The basis for Canada's new low-risk drinking guidelines: a relative risk approach to estimating hazardous levels and patterns of alcohol use

Reducing alcohol harms whilst minimising impact on hospitality businesses: 'Sweetspot' policy options

BACKGROUND

During COVID-19, hospitality businesses (e.g. bars, restaurants) were closed/restricted whilst off-sales of alcohol increased, with health consequences. Post-covid, governments face lobbying to support such businesses, but many health services remain under pressure. We appraised 'sweetspot' policy options: those with potential to benefit public services and health, whilst avoiding or minimising negative impact on the hospitality sector.

METHODS

We conducted rapid non-systematic evidence reviews using index papers, citation searches and team knowledge to summarise the literature relating to four possible 'sweetspot' policy areas: pricing interventions (9 systematic reviews (SR); 14 papers/reports); regulation of online sales (1 SR; 1 paper); place-shaping (2 SRs; 18 papers/reports); and violence reduction initiatives (9 SRs; 24 papers/reports); and led two expert workshops (n = 11).

RESULTS

Interventions that raise the price of cheaper shop-bought alcohol appear promising as 'sweetspot' policies; any impact on hospitality is likely small and potentially positive. Restrictions on online sales such as speed or timing of delivery may reduce harm and diversion of consumption from on-trade to home settings. Place-shaping is not well-supported by evidence and experts were sceptical. Reduced late-night trading hours likely reduce violence; evidence of impact on hospitality is scant. Other violence reduction initiatives may modestly reduce harms whilst supporting hospitality, but require resources to deliver multiple measures simultaneously in partnership.

CONCLUSIONS

Available evidence and expert views point to regulation of pricing and online sales as having greatest potential as 'sweetspot' alcohol policies, reducing alcohol harm whilst minimising negative impact on hospitality businesses.

Patterns of anxiety, depression, and substance use risk behaviors among university students in Canada

Objective: To identify subgroups of students with distinct profiles of mental health symptoms (MH) and substance use risk (SU) and the extent to which MH history and socio-demographics predict subgroup membership. Participants: University students (N = 10,935: 63% female). Methods: Repeated cross-sectional survey administered weekly to stratified random samples. Latent class analysis (LCA) was used to identify subgroups and multinomial regression was used to examine associations with variables of interest. Results: LCA identified an optimal 4-latent class solution: High MH-Low SU (47%), Low MH-Low SU (22%), High MH-High SU (19%), and Low MH-High SU (12%). MH history, gender, and ethnicity were associated with membership in the classes with high risk of MH, SU, or both. Conclusion: A substantial proportion of students presented with MH, SU, or both. Gender, ethnicity and MH history is associated with specific patterns of MH and SU, offering potentially useful information to tailor early interventions.

How do people drink alcohol at a low-risk level?

Reducing the risks associated with drinking is an ongoing public health goal. Approximately two-fifths of Australian adults consume alcohol within low-risk guidelines, yet little is known about their drinking patterns or practices. In this paper, we use social practice theory to consider low-risk drinking at home as a routinised social practice with material, meaning and competence dimensions. We analysed open-text survey responses from 252 Australian adults (30-65, 89% female) who were considered low-risk drinkers. A low-risk drinking occasion was typically closely linked to other practices such as eating dinner or connecting with family or friends. Drinking alcohol, even in small amounts, was associated with enjoyment. Being attuned to bodily sensations and applying some self-imposed rules were competencies that allowed low-risk drinkers to avoid intoxication. Low-risk drinking practices entail some elements that can inform health promotion, including encouraging efforts to limit drinking to times of the day (e.g. during meals) and to attend to bodily feelings of sufficiency. The study also shows how low-risk drinking is entangled with gendered and age-related norms about drinking, and facilitated by rarely being in 'intoxigenic' environments. These factors are imbricated with individual decisions in our respondents' capacity to consume alcohol moderately.

Use of Cannabis as a Harm Reduction Strategy Among People Who Use Drugs: A Cohort Study

Introduction: While substance use contributes to a substantial burden of disease, access to evidence-based harm reduction interventions remains limited or inaccessible. Preliminary research suggests that some individuals use cannabis to reduce the harms associated with their use of other substances, including opioids and stimulants. This study examines factors associated with the self-reported use of cannabis for harm reduction among people who use drugs (PWUD). Methods: We drew data from three prospective, community-recruited cohorts of PWUD in Vancouver, Canada, between June 2016 and May 2018. Multivariable generalized linear mixed-effects modeling was used to examine factors associated with the primary outcome of "use of cannabis for harm reduction," defined as self-reported use of cannabis to substitute for other substances, treat withdrawal, or come down off other drugs. Results: One thousand nine hundred thirty-six participants contributed 5706 observations. In adjusted analyses, daily methamphetamine use (adjusted odds ratio [AOR]=1.43, 95% confidence interval [CI]: 1.09-1.89), experiencing barriers to accessing addiction treatment (AOR=1.92, 95% CI: 1.21-3.03), and enrollment in addiction treatment modalities other than opioid agonist therapy (AOR=1.64, 95% CI: 1.17-2.29) were positively associated with using cannabis for harm reduction. Older age was negatively associated (AOR=0.97, 95% CI: 0.95-0.98). Among 1281 (66.2%) participants who use cannabis, daily cannabis use and obtaining cannabis from unregulated dispensaries were also independent correlates of using cannabis for harm reduction. Discussion and Conclusions: Individuals who were more likely to use cannabis for harm reduction reported difficulty accessing addiction treatment or used substances, such as methamphetamines, where effective treatments are limited. These findings highlight the need to better understand the potential harm-reducing impacts of cannabis among PWUD in these scenarios.

The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study

BACKGROUND

Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown.

OBJECTIVE

This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety.

METHODS

All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients' use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients' alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores.

RESULTS

During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients' drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week.

CONCLUSIONS

Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.

Lower-risk substance use guidelines accessible by youth

BACKGROUND

Lower-risk substance use guidelines (LRSUGs) are an evidence-based harm reduction strategy used to provide information to people who use drugs so they can reduce harms associated with substance use.

OBJECTIVES

This study aimed to identify LRSUGs accessible to youth and to characterize the recommendations within these guidelines. The overall goal is to identify gaps in current LRSUGs and to inform researchers and policymakers of the kinds of health information youth can access.

METHODS

We conducted a digital assessment using the Google search engine to identify LRSUGs that could be identified by youth when searching for official sources of information related to commonly used substances, including cannabis, caffeine, alcohol, hallucinogens, prescription opioids, nicotine, and/or prescription stimulants. LRSUGs were coded and data were extracted from them to identify gaps.

RESULTS

One hundred thirty LRSUGs were identified; most focused on alcohol (n = 40, 31%), cannabis (n = 30, 23%), and caffeine (n = 21, 16%). LRSUGs provided recommendations about dosing (n = 108, 83%), frequency of use (n = 72, 55%), and when to use (n = 86, 66%). Most LRSUGs were published by health (n = 51, 39%) and third-sector organizations (n = 41, 32%), followed by provincial/state (n = 18, 14%), government (n = 14, 11%), municipal (n = 4, 3%), and academic (n = 2, 2%) sources. Only 16% (n = 21) of LRSUGs were youth-specific and one-quarter (n = 32, 25%) of LRSUGs provided gender-specific recommendations. Most guidelines featured information on short (n = 76, 58%) and long-term (n = 69, 53%) negative effectives and positive effects of substances (n = 56, 43%). Less than half (n = 50, 38%) of LRSUGs cited evidence in support of the information they provided.

