Article

The association between alcohol access and alcohol‐attributable emergency department visits in Ontario, Canada

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Abstract

Background and Aims The availability of alcohol through retail outlets is associated with alcohol‐related harms, but few studies have demonstrated a causal relationship. We investigated the association between alcohol availability and alcohol‐attributable emergency department (ED) visits in the province of Ontario during a period of deregulation of controls on the number of alcohol outlets. Design Cross sectional and pre‐post design Setting and participants The study used data from two time periods: pre‐deregulation (2013‐2014) and post‐deregulation (2016‐2017), to compare rates of ED visits for 513 defined geographic regions in Ontario Canada, called Forward Sortation Areas (FSAs). Measurements The primary outcome was the age‐standardized rates of alcohol‐attributable ED visits. We compiled a list of all alcohol retail outlets in Ontario during 2014 and 2017 and matched them to their corresponding FSA. We fit mixed‐effects Poisson regression models to assess: (a) the cross‐sectional association between number of outlets and hours of operation and ED visits; (b) the impact of deregulation on ED visits using a difference‐in‐difference approach. Findings Alcohol‐attributed ED visits increased 17.8% over the study period; over twice the rate of increase for all ED visits. Increased hours of operation and numbers of alcohol outlets within a FSA were positively associated with higher rates of alcohol‐attributable ED visits. The increase in ED visits attributable to alcohol was 6% (IRR 1.06; 95% CI 1.04‐1.08) greater in FSAs that introduced alcohol sales in grocery stores following deregulation compared with FSAs that did not. Conclusions Deregulation of alcohol sales in Ontario, Canada in 2015 was associated with increased emergency department visits attributable to alcohol.

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... Stockwell et al. [22][23][24] and Zhao et al. [25] concluded that increases in private alcohol retail outlets in British Columbia contributed to increases in alcohol-related deaths, hospital admissions and crime. Recent research by Myran et al. [26,27] assessed the Ontario experience, focusing on before and after periods when selected grocery supermarkets were permitted to sell alcohol, starting in December 2015. They found a sharp increase in alcohol-related emergency room admissions associated with this change in availability of alcohol. ...
... Will these changes have any impact on health, safety and social problems? Recent research by Myran et al. [26,27] focusing on Ontario indicated that the increase in new supermarket outlets and longer hours following the December 2015 change in physical access was skewed towards low socio-economic areas. Myran et al [27] also indicate that this change was related to an increase in alcohol-related emergency department admissions after December 2015. ...
... Recent research by Myran et al. [26,27] focusing on Ontario indicated that the increase in new supermarket outlets and longer hours following the December 2015 change in physical access was skewed towards low socio-economic areas. Myran et al [27] also indicate that this change was related to an increase in alcohol-related emergency department admissions after December 2015. Stockwell et al. [22][23][24], focusing on British Columbia during their period of partial privatisation and expansion of outlet density, found an increase in alcohol-related harm. ...
Article
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.
... Alcohol use in Canada is on the rise with sales growing by 3.1% in 2019 [5]. Deregulatory measures that increase alcohol's availability and affordability are occurring at an unprecedented rate in some of the most populous areas of the country [6,7]. This trend has been further compounded by recent policy responses to the COVID-19 pandemic with many jurisdictions designating alcohol as an 'essential service' and fast-tracking accessibility by expanding online ordering and delivery services [8][9][10]. ...
... The adverse consequences of selling alcohol alongside ordinary commodities have already been demonstrated by the increase in acute harms following Ontario's widespread introduction of alcohol in grocery stores [7,8]. There will likely be further harms due to policy decisions made during the COVID-19 pandemic that serve to ease alcohol access. ...
