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.

Five Years After Cannabis Legalization, Is It Time to Ease Restrictions on Promotion?

In the spring of 2024, the federal government is expected to report on its legislative review of the Cannabis Act (2018). One of the most contentious issues is whether to relax restrictions on cannabis promotion. This commentary describes the tension between the public health aims of legalization and the secondary aim of displacing the illicit market. We maintain that among jurisdictions that have legalized cannabis, Canada stands out as having the stated primary objective of safeguarding public health, and its restrictions on promotion are evidence-based and innovative. These measures must be preserved, even in the face of growing industry pressure to loosen them.

Navigating the nexus between British Columbia's public consumption and decriminalization policies of illegal drugs.

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province's primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC's overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

The association between alcohol retail access and health care visits attributable to alcohol for individuals with and without a history of alcohol-related health-care use.

BACKGROUND AND AIMS: Alcohol retail access is associated with alcohol use and related harms. This study measured whether this association differs for people with and without heavy and disordered patterns of alcohol use. DESIGN: The study used a repeated cross-sectional analysis of health administrative databases. SETTING, PARTICIPANTS/CASES: All residents of Ontario, Canada aged 10-105 years with universal health coverage (n = 10 677 604 in 2013) were included in the analysis. MEASUREMENTS: Quarterly rates of emergency department (ED) and outpatient visits attributable to alcohol in 464 geographic regions between 2013 and 2019 were measured. Quarterly off-premises alcohol retail access scores were calculated (average drive to the closest seven stores) for each geographic region. Mixed-effect linear regression models adjusted for area-level socio-demographic covariates were used to examine associations between deciles of alcohol retail access and health-care visits attributable to alcohol. Stratified analyses were run for individuals with and without prior alcohol-attributable health-care use in the past 2 years. FINDINGS: We included 437 707 ED visits and 505 271 outpatient visits attributable to alcohol. After adjustment, rates of ED visits were 39% higher [rate ratio (RR) = 1.39, 95% confidence interval (CI) = 1.20-1.61] and rates of outpatient visits were 49% higher (RR = 1.49, 95% CI = 1.26-1.75) in the highest versus lowest decile of alcohol access. There was a positive association between alcohol access and outpatient visits attributable to alcohol for individuals without prior health-care attributable to alcohol (RR = 1.65, 95% CI = 1.39-1.95 for the highest to lowest decile of alcohol access) but not for individuals with prior health-care attributable to alcohol (RR = 1.08, 95% CI = 0.90-1.30). There was a positive association between alcohol access and ED visits attributable to alcohol for individuals with and without prior health-care for alcohol for ED visits. CONCLUSION: In Ontario, Canada, greater alcohol retail access appears to be associated with higher rates of emergency department (ED) and outpatient health-care visits attributable to alcohol. Individuals without prior health-care for alcohol may be more susceptible to greater alcohol retail access for outpatient but not ED visits attributable to alcohol.

The distribution of alcohol-attributable healthcare encounters across the population of alcohol users in Ontario, Canada.

Recent evidence suggests there may be no safe level of alcohol use as even low levels are associated with increased risk for harm. However, the magnitude of the population-level health burden from lower levels of alcohol use is poorly understood. The objective was to estimate the distribution of alcohol-attributable healthcare encounters (emergency department (ED) visits and hospitalizations) across the population of alcohol users aged 15+ in Ontario, Canada. Using the International Model of Alcohol Harms and Policies (InterMAHP) tool, wholly and partially alcohol-attributable healthcare encounters were estimated across alcohol users: (1) former (no past-year use); (2) low volume (≤67.3 g ethanol/week); (3) medium volume (>67.3-134.5 g ethanol/week for women and >67.3-201.8 g ethanol/week for men); and (4) high volume (>134.5 g ethanol/week for women and >201.8 g ethanol/week for men). The alcohol-attributable healthcare burden was distributed across the population of alcohol users. A small population of high volume users (23% of men, 13% of women) were estimated to have contributed to the greatest proportion of alcohol-attributable healthcare encounters, particularly among men (men: 65% of ED visits and 71% of hospitalizations, women: 49% of ED visits and 50% of hospitalizations). The 71% of women low and medium volumes users were estimated to have contributed to a substantial proportion of alcohol-attributable healthcare encounters (47% of ED visits and 34% of hospitalizations). Findings provide support for universal alcohol policies (i.e., delivered to the entire population) for reducing population-level alcohol-attributable harm in addition to targeted policies for high-risk users.

What is a public health approach to substance use? A qualitative systematic review and thematic synthesis.