CONCLUSIONS

We identified several areas in the current LRSUGs for youth that need to be addressed. Among the gaps are a lack of LRSUGs developed specifically for youth, a lack of youth engagement in developing harm reduction strategies centered around them, and a lack of evidence-based LRSUGs. Youth-oriented, evidence-based LRSUGs are needed to better support youth who use substances and help them manage the negative effects of substance use.

Active versus sham transcranial direct current stimulation (tDCS) as an adjunct to varenicline treatment for smoking cessation: Study protocol for a double-blind single dummy randomized controlled trial

BACKGROUND

Smoking is a chronic and relapsing disease, with up to 60% of quitters relapsing within the first year. Transcranial Direct Current Stimulation (tDCS), targets cortical circuits and acutely reduces craving and withdrawal symptoms among cigarette smokers. However, the efficacy of tDCS as an adjunct to standard smoking cessation treatments has not been studied. This study aims to investigate the effectiveness of tDCS in combination with varenicline for smoking cessation. We hypothesize that active tDCS combined with varenicline will improve cessation outcomes compared to sham tDCS combined with varenicline.

METHODS

This is a double-blind, sham-controlled randomized clinical trial where fifty healthy smokers will be recruited in Toronto, Canada. Participants will be randomized 1:1 to either active tDCS (20 minutes at 2 mA) or sham tDCS (30 seconds at 2 mA, 19 minutes at 0 mA) for 10 daily sessions (2 weeks) plus 5 follow up sessions, occurring every two weeks for 10 weeks. All participants will be given standard varenicline treatment concurrently for the 12-week treatment period. The primary outcome is 30 day continuous abstinence at end of treatment, confirmed with urinary cotinine. Measurements made at each study visit include expired carbon monoxide, self-reported craving and withdrawal. Three magnetic resonance imaging (MRI) scans will be conducted: two at baseline and one at end of treatment, to assess any functional or structural changes following treatment.

DISCUSSION

For every two smokers who quit, one life is saved from a tobacco-related mortality. Therefore, it is important to develop new and more effective treatment approaches that can improve and maintain long-term abstinence, in order to decrease the prevalence of tobacco-related deaths and disease. Furthermore, the addition of longitudinal neuroimaging can shed light on neural circuitry changes that might occur as a result of brain stimulation, furthering our understanding of tDCS in addiction treatment.

TRIAL REGISTRATION

This trial has been registered with Clinicaltrials.gov: NCT03841292 since February 15th 2019 (https://clinicaltrials.gov/ct2/show/NCT03841292)-retrospectively registered.

Not Too Much, Not Too Often, and Not Too Many: the Results of the First Large-Scale, International Project to Develop Lower-Risk Gambling Guidelines

Until now, there has been no evidence-based, specific advice for people who gamble who want to reduce their risk of experiencing gambling harms. This paper presents the results from the first large-scale, comprehensive, international project to develop lower-risk gambling guidelines. Specifically, we calculated relative risk estimates to determine risk of harm across the range of possible limits for gambling frequency, expenditure, and number of types of gambling engaged in; conducted an online survey (n = 4583) of people who gamble to assess whether they understood and found credible the proposed quantitative limits; conducted a series of interviews and focus groups with people who gamble to assess self-control strategies and reactions to proposed quantitative limits; conducted a meta-analysis of problem gambling risk factors in the general population; and consulted with a pan-Canadian, multi-sectoral committee of stakeholders. Project outcomes were examined and deliberated by a working group of scientists who decided upon a set of recommendations for lower-risk gambling. This paper presents these recommendations.

Differential effects of alcohol-drinking patterns on the structure and function of the brain and cognitive performance in young adult drinkers: A pilot study

INTRODUCTION

This study was aimed to determine how different patterns of alcohol consumption drive changes to brain structure and function and their correlation with cognitive impairments in young adult alcohol drinkers.

METHODS

In this study, we enrolled five groups participants and defined as: long-term abstinence from alcohol (LA), binge drinking (BD), long-term low dosage alcohol consumption but exceeding the safety drinking dosage (LD), long-term alcohol consumption of damaging dosage (LDD), and long-term heavy drinking (HD). All participants underwent magnetic resonance imaging (MRI) and functional MRI (fMRI) to acquire data on brain structure and function, including gray matter volume (GMV), fractional amplitude of low-frequency fluctuation (fALFF), regional homogeneity (ReHo), functional connectivity (FC), and brain network properties. The cognitive ability was evaluated with the California Verbal Learning Test (CVLT), intelligence quotient (IQ), and short delay free recall (SDFR).

RESULTS

Compared to LA, GMV significantly decreased in the brain regions in VN, SMN, and VAN in the alcohol-drinking groups (BD, LD, LDD, and HD). ReHo was significantly enhanced in the brain regions in VN, SMN, and VAN, while fALFF significantly increased in the brain regions in VN and SMN. The number of intra- and inter-modular connections within networks (VN, SMN, sensory control network [SCN], and VAN) and their connections to other modules were abnormally changed. These changes adversely affected cognition (e.g., IQ, CVLT, SDFR).

CONCLUSION

Despite the small sample size, this study provides new evidence supporting the need for young people to abstain from alcohol to protect their brains. These findings present strong reasoning for updating anti-alcohol slogans and guidelines for young people in the future.

Global Cardiovascular Risk Profile of Italian Medical Students Assessed by a QR Code Survey. Data from UNIMI HEART SURVEY: Does Studying Medicine Hurt?

Background: Few studies to date have addressed global cardiovascular (CV) risk profile in a “protected” young population as that of medical school students. Objective: to assess CV traditional risk factors and global CV risk profile of Italian medical students throughout the six years of university. Methods: A cross-sectional survey accessible online via quick response (QR) code was conducted among 2700 medical students at the University of Milan, Italy. Data on baseline characteristics, traditional CV risk factors, diet, lifestyle habits, and perceived lifestyle variations were evaluated across different years of school. Results: Overall, 1183 students (mean age, 22.05 years; 729 women (61.6%)) out of 2700 completed the questionnaire (43.8% rate response). More than 16% of the students had at least 3 out of 12 CV risk factors and only 4.6% had ideal cardiovascular health as defined by the American Heart Association. Overweight, underweight, physical inactivity, sub-optimal diet, smoke history, and elevated stress were commonly reported. Awareness of own blood pressure and lipid profile increased over the academic years as well as the number of high-blood-pressure subjects, alcohol abusers, and students constantly stressed for university reasons. Moreover, a reduction in physical-activity levels over the years was reported by half of the students. Conclusion and Relevance: This study demonstrates that a “protected” population as that of young medical students can show an unsatisfactory cardiovascular risk profile and suggests that medical school itself, being demanding and stressful, may have a role in worsening of the lifestyle.

Trajectories of Alcohol Use and Related Harms for Managed Alcohol Program Participants over 12 Months Compared with Local Controls: A Quasi-Experimental Study

AIM

Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence.

METHODS

A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants.

RESULTS

Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6--12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants' liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms.

