Per capita alcohol consumption and all-cause mortality in Canada, 1950-98

The impact of an alcohol policy change on developmental trajectories of youth alcohol use: examination of a natural experiment in Canada

OBJECTIVES

In 2015, the Liquor Control Board of Ontario (LCBO) authorized sale of alcohol in some Ontario grocery stores. This research evaluates the impact of the new policy on alcohol use patterns of youth in a quasi-experimental setting with two control groups.

METHODS

The sample consists of 2267 grade 9 students attending 60 secondary schools across Ontario (n = 56) and Alberta (n = 4), who provided 4-year linked longitudinal data (2013-2014 to 2016-2017) in the COMPASS study. The study used the frequency of drinking and the frequency of binge drinking to characterize alcohol use behaviours.

RESULTS

Latent transition analysis found four statuses of alcohol use: abstainer, periodic drinker, low-risk drinker, and high-risk regular drinker. The new policy had no negative impact among periodic and low-risk drinkers, but the risk of transitioning from the abstainer (lowest risk status) to high-risk regular drinker (highest risk status) among the exposed cohort was 1.71 times greater post-policy than pre-policy change, compared with those of Ontario-unexposed (0.50) and Alberta-unexposed cohorts (1.00). The probability of sustaining high-risk drinking among the exposed cohort increased by a factor of 1.76, compared with 1.13-fold and 0.89-fold among the Ontario-unexposed and Alberta-unexposed cohorts, respectively.

CONCLUSION

Youth are more likely to transition from abstinence to high-risk regular drinking, and high-risk regular drinkers are more likely to maintain their behaviours in the jurisdictions exposed to the latest change in LCBO policy authorizing grocery stores to sell alcohol. When formulating policy interventions, youth access to alcohol should be considered in order to reduce their harmful alcohol consumption.

The effect on emergency department visits of raised alcohol minimum prices in Saskatchewan, Canada

INTRODUCTION AND AIMS

The province of Saskatchewan, Canada introduced minimum prices graded by alcohol strength in April 2010. As previous research found this intervention significantly decreased alcohol consumption and alcohol-attributable morbidity, we aim to test the association between the intervention and the rate of emergency department (ED) visits in four alcohol-related injury categories [motor vehicle collisions (MVC), assaults, falls and total alcohol-related injuries].

DESIGN AND METHODS

Data on ED visits in the city of Regina were obtained from the Saskatchewan Ministry of Health. Auto-regressive integrated moving average time series models were used to test the immediate and lagged effects of the pricing intervention on rates of alcohol-related nighttime. ED visits and controlled for daytime rates of ED visits, economic variables, linear and seasonal trends, and auto-regressive and moving average effects.

RESULTS

The implementation of an alcohol minimum pricing strategy in Saskatchewan was associated with decreased MVC-related ED visits for women aged 26 and over after a 6 month lag period (-39.4%, P < 0.001). There was no significant abrupt effect of this intervention on ED visits of four injury types in any of four gender-age categories; however, rates of ED visits among young males for MVCs and assaults decreased substantially during this study.

DISCUSSION AND CONCLUSIONS

The minimum pricing policy change led to a lagged decrease in motor vehicle-collision-related ED visits for women older than 25. Of note, there did not appear to be an instantaneous effect on the rate of alcohol-related injury ED visits immediately after the policy implementation nor lagged effects for other gender-age groups.

Alcohol, Cannabis, and Opioid Use Disorders, and Disease Burden in an Integrated Health Care System

OBJECTIVES

We examined prevalence of major medical conditions and extent of disease burden among patients with and without substance use disorders (SUDs) in an integrated health care system serving 3.8 million members.

METHODS

Medical conditions and SUDs were extracted from electronic health records in 2010. Patients with SUDs (n = 45,461; alcohol, amphetamine, barbiturate, cocaine, hallucinogen, and opioid) and demographically matched patients without SUDs (n = 45,461) were compared on the prevalence of 19 major medical conditions. Disease burden was measured as a function of 10-year mortality risk using the Charlson Comorbidity Index. P-values were adjusted using Hochberg's correction for multiple-inference testing within each medical condition category.

