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Alcohol in Ontario: Consumption, High Risk Drinking, Harm & Policy Implications. Norman Giesbrecht & Anca Ialomiteanu Centre for Addiction & Mental Health Toronto, Ontario Presented at the 5 th annual Alcohol: No Ordinary Commodity Forum

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Alcohol in ontario consumption high risk drinking harm policy implications l.jpg
Alcohol in Ontario:Consumption, High Risk Drinking, Harm & Policy Implications

Norman Giesbrecht & Anca Ialomiteanu

Centre for Addiction & Mental Health

Toronto, Ontario

Presented at the 5th annual

Alcohol: No Ordinary Commodity Forum

Adapting National & Provincial Alcohol Strategies for Local Impact

Ben Franklin Centre, Ottawa, Ontario

March 27, 2008


Acknowledgements l.jpg
Acknowledgements

This presentation draws, in part, from other presentations, papers and

reports. We wish to thank the following persons: Lise Anglin, Thomas Babor,

Angela Boak, Thomas Greenfield, William Kerr, Robert Mann, Jayadeep

Patra, Svetlana Popova, Jürgen Rehm, John Rogers, Robin Room, and

Michael Roerecke.

Special thanks are extended to Edward Adlaf, the Principal

Investigator of the CAMH Monitor survey of Ontario Adults.

The views and opinions expressed in these slides and in this

presentation are those of the presenters and do not necessarily

reflect those of the persons acknowledged.


Overview l.jpg
Overview

  • Drinking patterns in Ontario since 1977

  • Trends in heavy and high risk drinking

  • Contributions of high risk drinkers to overall consumption

  • Damage from alcohol

  • Public opinion on alcohol policy

  • Policy implications


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Trends in self reported alcohol use in Ontario 1977-2005

  • Trends in drinking patterns

  • Trends in heavy and high risk drinking

  • Trends in drinking and driving


Ontario surveys 1977 2005 sampling designs l.jpg
Ontario Surveys 1977-2005 Sampling Designs

  • Our data is based on 20 repeated cross sectional surveys conducted conducted by the Addiction Research Foundation (ARF) from 1977 to 1998 and Centre for Addiction and Mental Health (CAMH) from 1999 to 2005).

  • 1977-1989 – the Ontario Adult Drug Use series - were face to face interviews and were conducted by Gallup Canada (sample sizes varied between 1,041 and 1,101).

  • 1991-1995 - the Ontario Adult and Other Drug Opinion Survey series were based on Computer Assisted Telephone interviewing, using random digit dialling methods and a two stage probability selection and were administered by the Institute for Social Research at York University (sample sizes varied between 1,000 and 2,022).


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CAMH Monitor 1996 –2005 Annual Ontario Adult Survey

  • The CAMH Monitor series started in 1996 and is on-going.

  • A repeated cross-sectional monthly telephone survey of Ontario adults, using random digit dialling techniques – one survey cycle is based on the aggregation of 12 independent monthly surveys, with approx. 200 completions each month (approx. 2400 completions each year).

  • Design – two-stage probability survey stratified by six geographical regions with sample sizes allocated equally.

  • Sample sizes for the years 1996-2005 varied between 2406 to 2721, and response rates varied between 58% to 69%.

  • The sample is representative for Ontarians aged 18 years and older (approx. 9, 120,000 individuals in 2005)


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Standard Drink of Alcohol in Canada

  • Beer 341 mL or 12 oz of 5% strength

  • Distilled Spirits 43 mL or 1.5 oz of 40% strength

  • Wine: 142 mL or 5 oz of 12% strength

    All contain about 13.6 grams of ethanol


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Prevalence of Past Year Alcohol Use

  • The prevalence of past year drinking is defined as the percentage consuming alcohol at least once during the past 12 months.

  • In 2005, 78.9% of Ontarians reported drinking in the past year. This rate was not significantly different from 2004 (81.2%).

  • Men were more likely to drink than women (84% vs. 76%) and rate was significantly higher among those living in the North (82%) and lowest in Toronto (74%).


Trends in alcohol use 1977 2005 l.jpg
Trends in Alcohol Use 1977-2005

  • 1977-1996 alcohol use increased between 1982 and 1992 (all-time high at 87%), and then decreased from 85% in 1995 to 79% in 1996.

