall Accessed 15th March 
2024. 
679 Available at https://www.met.police.uk/foi-ai/metropolitan-police/d/february-2022/cautions-arrests-supplying-
possession-of-cannabis-january2020-january2022/ Note that the number of unique individuals arrested will be lower 
than the number of arrests as some will have been arrested more than once over the course of the reporting period. 
680 See Table A_07, Arrest summary data tables: police powers and procedures, year ending 31 March 2023 (second 
edition) Accessed 15th March 2024. 
681 Stott, C., Radburn, M., Kyprianides, A. & Muscat, M. (2021). Understanding ethnic disparities in involvement in 
crime – a limited scope rapid evidence review. Commission on Race and Ethnic Disparities. Available at 
Understanding ethnic disparities in involvement in crime – a limited scope rapid evidence review, by Professor Clifford 
Stott et al - GOV.UK (www.gov.uk) 

   
 
250 
 
ethnic group. In 2022/23 the rates per 1,000 population stood at 20 for people 
from a black background, 13 for those from a mixed background, 9 for those of 
white background, 8 for people from an Asian background and 8 for those from 
any other group.682  
 
10.244 In London, however, we were able to gain a little more insight. In almost half 
(48%, n=2,480) of the 5,174 arrests made by the MPS in 2023, where cannabis 
was mentioned on the custody record and ethnicity was stated, the arrestee was 
black. (Arrests recorded as involving cannabis totalled 5,825 when including 
those where ethnicity was not stated, see para.10.238.) Just over one-third 
(36%) of arrests were of a person from a white background (n=1,847).683 
 
10.245 Data provided by the MPS in response to an earlier Freedom of Information (FOI) 
request shed further light.684 In 2021, white arrestees were more likely to be dealt 
with via a caution (rather than proceed to investigation) than arrestees from other 
ethnic groups – see Table 7. (Figures refer to post-arrest cautions but these can 
be issued without arrest: in 2021, the MPS dispensed a total of 875 cannabis-
related cautions).685 
 
Table 7: Outcomes of MPS-led arrests for cannabis by ethnicity, 2021 
 
 Caution 
Investigation: 
possession  
Investigation:  
intent to supply 
 n % n % n % 
White 
(n=4,635) 250 46 3,218 34 1,167 30 
Black 
(n=5,501) 153 28 3,719 39 1,629 41 
Asian 
(n=2050) 75 14 1,311 14 664 17 
Other 
(n=1,757) 65 12 1,217 13 475 12 
Total*  
(N= 13,943) 543 100 9,465 100 3,935 100 
Source: https://www.met.police.uk/foi-ai/metropolitan-police/d/february-2022/cautions-arrests-supplying-
possession-of-cannabis-january2020-january2022/ 
* Excludes cases where ethnicity was not stated. The total number of custody records made out in 2021 where 
cannabis was noted was 14,423: Cautions = 553; Possession = 9,844; Intent to supply = 4,026. 
 
10.246 In almost 40% of arrests where ethnicity was stated, the arrestee was from a 
black background, and in 28% of records indicating a caution was dispensed, the 
 
682 See Table A_04, Arrest summary data tables: police powers and procedures, year ending 31 March 2023 (second 
edition). Accessed 14th August 2024. 
683 See footnote #678. Accessed 15th March 2024. 
684 Available at https://www.met.police.uk/foi-ai/metropolitan-police/d/february-2022/cautions-arrests-supplying-
possession-of-cannabis-january2020-january2022/ 
685 https://assets.publishing.service.gov.uk/media/6466287fe14070000cb6e1ef/out-of-court-disposals-2022.xlsx 
Included offences of production, supply and possession with intent to supply a Class B drug, and possession of 
cannabis. Accessed 30th January 2024. 

   
 
251 
 
arrestee was black. In contrast, while one-third (33%) of arrests were of a person 
from a white ethnic group, this group accounted for 46% of records ending in a 
caution.  
 
10.247 Put another way, 5.4% of all cannabis-related arrests of people from a white 
ethnic group ended in a caution, compared with 2.8% of people from black 
backgrounds. Thus, white arrestees were almost twice as likely to be cautioned 
than black arrestees.  
 
10.248 Given the likelihood of being S&S multiple times is higher for black than white 
Londoners, the lower rate of cautioning is not surprising. Those caught with 
cannabis on two or more occasions are unlikely to be eligible for a non-arrest 
outcome (and may be arrested on the first occasion, depending on 
circumstances and police use of discretion).   
 
10.249 The majority of all groups, however, were investigated for possession or intent to 
supply cannabis. Here the disproportionality was less marked, i.e. 69% of white 
(n=3,218) and 68% (n=3719) of black arrestees were investigated for 
possession, with 25% (n=1,167) and 30% (n=1,629) accordingly investigated for 
supply. 
 
10.250 While outcomes of specific cannabis-related arrests are unknown, where an 
investigation was mounted for possession or intent to supply it will either have 
concluded with NFA or relevant evidence passed to the CPS. They review the 
case and apply a two-stage legal test: if the evidence is assessed as sufficiently 
strong to mean a court is more likely than not to find the defendant guilty, and it is 
in the public interest to prosecute, an arrestee will be prosecuted.  
 
Prosecutions, convictions and sentencing for cannabis offences686 
 
10.251 The CPS told us the number of prosecutions for cannabis offences has dropped, 
in line with those for other illegal drugs. In 2010, 10,450 prosecutions were 
brought in England & Wales where the principal offence was production, supply 
and possession with intent to supply (PSPWITS) cannabis, with a further 26,422 
for possession. By 2022, they had dropped to 5,324 and 12,350 – falls of around 
49% and 53% respectively.  
 
10.252 This is not surprising given the role of S&S for drugs, as their numbers fell by 
44% across England & Wales between 2010/11 and 2022/23 (from 595,212687 to 
331,856).688 Notably, there is no evidence to suggest drug use rose over that 
period. And fewer prosecutions mean fewer convictions: those for PSPWITS fell 
 
686 Unless otherwise referenced, sources for prosecution, conviction, sentencing and court statistics are at: Criminal 
Justice System statistics quarterly: December 2022 - GOV.UK (www.gov.uk) All-offence prosecutions and 
convictions data tool; Outcomes by Offence data tool; Magistrates Court data tool; Crown Court data tool. 
687 Table SS.02, Stops and searches tables (Police Powers and Procedures England & Wales 2010/11) Accessed 1st 
February 2024. 
688 Table SS_03, Stop and search summary data tables: police powers and procedures, year ending 31 March 2023 
Accessed 1st February 2024. 

   
 
252 
 
from 8,230 in 2010 to 5,469 in 2022689 (a drop of 34%), and for possession from 
25,158 to 11,256 (a fall of 55%). 
 
10.253 Despite the falls, however, cannabis-related offences continue to exert significant 
pressure on court resource, representing 45% of the overall drug prosecution 
caseload in 2022 (a total of 39,514 drug-related prosecutions were brought that 
year). 
 
10.254 The CPS suggested that, where a defendant is charged with possession only, it is 
a first offence and the amount involved is small, they are unlikely to be 
prosecuted (dealt with instead via an OOCD). Unfortunately, without case file 
analysis, administrative data alone shed little light on whether any of those who 
do reach court are first-time offenders or whether aggravating factors, including a 
history of similar offending, have supported prosecution and any subsequent 
sentencing.  
 
10.255 All criminal cases (with adult defendants) begin in the magistrates’ court, but the 
nature and severity of the offence determines whether a case is tried there or at 
Crown Court. Summary offences must be heard in the magistrates’ court, either-
way offences in either court (subject to a magistrate’s decision, although a 
defendant can choose to be tried by Crown Court jury). Indictable-only offences 
must be heard at Crown Court. 
   
10.256 Cannabis-related offences are triable either way.690 Reflecting, however, their 
relative seriousness, PSPWITS offences are more likely to be heard in the Crown 
Court than possession offences: in 2022, just under half (49%) of supply offences 
in England & Wales were sent for trial at Crown Court, with around the same 
proportion convicted in the magistrates’ court. In London, slightly more were 
heard at Crown Court (53%) and slightly fewer convicted in the magistrates’ 
court (40%). 
 
10.257 In comparison, and as we heard from the CPS, most cannabis possession 
offences are heard by magistrates: in 2022, only 2% of cases across England & 
Wales were sent for trial at Crown Court (2.7% in London), with 88% convicted in 
the magistrates’ court. 
 
10.258 A conviction for PSPWITS, not surprisingly, attracts a harsher sentence than 
possession. As shown in Table 8, in 2022 over one-third of PSPWITS offences 
attracted a custodial sentence (average length of 16.6 months) and a further 
 
689 A defendant committed from magistrates’ to Crown Court may not have both courts' processes complete within 
the same year, in which case they would be counted for each stage in the year that the court where it took place 
completed. This means for a given year, convictions may exceed prosecutions or sentences may not equal 
convictions. Defendants who appear before both courts may also be convicted at the Crown Court for a different 
offence to that for which they are counted as having been proceeded against at magistrates’ court, where the offence 
is changed after committal. 
690 See Drug Offences Definitive Guideline (sentencingcouncil.org.uk) Accessed 1st February 2024. 

   
 
253 
 
third a suspended sentence.691 In comparison, 2% of those convicted of 
possession were sent to custody (average length of 1.5 months). 
 
Table 8: Outcomes of convictions for cannabis offences at all courts in England & 
Wales, 2022 
 
Outcome 
Production, supply & 
possession with intent to 
supply (PSPWITS) Possession  
 n % n % 
Absolute discharge 2 <1 104 1 
Conditional 
discharge 89 2 2,219 20 
Immediate custody 2,074 36 232 2 
Suspended sentence 2,053 35 128 1 
Community sentence 1,191 21 1,445 13 
Fine 303 5 6,081 56 
Unknown  43 1 27 <1 
Otherwise dealt with 37 1 674 6 
Total sentenced 5,792 100 10,910 100 
Source: Criminal Justice System statistics quarterly: December 2022 - GOV.UK (www.gov.uk) Outcomes by 
Offence data tool. Totals may not sum to 100% due to rounding. 
 
10.259 Those given community or suspended sentences are actively managed by the 
Probation Service (adults) or Youth Offending Teams (young offenders) for the 
duration of their sentence. Offender managers ensure offenders comply with 
sentence requirements, which can include unpaid work, observing a curfew or 
attending a treatment and rehabilitation programme. 
 
10.260 In London, proportionally slightly fewer of those sentenced for cannabis 
possession (n=3,672) and for PSPWITS (n=1,057) were sent to custody in 2022, 
when compared with the national average: just under 2% (1.7%, 62 offenders) 
and around one-third (32%) respectively, with average sentence lengths of 1.1 
months for possession and 14.4 months for PSPWITS. 
 
10.261 Overall, 14%, (n=2,306) of the 16,702 cannabis-related offences sentenced in 
2022 received an immediate custodial sentence. Any time served in prison has 
widely documented detrimental effects on the individual, their family (particularly 
dependents), friendships and communities. Prison exacerbates harms already 
caused by a conviction, and, while costs to HMPS are dwarfed by those resulting 
from more serious crimes and thus longer prison sentences, they are not minor 
(see para.10.289). 
 
 
 
691 A custodial sentence of between 14 days and up to two years is suspended for a specified period. The offender 
does not go to custody but has opportunity to serve their sentence in the community, in accordance with court-
imposed requirements: non-compliance means they will likely be imprisoned to serve the original custodial term.  

   
 
254 
 
Disproportionality in prosecutions, convictions and sentencing for cannabis offences 
 
10.262 Racial disparities seen in S&S and arrests not surprisingly flow into subsequent 
stages of the justice system, most notably for defendants from black 
backgrounds, who are over-represented at each stage.692 
 
10.263 Disparities are particularly marked among those prosecuted and convicted of 
cannabis offences in London. Despite representing 14% of the capital’s 
population in 2021693, as Table 9 shows, black Londoners made up 44% of those 
prosecuted and convicted for possession and just over one-third of those 
prosecuted (36%) and convicted (37%) for PSPWITS in 2022.  
 
10.264 While at 39% slightly more defendants prosecuted and convicted of PSPWITS 
were white, far fewer were prosecuted for cannabis possession (28%). As over 
half of London’s population overall was white (54%), this group was therefore 
under-represented (as were Asian Londoners). For black defendants, the 
opposite was true. 
 
Table 9: Prosecutions and convictions* for cannabis offences in London by ethnicity, 
2022 
 
  Production, supply 
and possession 
with intent to 
supply 
 
Possession  
  n % n %* 
White  Prosecutions 327 39 959 28 
Convictions 329 39 854 29 
Black Prosecutions 298 36 1,491 44 
Convictions 310 37 1,315 44 
Asian Prosecutions 134 16 552 16 
Convictions 121 14 493 17 
Mixed Prosecutions 39 5 259 8 
Convictions 44 5 213 7 
Other Prosecutions 37 4 119 4 
Convictions 35 4 101 3 
Total** Prosecutions 835 100 3,380 100 
Convictions 839 100 2,976 100 
Source: Criminal Justice System statistics quarterly: December 2022 - GOV.UK (www.gov.uk) Outcomes by 
Offence data tool. Totals may not sum to 100% due to rounding. 
* Some convictions correspond to prosecutions brought in preceding years.  
** Excludes cases where ethnicity was not stated. The total numbers of i) prosecutions and ii) convictions for 
PSPWITS were 1,008 and 989. The total number of i) prosecutions and ii) convictions for possession were 4,340 
and 3,798. 
 
 
692 See footnote #591, Fig. 1.01. 
693 With 21% Asian, 6% mixed ethnicity and 6% from any other background. Regional ethnic diversity - GOV.UK 
Ethnicity facts and figures (ethnicity-facts-figures.service.gov.uk) Accessed 2nd February 2024. 

   
 
255 
 
10.265 Black defendants are also more likely to have their cases heard at Crown Court. 
In 2022, 48% of those charged with PSPWITS were tried in the higher court, 
compared with 42% of white defendants. While the majority of possession 
offences were heard in the magistrates’ court across all ethnic groups, black 
defendants were almost twice as likely to have their case go to Crown Court than 
white defendants (2.9% compared with 1.6%).  
 
10.266 At least some of that difference is probably explained by black defendants being 
more likely than others to choose a Crown Court trial694 (in 2022, 26% chose to 
do so, compared with 19% of defendants from a mixed ethnic background, 17% 
of Asian and other defendants, and 15% of white defendants). The extent to 
which this holds true for drug offences, specifically cannabis, is unclear, although 
we have no reason to believe the situation is any different. 
 
10.267 Research suggests many non-white defendants, continuing from a reluctance to 
admit guilt when found in possession of drugs, do not believe they will receive a 
fair hearing in the magistrates’ court. This can mean they plead not guilty and 
choose a jury trial, where they feel they will be treated more fairly, despite the 
higher sentencing powers available at Crown Court if convicted.695 
 
10.268 In London, however, there was little difference. Around half of both black and 
white defendants charged with PSPWIT were heard at Crown Court (51% and 
49% accordingly). Just under 3% of both groups charged with possession were 
transferred to the higher court (2.8% of black defendants and 2.7% of white). 
 
10.269 With respect to sentencing outcomes for offences in 2022, these were broadly 
similar across ethnic groups,696 although ethnic minority drug offenders were 
more likely to be given custodial sentences than those from white (British) 
backgrounds. White defendants also received on average lower custodial 
sentence lengths than those from other ethnic backgrounds.  
 
10.270 It is possible this was driven by a higher rate of guilty pleas among white 
defendants (which tend to result in shorter custodial sentences). Without detailed 
case analysis, however, the relative role of other factors (including the quantity of 
drugs involved and the part played by the defendant in the crime) cannot be 
determined. 
 
10.271 For cannabis offences, the racial disparities seen nationally in sentencing of drug 
offences overall appear reversed. In 2022, 28% of defendants from a black 
background who were sentenced for a PSPWITS offence across England & 
Wales were sent to custody, compared to 34% of white defendants.  
 
10.272 Consider those from the white British group separately, however, and the more 
usual pattern reappears. Less than one-fifth of that group (17%) received an 
 
694 See footnote #591. 
695 See footnote #665. 
696 See footnote #591. 

   
 
256 
 
immediate custodial sentence for a PSPWITS offence, compared with 76% of 
defendants from a white non-British background (including white Irish).   
 
10.273 In London the situation was no different. Almost one-third (30%) of black 
defendants sentenced for a PSPWITS offence received immediate custody, as 
did 35% of all white defendants. This latter figure, however, masks the fact that 
21% of white British offenders were sent to custody compared with 56% of the 
white non-British group. 
 
10.274 While far fewer custodial sentences were passed for the less serious offence of 
possession of cannabis, proportionally more black defendants than defendants 
from any white background were sent to custody in England & Wales (3% and 
2% respectively) and in London (2% versus 1%).  
 
10.275 But while fewer white British offenders received custody for cannabis possession 
than those from a white non-British background nationally (2% compared to 3%), 
in London the position was reversed. Here, 2% of white British defendants were 
sent to custody, compared with 1% of white non-British defendants. 
 
10.276 Overall, across England & Wales during 2022, over 2,300 individuals served time 
in prison for a cannabis offence at some point (n=2,074 for PSPWITS, n=232 for 
possession). Around one-quarter of the 9,206 custodial sentences handed to 
those convicted of drug offences that year were therefore in response to 
cannabis. (The number in custody at any one time for such offences is lower – for 
example, on 30th June 2024, 33 people were in prison for possession of 
cannabis).697 
  
Cannabis use among those managed by the justice system 
 
10.277 It was put to us that cannabis use among offenders managed by the Probation 
Service and Youth Offending Teams in London is rife. Around 7,000 offenders 
among a caseload of c.22,000 had, we were told, reportedly admitted some use 
of the drug when their individual needs and risk of further offending were 
assessed.698   
 
10.278 Assessments and discussion with offenders highlight how frequently cannabis is 
part of daily life and, as it was put to us, increasingly so over recent years. This is 
across the caseload, not just among those convicted of cannabis offences. Key 
drivers are reportedly easement of mental health problems and anger-related 
issues, particularly for younger offenders, which chimes with evidence we heard 
elsewhere (see chapter 4).  
 
 
697 See Table_1_A_11, Annual Prison Population 2015-2024. Available at Offender management statistics quarterly: 
January to March 2024 - GOV.UK (www.gov.uk) Accessed 5th September 2024. 
698 The primary tool used with offenders aged 18 and over is known as the Offender Assessment System (OASys). 
The tool assesses needs and risks in eight domains: accommodation; education, training and employment; 
relationships; lifestyle; drug misuse alcohol misuse; thinking and behaviour, and attitudes. 

   
 
257 
 
10.279 Those working with offenders in the community reported that many have been 
using the drug since a young age, with early-years trauma and frequent exposure 
to violence part and parcel of their lives. Regular use of high-potency cannabis is 
normalised, mirroring much of what was put to us more broadly about cannabis 
use, particularly among young people across London’s communities.  
 
10.280 Despite perceptions of self-medication among some offenders who use cannabis, 
those who manage them felt it has a detrimental effect. Particularly for regular 
users, the drug was considered to be at least partly responsible for isolating them 
still further from law-abiding society, threatening compliance with sentence 
requirements and compounding wider needs.  
 
10.281 Some suggested that making cannabis more easily available through a relaxation 
of the legal framework would jeopardise attempts to successfully rehabilitate 
those for whom life is already fraught with challenge. On the other hand, its illegal 
status arguably continues to expose them to associated risks that threaten 
broader compliance with the law and, more specifically, individual sentence 
requirements. 
 
10.282 Practitioners reported that cannabis use can seriously threaten an offender’s 
capacity and motivation to engage with and meet the terms of a suspended or 
community sentence. And the stakes are high. Persistent failure for those on a 
suspended sentence is likely to mean serving the original sentence in custody. 
Those on a community sentence risk additional requirements, sentence 
extension or, in the most serious cases, revocation in favour of a custodial 
sentence.  
 
10.283 However, we heard how difficult it is for offender managers working in London to 
secure mental health and addiction support for those on their caseload struggling 
with cannabis use. As we discuss in chapter 9, mental health services in the 
capital (and across the country) are hugely oversubscribed: funding and 
provision has not kept pace with rising demand, particularly since the Covid-19 
pandemic.699 
 
10.284 Even where services are available, funding to commission them is limited. We 
heard offender management tends to prioritise those with addiction to more 
serious drugs, particularly heroin, due to the need to focus resource on the high-
harm/high-risk caseload, i.e. offenders most likely to commit a serious further 
offence.  
 
Demand on police and justice system resources  
 
10.285 A substantial amount of policing and wider criminal justice (and Border Force) 
resource goes into tackling the production, supply, retail and consumption of 
 
699 Also reported in Black, C. (2020). Review of Drugs (parts 1 & 2). Home Office. Available at Independent review of 
drugs by Professor Dame Carol Black - GOV.UK (www.gov.uk) and Home Affairs Committee (2023). Drugs: Third 
Report of Session 2022–23. House of Commons. Available at Drugs - Committees - UK Parliament 

   
 
258 
 
illegal drugs. Based on 2010/11 prices, the annual cost of UK drugs enforcement 
was estimated in 2013 to be £1.1 billion,700 of which £370 million were costs to 
policing, £680 million were borne by the CJS and £70 million by the Border 
Force.  
 
