Alcohol Policy 101

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Alcohol Policy 101

• Norman Giesbrecht
• Senior Scientist
• Research Division
• Centre for Addiction and Mental Health
• norman_giesbrecht_at_camh.net
• Janet McAllister
• Project Consultant
• Education Health Promotion Division
• Centre for Addiction and Mental Health
• janet_mcallister_at_camh.net

2
Topics

• What is alcohol policy?
• What is the relationship between health promotion
  alcohol policy?
• Why have alcohol policies?
• Who makes alcohol policies and implements them?
• Which policies have been shown to be effective?
• What are recent examples from Ontario
• What are public views on alcohol policy?
• What are some challenges and conclusions?

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1. What are alcohol policies?

• Authoritative decisions made by governments and
  other leaders through laws, rules and
  regulations.
• Alcohol policies can be directed at
• individuals
• populations (such as underage drinkers or
  pregnant women)
• organizations and health care systems.  

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What are alcohol policies?

• Policies may involve the implementation of a
  specific strategy with regard to alcohol problems
  (e.g., increase alcohol taxes).
• Policies may involve the allocation of resources
  that reflect priorities with regard to prevention
  or treatment efforts.
• Policies that unintentionally increase harm
  should also be examined, in order to provide
  insight into the public health risks associated
  with ill-advised policy decisions.

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Setting the Policy Agenda

• Alcohol policies have been implemented throughout
  history to minimize the effects of alcohol on the
  health and safety of the population.
• All policies begin with a perceived problem. How
  that problem is defined, its social and political
  importance relative to other pressing issues and
  competing interests determines the policy
  response.

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A Definition of Alcohol Policy

• What governments institutions choose to do or
  not to do about alcohol the conditions that
  contribute to its misuse.

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2. Health Promotion and Policy

• Definition The process of enabling people (and
  
• communities) to increase control over and
  (thereby)
• to improve, their health (The Ottawa Charter
  for
• Health Promotion (WHO, 1986)
• Domains of determinants of health (CIHR)
• Social economic environment
• Physical environment
• Personal health practices
• Individual capacity coping skills
• Health services

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Health Promotion Actions(Ottawa Charter)

• Build Healthy Public Policy
• Strengthening community action
• Create supportive environments
• Advocate
• Mediate
• Enable
• Reorient

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Alcohol Policy and Health Promotion

• Alcohol Policy primarily affects
• social environment (social norms)
• physical environment (accessibility, safety)
• economic environment (alcohol sales)

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3. Why Have Alcohol Policies?

• Damage, disease, social disruption and death
  associated with alcohol
• Population level damage requires population level
  interventions

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(Babor et al. 2003)
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Evidence of the damage from alcohol

• Drinking-related events and conditions have been
  linked with trauma, chronic conditions, social,
  workplace and family disruption and associated
  with other social problems.
• The evidence is well established for liver
  cirrhosis and drinking and driving, but in other
  areas, such as cancer, it is not widely known.

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Evidence of the damage from alcohol

• WHO international projects, provide recent
  evidence of the risks and damage associated with
  alcohol consumption
• Alcohol Public Policy Project (Babor et al.
  2003) and
• Global Burden of Disease Project (e.g. Rehm et a.
  2003).

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Major alcohol-related health conditions
contributing to morbidity and mortality

• Cancers head and neck, gastrointestinal tract,
  liver cancer, and female breast cancer.
• Neuropsychiatric conditions alcohol-dependence
  syndrome, alcohol abuse, depression, anxiety
  disorder, organic brain disease.
• Cardiovascular conditions ischaemic heart
  disease, cerebrovascular disease.

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Major alcohol-related health conditions
contributing to morbidity and mortality
continued

• Gastrointestinal conditions alcoholic liver
  cirrhosis, cholelithiasis, pancreatitis.
• Maternal and perinatal conditions low birth
  weight, intrauterine growth retardation.
• Acute toxic effects alcohol poisoning.
• Accidents road and other transport injuries,
  fall, drowning and burning injuries, occupational
  and machine injuries.
• Self-inflicted injuries suicide.
• Violent deaths assault injuries.

