In recent years, there has been a growing recognition of the importance of public policy in improving the health and well-being of Ontario residents. One of the major health risks that can be successfully addressed through policy initiatives is the unsafe consumption of alcoholic beverages.

Alcohol is the drug of choice for many in our communities. In 1993, the General Social Survey revealed that 74.4% of the province's residents aged 15 or older, consumed alcoholic beverages.(1) And although alcohol is widely used, its consumption is not without risks.

The widespread use of alcoholic beverages is associated with a range of health and social problems, including traffic fatalities, suicides, sports and leisure injuries, violence and reduced productivity in the workplace (Edwards et al., 1994; West et al., 1995). A recent nationwide economic cost study estimated that alcohol-related health care, law enforcement, social welfare services and productivity losses, cost Ontarians some $2.9 billion in 1992, or $270 for every man, woman and child in the province (Single et al., 1996).

Partners in Action, the substance abuse prevention strategy developed by the Ontario government in 1992, notes that "alcohol plays a part in a long list of society's most pressing problems" (p. 7). Yet the link between alcohol consumption and its attendant health, social and economic consequences is often masked by a myriad of social myths.

One of the most enduring misconceptions is that alcohol problems are experienced mainly by those who are dependant on alcohol — "alcoholics" — and that controls on alcohol availability unfairly restrict the freedoms of the vast majority of the population that drinks responsibly. In fact, traffic and crime statistics show that everyone in our society is at risk of alcohol-related problems — including those who do not drink. Policies aimed at the entire population can thus be effective in protecting and promoting public health and safety.

Another misconception is that heavy drinkers cannot be influenced by broad-based control policies. In fact, research has consistently found that the proportion of heavy drinkers is related to the alcohol consumption patterns of the entire population (Edwards et al., 1994). Public policies aimed at preventing alcohol-related problems among the entire population can thus be expected to stem the alcohol-related problems attributable to heavy drinkers as well.

A third common misconception is that alcohol-related problems result solely from drinking to or past the point of intoxication. The World Health Organization, among others, notes that even low or moderate levels of alcohol use can impair workplace and traffic safety, increase the risk of certain cancers and harm the development of the fetus. Accordingly, measures promoting the responsible use of alcohol are a necessary part of any effective population health strategy.

Finally, there is the myth that if people only knew about the risks associated with alcohol they would make healthier choices. Although education is an important part of any comprehensive prevention strategy, by itself, it is not very effective. Personal choice is not the only factor influencing alcohol-related problems. Indeed, research shows that the consumption of alcoholic beverages is related to a range of social, cultural, economic and environmental determinants. Alcohol prices, for example, are a major determinant of consumption. Health-oriented public policies that regulate the retail price of alcoholic beverages, such as differential rates of taxation on the basis of alcoholic content, are among the most effective regulatory mechanisms for promoting responsible drinking practices.

When the links between alcohol consumption and the broader determinants of health such as economic status, employment and social supports are considered, a wide range of policy options emerges. Communities with high rates of poverty and unemployment, and limited access to health, recreational and other services are particularly vulnerable to alcohol-related social problems (Mosher, 1994). To promote a healthier Ontario, those responsible for the development and implementation of alcohol policies need to recognize and, where possible, address these broader issues.

OPHA has long recognized the importance of policy in promoting health. It has also become increasingly aware of the wide-ranging consequences of alcohol misuse. In 1995, a work group was formed to advise the Board on alcohol policy issues. Its main task was to develop a position paper that would:

In the pages that follow, we identify the assumptions on which this paper is based, as well as what we believe to be the cornerstones of health-oriented alcohol policy. We conclude by outlining potential steps that OPHA can take over the coming year — both independently and in collaboration with key partners — to help minimize and prevent alcohol-related harm to individuals and communities.

1. Alcohol is a drug with attendant physiological effects.

Unlike other commercially-marketed beverages and foodstuffs, alcohol products contain ethanol — a psychoactive drug classified as a central nervous system depressant. The acute physiologic effects of alcohol include: sensory and motor changes, visual impairment, a decreased ability to focus and concentrate on stimuli, reduced capacity to process information and make decisions, reduced reaction time and reduced fine motor control.

