A drink equals how many cigarettes? Equating mortality risks from alcohol and tobacco use in Canada.

Objective: To quantify and communicate risk equivalencies for alcohol-and tobacco-attributable mortality by comparing per standard drinks consumed to per number of cigarettes smoked in Canada. Methods: Alcohol-and tobacco-attributable premature deaths (≤75 years of age) and years of life lost (YLL) were estimated using a lifetime risk modeling approach. Alcohol-attributable death statistics were obtained from the 2023 Canadian Guidance on Alcohol and Health data source. Tobacco-attributable death statistics were derived from the Mortality Population Risk Tool (MPoRT) model. Results: The risk of alcohol use on premature death and YLL increased non-linearly with the number of drinks consumed, while the risk for tobacco use on these two measures increased linearly with the number of cigarettes smoked. Males who consumed 5 drinks/day-a standard drink contains 13.45 grams of alcohol in Canada-had an equivalent risk as smoking 4.9 cigarettes/day (when modeling for premature death) and 5.1 cigarettes/day (when modeling for YLL). Females who consumed 5 drinks/day experienced an equivalent risk as smoking 4.2 cigarettes/day for premature deaths and YLL. At all levels of alcohol consumption females and males who consumed <5 drinks/day have less risks from consuming a standard drink than from smoking a cigarette. For males who consumed 5 drinks/day, the increased risks of death from per drink consumed and per cigarette smoked were equal. Conclusion: Risk equivalencies comparing alcohol use to tobacco use could help people who drink improve their knowledge and understanding of the mortality risks associated with increased number of drinks consumed per day.

Why do only some cohort studies find health benefits from low volume alcohol use? A systematic review and meta-analysis of study characteristics that may bias mortality risk estimates.

OBJECTIVE: Assumptions about alcohol's health benefits profoundly influence global disease burden estimates and drinking guidelines. Utilising theory and evidence, we identify and test study characteristics that may bias estimates of all-cause mortality risk associated with low volume drinking. METHOD: We identified 107 longitudinal studies by systematic review with 724 estimates of association between alcohol consumption and all-cause mortality for 4,838,825 participants with 425,564 recorded deaths. "Higher quality" studies had a mean cohort age of ≤55 years, followed-up beyond 55 years, and excluded former and occasional drinkers from abstainer reference groups. "Low volume" alcohol use was defined as between one drink per week (>1.30g ethanol/day) and two drinks per day (<25g ethanol/day). Mixed linear regression was used to model relative risks (RRs) of mortality for subgroups of higher versus lower quality studies. RESULTS: As predicted, studies with younger cohorts and separating former and occasional drinkers from abstainers estimated similar mortality risk for low volume drinkers (RR=0.98, 0.87-1.11) as abstainers. Studies not meeting these quality criteria estimated significantly lower risk for low volume drinkers (RR=0.84, 0.79-0.89). In exploratory analyses, studies controlling for smoking and/or socio-economic status had significantly reduced mortality risks for low volume drinkers. However, mean RR estimates for low volume drinkers in non-smoking cohorts were above 1.0 (RR=1.16, 0.91-1.41). CONCLUSIONS: Studies with lifetime selection biases may create misleading positive health associations. These biases pervade the field of alcohol epidemiology and can confuse communications about health risks. Future research should investigate whether smoking status mediates, moderates or confounds alcohol-mortality risk relationships.

A systematic review of relative risks for the relationship between chronic alcohol use and the occurrence of disease.

