Public health efforts to prevent expansion of alcohol retail availability in neighbourhoods with factors associated with high rates of alcohol-related harms: A case report

This commentary illustrates a recent case study within Ontario, Canada, in which the application of sociodemographic and health data was used by public health to support a legal case to oppose a retail licence application to consume liquor at a corner store located within a neighbourhood that has experienced low socio-economic factors, including low income, high unemployment and low educational attainment levels. Communities in a similar situation may draw from this situation to prevent expansion of alcohol retail availability in neighbourhoods that have low socio-economic status populations and high unemployment and other factors associated with high rates of alcohol-related harms.

Analyzing 14-years of suicide rates in Chile: Impact of alcohol policy, domestic violence, and a suicide prevention program

Suicide is a major public health problem worldwide with far-reaching effects on families, communities, and societies. Influencing factors range from macro-level interventions like alcohol control policies and suicide prevention programs to individual contributors such as alcohol abuse and domestic violence. This study aimed to examine the relationship between Chile's suicide rate changes from 2002 to 2015 and the Alcohol Act of 2004, a national suicide prevention program implemented in 2007, alcohol abuse, and domestic violence. Assembling a unique longitudinal dataset from Chilean public institutions, the study employed an instrumental variable time-series cross-regional design. Results indicated that the Alcohol Act was not associated with suicide rates, domestic violence exhibited a significant association with increased suicide rates, and the national suicide prevention program was linked to reductions in suicide rates, especially among males. These findings align with research from neighbouring countries, showcasing the efficacy of suicide prevention programs in decreasing suicide rates in Chile. Results highlight the importance of integrating protocols to early-detect domestic violence in suicide prevention programs, as well as the need to further improving alcohol control policies to complement suicide prevention programs.

Alcohol policy effects on 100% chronic alcohol-attributable mortality across racial/ethnic subgroups

In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999-2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions ("100% chronic AAD"). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD.

Alcohol retail privatisation in Canadian provinces between 2012 and 2017. Is decision making oriented to harm reduction?

INTRODUCTION

Policy changes may contribute to increased alcohol-related risks to populations. These include privatisation of alcohol retailing, which influences density of alcohol outlets, location of outlets, hours of sale and prevention of alcohol sales to minors or intoxicated customers. Meta-analyses, reviews and original research indicate enhanced access to alcohol is associated with elevated risk of and actual harm. We assess the 10 Canadian provinces on two alcohol policy domains-type of alcohol control system and physical availability of alcohol-in order to track changes over time, and document shifting changes in alcohol policy.

METHODS

Our information was based on government documents and websites, archival statistics and key informant interviews. Policy domains were selected and weighted for their degree of effectiveness and population reach based on systematic reviews and epidemiological evidence. Government representatives were asked to validate all the information for their jurisdiction.

RESULTS

The province-specific reports based on the 2012 results showed that 9 of 10 provinces had mixed retail systems-a combination of government-run and privately owned alcohol outlets. Recommendations in each provincial report were to not increase privatisation. However, by 2017 the percentage of off-premise private outlets had increased in four of these nine provinces, with new private outlet systems introduced in several.

DISCUSSION AND CONCLUSIONS

Decision-making protocols are oriented to commercial interests and perceived consumer convenience. If public health and safety considerations are not meaningfully included in decision-making protocols on alcohol policy, then it will be challenging to curtail or reduce harms.

Impact of Alcohol Policies on Suicidal Behavior: A Systematic Literature Review

Alcohol consumption has been found to be related to suicidal behavior at the individual and population level, but there is lack of literature reviews on the effect of alcohol policies on suicidal behavior. Therefore, the aim of the current study is to conduct a systematic literature review of the impact of alcohol policies at the population level on suicidal behavior and ideation. We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases in March 2019. Papers analyzing alcohol policies limiting alcohol use and studying suicidal behaviors as an outcome measure were included; we identified 19 papers. Although the methods and effect sizes varied substantially in the studies, reducing alcohol often led to reduction in suicidal behavior. Ecological-level studies predominantly investigated the effect of restrictions on alcohol availability and increased cost of alcohol, and the majority presented a reduction in suicides across Western and Eastern Europe, as well as the US. The majority of studies were rated as unclear risk of bias for a number of domains due to a lack of clear reporting. Policies targeting harmful alcohol consumption may contribute towards a reduction in suicidal behavior at the population level.

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.