Alcohol is also an addictive substance. Repeated exposure leads to reduced sensitivity to the drug effects (tolerance). Removal is accompanied by recognized withdrawal syndrome, and a proportion of all individuals who use alcohol become dependent. In Ontario, it is estimated that 12% of the population over age 15 has experienced alcohol abuse or dependence(2) in their lifetimes (Ross, 1995).

2. Alcohol has widespread health and economic consequences for individuals and for society.

In Canada, alcohol use is second only to smoking as the greatest preventable cause of premature death (Single et al., 1996). Exposure to ethanol over a period of time increases the risk of chronic liver disease, heart disease, several forms of cancer, damage to the central and peripheral nervous systems and other chronic health problems.

Alcohol is also a major factor in thousands of preventable injuries and premature deaths due to crashes, falls, suicides, fires, drownings and homicides. Statistics Canada estimates that in 1992, 855 Canadians died as a result of alcohol-related falls, another 1,115 died as a result of self-inflicted injuries and 1,640 perished in alcohol-related motor vehicle crashes (Williams, 1995). Men between the ages of 25 and 45 are the most likely to report drinking and driving; and the most likely to experience trauma related to alcohol (Bierness, 1995). Disproportionately large numbers of young people also die as a result of alcohol-related leisure craft crashes, drownings and suicides.

In addition to health and mortality effects, there are other personal and social costs associated with alcohol use including absenteeism and employment loss, family and social disruption, and the adverse effects of contact with the criminal justice system. Recent data indicate that roughly one in three Ontarians who use alcohol experienced at least one type of alcohol-related health, work, financial or interpersonal problem in 1994 (West et al., 1995).

Problems as a result of others' drinking are also common. A national survey conducted by Health Canada shows that, of the estimated 9.4 million Canadians aged 15 and older who were negatively affected by alcohol in 1994:

The same study found that among all age groups, young people were the most likely to report being passengers in a car driven by a drinking driver; or to be pushed, shoved or insulted by someone who had been drinking (Health Canada, 1995).

And while the toll of alcohol on individual and community health and safety is considerable, its economic impact is no less striking. Alcohol misuse in Canada accounts for $4.1 billion in lost productivity, $1.36 billion in law enforcement costs and $1.3 billion in direct health care costs. The total bill in 1992 — $7.5 billion — represents 40.8% of the costs associated with substance abuse(3), or 1.09% of Canada's Gross Domestic Product (Single et al., 1996).

3. High risk drinking practices are strong predictors of alcohol-related problems.

The way alcohol is used is often more important than the absolute amount consumed. Many people who use alcohol do not experience long term health or psychological effects. In fact, alcohol, whether in the form of spirits, beer, red wine or white wine, can have health benefits. There is evidence to suggest that small amounts of alcohol, in the order of one to two drinks in a day, can reduce blood clots and discourage the build up of arterial plaque — risk factors for coronary heart disease.

Despite some documented health benefits(4), alcohol remains high on the priority list of public health officials. Its costs are high, largely avoidable, and often involving young people. The most recent studies show that every year alcohol is responsible for some 86,000 hospitalizations and 6,700 deaths across Canada, many of them preventable (Single et al., 1996).

Identifying what constitutes higher and lower risk drinking behaviour is an area of active research. Many of the types of acute social consequences associated with alcohol, such as suicide, violence, motor vehicle and other crashes, are associated with the consumption of larger quantities, or with intoxication, as much as with any other measure of total dose. Drinking practices known to be "high risk" include:

4. Comprehensive controls on alcohol availability, complemented by targeted injury prevention and harm reduction strategies, are very effective in minimizing alcohol-related harm to individuals and society.

Proponents of alcohol controls hold that increased access to alcohol leads to increased consumption which leads to increased alcohol-related problems among the general population. They are supported by studies from around the world (Bruun et al., 1975, Wagenaar, 1987, Osterberg and Saila, 1991, Edwards et al., 1994) which show that a decrease in alcohol availability, whether due to: a) reduced supply as a result of a strike, shutdown, wartime rationing or prohibition, or b) reduced demand as a result of higher taxes or prices, is associated with lower rates of liver cirrhosis deaths, alcoholic psychoses, drinking and driving fatalities, public drunkenness, fights and domestic violence (Giesbrecht, 1995).

