Cannabis control: costs outweigh the benefitsForAgainst
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7329.105 (Published 12 January 2002) Cite this as: BMJ 2002;324:105All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Propaganda aside, and reduced to essentials, it matters not whether
cannabis use is harmful, or deemed immoral by some. What matters is that a
large number of citizens in free societies the world over insist that
cannabis prohibition is a failure, and produces more harm than the drug
itself could possibly do. For example, a recent USA TODAY/CNN/Gallup Poll
indicates that 34% of Americans want marijuana prohibition ended. Even
greater support is found in other European countries and in Canada. This
fact brings up an important issue:
Considering generally-accepted principles of democracy, by what right
does a government refuse to accede to the demands of a large,
conscientiously dissenting minority? If a significant number of citizens
desire a change of law, yet the government refuses even to consider their
desires, we have the extremely anti-democratic situation which no small
number of writers and scholars have warned us about : the Tyranny of the
Majority.
After all, we surely cannot advance the idea that one-third or more
of a country's citizens are completely deluded and have no idea what they
are proposing by backing cannabis legalization! Prohibition of cannabis
forces the minority who wish to use cannabis sensibly to abstain, or
suffer severe legal penalties whereas, if prohibition were repealed, that
would not FORCE the majority to do or suffer ANYTHING AT ALL save perhaps
a wound to its dubious moral convictions. The idea that society would
suffer irreperable harms, that "the sky would fall" if cannabis were
leglaised -- the warning constantly made by prohibition's propagandists --
is patently absurd and contradicted by the best scientific evidence we
have on the subject.
Diversity of customs, opinions and pursuits is to be encouraged in a
society, not repressed. As Arnold Toynbee wrote,
"Civilizations in decline are consistently characterised by a
tendency towards standardization and uniformity. Conversely, during the
growth of civilization, the tendency is towards differentiation and
diversity."
Competing interests: No competing interests
DRUG POLICY IS ON THE MOVE – DEBATE OVER CANNABIS CONTROL
The contributions for and against the reduction in control of
cannabis highlight the difficulty in formulating drug policy based on
sound evidence (1,2). Reminiscent of political lobbying in other areas,
arguments are less scientific and evidence-based so much as based on views
on how society should be run and regulated. The issue for the medical
profession remains unexplored. How can the profession live up to
expectations now that controls are being progressively decreased and the
criminal justice system is repositioning itself?
There have been many and increasingly loud contributions to the
debate about what to do with drug users lately. Frustrated clinicians,
NHS fund managers, the newspapers and ACPO (Association of Chief Police
Officers) and the Home Secretary among others have been involved. Some
rely upon evidence from research trials, others see the political picture
while some still invoke human rights and global stability. Separating
soft and hard drugs has become less important than finding a solution and
for some the solution is simple, involving a relocation of responsibility
and therefore a "no longer my problem" approach. After 20 years of war on
drugs and the concerted efforts of the national and international law
enforcement agencies they seem to be increasingly happy to throw in the
towel and change the rules. The proposed cannabis law change will remove
33000 cases from the crime totals and the less publicised enthusiasm for
provision of pharmaceutical heroin and perhaps further legal moves make it
possible, they say, that one third of all crime will vanish at a stroke.
Ethan Nadelmann of the Lindesmith Centre once said the "the problem is not
whether or not to legalise drugs but how best to regulate the production,
distribution and consumption of the large number of psychoactive
substances already in use" (3).
For the medical profession this is a time to prepare for change. The NHS
is never terribly good at this so here is a chance. Legalising drugs of
any category or class is not likely to take work away from drug and
addiction services. All drugs have medical as well as psychiatric and
addiction consequences. Predicting the numbers of drug takers, the volume
of drugs misused and the efforts of marketing and sales on patterns of
drug taking is difficult. Anyone can speculate about the pros and cons of
decriminalisation but for the medical profession there may well be less
"dirty and contaminated" drugs used, maybe even less violence and physical
damage, but there will be more of other medical problems: because drugs
are legal, we do not seem to use them sensibly.
