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How should we regulate legally available substances that pose health risks? A lesson from Sweden

By Tim Stockwell      

A free market does not deliver good public health and safety outcomes for psychoactive substances.

Proponents of privatizing Canada's alcohol monopolies usually stress the virtues of consumer choice and convenience. Photograph courtesy of Pixabay

The regulation of legally available psychoactive substances that pose serious risks to health and safety is a challenge for all modern societies. Should we let the free market decide price, hours of sales, age of purchase, how products are promoted, and how hazardous the products are?

Looking at this coolly and rationally, one might suppose that the degree of control applied in these areas would depend on the potential for risk of the substance in question. In Canada, however, we are fast moving towards a situation in which the reverse is true: the less harm posed, the greater the restrictions applied, and vice versa.

Increasingly, safe vapour devices are becoming available that deliver nicotine (a virtually harmless substance) without the many carcinogens in conventional tobacco. Despite their harm reduction potential, these devices are heavily restricted. The availability of alcohol, on the other hand, is being increasingly liberalised as provinces race to keep up with each other’s bold moves to make its sale possible in more places and at more times than ever before.

Estimates of annual deaths in Canada attributable to alcohol range from 4,000 to 8,000. The World Health Organization recognizes alcohol as a carcinogen implicated in such common conditions as cancer of the breast, oesophagus and colon.

And then we have cannabis: implicated in many fewer deaths than alcohol, but which will likely be more tightly regulated as Canada moves nervously towards legalisation. As lawmakers weigh different models, there are lessons that can be learned from the many successes and failures documented with alcohol and tobacco. One such lesson is Sweden’s handling of alcohol.

Like most of our provinces and territories, Sweden has a distribution and retail alcohol monopoly. Theirs is called Systembolaget. But unlike its Canadian and U.S. counterparts, Systembolaget reports to a health ministry — not a finance ministry — and has a mandate to protect health and safety. It operates 400 retail stores, restricts days and hours of opening, sets prices partly on the basis of alcoholic strength, limits marketing, and sponsors research on how to limit adverse outcomes. Like other monopoly countries, Sweden has relatively low alcohol consumption for a European country and hence lower rates of alcohol-related harm.

Scientists who have studied public health outcomes for legal drugs agree on some fundamental points. First, strong policies on price, availability, and marketing are highly effective for reducing consumption. Second, the less a population consumes, the fewer negative consequences.

A team of international scientists led by the University of Victoria’s Centre for Addictions Research of BC has just released a report applying these lessons to estimate the consequences of privatizing Sweden’s alcohol monopoly. In it, they estimate the extent to which price, availability, marketing and cross-border purchases would change if Systembolaget stores were replaced by 1,200 private liquor stores or if alcohol was sold in grocery stores. Applying the available scientific literature, they estimated alcohol consumption would increase by 20 per cent in the first instance and 31 per cent in the second. Annual alcohol-related deaths were estimated to increase by about 800 in the first scenario and 1,400 in the second. Alcohol-related hospital stays would also increase by about 13,000 and 20,000 in each case.

Perhaps the most important lesson to draw from this is that a free market does not deliver good public health and safety outcomes for psychoactive substances. When more competition is introduced, prices go down, convenience increases, and an intoxicating, addictive carcinogen is delivered more efficiently and in greater quantities to the entire population.

Proponents of privatizing Canada’s alcohol monopolies usually stress the virtues of consumer choice and convenience. But as a society, we can also make choices about how best to regulate substances that alter mood (positively and negatively), impair judgement, and cause health problems.

Alcohol, nicotine, and cannabis can be made available in different strengths and for intake by different means (e.g. vaping versus smoking). Is the best choice to leave decisions about pricing, availability, and marketing to the private sector? Or should we collectively choose to sacrifice a little convenience to protect our overall health and safety, including that of the most vulnerable? Systembolaget provides a model we might emulate in Canada as a way of favouring safer products while raising government revenues to fund treatment, prevention and research.

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