Currently, alcohol availability is controlled at the provincial level primarily through:

Deterrence and enforcement initiatives generally go hand in hand with limits on alcohol availability. Police, customs officials, Liquor Board inspectors, retailers, bar and restaurant operators, municipal governments and ordinary citizens all play a part in reducing federal Criminal Code and provincial liquor and Highway Traffic Act offenses ranging from drinking and driving, to liquor smuggling, to withholding liquor taxes, to selling alcohol to minors or intoxicated persons.

Programs such as R.I.D.E. (Reduce Impaired Driving Everywhere); the Designated Driver and Sober Operator Programs; Operation Lookout (a community-based program which encourages ordinary citizens to report impaired drivers); and the new Peel Last Drink Program (where police officers ask intoxicated drivers where they had their last drink and pay a visit to the establishment) have been extremely effective in curbing drinking and driving and reducing the number of Ontarians killed or injured in alcohol-related incidents.

Graduated licensing (which prohibits new drivers from drinking and driving during their first two years behind the wheel), and newly improved ignition interlock systems (which prevent drivers from starting their cars if their breath shows signs of impairment) have also been effective in dealing with two groups at risk of alcohol-related harm: young people and repeat drinking drivers(8) (TIRF, 1994).

While the goal of stabilizing or reducing average alcohol consumption remains high on the priority list of health advocates, efforts to minimize the physical, financial and social harm associated with alcohol, without necessarily requiring a reduction in consumption, are attracting attention. In general, harm reduction initiatives use education and a variety of environmental controls to:

Advocates of harm reduction are supported by research from Australia, for example, which suggests that "heavy drinking occasions" are stronger predictors of alcohol-related social problems such as impaired driving, alcohol related family dysfunction and employment problems, than average level of consumption (Single, 1994). Researchers theorize that those who experience problems — generally low-level drinkers who occasionally drink too much — tend to have lower physical tolerance and fewer social supports and coping skills than their harder drinking counterparts.

According to experts like the Canadian Centre on Substance Abuse's Eric Single (1995), the harm reduction approach should be seen as a complementary and practical way to enhance public health and safety in an era of diminished resources and increased de-regulation.

Of course, control policies, even when they are appropriately targeted and strategically enforced, are more effective when they are accepted by a significant proportion of the population. According to the ARF's 1995 Alcohol and Other Drugs Survey, over 70% of Ontarians support current alcohol tax levels and oppose alcohol sales in corner stores. And over three quarters favour warnings labels on alcoholic beverages, an increase in efforts to prevent intoxicated customers from being served, and government measures to educate the public about alcohol.

These findings are consistent with those of seven earlier representative surveys, and show that Ontarians in general favour a strong government role in restricting alcohol availability and raising public awareness about the risks associated with misuse.

The Ontario Public Health Association (OPHA) commits itself to strengthening the public health voice in debates and discussions regarding alcohol policy by:

1) Lobbying for effective controls on the economic, physical and social availability of alcohol based upon the principles outlined in this paper.

Over the coming year, the OPHA Board and relevant committees will:

2) Advocating proactively for more effective health promotion, injury prevention and harm reduction measures at the municipal, provincial and federal levels.

Over the coming year, the OPHA will work with its members, the ARF, public health units, provincial associations and other key partners to:

3) Educating people active in community health about the potential public health and safety consequences of various alcohol-related policies and facilitating their effective involvement in the policy development process.

Over the coming year, the OPHA Substance Abuse Work Group will:

The years ahead present enormous opportunities — and challenges — for those in the public health field. Alcohol policy is an area where we can make a difference. OPHA commits itself to working with public and private sector partners, and the many committed individuals and organizations who have taken a leadership role in the field, to help build a healthier and safer Ontario for all.

Whereas the unsafe consumption of alcoholic beverages has widespread health, social and economic consequences for individuals and society; and

Whereas population-based approaches aimed at controlling the availability of alcohol, complemented by harm reduction strategies aimed at vulnerable segments of the population, have proven to be effective in preventing or reducing alcohol-related harm; and

Whereas the Ontario Public Health Association has an important role to play in fostering the development and maintenance of healthy public policies aimed at preventing or reducing the risk of alcohol-related harm.