CONCLUSION

MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.

Predicting future harm from gambling over a five-year period in a general population sample: a survival analysis

BACKGROUND

There is little longitudinal evidence on the cumulative risk of harm from gambling associated with excess spending and frequency of play. The present study sought to assess the risk of gambling problems over a five-year period in adults who exceed previously derived low-risk gambling limits compared to those who remain within the limits after controlling for other modifiable risk factors.

METHODS

Participants were adults (N = 4212) drawn from two independent Canadian longitudinal cohort studies who reported gambling in the past year and were free of problem gambling at time 1. Multivariate Cox regression was employed to assess the impact over time of gambling above low-risk gambling thresholds (frequency ≥ 8 times per month; expenditure ≥75CAD per month; percent of household income spent on gambling ≥1.7%) on developing moderate harm and problem gambling. Covariates included presence of a DSM5 addiction or mental health disorder at time 1, irrational gambling beliefs, number of stressful life events in past 12 months, number of game types played each year, and playing electronic gaming machines or casino games.

RESULTS

In both samples, exceeding the low-risk gambling limits at time 1 significantly increased the risk of moderate harm (defined as ≥2 consequences on the Problem Gambling Severity Index [PGSI]) within 5 years after controlling for other modifiable risk factors. Other significant predictors of harm were presence of a mental disorder at time 1, cognitive distortions about gambling, stressful life events, and playing electronic gaming machines or casino games. In one sample, the five-year cumulative survival rate for moderate harm among individuals who stayed below all the low-risk limits was 95% compared to 83% among gamblers who exceeded all limits. Each additional low-risk limit exceeded increased the cumulative probability of harm by 30%. Similar results were found in models when the outcome was problem gambling.

CONCLUSIONS

Level of gambling involvement represents a highly modifiable risk factor for later harm. Staying below empirically derived safe gambling thresholds reduces the risk of harm over time.

Agitation, confusion, and aggression in critically ill traumatic brain injury-a pilot cohort study (ACACIA-PILOT)

BACKGROUND

Agitated behaviors are problematic in intensive care unit (ICU) patients recovering from traumatic brain injury (TBI) as they create substantial risks and challenges for healthcare providers. To date, there have been no studies evaluating their epidemiology and impact in the ICU. Prior to planning a multicenter study, assessment of recruitment, feasibility, and pilot study procedures is needed. In this pilot study, we aimed to evaluate the feasibility of conducting a large multicenter prospective cohort study.

METHODS

This feasibility study recruited adult patients admitted to the ICU with TBI and an abnormal cerebral CT scan. In all patients, we documented Richmond Agitation Sedation Score (RASS) and agitated behaviors every 8-h nursing shift using a dedicated tool documenting 14 behaviors. Our feasibility objectives were to obtain consent from at least 2 patients per month; completion of screening logs for agitated behaviors by bedside nurses for more than 90% of 8-h shifts; completion of data collection in an average of 6 h or less; and obtain 6-month follow-up for surviving patients. The main clinical outcome was the incidence of agitation and individual agitated behaviors.

RESULTS

In total, 47 eligible patients were approached for inclusion and 30 (64% consent rate) were recruited over a 10-month period (3 patients/month). In total, 794 out of 827 (96%) possible 8-h periods of agitated behavior logs were completed by bedside nurses, with a median of 24 observations (IQR 28.0) per patient. During the ICU stay, 17 of 30 patients developed agitation (56.7%; 95% CI 0.37-0.75) defined as RASS ≥ 2 during at least one observation period and for a median of 4 days (IQR 5.5). At 6 months post-TBI, among the 24 available patients, an unfavorable score (GOS-E < 5 including death) was reported in 12 patients (50%). In the 14 patients who were alive and available at 6 months, the median QOLIBRI score was 74.5 (IQR 18.5).

CONCLUSIONS

This study demonstrates the feasibility of conducting a larger cohort study to evaluate the epidemiology and impact of agitated behaviors in critically ill TBI patients. This study also shows that agitated behaviors are frequent and are associated with adverse events.

Shooting shots: Estimating alcoholic drink sizes in real life using event-level reports and annotations of close-up pictures

INTRODUCTION AND AIMS

Drinks consumed in real life are diverse, in terms of beverage type, container size and alcohol by volume. To date, most ecological momentary assessment studies have assessed drinking amounts with 'standard' drinks, although their event-level design allows for more advanced assessment schemes. The purpose of this empirical study is to compare participants' estimates of alcoholic drink characteristics, assessed using drink-specific questions, with estimates generated by annotators based on pictures of the same drinks.

DESIGN AND METHODS

On weekend nights, 186 young adults took 1484 close-up pictures of their drinks using a custom-built smartphone application. Participants reported the beverage type, drink size and alcohol by volume. Annotators described the beverage type, container size and filling level. Correspondence between participants' and annotators' estimates was explored using descriptive statistics, difference tests and correlations.

RESULTS

Annotators were unable to precisely identify the beverage types in most pictures of liqueurs, spirits and mixed drinks. Participants' drink size estimates converged with annotators' estimates of the container size for beer (41 cl corresponding to 16 g of pure alcohol) and mixed drinks (28 cl/35 g), and of the content size for wine (10 cl/9 g). However, annotators estimated larger sizes for liqueur/fortified wine (12 cl/14 g vs. 7 cl/9 g) and spirits (8 cl/26 g vs. 4 cl/10 g) than participants.

DISCUSSION AND CONCLUSIONS

Annotations of pictures should be considered as a complement to participants' reports rather than a substitute. Except for wine, real-life drinks vary largely and often exceed 10 g 'standard' drinks.

A research plan to define Canada's first low-risk gambling guidelines

From a public health perspective, gambling shares many of the same characteristics as alcohol. Notably, excessive gambling is associated with many physical and emotional health harms, including depression, suicidal ideation, substance use and addiction and greater utilization of health care resources. Gambling also demonstrates a similar 'dose-response' relationship as alcohol-the more one gambles, the greater the likelihood of harm. Using the same collaborative, evidence-informed approach that produced Canada's Low-Risk Alcohol Drinking and Lower Risk Cannabis Use Guidelines, a research team is leading the development of the first national Low-Risk Gambling Guidelines (LRGGs) that will include quantitative thresholds for safe gambling. This paper describes the research methodology and the decision-making process for the project. The guidelines will be derived through secondary analyses of several large population datasets from Canada and other countries, including both cross-sectional and longitudinal data on over 50 000 adults. A scientific committee will pool the results and put forward recommendations for LRGGs to a nationally representative, multi-agency advisory committee for endorsement. To our knowledge, this is the first systematic attempt to generate a workable set of LRGGs from population data. Once validated, the guidelines inform public health policy and prevention initiatives and will be disseminated to addiction professionals, policy makers, regulators, communication experts and the gambling industry. The availability of the LRGGs will help the general public make well-informed decisions about their gambling activities and reduce the harms associated with gambling.

Beverage consumption and energy intake among Canadians: analyses of 2004 and 2015 national dietary intake data

Background

Among adults and children consuming Western diets, beverages are significant sources of free sugars, saturated fats, excess calories, and alcohol, with relevance to chronic disease risk. The impact of recent healthy eating policies and beverage market evolutions on population-level consumption patterns in Canada is unknown. The current study examined trends in intake of a range of beverage types among a nationally-representative sample of Canadians, with stratification by socio-demographic characteristics.

