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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 Shield and colleagues' results, 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 due to 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 in order to obtain more consistent estimates and to formulate, advocate for, and implement alcohol policies more effectively.

Aim Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence. Methods A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants. Results Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6–-12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants’ liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms. Conclusion MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.

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.

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.

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.

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.

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.

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.

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.

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

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

Introduction and Aims Managed alcohol programs (MAP) are intended for people with severe alcohol-related problems and unstable housing. We investigated whether MAP participation was associated with changes in drinking patterns and related harms. Design and Methods One hundred and seventy-five MAP participants from five Canadian cities (Hamilton, Ottawa, Toronto, Thunder Bay and Vancouver) and 189 same-city controls were assessed for alcohol consumption, health, safety and harm outcomes. Length of stay in a MAP was investigated as a predictor of drinking patterns, non-beverage alcohol consumption and related harms. Statistical controls were included for housing stability, age, gender, ethnic background and city of residence. Negative binomial regression and logistic regression models were used. Results Recently admitted MAP participants (≤2 months) and controls were both high consumers of alcohol, predominantly male, of similar ethnic background, similarly represented across the five cities and equally alcohol dependent (mean Severity of Alcohol Dependence Questionnaire = 29.7 and 31.4). After controlling for ethnicity, age, sex, city and housing stability, long-term MAP residents (>2 months) drank significantly more days (+5.5) but 7.1 standard drinks fewer per drinking day than did controls over the last 30 days. Long-term MAP residents reported significantly fewer alcohol-related harms in the domains of health, safety, social, legal and withdrawal. Discussion and Conclusions Participation in a MAP was associated with more frequent drinking at lower quantities per day. Participation was associated with reduced alcohol-related harms over the past 30 days. Future analyses will examine outcomes longitudinally through follow-up interviews, police and health care records.

Introduction In 2012, 10% of Canadians used cannabis and just under half of those who use cannabis were estimated to have driven under the influence of cannabis. Substantial evidence has accumulated to indicate that driving after cannabis use increases collision risk significantly; however, little is known about the extent and costs associated with cannabis-related traffic collisions. This study quantifies the costs of cannabis-related traffic collisions in the Canadian provinces. Methods Province and age specific cannabis-attributable fractions (CAFs) were calculated for traffic collisions of varying severity. The CAFs were applied to traffic collision data in order to estimate the total number of persons involved in cannabis-attributable fatal, injury and property damage only collisions. Social cost values, based on willingness-to-pay and direct costs, were applied to estimate the costs associated with cannabis-related traffic collisions. The 95% confidence intervals were calculated using Monte Carlo methodology. Results Cannabis-attributable traffic collisions were estimated to have caused 75 deaths (95% CI: 0–213), 4407 injuries (95% CI: 20–11,549) and 7794 people (95% CI: 3107–13,086) were involved in property damage only collisions in Canada in 2012, totalling $1,094,972,062 (95% CI: 37,069,392–2,934,108,175) with costs being highest among younger people. Discussion The cannabis-attributable driving harms and costs are substantial. The harm and cost of cannabis-related collisions is an important factor to consider as Canada looks to legalize and regulate the sale of cannabis. This analysis provides evidence to help inform Canadian policy to reduce the human and economic costs of drug-impaired driving.

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.

There is an interest globally in using Minimum Unit Pricing (MUP) of alcohol to promote public health. Canada is the only country to have both implemented and evaluated some forms of minimum alcohol prices, albeit in ways that fall short of MUP. To inform these international debates, we describe the degree to which minimum alcohol prices in Canada meet recommended criteria for being an effective public health policy. We collected data on the implementation of minimum pricing with respect to (1) breadth of application, (2) indexation to inflation and (3) adjustments for alcohol content. Some jurisdictions have implemented recommended practices with respect to minimum prices; however, the full harm reduction potential of minimum pricing is not fully realised due to incomplete implementation. Key concerns include the following: (1) the exclusion of minimum prices for several beverage categories, (2) minimum prices below the recommended minima and (3) prices are not regularly adjusted for inflation or alcohol content. We provide recommendations for best practices when implementing minimum pricing policy.