The profession needs to prepare for change, maybe lots of change, in
the use of psychoactive drugs. Our responses in the last 10-15 years have
been to direct people into contact with services by being sympathetic and
approachable and offering legal drugs. This may not be so important in
the future. All we know about drug treatments such as methadone and other
substitutes is that they stabilise lives and prevent crime. In the new
world, drug services may become like alcohol programmes. If drugs such as
heroin were to be legalised and supplied through commercial sources, this
would be the case but if the Health Service is to be the provider of
heroin then things are different. Provision for a few hundred may be
possible even with existing resources but even by today's figures there
are 130,000 individuals in the UK using heroin regularly.
Change is inevitable, possibly for the best. The responsibility is
shifting from the criminal justice system to the health and social care
providers. We should expect the money to flow in this direction. How
much has it cost to police, investigate, prosecute and provide custody for
one third of the crime in the UK? Change has not just started. For many
years legislation was behind clinical practice and had to try hard to keep
up. Only in the last ten years has social control become the main
treatment objective rather than abstinence. Clinical practice will now
have to try to keep up with legislative evolution.
References
1. Wodak, A., Reinarman, C., Cohen, P., Drummond, C. 2002: For and
against: Cannabis control: costs outweigh the benefits. The British
Medical Journal 324, 105 – 6.
2. Drummond, C. 2002: For and against: Cannabis control: costs
outweigh the benefits. The British Medical Journal 324, 107-8.
3. Nadelmann, E. A. 1993: Progressive legalisers, progressive
prohibitionists, and the reduction of drug-related harm. In Heather, N.,
Wodak, A., Nadelmann, E. A., O'Hare, P. (eds.), Psychoactive drugs and
harm reduction from faith to science. WHURR. London.
Competing interests: No competing interests
"Cannabis control: costs outweigh the benefits" for and against.
Dear Editor,
Wodak and colleagues present an unemotional, watertight
case that the costs DO outweigh the benefits based on
experience in a number of jurisdictions, careful research
of the field for over a century and an examination of the
negative aspects of the penal system.
Colin Drummond bravely tries to give a case for
continued prohibition in a near-hysterical comparison with
gun legalization and the Dunblane tragedy! Rather than
dealing with the issues in a consistent and logical manner,
he evokes motives, lobby-groups and the media in a
manner which is most unbecoming of a physician and a
scientist. He commences his case by denigrating those of
an opposite persuasion, claiming, without any reference,
that "legalisers" (no definition) "would have you believe
that [cannabis] is a harmless form of recreational
pleasure." I have never read such a statement by any
proponent of drug law reform, most of whom are careful
and conservative in what they claim.
In a way, Drummond eloquently argues the case for drug
law reform by pressing home the point that cannabis,
despite being 'relatively safe in overdose', may be more
harmful than is currently known. While this seems
unlikely after hundreds of years of experience, the
possibility should make parents and citizens even more
skeptical of laws which do not protect from any such
dangers. It is hard to imagine any system which makes a
drug MORE available in a uncontrolled manner to the
under-aged (even Royal offspring!). It would seem that
virtually 100% of children are exposed to cannabis these
days under the laws that Drummond supports.
We are fortunate that in most jurisdictions nowadays laws
are being introduced to deal with cannabis in a more
rational manner. The UK is doing so at present -
contrary, it would appear, to Drummond's best advice.
South Australia and Holland did it over a generation ago
without any serious suggestions of harm and many
indications that benefits have accrued. Administrations in
Lisbon, Canberra, Darwin and many other regions have
removed criminal sanctions for minor cannabis possession
and use.
It is now clear that all drugs should be dealt with in a
consistent manner and that the criminal justice system
should never be the first line. Our gains with tobacco and
alcohol use should give us confidence in education,
taxation, prevention, treatment and other measures rather
than giving young people criminal records for just doing
what most young people do.
But Drummond gives us more evidence against his own
side of this debate. In one UK study of fatal road
accidents, no alcohol was detected in the bodies of 80%
of people found positive for cannabis at necropsy. This
intriguing observation raises possibilities far too
speculative for Wodak and colleagues. However those
who consume cannabis just might be less inclined to use
alcohol. And if it were not banned, some drinkers may
choose to use cannabis in place, and could be better off in
some important respects such as liver disease. I admit
this to be wild speculation, but no more so than the
author's posturing that prohibition is good for people!