Methods

The 2004 (n = 34,775) and 2015 (n = 20,176) nutrition-focused cycles of the Canadian Community Health Surveys are cross-sectional surveys representative of the population of the 10 Canadian provinces. Based on a single multiple-pass 24-h dietary recall for each participant, fluids consumed as beverages were grouped into seven categories. Using linear regression, reported intake (volume, ml and energy, kcal) of each category was characterized over time and in relation to sex, age, ethnicity, income, body mass index (BMI), and province of residence.

Results

In 2015, Canadians reported consuming an average of 1806 ml (275 kcal) fluids as beverages per day, including: plain water 867 ml (0 kcal); other unsweetened beverages, e.g. coffee, 364 ml (6 kcal); sugar-sweetened beverages (SSBs) 204 ml (99 kcal); plain milk 132 ml (64 kcal); alcoholic drinks 120 ml (71 kcal); 100% juice 74 ml (34 kcal); and diet or low calorie beverages 44 ml (2 kcal). Differential consumption was observed across socio-demographic groups, with high consumption of sugary drinks (i.e., SSBs and 100% juice) and alcohol across groups. From 2004 to 2015, the reported volumes of beverages consumed decreased by 10% (energy: − 24%). With adjustment for socio-demographic characteristics, there were significant changes (p < 0.001) over time in intake of: 100% juice − 40% (− 38%); plain milk − 37% (− 35%); SSBs − 26% (− 20%); diet or low calorie beverages (− 46%); and other unsweetened beverages − 11% (− 42%). The volume of plain water consumed increased by 10% (p < 0.0001). Intake of alcoholic (volume and energy) and diet or light beverages did not change significantly.

Conclusions

Lower intake of beverages was reported by Canadians in 2015 versus 2004, with a shift towards plain water. Consumption of sugary drinks decreased, but these beverages continue to contribute substantially to Canadians' overall energy intake. The findings underscore the need for policies to further reduce the consumption of sugary and alcoholic beverages, as well as calories from beverages.

Patients' Perspectives on Early Liver Transplantation in Alcohol-Related Liver Disease

Liver transplant programs in Canada require a period of 6 months of abstinence from alcohol before considering a patient with liver disease secondary to alcohol for transplantation. Although some studies have demonstrated good outcomes following a transplant in carefully selected patients before the 6‐month abstinence period has been met, there have been arguments against this, including the claim that the public has a general negative perception of those with alcohol dependence. We performed a multicenter cross‐sectional survey to determine the perception of people in British Columbia, Canada, toward liver transplantation in patients with liver disease due to alcohol who have not demonstrated the capacity to remain abstinent from alcohol for 6 months. A total of 304 patient questionnaires were completed, and 83.1% agreed with a period of abstinence of 6 months. In those patients who were unlikely to survive 6 months without a transplant, 34.1% of respondents agreed with, 44.1% did not agree with, and 21.4% were neutral about, early transplantation; 42.8% would have less trust in the process of transplantation if a period of abstinence was not maintained, but relaxing the requirement for an abstinence period would not have an impact on the majority's decision to donate organs. Only 30.5% would support abandoning the abstinence criteria. Conclusion: Among patients followed at general gastroenterology, medicine, or transplant clinics, there is a willingness to relax the criteria in selected patients unlikely to survive without a transplant, although a general consensus remains in support of the existing 6‐month alcohol abstinence rule. A larger scale survey of all provinces in Canada would be required to assess support for such a change in policy.

Does prior recall of past week alcohol use affect screening results for at-risk drinking? Findings from a randomized study

Underreporting of alcohol consumption is one of the major challenges in survey research including self-reports. The aim of this study was to test whether underreporting can be reduced by prompting respondents to first reflect on their drinking in the past week and then answer quantity-frequency based screening questions on their typical alcohol use. Data come from 2,379 adults (54% female; mean age = 31.8 years, SD = 11.4 years) consecutively recruited at a local registration office in northeastern Germany. Participants responded to an electronic, self-administered questionnaire on different health behaviors. They were randomized to receiving the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) either before or after the assessment of past week timeline follow-back questions. Logistic regression models were calculated predicting positive screening results for at-risk drinking. Potential interaction effects with gender, age and educational background were explored. Results show that the assessment of past week alcohol consumption prior to the assessment of the AUDIT-C reduced the odds of obtaining positive screening results (OR = 0.83; 95% CI = 0.70-0.99). There were no interaction effects with gender, age and educational background. As a secondary finding, participants reported consistently lower alcohol consumption in the alcohol measure that was administered later in the questionnaire. Preceding questions about alcohol consumption in the past week reduced the probability of positive screening results for at-risk drinking. Our findings suggest that prompting people to recall past week alcohol use prior to screening may not be a solution to reduce underreporting.

How should we set consumption thresholds for low risk drinking guidelines? Achieving objectivity and transparency using evidence, expert judgement and pragmatism

Most high-income nations issue guidelines on low-risk drinking to inform individuals' decisions about alcohol consumption. However, leading scientists have criticized the processes for setting the consumption thresholds within these guidelines for a lack of objectivity and transparency. This paper examines how guideline developers should respond to such criticisms and focuses particularly on the balance between epidemiological evidence, expert judgement and pragmatic considerations. Although concerned primarily with alcohol, our discussion is also relevant to those developing guidelines for other health-related behaviours. We make eight recommendations across three areas. First, recommendations on the use of epidemiological evidence: (1) guideline developers should assess whether the available epidemiological evidence is communicated most appropriately as population-level messages (e.g. suggesting reduced drinking benefits populations rather than individuals); (2) research funders should prioritize commissioning studies on the acceptability of different alcohol-related risks (e.g. mortality, morbidity, harms to others) to the public and other stakeholders; and (3) guideline developers should request and consider statistical analyses of epidemiological uncertainty. Secondly, recommendations to improve objectivity and transparency when translating epidemiological evidence into guidelines: (4) guideline developers should specify and publish their analytical framework to promote clear, consistent and coherent judgements; and (5) guideline developers' decision-making should be supported by numerical and visual techniques which also increase the transparency of judgements to stakeholders. Thirdly, recommendations relating to the diverse use of guidelines: (6) guideline developers and their commissioners should give meaningful attention to how guidelines are used in settings such as advocacy, health promotion, clinical practice and wider health debates, as well as in risk communication; (7) guideline developers should make evidence-based judgements that balance epidemiological and pragmatic concerns to maximize the communicability, credibility and general effectiveness of guidelines; and (8) as with scientific judgements, pragmatic judgements should be reported transparently.

Sex-Specific Considerations in Guidelines Generation and Application

New knowledge about male-female differences in pathophysiology, diagnosis, and treatment is shifting the practice of medicine from a one-size-fits all approach to a more individualized process that considers sex-specific interventions at the point of care. In this article, we review how clinical practice guideline committees can incorporate a structured framework to determine whether sex-specific assessments of the quality of the evidence or the particular recommendations should be made. The process can be operationalized by societies who author clinical practice guidelines by developing formal policies to approach biological sex in a systematic way, and by ensuring that writing committees include an individual who will champion the formal appraisal of the literature for associations between sex and the outcomes of interest. Ongoing challenges are discussed, and solutions are provided for how to disaggregate the evidence, how to assess bias, how to improve search strategies, and what to do when the data are insufficient to make sex-specific recommendations. Application of sex-specific recommendations will involve routinely asking whether the presentation, diagnostic workup, or management might change for each patient if they were the opposite sex.