Alcohol use is causally linked to the development of and mortality from numerous diseases. The aim of this study is to provide an update to a previous systematic review of meta-analyses that quantify the sex-specific dose-response risk relationships between chronic alcohol use and disease occurrence and/or mortality. An updated systematic search of multiple databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to identify meta-analyses published from January 1, 2017, to March 8, 2021, which quantified the risk relationships between chronic alcohol use and the risk of disease occurrence and/or mortality. This systematic review was not preregistered. The comparator was people who have never consumed at least one standard drink of alcohol. Measurements included relative risks, odds ratios, and hazard ratios of disease occurrence and/or mortality based on long-term alcohol intake measured in grams per day. The systematic search yielded 5953 articles, of which 14 were included in the narrative review. All diseases showed an increased risk of occurrence as alcohol use increased. At all doses examined, alcohol had a significant detrimental effect on tuberculosis, lower respiratory infections, oral cavity and pharyngeal cancers, esophageal cancer, colorectal cancer, liver cancer, laryngeal cancer, epilepsy, hypertension, liver cirrhosis, and pancreatitis (among men). For ischemic heart disease, ischemic stroke, and intracerebral hemorrhage, protective effects from low-dose chronic alcohol use among both men and women were observed. Low-dose alcohol consumption also had a protective effect for diabetes mellitus and pancreatitis among women (approximately to 50 g/day and 30 g/day, respectively). Alcohol use increases the risk of numerous infectious and noncommunicable diseases in a dose-response manner. Higher levels of alcohol use have a clear detrimental impact on health; however, at lower levels of use, alcohol can have both disease-specific protective and detrimental effects.

Government Options to Reduce the Impact of Alcohol on Human Health: Obstacles to Effective Policy Implementation.

Evidence for effective government policies to reduce exposure to alcohol's carcinogenic and hepatoxic effects has strengthened in recent decades. Policies with the strongest evidence involve reducing the affordability, availability and cultural acceptability of alcohol. However, policies that reduce population consumption compete with powerful commercial vested interests. This paper draws on the Canadian Alcohol Policy Evaluation (CAPE), a formal assessment of effective government action on alcohol across Canadian jurisdictions. It also draws on alcohol policy case studies elsewhere involving attempts to introduce minimum unit pricing and cancer warning labels on alcohol containers. Canadian governments collectively received a failing grade (F) for alcohol policy implementation during the most recent CAPE assessment in 2017. However, had the best practices observed in any one jurisdiction been implemented consistently, Canada would have received an A grade. Resistance to effective alcohol policies is due to (1) lack of public awareness of both need and effectiveness, (2) a lack of government regulatory mechanisms to implement effective policies, (3) alcohol industry lobbying, and (4) a failure from the public health community to promote specific and feasible actions as opposed to general principles, e.g., 'increased prices' or 'reduced affordability'. There is enormous untapped potential in most countries for the implementation of proven strategies to reduce alcohol-related harm. While alcohol policies have weakened in many countries during the COVID-19 pandemic, societies may now also be more accepting of public health-inspired policies with proven effectiveness and potential economic benefits.

Use as directed: do standard drink labels on alcohol containers help consumers drink (ir)responsibly? Real-world evidence from a quasi-experimental study in Yukon, Canada.

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.

The burden of alcohol on health care during COVID-19.

Alcohol's impact on global health is substantial and of a similar order of magnitude to that from COVID-19. Alcohol now also poses specific concerns, such as increased risk of severe lung infections, domestic violence, child abuse, depression and suicide. Its use is unlikely to aid physical distancing or other preventative behavioural measures. Globally, alcohol contributes to 20% of injury and 11.5% of non-injury emergency room presentations. We provide some broad comparisons between alcohol-attributable and COVID-19-related hospitalisations and deaths in North America using most recent data. For example, for Canada in 2017 it was recently estimated there were 105 065 alcohol-attributable hospitalisations which represent a substantially higher rate over time than the 10 521 COVID-19 hospitalisations reported during the first 5 months of the pandemic. Despite the current importance of protecting health-care services, most governments have deemed alcohol sales to be as essential as food, fuel and pharmaceuticals. In many countries, alcohol is now more readily available and affordable than ever before, a situation global alcohol producers benefit from and have helped engineer. We argue that to protect frontline health-care services and public health more generally, it is essential that modest, evidence-based restrictions on alcohol prices, availability and marketing are introduced. In particular, we recommend increases in excise taxation coupled with minimum unit pricing to both reduce impacts on health-care services and provide much-needed revenues for governments at this critical time.