RESULTS

The most frequently diagnosed SUDs in 2010 were alcohol (57.6%), cannabis (14.9%), and opioid (12.9%). Patients with these SUDs had higher prevalence of major medical conditions than non-SUD patients (alcohol use disorders, 85.3% vs 55.3%; cannabis use disorders, 41.9% vs 23.0%; and opioid use disorders, 44.9% vs 26.1%; all P < 0.001). Patients with these SUDs also had higher disease burden than non-SUD patients; patients with opioid use disorders (M = 0.48; SE = 1.46) had particularly high disease burden (M = 0.23; SE = 0.09; P < 0.001).

CONCLUSIONS

Common SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care. This signals the need to explore the full impact SUDs have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.

Is there an association between trends in alcohol consumption and cancer mortality? Findings from a multicountry analysis

The aim of this analysis is to examine long-term trends in alcohol consumption and associations with lagged data on specific types of cancer mortality, and indicate policy implications. Data on per capita annual sales of pure alcohol; mortality for three alcohol-related cancers - larynx, esophageal, and lip, oral cavity, and pharynx; and per capita consumption of tobacco products were extracted at the country level. The Unobservable Components Model was used for this time-series analysis to examine the temporal association between alcohol consumption and cancer mortality, using lagged data, from 17 countries. Statistically significant associations were observed between alcohol sales and cancer mortality, in the majority of countries examined, which remained after controlling for tobacco use (P<0.05). Significant associations were observed in countries with increasing, decreasing, or stable trends in alcohol consumption and corresponding lagged trends in alcohol-related cancer mortality. Curtailing overall consumption has potential benefits in reducing a number of harms from alcohol, including cancer mortality. Future research and surveillance are needed to investigate, monitor, and quantify the impact of alcohol control policies on trends in cancer mortality.

Trends in binge drinking in Canada from 1996 to 2013: a repeated cross-sectional analysis

BACKGROUND

Heavy drinking is a major factor in morbidity and mortality worldwide. Little information is available on trends in Canada regarding alcohol abuse. We sought to estimate abstinence, binge drinking and alcohol intake exceeding low-risk drinking guidelines in the Canadian population from 1996 to 2013.

METHODS

The data sources for this analysis were a series of cross-sectional national health surveys of the Canadian population carried out by Statistics Canada between 1996 and 2013. These were cross-sectional files from the National Population Health Surveys of 1996 and 1998, plus the Canadian Community Health Surveys from 2000 to 2013. Respondents were aged 18 years and older.

RESULTS

The proportion of binge drinkers increased steadily from 13.7% (95% confidence interval [CI] 13.2%-14.2%) in 1996 to 19.7% (95% CI 19.1%-20.3%) in 2013. The corresponding proportions for men were 20.8% (95% CI 19.9%-21.7%) in 1996, and 25.7% (95% CI 24.7%-26.6%) in 2013; for women, these proportions were 6.9% (95% CI 6.4%-7.5%) in 1996, and 13.8% (95% CI 13.1%-14.5%) in 2013. No significant increases were seen in the proportion of people who exceeded low-risk drinking guidelines or of abstainers during the same period.

INTERPRETATION

The rate of self-reported binge drinking in Canada has increased from 1996 to 2013, relatively more so among women than among men. No evidence of an increase in the proportion of people exceeding low-risk drinking guidelines or of abstainers was seen during the same period. These results suggest that binge drinking is of particular concern regarding intervention strategies aimed at improvement of public health.

Alcohol Consumption and All-Cause Mortality in the United States, 1950–2002

The aim of the study was to estimate the relationship between per capita alcohol consumption and male all-cause mortality in the United States (U.S.) for the period 1950–2002. Alcohol sales (in litres of 100% alcohol) were used as proxy for per capita consumption. The data were analyzed using the Box-Jenkins technique. Two models were estimated, one including only female mortality as a control, the other including in addition cigarette sales. The first model yielded a significant alcohol effect that implied a 2.8% (p < 0.001) increase in mortality given a 1-litre increase in consumption. This estimate coincides with those obtained for Canada, northern Europe and Russia in previous research but is stronger than estimates for southern Europe. When cigarette sales were included in the model, the alcohol effect was almost halved but still statistically significant. The results indicate that population drinking is of great importance for public health.