10.286 In 2024 prices701 this equates to an overall price tag of over £1.65 billion 
(including £554 million in policing costs, £1 billion CJS costs and £105 million for 
Border Force). And given its dominance in recorded drug crime, cannabis-related 
enforcement activity is likely to drive a substantial proportion of these costs.  
 
10.287 Costs related specifically to dealing with cannabis sales and consumption have 
also been estimated for policing, criminal justice procedures and the 
implementation of sentencing following convictions for associated offences (using 
2010 prices).702 In 2024 prices, these equated to over £157 million for the total 
cost of cannabis policing alone. 
  
10.288 The cost of administering a formal cannabis warning in 2010 was estimated at 
£150, or £224 in 2024 prices. If all 96,628 cannabis possession offences 
recorded in the year to September 2023 had been dealt with by a formal warning 
only, the cost to police would be around £21.6 million. In reality, of course, many 
proceeded further into the CJS with costs increasing at each stage. 
 
10.289 The most expensive criminal sanction is a prison sentence. In 2022, the average 
custodial sentence length for cannabis possession offences was 1.5 months. For 
PSPWITS offences, it was 16.6 months. Assuming all those thus sentenced (232 
for cannabis possession, 2,074 for PSPWITS) were released from custody at the 
halfway point as per sentencing guidelines,703 this means offenders convicted of 
possession spent around 3 weeks in prison, and those convicted of PSPWITS 
around 34 weeks (8 months, 12 days).  
 
10.290 The average cost of housing one person in prison for one year is almost £50,000 
(£47,434 based on 2021–22 prices),704 so one week costs HM Prison Service 
(HMPS) around £900.705 The cost of three weeks in prison for cannabis 
possession is therefore £2,736, and the cost of 34 weeks in custody for a 
PSPWITS is around £31,000.  
 
10.291 Which equates to annual costs of around £635,000 for imprisoning those 
convicted of cannabis possession, and around £64 million for those convicted of 
 
700 Mills, H., Skodbo, S. & Blyth, P. (2013). Understanding organised crime: estimating the scale and the social and 
economic costs. Research Report 73. Home Office. Crown Copyright. Available at Understanding organised crime: 
estimating the scale and the social and economic costs (publishing.service.gov.uk) 
701 Using Inflation calculator | Bank of England Accessed 5th September 2024. 
702 Bryan, M., Del Bono, E. & Pudney, S. (2013). Licensing and Regulation of the Cannabis Market in England & 
Wales: Towards a Cost–Benefit Analysis. The Beckley Foundation and the Institute for Social and Economic Research 
University of Essex. 
703 Determinate prison sentences – Sentencing (sentencingcouncil.org.uk) Accessed 6th February 2024. 
704 Costs per prison place and costs per prisoner 2021 to 2022 summary (publishing.service.gov.uk) Accessed 6th 
February 2024. 
705 £912.20 per week.  

   
 
259 
 
PSPWITS, making the total cost to HMPS per year of cannabis-related offences 
almost £65 million. 
 
10.292 There are also, of course, costs associated with other sentencing outcomes, 
particularly community sentences. Although these will vary according to the 
nature and number of conditions attached, they are generally dwarfed by costs of 
imprisonment. 
 
10.293 Then there are the human costs of custody. Very short prison sentences are 
widely recognised to provide no opportunity for rehabilitative or substance abuse 
work. They serve solely to punish and around 60% of adults sentenced to six 
months or less in custody reoffend within a year of release.706 The detrimental 
impact of imprisonment and a prison record on family and friendship ties, 
employment (current and future) and mental health, are well known.  
 
10.294 Locking up those convicted of cannabis possession offers, in our view, no 
meaningful benefit to anyone, instead causing significant harm to those 
imprisoned. While we recognise that aggravating factors (including a prior record 
of similar convictions) may mean a magistrate or judge feels it necessary to 
impose the harshest of sentences, our view is that any period in custody is too 
harsh relative to the offence of possessing cannabis sufficient for personal use. 
 
10.295 When it comes to PSPWITS, we similarly consider imprisonment of over one-third 
of those convicted to be a poor use of prison places, which are in increasingly 
short supply.707 While a much greater proportion of those convicted of more 
serious Class A PSPWITS offences were sent to custody in 2022 (69%, n=5,907, 
average sentence length 50.8 months), in our view cannabis poses significantly 
less risk of both individual and societal harm. We are unconvinced that one-third 
of PSPWITS offences are serious enough to warrant a custodial sentence. 
 
10.296 Where non-medical cannabis use is at least decriminalised, individuals found in 
possession of the drug for personal use no longer face sanction and associated 
consequences of criminalisation. Demand on justice system resources inevitably 
falls as a result. (Where legalised, it falls more significantly, although arguably this 
might be offset by increased demand elsewhere, on health services for example, 
see chapters 7 and 8). 
 
10.297 It is undeniable that not subjecting hundreds of thousands of people every year 
firstly to S&S on suspicion of cannabis possession, then to arrest, charge, 
prosecution and, where convicted, a criminal sentence, would free up CJS 
agencies to concentrate on more serious crime – as demonstrated in the 
Lambeth ‘experiment’ (see chapter 4). The effective de-penalisation of 
 
706 Table C2a, Proven reoffending tables (3 monthly), July 2022 to September 2022. Available at Proven reoffending 
statistics: July to September 2022 - GOV.UK (www.gov.uk) Accessed 5th September 2024. 
707 As at 30th August 2024, the prison population in England & Wales stood at 88,350. Operational capacity was 
89,543. See Population Bulletin. Available at Prison population: weekly estate figures 2024 - GOV.UK (www.gov.uk) 
Accessed 5th September 2024. 

   
 
260 
 
possession of cannabis for personal use across the borough for a period of time 
allowed police to reallocate resources elsewhere. 
 
10.298 That said, jurisdictions that have adopted a less stringent approach to non-
medical cannabis than the UK arguably do not have justice systems that became 
awash with resources. Whether savings are genuinely cashable remains a 
significant question.  
 
10.299 Indeed, one estimate (albeit a decade old) suggested financial benefits to the 
CJS of a fully regulated market (i.e. where production, distribution/supply and 
sale are legalised alongside possession) would be relatively modest. Inclusive of 
savings to policing, court procedures and custody and community sentencing, 
alongside tax on earnings lost during incarceration, the estimated total was 
around £300 million (in 2009 prices).708 Slightly more recent analysis estimated 
annual savings inclusive of both criminal justice and health expenditure would be 
approximately £300 million.709  
 
10.300 On the other hand, while legalisation may not offer huge financial benefits to 
policing and the CJS, neither, it seems to us, does it materially increase 
pressures with respect to wider justice considerations. Crime rates do not 
skyrocket following introduction of more permissive approaches, and research 
has reported little evidence of drug-induced crime committed by people who use 
cannabis. One analysis reported only a small amount of volume crime (acquisitive 
and violent) could be attributed to activities of those involved in supplying 
cannabis.710 We think it unlikely this would change with any shift in the legal 
framework.  
 
Legislative interplay: the Misuse of Drugs Act 1971 and the Psychoactive Substances 
Act 2016 
 
10.301 To our mind, it is a quirk of legislative timelines that natural (botanical) cannabis is 
controlled in the MDA at all (see chapter 2 on the history of how cannabis came 
to be scheduled under dangerous drugs legislation in the first place). Had more 
recent legislation, namely the Psychoactive Substances Act 2016 (PSA),711 
existed when the MDA was enacted, we are confident this would have been 
viewed as a more appropriate vehicle of control.  
 
10.302 The PSA, an attempt to end sales of what were known as ‘legal highs’, responded 
to evidence of the potential of such substances (synthetic or natural) to cause 
various health and social harms. It prohibits production, sale and supply 
(including possession with intent to supply) of any psychoactive substance not 
otherwise exempt (see para.10.307). If convicted, an individual may face up to 
seven years in prison, an unlimited fine, or both. 
 
708 See footnote #702, p.104. 
709 Snowdon, C. (2018). Joint Venture: Estimating the Size and Potential of the UK Cannabis Market. IEA Discussion 
Paper No.90, p.39. Available at iea.org.uk   
710 See footnote #702. 
711 Psychoactive Substances Act 2016 (legislation.gov.uk) 

   
 
261 
 
 
10.303  The PSA does not, however, prohibit possession of psychoactive substances 
(except where a person is in a custodial setting). One of the reasons for this, it 
was put to us, was the widespread use of legal highs at the time. Had possession 
become illegal, it would have risked criminalising very many people. Indeed, 
during passage of the PSA, the responsible Minister noted in Parliamentary 
debate that the government did not wish to criminalise individuals for possession 
of psychoactive substances.712 
 
10.304 We think this applies equally to the use of cannabis. In widespread use, its 
inclusion in the MDA means many people in possession of small amounts risk 
what can be distressing and even harmful interactions with law enforcement, 
irrespective of whether a CJS sanction (which can include prison) results. 
Moreover, based solely on suspicion, many more people not in possession of 
cannabis are liable to similar interactions. 
 
10.305 We are not in favour of sending people to prison where their only or principal 
offence is possession of cannabis. On the basis of evidence put to us, we are 
clear that use of the drug carries some risks, but remain unconvinced those are 
sufficiently widespread to justify the sentencing options available while it remains 
under the MDA. In this, we agree with the view expressed in the Runciman 
Report.713  
 
10.306 We therefore consider the PSA to be a more appropriate vehicle through which 
to control the use of natural cannabis for non-medical purposes in the twenty-first 
century. Natural cannabis should be removed from the MDA, meaning as a 
psychoactive substance it would fall under the auspices of the PSA (R30).  
 
10.307 We are confident that cannabis meets the definition of a psychoactive drug, as 
set out in s.2 of the PSA, namely: 
 
2. Meaning of “psychoactive substance” etc 
1) In this Act “psychoactive substance” means any substance which: 
(a) is capable of producing a psychoactive effect in a person who 
consumes it, and 
(b) is not an exempted substance (see section 3). 
 
(2) For the purposes of this Act a substance produces a psychoactive 
effect in a person if, by stimulating or depressing the person’s central 
nervous system, it affects the person’s mental functioning or emotional 
state; and references to a substance’s psychoactive effects are to be 
read accordingly. 
 
 
712 Mike Penning MP, Minister for Policing, Crime & Criminal Justice: Psychoactive Substances Bill [Lords], vol. 600, 
19 October 2015, c.737. Psychoactive Substances Bill [Lords] - Hansard - UK Parliament Accessed 26th April 2024. 
713 See footnote #558, chapter 7, para.37. 

   
 
262 
 
10.308 In s.2(1b), section 3 refers to exempt substances listed in Schedule 1. Included 
are medicinal products, alcohol, nicotine, tobacco, caffeine and food – so long as 
they do not include any psychoactive ingredient. Schedule 1 also includes 
controlled drugs (within the meaning of the MDA 1971), making natural cannabis 
and synthetic equivalents (namely synthetic cannabinoid receptor agonists, 
SCRAs) currently exempt. 
 
Implications of bringing natural cannabis under the Psychoactive Substances Act 2016 
 
10.309 Removing natural cannabis from the MDA would bring it under the purview of the 
PSA. This would, we think, go some way towards reducing (though not 
eliminating, as evidence elsewhere indicates, see chapter 7) the 
disproportionality in policing felt particularly by black communities across 
London. Because the PSA does not prohibit possession of psychoactive 
substances, the use of S&S solely on suspicion of possession of cannabis would 
no longer be permissible.   
 
10.310 Undoubtably matters of disproportionality are a symptom of wider issues, as 
discussed by Baroness Casey714 and others. We do not consider this 
recommendation to be the solution per se but think it would be a good start. 
Indeed, as one witness expressed, were possession of cannabis no longer a 
cause for S&S it would ‘…not [be] a panacea but would go a long way towards 
repairing some of the damage’.  
 
10.311 Treating cannabis within the law in this way would also help ease disparities 
between those who can and those who cannot afford to purchase legally 
prescribed medical cannabis for relief of symptoms of ill health. 
 
10.312 Production, distribution/supply, sale and importation/exportation of natural 
cannabis would, under the PSA, remain illegal activities. However, the maximum 
sanctions for associated offences under this legislation compared with the MDA 
would, in our view, be more commensurate with the risks posed by cannabis 
relative to other controlled drugs. Synthetic cannabinoids would remain wholly 
controlled by the MDA, reflecting their increased risk of harm. 
 
10.313 In making this recommendation we have borne in mind the levels of public 
support for alternative legal approaches to non-medical cannabis (see chapter 
6), set against a dislike of public consumption of the drug.  
 
10.314 We find little evidence to suggest moving control of cannabis from the MDA to the 
PSA would cause use to rise overall.715 (See also para.7.157). Put another way, 
we agree with the suggestion made by the ACMD that there is little evidence of 
use reducing as a result of prohibition of possession.716  
 
714 See footnote #606. 
715 See also discussion in Stevens A., Eastwood N. & Douse K. (2024). In defence of the decriminalisation of drug 
possession in the UK. Drug Science, Policy and Law, 10. doi:10.1177/20503245241239200 
716 UK drug advisers recommended decriminalising possession in 2016, leak reveals | Drugs policy | The Guardian 
Accessed 26th April 2024. 

   
 
263 
 
 
10.315 We consider it unlikely that levels of public consumption would materially change, 
although acknowledge this is a risk. It is therefore important to ensure as far as 
possible that cannabis consumption does not further interfere with, or cause 
irritation to, the wider public. We therefore recommend local regulations 
(byelaws) should be deployed to prohibit and therefore prevent consumption of 
cannabis in public spaces, including parks, squares, beaches and pedestrian 
pavements (R31).     
 
10.316 Moreover, ensuring the production, supply and sale of cannabis remain illegal 
continues to allow police the power to address related behaviours such as 
dealing. As was put to us, particularly where this takes place in public spaces it 
can adversely affect perceptions of individual and community safety. 
 
10.317 We considered whether reclassifying cannabis within the MDA would be more 
appropriate and concluded that we do not wish to reopen this debate. Having 
been previously reclassified as a Class C drug, in 2009 cannabis was moved 
back to Class B, where it has remained since despite calls for it to be reinstated 
in Class C. While we consider Class C more appropriate given risks of cannabis 
relative to other drugs (death due to toxicity is, for example, negligible), as long 
as it remains listed anywhere in the MDA then two key issues remain.  
 
10.318 Firstly, the possession of cannabis remains a criminal offence and, due principally 
to application of S&S powers, this aspect of the law continues to be felt 
disproportionately, particularly by black communities. We heard time and again 
how badly the expectation and experience of S&S affects both individuals and 
wider communities across London.  
 
10.319 And secondly, where a person who uses cannabis is caught carrying small 
quantities, there is a chance – albeit slim in most cases – that prosecution and 
even prison might follow. While the maximum custodial sentence for possession 
of Class C drugs is two years rather than five for Class B,717 as above we 
consider any prison sentence a disproportionate sanction for personal 
possession. More broadly, risk of prosecution and potentially prison clearly has 
little deterrence effect given widespread use of cannabis. 
 
10.320 Reclassifying cannabis as a Class C drug would, in our view, do very little to 
address either of these consequences of the current law, which can pose in 
some cases considerable risk of harm to those affected.  
 
10.321 Furthermore, retaining cannabis within the MDA compounds complexities with 
respect to its medical use. If found in possession, those with a prescription (see 
chapter 11) can avoid police action (as long as they are not smoking their 
prescribed medication, which remains a criminal offence).718 Those who find 
 
717 See s.5 of the MDA 1971, available at Misuse of Drugs Act 1971 (legislation.gov.uk) Accessed 25th April 2024. 
718 See s.16A(3) of the Misuse of Drugs Regulations 2001 as Amended by Regulation 4 of the Cannabis Regulations 
2018 and s.18(1) of the MDA 1971. 

   
 
264 
 
cannabis alleviates symptoms of ill health but who, because they cannot afford to 
access it through legal channels, instead resort to the illicit market, do not have 
that protection. 
  
10.322 We have also had regard to conclusions drawn in recent years by the United 
Nations (UN), World Health Organization (WHO) and International Narcotics 
Control Board (INCB), namely that criminalising possession of cannabis (or any 
illicit drug) is not only disproportionate but fails to stem use. They, too, refer to the 
harm that criminalisation causes to life chances, as well as the distress and 
trauma of S&S and arrest, and associated detrimental impacts on how people 
view the police and engage with them in the future.  
 
10.323 Relatedly, we recognise that, if no longer criminal, a mechanism must be put in 
place to prevent the disclosure of prior criminal records of those who have 
sustained an historic caution or conviction for cannabis possession. This means 
what was categorised as an offence at the time will no longer be disclosable. 
 
10.324 While not as comprehensive as expungement (adopted elsewhere, see chapter 
7) because the record is not deleted, we consider the most expedient way of 
preventing disclosure to be adaptation of the existing system. This prevents a 
caution or conviction being revealed in eligible circumstances. Current disclosure 
rules mean that cautions and convictions for certain offences are ‘protected’, 
meaning they will not be disclosed after 6 years in the case of a caution and 11 
years where there is a conviction (subject to eligibility criteria). We recommend 
the regime governing disclosure of criminal convictions should be amended so 
that cannabis possession offences are protected from disclosure, regardless of 
the date of offence (R32). 
   
10.325 And of course, criminalisation further stigmatises those who choose to use drugs, 
which may deter help-seeking behaviour among those in need of treatment and 
support.719 We acknowledge that, in some cases, the justice process can route 
those in need into such services (where they exist), but consider that, if self-
referral no longer required admission of illegal drug consumption because 
possession was decriminalised, uptake would be higher.  
 
10.326 Recognition of these considerations is leading to a global shift in how drug 
possession for personal use is viewed and responded to. A total of 31 UN 
agencies (under the Chief Executive Board of the UN, which represents all UN 
agencies including the United Nations Office on Drugs & Crime, UNODC) have 
now signed up to a common position first articulated in 2019, which calls on 
member states to consider decriminalisation and adopt alternatives to arrest 
following an instance of drug possession.  
 
 
719 For example, less than one-third (29%) of 1,470 UK students in higher and further education surveyed about 
drugs reported feeling confident to disclose use to their institution without fear of punishment. Students Organising for 
Sustainability UK, Students and Drugs Survey 2020–21 (2021), p.41. Students and Drugs Survey - Research | SOS-
UK Accessed 14th March 2024. 

   
 
265 
 
10.327 To our mind, treating cannabis under the PSA rather than the MDA represents a 
reasonable response both to this call and to issues specific to the UK context. 
Our proposal is also, we believe, in line with advice submitted to government by 
the ACMD towards the end of 2016 (which remains unpublished). That, too, 
highlighted the inequitable way in which drug possession more broadly is treated 
in the MDA as compared to the PSA.720  
 
10.328 We acknowledge it is not a perfect solution to addressing other harms associated 
with prohibition. Issues related to violence and exploitation, inherent in aspects of 
the illicit drug trade, remain. As do the stigma associated with use of what 
otherwise remains an illegal drug, and the risk of consumption of contaminated 
product not subject to regulation and quality controls. We accept, too, that any 
potential to realise economic benefits associated with the legalisation of 
production, supply and sale remains out of reach.  
 
10.329 That said, in our view the extent of such benefits, net of any costs connected 
with, for example, increased demand on public health, remains unclear. And 
while demand on police resources would reduce further (beyond those 
associated with no longer criminalising possession of small quantities of 
cannabis) and some savings would be afforded to the CJS, to what extent, and 
whether these would be cashable, similarly remains unclear.  
 
10.330 Thus, we do not go so far as to recommend wholesale legalisation, for reasons 
that are explored in more detail elsewhere in our report. Principal among these is 
what we consider likely to be a heightened risk for some people, in some 
circumstances, of adverse health consequences of cannabis use – particularly 
where use is frequent and involves high-potency forms of the drug.  
 
10.331 Until evidence from elsewhere is more conclusive as to the impact of legalisation 
on that risk, we consider removing cannabis from the MDA to allow it to be 
controlled under the PSA to be, for now, the most appropriate way of addressing 
some of the more significant harms we find associated with the current legal 
framework in this country.   
 
10.332 There is one further related matter to which we have given thought, which is the 
somewhat contradictory position that no longer criminalising cannabis 
possession, while continuing to treat production and supply as criminal offences, 
creates: people who choose to use the drug remain reliant on the illegal market, 
with all the risks of access that this entails. The public also recognise this 
tension.721  
 
10.333 One solution, which falls short of legalisation but might go some way to 
addressing the issue, is to permit those who wish to, and are able, to cultivate a 
very small number of cannabis plants at home. This has particular merit for those 
 
720 See footnote #716. Accessed 26th April 2024. 
721 See footnote #11. 
 

   
 
266 
 
who find the drug alleviates symptoms of ill health but who cannot afford the high 
costs generally associated with its acquisition (see chapter 11). We think it is a 
measure that merits consideration, irrespective of the position adopted by 
government with respect to wider legalisation.  
 