Giesbrecht, N., Wettlaufer, A., Cukier, S., Geddie, G., Goncalves, A., & Reisdorfer, E. (2016). Do alcohol pricing and availability policies have differential effects on sub-populations? A commentary. The International Journal Of Alcohol And Drug Research, 5 (3), 89-99. doi: http://dx.doi.org/10.7895/ijadr.v5i3.227 Aims: Numerous policies have been shown to reduce the harm from alcohol; however, not all sub-populations respond similarly to policy interventions. This paper explores the specific effects of alcohol pricing policies and controls regarding physical availability on different types of harms from alcohol as well as on different sectors of the population, including impacts by gender, age, and drinking patterns. Design, Setting, Participants, and Measures: We focus on two dimensions. The first is alcohol pricing and taxation; the second is alcohol availability, comprising type of alcohol control system, outlet density, and hours/days of sale. We focused on peer-reviewed research and reviews published from 2005–2015, using several databases: PsycINFO, MEDLINE/PubMed, and Cochrane. Findings: Precautionary alcohol prices have substantial harm reduction potential, particularly among youth and high-risk drinkers. Restrictions on outlet densities and hours/days of sale impact the drinking patterns of underage youth, reduce high-risk drinking, and reduce alcohol-related harm. A reduction in prices or an increase in alcohol availability are associated with increase in high-risk drinking or alcohol-related harm. Conclusions: Future work should examine these policy measures in light of socioeconomic status and cultural factors, as well as impacts of policy interventions on evidence of harm to others from alcohol.

Giesbrecht, N., Wettlaufer, A., Simpson, S., April, N., Asbridge, M., Cukier, S., Mann, R., McAllister, J., Murie, A., Pauley, C., Plamondon, L., Stockwell, T., Thomas, G., Thompson, K., & Vallance, K. (2016). Strategies to reduce alcohol-related harms and costs in Canada: A comparison of provincial policies. The International Journal Of Alcohol And Drug Research, 5 (2), 33-45. doi: http://dx.doi.org/10.7895/ijadr.v5i2.221 Aims: To compare Canadian provinces across 10 research-based alcohol policy and program dimensions. Design and Measures: The 10 Canadian provinces were assessed on the following 10 policy dimensions: alcohol pricing; alcohol control system; physical availability; drinking and driving; marketing and advertising; legal drinking age; screening, brief intervention, and referrals; server training, challenge, and refusal programs; provincial alcohol strategy; warning labels and signs. Data were collected from official documents, including provincial legislation, regulations, and policy, and strategy documents. Three international experts on alcohol policy contributed to refining the protocol. Provincial scores were independently determined by two team members along a 10-point scale for each dimension, and the scores were expressed as a percentage of the ideal. Weighting of dimensions according to scope of impact and effectiveness was applied to obtain the final scores. National and provincial scores were calculated for each dimension and consolidated into overall averages. Findings: Overall, the consolidated national mean is 47.2% of the ideal, with Ontario scoring highest at 55.9%, and Quebec lowest at 36.2%. Across dimensions, Legal Drinking Age and Challenge and Refusal Programs scored highest at 75% and 61%, respectively, while Warning Labels and Signs scored lowest at 18% of the ideal. Pricing, rated third highest among dimensions at 57%, should nevertheless remain a priority for improvement, given it is weighted highest in terms of effectiveness and scope. Conclusions and Implications : Policy dimension scores vary among the provinces, with substantial room for improvement in all. Since spring 2013, several provinces have taken steps to implement specific alcohol policies. Concerted action involving multiple stakeholders and alcohol policies is required to reduce the burden of alcohol problems across Canada.

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).

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

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.

In order to reduce harms from alcohol, evidence-based policies are to be introduced and sustained.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.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.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.

The current report compares Canadian provinces across three policy/program dimensions demonstrated to reduce alcohol-related problems among 15–24-year-olds. The dimensions, Legal Drinking Age, Server and Manager Training/Challenge and Refusal Programs, and Drinking and Driving, were assessed using specified indicators with provincial scores reflecting the percentage of the ideal attained. National means for each dimension were also calculated. Legal Drinking Age attained the highest national mean at 75% of the ideal; Server and Manager Training/Challenge and Refusal Programs achieved 61%; Drinking and Driving achieved 34% of the ideal. Results specify how provinces can increase prevention impact through evidence-based policy and program measures.