Genetic polymorphisms and response to medications for alcohol use disorders: a systematic review and meta-analysis

Aim: To assess whether response to medications for alcohol use disorders varies by genotype. Methods: Systematic review and meta-analysis. Results: We found no studies that assessed the clinical utility of genotype-guided dosing strategies or genotype-guided medication selection, and none randomized by genotype. All included studies assessed the association between genotype and response to medication. Of 15 included studies, eight (n = 1365 participants) assessed variation in naltrexone response and polymorphisms of OPRM1. Our meta-analyses for return to heavy drinking found no significant difference between A allele homozygotes and those with at least one G allele, both without (risk difference: 0.26; 95% CI: -0.01–0.53; n = 174) and with inclusion of studies rated as high or unclear risk of bias (risk difference: 0.14; 95% CI: -0.03–0.3; n = 382). For all other polymorphism–medication pairs, we found just one eligible study. Conclusion: Estimates of effect for return to heavy drinking suggest it is possible that patients with at least one G allele of A118G polymorphism of OPRM1 might be more likely to respond to naltrexone, but confidence intervals were wide; additional studies are needed to improve confidence in the estimates.

Alcohol Retailing in Canadian and Nordic Contexts: Challenges and Opportunities in Balancing Trade and Prevention Agendas

This article involves a comparison of the Nordic alcohol-monopoly countries with Canadian provinces that have a tradition of off-premise alcohol retail monopolies. The aim of the article is to shed light on recent developments in Canadian and Nordic alcohol-retailing systems, and to propose a way forward for alcohol-control policy that involves balancing alcohol trade and damage-reduction agendas. The article first considers developments over the past three decades in alcohol production, marketing, and retailing involving a concentration of production, and an expansion and increased sophistication of alcohol marketing and retailing, and the underlying international and national pressures. Next, it examines examples of recent alcohol policy making in Canada and the Nordic countries, noting the challenges of controlling total alcohol consumption and high-risk drinking in a market-oriented environment. Third, it offers several steps forward that will facilitate a better balance of alcohol trade and problem-prevention agendas in the context of off-premise alcohol-retail-control systems.

A Complex Picture

This paper examines access to alcohol, trends in consumption, drinking patterns, damage from alcohol, and developments in prevention and alcohol policy – focusing on the Canadian experience over the last two decades. Consumption, as measured by official sales, declined initially and then has increased since 1996. During this time there was a gradual increase in access to alcohol, with steeper increase in some jurisdictions undergoing partial or full privatization of retail alcohol sales. According to survey data, the proportion drinking in a high risk manner is greater among youth and young adults, and the trend in the proportion of high risk drinkers does not necessarily follow the trend in alcohol sales. In light of intensive and multi-dimensional efforts to curtail drinking and driving, these rates have gone down during the period under study. Several provinces have introduced alcohol strategies and a national strategy introduced in 2007 is being implemented. Nevertheless there are ongoing challenges of getting alcohol on the broader public health agenda, even though it is major contributor to disease and disability. The rising consumption and increased access to alcohol, combined with intensive marketing, represent a major public health challenge. It is unlikely that there will be significant strides in reducing the damage from alcohol to Canadian populations, unless there is a substantial change in the status quo involving implementation of the most effective policies and prevention strategies.

Per capita alcohol consumption and alcohol-related harm in Belarus, 1970-2005

BACKGROUND

Although alcohol seems to be an important determinant of the mortality crisis in the former Soviet Republic of Belarus, little systematic research has been done on the relationship between alcohol consumption and harm at the aggregate level. The aims of the present study were to estimate the effect of per capita alcohol consumption on all-cause mortality, mortality from alcohol poisoning and hospital admissions for alcohol psychosis in Belarus.