Source Babor et al. (2003, p. 64) and Gutjahr et
al. (2001)
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Burden of disease in 2000 attributable to alcohol
by development status of region and sex
High mortality developing region High mortality developing region High mortality developing region Low mortality developing regions Low mortality developing regions Low mortality developing regions Developed regions Developed regions Developed regions World World World
(AFR-D, AFR-E, AMR-D, EMR-D, SEAR-D) (AFR-D, AFR-E, AMR-D, EMR-D, SEAR-D) (AFR-D, AFR-E, AMR-D, EMR-D, SEAR-D) (AMR-B, EMR-B, SEAR-B, WPR-B) (AMR-B, EMR-B, SEAR-B, WPR-B) (AMR-B, EMR-B, SEAR-B, WPR-B) (AMR-A, EUR-A, EUR-B, EUR-C, WPR-A) (AMR-A, EUR-A, EUR-B, EUR-C, WPR-A) (AMR-A, EUR-A, EUR-B, EUR-C, WPR-A) World World World
M F Both M F Both M F Both M F Both
Total DALYs (000s) 420711 412052 832763 223181 185316 408497 117670 96543 214213 761562 693911 1455373

Alcohol 2.6 0.5 1.6 9.8 2.0 6.2 14.0 3.3 9.2 6.5 1.3 4.0

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Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
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Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
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Development status patterns of
alcohol-attributable disorder ( of total in 1000
DALYs)
develop ing coun tries developed countries world
EMR-D, SEAR-D AFR-DE, AMR-D AMR-B, EMR.B, DEAR-B, WPR-B AMR-A, EUR-A, WPR-A EUR-BC
Perinatal conditions 0.5 0.7 0.1 0.1 0.1 0.2
Cancers 2.6 7.0 9.1 10.5 3.4 7.2
Mental disorders 29.8 23.5 39.7 72.1 22.1 37.6
Cardiovascular dis. 15.1 6.1 8.9 -19.6 16.4 6.8
Other non-communic-able diseases 5.1 8.3 7.3 10.0 8.6 7.8
Unintentional injuries 38.4 38.1 23.4 19.9 33.5 28.3
Intentional injuries 8.5 16.4 11.5 7.1 16.0 12.1
Total alc.-rel. DALYs 5966 7199 25,519 7897 11,742 58,323
Total DALYS 458,601 364,117 409,688 115,863 96,911 1,445,169
of GBD alc.-related 1.3 2.0 6.2 6.8 12.1 4.0
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Impact of Alcohol in Ontario

• 29 of major injury hospitalisations in 2000/01
  were alcohol-related (CIHI)
• 39 of preventable water-related deaths involved
  alcohol 1996-2000 (Lifesaving Society)
• 31 of suicide deaths involved alcohol / other
  drugs (SmartRisk)

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Alcohol Our Society

• Costs
• 7.5 billion annually in Canada (CCSA, 1992)
• Lost productivity, law enforcement costs and
  health care services.

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Interim Conclusions

• Alcohol is associated with a number of acute
  events and chronic conditions
• Current international estimates are likely low
  because they do not take into account social
  consequences
• Nevertheless the estimated global burden of
  death, disease and disability from alcohol is
  just about equal to tobacco
• In some countries is the highest of 25 risk
  factors examined
• It is expected that this burden will increase if
  our interventions and policies do not become more
  effective

Sources Room Rehm (2004) Rehm et al. 2003
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4. Who makes alcohol policy?

• Federal and provincial laws often establish the
  legislative framework regarding alcohol
• Alcohol issues have increasingly become the
  concern of health professionals
• The mass media can have a significant influence
  on the policy debate
• The alcoholic beverage industry and related
  groups involved in for-profit production are
  often key players (e.g., self-regulation)

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Regulating Alcohol Promotion in Ontario

• Internationally,
• e.g. Trade agreements GATT add full
• Federally,
• e.g. Canadian Code of Advertising Standards
• Provincially
• e.g., Liquor Licence Control Act Liquor Control
  Board of Ontario Alcohol Gaming Commission of
  Ontario

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Alcohol Policy in Ontario

• Key Groups (Ontario)
• - Alcohol Gaming Commission of Ontario
  Liquor Control Board of Ontario
• - The Beer Store Wine Council of Ontario
• - Hospitality Associations
• - Ministries of Consumer Business
  Services Economic Development and Trade
  Finance Health Long-Term Care
  Transportation