Article
Introduction: Effective alcohol control measures can prevent and reduce alcohol-related harms at the population level. This study aims to evaluate implementation of alcohol policies across 11 evidence-based domains in Canada's 13 jurisdictions. Methods: The Canadian Alcohol Policy Evaluation project assessed all provinces and territories on 11 evidence-based domains weighted for scope and effectiveness. A scoring rubric was developed with policy and practice indicators and peer-reviewed by international experts. The 2017 data were collected from publicly-available regulatory documents, validated by government officials, and independently scored by team members. Results: The average score for alcohol policy implementation across Canadian provinces and territories was 43.8%; Ontario had the highest (63.9%) and Northwest Territories the lowest (38.4%) jurisdictional scores. Only six of 11 policy domains had average scores above 50% with Monitoring and Reporting scoring the highest (62.8%) and Health and Safety Messaging the lowest (25.7%). A 2017 provincial/territorial current best practice score of 86.6% was calculated taking account of the highest scores for any individual policy indicators implemented in at least one jurisdiction across the country. Discussion and conclusions: Most of the evidence-based alcohol policies assessed by the Canadian Alcohol Policy Evaluation project were not implemented across Canadian provinces and territories as of 2017, and many provinces showed declining scores since 2012. However, the majority of policies assessed have been implemented in at least one jurisdiction. Improved alcohol policies to reduce related harm are therefore achievable and could be implemented consistently across Canada.
... The increase in ED visits and poison control calls is similar to changes observed in the United States. [12][13][14][15][16] We hypothesize increased visitation steams from increased cannabis use following legalization and increased social acceptability, leading to more individuals seeking help for cannabis-related health issues or reporting cannabis use. Though it is possible existing cannabis users are now consuming more cannabis than previously, we believe the increase in cannabis-related visits is due to new users. ...
... Though this figure indicates ED visits related to cannabis may be greater in comparison to some prescription drugs, the substance is associated with fewer ED visits in comparison with other common substances like alcohol and opiates. 14,15 LIMITATIONS Inherent to administrative data use is the possibility of miscoded patients. Additionally, it is likely that cannabis legalization has altered stigma and patient fears of legal repercussions. ...
Article
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Objectives Non-medical cannabis recently became legal for adults in Canada. Legalization provides opportunity to investigate the public health effects of national cannabis legalization on presentations to emergency departments (EDs). Our study aimed to explore association between cannabis-related ED presentations, poison control and telemedicine calls, and cannabis legalization. Methods Data were collected from the National Ambulatory Care Reporting System from October 1, 2013, to July 31, 2019, for 14 urban Alberta EDs, from Alberta poison control, and from HealthLink, a public telehealth service covering all of Alberta. Visitation data were obtained to compare pre- and post-legalization periods. An interrupted time-series analysis accounting for existing trends was completed, in addition to the incidence rate ratio (IRR) and relative risk calculation (to evaluate changes in co-diagnoses). Results Although only 3 of every 1,000 ED visits within the time period were attributed to cannabis, the number of cannabis-related ED presentations increased post-legalization by 3.1 (range -11.5 to 12.6) visits per ED per month (IRR 1.45, 95% confidence interval [CI]; 1.39, 1.51; absolute level change: 43.5 visits per month, 95% CI; 26.5, 60.4). Cannabis-related calls to poison control also increased (IRR 1.87, 95% CI; 1.55, 2.37; absolute level change: 4.0 calls per month, 95% CI; 0.1, 7.9). Lastly, we observed increases in cannabis-related hyperemesis, unintentional ingestion, and individuals leaving the ED pre-treatment. We also observed a decrease in co-ingestant use. Conclusion Overall, Canadian cannabis legalization was associated with small increases in urban Alberta cannabis-related ED visits and calls to a poison control centre.
... While evidence to date suggests modest increases in self-reported cannabis use in Canada following legalisation [22], no Canadian studies have examined associations between access to recreational cannabis stores and cannabis use and harms. In addition, while privately-run alcohol systems have been associated with higher per capita alcohol use, no studies to date have examined this relationship in regards to cannabis [8,23]. Further research, examining these associations using natural experiment designs, would provide high-quality evidence on the health impacts of cannabis retail access, and guide policy in regions where cannabis legalisation is currently underway or being considered. ...
