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OBJECTIVE: Self-reported alcohol consumption in U.S. public health surveys covers only 30%–60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths. METHOD: Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011–2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach. RESULTS: Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6). CONCLUSIONS: Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

ImportanceAlcohol consumption is a leading preventable cause of death in the US, and death rates from fully alcohol-attributable causes (eg, alcoholic liver disease) have increased in the past decade, including among adults aged 20 to 64 years. However, a comprehensive assessment of alcohol-attributable deaths among this population, including from partially alcohol-attributable causes, is lacking.ObjectiveTo estimate the mean annual number of deaths from excessive alcohol use relative to total deaths among adults aged 20 to 64 years overall; by sex, age group, and state; and as a proportion of total deaths.Design, Setting, and ParticipantsThis population-based cross-sectional study of mean annual alcohol-attributable deaths among US residents between January 1, 2015, and December 31, 2019, used population-attributable fractions. Data were analyzed from January 6, 2021, to May 2, 2022.ExposuresMean daily alcohol consumption among the 2 089 287 respondents to the 2015-2019 Behavioral Risk Factor Surveillance System was adjusted using national per capita alcohol sales to correct for underreporting. Adjusted mean daily alcohol consumption prevalence estimates were applied to relative risks to generate alcohol-attributable fractions for chronic partially alcohol-attributable conditions. Alcohol-attributable fractions based on blood alcohol concentrations were used to assess acute partially alcohol-attributable deaths.Main Outcomes and MeasuresAlcohol-attributable deaths for 58 causes of death, as defined in the Centers for Disease Control and Prevention’s Alcohol-Related Disease Impact application. Mortality data were from the National Vital Statistics System.ResultsDuring the 2015-2019 study period, of 694 660 mean deaths per year among adults aged 20 to 64 years (men: 432 575 [66.3%]; women: 262 085 [37.7%]), an estimated 12.9% (89 697 per year) were attributable to excessive alcohol consumption. This percentage was higher among men (15.0%) than women (9.4%). By state, alcohol-attributable deaths ranged from 9.3% of total deaths in Mississippi to 21.7% in New Mexico. Among adults aged 20 to 49 years, alcohol-attributable deaths (44 981 mean annual deaths) accounted for an estimated 20.3% of total deaths.Conclusions And RelevanceThe findings of this cross-sectional study suggest that an estimated 1 in 8 total deaths among US adults aged 20 to 64 years were attributable to excessive alcohol use, including 1 in 5 deaths among adults aged 20 to 49 years. The number of premature deaths could be reduced with increased implementation of evidenced-based, population-level alcohol policies, such as increasing alcohol taxes or regulating alcohol outlet density.

INTRODUCTION: Alcohol is a leading contributor to liver disease, however, estimating the proportion of liver disease deaths attributable to alcohol use can be methodologically challenging. METHODS: We compared three approaches for estimating alcohol-attributable liver disease deaths (AALDD), using the U.S. as an example. One involved summing deaths from alcoholic liver disease and a proportion from unspecified cirrhosis (direct method); two used population attributable fraction (PAF) methodology, including one that adjusted for per capita alcohol sales. For PAFs, the 2011–2015 Behavioral Risk Factor Surveillance System and per capita sales from the Alcohol Epidemiologic Data System were used to derive alcohol consumption prevalence estimates at various levels (excessive alcohol use was defined by medium and high consumption levels). Prevalence estimates were used with relative risks from two meta-analyses, and PAFs were applied to the 2011–2015 average annual number of deaths from alcoholic cirrhosis and unspecified cirrhosis (using National Vital Statistics System data) to estimate AALDD. RESULTS: The number of AALDD was higher using the direct method (28,345 annually) than the PAF methods, but similar when alcohol prevalence was adjusted using per capita sales and all alcohol consumption levels were considered (e.g., 25,145 AALDD). Using the PAF method, disaggregating non-drinkers into lifetime abstainers and former drinkers to incorporate relative risks for former drinkers yielded higher AALDD estimates (e.g., 27,686) than methods with all non-drinkers combined. DISCUSSION AND CONCLUSIONS: Using PAF methods that adjust for per capita sales and model risks for former drinkers yield more complete and possibly more valid AALDD estimates.