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Alcohol Policy in Ontario

• Key groups ( Canada)
• CRTC
• ASC, Consumer Response Council
• Canadian Heritage
• Department of Justice Canada
• Health Canada

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Local Policy Development

• MUNICIPALITIES
• Municipal Alcohol Policies
• Zoning
• Enforcement

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Local Policy Development

• INSTITUTIONS/GROUP
• Workplaces
• School / campus
• Community halls centres
• Charity Groups
• Sports Associations

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Tools for Action

• Research
• Lobbying
• Community mobilization
• Media advocacy

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Opportunities for Action

• Local policy development
• New partnerships
• Broader policy focus

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Opportunities for Action

• NEW PARTNERSHIPS
• Injury prevention community
• Community/safety/ratepayers groups
• Ethno-racial communities
• Progressive corporations/institutions
• National international groups

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Part 5 What are alcohol policy options? Which
have been shown to be most effective in either
reducing alcohol consumption or
drinking-related harm?

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Evidence of Effective Alcohol Policies

• In controlling the damage from alcohol, the most
  effective health promotion interventions are
  alcohol policies that focus on population-level
  interventions e.g. access to alcohol, drinking
  contexts and drinking-related behaviours.
• This evidence has been recently been summarized
  by Babor et al. (2003)

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Alcohol, No Ordinary CommodityResearch and
Public Policy

• Thomas Babor Linda Hill
• Raul Caetano Harold Holder
• Sally Casswell Ross Homel
• Griffith Edwards Esa Österberg
• Norman Giesbrecht Jürgen Rehm
• Kathryn Graham Robin Room
• Joel Grube Ingeborg Rossow
• Paul Gruenewald
• Assisted by
• Cees Coos, Maristela Monteiro, Shakar Saxena,
  Maggie Brady, Therese Reitan, Jacek Moskoliwicz

Published by Oxford University Press in 2003
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Prevention and Intervention Strategies Evaluated

• Hundreds of studies were reviewed by the
• project team of 15 persons and the
• 31 interventions -- grouped as follows --
• were examined and evaluated

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Prevention and Intervention Strategies Evaluated

• Regulating Physical Availability - e.g. days,
  hours of sale, legal drinking age
• Pricing and Taxation
• Altering the Drinking Context e.g. server
  intervention, training, bar policies, etc.
• Education and Persuasion e.g. mass media
  counter-advertising campaigns, warning labels
  and signs, school-based education programs

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Prevention and Intervention Strategies
Evaluatedcontinued

• Regulating Alcohol Promotion e.g. controls on
  alcohol advertising, advertising guidelines, bans
• Drinking-Driving Countermeasures e.g. lower
  blood alcohol levels, random road-side spot
  checks
• Treatment and Early Intervention

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Ratings of 31 Policy-relevant Prevention
Strategies and Interventions

• Evidence of Effectivenessa the quality of
  scientific information
• Breadth of Research Supporta quantity and
  consistency of the evidence
• Tested Across Culturesa, e.,g. countries,
  regions, subgroups
• Cost to Implement and Sustainb monetary and
  other costs
• aRating Scale 0, , , , (?)
• b Rating Scale Low, Moderate, High

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Results of Evaluation

• Based on extensive review of the evidence and
  scoring of the 31 interventions on each of the 4
  criteria noted above, the following 10 best
  practices were identified by the research team

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Best Practices

• Minimum legal purchase age
• Government monopoly of retail sales
• Restriction on hours or days of sale
• Outlet density restrictions
• Alcohol taxes

• Sobriety check points
• Lowered BAC limits
• Administrative license suspension
• Graduated licensing for novice drivers
• Brief interventions for hazardous drinkers

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Pricing and Taxation

• People increase their drinking when prices are
  lowered, and decrease their consumption when
  prices rise.
• Heavy or problem drinkers are no exception to
  this rule.
• Economic studies demonstrate that increased
  alcoholic beverage taxes and prices are related
  to reductions in alcohol-related problems.
• Alcohol taxes are thus an attractive instrument
  of alcohol policy because they can be used both
  to generate direct revenue and to reduce
  alcohol-related harm.
• The most important downside to raising alcohol
  taxes is smuggling and illegal in-country alcohol
  production.