Article
Introduction This study describes the legal recreational cannabis market across Canada over the 2 years following legalisation. We compared changes in access to the legal cannabis retail market for all provinces and territories (jurisdictions) in Canada and explored differences between jurisdictions. Methods We collected data for all legal cannabis stores in Canada over five time periods following legalisation in October 2018. We examined the following measures by jurisdiction and retail model (public vs. private operation): absolute and per capita store numbers, hours of operation and store access across neighbourhoods. Results Two years following legalisation, there were a total of 1183 legal cannabis stores open across Canada (3.7 stores per 100 000 individuals aged 15+). There was wide variation between jurisdictions in access to retail stores, with the lowest stores per capita in Quebec and Ontario (0.6 and 1.6 per 100 000), and the highest in Alberta and Yukon (14.3 per 100 000 in both). Jurisdictions with private retail models had more stores (4.8 vs. 1.0 per 100 000), held greater median weekly hours (80 vs. 69) and experienced greater store growth over time compared to public models. After adjusting for confounders, there were 1.96 times (95% confidence intervals: 1.84, 2.09) more cannabis stores within 1000 m of the lowest- compared to the highest-income quintile neighbourhoods. Discussion and Conclusions While access to the recreational cannabis retail market has increased following legalisation, there is substantial variation in access between jurisdictions and evidence of concentration in lower-income neighbourhoods. These differences may contribute to disparities in cannabis use and harms.
... Conversely, policy-makers focused on curbing youth and problematic cannabis use may be concerned that cannabis will follow similar patterns observed in the alcohol and tobacco control literature, where increased access to alcohol and tobacco retail is associated with higher use and subsequent harms. [23][24][25][26][27] Although cannabis has important differences from alcohol and tobacco, and caution should be used when applying this literature to cannabis, all 3 are mood-altering substances that can result in addiction. 9 Should trends with cannabis retail similar to those with alcohol retail occur, populations living in private and hybrid retail systems may exhibit higher cannabis use than those living in government systems. ...
Article
Background: On Oct. 17, 2018, Canada legalized recreational cannabis with the dual goals of reducing youth use and eliminating the illicit cannabis market. We examined factors associated with access to physical cannabis stores across Canada 6 months following legalization. Methods: We extracted the address and operating hours of all legal cannabis stores in Canada from online government and private listings. We conducted a descriptive study examining the association between private/hybrid (mixture of government and private stores) and government-only retail models with 4 measures of physical access to cannabis: store density, weekly hours of operation, median distance to the nearest school and relative availability of cannabis stores between low- and high-income neighbourhoods. Results: Six months after legalization, there were 260 cannabis retail stores across Canada: 181 privately run stores, 55 government-run stores and 24 stores in the hybrid retail system. Compared to jurisdictions with a government-run model, jurisdictions with a private/hybrid retail model had 49% (95% confidence interval 10%-200%) more stores per capita, retailers were open on average 9.2 more hours per week, and stores were located closer to schools (median 166.7 m). In both retail models, there was over twice the concentration of cannabis stores in neighbourhoods in the lowest income quintile compared to the highest income quintile. Interpretation: Marked differences in physical access to cannabis retail are emerging between jurisdictions with private/hybrid retail models and those with government-only retail models. Ongoing surveillance including monitoring differences in cannabis use and harms across jurisdictions is needed.
... 18,23 Research, including evidence from Ontario and British Columbia, suggests that such policies may increase alcohol consumption and related harms. 24,25,26 Further surveillance is needed of trends in alcohol-related harms in Ontario and Canada. ...