BACKGROUND: Psychoactive substance use and the regulations that govern it both have the potential to lead to harm. A 'public health approach' (PHA) is frequently invoked as a means of addressing these harms, but the term is used in inconsistent and contradictory ways. This study systematically reviewed the English-language academic literature to understand how a public health approach to substance use is defined and described. METHODS: This review employed thematic synthesis, a methodology designed to rigorously synthesize qualitative evidence. Eligible articles were published in peer-reviewed journals, in the English language, with full text available, and focused primarily on substance use. There were no limits on year of publication. Original research, opinion/commentary, and reviews were included. The searches were conducted in October 2021 in CINAHL, Embase, Medline, PAIS Index, PsycINFO, Scopus, Sociological Abstracts, and Web of Science. RESULTS: 272 articles from 25 countries, published between 1950 and 2021, were synthesized. Definitions of a PHA have changed over time and differ by substance. The most commonly cited characteristics of a PHA were: for alcohol, regulation, e.g. of price and availability (54% of articles); for cannabis: regulation (68%); for illicit drugs: that a PHA is distinct from a criminal justice approach (63%); for opioids: substance use disorder treatment (55%); and for tobacco: regulation (62%). CONCLUSION: There is no consensus on the definition of a public health approach to substance use, but there is substantial agreement when it comes to PHAs to specific substances. There are also similarities in how they are described for legal substances versus illicit ones. This review found areas of disagreement regarding the extent to which PHAs should focus on individual-level factors. Policymakers, academics, and others developing or implementing PHAs to substance use should be explicit about their aims and objectives - as well as the premises and assumptions underlying them.

The impact of cannabis legalization for recreational purposes on youth: A narrative review of the Canadian experience.

Cannabis legalization for non-medical purposes (subsequently referred to as "cannabis legalization" or "legalization") took place in Canada in October 2018. One of the federal government's stated goals with cannabis legalization was to protect Canadian youth from cannabis-related harms. The main objective of this narrative review is to describe the impact of cannabis legalization on Canadian youth. To that end, we discuss the regulation of the Canadian cannabis market, outline changes in the epidemiology and parameters of cannabis use (modes of use, potency of cannabis) among youth, and discuss prevention and education initiatives related to cannabis. The Canadian model differs from other jurisdictions that legalized recreational cannabis use, especially with regard to a higher degree of government regulation of the cannabis market. Another difference is the development and endorsement of lower-risk cannabis use guidelines to educate the public and health professionals. The results available for this review cover only 3 years post-legalization. Cannabis legalization in Canada brought an apparent increase in use among Canadian older than 25. However, results for youth are mixed, with the majority of studies showing no pronounced increase. Notably, the trend of a decrease in adolescents' cannabis use seen pre-legalization may have reversed. Emerging evidence also suggests that cannabis-related hospitalizations and emergency department visits among Canadian youth may have increased due to cannabis legalization. Data about changes in the age of initiation, the influence of legalization on sex and gender, and race/ethnicity are limited, with evidence suggesting that the age of initiation slightly increased. So far, there is limited data about the impact of cannabis legalization on Canadian youth. Further long-term monitoring and research to assess the effects of cannabis legalization on Canadian youth.

What is a public health approach to substance use? Protocol for a qualitative systematic review.

INTRODUCTION: The concept of a 'public health approach' to substance use is frequently but inconsistently invoked. This inconsistency is reflected in public policy, with governments using the term 'public health approach' in contradictory ways. This aim of this study is to clarify what is meant and understood when the term 'public health approach' is used in the context of substance use. METHODS AND ANALYSIS: We will conduct a systematic search of Medline, Embase, Scopus, CINAHL, PsycINFO, Sociological Abstracts and PAIS Index. Eligible articles will be from peer-reviewed journals, in English, with full text available. There will be no limits on year of publication. Substance use must be the primary topic of the article. Editorials, commentaries and letters to the editor will be included, but not commentaries on other articles, unless the definition of a public health approach is central to the commentary. Data selection and collection will be conducted independently by two researchers, with a third separately resolving any disagreement. To answer the research question, we will extract authors' definitions of a public health approach to substance use as well as any descriptions of the central principles, characteristics and components of such an approach. To synthesise the data, we will employ thematic synthesis. Coding will be conducted by one researcher and verified by a second; two researchers will then group the codes into themes using an inductive process. Finally, the full research team will develop a set of analytic themes, which will be presented as a narrative. ETHICS AND DISSEMINATION: Ethics approval is not needed since the research will only involve published work. Our findings will be disseminated in a peer-reviewed journal and, if possible, at conferences. PROSPERO REGISTRATION NUMBER: CRD42021270632.

Legalization as more effective control? Parallels between the end of alcohol prohibition (1927) and the legalization of cannabis (2018) in Ontario, Canada.