Does Drinking Within Low-Risk Guidelines Prevent Harm? Implications for High-Income Countries Using the International Model of Alcohol Harms and Policies.

OBJECTIVE: Many countries propose low-risk drinking guidelines (LRDGs) to mitigate alcohol-related harms. North American LRDGs are high by international standards. We applied the International Model of Alcohol Harms and Policies (InterMAHP) to quantify the alcohol-caused harms experienced by those drinking within and above these guidelines. We customized a recent Global Burden of Disease (GBD) analysis to inform guidelines in high-income countries. METHOD: Record-level death and hospital stay data for Canada were accessed. Alcohol exposure data were from the Canadian Substance Use Exposure Database. InterMAHP was used to estimate alcohol-attributable deaths and hospital stays experienced by people drinking within LRDGs, people drinking above LRDGs, and former drinkers. GBD relative risk functions were acquired and weighted by the distribution of Canadian mortality. RESULTS: More men (18%) than women (7%) drank above weekly guidelines. Adherence to guidelines did not eliminate alcohol-caused harm: those drinking within guidelines nonetheless experienced 140 more deaths and 3,663 more hospital stays than if they had chosen to abstain from alcohol. A weighted relative risk analysis found that, for both women and men, the risk was lowest at a consumption level of 10 g per day. For all levels of consumption, men were found to experience a higher weighted relative risk than women. CONCLUSIONS: Drinkers following weekly LRDGs are not insulated from harm. Greater than 50% of alcohol-caused cancer deaths are experienced by those drinking within weekly limits. Findings suggest that guidelines of around one drink per day may be appropriate for high-income countries.

The International Model of Alcohol Harms and Policies: A New Method for Estimating Alcohol Health Harms With Application to Alcohol-Attributable Mortality in Canada.

OBJECTIVE: Data regarding alcohol-caused health harms are required by policymakers for setting health priorities. However, these estimations are currently resource intensive, and estimates vary substantially by method. Thus, many countries, states, and regions do not track these harms. We address this limitation through creation of the International Model of Alcohol Harms and Policies (InterMAHP), an open-access alcohol harms estimator. InterMAHP consists of methodologies and program software designed to assist alcohol research teams in estimating alcohol-attributable mortality and morbidity, by region. It is available at www.intermahp.cisur.ca. Application is illustrated through updated estimates of alcohol-attributable mortality in Canada. METHOD: Mortality counts and per capita alcohol sales were obtained from Statistics Canada. Drinking and bingeing prevalences were obtained from the Canadian Substance Use Exposure Database. InterMAHP automated the calculations of alcohol-attributable fractions (AAF) using the modern AAF formulation and a gamma distribution to specify the continuous prevalence distribution of consumption. RESULTS: Alcohol is a leading driver of mortality in Canada. In 2016, more than 14,800 (95% CI [12,435, 17,127]) deaths were alcohol attributable, representing 5.5% of all deaths. This burden is borne disproportionately by men (79%). Among condition categories, cancer is the leading cause of alcohol-attributable mortality in both men and women. CONCLUSIONS: InterMAHP has the potential to assist public health researchers globally in estimating alcohol harms. This open-access software was used to estimate alcohol-attributable mortality in Canada, which was shown to be substantial. Policies proven to reduce alcohol consumption and related harms should be considered to reduce this burden.

Problematic substance use or problematic substance use policies? / Consommation problématique de substances ou politiques problématiques en la matière?