INTRODUCTION AND AIMS: The aim of our paper is to present trend data concerning public opinion on alcohol policy in the Canadian province of Ontario over a 16-year period (1996-2011), to assess if the level of support for alcohol control policies changed over this period and if any changes in public support for alcohol policy parallel real changes in alcohol distribution in Ontario. DESIGN AND METHODS: Selected policy-related items from 10 probability surveys of Ontario adults were analysed by means of logistic regression. RESULTS: A significant decline was found for attitudes supporting restricting corner stores sales and government control of liquor stores. A weaker decline was seen for attitudes towards reducing the number of places to buy alcohol. However, an increasing trend for attitudes favouring the status quo or greater control through taxes and hours of sale was found. There was no significant trend for attitudes towards maintaining the current level or reducing the number of liquor or beer stores. While there was some variation in trends in support by demographic characteristics and drinking level, not one sector stood out. DISCUSSION AND CONCLUSIONS: A gradual erosion of support is evident and concurrent with gradual increase in access to alcohol in Ontario during the time-period under study. The decline in support for alcohol control measures seems to be a general rather than a focused development. It appears that this was largely due to a shift in a greater percentage supporting the status quo, not a move towards increasing access to alcohol. Language: en

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.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.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, P0.001) 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, P0.001) 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).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.

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.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.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.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.

Managed alcohol programs (MAP) are intended for people with severe alcohol-related problems and unstable housing. We investigated whether MAP participation was associated with changes in drinking patterns and related harms.One hundred and seventy-five MAP participants from five Canadian cities (Hamilton, Ottawa, Toronto, Thunder Bay and Vancouver) and 189 same-city controls were assessed for alcohol consumption, health, safety and harm outcomes. Length of stay in a MAP was investigated as a predictor of drinking patterns, non-beverage alcohol consumption and related harms. Statistical controls were included for housing stability, age, gender, ethnic background and city of residence. Negative binomial regression and logistic regression models were used.Recently admitted MAP participants (≤2 months) and controls were both high consumers of alcohol, predominantly male, of similar ethnic background, similarly represented across the five cities and equally alcohol dependent (mean Severity of Alcohol Dependence Questionnaire = 29.7 and 31.4). After controlling for ethnicity, age, sex, city and housing stability, long-term MAP residents (2 months) drank significantly more days (+5.5) but 7.1 standard drinks fewer per drinking day than did controls over the last 30 days. Long-term MAP residents reported significantly fewer alcohol-related harms in the domains of health, safety, social, legal and withdrawal.Participation in a MAP was associated with more frequent drinking at lower quantities per day. Participation was associated with reduced alcohol-related harms over the past 30 days. Future analyses will examine outcomes longitudinally through follow-up interviews, police and health care records.

Aims There is a long-standing discussion about whether some beverages are more likely to be linked with high-risk drinking and damage than others, and implications for beverage specific alcohol policies. While the evidence is inconclusive, when controlling for individual consumption, some studies have shown elevated risks by beverage type. This paper examines the situation in Ontario, Canada, from 1995 to present (2011) on several dimensions in order to assess the differences by beverage and their rationale with a specific focus on the most recent policie. Methods This paper draws on archival consumption statistics, taxation and pricing arrangements, and retailing and marketing practices. Results Off-premise sales, which represent an estimated 75% of ethanol, involve several channels: stores controlled by the Liquor Control Board (LCBO) – which sell all spirits, imported and domestic wines, and beer products; the Beer Store network which sell all beers; and Ontario winery stores – which sell Ontario wines. In LCBO stores Ontario wines are more prominently displayed than other beverages, and extensive print advertising tends to feature wine over beer and spirits. There are also differences by beverage in terms of taxation and price. The taxes on higher alcohol content beverage types account for a higher portion of the retail price than taxes on lower alcohol content beverage types. Furthermore, minimum price regulations allow for differential minimum pricing per standard drink [17.05 ml ethanol] across beverage types. Conclusions The apparent rationale for these arrangements is not primarily that of favouring lighter-strength beverages in order to reduce harm, but rather to accommodate long-standing vested interests which are primarily financially based.

