Assessment methods for alcohol consumption, prevalence of high risk drinking and harm: a sensitivity analysis.

BACKGROUND: There are no standardized ways to assess alcohol consumption in epidemiological studies. The main objective of the present study was to compare three widely used methods for assessing alcohol consumption with respect to resulting prevalence estimates for high risk drinking and harm as defined by morbidity and mortality indicators. METHODS: A within-subjects design was used to compare a quantity frequency, a graduated frequency, and a weekly drinking recall measure. Data consisted of a representative sample of 3961 adult residents of the province of Ontario, Canada, who participated in a multi-wave cross-sectional survey between 1990-1994. Cross-tabulation, Spearman correlation, and standard methodologies for prevalence-based cost-of-illness studies were used. RESULTS: The graduated frequency measure consistently yielded higher estimates of the prevalences of high risk drinking and harm. Differences were marked on all indicators, but were most pronounced for harmful drinking as defined by consuming an average of >60 g pure alcohol per day for males, and >40 g per day for females. Prevalence estimates of harmful drinking were almost five times higher for graduated frequency versus weekly drinking measures, and almost three times higher for graduated frequency versus quantity frequency measures. CONCLUSIONS: The characteristics of different measures of alcohol consumption should be considered in future research in epidemiology.

The interaction between policy and research in the implementation of server training.

This paper describes the relationship between research and policy in the development of server training policy in Ontario. With the emergence of civil liability for the conduct of intoxicated patrons, there has been a growing movement toward the training of managers and servers in licensed establishment in the responsible service of alcohol. As part of a major government reform of alcohol regulations which has led to a new Liquor Licence Act, all persons who serve alcohol in licensed establishments in Ontario will be required to attend a server training course. The process leading to new alcohol regulations in Ontario is summarized with particular attention to the implementation of mandatory server training. The paper concludes with a discussion of the role of research in policy development. It is argued that the role of research in policy making is limited by an inherent conflict between the nature of scientific enquiry and the exigencies of policy development.

A comparison of alternative measures of alcohol consumption in the Canadian National Survey of alcohol and drug use.

Based on the results of the 1989 National Alcohol and Drug Survey in Canada, this paper compares alternative measures of alcohol consumption. Utilizing questions developed by Walter Clark, the volume of drinking in a variety of social situations is described. The results are presented in terms of aggregate consumption and the proportion of total consumption which occurs in different situations. It is found that anchoring self-reported alcohol use in specific social contexts results in higher estimated consumption than the more commonly used quantity/frequency questions.

The economic costs of alcohol, tobacco and illicit drugs in Canada, 1992.

UNLABELLED: AIMS, DESIGN AND SETTING: The economic costs of alcohol, tobacco and illicit drugs in Canadian society in 1992 are estimated utilizing a cost-of-illness framework and recently developed international guidelines. MEASUREMENTS: For causes of disease or death (using ICD-9 categories), pooled relative risk estimates from meta-analyses are combined with prevalence data by age, gender and province to derive the proportion attributable to alcohol, tobacco and/or illicit drugs. The resulting estimates of attributable deaths and hospitalizations are used to calculate associated health care, law enforcement, productivity and other costs. The results are compared wit other studies, and sensitivity analyses are conducted on alternative measures of alcohol consumption, alternative discount rates for productivity costs and the use of diagnostic-specific hospitalization costs. FINDINGS: The misuse of alcohol, tobacco and illicit drugs cost more than $18.4 billion in Canada in 1992, representing $649 per capita or 2.7% of GDP. Alcohol accounts for approximately $7.52 billion in costs, including $4.14 billion for lost productivity, $1.36 billion for law enforcement and $1.30 billion in direct health care costs. Tobacco accounts for approximately $9.56 billion in costs, including $6.82 billion for lost productivity and $2.68 billion for direct health costs. The economic of illicit drugs are estimated at $1.4 billion. CONCLUSIONS: Substance abuse exacts a considerable toll to Canadian society in terms of illness, injury, death and economic costs.

On the emerging paradigm of drinking patterns and their social and health consequences.

Recent epidemiological and social studies have increasingly pointed to the importance of drinking patterns in explaining consequences of alcohol consumption. This paper presents recommendations for research in the area based on the presentations and discussions of the first "International Conference on Social and Health Effects of Different Drinking Patterns" held in Toronto in November 1995. In particular, the social dimension in pattern research, and the relationship between patterns of drinking and casualties as well as social harm, are stressed. The paper also argues for better theories, incorporating knowledge from related basic disciplines. In addition, we emphasize the need for improved methodologies and standardized methods for assessing drinking patterns. Finally, implications of research on drinking patterns for policy and programme development are discussed.