This special issue on substance use issues comes at a critical time for Canadian health policy makers and researchers. Most attention is currently focussed on the opioid crisis and the potential impacts of cannabis legalization. However, our most widely used and harmful substances continue to be alcohol and nicotine. Our policies to reduce harms from these substances are failing. While alcohol control policies are being gradually abandoned, opportunities to maximize the harm reduction potential of new, alternative and safer nicotine delivery devices are not being grasped. More generally, a greater focus is needed on harm reduction strategies that are informed by the experience of marginalized people with severe substance use-related problems so as to not exacerbate health inequities. In order to better inform policy responses, we recommend innovative approaches to monitoring and surveillance that maximize the use of multiple data sources, such as those used in the Canadian Substance Use Costs and Harms (CSUCH) project. Greater attention to precision in defining patterns of risky use and harms is also needed to support policies that more accurately reflect and respond to actual levels of substance use-related harm in Canadian society.

Substance use in Canada cost $46 billion in 2017, with the great majority of these costs resulting from the use of tobacco and alcohol. Substance use-related costs, harms and rates of use have been increasing in Canada over the past decades for both legal and illegal substances, including those for cannabis. Canadian policies to address our most harmful substances, i.e. alcohol, cannabis and tobacco, are largely failing, despite significant opportunities to improve policies on pricing, taxation and marketing of legal substances. Canada's monitoring and surveillance efforts can be improved by developing more discerning measures of risk and maximizing the use of multiple data sources.

Au Canada, la consommation de substances a coûté 46 milliards de dollars en 2017, la grande majorité de ces coûts découlant du tabagisme et de la consommation d'alcool. Au Canada, les taux de consommation de substances ainsi que les coûts et les méfaits connexes ont augmenté au cours des dernières décennies, que ce soit pour les substances légales ou illégales, en particulier le cannabis. Les politiques canadiennes en matière de lutte contre la consommation des substances les plus nocives, soit l'alcool, le cannabis et le tabac, sont en grande partie inefficaces, malgré d'importantes possibilités d'amélioration en matière de tarification, de taxation et de commercialisation des substances légales. Il est possible d'améliorer les efforts de contrôle et de surveillance au Canada en élaborant des mesures de risque bien pensées et en maximisant l'utilisation de multiples sources de données.

The Effects of Alcohol Warning Labels on Population Alcohol Consumption: An Interrupted Time Series Analysis of Alcohol Sales in Yukon, Canada.

OBJECTIVE: There is limited evidence that alcohol warning labels (AWLs) affect population alcohol consumption. New evidence-informed AWLs were introduced in the sole government-run liquor store in Whitehorse, Yukon, that included a cancer warning (Ca), low-risk drinking guidelines (LRDGs) and standard drink (SD) messages. These temporarily replaced previous pregnancy warning labels. We test if the intervention was associated with reduced alcohol consumption. METHOD: An interrupted time series study was designed to evaluate the effects of the AWLs on consumption for 28 months before and 14 months after starting the intervention. Neighboring regions of Yukon and Northwest Territories served as control sites. About 300,000 labels were applied to 98% of alcohol containers sold in Whitehorse during the intervention. Multilevel regression analyses of per capita alcohol sales data for people age 15 years and older were performed to examine consumption levels in the intervention and control sites before, during, and after the AWLs were introduced. Models were adjusted for demographic and economic characteristics over time and region. RESULTS: Total per capita retail alcohol sales in Whitehorse decreased by 6.31% (t test p < .001) during the intervention. Per capita sales of labeled products decreased by 6.59% (t test p < .001), whereas sales of unlabeled products increased by 6.91% (t test p < .05). There was a still larger reduction occurring after the intervention when pregnancy warning labels were reintroduced (-9.97% and -10.29%, t test p < .001). CONCLUSIONS: Applying new AWLs was associated with reduced population alcohol consumption. The results are consistent with an accumulating impact of the addition of varying and highly visible labels with impactful messages.

Baseline Assessment of Alcohol-Related Knowledge of and Support for Alcohol Warning Labels Among Alcohol Consumers in Northern Canada and Associations With Key Sociodemographic Characteristics.