Alcohol Policies and Suicide: A Review of the Literature

Both intoxication and chronic heavy alcohol use are associated with suicide. There is extensive population-level evidence linking per capita alcohol consumption with suicide. While alcohol policies can reduce excessive alcohol consumption, the relationship between alcohol policies and suicide warrants a critical review of the literature. This review summarizes the associations between various types of alcohol policies and suicide, both in the United States and internationally, as presented in English-language literature published between 1999 and 2014. Study designs, methodological challenges, and limitations in ascertaining the associations are discussed. Because of the substantial between-states variation in alcohol policies, U.S.-based studies contributed substantially to the literature. Repeated cross-sectional designs at both the ecological level and decedent level were common among U.S.-based studies. Non-U.S. studies often used time series data to evaluate pre-post comparisons of a hybrid set of policy changes. Although inconsistency remained, the published literature in general supported the protective effect of restrictive alcohol policies on reducing suicide as well as the decreased level of alcohol involvement among suicide decedents. Common limitations included measurement and selection bias and a focus on effects of a limited number of alcohol policies without accounting for other alcohol policies. This review summarizes a number of studies that suggest restrictive alcohol policies may contribute to suicide prevention on a general population level and to a reduction of alcohol involvement among suicide deaths.

Acute alcohol use among suicide decedents in 14 US states: impacts of off-premise and on-premise alcohol outlet density

AIMS

To estimate the association between per capita alcohol retail outlet density and blood alcohol concentration (BAC) from 51 547 suicide decedents and to analyse the relationship between alcohol outlet density and socio-demographic characteristics among alcohol-positive suicide decedents in the United States by racial/ethnic groups and method of suicide.

DESIGN

Analysis of US data, 2003-11, National Violent Death Reporting System.

SETTING

Suicide decedents from 14 US states.

PARTICIPANTS

A total of 51 347 suicide decedents tested for BAC.

MEASUREMENTS

BAC and levels were derived from coroner/medical examiner reports. Densities of county level on-premises and off-premises alcohol retail outlets were calculated using the 2010 Census.

FINDINGS

Multi-level logistic regression models suggested that higher off-premises alcohol outlet densities were associated with greater proportions of alcohol-related suicides among men-for suicides with alcohol present [BAC >0; adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03-1.13]. Interactions between outlet density and decedents' characteristics were also tested. There was an interaction between off-premises alcohol availability and American Indian/Alaska Native race (AOR = 1.36; 95% CI = 1.10-1.69) such that this subgroup had highest BAC positivity. On-premises density was also associated with BAC >0 (AOR = 1.07; 95% CI = 1.03-1.11) and BAC ≥0.08 (AOR = 1.05; 95% CI = 1.02-1.09) among male decedents.

CONCLUSIONS

In the United States, the density of both on- and off-premises alcohol outlets in a county is associated positively with alcohol-related suicide, especially among American Indians/Alaska Natives.

A population-based study of premature mortality in relation to neighbourhood density of alcohol sales and cheque cashing outlets in Toronto, Canada

OBJECTIVE

Alcohol overuse and poverty, each associated with premature death, often exist within disadvantaged neighbourhoods. Cheque cashing places (CCPs) may be opportunistically placed in disadvantaged neighbourhoods, where customers abound. We explored whether neighbourhood density of CCPs and alcohol outlets are each related to premature mortality among adults.

DESIGN

Retrospective population-based study.

SETTING

140 neighbourhoods in Toronto, Ontario, 2005-2009.

PARTICIPANTS

Adults aged 20-59 years.

MEASURES

Our primary outcome was premature all-cause mortality among adults aged 20-59 years. Across neighbourhoods we explored neighbourhood density, in km(2), of CCPs and alcohol outlets, and the relation of each to premature mortality. Poisson regression provided adjusted relative risks (aRRs) and 95% CIs, adjusting for material deprivation quintile (Q), crime Q and number of banks.

RESULTS

Intentional self-harm, accidental poisoning and liver disease were among the top five causes of premature death among males aged 20-59 years. The overall premature mortality rate was 96.3/10,000 males and 55.9/10,000 females. Comparing the highest versus lowest CCP density Q, the aRR for death was 1.25 (95% CI 1.15 to 1.36) among males and 1.11 (95% CI 0.99 to 1.24) among females. The corresponding aRR comparing the highest Q versus lowest Q alcohol outlet density in relation to premature mortality was 1.36 (95% CI 1.25 to 1.48) for males and 1.11 (95% CI 1.00 to 1.24) for females. The pattern of the relation between either CCPs or alcohol outlet density and premature mortality was typically J shaped.