  • 1997 - 2005 significant variation, with a low found in 2000 at 77.1% and a high of 81.2% in 2004. This increase was especially evident among women, from a low of 72.5% in 1998 to a high of 77.5 % in 2004.





Average no of drinks consumed per week l.jpg
Average No. of Drinks Consumed per Week 1977-2005

  • In contrast to the prevalence of drinking, which describes the size of the drinking population, the estimated no. of drinks consumed is an indicator of the quantity of alcohol consumed.

  • In 2005, the average number of drinks reported by Ontario drinkers was 3.8 drinks/week.

  • Men consumed an average of 5 drinks/week compared to 2.6 drinks for women;

  • Those aged 18 to 29 reported the highest average number of drinks/week (4.4).


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Trends in Average No. of Drinks/ Week 1977-2005

  • 1992-1996: the average no. of drinks decreased from 4.7 in 1992 to 3.3 in 1996, but started increasing in 1997.

  • 1997 – 2005: the average no. of drinks consumed increased from 3.4 to 3.8, but the overall difference was not significant.

    There was however a significant increase

    • among women (from 1.9 in 1996 to 2.6 in 2005)

    • among 40 to 49 year olds (from 2.8 in 1995 to 4.3 in 2005) and

    • among those withless than high school education (from 3.4 in 1996 to 6.1 in 2005).


Average no of drinks consumed per week in the past 12 months ontario drinkers 1992 2005 l.jpg
Average No. of Drinks Consumed per Week in 1977-2005the Past 12 Months, Ontario Drinkers, 1992-2005


Average no of drinks consumed per week in the past 12 months by gender ontario drinkers 1992 2005 l.jpg
Average No. of Drinks Consumed per Week in 1977-2005the Past 12 Months by Gender, Ontario Drinkers, 1992-2005


Average no of drinks consumed per week in the past 12 months by age ontario drinkers 1992 2005 l.jpg
Average No. of Drinks Consumed per Week in 1977-2005the Past 12 Months by Age, Ontario Drinkers, 1992-2005


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Low Risk Drinking Guidelines - CAMH & Partners 1977-2005

  • No more than 2 standard drinks per day

  • Up to 14 standard drinks per week – males

  • Up to 9 standard drinks per week – females

    Please note that these guidelines were developed about 10 years ago, based on available epidemiological and other relevant research at that time. Health Canada is currently drafting national drinking guidelines, and when they are released, the specific numbers might be slightly different than those in the LRDG.


Exceeding the low risk drinking guidelines lrdg l.jpg
Exceeding the Low Risk Drinking Guidelines (LRDG) 1977-2005

  • Respondents are considered to have exceeded the LRDG if they report :

    • A weekly consumption of 15 drinks or more for men

    • 10 drinks or more for women,

    • OR for both, more than 2 drinks at least once over the past week.

  • In 2005, 25% of Ontarians (32% of drinkers) reported exceeding the LRDG.

  • Men are 2.3 times more likely than women to drink at this level (33.6% vs. 16.9%);

  • Rate was highest among those aged 18 to 29 (38%) and lowest among those 65 years and older (12%).


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Trends in Exceeding the LRD Guidelines in the Past 12 Months, Ontario Adults

  • Short term trends: Between 2003 and 2005, the percent of Ontarians exceeding the LRDG has increased significantly from 21.4% to 25%. This increase was especially evident for 40-49 years olds, and those with some post secondary education.


Percent exceeding the low risk drinking guidelines in the past 12 months ontario adults 2003 2005 l.jpg
Percent Exceeding the Low Risk Drinking Guidelines in the Past 12 Months, Ontario Adults, 2003-2005


Prevalence of heavy drinking episodes l.jpg
Prevalence of Heavy Drinking Episodes Past 12 Months, Ontario Adults, 2003-2005

  • We used 2 indicators to measure heavy drinking :

    • Monthly heavy drinking - consuming 5 or more drinks on a single occasion once a month or more often.

    • Weekly heavy drinking- consuming 5 or more drinks on a single occasion on a weekly basis - an indicator of regular heavy intake of alcohol.

  • In 2005, 30% of Ontarians reported monthly heavy drinking and 11% reported heavy drinking on a weekly basis.

  • For both measures rates were higher among men, among those aged 18 to 29 and lowest among those with university degree.