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.

Testing Alcohol Labels as a Tool to Communicate Cancer Risk to Drinkers: A Real-World Quasi-Experimental Study.

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.

Examining the Impact of Alcohol Labels on Awareness and Knowledge of National Drinking Guidelines: A Real-World Study in Yukon, Canada.

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.

News Media and the Influence of the Alcohol Industry: An Analysis of Media Coverage of Alcohol Warning Labels With a Cancer Message in Canada and Ireland.

OBJECTIVE: Media coverage of alcohol-related policy measures can influence public debate and is often more aligned with interests of the alcohol industry than public health. The purpose of this study was to examine the framing of news coverage of alcohol warning label (AWL) initiatives that included a cancer message on alcohol containers in two different countries. Policy contexts and industry perspectives were also evaluated. METHOD: We identified and systematically reviewed news articles published between 2017-2019 covering an AWL academic study in Yukon, Canada, and labeling provisions in a Public Health (Alcohol) Bill in Ireland. Both included a cancer message. News stories were coded for media type and topic slant; inclusion of alcohol industry perspectives was examined using content analysis. RESULTS: Overall, 68.4% of media articles covering the Yukon Study (n = 38) and 18.9% covering the Ireland Bill (n = 37) were supportive of AWLs with a cancer message. The majority of articles in both sites presented alcohol industry perspectives (Yukon, 65.8%; Ireland, 86.5%), and industry arguments opposing AWLs were similar across both contexts. In articles with statements from industry representatives, the label message was frequently disputed by distorting or denying the evidence that alcohol causes cancer (n = 33/43). CONCLUSIONS: News coverage of AWLs with a cancer message was more supportive in Canada than Ireland, where alcohol industry perspectives were consistently foregrounded. Industry arguments opposing the cancer label bore similarities across contexts, often distorting or denying the evidence. Increasing awareness of industry messaging strategies may generate more critical coverage of industry lobbying activities and increase public support for alcohol policies.

Cancer Warning Labels on Alcohol Containers: A Consumer's Right to Know, a Government's Responsibility to Inform, and an Industry's Power to Thwart.

OBJECTIVE: Although the World Health Organization (WHO) declared alcohol a Class 1 carcinogen 30 years ago, few governments have communicated this fact to the public. We illustrate how alcohol industry groups seek to keep their customers in the dark about alcohol-related cancer risks. In Canada, a federally funded scientific study examining the introduction of cancer warning labels on containers was shut down following industry interference. We show that the industry complaints about the study had no legal merit. Of 47 WHO member countries with alcohol warning labels, only South Korea requires cancer warnings on alcohol containers. However, industry complaints, supported by sympathetic governments, helped weaken the warning labels' implementation. Ireland has legislated for cancer warnings but faces continuing legal opposition expressed through regional and global bodies. Cancer societies and the public health community have failed to counter industry pressures to minimize consumer awareness of alcohol's cancer risks. Placing cancer warnings on alcohol containers could make a pivotal difference in motivating both drinkers to consume less and regulators to introduce more effective policies to reduce the serious harms of alcohol consumption.

Communicating risks to drinkers: testing alcohol labels with a cancer warning and national drinking guidelines in Canada.