BACKGROUND: In the 1920s, eight of nine Canadian provinces legalized alcohol sales, ending prohibition in favor of government control. Much has been written about the rise and fall of Prohibition in North America, but there is little work examining these events in the light of current drug policy debates. This paper attempts to fill some of these gaps. METHODS: The aims of this paper are primarily exploratory and descriptive. Following a literature review, it draws from secondary and some primary sources to explore the debate around ending alcohol prohibition (i.e. legalizing its distribution) in Ontario between 1920 and 1927. It then uses material drawn from a comprehensive search of the Canadian House of Commons debates on cannabis legalization between 2016 and 2018 to draw parallels with the debates around alcohol legalization in Ontario about 90 years earlier. RESULTS: While alcohol and cannabis legalization occurred in very different social and political contexts, there are similarities in both the arguments in favor of ending prohibition (ineffectiveness at preventing consumption and collateral social harms) and post-legalization debates around regulation (most notably the optimal way to replace the illicit market). CONCLUSION: The Canadian cannabis legalization debates of the 2010s echo the alcohol legalization debates of the 1920s in remarkable and relevant ways. Ultimately the most striking parallel may be the extent to which the political leaders advocating for legalization emphasized that their policy was not liberalization, but more effective control.

Effect of alcohol prohibition on liver cirrhosis mortality rates in Canada from 1901 to 1956: A time-series analysis.

INTRODUCTION AND AIMS: The extent to which alcohol consumption in Canada was affected by alcohol prohibition in the early 20th century remains unclear. Since there is a dearth of data on consumption during this time, we estimated the effect of alcohol prohibition on alcohol consumption, as measured by changes in liver cirrhosis mortality rates in Canada. DESIGN AND METHODS: Annual liver cirrhosis mortality data were obtained for 1901 to 1956 for the provinces of Alberta, British Columbia, Manitoba, New Brunswick, Nova Scotia, Ontario and Saskatchewan. Changes in death rates were assessed, by province, using autoregressive integrated moving average models. Results were pooled across provinces using a fixed effects meta-analysis. A secondary fixed effects meta-analysis was performed which only included provinces with data for before, during and after prohibition, and excluded provinces with data only beginning during prohibition. RESULTS: Prohibition was associated with a statistically significant decrease in liver cirrhosis death rates only in Nova Scotia (P = 0.01). Pooling of provincial results indicated that prohibition resulted in 0.39 (95% confidence interval 0.06, 0.72; P = 0.02) fewer liver cirrhosis deaths per 100 000 people. In the restricted meta-analysis, prohibition resulted in 0.65 (95% confidence interval 0.18, 1.12; P < 0.01) fewer liver cirrhosis deaths per 100 000 people. DISCUSSION AND CONCLUSIONS: Although alcohol prohibition in Canada did not eliminate alcohol consumption, our findings suggest that prohibition was associated with reduced consumption, as evidenced by a reduction in liver cirrhosis mortality rates. Further, it's important to reflect on alcohol's history in Canada and use those policy lessons to guide the construction of effective cannabis legislation.

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.

Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review.

The object of this contribution based on a systematic review of the literature is to examine to what degree the level of use and potency play a role in regulatory policies for alcohol, other psychoactive substances and gambling, and whether there is an evidence base for this role. Level of use is usually defined around a behavioural pattern of the user (for example, cigarettes smoked per day, or average ethanol use in grams per day), while potency is defined as a property or characteristic of the substance. For all substances examined (alcohol, tobacco, opioids, cannabis) and gambling, both dimensions were taken into consideration in the formulation of most regulatory policies. However, the associations between both dimensions and regulatory policies were not systematic, and not always based on evidence. Future improvements are suggested.

Cannabis Legalization in Canada: Reflections on Public Health and the Governance of Legal Psychoactive Substances.

The Canadian government is "taking a public health approach to legalizing, strictly regulating and restricting access to cannabis." There is, however, no universally accepted definition of a public health approach to cannabis. This paper presents what such an approach is, and is not, and discusses its applicability to legal psychoactive substances more generally. It critically reflects on the role of the public health sector in the governance of addictive substances and activities, noting its function of "responsibilizing" individuals and coaxing them to self-regulate-and the contradiction involved when other state actors involved in governance are actively inciting consumption of those substances and activities.

The Devil Is in the Details! On Regulating Cannabis Use in Canada Based on Public Health Criteria Comment on "Legalizing and Regulating Marijuana in Canada: Review of Potential Economic, Social, and Health Impacts".

This commentary to the editorial of Hajizadeh argues that the economic, social and health consequences of legalizing cannabis in Canada will depend in large part on the exact stipulations (mainly from the federal government) and on the implementation, regulation and practice of the legalization act (on provincial and municipal levels). A strict regulatory framework is necessary to minimize the health burden attributable to cannabis use. This includes prominently control of production and sale of the legal cannabis including control of price and content with ban of marketing and advertisement. Regulation of medical marijuana should be part of such a framework as well.

Realistically furthering the goals of public health by cannabis legalization with strict regulation: Response to Kalant.

Cannabis Policy Framework respond to select issues from Kalant's Commentary (in this issue).