I wonder if Colin Drummond would prefer to find a
young person in his care to be using tobacco or cannabis?
And what penalty does he think would be appropriate for
first, second or third offences with the latter?
comments by Andrew Byrne ..
citation: Wodak A, Reinarman C, Cohen PDA. BMJ
(2002);324:105-108 (12 January). [et Drummond C]
http://bmj.com/cgi/content/full/324/7329/105
Dr Andrew Byrne,
General Practitioner, Drug and Alcohol,
75 Redfern Street, Redfern,
New South Wales, 2016,
Australia
Competing interests: No competing interests
Dear Editor
Firstly, thank-you very much for publishing such a refreshing piece on cannabis in the BMJ.
I have been on the front-line of AIDS and drug-service provision in this country for almost 14 years. In that time, U.K. drug policies follow roughly 10 year cycles of tightening up and relaxing again. This does seem to be an incredible waste of time, money on law enforcers and of course government. Much more importantly, it has done little to reduce the nos. of people who become addicted to drugs, end up in prison for wasted periods of their youth or die young from AIDS and other blood borne infections.
Most folk I know who want to see cannabis decriminalised or even legalised are not ignoring the fact that it has its dangers, but simply that the benefits of reform far outweigh them. One that is often posited to me, is about people descending into psychosis as a result of cannabis use. My professional experience has shown me time and time again that the main reason that folk have repeated mental health psychotic episodes is because they stop taking their medication; if they are also using cannabis, doctors often attribute the breakdown to the cannabis, but more often than not, this is related to abstaining from the anti-psychotic medication.
Also, a strong argument for maintaining the prohibition on cannabis has been that it leads to addiction to harder drugs. I find this very disturbing, as it overlooks a fundamental issue of why this minority of kids go from cannabis to heroin addiction. Children who end up as addicts are having a much rougher time navigating adolescence - cannabis is the least of their problems.
Finally, I cannot wait till the day we can stop writing these letters and focus more on helping those whose lives got to the wall because of the fall-out of prohibition. Make no mistake, there will always be folk who need 'medication' to cope. Our job is to make the space and time available to help them to do just that.
Competing interests: No competing interests
If we knew a hundred years ago what we know now about tobacco, would
it be legal? Who knows? Would the industry have been given a free hand
to sell and promote it as they liked and profit unrestricted from
marketing a lethal , addictive product? Hopefully not - but profit is a
powerful
determinant of public policy.
So for over fifty years now we've been researching the tobacco toll
and trying to restrict the industry at last.
For forty years, we've systematically collected population data on the
role of alcohol in road trauma.
By design or accident, there appear to be no systematic collections
of information of harm and death associated with cannabis use - but the
usual heat between liberalisers and prohibitionists goes on.
In Australia, information on active Tetrahydrocannabinol levels in
road fatalities has been gathered at autopsy for most of the 1990s, but no
central collection of these results has been made, despite it being on the
same report containing the alcohol information, which is centrally
recorded.
A sample of coronial records indicated that nearly 5% of all
fatalities could be attributed to culpable THC affected drivers (1) and my
own local area work with our Coroner suggests that a quarter of young
drivers killed have used cannabis in the few hours immediately preceding
their death and have not used alcohol.(2)
So it looks like there is death from cannabis. But that is not in
itself proof for or against legalisation. It is a good argument for
effective, active education and enforcement to prevent cannabis users
hurting others. It is especially a good argument for systematic data
collection so we can at last answer the question - how many people does
cannabis kill?
1. Swann P The Real Risk of Being Killed When Driving Whilst Impaired
By Cannabis. 15th Intl Council on Alcohol, Drugs and Traffic Safety.
Stockholm 2000
2. Tutt D, Bauer L,Arms J, Perera C. Cannabis and Road Death: an emerging
injury prevention concern. Health Promotion Journal of Australia 2001: 12
(2) 159-162.
Competing interests: No competing interests
Repeatedly, objective assessment exposes the irrationality of current
drug policies. Nowhere is it more evidendt than with the war on
"marijuana." This gift to man was demonized purposfully to forward
virulent American racist and represive authoritarian agendas. The
"christian temperance movment" and its WASP( white angleo-saxon
protestant) morality underpined the original criminilzation of all
pleasure inducing substances. The seven decades of prostelitizing and
propagandazation of the political elite and ordinary citizen of America
has produced a "holy grail"
effect, i.e. when we achieve the "drug free socitety" we will see all of
our social ills evaporate.
