Ashini Weerasinghe’s research while affiliated with Public Health Ontario and other places

Background: This study examined changes in population-level co-use of cannabis and alcohol before and 12 months after nonmedical cannabis legalization in Canada, relative to the United States that had previously legalized and not legalized (US legal and illegal states, respectively). Methods: Data are from waves 1 and 2 of the International Cannabis Policy Study, collected in 2018 (before) and 2019 (12 months after legalization in Canada). Respondents aged 16-65 years from Canada (n = 25,313) and US legal (n = 25,189) and US illegal (n = 19,626) states completed an online survey. Changes in co-use between 2018 and 2019 in US legal and illegal states compared to those in Canada were assessed using multinomial logistic regression. Results: Descriptive analyses show increases in cannabis use and monthly or more frequent (MMF) co-use between 2018 and 2019 in all jurisdictions. Compared to no MMF use of cannabis or alcohol, there was no evidence suggesting differences in changes in MMF co-use in US legal or illegal states relative to Canada. However, respondents in US legal states had 33% higher odds of MMF alcohol-only use (OR = 1.33, 99% CI: 1.12, 1.57) compared to no MMF use relative to Canada. Conclusions: Increases in co-use were observed between 2018 and 2019 in all jurisdictions regardless of the legal status of cannabis. These shifts were largely due to increases in cannabis use across the population, including those that use alcohol, and may indicate changing societal norms toward cannabis generally. As the cannabis legalization transition in Canada matures, evaluation over the longer term will improve understanding of the influence of cannabis liberalization on co-use.

Objectives To test the efficacy of calorie labelling for alcoholic and non-alcoholic beverages on restaurant menus on noticing calorie information, calorie knowledge, and perceived and actual influence on hypothetical beverage orders.Methods Participants included upper-level university students of legal drinking age residing in Ontario, Canada (n = 283). Using a between-groups experiment, participants were randomized to view one of two menus: (1) No Calorie Information (control), and (2) Calorie Information adjacent to each beverage. Participants completed a hypothetical ordering task, and measures related to noticing calorie information, calorie knowledge, and actual and perceived influence of calorie information on beverages ordered were assessed. Linear, logistic, and multinomial logistic regression models were used to examine the four outcomes.ResultsThe odds of noticing calorie information were significantly higher in the Calorie Information (72.6%) versus No Calorie Information condition (8.0%) (OR = 43.7, 95% CI: 16.8, 113.8). Compared to those in the No Calorie Information condition, participants in the Calorie Information condition had significantly lower odds of responding ‘Don’t know’ (OR = 0.04, 95% CI: 0.02, 0.09), underestimating (OR = 0.06, 95% CI: 0.02, 0.2), and overestimating (OR = 0.05, 95% CI: 0.02, 0.2) versus accurately estimating calories in beverages ordered. No significant differences were observed between menu labelling conditions in the calories in beverages ordered or the perceived influence of calorie information on the number of beverages ordered.Conclusion Exposure to menus with calorie information increased consumers noticing the calorie information, and accurately estimating calories in alcoholic and non-alcoholic beverages ordered. These results have implications for policy-makers considering mandatory menu labelling policy inclusive of alcoholic beverages.

Introduction and aims: This paper examines the impact of an alcohol labelling intervention on recall of and support for standard drink (SD) labels, estimating the number of SDs in alcohol containers, and intended and unintended use of SD labels. Design and methods: A quasi-experimental study was conducted in Canada where labels with a cancer warning, national drinking guidelines and SD information were applied to alcohol containers in the single liquor store in the intervention site, while usual labelling continued in the two liquor stores in the comparison site. Three waves of surveys were conducted in both sites before and at two time-points after the intervention with 2049 cohort participants. Generalised estimating equations were applied to estimate changes in all outcomes. Results: Participants in the intervention relative to the comparison site had greater odds of recalling [adjusted odds ratio (AOR) 5.69, 95% confidence interval (CI) 3.02, 10.71] and supporting SD labels (AOR 1.49, 95% CI 1.04, 2.12) and lower odds of reporting using SD labels to purchase high strength, low-cost alcohol (AOR 0.65, 95% CI 0.45, 0.93). Exposure to the labels had negligible effects on accurately estimating the number of SDs (AOR 1.06, 95% CI 0.59, 1.93) and using SD labels to drink within guidelines (AOR 1.04, 95% CI 0.75, 1.46). Discussion and conclusions: Evidence-informed labels increased support for and decreased unintended use of SD labels. Such labels can improve accuracy in estimating the number of SDs in alcohol containers and adherence to drinking guidelines.