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Pricing and Taxation in Ontario

• Complex structure
• Federally
• Excise Act Adds excise duty to spirits, wine
  and beer at set rates.
• Provincially
• PST on manufactured goods services is 8, 10
  for beverage alcohol in licenced establishments,
  12 in retail stores
• 2004 budget added volume levies/wine levies /
  brewers basic fees

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Regulating Physical Availability

• Reductions in the hours and days of sale, numbers
  of alcohol outlets, and restrictions on access to
  alcohol are associated with reductions in both
  alcohol use and alcohol-related problems.
• Laws that raise the minimum legal purchasing age
  reduce alcohol sales and problems among young
  drinkers.
• Government-owned alcohol outlets (i.e.,
  off-premise monopoly systems) can limit alcohol
  consumption and alcohol-related problems
• Extreme restrictions (e.g., total prohibition)
  can lower drinking and reduce alcohol problems,
  but often have adverse side effects, such as the
  criminality associated with illicit markets

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Regulating Physical Availability in Ontario

• Liquor Licence Act
• Hours of Service 11 a.m. to 2 a.m. (New Years
  Eve 3 a.m.)
• Legal Drinking Age 19
• Liquor Control Board of Ontario
• Alcohol Gaming Commission of Ontario

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Modifying the Drinking Context

• Enforcement of serving regulations can be highly
  effective in reducing serving to intoxication
• Community mobilization can be extremely powerful
  but is costly to implement and typically not
  sustained over time
• Well-delivered training programs for bar staff
  have been shown to have immediate effects both on
  serving and aggression but require policy
  enforcement for continuing effects

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Drinking-Driving Countermeasures

• Consistently produce long-term problem reductions
  of between 5 and 30
• Deterrence-based approaches, using innovations
  such as Random Breath Testing, yield few arrests
  but substantial accident reductions
• The persistent delinquency of some impaired
  drivers should not detract from the enormous
  achievements of recent decades

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Drinking-Driving Countermeasures in Ontario

• Federally
• -Criminal Code of Canada Blood Alcohol Level
  .05
• Provincially
• - Zero BAC for first (minimum) 20 months
  (graduated licencing)
• - Licence suspension ignition interlock

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Education and Persuasion

• School-based alcohol education programs have been
  found to increase knowledge and change attitudes
  toward alcohol and other substances, but do not
  change actual use
• Approaches that address values clarification,
  self-esteem, general social skills, and
  alternatives approaches that provide activities
  inconsistent with alcohol use (e.g., sports) are
  equally ineffective
• Programs that include both resistance skills
  training and normative education (which attempts
  to correct adolescents tendency to overestimate
  the number of their peers who drink) have modest
  effects that are short-lived unless accompanied
  by ongoing booster sessions

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Education and Persuasion

• Programs that include both individual-level
  education and family- or community-level
  interventions may not be sufficient to delay the
  initiation of drinking, or to sustain a small
  reduction in drinking beyond the operation of the
  program
• Despite their good intentions, Public Service
  Announcements are an ineffective antidote to the
  high-quality pro-drinking messages that appear
  much more frequently as paid advertisements in
  the mass media
• Although a significant proportion of the
  population reports seeing counter-advertising
  warning labels, research indicates that exposure
  produces no change in drinking behavior

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Summary Education and Persuasion Strategies

• The impact of education and persuasion programs
  tends to be small at best
• When positive effects are found, they do not
  persist
• Among the hundreds of studies, only two show
  significant lasting effects (after 3 years), and
  the significance of these is questionable when
  reanalyzed
• If educational approaches are to be used, they
  should be implemented within the framework of
  broader environmental interventions that address
  availability of alcohol

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Regulating Alcohol Promotion

• Findings suggest that while the restrictions have
  not achieved a major reduction in drinking and
  related harms in the short-term, countries with
  greater restrictions on advertising have less
  drinking and fewer alcohol-related problems
• Self-regulation on advertising by the beverage
  alcohol industry tends to be fragile and largely
  ineffective

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Regulating Alcohol Promotion in Ontario

• Federally
• Canadian Code of Advertising Standards
• Provincially
• Liquor Licence Control Act

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Treatment and Early Intervention