What a drug free society means and which are the social ills we will
see evaporate are never defined. They don't have to justify rationally
their action(s) because they are founded in belief and faith.
Ultimatiely, the freeing of canibis is about the freeing of
individuals and religious freedom in the most deep and profound way.
To the adherants of drug prohiibition the linking of the freedom to
consume drugs and religion is blasphemy. Fortunately for them, as opposed
to the McCarthyites, they can verify one honoring the "urine purity oath"
inexpensively and the violators of the code most often identified,
marijuana users.
Facts and rational thought can and will never prevail over faith and
irrational thought grounded in bigotry.
Tollerance is the goal and the answer for evolving just socities and
when a dominant group in a free society pronounces it will exercise "ZERO
TOLERANCE" for disent and open discussion, we have a long way to go still.
Keep Up the Good Work
C. Gary Wainwright
2739 Tulane Ave.
New Orleans, LA. 70119
a urine heritic
Competing interests: No competing interests
Wodak et al. conveniently ignore the mounting evidence of the harmful
effects of cannabis. For example the quotations in their paragraph “high
costs of control noted decades ago” stem from a time, when cannabis was
only a fraction as strong as it is now. This is likely to make some older
studies on the adverse effects of cannabis obsolete.
In addition to the studies quoted by Drummond there is the following
evidence on adverse public health effects of cannabis and cannabis
legalisation:
Cannabis and cancer:
Smoking cannabis – as compared with smoking tobacco - is associated with a
nearly fivefold greater increment in the blood carboxyhaemoglobin level,
an approximately threefold increase in the amount of tar inhaled, and
retention in the respiratory tract of one third more inhaled tar(1). There
have been case reports of cancer in the aerodigestive tract in young
adults with a history of heavy cannabis use. Those cancers are unusual
rare in adults under the age of 60, even among those who smoke tobacco and
drink alcohol(2).
Adverse effects of maternal cannabis smoking:
Smoking marijuana during pregnancy was associated with mild withdrawal
symptoms in the newborn. Between four and six years of age, verbal
ability, memory and sustained attention were affected with in utero
marijuana exposure (3). There is an increased risk of non-lymphoblastic
leukaemia, rhabdomyosarcoma, and astrocytoma in children whose mothers
reported using cannabis during their pregnancies(2).
Evidence is mounting that Cannabis is more addictive than previously
thought:
The addictive effects of cannabis have been underestimated. In the US,
more than 100,000 people, most of them adolescents, seek treatment for
their inability to control their marijuana use. That makes it addicting,
certainly for a large number of people (4).
Long-term heavy marijuana users became more aggressive during abstinence
from marijuana than did former or infrequent users (5). In addition to
aggression, marijuana smokers experience other withdrawal symptoms such as
anxiety, stomach pain, and increased irritability during abstinence from
the drug (6).
Adverse affects on mental health:
An “amotivational syndrome” has been described in chronic heavy cannabis
users. This is characterised by loss of interest in hobbies, sports,
school, and other goal-directed activities and the inability to sustain
attention on environmental stimuli (7).
Fifteen percent of cannabis users reported psychotic symptoms following
use (8). Cannabis abuse – in particular heavy abuse – is a significant
risk factor in triggering a psychotic relapse in patients with
schizophrenia. In the cannabis-abusing group there were significantly more
and earlier relapses than in non-users (9). Patients under treatment for
schizophrenia who also used cannabis had a much higher degree of delusions
and hallucinations and required more hospital attendances than those who
did not use cannabis (10).
Early cannabis use appears to be associated with the adoption of an anti-
conventional lifestyle characterised by affiliations with delinquent and
substance using peers, and the precocious adoption of adult roles
including early school leaving, leaving the parental home and early
parenthood (11).