Trends in heavy drinking l.jpg
Trends in Heavy Drinking Past 12 Months, Ontario Adults, 2003-2005

  • 1996-2005: rates of monthly heavy drinking decreased from 1996 to 1998 and then increased significantly from 24% to 30% in 2005, especially among women and among 18 to 29 year olds.

  • 1977-1995: For weekly heavy drinking two distinct periods are evident.

  • Rates remained stable between 1977 and 1995 but have increased significantly in 1996 (from 7% to 12%) and have since remained at this elevated level. These increases were especially evident among men and 18 to 29 year olds.








Hazardous drinking audit 8 l.jpg
Hazardous Drinking (AUDIT 8+) Ontario Adults, 1977-2005

  • Hazardous drinking is based on the WHO’s Alcohol Use Disorder Identification Test (AUDIT).

  • The scale is based on 10 items measuring alcohol intake, alcohol adverse reactions and alcohol dependence. Each item has 5 options (0-4) and the total AUDIT score ranges from 0 to 40.

  • A score of 8 or more (out of 40) is used to estimate the percentage who drink at hazardous or harmful levels.


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Prevalence of Hazardous Drinking Ontario Adults, 1977-2005

  • In 2005, 10.4% of Ontarians, aged 18 and over, reported hazardous or harmful drinking; men were 3 times more likely than women to report this drinking pattern (15.5% vs. 5.6%) and 18 to 29 year olds reported the highest rate (26%).

  • Among drinkers, 8.7% reported at least one dependence symptom and 25% reported at least one alcohol problem.


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Trends in Hazardous Drinking (AUDIT 8+) Ontario Adults, 1977-2005

  • 1998-2005- although there was a numeric decline in hazardous drinking , the trend was not significant.

  • There was a significant decline between 2004 and 2005 (from 13.9% to 10.4%); however we cannot interpret changes between 2 annual surveys as indicative of a long-term trend.




Prevalence of drinking and driving among drivers l.jpg
Prevalence of Drinking and Driving Among Drivers Gender, Ontario Adults, 1998-2005

  • The prevalence of past year drinkingand driving is defined as the percentage of Ontarians with a valid driver’s licence driving within one hour of consuming 2 or more drinks at least once during the past 12 months.

  • In 2005, 6.2% of Ontario drivers reported drinking and driving.

  • Men were more likely to drink and drive than women (10% vs. 2%); those aged 30 to 39 years reported the highest rate (8%) and drinking and driving was lowest in Toronto (2.5%).


Trends in drinking and driving l.jpg
Trends in Drinking and Driving Gender, Ontario Adults, 1998-2005

  • 1996-2005: there was a significant steady linear decline from 13% in 1996 to 6% in 2005.

  • This decline occurred for both men and women, and for all age groups.




Prevalence of drinking and driving in the past 12months by age groups ontario drivers 1996 2005 l.jpg
Prevalence of drinking and driving in the past 12months by age groups, Ontario Drivers,1996-2005


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Summary: age groups, Ontario Drivers,1996-2005Some Positive Findings

  • There was some indication that the prevalence of hazardous drinking decreased. The 2005 estimate (10%) is the lowest since 1998. The decline was especially evident among men from 23% in 1998 to 16% in 2005.

  • The prevalence of drinking and driving displayed a significant linear decline from 13% in 1996 to 6% in 2005, and the 2005 estimate is the lowest since 1996.


Summary some public health flags l.jpg
Summary: Some Public Health Flags age groups, Ontario Drivers,1996-2005

  • Although the prevalence of drinking has not changed dramatically, there was some indication that drinking increased among women.

  • Past year drinking among women increased from 72.5% in 1998 to 77.5% in 2004, and the average no. of drinks/week increased from 1.9 in 1996 to 2.5 in 2005

  • Heavy drinking still remains at an elevated level, with one in 7 drinkers (14%) reporting weekly heavy drinking and one in 3 drinkers (34%) reporting monthly heavy drinking.

  • The rate of weekly heavy drinking increased between 1995 and 1996 and has since remained at this elevated level, especially among men.