• Exposure to any treatment is associated with
  significant reductions in alcohol use and related
  problems
• Behavioural treatments are likely to be more
  effective than insight-oriented therapies
• There is no consistent evidence that intensive
  inpatient treatment provides more benefit than
  less intensive outpatient treatment, but
  inpatient treatment is indicated for persons with
  certain problem profiles
• Brief interventions have shown the strongest
  evidence of effectiveness as general prevention
  strategies

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6. Examples of Provincial Alcohol Policy

• Taxes on alcohol
• Mandatory Server Training
• Closing Hours of Bars
• Density of Licensed Establishments
• Reduction of BAC
• Driving and Drinking for young drivers
• Standardized regulations related to alcohol
• workplace issues
• Advertising guidelines and controls

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Examples of Municipal Alcohol-Related Policies

• Licensing
• Zoning
• Transportation
• Patios
• Street Vendors
• Noise by-law
• Littering and public annoyance

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Other Avenues for Alcohol Policy Development

• Community Organisations (snowmobile association,
• church, sports group)
• Post secondary institutions residence etc.
• Workplace- social functions, fit to work
• Bars/Licensed Restaurants- internal policies
• Retail Stores- marketing and selling practices

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Environmental Supports

• Coalition building
• Media advocacy
• Alcohol accords
• Cleanliness and appearance
• Lighting
• Physical set up of licensed establishments
• Police scheduling and coverage
• RIDE programs
• Enforcement

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Part 7.What are public views on alcohol policies?
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Per Adult Rate of Official Sales in Litres of
Absolute Alcohol
Statistics Canada Control Sale of Alcoholic
Beverages
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Per Adult Rate of Official Sales Litres of
Absolute Alcohol by Beverage
Statistics Canada Control Sale of Alcoholic
Beverages
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Percent aged 15 supporting alcohol controls,
Canada, 1989 1994
Ns 11,634 in 89 12,155 in 1994
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Percent aged 15 supporting alcohol controlsby
gender, Canada, 1989 1994
Ns 11,634 in 89 12,155 in 94
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Percent aged 15 supporting alcohol controlsby
region of Canada, 1994
N 12,144
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Canada, 1989 and 1994Surveys

• Based on 11,634 respondents in 1989 and 12, 155
  in 1994
• Sampled by province, respondents aged 15 and
  older
• The next table shows odds ratios for logistic
  regressions on alcohol policy measures by year,
  gender, age and drinking pattern

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Policy Item Taxes increase Hours decreased Age raised No Corner Sales Govt ads increased Warning labels Prevent service to drunks
Yr 94 vs 89 0.76 0.84 0.58 0.67 0.55 0.74 0.60
Female vs male 1.35 1.49 1.35 2.58 1.58 1.77 1.48
Age 15-19 vs 35-44 0.74 0.77 0.32 1.12 0.90 1.31 0.50
20-34 vs 35-44 0.73 0.73 1.10 1.10 0.95 0.97 0.81
55 vs 35-44 0.88 0.98 1.66 1.12 0.74 1.07 0.83
Abstain. vs other drinkers 3.60 3.40 1.63 2.49 1.45 1.81 0.86
Freq. High-max vs other drinker 0.32 0.40 0.67 0.48 0.56 0.62 0.61
Source Giesbrecht Kavanagh, 1999, p.12, Table 2
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National Surveys 1989 1994 Main Findings

• Support declined for all policies over 5 yr
  interval
• Support more likely among women than among men
• Variation by age but not a consistent general
  pattern
• Abstainers more likely to support controls
  compared to other drinkers
• Frequent/high maximum drinkers less likely to
  support controls compared to other drinkers

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Ontario Surveys

• Sources Ontario sample of National Alcohol and
  Drug Survey Ontario samples of U.S. Warning
  Label Project provincial surveys sponsored by
  the Addiction Research Foundation the Centre
  for Addiction Mental Health
• Representative samples of adults selected by
  random digit dialing
• Ns varied by year from 1,034 to 2,721
• Results based on adults aged 20 and older