10.334 That said, we do not recommend the law on home cultivation be reformed as yet. 
Instead, we recommend that central government explore the possibility of 
permitting limited home cultivation, drawing on evidence from jurisdictions 
elsewhere that allow it (such as Washington D.C.). But home cultivation should 
not be legalised until such time as there is clear evidence it significantly reduces 
connection with illegal suppliers, and has public health benefits (R33). A better 
understanding of whether the practice reduces demand for product offered by 
illegal dealers, without simply creating a parallel market through over-production, 
would be valuable. In future, the legal definition of cannabis production could be 
amended to exclude limited home cultivation.  
 
  

   
 
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11. CANNABIS FOR MEDICAL PURPOSES  
 
While not initially within scope of our inquiries, as we progressed the importance of UK 
law regarding medical cannabis, its recent history722 and the implications for legalisation 
of non-medical use became increasingly clear. We welcome coverage of the subject in 
the recent report on drugs issued by the Home Affairs Committee (HAC)723 and, while 
we go into more detail, our findings broadly align with theirs in this area.  
 
We begin this chapter by setting out how the current law regarding use of cannabis for 
medical purposes was arrived at. We then explain the different categories of cannabis-
based medical products that may be prescribed for eligible patients, by whom and for 
what kind of physical and mental health conditions.  
   
We look at why the NHS is more limited in prescribing unlicensed cannabis-based 
medicines than the private health sector, as little seems to have changed since a review 
five years ago of barriers to access via NHS prescription724. We also explore implications 
of the way the system is structured for those who find cannabis alleviates their 
symptoms. This includes costs, as well as the risk of criminal sanction faced by those 
struggling to secure an NHS prescription but who cannot afford a private prescription, 
meaning they may turn to the illicit market.  
 
We finish by describing the medical cannabis industry, the supply chain, and several 
operational challenges. Establishment of a medical industry is an important part of 
development of legal non-medical markets, as it provides infrastructure, knowledge and 
operational capability to meet demand. Indeed, expansion of the market in Germany, 
where medical cannabis has been legal since 2017, likely played a role in advancement 
of recent debates in the country regarding legalisation of non-medical cannabis (see 
chapter 7).  
 
A brief history of cannabis used for medical purposes in the UK 
 
11.1 As set out in chapter 2, cannabis has been used around the world for millennia for 
a range of purposes, including to treat pain and various medical (physical and 
psychological) ailments. Its use in this regard is well documented and cannabis-
based products were legally available in the UK, via the NHS, until 1971 (although 
the drug had not, apart from a brief period of popularity in the late nineteenth 
century, been in widespread medical use). 
 
 
722 For a detailed synopsis see ‘Accessing Cannabis-Based Medicinal Products, 2009–21’ (chapter 8) in Taylor, S. 
(2022). Remedicalizing Cannabis: Science, Industry, and Drug Policy – Intoxicating Histories. McGill – Queen's 
University Press.  
723 Home Affairs Committee (2023). Drugs: Third Report of Session 2022–23. House of Commons, chapter 8. 
Available at Drugs - Committees - UK Parliament Accessed 29th September 2023. 
724 NHS England & NHS Improvement (2019). Barriers to accessing cannabis-based products for medicinal use on 
NHS prescription: Findings and Recommendations. Gateway Reference number: 000842. Available at 
https://www.england.nhs.uk/wp-content/uploads/2019/08/barriers-accessing-cannabis-based-products-nhs-
prescription.pdf Accessed 5th August 2024. 

   
 
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11.2 At which point, the Misuse of Drugs Act 1971 (MDA, ‘the Act’) came into force 
and cannabis for any purpose (medical or non-medical/recreational) became a 
Class B controlled substance, meaning it was illegal to possess, supply, produce 
or import/export. Its classification meant it was considered to have ‘no known or 
limited medical use’, thus ending medical prescriptions for cannabis. This mirrored 
the designation of cannabis in the United Nations 1961 Single Convention on 
Narcotic Drugs (ratified in the UK in 1964, amended by the 1972 protocol, and 
hereafter ‘the Convention’) as having ‘extremely limited medical or therapeutic 
value’.  
 
11.3 Article 2.5 (b) of the Convention, however, allowed governments the power to 
permit the prescription of cannabis and cannabis resin products without 
renegotiation of the international conventions, where they were satisfied that 
‘prevailing conditions… render it the most appropriate means of protecting the 
public health and welfare…’.725  
 
11.4 The UK, however, was not at that time satisfied this was the case and natural 
cannabis and its extracts remained prohibited for both medical and non-medical 
use. A manufactured, synthetic cannabinoid, however, which mimics the effects of 
THC, the principal psychoactive compound found in natural cannabis, was 
permitted. Nabilone was duly licensed in 1982 for hospital-based treatment of 
chemotherapy-related nausea, where a patient was deemed unresponsive to 
other treatments.726 
 
11.5 The Runciman Report727 details why cannabis in its natural plant form had 
previously been considered unsuitable for medical use. Having, however, 
assessed the various perspectives and their underpinnings, and considered 
findings from several other reviews, the authors concluded there was in fact 
evidence of therapeutic benefit for people with certain serious illnesses, and that 
these benefits outweighed any potential harm (to the individual).  
 
11.6 Accordingly, they agreed with the recommendation from the House of Lords 
Select Committee on Science and Technology in 1998728 that cannabis and 
cannabis resin be moved from Schedule 1 to Schedule 2 of the Misuse of Drugs 
Regulations 1985 (which allow changes to the classifications or scheduling of 
drugs listed in the MDA 1971).  
 
11.7 Had the government accepted that recommendation, it would have permitted the 
possession of cannabis for medical purposes, with doctors able to prescribe, albeit 
as an unlicensed medicine, and pharmacists able to supply.  
 
 
725 FINAL ACT OF THE UNITED NATIONS CONFERENCE (unodc.org) article 2.5 (b) p.3. Accessed 6th September 
2023. 
726 House of Lords (1998). Science and Technology Ninth Report: Chapter 5 – Medical Use of Cannabis and 
Cannabinoids: Review of the evidence, para.5.11, Box 4. Available at House of Lords - Science and Technology - 
Ninth Report (parliament.uk) Accessed 1st August 2024. 
727 Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971 (2000). The Police 
Foundation.  
728 See footnote #726. Accessed 25th September 2023. 

   
 
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11.8 Notably, a report from the British Medical Association (BMA) around the same 
time also recommended specific cannabinoids be rescheduled for medical 
prescription. Crucially, it connected that with the need for further understanding, 
recommending that impacts on receiving patients should be monitored long-term 
and research into potential therapeutic effects of cannabis on specified conditions 
be undertaken.729  
 
11.9 The government, however, rejected the recommendation from the Select 
Committee, leading the Runciman Report to issue the same recommendation, 
alongside another calling for cannabis to be transferred from Class B to Class C of 
Schedule 2 of the MDA. In recognition of the time this would likely take, the report 
also recommended creation of a ‘defence of duress of circumstance on medical 
grounds for those accused of possessing, cultivating or supplying cannabis’.730  
 
11.10 They had thus accepted evidence of the medical relief that cannabis was 
considered to bring to some serious health conditions, and sought to protect users 
in advance of a change to the drug’s legal status. 
 
11.11 Nothing changed, however, until 2010, when the Medicines and Healthcare 
products Regulatory Agency (MHRA) in the UK licenced a prescription-only 
cannabis-based medicine (in the form of an oral spray) for treatment of spasticity 
resulting from multiple sclerosis (MS).731 Nabiximols – commonly known by the 
brand name ‘Sativex®’ – contained both of the two principal active elements in 
botanical cannabis, namely delta-9-tetrahydrocannabinol (THC) 
and cannabidiol (CBD).732  
 
11.12 However, the National Institute for Health and Care Excellence (NICE) believed 
Sativex® offered poor cost-effectiveness, meaning the NHS resisted funding its 
prescription for qualifying patients. It was not until 2014 that the NHS in Wales 
agreed to fund Sativex® for MS patients, and some years later that it became 
available on the NHS in England, Scotland and Northern Ireland (see next 
section). 
 
11.13 So, until 2018 cannabis remained largely prohibited for both non-medical and 
medical use in the UK. Continued to be listed as a Schedule 1 drug in the Misuse 
of Drugs Regulations (MDR) 2001,733 it was thus deemed – with the exception of 
Sativex®, which had been reclassified as a Schedule 4 drug – to have no 
therapeutic value. 
 
 
 
 
729 British Medical Association. (1997). Therapeutic Uses of Cannabis. Harwood Academic Publishers, UK.  
730 See footnote #727, para.68, p.113. Accessed 25th September 2023. 
731 For detailed background see Crowther, S.M., Reynolds, L.A. & Tansey, E.M. (Eds) (2010). The Medicalization of 
Cannabis. Wellcome Witnesses to Twentieth Century Medicine (40). London: Wellcome Trust Centre for the History 
of Medicine at UCL.  
732 See chapter 4 for brief description of components of botanical cannabis. 
733 The Misuse of Drugs Regulations 2001 (legislation.gov.uk) 

   
 
270 
 
Recent changes to the status of cannabis for medical use in the UK 
 
11.14 In 2018, an important shift took place with respect to acceptance of the potential 
medical value of cannabis – at least in terms of a limited number of severe health 
conditions. A two-part review commissioned by the Home Secretary (the Home 
Office, HO, has responsibility for drug policy and licencing in the UK)734 concluded 
evidence had emerged of the medicinal benefit of cannabis for certain conditions, 
and recommended cannabis-based products for medicinal use (CBPMs) of 
appropriate medical standard be moved from Schedule 1 to Schedule 2 of the 
MDR 2001.  
 
11.15 The impetus for this review originated, at least in part, in an ongoing high-profile 
publicity campaign that began earlier in 2018.735 This focused on the plight of two 
children suffering rare forms of very severe epilepsy that cannabis-based 
medication (of a different type to Sativex®) procured from outside the UK had 
been alleviating. Their parents had attempted to bring this into the UK from 
Canada and the Netherlands (where CBPMs were legally available), whereupon it 
had been confiscated at the border.  
 
11.16 The review led to the rescheduling of CBPMs via regulations enacted in November 
2018 and set out in the Misuse of Drugs (Amendments) (Cannabis and Licence 
Fees) (England, Wales and Scotland) Regulations 2018.736  
 
11.17 The move permitted, in certain circumstances, the prescribing of cannabis-based 
products that fall into one of three categories, depending on their scheduling 
under the MDR 2001 and whether they have received marketing authorisation 
from the MHRA (or its European equivalent, the European Medicines Agency). A 
follow-up report commissioned by the HO from the Advisory Council on the 
Misuse of Drugs (ACMD) and published in 2020737 sets out the details, but broadly 
they are as follows: 
 
i. Licensed cannabis-based products for medicinal use (CBPMs): no products 
currently available in the UK fall into this category. 
ii. Licensed cannabis-based medicines: three such products are available in the 
UK, namely Sativex® (containing natural THC and CBD in spray form), 
Epidyolex® (natural CBD only, taken via oral solution) and Nabilone (man-
made THC only, taken in capsule form). 
iii. Unlicensed CBPMs: these include certain strains of herbal cannabis in flower 
or bud form. Levels of THC and CBD vary but are typically higher than those 
present in licensed medicines. Recommended route of administration is 
 
734 Part one was led by the then-Chief Medical Officer for the UK government, part two by the Advisory Council on the 
Misuse of Drugs (ACMD). 
735 See for example https://www.theguardian.com/society/2018/jul/26/medicinal-cannabis-how-two-heartbreaking-
cases-helped-change-law Accessed 5th August 2024. 
736 The Misuse of Drugs (Amendments) (Cannabis and Licence Fees) (England, Wales and Scotland) Regulations 
2018 (legislation.gov.uk) 
737 Cannabis-based products for medicinal use (CBPMs) in humans (publishing.service.gov.uk) Accessed 25th 
September 2023. 

   
 
271 
 
through a medical vaporiser device, and cannabis oils (containing THC) are 
also available for oral administration. 
 
11.18 To qualify as a CBPM, a product must:738 
• Contain cannabis, cannabis resin, cannabinol or cannabinol derivatives. 
• Be produced for medicinal use in humans, and 
• Be a medicinal product, or a substance or preparation for use as an ingredient 
of, or in the production of an ingredient of, a medicinal product. 
 
11.19 Prescribing of both unlicensed CBPMs and licenced cannabis-based medicines is 
very limited and unlicensed CBPMs are particularly difficult to access via the NHS. 
This is due to concerns regarding safety, efficacy and quality: herbal cannabis 
cannot be exactly replicated time and again because it is a botanical. This means 
it fails the test required for licenced medicines – namely that what is dispensed on 
one occasion is guaranteed to be identical to that dispensed on a subsequent 
occasion, within and across patients.  
 
11.20 There also remains a lack of what clinicians and regulators deem sufficiently high-
quality evidence (notably from comparative randomised controlled trials utilising 
large numbers of patients) of the effects of unlicensed CBPMs in medical settings 
to treat a variety of conditions, including chronic pain.  
 
11.21 The lack of reliable and replicable evidence, together with concerns regarding 
potential exposure to unknown harmful effects of component elements and fears 
of diversion to non-medical users once prescribed, means the Royal College of 
Physicians (RCP) and NICE do not support the use of unlicensed CBPMs for most 
medical purposes. Their position is reflected in associated guidance and 
recommendations739. While not mandatory for the NHS to follow that guidance, in 
reality practitioners tend not to prescribe outside its parameters, so unlicensed 
CBPMs are practically available largely through paid-for private healthcare only.  
 
11.22 This lack of support from influential stakeholders and advisory bodies is 
undoubtably a blocker to any future increase in use of unlicensed CBPMs, 
meaning what is in effect a two-tier system (as we discuss below) will continue to 
exist.  
 
11.23 Ongoing research is beginning to address the evidential issue, including through 
the Cannabis & Me study led by King’s College London740 (funded by the Medical 
Research Council, MRC, who have supported a substantial body of wider work 
into the effects of cannabis, including research exploring its impact on 
development of schizophrenia).741 The study focuses on effects of cannabis on the 
brain and how biological, behavioural and environmental factors might impact 
those effects, considering the role of different strains and potency of the drug. 
 
738 See the Royal Pharmaceutical Society’s Medicines, Ethics and Practice guide, edition 46, July 2023. 
739 See for example https://www.nice.org.uk/guidance/ng144/chapter/Recommendations Accessed 5th August 2024. 
740 See King's College London spearheads the largest ever independent study into cannabis use - King's College 
London (kcl.ac.uk) Accessed 5th October 2023. 
741 See Medical Research Foundation | Dissemination programme to debunk… Accessed 25th March 2024. 

   
 
272 
 
 
11.24 Separately, the Project Twenty21 (T21) study742 is exploring the impact of 
unlicensed CBPMs on a range of symptoms including pain relief, insomnia, anxiety 
and post-traumatic stress disorder (PTSD). We consider, however, that 
investment in a more comprehensive programme would hasten generation of 
reliable evidence of the extent and nature – including side effects – of medicinal 
impacts of cannabis. (This would also ensure opportunity for exaggeration either of 
the therapeutic benefits or, conversely, the lack of such benefits, would be 
significantly reduced.) In this regard, we agree with the recommendation made by 
the HAC, namely that: 
 
‘…the Government supports researchers to conduct randomised control trials 
into the effectiveness of CBPMs to treat chronic pain. If the evidence base 
supports this, and it is deemed to be cost-effective, we recommend that the 
Government enables the use of CBPMs for this purpose and works with 
clinicians to ensure that it is a treatment option in appropriate cases.’743 
 
11.25 We go further, however, and recommend that research programmes such as the 
T21 and Cannabis & Me studies should be funded to explore the effectiveness of 
CBPMs in treating a wider range of conditions, including but not limited to chronic 
pain. These must be funded and led by independent, objective bodies such as the 
Medical Research Council (R34). 
  
Licensed cannabis-based medicines 
 
11.26 Licensed cannabis-based medicines are available via NHS prescription744, 
although they are heavily regulated and available only for a limited number of 
conditions, namely: 
• Children and adults with rare, severe forms of epileptic related seizures 
(Epidyolex®). 
• Vomiting or nausea caused by chemotherapy (Nabilone). 
• Adults with muscle stiffness and spasms caused by MS (Sativex®).   
 
11.27 If conventional medicines have failed to provide relief, a GP may refer a patient to 
a doctor listed on the Specialist Register of the General Medical Council (GMC), 
whose role is to decide if medical cannabis is the right option. In 2019, around 
96,000 doctors were listed on this register,745 but we heard that fewer than 200 
have applied and been approved to prescribe medical cannabis. 
 
11.28 Those specialist doctors may then make an initial prescription for Sativex®, 
Epidyolex® or Nabilone. A GP (as well as nurses and pharmacists) may issue 
subsequent prescriptions under a principle known as ‘Shared Care’, although they 
must have formal direction to do so and in practice are often reluctant.  
 
 
742 Led by Drug Science. 
743 See footnote #723, para.234. Accessed 29th September 2023. 
744 https://www.medicines.org.uk/emc Accessed 5th August 2024. 
745 Medical register reaches 300,000 for the first time - GMC (gmc-uk.org) Accessed 27th September 2023. 

   
 
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11.29 It was suggested to us by several witnesses that GPs and other partners in multi-
disciplinary teams (MDTs) lack understanding of the medicines and their 
applications. This is in part because medical education and training (including for 
associated professions such as pharmacists and pharmacy technicians) tends not 
to cover the endocannabinoid system, or at least does not do so in any depth (see 
chapter 9.)746 The currently limited nature of their permitted applicability also 
means a GP is likely to have few patients presenting symptoms eligible for 
Sativex®, Epidyolex® or Nabilone. 
 
11.30 It was also suggested fear of reputational risk may be a factor: the use of cannabis 
in medical treatment remains contentious with a certain degree of stigma – no 
doubt in part because of the aforementioned lack of support among key bodies 
and alongside wider stigma associated with recreational use of an illegal drug. As 
a result, doctors may harbour some professional concern about defending 
prescription of medicines involving cannabis in medical spheres. 
 
11.31 Add in the time constraints and daily pressures faced by NHS doctors and others 
involved in primary care and it is not surprising that, firstly, relatively few have 
sought the additional training required to join the Specialist Register, and, 
secondly, may be uncomfortable with assuming legal responsibility for a medicine 
and the consequences of its use (standard requirements of any prescriber) about 
which they know very little, if anything at all. 
 
11.32 This, too, applies to pharmacists who not only are also liable for the products they 
dispense but must understand relevant supply chains and availability of medicines. 
We look in more depth at supply chains for medical cannabis later in this chapter.   
 
11.33 Moreover, while the Explanatory Memorandum to the MDR 2001747 states GPs 
can in fact prescribe licensed cannabis-based medicines, NHS England 
guidance748 advises the practice is limited to doctors on the Specialist Register. 
While not mandatory, GPs are understandably reluctant to operate outside that 
guidance, which means in practice that first prescriptions are issued by a 
specialist prescriber and relatively few prescriptions overall for these licensed 
medicines have been issued to date – a total of 10,244 over a three-year period 
(see Table 10).  
 
11.34 The NHS Business Services Authority was able to identify a unique patient for 
between 47% and 82% of those 10,244 prescriptions issued for each licensed 
medicine. This means that, while the figure is likely to be an underestimate, at 
least 1,479 NHS patients received a licensed cannabis-based medicine between 
2020 and 2023.749 
 
746 See also section 3.3, Barber, S. & Rough, E. (2021). Medical Use of Cannabis. House of Commons Library, No. 
8355. CBP-8355.pdf (parliament.uk) Accessed 27th September 2023. 
747 The Misuse of Drugs (Amendments) (Cannabis and Licence Fees) (England, Wales and Scotland) Regulations 
2018 (legislation.gov.uk) para.7.15. Accessed 19th July 2024. 
748 See footnote #64 in Barber, S. & Rough, E. (2021). Medical Use of Cannabis. House of Commons Library, No. 
8355. CBP-8355.pdf (parliament.uk) Accessed 27th September 2023. 
749 Refers to prescriptions issued in England and dispensed in England, Wales, Scotland, Guernsey, Alderney, Jersey 
and the Isle of Man. 

   
 
274 
 
Table 10: Number of prescriptions issued in England for licensed cannabis-based 
medicines, 2020–2023 
 
 Licensed cannabis-based medicine prescriptions issued in England* 
 Sativex® (n) Epidyolex® (n) Nabilone (n) Total (n) 
2020/21 2,112 2 578 2,692 
2021/22 2,688 4 489 3,181 
2022/23 3,833 36 502 4,371 
Total 8,633 42 1,569 10,244 
 *Source: bespoke analysis conducted for the LDC by the NHS Business Services Authority (NHSBSA). Figures 
refer to prescriptions issued in England and dispensed in England, Wales, Scotland, Guernsey, Alderney, Jersey 
and the Isle of Man. They differ slightly from published statistics, which include only prescriptions issued and 
dispensed in England, available at Prescription Cost Analysis – England – 2021/22 | NHSBSA 
 
11.35 It seems to us that a better understanding among healthcare professionals – as 
well as associated leadership bodies and regulators – of the endocannabinoid 
system and how cannabis products might treat various symptoms of ill health 
would be beneficial. Low levels of knowledge are not, however, unique to the UK – 
including in jurisdictions where medical cannabis has been legal for a much longer 
period of time.  
 
