Participation in Canadian Managed Alcohol Programs and Associated Probabilities of Emergency Room Presentation, Hospitalization and Death: A Retrospective Cohort Study.

INTRODUCTION: Managed Alcohol Programs (MAPs) are designed to improve health and housing outcomes for unstably housed people with an alcohol use disorder (AUD). The present study assesses the association of MAP participation with healthcare and mortality outcomes. METHODS: A retrospective cohort study assessed health outcomes for 205 MAP participants and 128 controls recruited from five Canadian cities in 2006-2017. Survival and negative binomial regression models were used to calculate hazard ratios (HR) of death and emergency room (ER) visits and hospital bed days (HBDs). Covariates included age, sex, AUD severity and housing stability score. RESULTS: In fully adjusted models, compared with times outside MAPs, participants had significantly reduced risk of mortality (HR = 0.37, P = 0.0001) and ER attendance (HR = 0.74, P = 0.0002), and fewer HBDs yearly (10.40 vs 20.08, P = 0.0184). Over the 12 years, people enrolled in a MAP at some point had significantly fewer HBDs per year than controls after MAP enrolment (12.78 vs 20.08, P = 0.0001) but not significantly different rates of death or ER presentation. MAP participants had significantly more alcohol-related but significantly fewer nonalcohol-related ER presentations than controls. CONCLUSION: Attendance at a MAP was associated with reduced risk of mortality or morbidity and less hospital utilization for individuals with unstable housing and severe AUDs. MAPs are a promising approach to reduce mortality risk and time spent in hospital for people with an AUD and experiencing homelessness.

"If I knew I could get that every hour instead of alcohol, I would take the cannabis": need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs.

BACKGROUND: While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool. METHODS: To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis. RESULTS: Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation. CONCLUSION: Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

Impact of exposure to alcohol marketing and subsequent drinking patterns among youth and young adults.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the impact of exposure to any form of alcohol marketing, compared to less exposure or no exposure, on alcohol consumption patterns among youth and young adults up to and including the age of 25 years (we want to be able to look at potential dose response relationships at different levels of exposure).

Can a Label Help me Drink in Moderation? A Review of the Evidence on Standard Drink Labelling.

INTRODUCTION: Understanding the concept of a standard drink (SD) is foundational knowledge to many public health policies aimed at reducing alcohol-related harms. These policies include adhering to low-risk drinking guidelines, screening brief intervention and referral activities, and counter alcohol-impaired driving initiatives. A lack of awareness of SDs might preclude the effectiveness of these interventions. A systematic review was conducted to review the evidence about how effective alcohol labels are in communicating SD information to the consumer. METHODS: A systematic review was conducted to identify peer-reviewed articles and grey literature from relevant indexes from January 1990 to January 2016. Additionally, policy makers and researchers in countries where standard drink labels (SDLs) have been implemented were consulted to help identify relevant literature. The search strategy was focused on the impact of SDLs relative to a range of outcomes, including awareness of SDs, pouring behaviors, and consumption patterns. RESULTS: Eleven records were eligible for inclusion. The evidence suggests that knowledge of the definition of an SD is low. However, SDLs can help individuals more accurately identify and pour an SD. SDLs need to be supported by educational initiatives to help the consumer understand the SD information provided on the beverage container. To date, there has been no comprehensive evaluation of the impact of SDLs. CONCLUSIONS: SDLs have the potential to increase awareness of SDs and facilitate the monitoring of personal alcohol consumption in the context of a comprehensive alcohol strategy. However, their impact on drinking behaviors requires further exploration, especially among high-risk populations.

Comparing Alcohol Marketing and Alcohol Warning Message Policies Across Canada.