The role of alcohol providers in prevention: an evaluation of a server intervention programme.

Server intervention is a relatively new approach in the attempt to reduce the incidence of drinking and driving. Although a number of evaluations have suggested that the approach may be effective, there have been few comprehensive evaluations of such programmes. The present study utilized process evaluation techniques to assess reactions to a programme developed by the Addiction Research Foundation, and a quasi-experimental design to determine the impact of the programme on the serving practices of servers. Actors portrayed behaviours often faced by servers, and observers rated the reactions of the servers, who were unaware of the simulations, to these situations. The programme appears to have been effective in changing behaviour, in that trained servers exhibited less inappropriate responses than did untrained servers. In addition the results suggested that the programme increased servers' knowledge about their obligations and potential strategies for dealing with these situations. The implications of these findings for future implementations of such programmes are discussed.

Current directions in research on understanding and preventing intoxicated aggression.

The present paper describes promising research directions that emerged from a recent international conference on intoxication and aggression and from the scientific literature generally. In this overview, intoxicated aggression is seen as arising from an interactional process involving multiple contributing factors or causes. This model helps to define research directions that can further understanding and prevention. First, the societal/cultural framing of intoxication and aggression exerts a powerful influence on drinking behaviour and needs to be better understood. Another important area for research is the moderating role on alcohol-related aggression of personal factors such as predisposition to aggression and individual differences in expectations about alcohol and aggression. Research on the role of basic pharmacological effects of alcohol in increasing the likelihood of aggressive behaviour is also a critical aspect of understanding intoxicated aggression. Drinking contexts and environments play a considerable role in the relationship between intoxication and aggressive behaviour and need to be better understood. Another critical direction for future research is the study of intoxicated aggression as a process involving the interaction of the person, the situation and the effects of alcohol in natural and experimental settings. Finally, the paper highlights promising directions for research on interventions to prevent intoxicated aggression and violence.

The impact of marijuana decriminalization: an update.

The available evidence indicates that the "decriminalization" of marijuana possession had little or no impact on rates of use. Although rates of marijuana use increased in those U.S. states which reduced maximum penalties for possession to a fine, the prevalence of use increased at similar or higher rates in those states which retained more severe penalties. There were also no discernable impacts on the health care systems. On the other hand, the so-called "decriminalization" measures did result in substantial savings in the criminal justice system.

The impact of cannabis decriminalisation in Australia and the United States.

This paper summarises and compares the impacts of cannabis decriminalisation measures in two countries. In Australia, an expiation model of decriminalisation succeeded in avoiding the imposition of criminal convictions for many offenders, but substantial numbers of offenders received criminal convictions because of a general "net-widening" in cannabis offence detections, and the failure of many offenders to pay expiation fees and thus avoid criminal prosecution. Despite these problems, the expiation approach has been cost-effective, reducing enforcement costs without leading to increased cannabis use. In the United States, cannabis decriminalisation similarly reduced enforcement costs, with enforcement resources generally redirected toward trafficking and other illicit drugs. There were no increases in cannabis use or substantial problems that could be ascribed to decriminalisation. The implications for other countries are discussed, with particular attention to the importance of implementation issues, monitoring, and evaluation. Although decriminalisation has succeeded in reducing enforcement and other costs without increasing the problems associated with cannabis use, the same impacts would not necessarily result from the legalisation of cannabis or the decriminalisation of other illicit drugs.

The structure of the alcohol industry as it relates to transportation issues.

The alcoholic beverage industry has undergone marked changes in its structure over the past several decades, and these changes have important implications to drinking and driving problems. In Canada and elsewhere, the industry has been generally transformed from a large set of small firms owned by entrepreneurs to a very small set of large international corporations with extensive and complex intercorporate connections. After describing trends in alcohol consumption and patterns of drinking, this paper examines the structure of the beverage alcohol industry in Canada. It is found that the distilling and brewing industries are highly concentrated and oligopolistic, while viticulture is more fragmented and regional in character. With regard to impact on drinking and driving problems, there are both positive and negative effects. On one hand, barriers to entry into the market are high and competition thereby restricted, thus avoiding certain excesses associated with fierce competition. Further, the large distillers and brewers, being able to afford advertising outlays and the temporary unprofitability necessary to introduce new products, have introduced lower alcohol content beverages which may eventually have a positive impact on drinking and driving incidents. On the other hand, there is little doubt that the industry structure greatly facilitates the promotion of alcohol consumption and, by contributing to the increased exposure of drivers to alcohol, thus exacerbates drinking and driving problems.

Drinking in various settings as it relates to demographic variables and level of consumption: findings from a national survey in Canada.