  • In addition, almost one in 3 drinkers (32%) consume alcohol at levels exceeding the recommended guidelines


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ALCOHOL SALES & HIGH RISK CONSUMPTION age groups, Ontario Drivers,1996-2005



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Drinking Patterns & Rates in Canada spirits, 4th is wine

  • Results from the Canadian Community Health Surveys suggest that high-risk drinking has increased from 10% to 14% between 1993 and 2004.

  • The 2004 Canadian Addiction Survey found that 23% of past-year drinkers exceeded the low-risk drinking guidelines.

  • Also, 17% of past-year drinkers were considered to drink hazardously (Alcohol Use Disorders Identification Test).

  • Both high risk drinking patterns and overall consumption levels have been shown to impact chronic disease and trauma related harm from alcohol.

Source: Statistics Canada, Canadian Community Health Surveys; Adlaf, Begin & Sawka, 2005




Concentration of u s alcohol consumption l.jpg
Concentration of U.S. Alcohol Consumption 1986-2005

Top 10% drinking > 3 drinks/day: 58% of Total

Top 5%drinking > 4 drinks/day:40% of Total

Source: adapted from Greenfield & Rogers, JSA,1999; also Kerr & Greenfield, ACER, 2007


Hazardous drinking u s percentage l.jpg
Hazardous Drinking: U.S. Percentage 1986-2005

OF TOTAL

OF BEVERAGE

Hazardous Nonhazardous Share

58.4%

14.9%

26.7%

(Hazardous drinking occurs more in bars, other people’s parties, and public places)

Source: adapted from Rogers & Greenfield, JSA,1999


Damage from alcohol l.jpg

DAMAGE FROM ALCOHOL 1986-2005

International & National examples


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Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences

Source: T. Babor et al. 2003

* Independent of intoxication or dependence


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Alcohol as a contributor to the mechanisms, and long-term consequencesGlobal Burden of Disease

  • Drinking-related events and conditions have been linked with trauma, chronic conditions, social, workplace and family disruption and also associated with other social problems.

  • In some areas the evidence has been well established for many years, such as liver cirrhosis and drinking and driving, but in other areas, such as chronic disease, it is not widely known.


Slide54 l.jpg

Developing countries mechanisms, and long-term consequences

Developed countries

High mortality

Low mortality

Underweight

14.9%

Alcohol

6.2 %

Tobacco

12.2 %

Unsafe sex

10.2 %

Blood pressure

5.0 %

Blood pressure

10.9 %

Unsafe water & sanitation

5.5 %

Tobacco

4.0 %

Alcohol

9.2 %

Indoor smoke (solid fuels)

3.6 %

Underweight

3.1 %

Cholesterol

7.6 %

Zinc deficiency

3.2 %

Body mass index

2.7 %

Body mass index

7.4 %

Iron deficiency

3.1 %

Cholesterol

2.1 %

Low fruit & vegetable intake

3.9 %

Vitamin A deficiency

3.0 %

Low fruit & vegetable intake

1.9 %

Physical inactivity

3.3 %

Blood pressure

2.5 %

Indoor smoke from solid fuels

1.9 %

Illicit drugs

1.8 %

Tobacco

2.0 %

Iron deficiency

1.8 %

Unsafe sex

0.8 %

Cholesterol

1.9 %

Unsafe water & sanitation

1.8 %

Iron deficiency

0.7 %

Leading risk factors for disease in emerging and established economies (% total DALYS*)(World Health Report, 2002)


Who study l.jpg
WHO STUDY mechanisms, and long-term consequences

Percent of Disability-Adjusted-Life Years of 26 risk factors considered, world-wide, 2002


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Relative Risk of Chronic Consequences by Daily Alcohol Intake

Sources: Adapted from Corrau et al, Preventive Medicine, 2004


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Canada: Long-term trends showing associations between alcohol consumption and damage

  • Canadian Nordic Study examined trends in Canada between 1950s and up to 2000

  • Positive associations found between consumption and:

    • Alcohol specific mortality (M. Ramstedt, 2003)

    • Liver cirrhosis mortality (M. Ramstedt, 2004)

    • Fatal accidents (O-J. Skog, 2003)

    • Suicides (M. Ramstedt, 2005)

    • Homicides (I. Rossow, 2004)

    • Total mortality (T. Norström, 2004)

      In other words an increase in consumption is

      associated with an increase in damage &

      harm


Slide58 l.jpg

Relationship between alcohol consumption (litres 100% per capita 15+) and (1) the fraction (%) of liver cirrhosis deaths specified as alcoholic; men and women. Average figures for each province for 1950-98

M. Ramstedt, 2003

Addiction, p. 1272


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The geographic relationship between alcohol consumption and explicitly alcohol-related mortality in Canada 1960-1998

M.Ramstedt, 2004, Can. J. of Public Health, p. 125


Slide60 l.jpg

Proportion of alcohol-attributable mortality and years of life lost (YLL) to all alcohol-attributable chronic disease mortality and YLL for persons < age 70 years

J.Rehm et al. The burden of cancer attributable to alcohol drinking in Canada, 2002.