Association between psychosocial work conditions and latent alcohol consumption trajectories among men and women over a 16-year period in a national Canadian sample

BACKGROUND

It is unclear how psychosocial working conditions influence future alcohol consumption. Using group-based trajectory modelling, this study aimed to determine: the number of latent alcohol consumption trajectories over 16 years in a representative sample of the Canadian workforce; the association between psychosocial working conditions and longitudinal alcohol consumption; and if the association between psychosocial work factors and longitudinal alcohol consumption differed among men and women.

METHODS

We included 5458 employed adults from the longitudinal Canadian National Population Health Survey. Average daily alcohol consumption was measured every 2 years from 1994 to 2010. Psychosocial work factors were measured in 1994 using the Job Content Questionnaire. Group-based trajectory modelling was used to derive the appropriate number of alcohol behaviour trajectories. The association between psychosocial work factors and alcohol trajectory membership was estimated using multinomial logistic regression. Models were stratified by sex to determine if these associations differed among men and women.

RESULTS

Three alcohol consumption trajectories were present: non-drinkers, light drinkers (0.5-1 drinks/day) and moderate drinkers (2-3 drinks/day). Higher workplace physical exertion and lower social support levels were associated with membership in the moderate drinking trajectory. Among men, lower psychological demands and higher physical exertion levels were associated with membership in the moderate drinking trajectory. Among women, lower levels of physical exertion were associated with membership in the light drinking trajectory, and higher psychological demand levels were associated with membership in the moderate drinking trajectory.

CONCLUSIONS

Our study suggests that workplace physical exertion and psychological demands may be associated with different alcohol consumption trajectories among men and women.

Deriving low-risk gambling limits from longitudinal data collected in two independent Canadian studies

AIMS

To derive low-risk gambling limits using the method developed by Currie et al. (2006) applied to longitudinal data.

DESIGN

Secondary analysis of data from the Quinte Longitudinal Study (n = 3054) and Leisure, Lifestyle and Lifecycle Project (n = 809), two independently conducted cohort studies of the natural progression of gambling in Canadian adults.

SETTING

Community-dwelling adults in Southeastern Ontario and Alberta, Canada.

PARTICIPANTS

A total of 3863 adults (50% male; median age = 44) who reported gambling in the past year.

MEASUREMENTS

Gambling behaviours (typical monthly frequency, total expenditure and percentage of income spent on gambling) and harm (experiencing two or more consequences of gambling in the past 12 months) were assessed with the Canadian Problem Gambling Index.

FINDINGS

The dose-response relationship was comparable in both studies for frequency of gambling (days per month), total expenditure and percentage of household income spent on gambling (area under the curve values ranged from 0.66 to 0.74). Based on the optimal sensitivity and specificity values, the low-risk gambling cut-offs were eight times per month, $75CAN total per month and 1.7% of income spent on gambling. Gamblers who exceeded any of these limits at time 1 were approximately four times more likely to report harm at time 2 [95% confidence interval (CI) = 2.9-6.6].

CONCLUSIONS

Longitudinal data in Canada suggest low-risk gambling thresholds of eight times per month, $75CAN total per month and 1.7% of income spent on gambling, all of which are higher than previously derived limits from cross-sectional data. Gamblers who exceed any of the three low-risk limits are four times more likely to experience future harm than those who do not.

Peri-Conceptual and Mid-Pregnancy Alcohol Consumption: A Comparison between Areas of High and Low Deprivation in Scotland

BACKGROUND

Alcohol-related mortality and morbidity among women has increased over recent decades, especially in areas of higher deprivation. Pre-pregnancy alcohol use is associated with continued consumption in pregnancy. We assessed whether general population alcohol consumption patterns were reflected among pregnant women in two Scottish areas with different deprivation levels.

METHODS

Cross-sectional study in two health boards (HB1, lower deprivation levels, n = 274; HB2, higher deprivation levels, n = 236), using face-to-face 7-day Retrospective Diary estimation of peri-conceptual and mid-pregnancy alcohol consumption.

RESULTS

A greater proportion of women in HB2 (higher deprivation area) sometimes drank peri-conceptually, but women in HB1 (lower deprivation area) were more likely to drink every week (49.6 vs 29.7%; p < 0.001) and to exceed daily limits (6 units) at least once each week (32.1 vs 14.8%; p < 0.001). After pregnancy recognition, consumption levels fell sharply, but women in HB2 were more likely to drink above recommended daily limits (2 units) each week (2.5 vs 0.0%; p < 0.05). However, women in HB1 were more likely to drink frequently. Women with the highest deprivation scores in each area drank on average less than women with the lowest deprivation scores.

CONCLUSIONS

Heavy episodic and frequent consumption was more common in the lower deprivation area, in contrast with general population data. Eliciting a detailed alcohol history at the antenatal booking visit, and not simply establishing whether the woman is currently drinking, is essential. Inconsistent messages about the effects of alcohol in pregnancy may have contributed to the mixed picture we found concerning peri-conceptual and mid-pregnancy alcohol consumption.

Short-term effects of announcing revised lower risk national drinking guidelines on related awareness and knowledge: a trend analysis of monthly survey data in England

OBJECTIVES

To evaluate short-term effects of publishing revised lower risk national drinking guidelines on related awareness and knowledge. To examine where drinkers heard about guidelines over the same period.

DESIGN

Trend analysis of the Alcohol Toolkit Study, a monthly repeat cross-sectional national survey.

SETTING

England, November 2015 to May 2016.

PARTICIPANTS

A total of 11 845 adults (18+) living in private households in England.

INTERVENTION

Publication of revised national drinking guidelines in January 2016 which reduced the male guideline by approximately one-third to 14 units per week.

MEASUREMENTS

Whether drinkers (1) had heard of drinking guidelines (awareness), (2) stated the guideline was above, exactly or below 14 units (knowledge) and (3) reported seeing the stated guideline number of units in the last month in each of 11 locations (exposure). Sociodemographics: sex, age (18-34, 35-64, 65+), social grade (AB, C1C2, DE). Alcohol consumption derived from graduated frequency questions: low risk (<14 units/week), increasing/high risk (14+ units/week).

RESULTS

Following publication of the guidelines, the proportion of drinkers aware of guidelines did not increase from its baseline level of 85.1% (CI 82.7% to 87.1%). However, the proportion of male drinkers saying the guideline was 14 units or less increased from 22.6% (CI 18.9% to 26.7%) in December to 43.3% (CI 38.9% to 47.8%) in January and was at 35.6% (CI 31.6% to 39.9%) in May. Last month exposure to the guidelines was below 25% in all locations except television/radio where exposure increased from 33% (CI 28.8% to 36.2%) in December to 65% (CI 61.2% to 68.3%) in January. Awareness and knowledge of guidelines was lowest in social grade DE and this gap remained after publication.

CONCLUSIONS

Publication of new or revised lower risk drinking guidelines can improve drinkers' knowledge of these guidelines within all sociodemographic groups; however, in the absence of sustained promotional activity, positive effects may not be maintained and social inequalities in awareness and knowledge of guidelines are likely to persist.