BACKGROUND: In order to reduce harms from alcohol, evidence-based policies are to be introduced and sustained. OBJECTIVES: To facilitate the dissemination of policies that reduce alcohol-related harms by documenting, comparing, and sharing information on effective alcohol polices related to restrictions on alcohol marketing and alcohol warning messaging in 10 Canadian provinces. METHODS: Team members developed measurable indicators to assess policies on (a) restrictions on alcohol marketing, and (b) alcohol warning messaging. Indicators were peer-reviewed by three alcohol policy experts, refined, and data were collected, submitted for validation by provincial experts, and scored independently by two team members. RESULTS: The national average score was 52% for restrictions on marketing policies and 18% for alcohol warning message policies. Most provinces had marketing regulations that went beyond the federal guidelines with penalties for violating marketing regulations. The provincial liquor boards' web pages focused on product promotion, and there were few restrictions on sponsorship activities. No province has implemented alcohol warning labels, and Ontario was the sole province to have legislated warning signs at all points-of-sale. Most provinces provided a variety of warning signs to be displayed voluntarily at points-of-sale; however, the quality of messages varied. Conclusions/Importance: There is extensive alcohol marketing with comparatively few messages focused on the potential harms associated with alcohol. It is recommended that governments collaborate with multiple stakeholders to maximize the preventive impact of restrictions on alcohol marketing and advertising, and a broader implementation of alcohol warning messages.

Alcohol, No Ordinary Commodity: policy implications for Canada.

Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity, and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it.

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.

Why Canadians deserve to have mandated health and standard drink information labels on alcohol containers.

To reduce deaths, morbidity, and social problems from alcohol in Canada, a multi-dimensional robust response is needed, including a comprehensive alcohol control strategy at the provincial, territorial, and federal levels. Alcohol container labels with health and standard drink information are an essential component of this strategy. This commentary provides a rationale for the mandatory labelling of all alcohol products, summarizes Canadian initiatives to date to legislate alcohol container warning labels, and addresses myths and misconceptions about labels. Canadians deserve direct, accessible information about (1) the inherent health risks associated with alcohol consumption, (2) the number of standard drinks per container and volume of a standard drink, and (3) guidance for preventing or reducing consumption-related health risks. Enhanced health labels on alcohol containers are long overdue.

RéSUMé: Pour réduire les décès, la morbidité et les problèmes sociaux causés par l'alcool au Canada, il est nécessaire de réagir vigoureusement et de manière multidimensionnelle, notamment avec une stratégie globale de mesures de contrôle de la part des gouvernements provinciaux, territoriaux et fédéral. Des étiquettes sur les contenants d'alcool comportant des informations sur la santé et sur ce qui constitue un verre standard sont un élément important et essentiel de cette stratégie. Cette analyse explique les raisons justifiant l'étiquetage obligatoire de tous les produits alcoolisés, résume les initiatives à ce jour pour établir des lois sur les étiquettes de mise en garde sur les contenants d'alcool et réfute les mythes et les idées fausses sur ces étiquettes. Les Canadiens ont le droit d'être informés directement et de manière accessible sur 1) les risques pour leur santé inhérents à la consommation d'alcool, 2) le nombre de verres standards par contenant, et le volume d'un verre standard, et 3) les recommandations pour prévenir et réduire les risques liés à cette consommation. Nous n'avons que trop attendu pour apposer des étiquettes de mise en garde sur la santé sur les contenants d'alcool.

The raising of minimum alcohol prices in Saskatchewan, Canada: impacts on consumption and implications for public health.

OBJECTIVES: We report impacts on alcohol consumption following new and increased minimum alcohol prices in Saskatchewan, Canada. METHODS: We conducted autoregressive integrated moving average time series analyses of alcohol sales and price data from the Saskatchewan government alcohol monopoly for 26 periods before and 26 periods after the intervention. RESULTS: A 10% increase in minimum prices significantly reduced consumption of beer by 10.06%, spirits by 5.87%, wine by 4.58%, and all beverages combined by 8.43%. Consumption of coolers decreased significantly by 13.2%, cocktails by 21.3%, and liqueurs by 5.3%. There were larger effects for purely off-premise sales (e.g., liquor stores) than for primarily on-premise sales (e.g., bars, restaurants). Consumption of higher strength beer and wine declined the most. A 10% increase in minimum price was associated with a 22.0% decrease in consumption of higher strength beer (> 6.5% alcohol/volume) versus 8.17% for lower strength beers. The neighboring province of Alberta showed no change in per capita alcohol consumption before and after the intervention. CONCLUSIONS: Minimum pricing is a promising strategy for reducing the public health burden associated with hazardous alcohol consumption. Pricing to reflect percentage alcohol content of drinks can shift consumption toward lower alcohol content beverage types.