Alcohol labels are one strategy for raising consumer awareness about the negative consequences of alcohol, but evidence to inform labels is limited. This quasi-experimental study sought to test the real-world impact of strengthening health messages on alcohol container labels on consumer attention, message processing (reading, thinking, and talking with others about labels), and self-reported drinking. Alcohol labels with a cancer warning, national drinking guidelines, and standard drink information were implemented in the intervention site, and usual labelling practices continued in the comparison site. Changes in key indicators of label effectiveness were assessed among a cohort of adult drinkers in both the intervention and comparison sites using three waves of surveys conducted before and at two time-points after the alcohol label intervention. Generalized Estimating Equations with difference-in-difference terms were used to examine the impact of the label intervention on changes in outcomes. Strengthening health messages on alcohol container labels significantly increased consumer attention to [Adjusted Odds Ratio (AOR)=17.2, 95%CI:8.2,36.2] and processing of labels (e.g., reading labels: AOR=2.6, 95%CI:1.8,3.7), and consumer reports of drinking less due to the labels (AOR=3.7, 95%CI: 2.0,7.0). Strengthening health messages on alcohol containers can achieve their goal of attracting attention, deepening engagement, and enhancing motivation to reduce alcohol use. Strengthening alcohol labelling policies should be a priority for alcohol control globally.

Objective: Evidence-informed alcohol warning labels (AWLs) are a promising, well-targeted strategy to increase consumer awareness of health risks. We assessed consumers' baseline knowledge of alcohol-related cancer risk, standard drinks, and low-risk drinking guidelines as well as levels of support for AWLs. We further assessed associations with sociodemographic factors. Method: Forming part of a larger study testing new evidence-informed AWLs in a northern Canadian territory compared with a neighboring territory, baseline surveys were completed among liquor store patrons systematically selected in both sites. Chi-square and multivariable logistic regression analyses were performed to assess outcomes. Results: In total, 836 liquor store patrons (47.8% female) completed baseline surveys across both sites. Overall, there was low knowledge of alcohol-related cancer risk (24.5%), limited ability to calculate a standard drink (29.5%), and low knowledge of daily (49.5%) and weekly (48.2%) low-risk drinking guideline limits. There was moderate support for AWLs with a health warning (55.9%) and standard drink information (51.4%), and lower support for low-risk drinking guideline labels (38.7%). No sociodemographic characteristics were associated with cancer knowledge. Identifying as female and having adequate health literacy were associated with support for all three AWLs; high alcohol use was associated with not supporting standard drink (adjusted odds ratio = 0.60, 95% CI [0.40, 0.88]) and low-risk drinking guideline (adjusted odds ratio = 0.57, 95% CI [0.38, 0.87]) labels. Conclusions: Few consumers in this study had key alcohol-related health knowledge; however, there was moderate support for AWLs as a tool to raise awareness. Implementation of information-based interventions such as evidence-informed AWLs with health messages including alcohol-related cancer risk, standard drink information, and national drinking guidelines is warranted.

Objective: This study tested the initial and continued effects of cancer warning labels on drinkers' recall and knowledge that alcohol can cause cancer. Method: A quasi-experiment was conducted to examine changes in the intervention versus comparison site for three outcomes: unprompted and prompted recall of the cancer warning, and knowledge that alcohol can cause cancer. The intervention site applied cancer warning labels to alcohol containers in its liquor store for 1 month, and the two liquor stores in the comparison site did not apply cancer labels. In total, 2,049 unique cohort participants (1,056 male) were recruited at liquor stores in the intervention and comparison sites to participate in surveys 4 months before labels were applied and 2 and 6 months after the cancer label was halted because of alcohol industry interference. Generalized estimating equations tested differences in outcomes between sites over time adjusting for socio-demographics and other covariates. Results: Two months after the cancer label, unprompted (+24.2% vs. +0.6%; adjusted odds ratio [AOR] = 32.7, 95% CI [5.4, 197.7]) and prompted (+35.7% vs. +4.1%; AOR = 6.2, 95% CI [3.6, 10.9]) recall increased to a greater extent in the intervention versus comparison site. There was a 10% greater increase in knowledge (+12.1% vs. +11.6%; AOR = 1.1, 95% CI [0.7, 1.5]) 2 months after the cancer label in the intervention versus comparison site. Similar results were found 6 months after the cancer label for all three outcomes. Conclusions: In a real-world setting, cancer warning labels get noticed and increase knowledge that alcohol can cause cancer. Additional cancer label intervention studies are required that are not compromised by industry interference.