11.36 Indeed, the experts who reviewed Canada’s Cannabis Act reported similar, 
despite medical cannabis being legal across the country since 2001. They found 
the lack of information, guidance and training on the use of cannabis for medical 
purposes to negatively impact on patient care (although noted steps taken by 
nursing and pharmacy professions to improve matters for their members).750  
 
11.37 In our view, it is a matter for the various health bodies and regulators (including the 
RCP, NHS England, NICE and the General Pharmaceutical Council, GPhC) to 
explore scope for addition of cannabis-related material to relevant education and 
training curriculums. Unquestionably there will be constant pressure to add new 
material in relation to a very wide range of medical considerations, and it is for 
those experts to consider cannabis as a subject relative to other priorities. 
 
11.38 However, in support of advancing basic knowledge across the sector, health 
bodies should consider how recommendations in the Canadian Review to provide 
information and evidence on the use of cannabis for medical purposes could be 
drawn on and actioned in England. This should include use of both licensed and 
unlicensed CBPMs (R35).  
 
Unlicensed CBPMs 
 
11.39 Unlicensed CBPMs, i.e. strains of whole-plant cannabis grown for medical use 
(and containing various ratios of CBD and THC alongside a range of terpenes – 
 
750 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca pp.70–1, recommendations 
44 & 45. Accessed 26th March 2024. 

   
 
275 
 
see chapter 4) are known as ‘specials’751 due to their unlicensed status. The initial 
decision to prescribe an unlicensed CBPM must legally be made by a doctor listed 
on the Specialist Register752 who has determined the product to be a valid 
treatment option following exhaustion of traditional medical routes. Provision does 
exist for continuation of prescribing by a doctor or other qualified health 
professional not on the Register – but this must remain under the direction of the 
specialist.  
 
11.40 This means that technically, unlicensed CPBMs are available through the NHS 
where a doctor on the Specialist Register has agreed suitability. Because of their 
unlicensed status, however, applications must be made to the local trust for 
funding – and these, we heard, are almost always turned down. As we understand 
it, to date fewer than ten such applications have been approved.  
 
11.41 This is likely due at least in part because of the current lack of endorsement for 
their use from the likes of NICE and the RCP, due to the challenge of 
demonstrating efficacy in the traditional way (via double-blind, placebo-based 
randomised controlled trials). As a result, the overwhelming majority of unlicensed 
CBPMs are prescribed via private healthcare. 
 
11.42 Based on evidence presented to us from those involved with medical cannabis – 
as suppliers, prescribers or patients – we are inclined to agree with the view 
expressed to the Health & Social Care Committee in 2019 that guidelines 
governing prescribing of unlicensed CBPMs (and licensed cannabis-based 
medicines) are too restrictive753  
  
11.43 Given the hundreds of compounds contained in the cannabis plant, the number of 
permutations that would need to be rigorously tested in the way of simpler medical 
formulations used in conventional medicine would be nigh on infinite. This 
suggests a different approach to testing and guidelines for medical cannabis that 
better accounts for its natural composition would be beneficial.  
 
11.44 Certainly, those we heard from who prescribe and dispense unlicensed CBPMs 
were optimistic about their potential to optimise quality of life. No one argued they 
are a panacea, but they were described as having elicited very positive outcomes 
with relatively minimal side effects.  
 
11.45 And patients themselves have similarly testified to the notion that medical 
cannabis has improved symptoms of a range of mental and physical health 
conditions, often allowing a reduction in use of traditional medicines (see also 
para.11.66) with reportedly few side effects.754  
 
751 Defined by the MHRA as a product which “has been specially manufactured or imported to the order of a doctor, 
dentist, nurse independent prescriber, pharmacist independent prescriber or supplementary prescriber for the 
treatment of individual patients”. See footnote #724, para.8. 
752 NHS England » Cannabis-based products for medicinal use (CBPMs) Accessed 19th July 2024. 
753 Oral evidence - Drugs policy: medicinal cannabis - 19 Mar 2019 (parliament.uk) Q51. Accessed 28th September 
2023. 
754 Beckett Wilson, H. & Metcalf McGrath, L. (2023). ‘It’s a big added stress on top of being so ill’: The challenges 
facing people prescribed cannabis in the UK. International Journal of Drug Policy, 122. Elsevier. 

   
 
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11.46 This does not mean, however, that cannabis used to relieve symptoms of ill health 
is without risk, particularly when over-used. The Canadian Review, for example, 
spoke of adverse effects including anxiety and paranoia.755 There is also emerging 
evidence of the potential for medicinal cannabis to elicit symptoms of Cannabis 
Use Disorder (CUD, see chapter 8).756  
 
11.47 There are difficulties in isolating those who take the drug solely for medical 
reasons from those who use it for non-medical purposes, or indeed for both. 
Symptoms of CUD, however, most commonly withdrawal and tolerance, have 
been reported in up to 25% of people using cannabis for medical reasons.757 As 
with non-medical cannabis, higher frequency of use and certain demographics 
(such as being younger and male)758 may increase risk.   
 
11.48 The potential for medical-use patients to develop CUD suggests those being 
prescribed unlicensed CBPMs should be regularly assessed for symptoms. The 
extent to which this happens currently, however, is not clear to us. Collation of 
assessment data would also help medical professionals and researchers develop 
a more complete understanding of population-level prevalence of the disorder 
among patients, particularly as the medical cannabis industry expands.  
 
11.49 The potential for adverse effects should be made clearer than, in our view, is 
apparent at present. We accept the need to develop understanding of risks and 
variance according to reason for use (some evidence, for example, suggests 
treating chronic pain with medicinal cannabis may heighten risk of CUD)759 and 
explore how these might be mitigated through type and strength of the drug. 
Public health messaging should underline the fact that using cannabis to alleviate 
medical symptoms, whether authorised by a medical practitioner or not, is not risk-
free.  
 
11.50 As with non-medical cannabis, risk of adverse consequences of medical use is 
probably heightened by use of high-potency product. As a result, those who find 
the drug alleviates symptoms but who cannot afford the cost of private 
prescription may be more exposed, as the vast majority of cannabis available 
through the illicit market is high-strength. We discuss the ramifications of 
affordability later in this chapter. 
 
11.51 More positively, licensed products must meet stringent quality controls so 
prescribing doctors can be confident in safety and consistency. In practice this 
 
755 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.83.  
756 Lapham, G.T., Matson, T.E., Bobb, J.F., Luce, C., Oliver, M.M. … & Bradley, K.A. (2024). Prevalence of Cannabis 
Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal. JAMA 
Network Open, 6(8). doi:10.1001/jamanetworkopen.2023.28934 
757 Dawson, D., Stjepanović, D., Lorenzetti, V., Cheung, C., Hall, W. & Leung, J. (2024). The prevalence of cannabis 
use disorders in people who use medicinal cannabis: A systematic review and meta-analysis. Drug and Alcohol 
Dependence, 257. Elsevier. 
758 Ibid. 
759 Ibid. 
 

   
 
277 
 
means they must meet the EU Good Manufacturing Practice (GMP) standard. 
Importation (all are currently imported products, though this is changing, see 
para.11.100) requires MHRA approval and an HO import license. All clinics in 
England are audited by the Care Quality Commission (CQC) and dispensing 
pharmacies in Great Britain are regulated by the GPhC. 
 
11.52 Largely available only via a small infrastructure of private clinics and pharmacies, 
specials may be considered suitable, for eligible patients, for treatment of a wider 
range of medical needs than licensed cannabis-based medicines. This is due to 
their greater range of respective strengths, formulations, and ratios of constituents 
(namely CBD and THC).   
 
11.53 Eligible patients are those with a particular diagnosis from a health professional 
(GP, specialist consultant etc) who have tried two non-cannabis-based treatments 
without success. Diagnoses include those for Alzheimer’s disease, Crohn’s 
disease, glaucoma, endometriosis, pain and nausea, as well as a range of mental 
health conditions including anxiety, depression and PTSD.   
 
11.54 Medical cannabis patients range in age from their late teens to their nineties, 
though those aged under 25 are treated as a vulnerable group due to risks that 
cannabis poses to the developing brain (brain maturation does not complete until 
around the age of 26; see chapter 8). Prescriptions are accordingly lower in 
volume and strength and are largely limited to oil-based products. Given evidence 
suggesting heightened risk of CUD in younger users, this is welcome. 
 
11.55 As with all private healthcare, an eligible patient must pay for the service and 
prescribing specialist doctors (many also have NHS roles) work with private 
medical cannabis clinics, of which several operate in the UK. The standard 
process adopted by most if not all is as follows: 
 
i. Prospective patient applies (typically online) and shares their medical records 
(or gives permission for the clinic to access on their behalf).   
ii. The application is reviewed by a clinical team, who will invite the applicant to 
book an online consultation if eligible. As per regulations, a key criterion is 
that the condition for which medical cannabis is sought must be registered 
with the GP. 
iii. A further regulatory requirement stipulates applicants must have tried and 
exhausted two other forms of prescription medicine or alternative therapy 
(e.g. anti-depressant medication, acupuncture). 
iv. Symptoms or a formal diagnosis of psychosis will almost always render an 
individual ineligible (see chapter 8 for discussion of the dynamic between 
psychosis and cannabis use). 
v. A clinical MDT assess whether medical cannabis would be suitable and agree 
a prescription.  
vi. If approved, a prescription is sent to a pharmacy (of which there are around 
20 across the UK currently set up to readily provide medical cannabis) and 
issued to (usually) the patient’s home. Cannabis flower prescriptions are 
typically intended for use with a dry-herb device that allows it to be heated 

   
 
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and inhaled as a vapour; other products are designed for topical application 
or oral intake. Patients must sign a waiver confirming they will neither smoke 
a dry herb prescription760 nor pass it to anyone else.  
 
11.56 Regulations require a follow-up appointment 30 days after the prescription is 
issued, after which two further 30-day prescriptions can be issued before the cycle 
begins again. Patients must pay for all appointments and prescriptions. 
 
11.57 As part of the consultation process, prescribing clinicians discuss with the patient 
any experiences of illegal cannabis and what they seek from medical cannabis. 
This typically involves consideration of the terpenes that might benefit particular 
conditions, as well as the most effective levels of CBD and THC. An important 
element of the process, this ensures patients are well acquainted with constituents 
of the cannabis plant and how they feature in their medicine.  
 
11.58 The relationship with a patient’s GP is key. A clinic is required to share with the GP 
all consultation notes and prescriptions, and, if a prescriber considers there to be 
medical issues beyond the focus of the cannabis consultation, they will advise a 
patient returns to their GP. Similarly, the GP should keep the clinic informed of any 
changes in the patient’s condition or other prescribed medication.  
 
11.59 The GP also plays an important role in ensuring patients do not sign up to receive 
prescriptions from more than one clinic simultaneously: a patient can transition 
from one clinic to another but must have a discharge letter from the first. If a GP 
receives a request from a second clinic but has not seen a discharge letter, they 
should refuse the request.  
 
11.60 This is presumably in an attempt to avoid the situation in the 1950s and 1960s 
with respect to private-sector dispensation of opiates and cocaine for medical use: 
patients seeking access through more than one practitioner was common.761  
 
11.61 Clinics report receiving several thousand enquiries a month from prospective 
patients, of which around 10% are typically deemed eligible for a consultation. The 
majority of those (80–85%) go on to receive a prescription, although the relatively 
small number of doctors on the Specialist Register limits the speed at which 
prescriptions can be issued.  
 
11.62 We heard this is more acute in cases where cannabis is sought for mental health 
conditions, as the Register is particularly low on psychiatrists able to prescribe 
cannabis. While initiating the prescription of medical cannabis remains limited to 
doctors listed on the Specialist Register, given the number of patients seeking 
such treatment is rising it would seem prudent to encourage more doctors – 
especially psychiatrists – to add this responsibility to their portfolio.  
 
 
760 Smoking prescribed cannabis medication is a criminal offence; see s.16A(3) of the Misuse of Drugs Regulations 
2001 as amended by Regulation 4 of the Cannabis Regulations 2018 and s.18(1) of the MDA 1971. 
761 Mold, A. (2008). Heroin. The Treatment of Addiction in Twentieth Century Britain. Northern Illinois University 
Press. 

   
 
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11.63 In terms of demand for unlicensed CBPMs, a total of 89,239 prescriptions were 
issued between November 2018 and July 2022762 (there are no official figures on 
the number of patients issued those prescriptions, though one recent estimate put 
it at around 20,000).763 While these data cover a slightly different and longer time 
period (almost four years) they nonetheless highlight a large gap between the 
number of NHS prescriptions issued for licensed cannabis-based medicines 
(10,224 over three years) and private prescriptions for unlicensed CBPMs – albeit 
the two types meet different medical needs.  
 
11.64 And private prescriptions do not come cheap: we understand average monthly 
costs (including initial consultation, prescriptions and follow-up fees) can exceed 
£300, depending on amount and type of product required. Some clinics offer a 
discounted rate for those on limited means (and participants in the T21 study, see 
para.11.24, are also eligible for a discount on certain products) but nonetheless 
the costs attached to private consultations remain unaffordable for many.  
 
Drivers for choosing prescribed unlicensed CBPMs  
 
11.65 People using cannabis for medical purposes find it provides relief where 
conventional medication has failed: their aim is to treat their condition, not get 
high. Particularly common among those with conditions causing severe and 
chronic pain is a desire to stop taking prescription opioids – a desire shared by 
government and health bodies who have raised considerable concern about 
opioid prescribing rates in the UK.  
 
11.66 So much so that there has been a recent crackdown on opioid prescribing764 and 
it seems to us anything that can help this effort should be fully considered. One 
survey (supported by the cannabis industry) reported the majority of participating 
medical cannabis patients were previously prescribed pharmaceuticals for their 
condition: since using prescription cannabis, 38% claimed to have stopped their 
use entirely while 46% reported using fewer.765  
 
11.67 It was put to us that around 90% of patients seen by private clinics have previously 
self-medicated with illegal cannabis (the survey above reported similar – 87% of 
participants reported consuming cannabis before accessing a medical 
prescription).766 And while a handful are referred to a clinic by their GP, most self-
refer as the GP focus tends to be on licensed medicines. This is unsurprising given 
the lack of systematic education regarding how cannabis affects the body and the 
way in which CBPMs operate.  
 
 
762 Written questions and answers - UK Parliament UIN 117459, tabled on 6 January 2023, answered on 13 January 
2023. Accessed 28th September 2023. 
763 Survey reveals broad spectrum of issues facing UK cannabis patients (cannabishealthnews.co.uk) Accessed 29th 
September 2023. 
764 NHS England » Opioid prescriptions cut by almost half a million in four years as NHS continues crackdown 
Accessed 28th September 2023.  
765 See footnote #763. 
766 Ibid. 

   
 
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11.68 Despite this, wider research undertaken in support of our inquiries (see Appendix 
C) suggested the public largely feel use of cannabis for medicinal purposes is 
appropriate if prescribed by GPs or other healthcare professionals. An inherent 
public trust in medical models of management leads to an assumption that 
cannabis would be safe in these circumstances, and that the healthcare system 
would prescribe appropriately. 
 
11.69 Despite the costs associated with accessing private prescriptions, increasing 
numbers of people who use cannabis for medical purposes are turning to the legal 
rather than illegal market (though it remains unaffordable for many) and numbers 
are expected to continue to rise (albeit slowly). Drivers for this include: 
 
• Legality: many feel more comfortable using cannabis for medical purposes where 
they have a prescription to prove it, if challenged by police or others when 
carrying or using it in public. (This is a significant issue, to which we return 
below.) 
• Cost: medical cannabis can be competitively priced against the illegal market, 
with prices for dried flower ranging from around £4 to £13 a gram (illegal market 
prices average around £10 a gram for the same). For those who live in areas 
where the illegal market commands higher prices, medical product can in fact be 
cheaper (though consultation fees of course bump up overall cost).  
• Unadulterated product: medical cannabis has not been sprayed or otherwise 
adulterated. Patients can also be confident they are receiving a product that 
contains the levels of THC and CBD claimed, which is tailored to their individual 
medical needs.  
• Greater balance between THC and CBD: some users do not wish to consume 
the high-strength cannabis commonly available through the illegal market, finding 
a better balance with CBD is more effective in addressing their symptoms.  
 
11.70 In terms of strength of medical cannabis, patients are typically prescribed product 
containing levels of THC below that common in illegal product but higher than that 
in licensed cannabis-based medicines. Higher-potency product is reserved for 
patients where the standard level (16–19%) is no longer effective. This can prove 
challenging for prescribers as patients will often argue they need stronger 
prescriptions. 
 
11.71 Demonstrating uncertainties in the composition of illegally sourced cannabis, 
however, is the fact that, on first consuming medical product, patients are 
reportedly often surprised. It can be stronger than expected based on what they 
think they’ve been buying from the illegal market.  
 
11.72 It was suggested to us that in some cases, having supplemented or replaced 
illegal with prescribed cannabis, a patient has reduced the amount they use to 
control their condition. This is an important consequence and would benefit from 
further, systematic research to explore the extent to which it features across 
patients and conditions.   
 

   
 
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11.73 Medical cannabis patients often do not relinquish purchases from the illegal 
market though, and a number continue to grow cannabis at home. These provide 
fallback options in case a prescription is i) not available (the UK’s fragile 
infrastructure with respect to supply of medical cannabis means prescriptions 
cannot always be fulfilled as intended, see para.11.91) or ii) delivered quickly. 
While dispensing pharmacies operate a next-day delivery service, this cannot 
compete against the ‘within the hour’ 24/7 doorstep delivery often offered by illegal 
dealers, especially in London.  
 
11.74 And many entering the medical market from the illegal also have strong, long-term 
relationships with their dealers and find the cannabis they provide meets their 
medical need, so are reluctant to put a complete stop to the arrangement. This is 
an issue we explored in chapter 7 in the context of challenges of transitioning 
users from illegal to legal markets for non-medical cannabis. 
 
11.75 And then there is the issue of cost. Many who find cannabis alleviates one or more 
symptom of poor health continue to rely on the illegal market because they cannot 
afford the costs of private access. Indeed, one recent estimate suggested 1.8 
million people in the UK source illicit cannabis to provide relief from a wide range 
of symptoms that can often very seriously affect quality of life.767  
 
11.76 While illicit product costs can broadly equate to those applicable to private 
prescriptions, there are of course no regular consultation fees payable in order to 
access that product. And in our view, the overall costs of accessing unlicensed 
CBPMs have created a two-tier health system for people suffering conditions from 
which cannabis products may offer relief.  
 
The implications of a two-tier system 
 
11.71 Those unable to sustain what can be a considerable financial burden are left 
accessing (or home-growing) illegal cannabis and incurring risks associated not 
only with illegal transaction but with consuming product of unknown provenance 
and quality. Moreover, they cannot prove a legal reason for possession if 
challenged by police. According to the estimate above, this equates to very many 
people potentially putting themselves at risk. 
 
11.72 Indeed, even where a patient is able to produce a legitimate prescription that 
matches cannabis found in their possession, it is not always well understood or 
accepted. We heard this has on occasion resulted in a patient being placed in 
overnight police custody while officers follow up with the prescribing clinic. 
 
11.73 Encouragingly, at least one clinic now has the means to immediately issue a legal 
document to a patient’s mobile phone to verify their prescription. This still, 
however, requires a police officer to understand that cannabis is legal for medical 
purposes for patients with a corresponding prescription (and that, in some 
 
767 Rise in people using cannabis to treat health conditions - but doctors warn patients are putting themselves at risk | 
UK News | Sky News Accessed 28th September 2023. 

   
 
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instances, the product may appear indistinguishable from illegal cannabis being 
used for non-medical purposes). 
 
11.74 It is unfortunate that, despite recommendations from several authorities over 
recent decades that more be done to ensure police are aware of the possibility of 
cannabis use to alleviate symptoms of some medical conditions,768 as we 
understand it there has been little meaningful change.   
 
11.75 We thus recommend forces across England & Wales, including the Metropolitan 
Police Service, should routinely ensure officers are aware of the law surrounding 
use and possession of cannabis for medical purposes, and are familiar with its 
prescription (R36).  
 
11.76 This recommendation, however, only safeguards those able to afford a legal 
(private) prescription for unlicensed CBPMs (as NHS access remains near 
impossible). We heard evidence from representatives of Cancard, an 
organisation that issues cards identifying holders as people with a condition that 
qualifies for a prescription of medical cannabis but who cannot afford to pay, so 
may seek cannabis illegally to meet their health needs.769 The intention is to 
protect card holders from criminal sanction or from having their cannabis 
confiscated if found in possession of the drug.  
 