Strategies for engaging policy stakeholders to translate research knowledge into practice more effectively: Lessons learned from the Canadian Alcohol Policy Evaluation project.

INTRODUCTION: Evidence-based alcohol policies have the potential to reduce a wide range of related harms. Yet, barriers to adoption and implementation within governments often exist. Engaging relevant stakeholders may be an effective way to identify and address potential challenges thereby increasing reach and uptake of policy evaluation research and strengthening jurisdictional responses to alcohol harms. METHODS: As part of the 2019 Canadian Alcohol Policy Evaluation project, we conducted interviews with government stakeholders across alcohol-related sectors prior to a second round of researcher-led policy assessments in Canada's 13 provinces and territories. Stakeholders were asked for feedback on the design and impact of an earlier policy assessment in 2013 and for recommendations to improve the design and dissemination strategy for the next iteration. Content analysis was used to identify ways of improving stakeholder engagement. RESULTS: We interviewed 25 stakeholders across 12 of Canada's 13 jurisdictions, including representatives from government health ministries and from alcohol regulation, distribution and finance departments. In providing feedback on our stakeholder engagement strategy, participants highlighted the importance of maintaining ongoing contact; presenting results in accessible online formats; providing advance notice of results; and offering jurisdiction-specific webinars. DISCUSSION AND CONCLUSIONS: This study offers important insight into the engagement preferences of government stakeholders involved in the health, regulation, distribution and financial aspects of alcohol control policy. Findings suggest that seeking input from stakeholders as part of conducting evaluation research is warranted; increasing the relevance, reach and uptake of results. Specific stakeholder engagement strategies are outlined.

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.

A systematic comparison of the global comparative risk assessments for alcohol.

AIMS: To compare systematically the alcohol-attributable mortality and burden of disease estimates for 2016 from a recent study by Shield and colleagues and the Global Burden of Disease study 2017 (GBD). METHOD: This study compared estimates of alcohol-attributable mortality and disability adjusted life years (DALYs) lost for 2016 with regards to absolute and relative differences, by region and by cause of disease or injury. Relative differences between the two studies are reported herein as percentage (%) differences. A difference of 10% or more was considered meaningful. RESULTS: The studies estimated similar global levels of overall alcohol-attributable mortality for 2016 (Shield and colleagues estimated 5.1% more alcohol-attributable mortality than the GBD study) but not alcohol-attributable DALYs lost (18.3% difference). There were marked differences by region and cause of disease or injury. Compared with the results from Shield and colleagues, the GBD study estimated a lower alcohol-attributable burden in Eastern Europe by 252 770 alcohol-attributable deaths (45.2% difference) and 6.1 million alcohol-attributable DALYs lost (32.9% difference) and in Western sub-Saharan Africa by 124 200 alcohol-attributable deaths (55.7% difference) and 7.0 million alcohol-attributable DALYs lost (63.4% difference), and estimated a higher alcohol-attributable burden in East Asia by 227 100 alcohol-attributable deaths (48.0% difference) and 2.2 million DALYs lost (11.0% difference). With regard to the cause of disease or injury, Shield and colleagues attributed an overall detrimental effect to alcohol on ischaemic heart disease mortality, whereas the GBD study attributed a net beneficial effect. The GBD study, as compared with Shield and colleagues' study, estimated a lower alcohol-attributable mortality because of liver cirrhosis and injuries by 262 500 (44.6% difference) and 398 800 (46.2% difference), respectively. CONCLUSIONS: Differences in estimates of the alcohol-attributable burden of disease in two recent studies indicate the need to improve the accuracy of underlying data and risk relations to obtain more consistent estimates and to formulate, advocate for, and implement alcohol policies more effectively.