Excessive alcohol use is a leading cause of preventable death in the United States (1) and costs associated with it, such as those from losses in workplace productivity, health care expenditures, and criminal justice, were $249 billion in 2010 (2). CDC used the Alcohol-Related Disease Impact (ARDI) application* to estimate national and state average annual alcohol-attributable deaths and years of potential life lost (YPLL) during 2011-2015, including deaths from one's own excessive drinking (e.g., liver disease) and from others' drinking (e.g., passengers killed in alcohol-related motor vehicle crashes). This study found an average of 93,296 alcohol-attributable deaths (255 deaths per day) and 2.7 million YPLL (29 years of life lost per death, on average) in the United States each year. Of all alcohol-attributable deaths, 51,078 (54.7%) were caused by chronic conditions, and 52,361 (56.0%) involved adults aged 35-64 years. Age-adjusted alcohol-attributable deaths per 100,000 population ranged from 20.3 in New Jersey and New York to 52.3 in New Mexico. YPLL per 100,000 population ranged from 613.8 in New York to 1,651.7 in New Mexico. Implementation of effective strategies for preventing excessive drinking, including those recommended by the Community Preventive Services Task Force (e.g., increasing alcohol taxes and regulating the number and concentration of alcohol outlets), could reduce alcohol-attributable deaths and YPLL.†.

This special issue on substance use issues comes at a critical time for Canadian health policy makers and researchers. Most attention is currently focussed on the opioid crisis and the potential impacts of cannabis legalization. However, our most widely used and harmful substances continue to be alcohol and nicotine. Our policies to reduce harms from these substances are failing. While alcohol control policies are being gradually abandoned, opportunities to maximize the harm reduction potential of new, alternative and safer nicotine delivery devices are not being grasped. More generally, a greater focus is needed on harm reduction strategies that are informed by the experience of marginalized people with severe substance use-related problems so as to not exacerbate health inequities. In order to better inform policy responses, we recommend innovative approaches to monitoring and surveillance that maximize the use of multiple data sources, such as those used in the Canadian Substance Use Costs and Harms (CSUCH) project. Greater attention to precision in defining patterns of risky use and harms is also needed to support policies that more accurately reflect and respond to actual levels of substance use-related harm in Canadian society.Ce numéro spécial sur les problèmes de consommation de substances paraît dans une période cruciale pour les responsables des politiques et pour les chercheurs canadiens en matière de santé. À l’heure actuelle, ce sont la crise des opioïdes et les répercussions possibles de la légalisation du cannabis qui retiennent le plus l’attention. Cependant, les substances les plus consommées et les plus nocives demeurent l’alcool et la nicotine. Les politiques visant à réduire les méfaits de ces substances ne suffisent pas : les politiques sur le contrôle de l’alcool sont progressivement abandonnées et on ne saisit pas les occasions de maximiser le potentiel de réduction des méfaits associé aux nouveaux dispositifs d’administration de nicotine plus sécuritaires. Plus généralement, il faut davantage cibler les stratégies de réduction des méfaits fondées sur l’expérience des personnes marginalisées ayant de graves problèmes de consommation de substances, de manière à ne pas aggraver les inégalités en matière de santé. Afin de mieux éclairer les interventions stratégiques, nous recommandons des approches novatrices de contrôle et de surveillance qui maximisent le recours à de multiples sources de données, comme celles utilisées dans le cadre du projet Coûts et méfaits de l’usage de substances au Canada (CEMUSC). Il faut également accorder une plus grande attention à la précision des définitions de ce qu’est une habitude de consommation à risque et un méfait, afin de favoriser l’adoption de politiques qui tiennent mieux compte des taux réels de méfaits liés à la consommation de substances dans la société canadienne et qui sont davantage capables de les contrer.Substance use in Canada cost $46 billion in 2017, with the great majority of these costs resulting from the use of tobacco and alcohol. Substance use-related costs, harms and rates of use have been increasing in Canada over the past decades for both legal and illegal substances, including those for cannabis. Canadian policies to address our most harmful substances, i.e. alcohol, cannabis and tobacco, are largely failing, despite significant opportunities to improve policies on pricing, taxation and marketing of legal substances. Canada's monitoring and surveillance efforts can be improved by developing more discerning measures of risk and maximizing the use of multiple data sources.Au Canada, la consommation de substances a coûté 46 milliards de dollars en 2017, la grande majorité de ces coûts découlant du tabagisme et de la consommation d’alcool. Au Canada, les taux de consommation de substances ainsi que les coûts et les méfaits connexes ont augmenté au cours des dernières décennies, que ce soit pour les substances légales ou illégales, en particulier le cannabis. Les politiques canadiennes en matière de lutte contre la consommation des substances les plus nocives, soit l’alcool, le cannabis et le tabac, sont en grande partie inefficaces, malgré d’importantes possibilités d’amélioration en matière de tarification, de taxation et de commercialisation des substances légales. Il est possible d’améliorer les efforts de contrôle et de surveillance au Canada en élaborant des mesures de risque bien pensées et en maximisant l’utilisation de multiples sources de données.

