ALCOHOL POLICIES: Context, Examples & Challenges

1. ALCOHOL POLICIES:Context, Examples & Challenges Norman Giesbrecht Centre for Addiction & Mental Health, Toronto, Ontario M5S 2S1 Canada Email: norman_giesbrecht@camh.net Fax: 416-595-6899 For OPHA Session on Alcohol Policy June 20, 2006

2. Outline What are alcohol policies? Why are they important? What are examples of policies? What are policy priorities? Which policies have been shown to be effective? How does the public view alcohol policies? What are emerging challenges?

3. What are alcohol policies? Authoritative decisions made by governments 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

4. What are alcohol policies? (2) Any purposeful effort or authoritative decision on the part of governments or non-governmental groups to: minimize or prevent alcohol-related consequences; or, modify the distribution, retailing, marketing or control of alcoholic beverages. Policies may involve the implementation of a specific strategy with regard to alcohol problems (e.g., increase alcohol taxes)

5. What are alcohol policies? (3) Policies may involve the allocation of resources that reflect priorities with regard to prevention or treatment efforts Policies that increase access to alcohol & increase harm from alcohol should also be considered, in order to provide insight into the public health risks associated with ill-advised policy decisions

6. What are the dimensions & contexts of alcohol policies? Jurisdictional level International National Provincial Local Dimensions Laws & regulations Protocols & Guidelines Enforcement issues Social mores and norms

7. What are the dimensions & contexts of alcohol policies? (2) Jurisdictional Precident--provincial may typically control municipal Legal drinking age, Outlet density, Pricing Municipalities not have stricter laws than provincial Caveats Problems experienced locally, but most decisions on policy are provincial or federal External forces Other health and safety issues Other policy measures (e.g. alcohol taxes vs. other taxes)

8. Why are alcohol policies important? Their potential for impact: Status - power of law, regulation and institution Scope - Impact all drinkers Measure & modify Enforce

11. Alcohol & Global Burden of Disease • Alcohol is associated with a number of acute events and trauma and numerous chronic conditions • Many of the injuries have chronic side effects or can contribute to aggravating chronic diseases • 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 and in some countries is the highest of 25 risk factors examined

12. Drinking Patterns & Rates in Canada • Both high risk drinking patterns and overall consumption levels have been shown to impact chronic disease and other harm from alcohol • 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)

13. Drinking Patterns & Rates in Canada (2) • Trend studies focusing on Canada indicate a strong positive association between average consumption levels and alcohol mortality: • alcohol-related mortality • liver cirrhosis deaths • traffic fatalities • suicide • homicide • total mortality • The per capita (aged 15+) has increased from 7.3 to 7.9 litres between 1997 and 2004 • Given these developments, the levels of chronic disease & injuries related to alcohol are expected to increase

14. Why are alcohol policies important? (2) Given the burden of disease, death and disability from alcohol the most effective interventions with the widest scope of impact are needed With both per capita consumption & high risk drinking increasing, the chronic and acute damage from alcohol is expected to increase in Canada unless our interventions are more effective

15. What are examples of alcohol policies International World Trade Organization Treaties World Health Organization Resolution Europe Alcohol Action Plan

16. What are examples of alcohol policies (2) National Canada’s Drug Strategy BAC level of 0.08 as part of Criminal Code of Canada

17. What are examples of alcohol policies (3) Provincial Challenge and Refusal Program DUI legislation Alcohol & boating legislation Liquor licencing (on-premise): Bars and Restaurants Off-premise density: N. of liquor stores, Agency stores, Beer Stores, Ontario Wine stores

18. What are examples of alcohol policies (4) Muncipal Municipal Alcohol Policy Safer Bars Program Outlet density restrictions/conditions

19. What have been policy priorities? Combination of ad hoc, rational & evolutionary Public versus private consumption Visible aspects/damage of alcohol consumption More damage - more policies? Many not evaluated Considered together they do not exemplify a systematic & comprehensive approach

20. What are alcohol policy options? Which have been shown to be most effective in either reducing drinking or drinking-related damage or harm?

21. Evidence of Effective Alcohol Policies • In controlling the damage from alcohol, the most effective health promotion 21 interventions are alcohol policies that focus on population-level interventions: e.g. access to alcohol, drinking contexts and drinking-related behaviours • This evidence has recently been summarized by Babor et al. (2003)

22. Alcohol, No Ordinary Commodity:Research 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

23. Prevention and Intervention Strategies Evaluated Hundreds of studies were reviewed by the project team of 15 persons and the 32 interventions grouped as follows were examined and evaluated:

24. Prevention and Intervention Strategies Evaluated (2) • 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

25. Prevention and Intervention Strategies Evaluated (3) • 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

26. Ratings of 32 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

27. Results of Evaluation Based on extensive review of the evidence and scoring of the 32 interventions on each of the 4 criteria noted above, the following 10 best practices were identified by the research team

28. 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 Best Practices

29. 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-countryalcohol production.

30. 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 / brewer’s basic fees

31. 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, in principle, limit alcohol consumption and alcohol-related problems

32. Regulating Physical Availability in Ontario • Liquor Licence Act • Hours of Service: 11 a.m. to 2 a.m. (New Year’s Eve 3 a.m.) • Legal Drinking Age: 19 • The L.C.B.O.

33. 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

34. 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

35. 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

36. 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

37. Education and Persuasion (2) • 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 • 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

38. Education and Persuasion (3) • 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

39. 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 a few 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

40. 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

41. Regulating Alcohol Promotion in Ontario Federally: Canadian Code of Advertising Standards Provincially: Liquor Licence Control Act

42. 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

44. Public Opinion on Alcohol Policy National surveys: CADS 1989, NADS 1994, CAS 2004 & annual data from Ontario since 1989 Support for status quo and seeking more control in some areas Very supportive of monopoly-based system Public opinion not in close step with extensive marketing Not strongly supportive of the most effective interventions, and supportive of some ineffective ones

45. What are some emerging 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

46. Challenges (2) • Higher priority needs to be given to the more effective interventions & alcohol policies. • Ineffective interventions should be phased out -- there are not unlimited resources to sponsor both effective and ineffective programs.

47. Challenges (3) • 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 need to see alcohol as an important risk factor chronic diseases and injuries. • The relevant lessons from other arenas, e.g. the tobacco control experiences, provide a useful guide for developing and implementing effective alcohol policies.

48. Conclusions • Alcohol policies can be effective at the community, provincal & 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.