11.77 Supported by the Police Federation and designed in partnership with doctors 
(although neither the BMA nor the RCP support it), the card is available to adult 
users certified by a GP as suffering from a condition eligible for a legal cannabis 
prescription. The initial card costs £29 and is valid for 12 months, after which a 
holder must resubmit medical evidence of their continued need for cannabis and 
is charged £19 per year thereafter.  
 
11.78 Alongside a 24/7 helpline to support police officers to respond appropriately to 
card holders, Cancard provide free training to help police understand the law 
governing medical cannabis. This sets out the conditions for which it is a legally 
permitted treatment, the various forms that medical cannabis can take, and the 
different routes of prescription.   
 
11.79 Despite the Cancard offer, however, the two-tier system operating with respect 
to unlicensed CBPMs is, to our mind, not acceptable. It is deeply unfair that many 
people who find cannabis provides relief from conditions that adversely affect 
their quality of life are unable, because of financial constraints, to access it 
through legal channels.  
 
11.80 It seems to us the law now takes the position that, for some people, unlicensed 
cannabis can alleviate some health conditions. In practice, such products are 
only really obtainable through private clinics at what, for many, equates to very 
 
768 Including a recommendation made by the BMA, see British Medical Association. (1997). Therapeutic Uses of 
Cannabis. Harwood Academic Publishers, UK.  
769 See footnote #722. 
 

   
 
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considerable cost. Equally, however, we recognise there may be training 
implications and attendant costs, plus issues with priorities, if NHS prescribers 
were more widely equipped to routinely prescribe unlicensed cannabis products.  
 
11.81 We also recognise, of course, that wider NHS prescribing risks the health service 
effectively providing access to forms of an otherwise illegal drug that is used 
widely for non-medical, recreational purposes. We fully accept that this ultimately 
may not be the right idea. However, the possibility, with all the attendant risks 
and opportunities to manage those, should at least be investigated.   
 
11.82 We therefore recommend, if sufficiently robust, favourable conclusions emerge 
from research recommended in R34, that further research be undertaken into 
training and cost implications of equipping the NHS to provide unlicensed CBPM 
product scripts more widely, where (initially) sanctioned by a doctor on the 
Specialist Register. This should consider the potential burden on those doctors in 
the context of their overall burden as front line practitioners, as well as the 
opportunity costs of prescribing traditional medicines (including opiates) over 
unlicensed CBPMs. Findings should inform decisions as to whether the current 
system should be changed and the implications of doing so for medical cannabis 
supply chains should be considered (R37).  
 
The medical cannabis industry: supply and operation 
 
11.83 Despite growth in the market, in addition to difficulties faced by patients with 
respect to both access and cost, the industry faces challenges that arguably 
result from the legislative model governing the supply chain and clinic operations. 
Data shared by some of those we heard from suggest it is not easy to make a 
profit. This is partly due to subsidies provided by clinics to cover costs of 
specialist prescribing doctors, which can be over 50%. Across the sector, profit 
is reportedly made primarily on prescriptions. 
 
11.84 Despite an often evangelical level of positivity surrounding the economic potential 
of legal cannabis industries, at least some parts of the medical market have to 
work hard to maintain investors. And it was put to us that in Canada and various 
US states, where unlicensed CBPMs have been available for some time, the 
industry as a whole has seen increasing numbers of insolvencies and 
bankruptcies.  
 
11.85 These problems are not limited to the medical market. That said, it was 
suggested that, where cannabis is legalised for non-medical use, depending on 
the framework deployed the demand for medical product can be suppressed as 
patients opt for a non-medical equivalent to avoid additional costs of 
consultations. 
 
11.86 Despite this, UK clinics are largely optimistic about the medium to longer term. 
We heard the market is currently estimated to be worth around £50 million, 
supporting around 25,000 registered patients. With clinics registering new 
patients each month, the sector is widely seen as a growth market. There is 

   
 
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some concern, however, that available supply may be insufficient to meet rising 
demand.  
 
11.87 This is somewhat ironic because the UK is the world’s biggest producer and 
exporter of legal cannabis for medical and scientific purposes.770 Jazz 
Pharmaceuticals (previously GW Pharmaceuticals) became, in 1998, the first UK-
based cannabis cultivator to obtain licences from the HO and MHRA which 
allowed them to cultivate, possess and supply cannabis for research into medical 
use.  
 
11.88 They became, and remain, the sole producer and distributor of Sativex® and 
Epidyolex® but are not licensed to produce cannabis for unlicensed CBPMs. And 
until recently (see para.11.100), no UK-based cultivator has been licensed to 
produce cannabis for this purpose for use in the UK. 
 
11.89 This means the cannabis plant that is cultivated for medical purposes and from 
which unlicensed CBPMs are derived (either in dried flower form or extracts used 
for oils, vapes and oral ingest) must be sourced by UK clinics from overseas. 
Most of it (which we heard amounts to around five tonnes annually) is imported 
from Europe, with smaller amounts coming from Canada and Australia.  
 
11.90 All products adhere to EU Good Manufacturing Practice (EU-GMP) standards 
and are manufactured in sterilised conditions to ensure no contamination. In 
addition to products being tested several times throughout the process for 
pesticides, heavy metals and microbial growth, rigorous tests are also applied to 
confirm CBD and THC levels in end products.  
 
11.91 Once a supplier is approved by a clinic, the process of acquiring registration and 
import licences from the HO and MHRA can take several months. And until 
recently, clinics were limited in the amount of product they could import at any 
one time. Supply issues could lead to over reliance on particular products and 
stocks – particularly of new or renowned products – could be depleted quickly, 
leaving prescriptions unable to be fulfilled in a timely way.  
 
11.92 Demand for particular products can also be raised by patients sharing positive 
experiences on social media – although the content of prescriptions is ultimately 
the decision of the prescriber. While a patient may request a certain product, it 
may not necessarily be what is prescribed. 
 
11.93 The time required to replenish depleted stocks can often be significant, given 
reliability on overseas products and a consequently lengthy and complex supply 
chain. This, of course, risks a patient (re)turning to the illicit market.  
 
 
770 Buchanan, I., Booth, L. & Brien, P. (2023). Economic contribution of medicinal cannabis: Debate pack 14 April 
2023. Number CDP-0086 (2023). House of Commons Library. CDP-2023-0086.pdf (parliament.uk) Accessed 29th 
September 2023. 

   
 
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11.94 We heard, too, about the opposite problem, whereby clinics end up with a 
surplus of product that has to be destroyed. This can result from poor-quality 
product being received by patients, which is then returned (it can, for example, 
arrive mouldy as a result of the length of time between harvest, packaging, 
shipping and delivery).  
 
11.95 Supply chain issues were raised with us by those witnesses who were themselves 
users of cannabis for medical purposes, and research elsewhere has reported 
challenges with last-minute changes to prescriptions because a patient’s usual 
product is out of stock. This can often mean an unexpected price hike, with the 
sudden inability to access a product that had been working well in alleviating 
symptoms causing stress and anxiety.771 
 
11.96 It was also put to us that the quality of medical cannabis supplied to the UK has 
not always been the highest (though compliant with necessary standards and 
regulations) because the market is relatively small. As this slowly changes and 
demand rises, quality is improving as cultivators overseas achieve a greater 
return from the UK market – but it is taking time. We heard that in some cases 
this, again, can cause patients, frustrated with quality issues and cost of 
consultations, to return to the illegal market.  
 
11.97 Issues are compounded by marketing restrictions governing prescription 
medicines in the UK. These mean clinics cannot advertise the various cannabis 
products they offer, only the services they provide. They do so to varying degrees 
in social and print media and increasingly via television adverts, often focusing on 
raising awareness that cannabis for medical purposes is legal and promoting 
patient experiences.  
 
11.98 The general restrictions arguably mean discussion about the effects of different 
types of cannabis products on a wide range of conditions, alongside guidance 
around sensible consumption, is not possible. That said, some clinics are 
investing in celebrity or influencer endorsements, using well-known figures to 
explain, for example, how to access legal unlicensed CBPMs, or how to travel 
abroad with prescribed medical cannabis – a situation that many users find 
difficult to navigate.  
 
11.99 While there remains some desire to advertise specific products themselves (e.g. 
particular strains of cannabis offered by a clinic), it is difficult to see how this 
could ever be permitted for a product provided as a medicine.  
 
Future supply and implications 
 
11.100 Several UK-based cultivators are in the process of preparing and applying for HO 
and MHRA licences to supply the UK medical market (for both flower- and 
extract-based prescriptions) but we understand only two – Celadon and Glass 
Pharms – are likely to be able to start supplying substantial quantities of product 
 
771 See footnote #754. 

   
 
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in the foreseeable future. Other smaller operators are thought to be some way off 
licensing, never mind production.  
 
11.101 Their core market will be the UK and product will comply with UK GMP standards 
(rather than EU GMP), which means that, unlike in jurisdictions elsewhere where 
cannabis is grown for medical use, in the UK it must be grown indoors in order to 
meet particularly stringent regulations regarding risk of contamination. 
 
11.102 Once operational, facilities should significantly reduce reliance on product 
imported from overseas, and a much shorter supply chain will ensure product 
reaches distributing pharmacies, and therefore patients, more rapidly. This ought 
to mean product is less likely to deteriorate so patients can be more confident of 
consistently high-quality medical cannabis, and there should be fewer challenges 
with respect to clinics and pharmacies having access to adequate stock.  
 
11.103 Indeed, at time of writing, Celadon told us they had completed phase one of 
operational implementation and produced the first four harvests, amounting to 
around 40kg of medical cannabis across three different strains (each suited to 
addressing different health conditions). Future harvests are expected every three 
weeks.  
 
11.104 How overall price will fare remains to be seen. Production costs may well be 
lower in overseas facilities, but import costs might mean that, ultimately, 
domestically produced cannabis will be competitively priced. And a domestic 
medical market with a strong, resilient supply chain is relevant for our primary 
considerations regarding how cannabis use for non-medical purposes should be 
treated within the law.  
 
11.105 A medical community and a general public familiar with, and accepting of, 
cannabis for treatment of medical conditions, recognising that patients can live 
and work in mainstream society without difficulty, would presumably help cement 
demand for product. This in turn helps create the necessary conditions for a 
robust supply chain.  
 
11.106 As we heard, too, an established medical market is typically an important 
forerunner to any move away from prohibition of non-medical use. It creates an 
infrastructure with at least some knowledge and delivery capability to meet 
emerging demand, whether for medical or non-medical cannabis.   
 
11.107 But the UK’s medical cannabis market remains in its infancy, particularly in 
comparison to other jurisdictions. In Canada, medical cannabis has been legal 
since 2001 and at time of writing it is legal in 38 US states, four territories and 
Washington D.C. (though state laws vary regarding how it is produced, 
distributed and consumed, and the conditions it is used to treat). California 
became the first US state to legalise cannabis for medical use in 1996, and ten 
years later the majority have followed suit.  
 

   
 
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11.108 In Europe, the position varies. While cannabis remains illegal for medical 
purposes in several countries, established medical markets have existed 
elsewhere for some time, albeit for varying conditions and with differences in 
permitted products. Not all, for example, allow cannabis flower for medical use. 
Medical cannabis has been available in countries including, for example, the 
Netherlands since 2003, Denmark since 2011, Italy from 2013, Norway since 
2016, Luxembourg, Germany, and Greece from 2017 and Portugal and Malta 
since 2018.  
 
11.109 Elsewhere, in 2013 Uruguay became the first country in the world to legalise 
cannabis for both medical and non-medical use in parallel, and medical use was 
also legalised in Australia (at federal level) in 2016. It is increasingly being 
prescribed in the latter to young men presenting to doctors with anxiety and 
sleep problems, allowing immunity from prosecution in states where use of the 
drug is otherwise illegal.  
 
11.110 We considered the position of several of these jurisdictions with respect to legality 
of non-medical cannabis in chapter 7, including the variety of approaches taken 
and the evidence so far in terms of associated consequences.  
 

   
 
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12. EDUCATION AND CANNABIS 
 
While we did not explore education strategies for, or cannabis use among children and 
young people in depth, accounts from frontline practitioners informed our consideration 
of public health and harm reduction. While our focus is school-aged children, the impact 
of cannabis on processes of brain development, which continue until a person reaches 
their mid-twenties, means it is important that young adults, too, are educated about 
ways to lessen the risks of cannabis use.  
 
In this chapter, we set out what we heard about consumption of cannabis during the 
school day: while it is not widespread, there are obvious consequences for behaviour 
and performance. Similarly, dealing within school premises is very problematic and 
poses a number of challenges, which establishments deal with in different ways. 
 
We explored why practitioners thought young people used cannabis and their views of 
the risks in doing so, as well as their perceptions of awareness, or acceptance, of the 
potential for risks among young people themselves. 
 
Finally, we considered the challenges faced by schools in delivering compulsory, age-
appropriate, credible education about cannabis, exploring the likely adequacy of 
content, stage of the curriculum at which it is introduced, and different approaches to 
delivery.  
 
The reality of cannabis in London’s schools 
 
12.1 We set out the national picture in terms of prevalence and drivers of cannabis use 
among children and young people, as well as sources of the drug, in chapters 4 
and 5. Evidence we took from witnesses working with young people across 
London in a range of school and other settings supported that picture. Not only did 
this highlight use of cannabis by a substantial minority of schoolchildren 
(described as endemic by one borough), it illustrated several considerations 
regarding education and harm reduction. 
 
12.2 It is a universal truth that many young people experiment with alcohol, smoking 
and sex. So too will they experiment with drugs and, as shown by countless 
numbers of surveys and statistics, as well as our own inquiries and forerunners, 
cannabis is no exception. It was put to us that education strategies must be 
realistic about the fact of relatively widespread cannabis use among young people, 
while acknowledging the context and drivers, methods of consumption and the 
consequences – both positive and adverse.  
 
12.3 Compared with the consequences of alcohol, the effects of cannabis are often 
perceived as similar or less harmful, perhaps in part because they can be less 
obviously dramatic: being drunk tends to be behaviourally more obvious than 
being high. And many young people see cannabis simply as an alternative to 
alcohol in terms of an aid to relaxation and recreation. 
 

   
 
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12.4 Some therefore view the approach to cannabis use by authority figures as 
somewhat hypocritical. Parents, teachers and other adults admit to use of alcohol 
and tobacco as a means of coping with stress, as well as to enhance relaxation 
and have fun. Young people, some of whom eschew alcohol and cigarettes but 
who might choose cannabis for arguably similar reasons, feel they face critical 
judgement and ultimately criminalisation for doing so. 
 
12.5 The majority of young people who try or go on to use cannabis more regularly do 
not do so within school hours or on school premises. It is therefore not thought 
very common for them to bring cannabis into school, either for personal use or to 
sell to others. In some establishments, particularly those offering alternative 
education provision,772 searches on entry are largely considered to be an effective 
mechanism of preventing drugs being brought onto school premises where pupils 
have tried to do so.  
 
12.6 That said, cannabis edibles pose a particular (and increasing) problem due to the 
ease with which they can be concealed, often in plain sight: largely odourless, they 
typically resemble legitimate foodstuffs. We heard several anecdotes of children 
becoming very unwell as a result of consuming edibles during school hours, and it 
is also not unheard of for a child or young person to smoke a joint en route to 
school in the morning.  
 
12.7 Cannabis consumption before or during school has obvious consequences. While 
it was put to us that incidents are relatively rare, we heard about children falling 
asleep at their desk or being unable to concentrate, with increased levels of 
apathy and decreased motivation to learn. More serious effects are possible too – 
one school reported around one or two incidents a term where an ambulance is 
required to treat a child rendered incapacitated by cannabis consumption during 
the school day.  
 
12.8 Children known or suspected by schools to be using cannabis are often flagged 
for other safeguarding reasons including challenges at home, vulnerabilities to 
criminal exploitation and difficulties with mental health. We also heard about a 
substantial overlap with deprivation and poverty (as we discuss elsewhere). 
 
12.9 Where dealing cannabis does take place on site, it presents a significant problem 
for a school. All those we heard from operate ‘zero tolerance’ policies that stipulate 
dealing must result in automatic permanent exclusion – but this is not always 
activated when it results from, for example, instruction from parents or criminal 
gangs and where young people have little perceived agency. In some cases, 
schools seek a mentor figure to support the pupil concerned, to help them 
understand the heightened risk of harm of cannabis use for young people, and the 
dangers of dealing and criminal gang involvement.  
 
772 Alternative provision establishments cater for children and young people who require greater care and support. 
This includes those excluded, or at risk of such, from mainstream school for behaviour reasons, and those who are 
experiencing severe emotional or behavioural difficulties.  

   
 
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12.10 Others would almost certainly immediately exclude a pupil for dealing cannabis 
within school grounds, due to the risk of reputational damage and pressure from 
the governing body. Such a move is not without significant concerns regarding the 
likelihood of heightening safeguarding risks faced by the young person, particularly 
with respect to increased vulnerability to gang involvement. 
 
12.11 Where a pupil is permanently excluded or has otherwise demonstrated challenging 
behaviour to the extent that they cannot be managed in mainstream school, they 
will usually be referred to an alternative education setting. These pupils are more 
likely than their peers remaining in mainstream settings to have had contact with 
the criminal justice system by the point of referral, and we heard how a substantial 
driver of that contact can be involvement with cannabis. Most have been caught in 
possession of or dealing the drug and some, particularly those involved in gang or 
county line activity (see chapter 5), end up carrying a weapon because they feel 
threatened by members of opposing factions.  
 
12.12 There was broad acceptance among those who work with young people that 
cannabis use, for some at least, is a critical problem. It increases wider risks not 
only to individual health but of being caught up in criminality, with all the 
associated implications for longer-term life chances – particularly if caught 
carrying a weapon. There were mixed views, however, as to the extent to which a 
legally regulated market for cannabis represented the most appropriate solution. 
 
Awareness of the risks of cannabis use among young people  
 
12.13 Young people are well aware that cannabis is legal for non-medical use elsewhere 
in the world; this is driven at least in part by celebrity endorsements and US-based 
influencer activity on social media platforms (see chapters 4 and 5). The fact that it 
is illegal in the UK, and thus growing, selling and possessing the drug all carry the 
risk of criminal conviction, can come as a surprise.  
 
12.14 Those working with children and young people referred to the fact that some 
parents use cannabis openly within the home environment, which likely 
contributes to views that cannabis is not harmful, or at least is no more so than 
alcohol or tobacco. It can also serve to undermine messages delivered in school 
about the risks of cannabis. 
 
12.15 Children reportedly often remonstrate with their parents for use of alcohol and 
tobacco, where evidence of harm is widely accepted and discussed. But unless 
adult users understand and accept that cannabis too can pose a risk, heightened 
in certain circumstances and for some individuals, it is difficult to similarly embed 
messages around harm. 
 
12.16 Older children (Years 10 and 11, i.e. aged 14–16) are widely thought to believe 
cannabis use is ‘not a big deal’, particularly when compared to other illegal drugs. 
The disparity referred to by witnesses across sectors about the legal status of 
cannabis compared with alcohol and tobacco is reportedly also often raised by 

   
 
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young people: this can, it was suggested, make school-based discussions about 
relative harms and rationale for the legal position somewhat challenging.  
 
12.17 While largely cognisant and accepting of risks associated with alcohol and 
tobacco, research shared with us suggested that among young adults (aged 
between 16 and 24) there is some disbelief that cannabis can be addictive, 
whereas tobacco addiction was commonly acknowledged.773 This was reinforced 
by evidence put to us from local authorities that highlighted how young people 
often consider themselves ‘social smokers’ of cannabis, when in fact they are likely 
to be addicted. One borough referred to a boy smoking up to 20 joints a day, 
wholly unaware of the risks attached to such heavy use.  
 
12.18 Beliefs about reduced levels of risk associated with cannabis can be accentuated 
by narratives around vaping, widely understood as a less harmful means of 
consuming nicotine than smoking tobacco. Many are unaware, however, that as a 
means of consuming cannabis without tobacco, vapes, or e-cigarettes, are not 
necessarily safer, despite the avoidance of nicotine.  
 
12.19 Cannabis that is vaped rather than smoked tends to be more concentrated, i.e. it 
contains higher levels of THC. It is also no less likely to be adulterated with 
synthetic compounds than smoked cannabis, heightening the possibility of harmful 
effect. Indeed, a chemical added to some THC-containing vapes in the US has 
been identified as one of the major causes of lung injury associated with use of the 
devices (E-cigarette, or Vaping Product, Use Associated Lung Injury, EVALI).  
 
12.20 Moreover, the risk of developing EVALI is likely to be higher when vapes or e-
cigarettes containing THC are obtained from informal sources rather than 
commercial outlets,774 i.e. where there is greater risk of adulteration.  
 