The Global Impact of Alcohol Consumption on Premature Mortality and Health in 2016.

This study aimed to estimate the impact of alcohol use on mortality and health among people 69 years of age and younger in 2016. A comparative risk assessment approach was utilized, with population-attributable fractions being estimated by combining alcohol use data from the Global Information System on Alcohol and Health with corresponding relative risk estimates from meta-analyses. The mortality and health data were obtained from the Global Health Observatory. Among people 69 years of age and younger in 2016, 2.0 million deaths and 117.2 million Disability Adjusted Life Years (DALYs) lost were attributable to alcohol consumption, representing 7.1% and 5.5% of all deaths and DALYs lost in that year, respectively. The leading causes of the burden of alcohol-attributable deaths were cirrhosis of the liver (457,000 deaths), road injuries (338,000 deaths), and tuberculosis (190,000 deaths). The numbers of premature deaths per 100,000 people were highest in Eastern Europe (155.8 deaths per 100,000), Central Europe (52.3 deaths per 100,000 people), and Western sub-Saharan Africa (48.7 deaths per 100,000). A large portion of the burden of disease caused by alcohol among people 69 years of age and younger is preventable through the implementation of cost-effective alcohol policies such as increases in taxation.

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

INTRODUCTION: Policy changes may contribute to increased alcohol-related risks to populations. These include privatisation of alcohol retailing, which influences density of alcohol outlets, location of outlets, hours of sale and prevention of alcohol sales to minors or intoxicated customers. Meta-analyses, reviews and original research indicate enhanced access to alcohol is associated with elevated risk of and actual harm. We assess the 10 Canadian provinces on two alcohol policy domains-type of alcohol control system and physical availability of alcohol-in order to track changes over time, and document shifting changes in alcohol policy. METHODS: Our information was based on government documents and websites, archival statistics and key informant interviews. Policy domains were selected and weighted for their degree of effectiveness and population reach based on systematic reviews and epidemiological evidence. Government representatives were asked to validate all the information for their jurisdiction. RESULTS: The province-specific reports based on the 2012 results showed that 9 of 10 provinces had mixed retail systems-a combination of government-run and privately owned alcohol outlets. Recommendations in each provincial report were to not increase privatisation. However, by 2017 the percentage of off-premise private outlets had increased in four of these nine provinces, with new private outlet systems introduced in several. DISCUSSION AND CONCLUSIONS: Decision-making protocols are oriented to commercial interests and perceived consumer convenience. If public health and safety considerations are not meaningfully included in decision-making protocols on alcohol policy, then it will be challenging to curtail or reduce harms.

The Canadian Alcohol Policy Evaluation project: Findings from a review of provincial and territorial alcohol policies.

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.

What is the best indicator of the harmful use of alcohol? A narrative review.

ISSUES: The monitoring of the harmful use of alcohol is a key focus of global health efforts, including the Sustainable Development Goals. The current indicator of harmful alcohol use for Sustainable Development Goals is the national adult (15+ years) alcohol per capita consumption (APC) in litres of pure alcohol. Recently, the age-standardised prevalence of heavy episodic drinking (HED) has been advanced as an alternative indicator. APPROACH: This narrative review is composed of a review of advantages and disadvantages of both indicators and an empirical analysis of their associations with alcohol-attributable health harm. KEY FINDINGS: APC is greatly associated with harm and is available for almost all countries on a yearly basis as it is largely derived from routinely collected statistics. HED is based on responses to population surveys not routinely performed for most countries. These surveys commonly exclude heavy drinking populations (e.g. army personnel, institutionalised, homeless). Even when included within the sampling frame, heavy drinkers are less likely to participate than other groups. The questions used to measure HED are susceptible to biases due to issues with respondents' comprehension, recall and misreporting. Furthermore, in a regression analysis of 182 countries, APC was better at predicting alcohol-attributable harm than HED. APC was also correlated with changes in the alcohol-attributable burden of disease (from 2010 to 2016), while HED was not. IMPLICATIONS: Based on these factors, APC was found to be the preferred indicator. CONCLUSIONS: APC should be retained as the main indicator of the harmful use of alcohol.