Alcohol abstention in early adulthood and premature mortality: Do early life factors, social support, and health explain this association?

OBJECTIVE

Adult alcohol abstainers have a heightened risk of premature mortality compared to light-to-moderate drinkers. We examine three plausible explanations, other than lack of alcohol, for this observed difference: Abstainers 1) have early life disadvantages that undermine long-term health; 2) lack social support; 3) are less healthy.

METHOD

In the National Child Development Study, an ongoing national British cohort study of individuals born in 1958, we investigated whether early life disadvantages, lack of social support, and poor physical health reduce or eliminate the elevated risk of mortality through age 51 among those abstaining from alcohol at age 33. Using Cox proportional hazard models in a stepwise approach we examined whether the alcohol-mortality relationship changed when potential confounders were included.

RESULTS

The risk of mortality by age 51 was greater among age-33 abstainers compared to light drinkers (Hazard Ratio [HR] = 2.18; 95% CI = 1.40, 3.40). Including early life disadvantages and social support in the hazard models did not alter these associations (HR = 2.12; 95% CI = 1.27, 3.54). Including physical health in the model resulted in a 25% reduction in risk of death among abstainers, though the difference in risk remained statistically significant (HR = 1.75; 95% CI = 1.04, 2.94).

CONCLUSIONS

Abstaining from alcohol in early adulthood, in comparison to light drinking, predicts increased risk for premature mortality, even after accounting for numerous early and young adult confounders. Future research should examine potential moderators of this association.

Estimating under- and over-reporting of drinking in national surveys of alcohol consumption: identification of consistent biases across four English-speaking countries

BACKGROUND AND AIMS

Questions about drinking 'yesterday' have been used to correct under-reporting of typical alcohol consumption in surveys. We use this method to explore patterns of over- and under-reporting of drinking quantity and frequency by population subgroups in four countries.

DESIGN

Multivariate linear regression analyses comparing estimates of typical quantity and frequency of alcohol consumption with and without adjustments using the yesterday method.

SETTING AND PARTICIPANTS

Survey respondents in Australia (n = 26 648), Canada (n = 43 371), USA (n = 7969) and England (n = 8610).

MEASUREMENTS

Estimates of typical drinking quantities and frequencies over the past year plus quantity of alcohol consumed the previous day.

FINDINGS

Typical frequency was underestimated by less frequent drinkers in each country. For example, after adjustment for design effects and age, Australian males self-reporting drinking 'less than once a month' were estimated to have in fact drunk an average of 14.70 (± 0.59) days in the past year compared with the standard assumption of 6 days (t = 50.5, P < 0.001). Drinking quantity 'yesterday' was not significantly different overall from self-reported typical quantities during the past year in Canada, the United States and England, but slightly lower in Australia (e.g. 2.66 versus 3.04 drinks, t = 20.4, P < 0.01 for women).

CONCLUSIONS

People who describe themselves as less frequent drinkers appear to under-report their drinking frequency substantially, but country and subgroup-specific corrections can be estimated. Detailed questions using the yesterday method can help correct under-reporting of quantity of drinking.

Alcohol: taking a population perspective

Alcohol consumption is a global phenomenon, as is the resultant health, social and economic harm. The nature of these harms varies with different drinking patterns and with the societal and political responses to the burden of harm; nevertheless, alcohol-related chronic diseases have a major effect on health. Strong evidence exists for the effectiveness of different strategies to minimize this damage and those policies that target price, availability and marketing of alcohol come out best, whereas those using education and information are much less effective. However, these policies can be portrayed as anti-libertarian and so viewing them in the context of alcohol-related harm to those other than the drinker, such as the most vulnerable in society, is important. When this strategy is successful, as in Scotland, it has been possible to pass strong and effective legislation, such as for a minimum unit price for alcohol.

University students’ beliefs about unit-based guidelines: A qualitative study

UK government guidance for alcohol consumption is expressed in ‘units’ of alcohol. This study employed semi-structured interviews to explore university students’ knowledge of, attitudes towards, and use of unit-based guidelines. Thematic analysis revealed that participants were not motivated to adhere to unit-based guidelines and that they lacked the skills required to apply them to reduce their own drinking. Instead, interviewees used individual strategies to monitor their drinking. The results suggest that public health interventions should include provision of information, efforts to motivate young people to change their behaviour and strategies to develop skills for managing alcohol consumption.

Predictors of awareness of standard drink labelling and drinking guidelines to reduce negative health effects among Australian drinkers

INTRODUCTION AND AIMS

This study examined rates of awareness of standard drink labelling and drinking guidelines among Australian adult drinkers. Demographic predictors of these two outcomes were also explored.

DESIGN AND METHODS

Online survey panel participants aged 18-45 years(n = 1061; mean age = 33.2 years) completed an online survey assessing demographics, alcohol consumption patterns, awareness of standard drink labels and the National Health and Medical Research Council (NHMRC) guidelines, and support for more detailed labels.

RESULTS

The majority (80%) of participants had seen standard drink labels on alcohol products; with younger drinkers, those from a regional/rural location and high-risk drinkers significantly more likely to have seen such labelling. Most respondents estimated at or below the maximum number of drinks stipulated in the NHMRC guidelines. However, their estimates of the levels for male drinkers were significantly higher than for female drinkers. High-risk drinkers were significantly less likely to provide accurate estimates, while those who had seen the standard drink logo were significantly more likely to provide accurate estimates of drinking levels to reduce the risk of long-term harms only. Just under three-quarters of respondents supported the inclusion of more information on labels regarding guidelines to reduce negative health effects.

DISCUSSION AND CONCLUSIONS

The current standard drink labelling approach fails to address high-risk drinkers. The inclusion of information about NHMRC guidelines on alcohol labels, and placing standard drink labelling on the front of products could improve awareness of what constitutes a standard drink and safe levels of consumption among Australian drinkers.[Kerri Coomber, Sandra C. Jones, Florentine Martino, Peter G. Miller. Predictors of awareness of standard drink labelling and drinking guidelines to reduce negative health effects among Australian drinkers. Drug Alcohol Rev 2017;36:200-209].

The Influence of Alcohol Consumption, Cigarette Smoking, and Physical Activity on Leukocyte Telomere Length

BACKGROUND

Telomeres protect from DNA degradation and maintain chromosomal stability. Short telomeres have been associated with an increased risk of cancer at several sites. However, there is limited knowledge about the lifestyle determinants of telomere length. We aimed to determine the effect of three factors, known to be important in cancer etiology, on relative leukocyte telomere length (rLTL): alcohol consumption, smoking, and physical activity.

METHODS

This cross-sectional study included 477 healthy volunteers ages 20 to 50 years who completed a questionnaire and provided a fasting blood sample. Multiplex quantitative real-time PCR (qPCR) was used to measure rLTL. Regression coefficients were calculated using multiple linear regression while controlling for important covariates.

RESULTS

There was no association between alcohol consumption and rLTL. Daily smokers and those in the middle and lower tertile of pack-years smoking had shorter rLTL than never daily smokers (P = 0.02). Data were suggestive of a linear trend with total physical activity (P = 0.06). Compared with the lowest quartile, the highest quartile of vigorous physical activity was associated with longer rLTL. A significant linear trend of increasing rLTL with increasing vigorous physical activity was observed (P = 0.02).