12.21 Young adults receiving treatment for psychosis and cannabis addiction similarly 
told us they considered vaping cannabis to be lower-risk than co-consuming with 
tobacco. Clinicians confirmed there is relatively low awareness of the dangers of 
adulterated product and the potential for vapes to be much more potent than a 
user expects.  
 
12.22 We also heard of young cannabis users increasingly turning to edibles as an 
alternative to smoking cannabis with tobacco, due both to ease of consumption 
and greater awareness of the health risks associated with nicotine. There are, 
however, several mistaken beliefs about edibles – namely that they are less potent 
than herbal cannabis and less harmful because there is no parallel consumption of 
tobacco.  
 
 
773 Walsh, H. (2023). Unpublished PhD findings shared with the London Drugs Commission. 
774 The Centers for Disease Control and Prevention (CDC) reported that, of EVALI patients in the US who reported 
using vapes containing THC and provided information on their source, almost 80% had obtained them from informal 
sources, including friends, family, dealers and online outlets. See Outbreak of Lung Injury Associated with the Use of 
E-Cigarette, or Vaping, Products | Electronic Cigarettes | Smoking & Tobacco Use | CDC Accessed 19th March 
2024. 

   
 
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12.23 The reality is they can be very much stronger. Without proper understanding of 
dosing (relative to a person’s size, metabolism, tolerance, recency of consuming 
non-cannabis foodstuffs etc) and awareness of the fact that psychoactive effects 
take longer to take hold than when the drug is smoked, it is easy to consume too 
much. This is particularly the case where dose sizes are unclear or unrealistic – we 
heard, for example, of one dose equating to two small gummies from a much 
larger bag, or to one-fourteenth of a cookie.   
 
Cannabis education in schools 
 
12.24 Coverage of drug use and associated considerations is compulsory in state 
schools (primary and secondary) under the Relationships Education, Relationships 
and Sex Education and Health Education (England) Regulations 2019.775 The topic 
is made compulsory in independent schools under the Personal, Social, Health 
and Economic (PSHE) curriculum.  
 
12.25 While clearly required as part of the statutory education programme, we 
understand there is little guidance provided centrally in terms of specific content 
on cannabis, beyond key messages to impart around illegal drugs more broadly. 
The Department for Education (DfE) provides a range of training materials on 
which schools are encouraged to base their provision and suggests these be 
adapted to suit the needs of different contexts.776   
 
12.26 This tends to mean, as it was put to us, there is something of a postcode lottery in 
play, with different schools taking different approaches. Most tend not to broach 
cannabis in detail until students reach Year 9, although schemes of work in earlier 
years, including those focusing on mental and physical health as well as grooming 
and county line activity, will touch on drug use more widely.  
 
12.27 This means that, before the age of 13, most young people have little to no formal 
education regarding cannabis, which feels to us to be a gap. Statistics suggest 
that – while a very small minority – some children have in fact used the drug before 
they reach 13 and most will almost certainly have heard of it, often through the 
media (including social media). Some will likely have been exposed through family 
or peer networks, particularly where cannabis plays a role in cultural and religious 
settings. 
 
12.28 Moreover, for whatever reason some children and young people may never have 
been exposed to formal drugs education. It was put to us that a substantial 
number of those found by police in possession of small quantities of cannabis and 
referred to a pre-arrest diversion programme run in the West Midlands by 
Cranstoun (see chapter 10) recall no such input through their formal schooling.  
 
 
775 Relationships Education, Relationships and Sex Education and Health Education guidance 
(publishing.service.gov.uk) Accessed 21st May 2024. 
776 Ibid. 

   
 
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12.29 Where drugs education does take place, statistics bear out the focus on Year 9. 
Surveys show almost three-quarters of Year 9 pupils (72%) reported receiving 
lessons covering drugs during 2021, compared with 48% in Year 7 and 60% in 
Year 11.777 Cannabis content focuses primarily on the law, consequences of use 
for mental and physical health and wider social and economic implications of the 
drugs trade. 
 
12.30 There is desire among young people themselves for more information. Just under 
half of Year 7–11 pupils felt their school had provided sufficient information about 
drugs (just over half felt they received sufficient information about alcohol and 
tobacco). This is not perhaps surprising given the frequency with which most 
schools report delivering lessons about drugs, namely less than once a term (but 
at least once a year).778  
 
12.31 Several witnesses we heard from suggested drugs education should begin before 
secondary school, to reflect modern life and day-to-day realities of many children 
and young people. This mirrors suggestions made during the review of Canada’s 
Cannabis Act,779 where stakeholders suggested tailored material appropriate for 
different life stages should be introduced from grade three (around eight years 
old). And this attracts some degree of public support in Great Britain: over one-
quarter of those polled by YouGov in 2021 thought education about recreational 
drugs should begin at age 10 or younger (though one-fifth felt it should not be 
delivered until children were 13 or older).780  
 
12.32 Indeed, it was put to us that children as young as nine, outside London as well as 
within the capital, are often well aware of different types of drugs. The lack of 
routine engagement on the subject in school, however, means there is little 
chance of countering messaging that children may be exposed to elsewhere. 
 
12.33 We also heard that more could be done post-GCSE to help young people make 
informed choices about cannabis, recognising that by this stage many will likely 
have tried the drug. Indeed, evidence put to us suggested young adults may find it 
difficult to find accessible, credible (from their perspective) information, describing 
much of what they see as unbalanced with little recognition of why they may 
choose to use cannabis.781  
 
12.34 The overwhelming message tends to be ‘cannabis is illegal, do not use it’. 
Because this fails to resonate with lived realities of the drug for many, or to 
acknowledge its perceived potential for bringing some relief of, for example, 
symptoms of anxiety and stress, may tend to disregard the material. Instead, they 
develop understanding and knowledge about cannabis from personal experiences 
 
777 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Table 12.2. 
Accessed 14th December 2023. 
778 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Tables 12.3, 
12.7. Accessed 14th December 2023. 
779 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.33. 
780 Q30, Big_Surveys_Drugs_Y1 (w) (for non drug users).xlsx (d3nkl3psvxxpe9.cloudfront.net) Accessed 1st August 
2024. 
781 Walsh, H. (2023). Unpublished PhD findings shared with the London Drugs Commission. 

   
 
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and those of their peers, as well as online unregulated content – often through 
chat forums such as Reddit.  
 
12.35 This risks development of erroneous beliefs about the potential risks of cannabis – 
that it is not addictive, for example, or that herbal cannabis sourced from a known 
dealer is ‘natural’ and therefore safer. We heard about work undertaken by 
Cranstoun in partnership with the Rave Aid Crew782 to develop pragmatic, non-
authoritative advice for young people. This recognises the realities of drug-taking, 
addresses common misconceptions and focuses on educating those who choose 
to use drugs to reduce the risk of harm.  
 
12.36 Advocates of more comprehensive drugs education – both within and outside the 
sector – were keen to better understand what age-appropriate material looks like 
for children at key touchpoints. Attenuating messages so they engage children 
and young people but avoid glorifying drug use was recognised as a difficult 
balance, particularly given the ways in which drugs and the potential to make a lot 
of money from the trade are widely referenced in popular culture, including music 
and film.  
 
12.37 We heard about the Drugs, Alcohol and Resilience Training (DART) delivered by 
the City of London Police (CoLP) to year 6 pupils (aged 10–11) attending two 
primary schools within the remit of the City of London Corporation (CoLC). 
Focusing on the nature of choices related to drugs and alcohol, this might offer 
useful insights for development of similar packages to be run elsewhere. We 
recommend the CoLC should commission independent evaluation of DART and, if 
appropriate, the Mayor should explore potential for it to be delivered in primary 
schools across London boroughs (R38).  
 
12.38 We note the finding reported in the most recent inspection of the CoLP that some 
schools were reluctant to engage with police in wider prevention and intervention 
work.783 While the force has since introduced schools officers to help address this, 
it is worth bearing in mind the potential for similar reluctance elsewhere when 
considering delivery mechanisms for expansion of school-based education around 
cannabis and drug use.  
 
12.39 Other materials have also been developed based around research on the effects 
of cannabis, expressed through children and young people’s lived experiences of 
its use. Not in widespread use across the statutory education sector, they are 
drawn on by a small number of London-based charities working with young 
people.784 While we welcome such endeavours, the lack of signposted provision 
within mainstream settings means it is likely only a small number of schoolchildren 
are reached. 
 
782 A grassroots activist organisation providing drug welfare services and harm-reduction advice to the free party 
scene. 
783 His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (2021). PEEL 2021/22: Police 
effectiveness, efficiency and legitimacy – An inspection of the City of London Police, p.16. Accessed 19th March 
2024. 
784 Medical Research Foundation | Spreading the word about harmful ‘skunk’ Accessed 27th March 2024. 

   
 
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12.40 The Mayor should consult with parents, schools, youth workers, substance-use 
services and other organisations such as Cranstoun to consider how more 
comprehensive content focusing on risks of cannabis use could be systematically 
introduced to younger children, and revisited during post-16 education, in 
meaningful, age-appropriate ways. Existing resources, including the DART 
material, should be considered, as should the efficacy and appropriateness of 
police involvement in delivery (R39). 
 
Content of cannabis education 
 
12.41 We heard mixed views on this. Some considered school-based resources to be 
inadequate, relying too heavily on academic, government and medical material. 
Perceived to lack credibility among young people, it reportedly fails to engage. The 
PSHE Association is the most common source drawn on by schools in preparation 
for lessons about drugs (as well as alcohol and tobacco), followed by DfE 
guidance:785 while we have not examined the material or explored the views of 
young people, it may not succeed in striking the most effective tone to reach this 
audience. 
 
12.42 It was put to us that material may not cover the role of cannabis in different cultural 
and religious settings, nor adequately explain the ramifications of a criminal 
conviction for future life opportunities, including, for example, travel to the US.  
 
12.43 But at the same time, for some young people consequences of this nature, 
particularly when set against some of the perceived positive aspects of cannabis 
consumption and dealing (see chapter 5), may have little resonance. Foreign 
travel, for example, will feel completely out of reach for many. This illustrates the 
complexity and nuances of issues that education must help draw out.    
 
12.44 For some teachers, the illegal status of non-medical cannabis is a barrier to open, 
honest and practical conversations with pupils. While recognising that some will 
experiment with the drug, any discussion of experiences is inevitably more 
challenging where admission of use is admission of criminality. Certainly, we heard 
that beginning with messages around illegality and criminal consequences can 
easily shut down perhaps more useful conversations about the effects of taking 
cannabis and how to manage risk. 
 
12.45 Moreover, we heard of fears among senior leaders that drugs education can risk 
suggesting a school has a drug problem, sparking negative publicity and 
discouraging future applications. There are concerns, too, that discussion of 
consumption methods and relative advantages and disadvantages with respect to 
harm reduction risks being seen as enabling young people to engage in illegal 
behaviour.  
 
 
785 Smoking, Drinking and Drug Use among Young People in England, 2021: Data tables - NHS Digital Table 12.9. 
Accessed 14th December 2023. 

   
 
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12.46 This in turn raises fears of parental or guardian anger, which we heard can 
manifest if a school goes beyond the illegal status of cannabis and the ‘Just Say 
No' approach – which is reportedly often how the issue is presented in the home.  
 
12.47   We heard similar views from other jurisdictions, some of whom reflected that 
comprehensive education packages about cannabis were beginning to be made 
easier following the introduction of some model of legal regulation – although 
progress is slow. Stakeholders consulted as part of the Canadian review,786 for 
example, commented that previous prohibition continues to exert a lasting 
influence on many education initiatives that remain focused on abstinence and 
risk.  
 
12.48 They advocated for initiatives to refocus and address what is considered to be 
continuing and widespread misinformation about cannabis. Indeed, the review 
panel recommended development of evidence-based school prevention 
programmes, alongside other interventions, to help young people make better 
decisions about cannabis use. Avoiding or delaying onset, as well as how to 
engage in lower-risk behaviours, were identified as key messages.787  
 
12.49 The situation seems similar in London and across the UK. We heard that 
misinformation about cannabis is rife, not only among children and young people 
but among adults too. Addressing this should be a crucial part of education 
programmes: we agree with the approach advocated by the Canadian review 
whereby pupils are enabled to make more informed choices and, where they 
continue to choose to try cannabis regardless of its illegal status, can better guard 
against risks of misuse.  
 
12.50  Among those working with young people outside school settings, we found a 
widespread view that current provision of cannabis education is limited, lacks 
detail and fails to adequately engage young people. In part this was thought to be 
through a failure to acknowledge the range of drivers of use and effects – including 
the positive impacts that some derive from using the drug.   
 
12.51 We heard how material lacked detail about the impact of edibles, specifically their 
strength, how quickly they take effect and how long that effect can last. If the 
effect is unpleasant or overpowering, a consumer cannot simply stop consuming: 
a joint can be extinguished but, once an edible(s) has entered the body, a person 
is at its mercy until it becomes sufficiently diluted. Given that use of edibles is 
reportedly on the rise, this lack of information is a considerable gap.  
 
12.52 Youth workers told us that focusing on legal and health implications of cannabis 
use can lead many young people to switch off: it is arguably part of the ‘teenage 
condition’ to take risks and, where those risks are associated with something that 
is a daily reality for many, there is little traction.  
 
786 Legislative Review of the Cannabis Act: What We Heard Report - Canada.ca p.33. 
787 Legislative Review of the Cannabis Act: Final Report of the Expert Panel - Canada.ca p.28, recommendation 4. 
Accessed 27th March 2024. 

   
 
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12.53 Moreover, many young people deliberately choose to use cannabis because they 
believe it to be an effective means of coping with previous or ongoing trauma, or to 
otherwise alleviate symptoms of mental health distress (although the relationship 
between cannabis and mental health is complex, as is the potential for side 
effects).  
 
12.54 Simply telling those involved with cannabis to desist is, as was put to us, likely to 
fall on deaf ears, particularly where selling is concerned. As we discuss in chapter 
5, for some young people, particularly those from very deprived backgrounds, 
selling the drug offers a way to make money easily and the lure can be very 
strong, particularly in areas of London where differences between affluence and 
poverty are stark.  
 
12.55 Completing school and achieving the necessary qualifications would of course 
support young people to earn a decent wage legitimately in due course – but the 
pull of immediate opportunity, irrespective of illegality, can be difficult to combat in 
the face of poverty.  
 
12.56  In terms of health, the risks of cannabis are not considered by children and young 
people in the same bracket as Class A drugs, which tend to be associated with 
those seriously unwell crack and heroin addicts often visible in local communities. 
For young people living chaotic lives often characterised by anxiety and trauma, 
the risks of cannabis addiction and other associated health harms are likely to 
seem the least of their problems. Indeed, for many the drug is considered an 
accessible means of help in the (perceived or real) absence of other sources, 
including clinical services.  
 
12.57 That said, we heard how young people are largely unaware of the detrimental 
impact that cannabis use has on the developing brain, or that their brain does not 
reach full maturation until they reach their mid-twenties. Simply helping pupils 
understand this, with no associated judgement or pronouncement, might, it was 
suggested to us, achieve greater cut-through.  
 
12.58 Focusing on exploitative aspects of cannabis was also thought helpful. Setting out 
how organised crime gangs groom young people into becoming involved in 
dealing or moving cannabis (through ‘free’ drugs, or ‘gifts’ of money or material 
goods) would raise awareness so they ‘…know the price attached. You don’t get 
anything for free’. While those in their mid-teens make up the majority of 
vulnerable people involved in county lines, those of primary school age are also at 
risk,788 meaning the subject should at least be introduced (appropriately) before 
secondary education. 
 
12.59 Directly confronting why young people choose to use cannabis, signposting 
alternatives to self-medicating particularly mental health conditions via the drug, 
 
788 See Criminal exploitation of children and vulnerable adults: county lines (accessible version) – GOV.UK 
(www.gov.uk) Accessed 21st May 2024. 

   
 
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was considered by some to be more important than its illegality – although such 
alternatives are under immense pressure and access can be difficult.  
 
12.60 Such a shift in focus was underlined by powerful testimonies we heard from 
parents whose children have tragically died following drug use. They emphasised 
that education of children, parents and wider society to help those who choose to 
use illegal drugs to do so more safely is paramount to preventing deterioration to, 
or loss of, life.  
 
12.61 We did not hear directly from those working with young people in further education 
settings (i.e. post-16, following secondary school), but heard that material 
designed to inform understanding among this group of the effects of cannabis (as 
well as other drugs) is available.  
 
12.62 Accessible harm reduction advice also forms a core part of content towards which 
we were pointed and which is aimed specifically at university students (i.e. from 
age 18) – namely the ‘Staying Safe Programme’. The Mayor should consider 
ensuring all establishments across London that provide education post-18 are 
aware of and have access to such materials, and signpost this to all students at 
the point of entry (R40).789 
 
Delivery of cannabis education 
 
12.63 We heard concerns that teachers, given their wider roles in school, may lack 
credibility to deliver educational material about cannabis. This risks compounding 
the problem of inadequate content that fails to speak to lived realities of many 
pupils.  
 
12.64 The review of Canada’s Cannabis Act 2018 illustrated how youth perceptions of 
message credibility vary according to source. The most effective messengers 
were reportedly trusted adults, peers, and people with lived experience – authority 
figures tended not to be seen in the same way.  
 
12.65 Whether teachers are perceived as trusted figures or authority figures presumably 
depends at least to some extent on the nature of their relationship with pupils. We 
heard how powerful and transformative it can be when they do connect on 
sensitive issues, but at the same time that, more often than not, teachers tended 
not to have the credibility to guide sufficiently open, realistic discussions on drug 
use. 
 
12.66 The importance of consistency between school and home messaging was also 
highlighted. Getting families involved in discussions might not only reinforce drug 
education but serve to inform parents and guardians too about harm reduction 
and the risks to young people of cannabis use (although we acknowledge the 
likely challenges where cannabis is used routinely within the home environment).   
 
 
789 See for example video trailers at Staying Safe Programme Accessed 4th April 2024. 

   
 
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12.67 Local workshops, held in partnership with schools in parts of some London 
boroughs, were highly spoken of as an alternative means of delivering cannabis 
education. These are led by substance use workers and other professionals from 
youth-focused organisations, who bring similar experiences and backgrounds as 
many of the young people they work with.  
 
12.68 Based on feedback from young people, youth workers and local authority 
representatives described these providers to us as trusted voices. They 
considered them much better able to facilitate open discussion of lived 
experiences and to speak credibly to young people not only about their views but 
about the risks, particularly of heavy use which considerably heightens the 
likelihood of adverse consequences.  
 
12.69 Such providers are, however, entirely dependent upon local knowledge, 
capabilities and partnerships, which speaks to the patchwork nature of wider 
commissioning practices across London, with each borough individually 
responsible for acquiring services to meet the needs of their local population (see 
chapter 9). The universality of cannabis use, however, means a majority of 
children and young people are likely to be offered the drug, and many of those will 
go on to try it. Some will become regular users, and the risks of being drawn into 
associated criminal activity play out across boroughs. 
 
12.70 Overall, it seems to us that provision of education focusing on cannabis and 
associated risks is random and patchy across London’s schools. Beyond the DfE 
adding more detailed content to its mandatory syllabus and associated guidance, 
there seems to be no legal way to ensure provision is consistent and uniform. 
 
12.71 We therefore recommend that representatives of schools, parent bodies, 
substance-use services and other organisations involved in localised endeavours, 
as well as developers of material designed for post-18 students, form a working 
party. This should aim to produce detailed, age-appropriate guidance for use 
across London’s schools, to help young people better understand the risks and 
make more informed choices. (R41)   

   
 
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13. CANNABIS SOCIAL CLUBS 
 
Pioneered in Spain, the ‘Cannabis Social Club’ (CSC) model operates in several places 
across the world as a means of facilitating access to cannabis – whether the drug is 
legalised or not. We discuss international CSCs in more detail in chapter 7 and focus in 
this chapter on their operation in this country. 
 
We begin by describing the CSC model more broadly, and then set out what we 
understand about their presence in the UK, including their genesis and asserted aims. 
By means of a case study, we illustrate how one such CSC operates today, exploring its 
structure and membership as well as how the club fits within the local community and its 
relationships with authorities, including the police.  
 
We end by offering our reflections on the CSC model, including some of the challenges 
as we understand them and the importance of positive local relationships to their 
successful operation.   
 
Features of the Cannabis Social Club model 
 
13.1 Central to the CSC model is a non-profit approach to production and supply of 
cannabis. While other non-profit legal models have been proposed (based on 
CSCs and regulation of other substances or potentially addictive behaviours or 
activities),790 none as yet have been adopted so across the world, where non-
medical cannabis is legal, profit-based models dominate (with some notable 
exceptions, see chapter 7 and para.13.3).  
 
13.2 A CSC typically operates by making available to its membership cannabis that is 
grown by members, owners or a grower with links to the club. In some, 
membership fees are inclusive of cannabis (and are set according to expected 
consumption). In others, the fee permits access to the club, with further charges 
made for the cannabis a person wishes to consume. Some – but by no means all – 
are open to temporary membership for non-residents (such as tourists), usually by 
way of a fee for one-time access.  
 