National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study.

BACKGROUND: Alcohol use has increased globally, with varying trends in different parts of the world. This study investigates gender, age, and geographical differences in the alcohol-attributable burden of disease from 2000 to 2016. METHODS: This comparative risk assessment study estimated the alcohol-attributable burden of disease. Population-attributable fractions (PAFs) were estimated by combining alcohol exposure data obtained from production and taxation statistics and from national surveys with corresponding relative risks obtained from meta-analyses and cohort studies. Mortality and morbidity data were obtained from the WHO Global Health Estimates, population data were obtained from the UN Population Division, and human development index (HDI) data were obtained from the UN Development Programme. Uncertainty intervals (UIs) were estimated using a Monte Carlo-like approach. FINDINGS: Globally, we estimated that there were 3·0 million (95% UI 2·6-3·6) alcohol-attributable deaths and 131·4 million (119·4-154·4) disability-adjusted life-years (DALYs) in 2016, corresponding to 5·3% (4·6-6·3) of all deaths and 5·0% (4·6-5·9) of all DALYs. Alcohol use was a major risk factor for communicable, maternal, perinatal, and nutritional diseases (PAF of 3·3% [1·9-5·6]), non-communicable diseases (4·3% [3·6-5·1]), and injury (17·7% [14·3-23·0]) deaths. The alcohol-attributable burden of disease was higher among men than among women, and the alcohol-attributable age-standardised burden of disease was highest in the eastern Europe and western, southern, and central sub-Saharan Africa regions, and in countries with low HDIs. 52·4% of all alcohol-attributable deaths occurred in people younger than 60 years. INTERPRETATION: As a leading risk factor for the burden of disease, alcohol use disproportionately affects people in low HDI countries and young people. Given the variations in the alcohol-attributable burden of disease, cost-effective local and national policy measures that can reduce alcohol use and the resulting burden of disease are needed, especially in low-income and middle-income countries. FUNDING: None.

Counting the cold ones: A comparison of methods measuring total alcohol consumption of managed alcohol program participants.

INTRODUCTION AND AIMS: Managed alcohol programs (MAP) aim to reduce harms experienced by unstably housed individuals with alcohol use disorders by providing regulated access to beverage alcohol, usually alongside housing, meals and other supports. This study compares two methods of estimating participants' outside alcohol consumption in order to inform program policies and practices around alcohol dosing and reducing risks of alcohol-related illnesses. METHODS: The total alcohol consumption of 65 people participating in Canadian MAPs was assessed comparing daily MAP records (1903 client days) with researcher-administered surveys over the same time period. A sub-sample of more complete daily MAP records for 39 people (696 client days) was also compared with the equivalent survey data on drinking. RESULTS: Significantly more standard drinks per day (SDs, one SD = 17.05 mL ethanol) were reported in research interviews than recorded by program staff, whether for program administered drinks alone (means 16.04 vs. 8.32 SDs, t = 5.79, P < 0.001) or including outside-program drinks as reported to staff (16.04 vs. 8.89 SDs, t = 5.37, P < 0.001). Consistent results were found in the sub-sample. The number of outside drinks estimated by comparing program records with the research interviews, varied between 2.71 and 9.94 mean drinks per day per site. DISCUSSION AND CONCLUSIONS: At two sites, MAP participants reported consuming more than twice the amount of alcohol administered on the program. At most sites, there was significant under-reporting of outside drinking. Addressing the problem of outside drinking and total daily consumption is critical for achieving program goals of both short and long-term harm reduction.

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.