CONCLUSIONS

Cigarette smoking and vigorous physical activity have an impact on telomere length. Smoking was related to shorter telomere length while vigorous physical activity was related to longer telomeres.

IMPACT

The findings from this study suggest that lifestyle may play an important role in telomere dynamics and also suggest that engaging in healthy behaviors may mitigate the effect of harmful behaviors on telomere length.

Lay epidemiology and the interpretation of low-risk drinking guidelines by adults in the United Kingdom

AIMS

To explore how the concept of lay epidemiology can enhance understandings of how drinkers make sense of current UK drinking guidelines.

METHODS

Qualitative study using 12 focus groups in four sites in northern England and four sites in central Scotland. Participants were 66 male and female drinkers, aged between 19 and 65 years, of different socio-economic backgrounds. Data were analysed thematically using a conceptual framework of lay epidemiology.

RESULTS

Current drinking guidelines were perceived as having little relevance to participants' drinking behaviours and were generally disregarded. Daily guidelines were seen as irrelevant by drinkers whose drinking patterns comprised heavy weekend drinking. The amounts given in the guidelines were seen as unrealistic for those motivated to drink for intoxication, and participants measured alcohol intake in numbers of drinks or containers rather than units. Participants reported moderating their drinking, but this was out of a desire to fulfil work and family responsibilities, rather than concerns for their own health. The current Australian and Canadian guidelines were preferred to UK guidelines, as they were seen to address many of the above problems.

CONCLUSIONS

Drinking guidelines derived from, and framed within, solely epidemiological paradigms lack relevance for adult drinkers who monitor and moderate their alcohol intake according to their own knowledge and risk perceptions derived primarily from experience. Insights from lay epidemiology into how drinkers regulate and monitor their drinking should be used in the construction of drinking guidelines to enhance their credibility and efficacy.

Impact of binge alcohol on mortality among people who inject drugs

INTRODUCTION

While the impacts of illicit drug use on mortality have been well described, the impact of poly-substance that includes alcohol has received less attention. We examined the impact of binge alcohol use on mortality among a cohort of people who inject drugs (PWID) in a Canadian setting.

METHODS

Using data derived from a prospective cohort study of PWID in Vancouver, Canada recruited between May 1996 and November 2013. We ascertained dates and causes of death through a confidential linkage with the provincial registry and examined the impact of binge alcohol use. The primary outcome of interest was all-cause mortality. We used Cox proportional hazard regression to determine factors associated with mortality, including socio-demographic characteristics, drug use patterns and other risk behaviours.

RESULTS

During the study period, 2550 individuals were followed (844 of whom were HIV positive at baseline) for a median of 75.4 months (interquartile range 37.9 113.2). Of these, 795 (31%) participants reported binge alcohol use at some time during the study period. In multivariable analyses, binge alcohol use remained independently associated with all-cause-mortality (adjusted hazard ratio=1.41; 95% confidence interval: 1.06-1.88) after adjustment for other drug use patterns.

CONCLUSIONS

Binge alcohol use was associated with time to all-cause mortality among PWID in this setting. Since alcohol use is often overlooked as a risk factor for mortality among this population, these findings highlight the continued need to incorporate addiction treatment and public health interventions and policies that address binge alcohol use to reduce alcohol related-harms.

Primary Care Management of Alcohol Misuse

More than one in four American adults consume alcohol in quantities exceeding recommended limits. One in 12 have an alcohol use disorder marked by harmful consequences. Both types of alcohol misuse contribute to acute injury and chronic disease, making alcohol the third largest cause of preventable death in the United States. Alcohol misuse alters the management of common conditions from insomnia to anemia. Primary care providers should screen adult patients to identify the full spectrum of alcohol misuse. A range of effective treatments are available - from brief counselling interventions and mutual help groups to medications and behavioral therapies.

An adaptation of the Yesterday Method to correct for under-reporting of alcohol consumption and estimate compliance with Canadian low-risk drinking guidelines

OBJECTIVES

To estimate compliance with Canada's Low-Risk Alcohol Drinking Guidelines (LRDG) in different groups of drinkers after adjusting for underreporting of alcohol use, and to identify which types of beverage are more likely to be consumed when LRDGs are exceeded.

METHOD

Our sample consisted of 43,242 Canadians aged 15 and over who had responded to the Canadian Alcohol and Drug Use Monitoring Survey, 2008-2010. Consumption in excess of LRDG was estimated for subgroups of drinkers after adjustment for under-reporting of consumption. Responses to Beverage-Specific Yesterday questions were used to make age-, gender- and beverage-specific corrections to under-reporting for data from the last 12 months Quantity-Frequency questions. Statistics Canada data on sales of beer, wine and spirits were also incorporated into the adjusted calculations.

RESULTS

After adjustment for under-reporting, non-compliance with weekly LRDG limits to reduce risk of long-term harm increased from 6.8% to 27.3% among drinkers, and from 42.3% to 68.3% with respect to drinks. Non-compliance with daily LRDG limits to reduce risk of short-term harm increased from 16.7% to 38.6% among drinkers, and from 53.3% to 80.5% with respect to drinks. After adjustment, over 92% of total consumption occurred on risky drinking days among underage Canadians and over 91% of consumption reported by young adults took place during risky drinking occasions. Wine was least likely to be drunk in a risky fashion, spirits were the most likely.

CONCLUSION

When corrections for under-reporting are made, most Canadian alcohol consumption occurs on days when national LRDG are exceeded, especially for underage and young adult drinkers.

Do women grow out of risky drinking? A prospective study of three cohorts of Australian women

INTRODUCTION AND AIMS

To examine women's drinking behaviour relative to Australian guidelines and identify associated factors over the lifespan.

DESIGN AND METHODS

Data came from three prospective cohorts of the Australian Longitudinal Study on Women's Health aged 18-23 (n = 14,247), 45-50 (n = 13,715) and 70-75 years (n = 12,432) when first surveyed in 1996. The same women were re-surveyed at roughly 3-year intervals until 2012. At each survey, four drinking behaviours were based on two guidelines: long-term drinking (no more than two standard drinks per day) and episodic drinking (no more than four standard drinks on an occasion): (i) no risk (within both guidelines); (ii) low episodic risk (less than once a month); high episodic risk (at least once a month); long-term risk (more than two drinks per day regardless of episodic drinking).

RESULTS

No risk drinking increased with age, low episodic risk drinking remained almost constant between ages 18 and 39, and high episodic risk drinking declined rapidly. Few women drank at long-term risk. Factors associated with risky drinking varied with age; however, being a past or current smoker consistently increased the risk, and risks for smokers increased with age. Risky drinking was less likely to be practised by women providing care and needing help with daily tasks, or by pregnant women and those living with children.

DISCUSSION AND CONCLUSIONS

Risky drinking behaviour should be addressed in younger women and in those who smoke. Interventions to reduce risky drinking, possibly in combination with reducing smoking, could be offered through general practice centres.