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Background: Alcohol use causes a large burden on the health of Canadians, and alcohol-related harms appear to be increasing in many high-income countries. We sought to analyze changes in emergency department visits attributable to alcohol use, by sex, age and neighbourhood income over time. Methods: All individuals aged 10 to 105 years living in Ontario, Canada, between 2003 and 2016 were included in this study. The primary outcome was age-standardized rates of emergency department visits attributable to alcohol use, defined using diagnostic codes from the Canadian Institute for Health Information Health Indicator "hospitalizations entirely caused by alcohol." We compared rates of these visits using a retrospective population-level design. Results: Among 15 121 639 individuals, there were 765 346 emergency department visits attributable to alcohol use over the study period. Between 2003 and 2016, the age-standardized rates of these visits increased more in women (86.5%) than in men (53.2%), and the increase in rates of emergency department visits attributable to alcohol use was 4.4 times greater than the increases in the rates of overall emergency department visits. Individuals aged 25-29 years experienced the largest change in the rate of emergency department visits attributable to alcohol use (175%). We found evidence of age-cohort effects, whereby the rate of emergency department visits attributable to alcohol use at age 19 years increased on average by 4.07% (95% confidence interval [CI] 3.71%-4.44%) per year for each cohort born between 1986 and 1999. Individuals in the lowest neighbourhood income quintile had 2.37 (95% CI 2.27-2.49) times the rate of emergency department visits attributable to alcohol use than those in the highest income quintile. This disparity increased slightly over the study period. Interpretation: Although men and lower-income individuals have the highest burden of emergency department visits attributable to alcohol use, the largest increases in visits have been in women and younger adults. Further research should focus on potential causes of these trends to provide guidance on how to reduce alcohol-related harms.
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Purpose: Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits and hospitalizations in Ontario to better understand this rural-urban disparity. Methods: This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models. Findings: Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate [aRR]: 1.67, 95% credible interval [CI]: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97). Conclusions: There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.
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Reviews recommend controlling alcohol availability to limit alcohol-related harm. However, the translation of this evidence into policy processes has proved challenging in some jurisdictions. This paper presents a critical review of empirical spatial and temporal availability research to identify its features and limitations for informing alcohol availability policies. The UK is used as an example jurisdiction. It reviews 138 studies from a 2008 systematic review of empirical availability research and our update of this to January 2014. Data describing study characteristics (settings, measures, design) were extracted and descriptively analysed. Important limitations in current evidence were identified: (i) outlet-level temporal availability was only measured in three studies, and there has been little innovation in measurement of spatial availability; (ii) empirical analyses focus on acute harms with few studies of longer-term harms; (iii) outlets are typically classified at aggregated levels with little empirical analysis of variation within outlet categories; (iv) evidence comes from a narrow range of countries; and (v) availability away from home, online availability and interactions between availability, price and place are all relatively unexamined. Greater innovation in study and measure design and enhanced data quality are required. Greater engagement between researchers and policy actors when developing studies would facilitate this. Research and data innovations are needed to address a series of methodological gaps and limitations in the alcohol availability evidence base, advance this research area and enable findings to be translated effectively into policy processes.
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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. 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. 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. 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.
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Excessive alcohol consumption is the third-leading cause of preventable death in the U.S. This systematic review is one in a series exploring effectiveness of interventions to reduce alcohol-related harms. The focus of this review was on studies evaluating the effects of the privatization of alcohol retail sales on excessive alcohol consumption and related harms. Using Community Guide methods for conducting systematic reviews, a systematic search was conducted in multiple databases up to December 2010. Reference lists of acquired articles and review papers were also scanned for additional studies. A total of 17 studies assessed the impact of privatizing retail alcohol sales on the per capita alcohol consumption, a well-established proxy for excessive alcohol consumption; 9 of these studies also examined the effects of privatization on the per capita consumption of alcoholic beverages that were not privatized. One cohort study in Finland assessed the impact of privatizing the sales of medium-strength beer (MSB) on self-reported alcohol consumption. One study in Sweden assessed the impact of re-monopolizing the sale of MSB on alcohol-related harms. Across the 17 studies, there was a 44.4% median increase in the per capita sales of privatized beverages in locations that privatized retail alcohol sales (interquartile interval: 4.5% to 122.5%). During the same time period, sales of nonprivatized alcoholic beverages decreased by a median of 2.2% (interquartile interval: -6.6% to -0.1%). Privatizing the sale of MSB in Finland was associated with a mean increase in alcohol consumption of 1.7 liters of pure alcohol per person per year. Re-monopolization of the sale of MSB in Sweden was associated with a general reduction in alcohol-related harms. According to Community Guide rules of evidence, there is strong evidence that privatization of retail alcohol sales leads to increases in excessive alcohol consumption.