Background Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase. Methods Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance. Results Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p Conclusions Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

OBJECTIVE: Policy makers require evidence-based estimates of the economic costs of substance use-attributable lost productivity to set strategies aimed at reducing substance use-related harms. Building on a study by Rehm et al. (2006), we provide estimates of workplace costs using updated methods and data sources. METHODS: We estimated substance use-attributable productivity losses due to premature mortality, long-term disability, and presenteeism/absenteeism in Canada between 2007 and 2014. Lost productivity was estimated using a hybrid prevalence and incidence approach. Substance use prevalence data were drawn from three national self-report surveys. Premature mortality data were from the Canadian Vital Statistics Death Database, and long-term disability and workplace interference data were from the Canadian Community Health Survey. RESULTS: In 2014, the total cost of lost productivity due to substance use was $15.7 billion, or approximately $440 per Canadian, an increase of 8% from 2007. Substances responsible for the greatest economic costs were alcohol (38% of per capita costs), tobacco (37%), opioids (12%), other central nervous system (CNS) depressants (4%), other CNS stimulants (3%), cannabis (2%), cocaine (2%), and finally other psychoactive substances (2%). CONCLUSION: In 2014, alcohol and tobacco represent three quarters of substance use-related lost productivity costs in Canada, followed by opioids. These costs provide a valuable baseline that can be used to assess the impact of future substance use policy, practice, and other interventions, especially important given Canada’s opioid crisis and recent cannabis legalization. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.17269/s41997-019-00271-8) contains supplementary material, which is available to authorized users.

Alcohol minimum unit pricing is a strategy capable of reducing alcohol-related harm from cheap alcoholic beverages. We used the International Model of Alcohol Harms and Policies (InterMAHP), an open-access alcohol harms estimator and policy scenario modeler, to estimate the potential health benefits of introducing minimum unit pricing in Québec, Canada.Aggregated mortality and hospitalization data were obtained from official administrative sources. Alcohol sales and pricing data were obtained from the partial government retail monopoly and Nielsen. Exposure data were from the Canadian Substance Use Exposure Database. Average price changes under two minimum-unit-pricing scenarios were estimated by applying a product-level pricing analysis. The online InterMAHP tool was used to automate the estimation of observed alcohol-attributable harm and what was projected in each policy scenario.Alcohol was estimated to cause 2,850 deaths and 24,694 hospitalizations in Québec in 2014. Introducing minimum unit pricing of CAD$1.50 was estimated to reduce consumption by 4.4%, alcohol-attributable deaths by 5.9% (95% CI [0.2%, 11.7%]), and alcohol-attributable hospital stays by 8.4% (95% CI [3.2%, 13.7%]). Higher minimum unit pricing of CAD$1.75 was estimated to reduce alcohol-attributable deaths by 11.5% (95% CI [5.9%, 17.2%]) and alcohol-attributable hospital stays by 16.3% (95% CI [11.2%, 21.4%]).The results of this policy modeling study suggest that the introduction of minimum unit pricing between CAD$1.50 and $1.75 would substantially reduce the alcohol-caused burden of disease in Québec. The quantification of alcohol-caused death and disability, and the changes in these measures under two scenarios, was significantly automated by the open-access resource, InterMAHP.