METHODS

Annual data on the three outcomes and alcohol sale per capita for the period 1970-2005 were analysed using the Box-Jenkins technique. Female mortality was included as a control variable and regarded as a proxy for other causal factors. To incorporate the lag structure, a weighted input was used in which a geometrical lag-scheme was applied.

RESULTS

The outcomes suggest that a 1 l increase in consumption was associated with an increase in male all-cause mortality of ∼2.3%. The corresponding figures for alcohol poisoning mortality and alcohol psychosis admissions are 12 and 25%.

CONCLUSIONS

The present study strengthens the notion of alcohol consumption as an important determinant of population health in this part of the world, and thus the notion that alcohol control must be a key priority for Belorussian public health policy.

An evaluation of the impact of a large reduction in alcohol prices on alcohol-related and all-cause mortality: time series analysis of a population-based natural experiment

BACKGROUND

We examined the effect of a large reduction in the price of alcohol that occurred in Finland in 2004 on alcohol-related and all-cause mortality, and mortality due to cardiovascular diseases (CVDs) from which alcohol-attributable cases were excluded.

METHODS

Time series intervention analysis modelling was applied to the monthly aggregations of deaths in Finland for the period 1996-2006 to assess the impact of the reduction in alcohol prices. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. Analyses were carried out for men and women aged 15-39, 40-49, 50-69 and >69 years.

RESULTS

Alcohol-related deaths increased in men aged 40-49 years, and in men and women aged 50-69 years, after the price reduction when trends and seasonal variation were taken into account: the mean rate of alcohol-related mortality increased by 17% [95% confidence interval (CI) 1.5, 33.7], 14% (95% CI 1.1, 28.0) and 40% (95% CI) 7.1, 81.7), respectively, which implies 2.5, 2.9 and 1.6 additional monthly deaths per 100,000 person-years following the price reduction. In contrast to alcohol-related mortality, CVD and all-cause mortality decreased: among men and women aged >69 years a decrease of 7 and 10%, respectively, in CVD mortality implied 19 and 25 fewer monthly deaths per 100,000 person-years, and a decrease of 7 and 14%, respectively, in all-cause mortality similarly implied 42 and 69 fewer monthly deaths.

CONCLUSION

These results obtained from the time series analyses suggest that the reduction in alcohol prices led to an increase in alcohol-related mortality, except in persons <40 years of age. However, it appears that beneficial effects in older age, when CVD deaths are prevalent, counter-balance these adverse effects, at least to some extent.

Is alcohol good or bad for Canadian hearts? A time-series analysis of the link between alcohol consumption and IHD mortality

The objective of this study was to analyse the population level association between alcohol consumption and ischaemic heart disease (IHD) mortality in Canada. Yearly changes in IHD mortality rates from 1950 to 1998 were analysed in relation to yearly changes in alcohol consumption, employing the Box & Jenkins technique for time-series analyses. All models controlled for cigarette smoking and one analysis with focus on men also included female IHD mortality as an indicator of other risk factors for IHD. A 1-litre increase in per capita alcohol consumption was associated with an increase in overall IHD mortality as well as among men and women with fully 1%, but no estimate reached statistical significance. A positive and significant relationship between smoking and IHD mortality was demonstrated in all models. According to the model with focus on male IHD mortality, an increase in per capita consumption by 1 litre was related significantly to a 1% increase in male IHD mortality. No significant effects were found in different male age groups. The idea that alcohol saves more IHD deaths than it causes in Canada is not in accordance with these findings. An increase in overall alcohol consumption is more likely to cause an increase in IHD mortality than to lower the number of IHD deaths, at least among men.

Per capita alcohol consumption and sickness absence in Norway

BACKGROUND

There is only one previous study addressing the relationship between population drinking and sickness absence. That study, based on Swedish time-series data, showed a statistically significant relationship between per capita alcohol consumption and the male sickness absence rate. Estimates suggested that a 1-l increase in consumption was associated with a 13% increase in sickness absence among men. In the present study, we aim at replicating and expanding the Swedish study on the basis of data for Norway.

