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Official websites use. Share sensitive information only on official, secure websites. Corresponding author. With the enforcement of the Cannabis Act on 1 April , Germany has adopted one of the most liberal legal approaches to cannabis on the continent. The German model prioritises a non-profit approach and precludes legal market mechanisms. We believe these are the main drivers for increasing cannabis use and related health problems, based on observations following cannabis legalisation in Canada and many states in the U. Although legalising cannabis possession and cultivation may not immediately eliminate the illegal market, it is expected to serve public health goals. Despite the overall positive evaluation of the Cannabis Act in Germany, there are three potential areas of concern: the potential for misuse of the medical system, the normalization of cannabis use, and the influence of the cannabis industry. The German model may herald the beginning of a new generation of European cannabis policies, but concerted efforts will be required to ensure that these policy reforms serve rather than undermine public health goals. While Germany is not the first European country to reform their cannabis policy, given its size and political importance we expect this day to be a major milestone for a new generation of European cannabis policies. In this viewpoint, we: 1 outline the political process that led to the final bill; 2 describe the proposed legislation; 3 compare the proposed legislation to regulation models implemented in other European and non-European countries; 4 anticipate the public health impact based the empirical evidence concerning cannabis regulation from Canada, Uruguay, and US states. Lastly, we outline three major risks of the Cannabis Act that may undermine public health goals. In , the prescribing of cannabis flowers for medical purposes by physicians was legalised in Germany. This decision followed a court ruling directing the federal government to reform the previous process, which required patients to undergo a year-long legal process to obtain permission for its use. The SPD advocated for scientific pilot projects to assess the effects of legal cannabis access before committing to further steps. In October of , the Ministry of Health outlined the core pillars of a new cannabis policy in a White Paper. The commercial production and distribution to adults aged 18 or over was to be legalised under a licence-based model. The introduction of a cannabis tax was planned, alongside a comprehensive ban on marketing. This policy reform plan was subsequently discussed with the European Commission. Since the commercial production and trade of cannabis for recreational purposes might have violated international and European treaties, the initial plan was abandoned and replaced by a two-step program. While the first step was approved by parliament on February 23, —and will be in effect on April 1, —it remains uncertain whether the second step will be realized at all. We will therefore focus on the first step in the following. The approved Cannabis Act reschedules cannabis from narcotic drug classification and allows the personal but not commercial handling of that substance. These privately-run clubs are legally required to operate on a non-profit basis and adopt a distribution model that has been used in some European countries and in Uruguay for several years see e. In each cannabis club, one member will be trained in prevention activities and will facilitate access to counselling and therapy options for other members. Compared to commercial for-profit production and distribution models, cannabis clubs in Germany have caps on their membership size and thus their production capacities, will not levy value-added or excise taxes on their products, and must not levy charges for their distributed products. Moreover, minimum distance rules zoning laws will likely result in very few cannabis clubs receiving licences in urban regions, resulting in a natural cap on the density of these clubs. Technically, cannabis will not be sold in the clubs but will be distributed among members against membership fees. While there are no limits on the THC concentration in cannabis produced privately or collectively, the production of THC extracts e. However, possession of THC extracts or edibles is not explicitly regulated. No regulation on possession of specific products, particularly concentrates. Harvest of three plants can easily exceed legal possession limits. Monthly limit: 30 g for 18—year-olds; 50 g for those 21 years or older. With about 70 pages of text, the Cannabis Act is a very complex document and limits our confidence in the real-world impact of this policy reform. While the interpretation of some legal details will likely be subject to future court decisions, we outline what we anticipate the real-world impact of the Cannabis Act to be. In the absence of comparable equivalent cannabis policy scales, we narratively compare the regulations to those implemented elsewhere. Clearly, the German model takes a more liberal stance on cannabis use than most, if not all, European countries. A notable exception may be the Netherlands, where adults can buy cannabis in designated shops, but these are only tolerated not legally regulated and the supply chain relies entirely on illicit sources. In no other European country is personal possession legal, but in Switzerland pilot projects currently evaluate the effects of legal access to cannabis for recreational purposes in select jurisdictions. In several European countries, such as Czechia, the Netherlands, Spain, and Portugal, cannabis possession has been de facto or de jure decriminalized. However, administrative fees may be levied for possession of even small amounts. In Portugal, possession can also result in referrals to drug counselling or treatment. In Europe, there are only two other countries that have formally legalised home cultivation. While in the