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In high-income countries like Canada, alcohol consumption ranks second (behind tobacco use) as an etiologic risk factor in the World Health Organization (WHO) burden of disease studies.1,2 Based on 2002 data, the estimated annual cost in Canada for health care directly related to alcohol consumption was $3.3 billion, and the total direct and indirect cost was $14.6 billion, compared with $17 billion related to tobacco and $8.2 billion related to illicit drugs.3 Several critical developments point to a likely increase in the already high disease burden from alcohol in Canada. Overall per capita sales have been rising since 1996,4 from 7.2 L of pure alcohol in 1996 to 8.2 L in 2009 — a 13.0% increase in 13 years.4 The increase was most marked in regions where control systems have eroded.5 In addition, high-risk drinking is common and is highest among young adults.6 About one in five Canadians drink amounts that exceed recommended low-risk drinking guidelines and over 32% experienced problems in the past year due to drinking by others.6 In 2002 in Canada, there were an estimated 450 000 dependent drinkers, 1.3 million high-risk drinkers7 and in excess of 8300 alcohol-caused deaths.8 And these figures do not reflect the much greater adverse impact of alcohol reflected in social problems, trauma and disability.2 Further, the impacts of rising consumption and high-risk drinking also affect nondrinkers and create innocent victims.9 At the same time as consumption has been rising, controls have been eroded. As a result, the already high burden from alcohol is expected to increase if the status quo persists. Drawing on evaluations of programs and policies, this analysis outlines three main things that must be done to reduce the burden of alcohol to society, to high-risk drinkers and to those dependent on alcohol.
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We examined whether the geographic density of alcohol retailers was greater in geographic areas with higher levels of demographic characteristics that predict health disparities. We obtained the locations of all alcohol retailers in the continental United States and created a map depicting alcohol retail outlet density at the US Census tract level. US Census data provided tract-level measures of poverty, education, crowding, and race/ethnicity. We used multiple linear regression to assess relationships between these variables and retail alcohol density. In urban areas, retail alcohol density had significant nonlinear relationships with Black race, Latino ethnicity, poverty, and education, with slopes increasing substantially throughout the highest quartile for each predictor. In high-proportion Latino communities, retail alcohol density was twice as high as the median density. Retail alcohol density had little or no relationship with the demographic factors of interest in suburban, large town, or rural census tracts. Greater density of alcohol retailers was associated with higher levels of poverty and with higher proportions of Blacks and Latinos in urban census tracts. These disparities could contribute to higher morbidity in these geographic areas.
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The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time-series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements-all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.
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The aim of this study was to examine recent research studies published from 2000 to 2008 focusing on availability of alcohol: hours and days of sale and density of alcohol outlets. Systematic review. Forty-four studies on density of alcohol outlets and 15 studies on hours and days of sale were identified through a systematic literature search. The majority of studies reviewed found that alcohol outlet density and hours and days of sale had an impact on one or more of the three main outcome variables, such as overall alcohol consumption, drinking patterns and damage from alcohol. Restricting availability of alcohol is an effective measure to prevent alcohol-attributable harm.
