An assessment of federal alcohol policies in Canada and priority recommendations: Results from the 3rd Canadian Alcohol Policy Evaluation Project.

OBJECTIVE: To systematically assess the Canadian federal government's current alcohol policies in relation to public health best practices. METHODS: The 2022 Canadian Alcohol Policy Evaluation (CAPE) Project assessed federal alcohol policies across 10 domains. Policy domains were weighted according to evidence for their relative impact, including effectiveness and scope. A detailed scoring rubric of best practices was developed and externally reviewed by international experts. Policy data were collected between June and December 2022, using official legislation, government websites, and data sources identified from previous iterations of CAPE as sources. Contacts within relevant government departments provided any additional data sources, reviewed the accuracy and completeness of the data, and provided amendments as needed. Data were scored independently by members of the research team. Final policy scores were tabulated and presented as a weighted overall average score and as unweighted domain-specific scores. RESULTS: Compared to public health best practices, the federal government of Canada scored 37% overall. The three most impactful domains-(1) pricing and taxation, (2) marketing and advertising controls, and (3) impaired driving countermeasures-received some of the lowest scores (39%, 10%, and 40%, respectively). Domain-specific scores varied considerably from 0% for minimum legal age policies to 100% for controls on physical availability of alcohol. CONCLUSION: Many evidence-informed alcohol policies have not been adopted, or been adopted only partially, by the Canadian federal government. Urgent adoption of the recommended policies is needed to prevent and reduce the enormous health, social, and economic costs of alcohol use in Canada.

RéSUMé: OBJECTIF: Évaluer de manière systématique les politiques sur l'alcool actuelles du gouvernement fédéral canadien dans le cadre de pratiques de santé publique exemplaires. MéTHODES: Le projet de l'Évaluation des politiques canadiennes sur l'alcool 2022 a évalué les politiques fédérales sur l'alcool dans dix domaines. Ces domaines de politiques ont été pondérés en fonction de preuves sur leurs répercussions relatives, notamment leur efficacité et leur portée. Une échelle d'évaluation descriptive détaillée de pratiques exemplaires a été élaborée et examinée à l'externe. Entre juin et décembre 2022, des données sur les politiques ont été recueillies dans la législation officielle, sur des sites Web du gouvernement et au moyen de sources identifiées comme telles au cours des itérations précédentes du projet de l'Évaluation des politiques canadiennes sur l'alcool. Des personnes-ressources au sein des ministères concernés ont communiqué d'autres sources de données, examiné l'exactitude et le caractère exhaustif de ces données et apporté les modifications nécessaires. Les données ont été évaluées indépendamment par des membres de l'équipe de recherche. Les scores de politiques finaux ont été inscrits dans des tableaux et présentés sous forme d'une moyenne générale pondérée et de scores non pondérés par domaine. RéSULTATS: Comparativement aux pratiques de santé publique exemplaire, le gouvernement fédéral du Canada a obtenu un score général de 37 %. Les trois domaines susceptibles d'avoir les plus grandes répercussions, à savoir 1) la fixation des prix et la taxation, 2) le contrôle du marketing et de la publicité, et 3) les mesures contre la conduite avec facultés affaiblies, se sont vu attribuer parmi les scores les plus bas (39 %, 10 %, et 40 % respectivement). Les scores par domaine variaient considérablement, allant de 0 % pour les politiques sur l'âge minimum légal à 100 % pour le contrôle de la disponibilité physique de l'alcool. CONCLUSION: De nombreuses politiques sur l'alcool reposant sur des preuves n'ont pas été adoptées, ou l'ont été seulement partiellement, par le gouvernement fédéral canadien. Il est urgent d'appliquer les politiques recommandées pour prévenir et réduire les énormes coûts sanitaires, sociaux et économiques de la consommation d'alcool au Canada.

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.

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.

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.

On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement.

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness.

Community managed alcohol programs in Canada: Overview of key dimensions and implementation.

INTRODUCTION AND AIMS: People with severe alcohol dependence and unstable housing are vulnerable to multiple harms related to drinking and homelessness. Managed Alcohol Programs (MAP) aim to reduce harms of severe alcohol use without expecting cessation of use. There is promising evidence that MAPs reduce acute and social harms associated with alcohol dependence. The aim of this paper is to describe MAPs in Canada including key dimensions and implementation issues. DESIGN AND METHODS: Thirteen Canadian MAPs were identified through the Canadian Managed Alcohol Program Study. Nine key informant interviews were conducted and analysed alongside program documents and reports to create individual case reports. Inductive content analysis and cross case comparisons were employed to identify six key dimensions of MAPs. RESULTS: Community based MAPs have a common goal of preserving dignity and reducing harms of drinking while increasing access to housing, health and social services. MAPs are offered as both residential and day programs with differences in six key dimensions including program goals and eligibility, food and accomodation, alcohol dispensing and administration, funding and money management, primary care services and clinical monitoring, and social and cultural connections. DISCUSSION AND CONCLUSIONS: MAPs consist of four pillars with the alcohol intervention provided alongside housing interventions, primary care services, social and cultural interventions. Availability of permanent housing and re-establishing social and cultural connections are central to recovery and healing goals of MAPs. Additional research regarding Indigenous and gendered approaches to program development as well as outcomes related to chronic harms and differences in alcohol management are needed.