Netherlands, growing up to five cannabis plants will not be prosecuted not formally legalised , 6 Malta and Luxembourg allow for up to four plants per household or adult, respectively. The collective cultivation in cannabis clubs, however, is formally legalised only in Malta, with the first legal club opened in January of , 9 while in other European countries, clubs are operating mostly illegally or in a grey zone. The Uruguayan model is similar to the German model yet people using cannabis are required to register with a federal agency in order to legally acquire cannabis from home cultivation, cannabis clubs, or selected pharmacies. Compared to the North American regulation models, the German model does not allow for any commercial retailers, either in the form of brick-and-mortar stores or online delivery options. Thus, in terms of international legalisation efforts, the German model appears to be quite restrictive. In a systematic review of studies conducted to inform German policy-makers in drafting the Cannabis Act, we assessed the impact of legalising cannabis for recreational purposes. This effect was particularly evident in controlled study designs that involved time periods of at least two years following the law's implementation. While acknowledging the uncertainties in observational study designs, we propose that the main causal mechanism leading to increasing use and health problems lies in legal market dynamics. Specifically, we identify three core pathways: 1 the increasing availability of cannabis, e. The importance of cannabis market dynamics for public health is consistent with experiences gained from the regulation of alcohol see e. In Ontario, Canada, the relaxation of a cap on retail licences has not only resulted in a surge in retail shops but also in an increase in acute and chronic cannabis harms. Assuming that market factors, such as availability, affordability, and new products are more important drivers for substance use and attributable harm than the legal status, we can conclude that the German non-profit model with a low density of cannabis clubs will be more effective in protecting public health than the North American more commercial models. Accordingly, we expect that the Cannabis Act will not have a substantial impact on the rising trend in the prevalence of cannabis use in Germany. In Canada, with legal commercial retailers offering various cannabis products at low cost, it took several years before a majority of users switched to the legal market. Importantly, we need to stress that substance use is not entirely determined by the substance's legal status or even by market factors. Prevalence estimates since show that cannabis use has gained and lost its appeal over time first temporary peak in 29 : without any meaningful changes in the regulation of cannabis during that period. Since , cannabis use has increased not only in Germany, but also in many European countries, including France and the Netherlands. While we do not anticipate that the Cannabis Act will have any major immediate adverse consequences for public health, we do expect benefits for individuals using cannabis, in particular with respect to legal matters. Despite the overall positive evaluation of the Cannabis Act, we do anticipate three major risks of the German model. Since , the prescription of medical cannabis has increased steadily. Annual domestic production of medical cannabis flower was capped at 10, kg. However, imports of medical cannabis flower have risen steadily, from kg in the first three quarters in to 14, kg in the first three quarters of The Cannabis Act will affect the medical realm as it will reschedule cannabis as a drug separated from drugs covered by the narcotics law and thereby ease prescription rules. The current constraints on domestic production will be replaced by a rather liberal market. Thus far, three companies have been contracted by the government to produce a fixed amount of cannabis flower to be sold to, and distributed by, the regulating agency, regardless of the actual demand. With the Cannabis Act, new licences will be issued for domestic production and distribution, thereby liberalising the market, increasing competition, and possibly strengthening the industry see also Risk 3. In April , there are more than different types of cannabis flower available for prescription, in addition to various concentrates. In our view, people who are interested in easy access to quality-controlled cannabis flower or concentrates specifically, may choose to obtain a medical prescription and get their choice of cannabis delivered to their home rather than engaging in private or collective cultivation. In light of these considerations, it appears plausible that medical cannabis will become the third legal source—in addition to home and collective cultivation. The extent of medical cannabis sourcing will largely depend on the willingness of physicians to prescribe cannabis, which can theoretically be given for any physical or mental condition, regardless of any available evidence on its effectiveness. Considering the increasing demand for medical cannabis as well as the liberalised production, distribution, and prescription rules, an expansion of this business model also appears plausible. While access to medical cannabis by people using it for recreational purposes may primarily replace illegal demand, there is some risk that it could incentivise consumption and be detrimental for public health. Legalising cannabis use is bound to normalize its consumption, with possible positive and negative consequences that need to be considered. By removing the punishment, structural stigmatization is removed, and it can also facilitate a reduction in the public and internalised stigma of cannabis use. While this outcome is desirable and well accepted among both legalisation opponents and advocates, the latter often argue that the de-stigmatization can improve treatment-seeking behaviour and thus improve public health. We have some doubts