13.3 Despite the dominance of profit-based models where non-medical cannabis is now 
legal, the CSC approach is gaining popularity and lies at the heart of alternatives 
to prohibition being explored elsewhere, notably in Malta, Germany and 
Switzerland. Clubs are also one of the three supply routes (in addition to non-profit 
pharmacies and home cultivation) permitted in Uruguay. 
 
13.4 Irrespective of jurisdiction, members must almost always be a resident aged at 
least 18. The maximum number of members a club can register varies, however, 
 
790 See Pardal, M., Kilmer, B., d'Auria, S., Strabel, T., Galimberti, S., Hoorens, S., Decorte, T. & Senator, B. (2023). 
Alternatives to profit-maximising commercial models of cannabis supply for non-medical use. Santa Monica, CA: 
RAND Corporation, 2023. https://www.rand.org/pubs/research_reports/RRA2190-1.html  

   
 
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as does the amount of cannabis a member can receive daily (up to a maximum 
monthly allowance) and the amount a club may store in the premises. 
 
13.5 Clubs also vary with respect to facilities. Some offer a space for members to 
consume cannabis and socialise, others act solely as a collection point. We are 
not aware of any that sell or otherwise permit consumption of alcohol on site, but 
many offering social spaces sell or otherwise provide soft drinks and snacks.  
 
13.6 Where cannabis remains illegal for non-medical use, CSCs can provide a route – 
albeit unregulated – to acquisition of cannabis with a clearer provenance, allowing 
users to avoid some of the risks associated with purchases from a street or other 
type of dealer.  
 
Cannabis Clubs in the UK 
 
13.7 Despite continued illegality of non-medical cannabis and only relatively recent 
permissions afforded to medical use, CSCs have existed across the UK for some 
time. Operating physical premises or based solely online, in 2018 they were 
estimated to number over 80,791 and numbers have likely risen since. Many are 
registered with the non-profit UK Cannabis Social Clubs (UKCSC) organisation, 
which advocates for legalisation of non-medical cannabis and acts in a semi-
regulatory capacity for its member clubs. 
 
13.8 While clubs provide cannabis for medical and non-medical use, several were born 
out of a desire to offer quality, home-grown product with known THC and CBD 
content for those who found the drug provided relief from symptoms of ill health. 
They sought to reduce reliance on street cannabis, which, as very often the 
product of forced labour overseen by criminal gangs, makes many people who 
wish to use it uncomfortable. It can also be poor quality, even adulterated with 
dangerous synthetic compounds, and comes with little or no accurate information 
about strength and composition. Some clubs also wished to offer a safe space for 
users to consume in company, should they wish.  
 
13.9 It was put to us that this remains a core aim of the CSC community. As we set out 
in chapter 11, many whose ill health symptoms are alleviated by use of what are 
known as unlicensed cannabis-based products for medicinal use (CBPMs) and 
who would likely be eligible for a private prescription cannot afford to meet the 
costs.792 Others who can afford to do so may struggle to find a safe space to 
consume their medication – for many, their home environment is not appropriate. 
And as we heard, even those in possession of a prescription to support their use 
are liable to police challenge if found consuming in public. 
 
 
791 See In Their Own Words: The Story of the UK's Cannabis Social Clubs - Volteface Accessed 4th March 2024. 
792 While in theory unlicensed CBPMs can be obtained through the NHS, it is very difficult and as far as we 
understand it, only a handful of such prescriptions have so far been provided. Prescriptions can also be obtained 
through private health care, at cost to the individual – see chapter 11. 

   
 
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The Exhale Harm Reduction Centre (Teesside Cannabis Club): a case study 
 
Origins  
• Set up ten years ago, the club sought to provide home-grown cannabis to those 
using it to treat ill health. Its first iteration, which operated for 18 months with local 
police aware and tacitly supportive, also attracted other drug sellers and users. As a 
result, it closed down, reopening elsewhere two weeks later with measures in place to 
address the early operational issues.  
 
The current model 
• Since 2018 the club, rebranded the Exhale Harm Reduction Centre (EHRC), has 
been situated on a local high street, providing cannabis to members seeking medical 
or non-medical effects. They must be aged over 21 and provide appropriate forms of 
identification to be accepted. Annual membership costs £120, with discounts for 
those aged over 65, in receipt of disability benefits, NHS and Fire Brigade workers, 
and serving or ex-military personnel.  
 
• The building has a plain exterior and CCTV deployed inside and outside, and those 
wishing to enter must be admitted by a member of staff. Access to the consumption 
room is via a locked internal door, meaning only registered members may gain entry 
and the club keeps control of who and how many members are inside at any time.  
 
• Five paid staff manage entry, sales and refreshments, run the consumption room and 
supervise members. Open for several hours over five days a week, the club 
occasionally hosts live events and we heard how several users, particularly the 
elderly, regularly socialise there, smoking or vaping cannabis alongside a cup of tea. 
 
• VAT registered, operating costs are covered by membership fees and sales of 
cannabis (which amount to around one-third of the club’s income) and merchandise. 
Cannabis grown by members and distributed through the club is dated and labelled: 
risk of it making its way onto the streets is managed through limits on daily purchases 
and prices set at a level that offers little value in attempting to sell product on. 
 
• Now focused on harm reduction, staff are trained to identify and support members 
who might benefit from help with mental health or substance abuse. Partnerships with 
local providers mean the club is well placed to signpost into services with their details, 
alongside material on safer cannabis use, shared with members upon joining. 
 
• In turn, the club increasingly receives enquiries from people referred through their GP 
or other health services, including those seeking to desist from Class A drug use. It 
was put to us that awareness of the club’s partnership with a private cannabis clinic, 
providing access to advice about medical use, is becoming more widespread across 
the local health sector. Where affordable and desirable (it may be neither), the club 
helps members access prescriptions for medical cannabis where other medications, 
including opiates, have failed. 
 
• Its role in supporting users of cannabis for medical purposes has also been 
recognised by the council, which afforded the club ‘essential service’ status following 
its closure during the first Covid-19 lockdown in 2020. That had led to notable 
adverse effects, particularly for members relying on it for medical-use cannabis, so 
during subsequent lockdowns the club was permitted to operate a click and collect 
service.  
  

   
 
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• In line with law prohibiting smoking in enclosed work- and public places, cigarettes 
cannot be consumed in the club. Tobacco alternatives are provided for those who 
wish to smoke cannabis in diluted form and vapes are available. Consumption of 
other drugs, alcohol or drinks purchased outside is forbidden.  
 
Membership 
• Over 800 members are registered with the club, ranging from their early twenties to 
their late eighties. Older members are common among those advised to approach 
the club by GPs after experiencing adverse consequences from use of opiates and 
other medication prescribed for a range of health complaints.  
 
• Several members use the club to access cannabis for medical use but do not wish to 
pursue a private prescription. Some cannot afford to; others, including medical 
doctors, are deterred because, despite the drug now being legal for such use, a 
certain stigma remains and they do not want it on their medical record.  
 
• While most collect their cannabis and consume at home, a minority consume on site 
because of opportunities to socialise, or because consumption elsewhere is difficult. 
This can result from terms of rental agreements, disapproval from house-hold 
members or complaints from neighbours if cannabis is smoked outside.  
 
Relationships with local authorities and the public 
• The club’s model was developed in partnership with local senior police and their tacit 
support, along with that from the regional Police & Crime Commissioner and the local 
council, remain key to its continued operation.  
 
• Occasional attempts to close it down tend, we heard, to be led by officers unaware of 
that senior support, which highlights the somewhat precarious nature of the club’s 
existence as personnel changes could risk more significant attempts at closure. For 
now, though, an ethos shared by the local police, council and several local politicians 
that possession and use of drugs should be seen through a health rather than 
criminal justice lens ensures the club continues to operate largely unimpeded. 
 
• Local public knowledge is relatively high, helped by increasing media coverage. The 
club is something of an ‘open secret’ and its presence attracts little public dispute (its 
location in a more industrial rather than residential area is likely helpful). Its substantial 
filtration unit ensures there are no issues with smell. 
 
• Keen to support the community, the club ploughs surplus funds into local projects. It 
has turned down offers of substantial investment from international cannabis 
companies to maintain its focus on providing a service for local people, and control 
over how surplus proceeds are deployed.  
 
The future 
• The EHRC is growing, with three or four new members each week. It is receiving 
increasing interest from public authorities outside the area, including police forces, 
who are keen to explore the possibility of adopting a similar model.    
 
• The club is also exploring ways in which it might access a range of funding streams in 
order to build on partnerships with local mental health providers and support their 
provision of services across the community.  
 
 

   
 
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Reflections on the CSC model 
 
13.10 Active management of a CSC is crucial to ensure members are properly 
registered, access appropriately restricted and the provenance of cannabis 
received and distributed is known and assured. Where that happens, arguably the 
model represents a means of reducing the risk of consumption of adulterated 
product. It also means people who choose to use the drug are more cognisant of 
the strength of their cannabis and do not need to source it through street dealers, 
with all the associated risks that entails.  
 
13.11 The EHRC demonstrates how a CSC can support wider harm-reduction efforts 
and provide credible advice on how to lessen the risks of using cannabis. Indeed, 
this is a key aspect of the model developed in Malta. Where partnerships exist, a 
CSC’s ability to signpost or actively link members into drug and alcohol treatment, 
as well as providers of mental health and other support, is to our mind a valuable 
benefit.  
 
13.12 Evidence suggests belonging to a CSC does not tend to increase individual rates 
of consumption.793 While merchandise sales and its increasing membership base 
means the EHRC generates increasing income from fees (after operating at a loss 
for some years), restrictions on the amount of cannabis each member can 
purchase mean the level of funds raised beyond operating costs will remain 
limited. There is therefore little incentive to encourage members to increase 
consumption, unlike in the profit-based models seen in the majority of jurisdictions 
which have legalised cannabis for non-medical use. 
 
13.13 That said, it is unclear whether the existence of a CSC drives up consumption 
among local populations through encouraging previous non-users to try cannabis. 
We recognise the challenges inherent in answering this question but consider it 
worthy of investigation.  
 
13.14 Given the central role played by Cannabis Social Clubs in approaches being 
developed in Malta and Germany, City Hall should maintain a watching brief on 
how those proceed. Consideration should be paid to any indications of a 
subsequent rise in prevalence of cannabis use and adverse health outcomes, as 
well as any reduction in demand or burdens on criminal justice systems and 
changes in take-up of other illegal substances and alcohol (R42). (Accepting the 
difficulties in unpicking whether any change in prevalence is genuine or an artefact 
of increased willingness to report use of a now legal drug in those jurisdictions). 
 
13.15 Licensing and some form of regulation will no doubt be critical to ensuring any 
CSC that legally provides access to cannabis complies with restrictions laid out in 
the corresponding legal framework and effectively manages, with the support of 
law enforcement, risk of infiltration by criminal operatives.  
 
793 See for example Parés-Franquero, Ò., Jubert-Cortiella, X., Olivares-Gálvez, S., Díaz-Castellano, A., Jiménez-
Garrido, D.F. & Bouso, J.C. (2019). Use and Habits of the Protagonists of the Story: Cannabis Social Clubs in 
Barcelona. Journal of Drug Issues, 49(4), pp.607–24. doi.org/10.1177/0022042619852780 

   
 
305 
 
 
13.16 We heard that clandestine clubs operate across the UK (likely not registered with 
the UKCSC), a number of which are thought to be run by criminals who use the 
model to complement sales of cannabis via street dealer networks, which they 
also control. In these instances, a club offers opportunity to increase criminal profit 
though membership fees.  
 
13.17 Rather than providing access to a safe space for quality-assured cannabis 
purchase and consumption, alongside harm-reduction advice, these so-called 
clubs simply offer the same poor-quality, sometimes adulterated product available 
on the street. In some cases, we heard, they have also provided a store for 
weapons and stolen property, discovered through police raids.  
 
13.18 Unfortunately, it is perhaps an inevitable consequence of the continued illegality of 
CSCs in this country. Without the tacit understanding and tolerance of local police, 
while cannabis continues to be prohibited it is difficult to see how the risk of 
criminal involvement can be easily withstood. Arguably, the EHRC’s success in 
maintaining its focus on harm-reduction practices lies at least in part in its 
relationship with the local police.  
 
13.19 It is, therefore, difficult to see how the model could easily be replicated under the 
auspices of the UKCSC without mandated cooperation from every police force 
and its associated Police & Crime Commissioner. 
 
 
  

   
 
306 
 
APPENDIX A: TERMS OF REFERENCE 
 
Purpose of the London Drugs Commission 
The Misuse of Drugs Act is now 50 years old and our approach to tackling drugs, and 
the harm they cause, has been largely consistent throughout that period. But drugs 
remain a scourge on society and a significant driver of violent crime. It is time for a fresh 
look at and new ideas on the legal framework in the UK, to consider what is needed to 
reduce the harm caused by drugs in society.   
   
The purpose of the London Drugs Commission will be to assess the latest evidence on 
the effectiveness of our drugs laws, with a specific focus on cannabis. It will analyse 
alternative policy options and instigate an overdue national debate on this important 
issue. The Commission’s findings will aim to inform and drive effective and lasting 
change and will build on research already commissioned by the Mayor of London to 
assess the effectiveness of cannabis enforcement in tackling violence across the 
capital.  
   
Scope of the Commission  
The Commission will consider the impact and effect of current cannabis laws on crime, 
particularly violent crime, public health and economic outcomes. It will explore police 
enforcement of those laws, and look at support and treatment services for addicts, 
seeking to improve understanding of these issues.    
   
The Commission will examine the latest evidence from the UK and across the globe on 
the harms of cannabis, the best methods of prevention, the most effective criminal 
justice responses (including in terms of tackling organised crime), the public health 
benefits of different approaches and any other relevant factors.    
   
Informed by comparative research and oral and written evidence, the Commission 
will make recommendations for the best ways to improve the current legal framework 
and practice in the following areas: 
i. The legal framework for regulating the use of cannabis. 
ii. Criminal justice responses – legal enforcement and regulation. 
iii. Public health responses – prevention; risk factors; treatment and support 
systems; and   
iv. Any other areas the Commission determine relevant. 
   
The Commission will report to the Mayor of London with policy recommendations for 
City Hall, the government, the police, the criminal justice system and public health 
services. Those recommendations will include how best to ameliorate practice in 
London within the existing legal framework.  
  
The Commission will not consider the legalisation of Class A drugs, which the Mayor has 
been clear must remain illegal.    
   
Consultations and submissions will be invited, and expert parties will be given the 
opportunity to provide evidence.   

   
 
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APPENDIX B: MEETINGS & SUBMISSIONS 
 
Without the engagement and input from very many people, our work would not have 
been possible: we are hugely grateful for their generous participation. The following is a 
list of individuals and organisations who contributed either in person or in writing: 
MEMBERS OF PARLIAMENT  
Karen Buck, former MP, Westminster North  
Dr Rupa Huq MP, Ealing Central & Acton 
Andy Slaughter MP, Hammersmith & 
Chiswick 
Sam Tarry, former MP, Ilford South 
All Party Parliamentary Group on Drug Policy 
Reform 
 
LONDON ASSEMBLY MEMBERS 
Shaun Bailey AM 
Elly Baker AM 
Andrew Boff AM 
Krupesh Hirani AM 
Caroline Russell AM 
Dr Onkar Sahota, former AM 
Sakina Sheikh, former AM 
 
LOCAL AND CITY GOVERNMENT 
London Council Leaders 
Cllr Muhammed Butt, Leader, Brent Council  
Cllr Kaya Comer-Schwartz, Leader, Islington 
Council 
Damien Egan MP, Bristol North East, 
formerly Mayor and Leader, Lewisham 
Council 
Cllr Gillian Ford, Deputy Leader, Havering 
Council 
Cllr Barry Rawlings, Leader, Barnet Council 
 
 
 
 
London Council Chief Executives and senior 
officials  
Adrian Ash, Executive Director, London 
Borough of Merton 
Curtis Ashton, Director, Young Islington, 
London Borough of Islington 
Helen Bailey, Chief Executive, London 
Borough of Sutton 
Niall Bolger, Chief Executive, London 
Borough of Hounslow 
Gary Connors, Assistant Director of 
Community Safety, London Borough of 
Newham 
Keith Daley, Head of Substance Misuse, 
London Borough of Tower Hamlets  
Carolyn Downs, Chief Executive, London 
Borough of Brent 
Althea Loderick, Chief Executive, London 
Borough of Southwark 
Iain McDermid, Assistant Director for Adult 
Integrated Commissioning, London Borough 
of Lewisham 
Anna Raleigh, Director of Public Health for 
Westminster City Council and the Royal 
Borough of Kensington and Chelsea 
Chris Rowney, Violence Reduction Network, 
London Borough of Croydon  
Dudu Sher-Arami, Director of Public Health, 
London Borough of Enfield   
Claire Symonds, Chief Executive, London 
Borough of Redbridge 
Louise Watkinson, Assistant Director of 
Public Protection, London Borough of 
Bromley 
 
 
 

   
 
308 
 
Kirsten Watters, Director of Public Health 
and Integrated Children's Commissioning, 
London Borough of Camden 
 
Greater London Authority 
Vicky Hobart, GLA Group Director of Public 
Health  
The Young People’s Action Group (The 
Violence Reduction Unit, London City Hall)  
The Youth Practitioners Advisory Board (The 
Violence Reduction Unit, London City Hall) 
 
CRIMINAL JUSTICE AGENCIES 
Joanna Coleman, Deputy Chief Crown 
Prosecutor, Crown Prosecution Service, 
(London North) 
Chris Farrimond, Director, National Crime 
Agency 
Henry Smithers, Head of Region (London), 
Youth Justice Board 
Kilvinder Vigurs, Regional Director, London 
Probation, HM Prison & Probation Service 
 
POLICING 
UK  
Chief Constable (Ret.) Mike Barton CBE 
Assistant Commissioner Paul Betts, 
Operational Policing, City of London Police 
Lord Bernard Hogan-Howe QPM 
Commander Umer Khan, Policing 
Operations & Security, City of London Police 
Lord Brian Paddick 
Sir Mark Rowley QPM, Commissioner, 
Metropolitan Police Service  
Superintendent Richard Waight, Head of 
Investigation Services, Specialist 
Operations, City of London Police 
Wendy Williams CBE, HM Inspector of 
Constabulary and Fire & Rescue Services 
 
 
International  
Chief (Ret.) Brendan Cox, Director of 
Policing Strategies, Law Enforcement 
Assisted Diversion, National Support Bureau  
Lieutenant Diane M. Goldstein (Ret.), Law 
Enforcement Action Partnership  
Commissioner John Harrington, Minnesota 
Department of Public Safety for the U.S. 
State of Minnesota 
Tom Synan, Chief of Police, Newton (Ohio) 
 
POLICE & CRIME COMMISSIONERS 
PCC Joy Allen, Durham 
PCC Alison Hernandez, Devon & Cornwall 
PCC Chris Nelson, Gloucestershire 
PCC Mark Shelford, Avon & Somerset 
PCC David Sidwick, Dorset  
 
CENTRAL GOVERNMENT 
Other officials from: 
Crown Prosecution Service  
Ministry of Justice 
 
EDUCATION 
Will Berridge, Assistant Headteacher, Park 
View School 
Ammie Ferguson, Assistant Headteacher, 
Park View School 
Christopher Lamb, Headteacher, Enfield 
Grammar 
Shelley-Ann Sobers, Operational 
Safeguarding Lead, Park View School 
Ms Cathy Stygal, Headteacher, Mayesbrook 
Park School 
Andrew Webster, Headteacher, Park View 
School 
 
 
 
 

   
 
309 
 
HEALTH CLINICIANS AND ACADEMICS 
Professor Emeritus H Valerie Curran, Clinical 
Psychopharmacology Unit, University 
College London 
Mark Dronfield, Senior Operations Manager 
for City of Westminster, Hammersmith & 
Fulham and the Royal Borough of 
Kensington & Chelsea, Turning Point  
Dr Emily Finch, Consultant Addiction 
Psychiatrist, South London and Maudsley 
NHS Trust, Clinical Director, Addictions 
Clinical Academic Group, & Chair of 
Addictions Faculty, Royal College of 
Psychiatrists  
Roz Gittins, Chief Pharmacy Officer & 
Deputy Registrar, General Pharmaceutical 
Council  
Professor Ian Hamilton, Department of 
Health Sciences, University of York 
Professor Sir Robin Murray, Professor of 
Psychiatric Research, King’s College London 
Dr Diego Quattrone, Consultant Psychiatrist, 
Lewisham Hospital 
Dr Anne Schlag, Head of Research, Drug 
Science  
Professor Sir John Strang, Head of 
Addictions Department, King’s College 
London  
 
NOT-FOR-PROFIT ORGANISATIONS & 
CHARITIES  
UK 
Viv Ahmun, Chief Executive Officer, Blaksox 
Elizabeth Burton-Phillips MBE, Founder, 
DrugFAM  
Hazel Cheeseman, Chief Executive, Action 
on Smoking and Health (ASH) 
Martin Drewry, Director, Health Poverty 
Action 
Robbie Eyles, Youth Justice (Crime) 
Solicitor, Just for Kids Law 
 