How do people with homelessness and alcohol dependence cope when alcohol is unaffordable? A comparison of residents of Canadian managed alcohol programs and locally recruited controls.

INTRODUCTION AND AIMS: We investigated coping strategies used by alcohol-dependent and unstably housed people when they could not afford alcohol, and how managed alcohol program (MAP) participation influenced these. The aim of this study was to investigate potential negative unintended consequences of alcohol being unaffordable. DESIGN AND METHODS: A total of 175 MAP residents in five Canadian cities and 189 control participants from nearby shelters were interviewed about the frequency they used 10 coping strategies when unable to afford alcohol. Length of stay in a MAP was examined as a predictor of negative coping while controlling for age, sex, ethnicity, housing stability, spending money and drinks per day. Multivariate binary logistic and linear regression models were used. RESULTS: Most commonly reported strategies were re-budgeting (53%), waiting for money (49%) or going without alcohol (48%). A significant proportion used illicit drugs (41%) and/or drank non-beverage alcohol (41%). Stealing alcohol or property was less common. Long-term MAP participants (>2 months) exhibited lower negative coping scores than controls (8.76 vs. 10.63, P < 0.001) and were less likely to use illicit drugs [odds ratio (OR) 0.50, P = 0.02], steal from liquor stores (OR 0.50, P = 0.04), re-budget (OR 0.36, P < 0.001) or steal property (OR 0.40, P = 0.07). Long-term MAP participants were also more likely to seek treatment (OR 1.91, P = 0.03) and less likely to go without alcohol (OR 0.47, P = 0.01). DISCUSSION AND CONCLUSIONS: People experiencing alcohol dependence and housing instability more often reduced their alcohol consumption than used harmful coping when alcohol was unaffordable. MAP participation was associated with fewer potentially harmful coping strategies.

Testing the Efficacy of Alcohol Labels with Standard Drink Information and National Drinking Guidelines on Consumers' Ability to Estimate Alcohol Consumption.

AIMS: Despite the introduction of national drinking guidelines in Canada, there is limited public knowledge of them and low understanding of 'standard drinks (SDs)' which limits the likelihood of guidelines affecting drinking behaviour. This study tests the efficacy of alcohol labels with SD information and Canada's Low-Risk Drinking Guidelines (LRDGs) as compared to %ABV labels on consumers' ability to estimate alcohol intake. It also examines the label size and format that best supports adults' ability to make informed drinking choices. METHODS: This research consisted of a between-groups experiment (n = 2016) in which participants each viewed one of six labels. Using an online survey, participants viewed an alcohol label and were asked to estimate: (a) the amount in a SD; (b) the number of SDs in an alcohol container and (c) the number of SDs to consume to reach the recommended daily limit in Canada's LRDG. RESULTS: Results indicated that labels with SD and LRDG information facilitated more accurate estimates of alcohol consumption and awareness of safer drinking limits across different beverage types (12.6% to 58.9% increase in accuracy), and labels were strongly supported among the majority (66.2%) of participants. CONCLUSION: Labels with SD and LRDG information constitute a more efficacious means of supporting accurate estimates of alcohol consumption than %ABV labels, and provide evidence to inform potential changes to alcohol labelling regulations. Further research testing labels in real-world settings is needed. SHORT SUMMARY: Results indicate that the introduction of enhanced alcohol labels combining standard drink information and national drinking guidelines may be an effective way to improve drinkers' ability to accurately assess alcohol consumption and monitor intake relative to guidelines. Overall support for enhanced labels suggests probable acceptability of introduction at a population level.

Pricing of alcohol in Canada: A comparison of provincial policies and harm-reduction opportunities.

INTRODUCTION AND AIMS: Alcohol pricing is an effective prevention policy. This paper compares the 10 Canadian provinces on three research-based alcohol pricing policies-minimum pricing, pricing by alcohol content and maintaining prices relative to inflation. DESIGN AND METHODS: The selection of these three policies was based on systematic reviews and seminal research papers. Provincial data for 2012 were obtained from Statistics Canada and relevant provincial ministries, subsequently sent to provincial authorities for verification, and then scored by team members. RESULTS: All provinces, except for Alberta, have minimum prices for at least one beverage type sold in off-premise outlets. All provinces, except for British Columbia and Quebec, have separate (and higher) minimum pricing for on-premise establishments. Regarding pricing on alcohol content, western and central provinces typically scored higher than provinces in Eastern Canada. Generally, minimum prices were lower than the recommended $1.50 per standard drink for off-premise outlets and $3.00 per standard drink in on-premise venues. Seven of 10 provinces scored 60% or higher compared to the ideal on indexing prices to inflation. Prices for a representative basket of alcohol products in Ontario and Quebec have lagged significantly behind inflation since 2006. DISCUSSION AND CONCLUSIONS: While examples of evidence-based alcohol pricing policies can be found in every jurisdiction in Canada, significant inter-provincial variation leaves substantial unrealised potential for further reducing alcohol-related harm and costs. This comparative assessment of alcohol price policies provides clear indications of how individual provinces could adjust their pricing policies and practices to improve public health and safety. [Giesbrecht N, Wettlaufer A, Thomas G, Stockwell T, Thompson K, April N, Asbridge M, Cukier S, Mann R, McAllister J, Murie A, Pauley C, Plamondon L, Vallance K. Pricing of alcohol in Canada: A comparison of provincial policies and harm-reduction opportunities. Drug Alcohol Rev 2016;35:289-297].

