A Public Policy Approach to Reducing Harms

Associated with Alcohol and Other Drugs

Canadian Public Health Association

Monday, June 2, 2008

Denise De Pape, M.Sc.Toronto Public Health

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Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences

Chronic Disease

Accidents/Injuries (acute disease)

Acute Social

ChronicSocial

IntoxicationToxic and

benefical biochemicaleffects*

Dependence

Patterns of drinking Average volume

* Independent of intoxication or dependence

Source: T. Babor et al. 2003

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Leading risk factors for disease in emerging and established economies (% total DALYS*) World Health Report, 2002)

0.7 %Iron deficiency1.8 %Unsafe water & sanitation1.9 %Cholesterol

0.8 %Unsafe sex1.8 %Iron deficiency2.0 %Tobacco

1.8 %Illicit drugs1.9 %Indoor smoke from solid fuels2.5 %Blood pressure

3.3 %Physical inactivity1.9 %Low fruit & vegetable intake3.0 %Vitamin A deficiency

3.9 %Low fruit & vegetable intake2.1 %Cholesterol3.1 %Iron deficiency

7.4 %Body mass index2.7 %Body mass index3.2 %Zinc deficiency

7.6 %Cholesterol3.1 %Underweight3.6 %Indoor smoke (solid fuels)

9.2 %Alcohol4.0 %Tobacco5.5 %Unsafe water & sanitation

10.9 %Blood pressure5.0 %Blood pressure10.2 %Unsafe sex

12.2 %Tobacco6.2 %Alcohol14.9%Underweight

Low mortalityHigh mortalityDeveloped countries

Developing countries

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Drinking Patterns & Rates -- Canada

• Both high risk drinking patterns and overall consumption levels have been shown to impact chronic disease and trauma related harm from alcohol.

• Results from the Canadian Community Health Surveys suggest that high-risk drinking has increased from 10% to 14% between 1993 and 2004.

• The per capita (aged 15+) has increased from 7.3 to 7.9 litres between 1997 and 2004

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Drinking Patterns & Rates -- Canada...continued

• The 2004 Canadian Addiction Survey found that 23% of past-year drinkers exceeded the low-risk drinking guidelines.

• Also, 17% of past-year drinkers were considered to drink hazardously (8+ on AUDIT)

• Overall consumption and high risk drinking are on the increase Source: Statistics Canada, Canadian Community Health Surveys; Adlaf, Begin & Sawka, 2005

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Ratings of policy-relevant strategies and interventions

Policy - strategyEffectivenes

sBreadth of research

support

Cross-cultural Testing

Cost to implement

Retail monopoly +++ +++ ++ Low

Restrict outlet density ++ +++ ++ Low

Increase alcohol taxes +++ +++ +++ Low

No service to intoxicated + +++ ++ Moderate

Server liability +++ + + Low

School programs 0 +++ ++ High

Warning labels 0 + + Low

Min. legal purchase age +++ +++ ++ Low

Drivers <21 ‘zero tolerance’

+++ +++ ++ Low

Brief intervention-at risk ++ +++ +++ Moderate

Source: Adapted from T. Babor et al, Alcohol: No ordinary commodity (Table 16.1), 2003, by T. Greenfield, et al. 2007

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Best Practices & Practices with Good Support & Feasibility

• Alcohol taxesAlcohol taxes

• Minimum legal Minimum legal

purchase agepurchase age

• Government monopoly Government monopoly

of retail salesof retail sales

• Sobriety check pointsSobriety check points

• Lowered BAC limitsLowered BAC limits

• Administrative license Administrative license

suspensionsuspension

• Graduated licensing for Graduated licensing for novice driversnovice drivers

• Restrictions on hours Restrictions on hours and days of saleand days of sale

• Restrictions on outlet Restrictions on outlet densitydensity

• Enforcement of on-Enforcement of on-premise regulationspremise regulations

• Brief interventions for Brief interventions for high risk drinkershigh risk drinkers

Source: T. Babor et al. 2003, chapter 16

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A Prediction

Alcohol-related burden (mortality, damage, social and

personal and financial costs) is expected to increase in

Canada in the coming years, because:

• Overall consumption is increasing• High risk drinking is increasing• Alcohol is not on agenda, or only modestly so, with

regard to generic/general chronic disease and injury prevention efforts

• Substantial attention is still devoted to the least or less effective interventions and prevention strategies

- Drinking & driving prevention initiatives are a significant exception

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Lessons from Tobacco Control

1. There are no “magic bullets”

2. Health behaviour is social behaviour

3. Combine scientifically valid interventions and

social movements

4. Multi-faceted, multi-level approaches are needed

5. Research, monitoring and evaluation must be

integral

6. Dose matters; investment is essential

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*

*

(courtesy of John Garcia, PhD)

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Lessons from Tobacco Control...continued

7. Public Health infrastructure is essential

8. Take advantage of inter-dependence of strategies

to achieve multiple ends

9. Prevention among youth requires societal approach,

as opposed to a narrowly targeted approach

10.Leadership is essential

11.A long-term perspective is needed

12.Gains can be reversed

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*

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* Key considerations

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Challenges

1.1. Bridging perspectives that are based on Bridging perspectives that are based on

values rather than evidencevalues rather than evidence

2.2. Generating political leadershipGenerating political leadership

3.3. Securing resources and sustainabilitySecuring resources and sustainability

4.4. Negotiating the divide between public health Negotiating the divide between public health

and community safety and community safety

5.5. Shifting policy environment across levelsShifting policy environment across levels

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Elements for Success

1.1. (Political) leadership and support(Political) leadership and support

2.2. Multi-sector involvement, including major Multi-sector involvement, including major

NGOs and governmentNGOs and government

3.3. Use of evidence to inform policyUse of evidence to inform policy

4.4. Relevance/resonanceRelevance/resonance

5.5. A focus on healthA focus on health

6.6. A provincial/national advocacy networkA provincial/national advocacy network

7.7. Dedicated staff/supportDedicated staff/support

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Role for the Public Health Community• Advocacy skills

• Experience in partnerships

• Understanding of the need to be comprehensive

• Leadership

• Implementing some of the recommendation

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Some specific activities for the Public Health Community:

1. Engage in development of Municipal Alcohol Policies

2. Analyze learnings from tobacco use prevention and apply to alcohol

3. Stop doing ineffective activities

4. Promote Low-Risk Drinking Guidelines and combine with controls on alcohol and partner with advocates for other health issues

5. Hone advocacy skills

6. Advocate for and support municipal, provincial and national

drug/alcohol strategies through reports to Board of Health

7. Collaborate