Adverse effect of cannabis on driving and piloting skills:
Effects of cannabis which impair driving and piloting skills include:
Slowed complex reaction time; poor detection of peripheral light stimuli;
poor oculomotor tracking; space and time distortion; impaired co-
ordination; brake and accelerator errors, poor speed control; poor
judgement, increased risk in overtaking; impaired attention, especially
for divided attention tasks; impaired short-term memory; additive effects
with alcohol and other drugs (12).
Association between cannabis use and violent crime:
Violent behaviour may also be associated with acute paranoid or manic
psychosis induced by cannabis intoxication. An investigation of criminal
behaviour found that 30% of 73 cannabis-users incarcerated for homicide
had taken the drug within 24 hours of the crime. Although usually alcohol
or other drugs had also been taken, 18 prisoners said that cannabis had
contributed to their homicidal act(12).
Cannabis – the “gateway drug”:
A study following 1265 New Zealanders from birth to the age of 21, found
that although two thirds of cannabis-users did not progress to other
illicit drugs, nearly all hard drug users started off on cannabis and
heavy cannabis-users were most at risk. Even taking account of
confounding factors, there was still a link between heavy cannabis use and
progression to harder drugs (13).
Adolescents who use marijuana are 104 times as likely to use cocaine
compared with peers who never smoked marijuana (7).
Decriminalising cannabis is likely to lead to increased use,
especially among the most vulnerable group of regular users and is likely
to lead to increased use among children:
Although cannabis use is widespread and increasing in Australia, the legal
prohibitions against cannabis use and/or possession is more effective in
limiting drug consumption than many researchers had realised: 91% of
those who currently use cannabis weekly said that they would use more
cannabis if it were made legal. In conclusion: Those who would be most
likely to use more cannabis if it were legalised are regular users of the
drug, the group whose use of cannabis is mostly likely to prove harmful
both to themselves and to the wider community (14).
“Whenever a drug is legalised, its use spreads far beyond the group for
whom it is intended and within weeks, children will be taking cannabis in
the same way they now acquire alcohol. To assume that the population is
responsible enough to deal with the risks of drugs, such as cannabis, is
to ignore the immaturity of youth and the risk to adults who are not able
to control their personal behaviour (15).
At a time, when we are attempting to reduce smoking cigarettes –
especially among adolescents – legalising the smoking of cannabis will
send the completely wrong signal.
Dr HC Raabe, The Family Practice 95-97 Railway Road, Leigh,
Lancashire WN7 4AD
hcraabe@btinternet.com
1.Wu T-C, et al. New England Journal of Medicine 1998; 318: 347-51
2. Hall W, Solowij N: Adverse Effects of Cannabis. Lancet 1998; 35: 1611-
16
3. Fried PA: Prenatal exposure to marijuana and tobacco during infancy,
early and middle childhood. Archives of Toxicology, 1995 (Supplement); 17:
233-60
4. Alan I. Leshner, Director, National Institute on Drug Abuse, National
Institutes of Health, The essence of drug addiction; NIDA publication;
accessed on 25 January 2001
5. Kouri EM, et al; Changes in aggressive behaviour during withdrawal
from long-term marijuana use. Psychopharmacology 1999, 134: 302-8
6. Haney M et al; Abstinence symptoms following smoked marijuana in
humans. Psychopharmacology 1999; 141: 395-404
7. American Academy of Pediatrics; Marijuana: A Continuing Concern for
Pediatricians. Pediatrics 1999
8. Thomas H: A community survey of adverse effects of cannabis use. Drug
Alcohol Depend 1996; 42: 201-7
9. Linszen DH, Dingemans PM, Lenior ME: Cannabis abuse and the course of
recent-onset schizophrenic disorders. Archives of General Psychiatry
1994; 51: 273-9
10. Negrete JC, et al: Cannabis affects the severity of schizophrenic
symptoms: results of a clinical survey. Psychol Med 1986; 16: 515-20
11. Lynsky M, Hall W: The effects of adolescent cannabis use on
educational attainment: a review. Addiction 2000: 95: 1621-30
12. Ashton C.H., Adverse effects of cannabis and cannabinoids. British
Journal of Anaesthesia 1999; 83: 637-49
13. New Scientist; 3 November 2001
14. Does prohibition deter cannabis use? New South Wales Bureau of Crime
Statistics and Research; Press Release 22.08.2001
15. Dr A Rogers, Daily Telegraph 9.7.01
Competing interests: No competing interests
What if it is alcohol that is being debated? I am sure that the case
for banning alcohol is greater- more health risk, greater risk of
addiction including promiscuity and sexually transmitted disease! What
spurious arguments. No one is advocating asking patients to smoke cannabis
which is the greatest health risk. There are other methods of taking the
drug. As usual, addiction specialists see a biased sample of patients.