OBJECTIVE: To test whether alcohol labels with a cancer warning and national drinking guidelines are an effective tool for supporting more informed and safer alcohol consumption among drinkers. METHODS: Using a quasi-experimental design, pre-post surveys were conducted with 1647 cohort participants systematically selected in liquor stores in two matched sites in Canada in 2017-2018. Enhanced labels designed according to best practices for effective product labels were applied to alcohol containers in the liquor store in the intervention site for one month, and usual practice continued in the comparison site. Generalized estimating equations tested the differences between sites over time in label salience and processing, and self-reported impact of the labels on drinking behaviours. RESULTS: After the intervention, recall of the cancer warning label increased to a greater extent in the intervention versus comparison site (adjusted odds ratio (AOR) = 32.2, 95% CI = 5.4, 191.1), but not the national drinking guideline label (AOR = 2.7, 95% CI = 0.2, 31.8). There were significant label effects in the intervention versus comparison site for reading (AOR = 1.8, 95% CI = 1.3, 2.5), thinking about (AOR = 2.0, 95% CI = 1.4, 2.9), and talking with others about (AOR = 2.1, 95% CI = 1.3, 3.6) the labels, as well as self-reported impact to cut down on drinking (AOR = 2.5, 95% CI = 1.3, 4.7) and to drink less (AOR = 2.4, 95% CI = 1.3, 4.3). CONCLUSIONS: Alcohol labels with a cancer warning and national drinking guidelines do a better job conveying risk information and promoting safer consumption than existing practices. Industry has a legal duty to adequately inform consumers about their products and should be mandated to include key information on alcohol containers.

Effects of strengthening alcohol labels on attention, message processing, and perceived effectiveness: A quasi-experimental study in Yukon, Canada.

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.

Improving Knowledge that Alcohol Can Cause Cancer is Associated with Consumer Support for Alcohol Policies: Findings from a Real-World Alcohol Labelling Study.

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.

Estimation of the impacts of substance use on workplace productivity: a hybrid human capital and prevalence-based approach applied to Canada.

OBJECTIVE: Policy makers require evidence-based estimates of the economic costs of substance use-attributable lost productivity to set strategies aimed at reducing substance use-related harms. Building on a study by Rehm et al. (2006), we provide estimates of workplace costs using updated methods and data sources. METHODS: We estimated substance use-attributable productivity losses due to premature mortality, long-term disability, and presenteeism/absenteeism in Canada between 2007 and 2014. Lost productivity was estimated using a hybrid prevalence and incidence approach. Substance use prevalence data were drawn from three national self-report surveys. Premature mortality data were from the Canadian Vital Statistics Death Database, and long-term disability and workplace interference data were from the Canadian Community Health Survey. RESULTS: In 2014, the total cost of lost productivity due to substance use was $15.7 billion, or approximately $440 per Canadian, an increase of 8% from 2007. Substances responsible for the greatest economic costs were alcohol (38% of per capita costs), tobacco (37%), opioids (12%), other central nervous system (CNS) depressants (4%), other CNS stimulants (3%), cannabis (2%), cocaine (2%), and finally other psychoactive substances (2%). CONCLUSION: In 2014, alcohol and tobacco represent three quarters of substance use-related lost productivity costs in Canada, followed by opioids. These costs provide a valuable baseline that can be used to assess the impact of future substance use policy, practice, and other interventions, especially important given Canada's opioid crisis and recent cannabis legalization.

Calorie Intake from Alcohol in Canada: Why New Labelling Requirements are Necessary.

We estimated calorie intake from alcohol in Canada, overall and by gender, age, and province, and provide evidence to advocate for mandatory alcohol labelling requirements. Annual per capita (aged 15+) alcohol sales data in litres of pure ethanol by beverage type were taken from Statistics Canada's CANSIM database and converted into calories. The apportionment of consumption by gender, age, and province was based on data from the Canadian Tobacco, Alcohol and Drug Survey. Estimated energy requirements (EER) were from Canada's Food Guide. The average drinker consumed 250 calories, or 11.2% of their daily EER in the form of alcohol, with men (13.3%) consuming a higher proportion of their EER from alcohol than women (8.2%). Drinkers consumed more than one-tenth of their EER from alcohol in all but one province. By beverage type, beer contributes 52.7% of all calories derived from alcohol, while wine (20.8%); spirits (19.8%); and ciders, coolers, and other alcohol (6.7%) also contribute substantially. The substantial caloric impact of alcoholic drinks in the Canadian diet suggests that the addition of caloric labelling on these drinks is a necessary step.