Katrina Ffrench, Founder and Managing 
Director, UNJUST 
Rebecca Gray, Chief Executive Officer, The 
Maudsley Charity 
Megan Jones, Partnership Director, 
Cranstoun 
Jason Kew, Senior Innovative Practice 
Officer, Centre for Justice Innovation 
Fiona Measham, Founder, The Loop 
Abshir Mohamed, Community Peacebuilder, 
The 4Front Project 
Kirsty Morrison, Head of Relationships, 
Cancard 
Hope Chilokoa Mullen, Community 
Organiser, The 4Front Project  
Temi Mwale, Co-Director, The 4Front 
Project 
Juan Fernández Ochoa, Campaigns & 
Communications Officer, International Drug 
Policy Consortium 
Miranda Paris, Centre for Justice Innovation 
Kusai Rahal, Co-Director, The 4Front Project 
Jason Reed, Executive Director, LEAP UK 
Steve Rolles, Senior Policy Analyst, 
Transform Drug Policy Foundation  
Paul Rompani, Chief Executive Officer, 
DrugFAM  
Julia Ryland-Henchoz, Co-Executive 
Director, LEAP UK 
Harry Shapiro, Director, Drugwise  
Lucy Slade, Head of Policy, Centre for 
Justice Innovation 
Vicky Unwin, Anyone’s Child 
 
International 
Kassandra Frederique, Executive Director, 
Drug Policy Alliance 
Shanel Lindsay, Entrepreneur Director, 
Parabola Centre and founder & CEO, Ardent 
Life 

   
 
310 
 
Kristin Nevedal, Vice Chair, Cannabis 
Advisory Committee & co-founder, 
International Cannabis Farmers Association  
Cat Packer, Director of Drug Markets and 
Legal Regulation, Drug Policy Alliance, Vice 
Chair, Cannabis Regulators of Color 
Coalition, & cannabis policy practitioner at 
The Ohio State University Moritz College 
Òscar Parés, Deputy Director, International 
Centre for Ethnobotanical Education, 
Research and Services, Barcelona 
Lisa Sanchez, Director, Mexico United 
Against Crime 
 
INTERNATIONAL POLICY EXPERTS, 
REVIEWERS AND REGULATORS 
Dr Oyedeji Ayonrinde, Associate Professor, 
Departments of Psychiatry & Psychology, 
Queen's University, & member of the 
Canadian Cannabis Act Expert Review 
Panel   
Dr Nuno Capaz, Head of the 
Portuguese Dissuasion Commission  
Helen Clark, Commissioner, Global 
Commission on Drug Policy, former Prime 
Minister of New Zealand & Administrator of 
the United Nations Development 
Programme 
Professor Patricia J. Conrod, Department of 
Psychiatry & Addiction, University of 
Montreal, & member of the Canadian 
Cannabis Act Expert Review Panel  
Ruth Dreifuss, Commissioner and former 
Chair, Global Commission on Drug Policy, 
former President of Switzerland & Head of 
the Federal Department of Home Affairs  
Bob Lessel, Coordinator, Luxembourgish 
Inter-Ministerial Cannabis Task Force, 
Ministry of Health, Luxembourg  
Lynda L. Levesque, Crown Prosecutor, 
Government of Alberta, & member of the 
Canadian Cannabis Act Expert Review Panel 
 
Leonid McKay, Executive Chair, Authority for 
the Responsible Use of Cannabis, Malta 
Honourable A. Anne McLellan, Senior 
Advisor, Bennet Jones, former Deputy Prime 
Minister of Canada and Minister of Public 
Safety and Emergency Preparedness, & 
Task Force Chair on Cannabis Legalization 
and Regulation  
Nazlee Maghsoudi, Manager, Policy Impact 
Unit, Centre on Drug Policy Evaluation, 
Toronto 
Karen Mamo, Manager, Policy, Research 
and Harm Reduction, Authority for the 
Responsible Use of Cannabis, Malta   
Dominique Mendiola, Senior Director, 
Marijuana Enforcement Division, Office of 
Marijuana Policy, Colorado 
Dr Jane Philpott, Dean of Queen’s University 
Faculty of Health Sciences and Director of 
Queen’s School of Medicine, Commissioner, 
Global Commission on Drug Policy, & former 
Canadian Minister of Health  
Morris Rosenberg O.C., Chair, Canadian 
Cannabis Act Expert Review Panel, former 
Canadian Deputy Minister of Justice, of 
Health and of Foreign Affairs, & former 
Deputy Attorney General 
Ean Seeb, Governor's Special Advisor on 
Cannabis, Colorado 
Professor Peter Selby, Head of the Mental 
Health and Addiction Division, Department 
of Family & Community Medicine, University 
of Toronto, & member of the Canadian 
Cannabis Act Expert Review Panel  
 
CANNABIS INDUSTRY 
Paul Allen, Co-Founder, Celadon 
Pharmaceuticals Plc 
Gary Carroll, Police adviser on drug policy, 
organised crime and expert witness, 
Celadon Pharmaceuticals Plc 
Stuart Cornwell, Business Development 
Director, Celadon Pharmaceuticals Plc 
 

   
 
311 
 
Marika Graham-Woods, Executive Director, 
Cannabis Trades Association  
Stephen Kon, Chief Legal Adviser, 
Mamedica 
Lewis Koski, Chief Strategy Officer, Metrc  
Nick Morland, Chief Executive Officer, 
Tenacious Labs 
Nick Pateras, Chief Executive, Lyphe Group 
Sian Philips, Executive Director, Cannabis 
Trades Association 
Peter Reynolds, Executive Committee 
member, Cannabis Industry Council & 
President of CLEAR UK 
Jon Robson, Founder & Managing Director, 
Mamedica 
Dr Callie Seaman, Co-Chair, Cannabis 
Industry Council 
James Short, Co-Founder & CEO, Celadon 
Pharmaceuticals Plc  
Dr Niraj Singh, Psychiatry Consultant, 
Mamedica 
Sarabjeet Sira, Clinical Operations Officer & 
Superintendent Pharmacist, Mamedica 
Andrew Tyler, Chief Marketing Officer & 
Head of Digital, Mamedica 
Tom White, Managing Director, Global 
Counsel 
 
RESEARCH AND ACADEMIA 
UK 
Bisola Akintoye, University of Kent 
Professor Sir John Aston, Statistics in Public 
Life, University of Cambridge  
Professor Julia Buxton, British Academy 
Global Professor, Manchester University  
Dr Tom Freeman, Director of the Addiction & 
Mental Health Group, University of Bath  
Dr Kojo Koram, Department of Law, 
Birkbeck University  
 
 
Professor Susanne MacGregor, London 
School of Hygiene & Tropical Medicine  
Amber Marks, Criminal Law & Co-Director, 
Criminal Justice Centre, Queen Mary 
University  
Professor Jim Mills, Centre for the Social 
History of Health and Healthcare, University 
of Strathclyde 
Dr Mark Monaghan, Criminology, Sociology 
& Social Policy, University of Loughborough  
Professor Alex Stevens, Criminal Justice, 
University of Kent  
Professor Harry Sumnall, Substance Use, 
Liverpool John Moores University  
Dr Lucy Troup, Reader in Psychology, 
University of the West of Scotland 
 
International 
Professor Daniel Bear, Faculty of Social and 
Community Services, Humber College, 
Ontario 
Professor Jonathan Caulkins, Operations 
Research & Public Policy, Carnegie Mellon 
University 
Dr Davide Fortin, Aix-Marseille University 
Emeritus Professor Wayne Hall, National 
Centre for Youth Substance Use Research, 
University of Queensland 
Professor Andrew Hathaway, Department of 
Sociology and Anthropology, University of 
Guelph 
Stijn Hoorens, Director of RAND Brussels & 
Senior Research Lead, RAND Europe 
Professor Caitlin Hughes, Centre for Crime 
Policy and Research, Flinders University 
Professor Keith Humphreys, Psychiatry & 
Behavioral Sciences, Stanford University 
Beau Kilmer, McCauley Chair in Drug Policy 
Innovation & Co-Director, RAND Drug Policy 
Research Center, California 
Professor Simon Lenton, Director, National 
Drug Research Institute, Curtin University 

   
 
312 
 
Professor (Assistant) Meredith Meacham, 
Department of Psychiatry & Behavioral 
Sciences, University of California, San 
Francisco 
Professor (Associate) Akwasi Owusu-
Bempah, Department of Sociology, 
University of Toronto, & Director of Research 
for the Campaign for Cannabis Amnesty 
Professor Rosalie Pacula, Elizabeth Garrett 
Endowed Chair in Health Policy, Economics, 
& Law, Price School of Public Policy, 
University of Southern California  
Dr Mafalda Pardal, Research Leader & 
European lead, RAND Drug Policy Research 
Centre 
Professor Rosario Queirolo, Department of 
Social & Political Sciences at the 
Universidad Católica del Uruguay 
Professor Peter Reuter, Director of 
Programme, Economics of Crime and 
Justice Policy, University of Maryland 
Professor Alison Ritter, Director, Drug Policy 
Modelling Program, University of New South 
Wales 
Professor Thomas Friis Søgaard, 
Department of Psychology & Behavioural 
Sciences, Centre for Alcohol and Drug 
Research, Aarhus University  
 
OTHER 
UK 
Ben Bond, facilitator, Cannabis Clinic for 
Patients with Psychosis, South London and 
Maudsley NHS Foundation Trust  
Adrian Brearey, Main Manager, Exhale Harm 
Reduction Centre 
Michael Fisher, Founder, Exhale Harm 
Reduction Centre 
Ad Gridley, PEER mentor, Cannabis Clinic 
for Patients with Psychosis, South London 
and Maudsley NHS Foundation Trust 
Robert Jappie, Partner (Regulatory), 
Fieldfisher 
Chris Snowden, Head of Lifestyle 
Economics, Institute of Economic Affairs  
Sharon Thompson, Novel Foods Policy 
Advisor, Food Standards Agency  
Paul Tossell, Team Leader, CBD and 
Radiological Policy Team, Food Policy 
Division, Food Standards Agency 
Patrick W  
 
International 
Dr Kenneth Finn, Medical School, University 
of Colorado  
Pat Oglesby, Attorney, tax policy consultant 
and founder & CEO of the Center for New 
Revenue 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

   
 
313 
 
WRITTEN SUBMISSIONS  
We were grateful to receive written 
submissions and materials from a range of 
individuals and organisations: 
 
UK 
Action on Smoking & Health 
Black Thrive (via London Borough of 
Lambeth) 
Centre for Evidence Based Drug Policy 
Centre for Justice Innovation  
City of London Police 
Dr Tom Coffey, Senior Health Policy Adviser 
to the Mayor of London & Vicky Hobart, GLA 
Group Director of Public Health  
Conservative Group on the Greater London 
Assembly (via correspondence from Emma 
Best AM, Deputy Chairperson, Health 
Committee) 
Cranstoun 
Trishna Gautama, Teacher of Citizenship, 
Religious Education and Personal, Social, 
Health & Economic Education, Stoke 
Newington School 
Chief Constable Dr Richard Lewis, Drugs 
Lead, National Police Chiefs Council 
Liberal Democrat Group on the London 
Assembly 
London Borough of Barking & Dagenham 
London Borough of Bromley 
London Borough of Haringey 
London Borough of Richmond Upon Thames 
London Borough of Southwark 
London Borough of Wandsworth 
Richard Malkin, Jodie Lynn & Naba Siddiqui, 
Dual Diagnosis Practitioners, Cannabis 
Clinic for Patients with Psychosis, South 
London and Maudsley NHS Foundation 
Trust 
 
Chief Constable Sir Andy Marsh QPM, CEO, 
College of Policing 
Metropolitan Police Service, London  
David Sidwick, Police & Crime 
Commissioner, Dorset 
Hamish Stewart, Chair, London Cannabis 
Legalisation Commission 
Dr Hannah Walsh, King’s College London 
 
International 
Lieutenant Diane M. Goldstein (Ret.), Law 
Enforcement Action Partnership  
Lars Küthe, Chief Detective Inspector, 
Frankfurt Police, Germany 
 
MEETINGS & VISITS 
We also attended wider events and made 
several visits:  
Celadon Pharmaceuticals, Birmingham 
International round table co-hosted by the 
All Party Parliamentary Group for Drug 
Policy Reform and UNITE 
Mamedica Clinic, London  
Study Tour of Cannabis Social Clubs, 
Barcelona 
 
 
 
 
 
 
 

   
 
314 
 
APPENDIX C: LONDONERS’ 
PERSPECTIVES ON USE OF CANNABIS  
 
As part of our evidence gathering we ran an opt-in survey, available online over the 
summer of 2023 to those living or working in London, to investigate perspectives on 
non-medical cannabis use. Data tables are presented below. Totals may not sum to 
100% due to rounding. 
 
A total of 153 responses were received, although not every respondent answered every 
question so base sizes vary. Most respondents (n=126, 82%) lived in London, with the 
remainder (n=27, 18%) working but not living in London. 
 
These results cannot be considered representative of Londoners’ views more broadly 
due to the methodology employed and the small sample. Findings have not been 
weighted to improve representativeness.  
 
Demographics  
 
Gender n % 
Male 83 62 
Female 38 29 
Other 12 9 
Total 133 100 
 
 
Age n % 
16–24 20 13 
25–34 51 33 
35–44 39 25 
45–54 26 17 
55–64 10 7 
65+ 7 5 
Total 153 100 
 
 
Ethnicity n % 
Asian/Asian British 5 4 
Black/African/Caribbean/ 
Black British 13 10 
Mixed/multiple 6 5 
White 92 70 
Other 5 4 
Prefer not to say 11 8 
Total 132 101 

   
 
315 
 
 
Sexuality n % 
Bisexual  18 14 
Gay or lesbian 8 6 
Heterosexual 90 69 
Other 4 3 
Prefer not to say 10 8 
Total 130 100 
 
 
Disability n % 
No 100 76 
Yes 21 16 
Prefer not to say 10 8 
Total 131 100 
 
 
Household status n % 
Owned outright 33 25 
Mortgage 36 27 
Rented (council/local 
authority) 6 5 
Rented (housing 
association) 9 7 
Rented (private landlord) 41 31 
Other 7 5 
Total 132 100 
 
 
 
Views on cannabis 
 
How much of a problem is recreational cannabis use in 
your local area? 
 n % 
A big problem 10 7 
Somewhat of a problem 12 8 
Not really a problem 39 25 
Not a problem 89 58 
Don’t know 3 2 
Total 153 100 
 
 
 
 
 

   
 
316 
 
 
What do you think are the most common effects desired by 
those who use cannabis? (Choose up to 3) 
 n % 
Relaxation 108 71 
Management of psychological 
discomfort (e.g. stress, anxiety) 79 52 
Pain relief 73 48 
Improved sleep 51 34 
To have fun 39 26 
To be sociable 26 17 
To get stoned 22 14 
To reduce or cope with boredom 12 8 
Detachment from reality 11 7 
Peer acceptance 7 5 
Don’t know 4 3 
Total (respondents) 152 N/A 
*Respondents gave up to three answers, so totals do not sum to 152 or 100%.  
 
 
What do you think are the most common harms from which 
people who use cannabis may be at risk? (Choose up to 3) 
 n % 
Lung health problems 90 59 
A criminal record 72 47 
Paranoia 43 28 
Psychosis 31 20 
Loss of motivation 31 20 
Dependence 30 20 
Problems with memory 26 17 
Panic or anxiety 17 11 
Difficulties in learning new things or 
studying 7 5 
Mood swings 5 3 
Violence 5 3 
Intense nausea and/or vomiting 3   2 
Suicide 0 0 
Don’t know 5 3 
Total (respondents) 152 N/A 
*Respondents gave up to three answers, so totals do not sum to 152 or 100%.  
 
 
 
 
 
 
 

   
 
317 
 
 
Respondents gave up to three answers, so totals do not sum to 152 or 100%.  
 
 
 
Cannabis and the law 
 
What is your understanding of the criminal law related to 
cannabis? 
 n % 
Production, supply and use of cannabis for 
any reason are criminal offences 
29 19 
Production, supply and use of cannabis for 
recreational purposes are criminal offences, 
but production, access and use for 
prescribed medical purposes is legal 
105 70 
Production and supply of cannabis is a 
criminal offence but possession of small 
amounts of cannabis for personal use is 
permitted 
9 6 
Don’t know  6 4 
Total  149 99 
 
 
Who do you think is most vulnerable to any harmful effects of 
cannabis? (Choose up to three) 
 n % 
Those aged under 16 years 107 70 
People with a current mental illness 66 43 
People with a family history of psychosis 
or other major mental illness 65 43 
Pregnant women 39 26 
16–24-year-olds 37 24 
25–34-year-olds 5 3 
35+-year-olds 1 <1 
Don’t know 9 6 
Total (respondents) 152 N/A 

   
 
318 
 
In the UK, cannabis is classified as a class B drug and is therefore illegal (unless 
prescribed for medical purposes). Below are several ways in which the current law is 
applied and enforced. For each, please tell us whether you think it is likely to be 
effective or ineffective in helping manage or reduce any harmful effects that can be 
associated with using recreational cannabis. 
 
 Being convicted 
of producing and 
supplying 
cannabis risks up 
to 14 years in 
prison, an 
unlimited fine, or 
both  
A person caught 
in possession of 
cannabis for their 
own use risks up 
to five years in 
prison, an 
unlimited fine, or 
both 
Police are able to 
issue a warning 
and/or an on-the-
spot fine of £90 if 
they discover an 
individual to be 
carrying a small 
quantity of 
cannabis deemed 
for personal use 
A police officer 
has the power to 
stop and search 
any person if they 
have reasonable 
grounds to 
suspect they are 
carrying cannabis 
 n % n % n % n % 
Very 
effective 
6 5 5 4 4 3 2 2 
Fairly 
effective 
11 8 6 5 15 11 9 7 
Fairly 
ineffective 
21 16 14 11 20 15 20 15 
Very 
ineffective 
93 70 105 79 92 69 98 74 
Don’t know 2 2 3 2 3 2 4 3 
Total 133 101 133 101 134 100 133 101 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

   
 
319 
 
Below are different ways that cannabis is managed in different countries to try to 
manage or reduce the risk of harmful impacts that can be associated with its use. 
Please select which ONE of these models you would most support being used in 
London. 
 
 n % 
Production, supply and possession of cannabis for recreational (i.e. 
non-medical) use remain criminal offences as now 4 3 
Production and supply of cannabis for recreational use remain 
criminal offences but possession of up to a specified (small) amount 
for personal use results in diversion from criminal proceedings to 
assessment and support (e.g. drug education or a drug treatment 
programme). Refusal to engage could result in referral back to the 
criminal justice system. 
5 4 
Production and supply of cannabis for recreational use remain 
criminal offences but possession of up to a specified (small) amount 
for personal use is a minor non-criminal matter which could attract 
an administrative penalty (e.g. a fine). 
1 <1 
Production and supply of recreational cannabis for sale remain 
criminal offences, but an individual may grow up to a specified 
(small) number of plants for personal use OR they may join a 
cannabis club where their personal allowance is transferred to a 
registered grower who supplies members for consumption on club 
premises. 
13 10 
Production, supply, and use of cannabis for recreational use are 
legal activities and regulated by the government. The recreational 
cannabis market is controlled by the government in a not-for-profit 
model. 
39 29 
Production, supply, and use of cannabis for recreational use are 
legal activities and regulated by the government. The market is 
commercial (i.e.: a for-profit model), but producers and vendors 
(sellers) must have a licence to operate. 
69 51 
None of these models 2 1 
Don’t know 1 <1 
Total 134 100 
 
 
 
 
 
 
 
 
 
 
 

   
 
320 
 
APPENDIX D: LONDONERS’ VIEWS ON 
LEGAL APPROACHES TO CANNABIS  
 
As part of our evidence-gathering we added two bespoke questions to the quarterly 
survey of public attitudes that is run by the Mayor’s Office for Policing and Crime.  
 
These explored Londoners’ views of how non-medical cannabis should be treated in 
law, and were added to the quarter 2 (July–September) survey wave in 2022/23.  
 
Data tables are presented below (totals may not sum due to rounding). 
 
 
Thinking about cannabis laws in the UK, which one of the following statements comes 
closest to your view? 
 
Question n % 
The sale and possession of cannabis should remain 
criminal offences as now 2,024  42 
The sale of cannabis should remain a criminal offence but 
possession should be regarded as a minor non-criminal 
matter 
1,398 29 
The sale and possession of cannabis should be legally 
permitted (sometimes called legalisation) 1,398  29 
Total 4,820 100 
 
 
Do you think the police should do more or less to control cannabis use in your 
community? 
 
Question n % 
Do more 2,362   49 
What they do now is about right 1,591  33 
Do a little less  9 
Do a lot less 868  10 
Total 4,820 100