More information is needed about just how "dangerous" cannabis is. There
is already plenty of noise and heat and very little light shed on this
subject. Go out and do some research instead.
Competing interests: No competing interests
Regarding Cannabis control: costs outweigh the benefits, by Wodak,
Cohen and Drummond.
The arguments presented by Drummond for continued cannabis
prohibition range from logically flawed to erroneous in the extreme.
Prohibition is a net expense on public health. It manufactures a
matrix of dysfunction for which evidence for a more precautionary response
is exonerative. Maintaining prohibition under the guise of "protecting
public health" is an abrogation under the first principles of the Ottawa
Charter.
The obsfucated and obtuse "medical" reasons Drummond presented in
defence of a "do nothing" strategy except to educate and treat our way
out of an ever escalating problem suggests a fundamental misunderstanding
of what's broken and why.
If, say Cannabis and cancer of the throat is "causative",
epidemiological studies (Kaiser Permente) do not support it, but lets
follow Drummond's reasoning in public health context, the question
remains, how does prohibition help? Or, if cannabis is 10 times more
potent (and all evidence is too the contrary) how is this an argument
"for" when prohibition is purportedly responsible for the increase
in potency. All indications are that in a health context, potency is a
harm reduction strategy.
Prohibition is an impediment to credible antidrug education (health
promotion) and a barrier to treatment.
As to the logic of debate within the medical dominion, I applaud
Wodak and Cohen for indicating the public health externalities.
The reader might consider the following a more complete summary. see
http://www.alcp.org.nz/reports/costben.htmfor public health benefits of
legal regulation.
major impediments to health promotion and safety
ineffective drug education
reaction against state intrusion
- demand increased
& uptake maximised (drugs glamorised)
mode of use (smoking) less safe
context of use (duress) dangerous
quality of available product, uncontrolled
soft and hard drug markets joined
health research very difficult
masking of public health outcomes (eg liquor)
criminal records hurt and stigmatise people
ruined lives - suicide
major law and order problems created
motivation to act responsibly undermined
supply incentive (black market profit)
alienation of youth, males, maori, unemployed
deviant behaviours inadvertently promoted
criminal underworld promoted
voilent crime occurs over black market commodity
corruption of enforcement agencies
police highly unpopular
"no narc" culture - crimes remain undetected
harmful social repercussions
civil liberties and free will restricted
fear, discrimination, & hatred in the community
families split apart
society "dumbed-down" & repressed
beneficial uses of cannabis unavailable
highly visible "pro-drug" movement
untruthful policy corrupts community honesty
Prohibition is a politically sensitive problem domain for which there
is a public health solution.
sig/Blair Anderson, Christchurch, New Zealand
Blair Anderson mailto:blair@technologist.com
Mild Green Media Centre
Web site http://pages.quicksilver.net.nz/blair
News forum news://www.reddfish.co.nz/alcp
social capital
Competing interests: No competing interests
Just a drug?
Dear editors,
the health aspect is just one dimension of the problem. Cannabis was
used for industrial purposes for years in many countries - yielding a
broad scale of products (what current industries would feel endangered by
eventually cheaper and better products from cannabis?). There is no
reasonable evidence, that in those European contries, where cannabis was
grown as an industrial plant, there was an outburst of addiction to
cannabis. The social and medical problem reported was alcohol, not
marijuana.
Discussing the cost/benefit in this debate we have to include also
the benefit of the industrial use of canabis for other than drug purposes
which is now prohibited (or at least heavily disadvantaged agains e.g.
cotton industry).
As an example - poppy can be legally grown by anybody in many European
countries, however there is no evidence of broad illegal opium production
and use in those countries compared with broad production and use of home-
made alcohol.
Regards
Jan Stanek, MD
Competing interests: No competing interests