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Researchers often use census-derived measures of socioeconomic status (SES) when personal information is not available. Theory predicts that the resulting misclassification will blunt associations between outcomes and SES and that control for confounding by SES will be less effective. The purpose of this paper was to examine the magnitude of this problem using data from the National Population Health Survey (NPHS). Subjects were 4,037 respondents to the NPHS who were linked to the Ontario Health Insurance Plan. An ecologic measure of income was obtained by linkage of subjects' postal codes to the Census. The relationships between the ecologic-level measure and health outcomes or health services utilization were attenuated in comparison to the relationships relative to the direct measure of household income. The ecologic measure also produced poorer control for confounding by income in the analysis of other health relationships. Many interesting public health and health services questions can be addressed only with the use of ecologic level socioeconomic information. While most of the results were qualitatively similar when the direct and ecologic measures were compared, researchers and users of research findings should be aware that attenuated or potentially misleading findings may result from the use of these methods.
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This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. This section also documents how international beer and spirits production has been consolidated recently by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is reviewed critically in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy-making process at the local, national and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers and treatment of drinkers with alcohol dependence. No Yes
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Objective: Evidence on the comparative cost-effectiveness of alcohol control strategies is a relevant input into public policy and resource allocation. At the global level, this evidence has been used to identify so-called best buys for noncommunicable disease prevention and control. This article uses global evidence on alcohol use exposures and risk relations, as well as on intervention costs and impacts, to re-examine the comparative cost-effectiveness of a range of alcohol control strategies. Method: A "generalized" approach to cost-effectiveness analysis was adopted. A new modeling tool (OneHealth) was used to estimate the population-level effects of interventions. Interventions that reduce the harmful use of alcohol included brief psychosocial interventions, excise taxes, and the enactment as well as enforcement of restrictions on alcohol marketing, availability, and drink-driving laws. Costs were estimated in international dollars for the year 2010 and effects expressed in healthy life years gained. Analysis was carried out for 16 countries spanning low-, middle-, and high-income settings. Results: Increasing excise taxes has a low cost (<I$0.10 per capita) and a highly favorable ratio of costs to effects (<I$100 per healthy life year gained in both low- and high-income settings). Availability and marketing restrictions are also highly cost effective (<I$100 in low-income settings and <I$500 in high-income settings). Enforcement of drink-driving laws and blood alcohol concentration limits via sobriety checkpoints had cost-effectiveness ratios in the range of I$1,500-3,000. Brief psychosocial treatments were <I$150 and <I$1,500 in low- and high-income settings, respectively. Conclusions: More than a decade after an initial global analysis, the findings of this study indicate pricing policies and restrictions to alcohol availability and marketing continue to represent a highly cost-effective use of resources.
Article
Objective: Systematic reviews and meta-analyses were completed studying the effect of changes in the physical availability of take-away alcohol on per capita alcohol consumption. Previous reviews examining this topic have not focused on off-premise outlets where take-away alcohol is sold and have not completed meta-analyses. Method: Systematic reviews were conducted separately for policies affecting the temporal availability (days and hours of sale) and spatial availability (outlet density) of take-away alcohol. Studies were included up to December 2015. Quality criteria were used to select articles that studied the effect of changes in these policies on alcohol consumption with a focus on natural experiments. Random-effects meta-analyses were applied to produce the estimated effect of an additional day of sale on total and beverage-specific consumption. Results: Separate systematic reviews identified seven studies regarding days and hours of sale and four studies regarding density. The majority of articles included in these systematic reviews, for days/hours of sale (7/7) and outlet density (3/4), concluded that restricting the physical availability of take-away alcohol reduces per capita alcohol consumption. Meta-analyses studying the effect of adding one additional day of sale found that this was associated with per capita consumption increases of 3.4% (95% CI [2.7, 4.1]) for total alcohol, 5.3% (95% CI [3.2, 7.4]) for beer, 2.6% (95% CI [1.8, 3.5]) for wine, and 2.6% (95% CI [2.1, 3.2]) for spirits. The small number of included studies regarding hours of sale and density precluded meta-analysis. Conclusions: The results of this study suggest that decreasing the physical availability of take-away alcohol will decrease per capita consumption. As decreasing per capita consumption has been shown to reduce alcohol-related harm, restricting the physical availability of take-away alcohol would be expected to result in improvements to public health.