Aims Building upon an existing methodology and conceptual framework for estimating the association between the use of substances and crime, we calculated attributable fractions that estimate the proportion of crimes explained by alcohol and six other categories of psychoactive substances. Design Cross-sectional surveys. Setting Canadian federal correctional institutions. Participants Canadian men (n = 27 803) and women (n = 1335) offenders who began serving a custodial sentence in a Canadian federal correctional institution between 2006 and 2016. Measurements Offenders completed the computerized assessment of substance abuse, a self-report tool designed to assess (1) whether the offence for which they were convicted would have occurred had they not been intoxicated from alcohol or another substance, (2) whether they committed the offence to support their alcohol or other substance use and (3) whether they were dependent on alcohol (alcohol dependence scale) or another substance (drug abuse screening test). Offences were grouped into four mutually exclusive categories: violent crimes, non-violent crimes, impaired driving and substance-defined crimes. This study focused on violent and non-violent crime categories. Substances assessed were: alcohol, cannabis, opioids, other central nervous system (CNS) depressants, cocaine, other CNS stimulants and other substances. Findings According to offender self-report, 42% of all violent and non-violent crime would probably not have occurred if the perpetrator had not been under the influence of, or seeking, alcohol or other substances. Between 2006 and 2016, 20% of violent crimes and 7% of non-violent crimes in Canada were considered attributable to alcohol. In contrast, all other psychoactive substance categories combined were associated with 26% of all violent crime and 25% of non-violent crime during the same time-frame. Conclusions Attributable fraction analyses show that more than 42% of Canadian crime resulting in a custodial sentence between 2006 and 2016 would probably not have occurred if the perpetrator had not been under the influence of or seeking alcohol or other drugs. Attributable fractions for alcohol and substance-related crime are a potentially useful resource for estimating the impact of alcohol and other substances on crime.

The COVID‐19 pandemic and subsequent restrictions have resulted in additional challenges for persons with alcohol use disorders as well as for the effective operation of alcohol controls in different societies. The challenges are different in different systems and economies. Crises such as these often provide governments with opportunities to remake systems. We use the recent experience from India, which rapidly shifted between total countrywide prohibition of alcohol and unrestricted sales during this brief period, to argue against using the present crisis to bring about quick changes in alcohol policy in India. Instead, we advocate sustained, incremental pressure to develop and enforce alcohol control measures in public health delivery systems, in addition to demand reduction measures.

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

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

This summary article compares government revenue from the sale and distribution of alcohol to the societal costs caused by alcohol use for the year 2014. Statistics Canada data reported government revenue of $10.9 billion; however, this was offset by net societal costs of $14.6 billion, as reported by Canada's national substance use surveillance system, the Canadian Substance Use Costs and Harms project. The societal costs include health care, economic loss of production, criminal justice and other direct costs. Though revenue from alcohol sales has been described as a benefit to public coffers, accounting that includes costs incurred shows that all provinces and territories in Canada are running an alcohol deficit, totalling $3.7 billion nationally.Cet aperçu offre une comparaison entre les recettes publiques provenant de la vente et de la distribution d’alcool et les coûts pour la société associés à la consommation d’alcool, et ce, pour l’année 2014. Les données de Statistique Canada font état de recettes publiques de 10,9 milliards de dollars. Toutefois, ce montant est contrebalancé par des coûts nets pour la société de 14,6 milliards de dollars, comme le rapporte le projet Coûts et méfaits de l’usage de substances au Canada, un projet de surveillance nationale de la consommation de substances. Les coûts pour la société sont constitués des soins de santé, de la perte de productivité économique, de la justice pénale et de divers autres coûts directs. Bien que les recettes de vente d’alcool soient considérées comme un avantage pour les coffres de l’État, une comptabilisation tenant compte des coûts engagés montre que les provinces et les territoires du Canada subissent plutôt un déficit associé à l’alcool, pour un total de 3,7 milliards de dollars à l’échelle nationale.Canada runs an alcohol deficit of $3.7 billion per year, when accounting considers both government revenue and societal costs from established sources. Government revenue totalled $10.9 billion in 2014, but this was more than offset by societal costs of $14.6 billion, as reported by the Canadian Substance Use Costs and Harms project. Societal costs include health care, lost productivity, criminal justice and other direct costs. Among provinces and on a per capita basis, Alberta had the lowest government revenue and the highest alcohol deficit.Le Canada subit un déficit associé à l’alcool d’environ 3,7 milliards de dollars par année si on comptabilise à la fois les recettes publiques et les coûts pour la société provenant de sources établies. Les recettes publiques étaient de 10,9 milliards de dollars en 2014, mais ce montant a été plus que contrebalancé par des coûts pour la société de 14,6 milliards de dollars, comme le rapporte le projet Coûts et méfaits de l’usage de substances au Canada. Les coûts pour la société sont constitués des soins de santé, de la perte de productivité, de la justice pénale et de divers autres coûts directs. Au sein des provinces, et sur la base d’un calcul par habitant, c’est en Alberta que les recettes publiques sont les plus faibles et que le déficit associé à l’alcool a été le plus élevé.