Introduction and Aims.This paper contrasts health-oriented low-risk drinking guidelines (LRDGs) with social drinking marketing and popular advice on the amount of alcohol to be provided for social occasions. The questions addressed include: What is the underlying evidence base and rationale for health-oriented versus socially oriented drinking guidelines? What are the recommended amounts of alcohol per person from the LRDGs and from popular advice? Design and Methods.This paper draws on existing research, archival data, websites, print media and key informant interviews. The focus is on recent information on LRDGs and social drinking indicators in Canada, the USA, Australia and the UK. Results.There is extensive epidemiological research indicating the associations between drinking pattern and risk for chronic disease and trauma as well as certain potential health benefits from drinking small amounts regularly. This body of evidence is one resource for government or medically sanctioned LRDGs in many jurisdictions. In contrast, for those planning social events where liquor is served, information is available from the hospitality industry, retailers and liquor control boards. While some overlap exists between these two sources of information, in some contexts normative recommendations support drinking at potentially dangerous levels. Discussion and Conclusions.The inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is integrated into social life and used extensively. It also reflects a siloed approach to alcohol policy—where retailing and harm reduction practices are managed by different sectors of government that seldom reflect a coordinated response.[Wettlaufer A, Cukier S, Giesbrecht N, Greenfield TK. The marketing of responsible drinking: Competing voices and interests. Drug Alcohol Rev 2012;31:231–239]

To examine (1) the harms related to the drinking of others in five Canadian provinces, stratified by socio-demographic variables, and (2) the relationship between these harms and mental well-being. A telephone survey sampled 375 adults from British Columbia, Saskatchewan, Ontario, Quebec, and Nova Scotia. Harms related to the drinking of others were measured through 16 questions in the domains of psychological, physical, social, and financial harms. Self-perceived mental well-being was measured with his or her mental well-being. In 2012, 40.1% of Canadian adults surveyed experienced harm in the previous year related to the drinking of another person. These harms were more frequent among people who had a higher education level, were widowed, separated, divorced or never married, and were employed. Psychological, physical, and financial harms related to the drinking of others were significantly correlated to a person’s mental well-being. Harms related to the drinking of others are prevalent in this Canadian survey. Furthermore, the psychological, physical, and financial harms related to the drinking of others negatively impact the mental well-being of the affected individuals.

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

The aim of our paper is to present trend data concerning public opinion on alcohol policy in the Canadian province of Ontario over a 16-year period (1996-2011), to assess if the level of support for alcohol control policies changed over this period and if any changes in public support for alcohol policy parallel real changes in alcohol distribution in Ontario.Selected policy-related items from 10 probability surveys of Ontario adults were analysed by means of logistic regression.A significant decline was found for attitudes supporting restricting corner stores sales and government control of liquor stores. A weaker decline was seen for attitudes towards reducing the number of places to buy alcohol. However, an increasing trend for attitudes favouring the status quo or greater control through taxes and hours of sale was found. There was no significant trend for attitudes towards maintaining the current level or reducing the number of liquor or beer stores. While there was some variation in trends in support by demographic characteristics and drinking level, not one sector stood out.A gradual erosion of support is evident and concurrent with gradual increase in access to alcohol in Ontario during the time-period under study. The decline in support for alcohol control measures seems to be a general rather than a focused development. It appears that this was largely due to a shift in a greater percentage supporting the status quo, not a move towards increasing access to alcohol.

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.

This paper contrasts health-oriented low-risk drinking guidelines (LRDGs) with social drinking marketing and popular advice on the amount of alcohol to be provided for social occasions. The questions addressed include:What is the underlying evidence base and rationale for health-oriented versus socially oriented drinking guidelines?What are the recommended amounts of alcohol per person from the LRDGs and from popular advice?This paper draws on existing research, archival data, websites, print media and key informant interviews. The focus is on recent information on LRDGs and social drinking indicators in Canada, the USA, Australia and the UK.There is extensive epidemiological research indicating the associations between drinking pattern and risk for chronic disease and trauma as well as certain potential health benefits from drinking small amounts regularly. This body of evidence is one resource for government or medically sanctioned LRDGs in many jurisdictions. In contrast, for those planning social events where liquor is served, information is available from the hospitality industry, retailers and liquor control boards.While some overlap exists between these two sources of information, in some contexts normative recommendations support drinking at potentially dangerous levels.The inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is integrated into social life and used extensively. It also reflects a siloed approach to alcohol policy—where retailing and harm reduction practices are managed by different sectors of government that seldom reflect a coordinated response.