Article
This article summarizes the contents of Alcohol: No Ordinary Commodity—Research and public policy (Babor et al. 2003). The first part of the book describes why alcohol is no ordinary commodity, and presents epidemiological data on the global burden of alcohol-related problems. The second part of the book reviews the scientific evidence for strategies and interventions designed to prevent or minimize alcohol-related harm: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drinking-driving countermeasures, regulating alcohol promotion, education and persuasion strategies and treatment services. The final section considers the policymaking process on the local, national and international levels, and provides a synthesis of evidence-based strategies and interventions from a policy perspective.
Article
This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not suffi cient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most eff ective and cost-eff ective policies to reduce alcohol-related harm
Article
There have been reviews on the association between density of alcohol outlets and harm including studies published up to December 2008. Since then the number of publications has increased dramatically. The study reviews the more recent studies with regard to their utility to inform policy. A systematic review found more than 160 relevant studies (published between January 2009 and October 2014). The review focused on: (i) outlet density and assaultive or intimate partner violence; (ii) studies including individual level data; or (iii) 'natural experiments'. Despite overall evidence for an association between density and harm, there is little evidence on causal direction (i.e. whether demand leads to more supply or increased availability increases alcohol use and harm). When outlet types (e.g. bars, supermarkets) are analysed separately, studies are too methodologically diverse and partly contradictory to permit firm conclusions besides those pertaining to high outlet densities in areas such as entertainment districts. Outlet density commonly had little effect on individual-level alcohol use, and the few 'natural experiments' on restricting densities showed little or no effects. Although outlet densities are likely to be positively related to alcohol use and harm, few policy recommendations can be given as effects vary across study areas, outlet types and outlet cluster size. Future studies should examine in detail outlet types, compare different outcomes associated with different strengths of association with alcohol, analyse non-linear effects and compare different methodologies. Purely aggregate-level studies examining total outlet density only should be abandoned. [Gmel G, Holmes J, Studer J. Are alcohol outlet densities strongly associated with alcohol-related outcomes? A critical review of recent evidence. Drug Alcohol Rev 2015]. © 2015 Australasian Professional Society on Alcohol and other Drugs.
Article
To study relationships between rates of alcohol-related deaths and (i) the density of liquor outlets and (ii) the proportion of liquor stores owned privately in British Columbia (BC) during a period of rapid increase in private stores. Multi-level regression analyses assessed the relationship between population rates of private liquor stores and alcohol-related mortality after adjusting for potential confounding. The 89 local health areas of BC, Canada across a 6-year period from 2003 to 2008, for a longitudinal sample with n = 534. Population rates of liquor store density, alcohol-related death and socio-economic variables obtained from government sources. The total number of liquor stores per 1000 residents was associated significantly and positively with population rates of alcohol-related death (P < 0.01). A conservative estimate is that rates of alcohol-related death increased by 3.25% for each 20% increase in private store density. The percentage of liquor stores in private ownership was also associated independently with local rates of alcohol-related death after controlling for overall liquor store density (P < 0.05). Alternative models confirmed significant relationships between changes in private store density and mortality over time. The rapidly rising densities of private liquor stores in British Columbia from 2003 to 2008 was associated with a significant local-area increase in rates of alcohol-related death.
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Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.
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A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective
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Burton R, Henn C, Lavoie D, O'Connor R, Perkins C, Sweeney K, et al. A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective. Lancet (London, England) [Internet]. 2017 Apr 15 [cited 2018
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Focus on: alcohol marketing
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