regarding this argument. First, the destigmatization of cannabis use may not extend to cannabis use disorder. Empirical data from the US show that the demand for treatment of cannabis use disorders is on the decline—in parallel to decreasing risk perception—and legalisation does not, in fact, reverse this trend. Clearly, coerced treatment should be abolished, but we should acknowledge the risk that a legalisation, including normalization of use, may result in lower—not higher—treatment uptake. To further illustrate our point, we can look to perhaps the most-normalized drug on our continent: alcohol. We want to sketch out one possible route by which the ongoing normalisation of cannabis use in Germany could be facilitated by the Cannabis Act. The Cannabis Act only restricts public consumption close to schools, playgrounds, and kindergartens, but we expect that cannabis use in public will still become a more common sight. Wherever tobacco smoking is allowed, people may in future also smoke cannabis. This may not only concern bars, restaurants, or dance venues but also bus stops, train stations, or shopping areas—due to relatively weak tobacco control legislation in Germany. The Cannabis Act does not allow a commercial distribution model, but there is a vocal cannabis industry that publicly engages with policy makers and increasingly dominates the discussion on regulation best practices. For instance, various industry stakeholders were invited to the parliamentary hearing on the Cannabis Act see list of participants 43 :. While the involvement of industry stakeholders in parliamentary processes may not constitute a problem per se, we begin to see a shift in the public discussion driven by industry arguments. As observed in Canada, the industry effectively lobbies for a dismantling of regulations e. The commercial for-profit production and distribution of cannabis is not only considered to constitute a key mechanism responsible for increased cannabis use prevalence see The expected impact of the German model based on empirical evidence , it is also bound to change the market and consumption practices entirely. On a largely decentralised illegal market, competition was only important locally and there was little incentive or capacity to invest in research and development. In a legal market, however, a small number of companies can produce large amounts of cannabis at much lower costs than any illegal producer would be capable of. Moreover, the heavy competition can lead to innovative new products with increasingly high THC levels. The discussion on the displacement of an ineffective, illegal market by an effective, legal market serves to illustrate that a growing cannabis industry in the largest European Union member state can weaken any future regulation and thus have adverse consequences for public health. Germany attempts to legalise cannabis in a two-step approach. Effective from April 1, , as a first step the Cannabis Act legalises the possession as well as home- and collective cultivation of cannabis for adults. The German model does not seem to have the market dynamics that are presumably responsible for the increased uptake of cannabis observed in North America, and we therefore do not expect the Cannabis Act to result in any major adverse consequences for public health in Germany. There are, however, three major risks that pertain to: 1 the possible misuse of the medical dispensary system, 2 the fallout of an ongoing normalization of cannabis, and 3 the growing influence of the cannabis industry. Since Germany is the most populous and economically largest member state in the European Union, its model is expected to gain the attention of other member states. We also expect more rigorous empirical investigation of the effects of legalisation in Germany over other European models e. If the German model meets our expectations, it will be an attractive policy option for European countries seeking to reform their cannabis laws. In fact, Czechia has already expressed interest in the German model after decriminalizing cannabis use not long ago. With the Cannabis Act, Germany has stepped up as the current leader in reforming cannabis policy in Europe. The German model as it exists today relies on a non-profit distribution system that will not effectively displace but reduce the illegal market. However, the impact of the Cannabis Act may only become clear in a few years. This will depend on how the reforms are implemented in each federal state and any potential political resistance or local issues. We anticipate that a commercial distribution model will be legalised in some European countries by the end of the decade, either by altering European treaties or by implementation of large-scale research projects proposed in Germany as the second step in cannabis legalisation. Against this backdrop, concerted efforts are needed to investigate the causal pathways between policy reforms, market mechanisms, cannabis use, and health consequences. Only with a detailed understanding of these pathways will we be able to derive precise, evidence-based recommendations for a legal commercial distribution model that serves public health. Unrelated to the present work, JM has worked as consultant for and received honoraria from various public health organizations World Health Organization, European Monitoring Centre for Drugs and Drug Addiction, national non-governmental organisations and has received payment for expert testimony in the German parliament. Moreover, all authors were involved in a research project on potential outcomes of cannabis legalisation based on empirical evidence from other countries funded by the German Ministry of Health. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Lancet Reg Health Eur. Germany's cannabis act: a catalyst for European drug policy reform? Find articles by Jakob Manthey. Find articles by Uwe Verthein. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. 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Leipzig buy marijuana