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Percent aged 20 supporting increased taxes on
alcohol, Ontario, 1989-2000
72
Percent aged 20 supporting shorter store hours
or opposed to corner store sales, Ontario,
1989-2003
73
Percent aged 20 supporting a ban on alcohol ads
on TV or ban on sponsorship by alcohol producers,
Ontario, 1989 - 2001
74
Percent aged 20 supporting warning labels or
increased counter-advertising, Ontario, 1989-2001
75
Percent aged 20 supporting an increase in
preventing service to drunken customers, Ontario,
1989-2001
76
Percent against privatizationby total sample and
gender, Ontario,1999 2002
Ns 1,288 in99 1,206 in 02
77
Percent against privatization of government
stores,by age, Ontario, 1999 2002
Ns 1,288 in 99 1,206 in 02
78
Percent against privatizationby drinking
pattern, Ontario, 1999 2002
Ns 1,288 in 99 2,002 in 02
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Conclusions

• There is support for a number of control
  measures, but it has declined
• Majority of respondents support interventions
  with low impact (e.g.warning labels) and also
  modest potential (e.g.server intervention)
• However a minority support interventions with
  demonstrated potential in reducing damage e.g.,
  higher taxes on alcohol and fewer outlets
• Less support among males and frequent/heavier
  drinkers

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Questions

• Is there an interaction between increased
  marketing and extensive retailing of alcohol and
  declining support for controls?
• What is the basis for the strong support for
  government liquor stores and opposition to corner
  store sales
• Prevention agenda?
• Fear of losing current modernized and customer
  friendly government retailing system?
• Both?
• Why have per adult sales increased in recent
  years?

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Part 8.What are challenges and conclusions?
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Challenges

• Much of government alcohol policy-making is still
  based mainly on commercial agendas
• The associations between increasing alcohol
  distribution and promotion and alcohol-related
  damage are typically not considered when policy
  decisions are made.
• Ongoing challenge is that of having research and
  epidemiological findings provide a stronger basis
  for priorities in service and practice

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Challengescontinued

• Higher priority needs to be given to the more
  effective interventions alcohol policies.
• Opportunities for synergistic combinations of
  interventions and effective partnerships need to
  be further explored and effective partnerships
  developed.
• A current challenge is that of getting alcohol on
  the agenda e.g. governments see alcohol as a
  risk factor re chronic disease prevention.
• The relevant lessons from other arenas, e.g. the
  tobacco control experiences, provide a useful
  guide for developing and implementing effective
  alcohol policies.

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Conclusions

• Alcohol policies can be effective at both the
  community level and the national level.
• Policies can be targeted at the general
  population, at high-risk drinkers, and at people
  already experiencing alcohol-related problems.
• Alcohol policies rarely operate independently or
  in isolation from other measures. Complementary
  system strategies that seek to restructure the
  total drinking environment are more likely to be
  effective than single strategies.
• Full-spectrum interventions are needed to achieve
  the greatest population impact.

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References Resource Material

• Babor, T. et al. (2003) Alcohol No Ordinary
  Commodity. Research and Public Policy. Oxford
  Oxford University Press.
• Centre for Addiction Mental Health (2004)
  Alcohol Policy Framework for Reducing
  Alcohol-Related Problems.
• Centre for Addiction Mental Health (2004)
  Position Paper Retail Alcohol Monopolies and
  Regulation Preserving the Public Interest.
• Centre for Addiction Mental Health (2004)
  Strategies to Prevent Community Alcohol-Related
  Problems Bar Areas
• Giesbrecht, N. et al. (2001) Trends in public
  opinion on alcohol policy measures Ontario
  1989-1998. Journal of Studies on Alcohol vol 62
  142-149.
• Gutjahr E. et al. (2001) The relation between
  average alcohol consumption and disease an
  overview. European Addiction Research 7 117-127.
• Rehm, J. et al. Alcohol as a risk factor for
  global burden of disease. European Addiction
  Research, vol. 9, no. 4 157-164.
• Room R. J. Rehm (2004) Alcohol-related global
  burden of disease. Presentation at the Research
  Society on Alcoholism, Vancouver 26-30 June 2004.

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Contact Information

• Norman Giesbrecht
• Senior Scientist
• Research Division
• Centre for Addiction Mental Health
• 33 Russell Street
• Toronto, Ontario, Canada M5S 2S1
• 416 535-8501 ext. 6895
• Fax [phone]
• Email norman_giesbrecht_at_camh.net

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Contact Information

• Janet McAllister
• Project Consultant
• Education and Health Promotion Division
• 171 Queens Avenue, Suite 330
• London, Ontario N6A 5J7
• 519 433-3171
• Fax [phone]
• Email janet_mcallister_at_camh.net