Aim To establish whether the population-level pattern of cannabis use by quantity is similar to the distributions previously reported for alcohol, in which a small subset of drinkers accounts for a majority of total population alcohol consumption. Method The current study pooled Waves 1–3 of the 2018 National Cannabis Survey (n = 18,900; 2584 past-three-month cannabis users), a set of stratified, population-based surveys designed to assess cannabis consumption and related behaviors in Canada. Each survey systematically measured self-reported cannabis consumption by quantity across seven of the major cannabis-product types. In order to enable the conversion of self-reported consumption of non-flower cannabis products into a standard joint equivalent (SJE: equal to 0.5 g of dried cannabis), we created conversion metrics for physical production equivalencies across cannabis products. Results Similar to the findings in the alcohol literature, study results show that cannabis consumption is highly concentrated in a small subset of users: the upper 10% of cannabis users accounted for approximately two-thirds of all cannabis consumed in the country. Males reported consuming more cannabis by volume than females (approximately 60% versus 40%), with young males (15–34 years old) being disproportionately represented in the heaviest-using subgroups. Conclusions Most of the cannabis used in Canada is consumed by a relatively small population of very heavy cannabis users. Future research should attempt to identify the characteristics of the heaviest-using groups, as well as how population-level cannabis consumption patterns relate to the calculus of cannabis-related harms in society.

Alcohol use causes approximately 10% of deaths among adults ages 20-65 in the United States. Although previous research has demonstrated differential age-related risk relationships, it is difficult to estimate the magnitude of selection bias attributable to premature mortality based on existing cohort studies, the average age of which is greater than 50 years. The objective of our study was to assess the distribution of mortality-related harms and benefits from alcohol among adults ages 20 and older in comparison with the distribution among those older than age 50.Data from the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact software application from 2006-10 were used to determine the distribution of alcohol-attributable deaths (AADs) and the years of potential life lost (YPLLs) that was caused or prevented by alcohol for 54 conditions by 15-year age groupings (20-34, 35-49, 50-64, 65+) in the United States. We also determined the proportion of net deaths and YPLLs occurring in each age group, overall and by cause of death.Adults ages 20-49 years experienced 35.8% of the deaths and 58.4% of the YPLLs caused by alcohol, whereas the same group accrued only 4.5% of AADs and 14.2% of YPLLs gained. Overall, 46.3% of the total net deaths and 64.7% of the net YPLLs occurred among those ages 20-49; adding net deaths occurring among those ages 20-49 to those occurring after age 50 would result in an 86.3% relative increase in net deaths.Because of premature mortality, alcohol-mortality associations based on cohort studies may underestimate negative health consequences compared with those observed among the general population.

Background Government alcohol monopolies were created in North America and Scandinavia to limit health and social problems. The Swedish monopoly, Systembolaget, reports to a health ministry and controls the sale of all alcoholic beverages with > 3.5% alcohol/volume for off-premise consumption, within a public health mandate. Elsewhere, alcohol monopolies are being dismantled with evidence of increased consumption and harms. We describe innovative modelling techniques to estimate health outcomes in scenarios involving Systembolaget being replaced by 1) privately owned liquor stores, or 2) alcohol sales in grocery stores. The methods employed can be applied in other jurisdictions and for other policy changes. Methods Impacts of the privatisation scenarios on pricing, outlet density, trading hours, advertising and marketing were estimated based on Swedish expert opinion and published evidence. Systematic reviews were conducted to estimate impacts on alcohol consumption in each scenario. Two methods were applied to estimate harm impacts: (i) alcohol attributable morbidity and mortality were estimated utilising the International Model of Alcohol Harms and Policies (InterMAHP); (ii) ARIMA methods to estimate the relationship between per capita alcohol consumption and specific types of alcohol-related mortality and crime. Results Replacing government stores with private liquor stores (Scenario 1) led to a 20.0% (95% CI, 15.3–24.7) increase in per capita consumption. Replacement with grocery stores (Scenario 2) led to a 31.2% (25.1–37.3%) increase. With InterMAHP there were 763 or + 47% (35–59%) and 1234 or + 76% (60–92%) more deaths per year, for Scenarios 1 and 2 respectively. With ARIMA, there were 850 (334–1444) more deaths per year in Scenario 1 and 1418 more in Scenario 2 (543–2505). InterMAHP also estimated 10,859 or + 29% (22–34%) and 16,118 or + 42% (35–49%) additional hospital stays per year respectively. Conclusions There would be substantial adverse consequences for public health and safety were Systembolaget to be privatised. We demonstrate a new combined approach for estimating the impact of alcohol policies on consumption and, using two alternative methods, alcohol-attributable harm. This approach could be readily adapted to other policies and settings. We note the limitation that some significant sources of uncertainty in the estimates of harm impacts were not modelled.