Objective: Alcohol labels are one strategy for communicating health information to consumers. This study tested the extent to which consumers recalled alcohol labels with national drinking guidelines and examined the impact of labels on awareness and knowledge of the guidelines. Method: A quasi-experimental study was conducted in two jurisdictions in northern Canada examining the impact of labels on the following outcomes: unprompted and prompted recall of the drinking guideline label message, awareness of the drinking guidelines, and knowledge of the daily and weekly recommended drink limits. The intervention site applied labels with national drinking guidelines, a cancer warning, and standard drink information to alcohol containers in its liquor store, whereas the comparison site did not apply these labels. In total, 2,049 cohort participants in both sites were recruited to complete surveys before and at two time points after the intervention. Changes in outcomes were examined using generalized estimating equations. Results: After the intervention, unprompted and prompted recall of the drinking guideline label message increased more in the intervention versus comparison site (adjusted odds ratio [AOR] = 10.8, 95% CI [0.9, 127.6]; AOR = 7.0, 95% CI [3.3, 14.9], respectively). Awareness of the drinking guidelines increased 2.9 times more in the intervention versus comparison site (AOR = 2.9, 95% CI [2.0, 4.3]). In addition, knowledge of the daily and weekly drink limits increased 1.5 and 1.4 times more in the intervention versus comparison site, respectively (daily: AOR = 1.5, 95% CI [1.0, 2.1]; weekly: AOR = 1.4, 95% CI [1.0, 2.0]). Conclusions: Enhanced alcohol labels get noticed and may be an effective population-level strategy for increasing awareness and knowledge of national drinking guidelines.

Knowledge that alcohol can cause cancer is low in Canada. Alcohol labels are one strategy for communicating alcohol-related harms, including cancer. Extending existing research observing an association between knowledge of the alcohol–cancer link and support for alcohol policies, this study examined whether increases in individual-level knowledge that alcohol is a carcinogen following an alcohol labelling intervention are associated with support for alcohol polices. Cancer warning labels were applied to alcohol containers at the intervention site, and the comparison site did not apply cancer labels. Pre-post surveys were conducted among liquor store patrons at both sites before and two-and six-months after the intervention was stopped due to alcohol industry interference. Limiting the data to participants that completed surveys both before and two-months after the cancer label stopped, logistic regression was used to examine the association between increases in knowledge and support for policies. Support for pricing and availability policies was low overall; however, increases in individual-level knowledge of the alcohol-cancer link was associated with higher levels of support for pricing policies, specifically, setting a minimum unit price per standard drink of alcohol (OR = 1.86, 95% CI: 1.11–3.12). Improving knowledge that alcohol can cause cancer using labels may increase support for alcohol policies. International Registered Report Identifier (IRRID): RR2-10.2196/16320

Background: Very few experimental studies exist describing the effect of changes to the built environment and opportunities for physical activity (PA). We examined the impact of an urban trail created on a frozen waterway on visitor counts and PA levels. Methods: We studied a natural experiment in Winnipeg, Manitoba, Canada that included 374,204 and 237,362 trail users during the 2017/2018 and 2018/2019 winter seasons. The intervention was a 10 km frozen waterway trail lasting 8–10 weeks. The comparator conditions were the time periods immediately before and after the intervention when ~10 kms of land-based trails were accessible to the public. A convenience sample of 466 participants provided directly measured PA while on the frozen waterway. Results: Most trail users were 35 years or older (73%), Caucasian (77%), and had an annual household income >$50,000 (61%). Mean daily trail network visits increased ~four-fold when the frozen waterway was open (median and interquartile range (IQR) = 710 (239–1839) vs. 2897 (1360–5583) visits/day, p < 0.001), compared with when it was closed. Users achieved medians of 3852 steps (IQR: 2574–5496 steps) and 23 min (IQR: 13–37 min) of moderate to vigorous intensity PA (MVPA) per visit, while 37% of users achieved ≥30 min of MVPA. Conclusion: A winter-specific urban trail network on a frozen waterway substantially increased visits to an existing urban trail network and was associated with a meaningful dose of MVPA. Walking on water could nudge populations living in cold climates towards more activity during winter months.