Based on a large-scale 1989 national survey in Canada, the extent of drinking in different social settings is estimated. Home consumption accounts for the greatest share of total drinking. while drinking in licensed establishments accounts for approximately one-fourth of consumption. This estimate is externally validated against scales data. The set of questions on drinking venues produces estimates of individual's alcohol consumption which have higher coverage rates than the more commonly used quantity-frequency or recent occasion approaches. The distribution of total drinking in different settings is strongly related to demographic variables and individual level of consumption. In particular, drinking in bars and taverns is related to higher levels of drinking and self-reported drinking problems. The proportion of drinking in different venues is not strongly related to drinking problems, once demographic variables and individual consumption patterns are taken into account. This does not mean that drinking venue is not a significant factor in the development of problems--it may be via its impact on consumption level and heavy drinking occasions that drinking venue relates to drinking problems.

The 1993 General Social Survey II: alcohol problems in Canada.

Rates and correlates of problems associated with the use of alcohol are reported from the 1993 General Social Survey in Canada. Approximately 1 in 11 drinkers (9.2%) reported that drinking has had an adverse effect on his or her social life, physical health, happiness, home life or marriage, work, or finances in the past year. The most commonly reported problems concerned physical health (5.1%), and financial position (4.7%). Approximately one in eight drinkers (12.9%) had driven a car within an hour after consuming two or more drinks in the previous year. Furthermore, more than two of every five respondents reported that they had experienced some problem due to other people's drinking. In a multivariate analysis, age, marital status, gender, religious attendance and employment status were the strongest predictors of problem drinking. The number of heavy drinking occasions is a stronger predictor of drinking problems than is overall level of consumption.

The 1993 General Social Survey I: alcohol use in Canada.

Rates and correlates of alcohol use are reported from the 1993 General Social Survey, a household telephone survey of 10,385 Canadians carried out by Statistics Canada. Continuing a recent trend, alcohol use has declined. The portrait of the Canadian who is most likely to drink and drink heavily is that of a young adult male who is not married, relatively well-off, and rarely or never attends religious services. In a multivariate analysis of the combined impact of sociodemographic factors on drinking and drinking levels, it was found that the frequency of religious attendance and age were the strongest predictors of current drinking. Gender was the strongest predictor of volume of alcohol consumption, while religious attendance, age, marital status and employment status were also significant predictors.

Low-risk drinking guidelines: the scientific evidence.

In 1997 the Addiction Research Foundation of Ontario and Canadian Centre on Substance Abuse released updated guidelines for low-risk alcohol consumption. This paper presents the scientific rationale behind this statement. Important comprehensive overviews on the consequences of alcohol use were studied. Formal meta-analyses on morbidity and mortality were examined wherever possible. Individual elements from similar guidelines were investigated for their scientific foundation. Limited original analyses defined risk levels by average weekly consumption. The evidence reviewed demonstrated that placing limits on both daily intake and cumulative intake over the typical week is justifiable for the prevention of important causes of morbidity and mortality. Gender-specific limits on weekly consumption were also indicated. In these updated guidelines intended for primary prevention, days of abstinence are not necessarily recommended. Intoxication should be avoided and abstinence is sometimes advisable. Available evidence does not strongly favour one alcoholic beverage over another for cardiovascular health benefits.

Defining harm reduction.

Harm reduction attempts to reduce the adverse consequences of drug use among persons who continue to use drugs. It developed in response to the excesses of a "zero tolerance approach". Harm reduction emphasizes practical rather than idealized goals. It has been expanded from illicit drugs to legal drugs and is grounded in the evolving public health and advocacy movements. Harm reduction has proved to be effective and it has gained increasing official acceptance; for example, it is now the basis of Canada's Drug Strategy. However, the concept is still poorly defined, as virtually any drug policy or programme, even abstinence-oriented programmes, attempt to reduce drug-related harm. The principle feature of harm reduction is the acceptance of the fact that some drug users cannot be expected to cease their drug use at the present time. Harm reduction is neutral about the long term goals of intervention while according a high priority to short-term realizable goals. Harm reduction should be neutral about legalization. The essence of the concept is to ameliorate adverse consequences of drug use while, at least in the short term, drug use continues.

Recent developments in alcoholism:public drinking.

Drinking in bars and other public establishments has been a relatively neglected subject of research, despite its epidemiological significance. This chapter briefly summarizes the findings of observational studies in bars and taverns, as well as general population surveys on the correlates of tavern patronage. Recent developments in the control of public drinking are described. It is argued that greater attention should be placed on prevention programs that focus on drinking environments. In particular, the emergence of server intervention programs represents a promising new mechanism for the prevention of impaired driving and other alcohol-related problems.