METHODS

The outcome measure comprised annual data for Norway on registered sickness absence for manual employees covering the period 1957-2001. The unemployment rate was included as a control, as this factor may be correlated with alcohol as well as sickness absence. Alcohol consumption was gauged by sales of alcohol (total and beverage specific by beer, spirits and wine) per inhabitant 15 years and above. The data were analysed using the Box-Jenkins method for time-series analysis.

RESULTS

The results suggested that a 1-l increase in total consumption was associated with a 13% increase in sickness absence among men (P < 0.05). This corresponds to an elasticity coefficient equal to 0.62. The alcohol effect was not significant for women. Unemployment was negatively associated with the outcome for men as well as for women (P < 0.05). In the beverage-specific analyses, spirits were statistically significant for men (P < 0.05), but not beer and wine.

CONCLUSION

The present findings strengthen the conclusion from the Swedish study, that sickness absence may be added to the list of indicators of alcohol-related harm.

Alcohol-use disorders

Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence-the more severe disorder-can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or discourage relapses.

Reducing alcohol-related damage in populations: rethinking the roles of education and persuasion interventions

AIM

In order to potentially enhance the impact of most effective policies and interventions in reducing the population level damage from alcohol, a new perspective with regard to education and persuasion interventions is offered.

METHODS

Recent studies were examined on the global burden of alcohol and also those focusing on the links between overall consumption and high-risk drinking, on one hand, and drinking-related damage on the other hand. A synopsis of main findings from reviews and other analysis provides the basis for conclusions about the impacts of education and persuasion interventions.

RESULTS

There is a relative absence of evidence of the effectiveness of education and persuasion in reducing consumption, curtailing high-risk drinking or reducing damage from alcohol. This is in contrast to the rising levels of damage from alcohol, and also to the demonstrated effectiveness of certain alcohol policies and interventions, as summarized in Babor et al.

CONCLUSIONS

Given that only a small fraction of education and persuasion interventions have any positive impact, generating 'more of the same' is not an impact-effective and cost-efficient approach. Therefore, interventions that have not been shown to be effective need to be phased out and those most effective and of widest scope should receive more attention and enhanced resources. A reframing of the roles and foci of persuasion interventions is advised, including, for example, focusing on informing policy-makers, and stimulating public discussions about the rationale of alcohol policies and the roles that citizens can play in promoting and supporting these policies.

Community-based prevention of alcohol problems: addressing the challenges of increasing deregulation of alcohol

This article focuses on the erosion of alcohol management policies and the implications for local prevention efforts. It draws lessons from three large-scale multi-year multi-site programs in Canada, e.g., local addiction prevention projects, heart health programs, and tobacco control experiences. It explores five themes: getting alcohol on the agenda and implementing effective local responses to alcohol problems; assessing conceptual frameworks in order to identify the essential components of an effective prevention strategy; developing a system of local prevention initiatives that give priority to long-lasting structural changes; generating accurate information on alcohol-related damage in order to set priorities; and developing a prevention action plan in order to support local initiatives.

Per capita alcohol consumption and sickness absence

AIM

The purpose of the study was to assess the relationship between aggregate alcohol consumption and sickness absence in Sweden.

DATA AND METHODS

Two indicators of sickness absence were used, one based on sickness insurance data, the other on data from the labour force surveys. Alcohol consumption was gauged by sales of pure alcohol (100%) per inhabitant 15 years of age and older. Because changes in the economy may affect alcohol consumption as well as sickness absence, two macroeconomic indicators were included as control variables: unemployment and real wages. The study period was 1935-2002. The data were analysed through the Box-Jenkins method for time-series analyses.

FINDINGS

A 1-litre increase in total consumption was associated with a 13% increase in sickness absence among men (P < 0.05). The relationship was not statistically significant for women.

CONCLUSIONS

Previous research has documented that aggregate alcohol consumption is related to a large number of harm indicators, such as cirrhosis and accident mortality. The present findings add yet another indicator to this list.