Seminar: Alcohol, Cancer & Public Policy, Toronto, October 31, 2007


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Costs attributable to substance abuse in Canada, 2002 life lost (YLL) to all alcohol-attributable Total cost $39.8 billion

Source: CCSA J. Rehm, D. Baliunas, S. Brochu et al. 2006


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Per capita costs of substance abuse in Canada, 2002 Total cost : $ 1,267

Source: CCSA J. Rehm, D. Baliunas, S. Brochu et al. 2006


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PUBLIC OPINION ON ALCOHOL POLICY cost : $ 1,267

Canada & Ontario


Canada 1989 and 1994 surveys l.jpg
Canada: 1989 and 1994 Surveys cost : $ 1,267

  • National Alcohol and Other Drugs Survey (NADS): 11,634 respondents in 1989

  • Canada’s Alcohol and Other Drugs Survey (CADS): 12,155 in 1994

  • Respondents aged 15 and older

  • Sampled by province

  • Conducted by Statistics Canada for Health Canada



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Drinking Status: Percent supporting 1994alcohol controls/interventions, 1994


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Canadian Addiction Survey (CAS) 19942003-2004Brief Synopsis-Design and Methodology

  • Random-digit-dialling (RDD) methods in combination with Computer Assisted Telephone interviewing (CATI)

  • Random sample of household telephone numbers selected, and respondents age 15 and older where selected who completed the interview in English and French

  • Interviews conducted Dec ‘03 and Jan - April ‘04

  • Base sample of 1,000 per province and some provinces purchased additional cases, total N 13,909

  • Effective response rate 47.0%

Source: Adlaf & Rehm, 2005


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Gender: Percent aged 15+ supporting alcohol controls/interventions, Canada, 2004


Age percent supporting alcohol controls canada 2004 l.jpg
Age: Percent supporting controls/interventions, Canada, 2004alcohol controls, Canada, 2004


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Drinking Status: Percent supporting controls/interventions, Canada, 2004alcohol controls, Canada, 2004


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Main Findings: National Surveys controls/interventions, Canada, 2004

  • Greater support for some policy measures than others.

  • Gradual decline in support

  • Level of support seems to be inverse of effectiveness, e.g. greater support for information and education than for controls on access

  • High support for increased server intervention

  • Greater support for alcohol control/interventions among females than males

  • In 2004 general less support for interventions among younger respondents, but 15-19 most likely to be opposed to privatization

  • Dramatic differences by drinking status: greater support for interventions among lighter drinkers than heavy consumers


Ontario surveys l.jpg
Ontario Surveys controls/interventions, Canada, 2004

  • Results based on adults aged 20 and older

  • Representative samples of adults selected by random digit dialing techniques

  • Ns varied by year from 652 to 2,721

    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 (conducted by York U., Institute of Social

    Research)


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CAMH Monitor: Public Opinion on Alcohol Policy controls/interventions, Canada, 2004 Trends (1)

  • Taxes on alcoholic beverages

  • Beer and liquor store hours

  • Hours of alcoholic beverage sales in bars and restaurants

  • Number of government liquor stores in Ontario

  • Number of beer stores

  • Number of places to buy alcohol

  • Minutes to get to nearest liquor or beer store

  • Sale of alcoholic beverages in corner stores Y/N

  • Close government stores and privatize alcohol retailing


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CAMH MONITOR – ONTARIO ADULTS controls/interventions, Canada, 2004

% of respondents supporting


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CAMH Monitor: Public Opinion on Alcohol Policy controls/interventions, Canada, 2004Trends (2)