The existence and potential level of cardioprotection from alcohol use is contested in alcohol studies. Assumptions regarding the risk relationship between alcohol use and ischaemic heart disease (IHD) are critical when providing advice for national drinking guidelines and for designing alcohol harm monitoring systems. We use three meta-analyses regarding alcohol use and IHD risk to investigate how varying assumptions lead to differential estimates of alcohol-attributable (AA) deaths and weighted relative risk (RR) functions, in Australia and Canada. Alcohol exposure and mortality data were acquired from administrative sources and AA fractions were calculated using the International Model of Alcohol Harms and Policies. We then customized a recent Global Burden of Disease (GBD) analysis to inform drinking guidelines internationally. Australians drink slightly more than Canadians, per person, but are also more likely to identify as lifetime abstainers. Cardioprotective scenarios resulted in substantial differences in estimates of net AA deaths in Australia (between 2933 and 4570) and Canada (between 5179 and 8024), using GBD risk functions for all other alcohol-related conditions. Country-specific weighted RR functions were analyzed to provide advice toward drinking guidelines: Minimum risk was achieved at or below alcohol use levels of 10 g/day ethanol, depending on scenario. Consumption levels resulting in &lsquo, no added&rsquo, risk from drinking were found to be between 10 and 15 g/day, by country, gender, and scenario. These recommendations are lower than current guidelines in Australia, Canada, and some other high-income countries: These guidelines may be in need of downward revision.

Estimated alcohol consumption from national self-report surveys is often only 30-40% of official estimates based on sales or taxation data. Global burden of disease (GBD) estimates for alcohol adjust survey estimates up to 80% of total per capita consumption. This assumes that cohort studies needed to estimate relative risks for disease suffer less from under-reporting than typical national surveys. However, there is limited evidence on which to base that assumption. This paper aims to assess the extent of underestimation of alcohol consumption in cohort studies concerning alcohol and mortality compared with official total consumption estimates.Comparisons of estimated per capita consumption from a comprehensive sample of cohort studies against official estimates by country and year.A total of 1 876 046 participants in 40 cohort studies from 18 countries on alcohol use and all-cause mortality identified by systematic review.Alcohol consumption data from the cohort studies were converted into usual grams of ethanol per day and then to total age 15+ per capita consumption. Matched estimates were sourced from the World Health Organization (WHO) Global Health Observatory.The cohort studies had mean coverages of age 15+ per capita alcohol consumption of 61.71% (ranging from 29.19% for Russia to 96.53% for Japan), after weighting estimates by sample size for within-country estimates and by number of studies per country for the overall estimate. Regional estimates were higher for the United States (66.22%) and lower for western European countries (55.35%).Underestimation of alcohol consumption in cohort studies is less than in typical population surveys. Because some under-coverage is caused by under-sampling heavier drinkers, the current practice of uplifting survey estimates to 80% of total population consumption in global burden of disease studies appears to be appropriate.