Minimum alcohol prices and outlet densities in British Columbia, Canada: estimated impacts on alcohol-attributable hospital admissions.

OBJECTIVES: We investigated whether periodic increases in minimum alcohol prices were associated with reduced alcohol-attributable hospital admissions in British Columbia. METHODS: The longitudinal panel study (2002-2009) incorporated minimum alcohol prices, density of alcohol outlets, and age- and gender-standardized rates of acute, chronic, and 100% alcohol-attributable admissions. We applied mixed-method regression models to data from 89 geographic areas of British Columbia across 32 time periods, adjusting for spatial and temporal autocorrelation, moving average effects, season, and a range of economic and social variables. RESULTS: A 10% increase in the average minimum price of all alcoholic beverages was associated with an 8.95% decrease in acute alcohol-attributable admissions and a 9.22% reduction in chronic alcohol-attributable admissions 2 years later. A Can$ 0.10 increase in average minimum price would prevent 166 acute admissions in the 1st year and 275 chronic admissions 2 years later. We also estimated significant, though smaller, adverse impacts of increased private liquor store density on hospital admission rates for all types of alcohol-attributable admissions. CONCLUSIONS: Significant health benefits were observed when minimum alcohol prices in British Columbia were increased. By contrast, adverse health outcomes were associated with an expansion of private liquor stores.

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

AIM: To investigate relationships between periodic increases in minimum alcohol prices, changing densities of liquor stores and alcohol-attributable (AA) deaths in British Columbia, Canada. DESIGN: Cross-section (16 geographic areas) versus time-series (32 annual quarters) panel analyses were conducted with AA deaths as dependent variables and price, outlet densities and socio-demographic characteristics as independent variables. SETTING AND PARTICIPANTS: Populations of 16 Health Service Delivery Areas in British Columbia, Canada. MEASUREMENTS: Age-sex-standardized rates of acute, chronic and wholly AA mortality; population densities of restaurants, bars, government and private liquor stores; minimum prices of alcohol in dollars per standard drink. FINDINGS: A 10% increase in average minimum price for all alcoholic beverages was associated with a 31.72% [95% confidence interval (CI): ± 25.73%, P < 0.05] reduction in wholly AA deaths. Significantly negative lagged associations were also detected up to 12 months after minimum price increases for wholly but not for acute or chronic AA deaths. Significant reductions in chronic and total AA deaths were detected between 2 and 3 years after minimum price increases. Significant but inconsistent lagged associations were detected for acute AA deaths. A 10% increase in private liquor stores was associated with a 2.45% (95% CI: ± 2.39%, P < 0.05), 2.36% (95% CI: ± 1.57%, P < 0.05) and 1.99% (95% CI: ± 1.76%, P < 0.05) increase in acute, chronic and total AA mortality rates. CONCLUSION: Increases in the minimum price of alcohol in British Columbia, Canada, between 2002 and 2009 were associated with immediate and delayed decreases in alcohol-attributable mortality. By contrast, increases in the density of private liquor stores were associated with increases in alcohol-attributable mortality.

Courtesy stigma: a hidden health concern among front-line service providers to sex workers.

Courtesy stigma, also referred to as 'stigma by association', involves public disapproval evoked as a consequence of associating with a stigmatised individual or group. While a small number of sociological studies have shown how courtesy stigma limits the social support and social opportunities available to family members of stigmatised individuals, there is a paucity of research examining courtesy stigma among the large network of people who provide health and social services to stigmatised groups. This article presents results from a mixed methods study of the workplace experiences of a purposive sample of workers in a non-profit organisation providing services to sex workers in Canada. The findings demonstrate that courtesy stigma plays a role in workplace health as it shapes both the workplace environment, including the range of resources made available to staff to carry out their work activities, as well as staff perceptions of others' support. At the same time, it was evident that some workers were more vulnerable to courtesy stigma than others depending on their social location. We discuss these results in light of the existing literature on courtesy stigma and conclude that it is an under-studied determinant of workplace health among care providers serving socially denigrated groups.

Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: a local area multi-level analysis.

AIMS: 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. DESIGN: Multi-level regression analyses assessed the relationship between population rates of private liquor stores and alcohol-related mortality after adjusting for potential confounding. SETTING: The 89 local health areas of BC, Canada across a 6-year period from 2003 to 2008, for a longitudinal sample with n = 534. MEASUREMENTS: Population rates of liquor store density, alcohol-related death and socio-economic variables obtained from government sources. FINDINGS: 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. CONCLUSIONS: 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.