  • Change legal drinking age

  • Efforts to prevent service to drunken customers

  • Government advertising against drinking

  • Warning labels on alcoholic beverage containers Y/N

  • Prohibit wine, liquor and beer advertising on TV Y/N

  • Prohibit wine, liquor and beer companies from sponsoring events Y/N

  • Consult with health experts before making policy decisions

  • Government involvement in prevention

  • Reducing alcohol access and impact on alcohol-related problems


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CAMH MONITOR – ONTARIO ADULTS controls/interventions, Canada, 2004

% of respondents supporting


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Trends in Public Opinion on Alcohol Policies controls/interventions, Canada, 2004Ontario, 1996 – 2005 (1)

  • Declining support some access variables:

    • Beer and liquor store hours

    • Hours of bars and restaurants

    • Places to buy alcohol

    • Density of outlets

    • Raising the legal drinking age

  • Declining Support for some Interventions

    • Decline in support for server intervention

    • Decline in support for warning labels

    • Opposition to TV ads decline


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Trends in Public Opinion on Alcohol Policies controls/interventions, Canada, 2004Ontario, 1996 – 2005 (2)

  • High opposition to:

    • Alcohol sales in corner stores

    • Privatization of government liquor store system

  • Increase support:

    • Using health experts in policy planning

    • View that reducing access will control problems

  • High support for government role in prevention of alcohol problems


Ontario public opinion on alcohol policy l.jpg
Ontario: Public Opinion on Alcohol Policy controls/interventions, Canada, 2004

  • There is support for a number of control measures, but it has declined gradually since late 1980s

  • Low support for longer hours, more outlets or changes in alcohol taxes.

  • High support for increased efforts to control service to intoxicated patrons/customers

  • Majority report quick/easy access to alcohol outlets

  • Majority opposed to corner sales and privatization

  • Majority of respondents support interventions with low impact (e.g. warning labels) and 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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IMPLICATIONS & PREVENTION OPTIONS controls/interventions, Canada, 2004


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Alcohol Policies & Public Opinion controls/interventions, Canada, 2004

  • Tax changes are not driving by public health considerations

  • Changes in density, hours & days of sale do not reflect public support for status quo

  • Reluctance to privatize retailing appears to reflect public opinion

  • Advertising and sponsorship more aggressive than public view

  • Majority public support has not lead to warning labels

  • In general, public opinion as shown by national and Ontario surveys is not a good predictor of alcohol policies

  • Alcohol policy developments tend to reflect the views of younger adult males with above average incomes - who drink more than average – the ‘best’ or ‘good’ customers


Summary implications 1 l.jpg
Summary & controls/interventions, Canada, 2004Implications (1)

1. Between 1996 and 2005 there appears to be combination of:

  • rising consumption,

  • increasing % of the population is drinking in a high risk manner

  • increase in average drinks, &

  • declining public support for some alcohol policies

    2. This combination will

  • likely strengthen the demand for access to alcohol

  • not provide a strong basis for public health advocacy for effective alcohol policies, &

  • facilitate a domination of alcohol marketing and trade perspectives in the policy arena.


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Summary & controls/interventions, Canada, 2004Implications (2)

3. Based on the experience & evidence -- including cross-sectional and longitudinal analysis -- it is expected that:

  • Alcohol-related problems and attendant costs will likely increase.

  • If these problems come to the attention of policy-makers, advisors and the general public, then

    4. This may lead to

  • a renewed interest in alcohol as a risk factor for trauma and chronic disease, &

  • implementing effective population-level policies


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Summary & controls/interventions, Canada, 2004Implications (3)

5. In addition to current effective measure already in place, an alcohol control strategy for Ontario should include at a minimum:

  • An increase in the real price of alcoholic beverages and a discontinuation of discount pricing and sale pricing.

  • A ceiling on other types of availability – hours and day of sale, density of on-premise and off-premise outlets, and so on.

  • A reduction in alcohol marketing and promotion, and including more effective control of marketing that is especially attractive to youth.

  • Increased access to brief interventions so that all high risk drinkers can benefit, &

  • Resources and priority commitments to make this happen.


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Contact Information controls/interventions, Canada, 2004

Norman Giesbrecht & Anca Ialomiteanu

Centre for Addiction & Mental Health

33 Russell St.

Toronto, Ontario, Canada M5S 2S1

Fax: 416 595-6899

email: [email protected];

[email protected]


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