The province of Saskatchewan, Canada introduced minimum prices graded by alcohol strength in April 2010. As previous research found this intervention significantly decreased alcohol consumption and alcohol-attributable morbidity, we aim to test the association between the intervention and the rate of emergency department (ED) visits in four alcohol-related injury categories [motor vehicle collisions (MVC), assaults, falls and total alcohol-related injuries].Data on ED visits in the city of Regina were obtained from the Saskatchewan Ministry of Health. Auto-regressive integrated moving average time series models were used to test the immediate and lagged effects of the pricing intervention on rates of alcohol-related nighttime. ED visits and controlled for daytime rates of ED visits, economic variables, linear and seasonal trends, and auto-regressive and moving average effects.The implementation of an alcohol minimum pricing strategy in Saskatchewan was associated with decreased MVC-related ED visits for women aged 26 and over after a 6 month lag period (-39.4%, P 0.001). There was no significant abrupt effect of this intervention on ED visits of four injury types in any of four gender-age categories; however, rates of ED visits among young males for MVCs and assaults decreased substantially during this study.The minimum pricing policy change led to a lagged decrease in motor vehicle-collision-related ED visits for women older than 25. Of note, there did not appear to be an instantaneous effect on the rate of alcohol-related injury ED visits immediately after the policy implementation nor lagged effects for other gender-age groups.

Saskatchewan's introduction in April 2010 of minimum prices graded by alcohol strength led to an average minimum price increase of 9.1% per Canadian standard drink (=13.45 g ethanol). This increase was shown to be associated with reduced consumption and switching to lower alcohol content beverages. Police also informally reported marked reductions in night-time alcohol-related crime.This study aims to assess the impacts of changes to Saskatchewan's minimum alcohol-pricing regulations between 2008 and 2012 on selected crime events often related to alcohol use.Data were obtained from Canada's Uniform Crime Reporting Survey. Auto-regressive integrated moving average time series models were used to test immediate and lagged associations between minimum price increases and rates of night-time and police identified alcohol-related crimes. Controls were included for simultaneous crime rates in the neighbouring province of Alberta, economic variables, linear trend, seasonality and autoregressive and/or moving-average effects.The introduction of increased minimum-alcohol prices was associated with an abrupt decrease in night-time alcohol-related traffic offences for men (-8.0%, P 0.001), but not women. No significant immediate changes were observed for non-alcohol-related driving offences, disorderly conduct or violence. Significant monthly lagged effects were observed for violent offences (-19.7% at month 4 to -18.2% at month 6), which broadly corresponded to lagged effects in on-premise alcohol sales.Increased minimum alcohol prices may contribute to reductions in alcohol-related traffic-related and violent crimes perpetrated by men. Observed lagged effects for violent incidents may be due to a delay in bars passing on increased prices to their customers, perhaps because of inventory stockpiling. [Stockwell T, Zhao J, Sherk A, Callaghan RC, Macdonald S, Gatley J. Assessing the impacts of Saskatchewan's minimum alcohol pricing regulations on alcohol-related crime. Drug Alcohol Rev 2017;36:492-501].

OBJECTIVE: Systematic reviews and meta-analyses were completed studying the effect of changes in the physical availability of take-away alcohol on per capita alcohol consumption. Previous reviews examining this topic have not focused on off-premise outlets where take-away alcohol is sold and have not completed meta-analyses. METHOD: Systematic reviews were conducted separately for policies affecting the temporal availability (days and hours of sale) and spatial availability (outlet density) of take-away alcohol. Studies were included up to December 2015. Quality criteria were used to select articles that studied the effect of changes in these policies on alcohol consumption with a focus on natural experiments. Random-effects meta-analyses were applied to produce the estimated effect of an additional day of sale on total and beverage-specific consumption. RESULTS: Separate systematic reviews identified seven studies regarding days and hours of sale and four studies regarding density. The majority of articles included in these systematic reviews, for days/hours of sale (7/7) and outlet density (3/4), concluded that restricting the physical availability of take-away alcohol reduces per capita alcohol consumption. Meta-analyses studying the effect of adding one additional day of sale found that this was associated with per capita consumption increases of 3.4% (95% CI [2.7, 4.1]) for total alcohol, 5.3% (95% CI [3.2, 7.4]) for beer, 2.6% (95% CI [1.8, 3.5]) for wine, and 2.6% (95% CI [2.1, 3.2]) for spirits. The small number of included studies regarding hours of sale and density precluded meta-analysis. CONCLUSIONS: The results of this study suggest that decreasing the physical availability of take-away alcohol will decrease per capita consumption. As decreasing per capita consumption has been shown to reduce alcohol-related harm, restricting the physical availability of take-away alcohol would be expected to result in improvements to public health.