CONCLUSIONS

There is a J-shaped relation between CCP or alcohol outlet density and premature mortality, even on controlling for conventional measures of poverty. Formal banking and alcohol reduction strategies might be added to health promotion policies aimed at reducing premature mortality in highly affected neighbourhoods.

The relationship between minimum alcohol prices, outlet densities and alcohol-attributable deaths in British Columbia, 2002-09

AIM

To investigate relationships between periodic increases in minimum alcohol prices, changing densities of liquor stores and alcohol-attributable (AA) deaths in British Columbia, Canada.

DESIGN

Cross-section (16 geographic areas) versus time-series (32 annual quarters) panel analyses were conducted with AA deaths as dependent variables and price, outlet densities and socio-demographic characteristics as independent variables.

SETTING AND PARTICIPANTS

Populations of 16 Health Service Delivery Areas in British Columbia, Canada.

MEASUREMENTS

Age-sex-standardized rates of acute, chronic and wholly AA mortality; population densities of restaurants, bars, government and private liquor stores; minimum prices of alcohol in dollars per standard drink.

FINDINGS

A 10% increase in average minimum price for all alcoholic beverages was associated with a 31.72% [95% confidence interval (CI): ± 25.73%, P < 0.05] reduction in wholly AA deaths. Significantly negative lagged associations were also detected up to 12 months after minimum price increases for wholly but not for acute or chronic AA deaths. Significant reductions in chronic and total AA deaths were detected between 2 and 3 years after minimum price increases. Significant but inconsistent lagged associations were detected for acute AA deaths. A 10% increase in private liquor stores was associated with a 2.45% (95% CI: ± 2.39%, P < 0.05), 2.36% (95% CI: ± 1.57%, P < 0.05) and 1.99% (95% CI: ± 1.76%, P < 0.05) increase in acute, chronic and total AA mortality rates.

CONCLUSION

Increases in the minimum price of alcohol in British Columbia, Canada, between 2002 and 2009 were associated with immediate and delayed decreases in alcohol-attributable mortality. By contrast, increases in the density of private liquor stores were associated with increases in alcohol-attributable mortality.

Relationships of Alcohol Use and Alcohol Problems to Probable Anxiety and Mood Disorder

We examine the effects of alcohol consumption and problem drinking on probable anxiety and mood disorder (AMD). Data were taken from the 2000–2006 CAMH Monitor (N = 15,653) general population survey of Ontario adults. Scoring 4+ on the 12-item General Health Questionnaire defined probable AMD, as suggested by recent research. Logistic regression showed that respondents with alcohol problems had significantly increased odds of probable AMD, but those reporting moderate daily alcohol consumption (up to 2 drinks) had decreased odds of probable AMD compared to abstainers. These data replicate other recent research in suggesting that the relationship between alcohol and adverse psychological states, such as psychological distress and probable anxiety and mood disorder, may not be monotonic. Several ways in which selection bias could account for these findings are discussed, as well as other possible causative mechanisms.

Cost of privatisation versus government alcohol retailing systems: Canadian example

INTRODUCTION AND AIMS

Alcohol retail monopolies have been established in many countries to restrict alcohol availability and thus, minimise alcohol-related harm.The aim of this study was to estimate the impact of the privatisation of alcohol sales on the burden and direct health-care, law enforcement costs and indirect costs (lost productivity due to disability or premature mortality) in Canada.

DESIGN AND METHODS

Simulation modelling. International Guidelines for the Estimation of the Avoidable Costs of Substance Abuse were used. All burden and costs were compared with the baseline taken from the aggregate Cost Study on Substance Abuse in Canada 2002.

RESULTS

If all Canadian provinces and territories were to privatise alcohol sales we assume that consumption would increase from 10% to 20% based on available Canadian literature. Under the 10% scenario the costs would increase from 6% ($828 million) and under the 20% scenario costs would increase 12% ($1.6 billion).This increase is substantially greater than the tax and mark-up revenue gained from increased sales,and represents a net loss.

DISCUSSION AND CONCLUSIONS

Alcohol-attributable burden and associated costs will increase markedly if all Canadian provinces and territories gave up the government alcohol retailing systems.For public health and economic reasons, governments should continue to have a strong role in alcohol retailing.

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.