Geostatistical modelling of arsenic in drinking water wells and related toenail arsenic concentrations across Nova Scotia, Canada

Arsenic is a naturally occurring class 1 human carcinogen that is widespread in private drinking water wells throughout the province of Nova Scotia in Canada. In this paper we explore the spatial variation in toenail arsenic concentrations (arsenic body burden) in Nova Scotia. We describe the regional distribution of arsenic concentrations in private well water supplies in the province, and evaluate the geological and environmental features associated with higher levels of arsenic in well water. We develop geostatistical process models to predict high toenail arsenic concentrations and high well water arsenic concentrations, which have utility for studies where no direct measurements of arsenic body burden or arsenic exposure are available. 892 men and women who participated in the Atlantic Partnership for Tomorrow's Health Project provided both drinking water and toenail clipping samples. Information on socio-demographic, lifestyle and health factors was obtained with a set of standardized questionnaires. Anthropometric indices and arsenic concentrations in drinking water and toenails were measured. In addition, data on arsenic concentrations in 10,498 private wells were provided by the Nova Scotia Department of Environment. We utilised stepwise multivariable logistic regression modelling to develop separate statistical models to: a) predict high toenail arsenic concentrations (defined as toenail arsenic levels ≥0.12 μg g(-1)) and b) predict high well water arsenic concentrations (defined as well water arsenic levels ≥5.0 μg L(-1)). We found that the geological and environmental information that predicted well water arsenic concentrations can also be used to accurately predict toenail arsenic concentrations. We conclude that geological and environmental factors contributing to arsenic contamination in well water are the major contributing influences on arsenic body burden among Nova Scotia residents. Further studies are warranted to assess appropriate intervention strategies for reducing arsenic body burden among human populations.

Methodological biases in estimating the relationship between alcohol consumption and breast cancer: the role of drinker misclassification errors in meta-analytic results

BACKGROUND

While alcohol consumption has been linked to breast cancer in women, few studies have controlled for possible biases created by including former or occasional drinkers in the abstainer reference group. We explored the potential for such misclassification errors as sources of bias in estimates of the alcohol-breast cancer relationship.

METHODS

Meta-analyses of population case-control, hospital case-control, and cohort studies to examine relationships between level of alcohol use and breast cancer morbidity and/or mortality in groups of studies with and without different misclassification errors.

RESULTS

Of 60 studies identified, only 6 were free of all misclassification errors. The abstainer reference group was biased by the inclusion of former drinkers in 49 studies, occasional drinkers (<10 g ethanol [EtOH] per week) in 22 and by both these groups in 18. Occasional drinkers were also mixed with light or hazardous-level drinkers in 22 studies. Unbiased estimates of the odds ratio (OR) for breast cancer were 1.011 (95% confidence interval [CI]: 0.891 to 1.148) among former drinkers (n = 11) and 1.034 (95% CI: 1.003 to 1.064) among occasional drinkers (n = 17). Hazardous-level drinking (>20 g < 41 g EtOH/d) was not significantly associated with breast cancer in studies with occasional drinker bias. However, in studies free from occasional drinker bias, the OR for breast cancer was 1.085 (95% CI: 1.015 to 1.160) for low-level (<21 g/d) drinkers (n = 17), 1.374 (95% CI: 1.319 to 1.431) for hazardous-level drinkers (n = 26), and 1.336 (95% CI: 1.228 to 1.454) for harmful-level (>40 g/d) drinkers (n = 9).

CONCLUSIONS

While the great majority of studies of the alcohol-breast cancer link include misclassification errors, only misclassification of occasional drinkers was found to bias risk estimates significantly. Estimates based on error-free studies confirmed that low, hazardous and harmful levels of alcohol use each significantly increase the risk of breast cancer.

What is the role of obesity in the aetiology of arsenic-related disease?

Consumption of arsenic contaminated drinking water causes a large variety of adverse health outcomes. Body mass index (BMI), which is linked to diet, is positively associated with arsenic methylation capacity. We investigated the association between an obesity-related diet and arsenic body burden from exposure to naturally contaminated drinking water among Nova Scotia residents. We collected home drinking water and toenail clipping samples among 960 men and women aged 35 to 69 years in Nova Scotia, Canada from 2009 through 2010. We measured body composition and arsenic concentrations in drinking water and toenails clipping samples and collected socio-demographic, behavioural, and dietary information via standardized questionnaires. We derived an obesity-related dietary pattern score using reduced rank regression. Across quartiles of the obesity-related dietary pattern score there were no significant differences in drinking water arsenic concentrations, but there was an inverse trend in arsenic concentrations in toenails across the dietary pattern score (P=0.01). Compared with individuals in the first quartile of the dietary pattern score, those in the second through fourth quartiles had decreased likelihoods of high toenail arsenic (≥ 85 percentile). The corresponding odds ratios (95% confidence intervals [CI]) were 0.81 (95% CI, 0.49, 1.36), 0.57 (95% CI, 0.33, 0.99), and 0.55 (95% CI, 0.31, 0.98), respectively (P for trend=0.02). We conclude that given similar levels of naturally occurring arsenic exposure via drinking water, an obesity-related dietary pattern was associated with significantly lower arsenic concentrations in toenails. Further studies to investigate the underlining mechanisms are warranted.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND

Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality.

METHODS

Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate.

RESULTS

We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes.

CONCLUSIONS

Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Mental health promotion and illness prevention: a challenge for psychiatrists

Mental health is essential for individual and public health. To improve mental health, promotion, prevention, and the treatment of disease are required. These three kinds of interventions are interrelated but independent from one another. Although separate efforts for mental health promotion and prevention are needed as well as the public need of mental health promotion and well-being, psychiatrists usually are not accustomed to mental health promotion and prevention. This review introduces an overview of the concept, subjects according to target populations, and various intervention strategies for mental health promotion and prevention of mental illnesses. Based on literatures to date, understanding of developmental psychology, lifestyle medicine, and biopsychosocial contributors of mental health with a macroscopic perspective might help to practice mental health promotion and illness prevention.

Confounding and studies of 'moderate' alcohol consumption: the case of drinking frequency and implications for low-risk drinking guidelines

AIMS

Many observational studies suggest that increased drinking frequency is associated with reduced mortality among those with low-dose alcohol consumption. The purpose of this paper was to examine whether frequent drinkers consume lower-risk amounts during drinking days or have favorable risk factor profiles compared with those who drink less frequently, and discuss implications for the larger debate about the limitations of non-randomized studies about 'moderate' drinking and the development of low-risk drinking guidelines.

METHODS

Data from the 2008 Behavioral Risk Factor Surveillance System survey were used to characterize alcohol consumption characteristics and their relationship with risk factors among adult drinking men who consumed an average of fewer than two drinks per day and adult drinking adult women who consumed an average of less than one drink per day.

RESULTS

Those who drank relatively infrequently (14 or fewer days per month) consumed more during drinking days, were more likely to exceed the US Dietary Guidelines drinking limits (41.0% versus 9.7%) and had a larger proportion of drinking days that included binge drinking (13.4% versus 4.3%). Infrequent drinkers also had a higher prevalence of 13 of 15 risk factors assessed. Findings from analyses of those aged ≥40 years were similar.

CONCLUSIONS

Among those with low average alcohol consumption, infrequent drinkers drink more during drinking days and have unfavorable risk factors profiles compared with more frequent drinkers, suggesting that confounding may contribute to favorable associations with 'moderate' average alcohol consumption and increased drinking frequency observed in non-randomized studies.