Therefore be it resolved that OPHA adopt the principles and recommendations outlined in the position paper entitled, Promoting Healthy Communities: a position paper on alcohol policy and public health, as the basis for its position on alcohol policies at the local, provincial and federal levels;

Be it further resolved that the OPHA Substance Abuse Work Group work in conjunction with the OPHA Executive, Board and Membership to lobby and advocate to the appropriate levels of government.

Adopted at the Ontario Public Health Association Annual General Meeting on November 14, 1996.

END NOTES

Addiction Research Foundation. The Path of Least Resistance: The Trend to Normalize Alcohol. Best Advice series. Toronto: Addiction Research Foundation, 1993.

Addiction Research Foundation. Drugs in Ontario. Toronto: Addiction Research Foundation, 1995.

Addiction Research Foundation, Canadian Centre on Substance Abuse and the Inter-Departmental Division of Drug and Alcohol Studies and the Department of Preventive Medicine and Biostatistics, "Moderate Drinking and Health, report of an International Symposium" in Canadian Medication Association Journal, 151(6), 1994.

Addiction Research Foundation. Retail Alcohol Monopolies: Preserving the Public Interest. Toronto: Addiction Research Foundation, 1993.

Adlaf, Edward, Frank J. Ivis, Reginald G. Smart and Gordon W. Walsh. Ontario Student Drug Use Survey, 1977-1995. Toronto: Addiction Research Foundation, 1995.

Alberta Liquor Control Board. A New Era in Liquor Administration: The Alberta Experience. St. Albert: Alberta Liquor Control Board, 1994.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, D.C.: American Psychiatric Association, 1980.

American Society of Addiction Medicine. Principles of Addiction Medicine. Chevy Chase, MD: American Society of Addiction Medicine, 1994.

Andrews, J. Craig. "The Effectiveness of Alcohol Warning Labels: A Review and Extension." American Behavioral Scientist Vol. 38, No. 4 (1995): 622-632.

Anglin, Lise (Ed.). The Ontario Experience of Alcohol and Tobacco: New Focus on Accessibility, Violence and Mandatory Treatment. A Report of the Ontario Alcohol and Other Drugs Opinion Survey (OADOS), 1995.Toronto: Addiction Research Foundation, 1995.

Ashley, M. J., R. Ferrence, R. Room, S. Bondy, J. Rehm and E. Single, "Moderate drinking and health: Implications of recent evidence for clinical practice" in Canadian Family Physician, in press.

Bierness, D. J. et al. Statistical Yearbook: Drinking & Driving in Ontario, 1993. Ottawa: Drinking/Driving Countermeasures Office, Ministry of the Attorney General, 1993.

Bierness, D. J., H. M. Simpson, D. R. Mayhew and S. W. Brown. Drinking and Driving in Ontario, Statistical Yearbook 1994 Highlights (in press).

Butler, Barbara. Alcohol and Drugs in the Workplace. Markham, Ontario: Butterworths, 1993.

Canadian Centre on Substance Abuse. "Traffic Injury Research Foundation to Study Ignition Locks." Action News Vol. 6, No. 3 (1995): 5.

Canadian Centre on Substance Abuse (CCSA) National Working Group on Policy. "Fetal Alcohol Syndrome: An Issue of Child and Family Health. A Policy Discussion Paper," September 19, 1994.

Canadian Wine Institute. The Impact of Privatization on the Distribution and Sale of Beverage Alcohol in Alberta. Mississauga: Canadian Wine Institute, July 1994.

Chenier, Nancy Miller. Substance Abuse and Public Policy. Ottawa: Minister of Supply and Services Canada, 1995.

Conference Board of Canada. The Economic Impact and Taxation Burden from the Distilled Spirits Industry. Ottawa: Conference Board of Canada, 1995.

Danaher, Audrey and Carolyn Kato. Making a Difference in Your Community: A Guide for Policy Change. Toronto: Ontario Public Health Association, 1995.

De Pape, Denise, Marlene Leonard and Graham Pollett. "The Health Benefits of Municipal Alcohol Policy: A Role for Public Health," PHERO (Public Health and Epidemiology Reports Ontario), Oct. 27, 1995.

Edwards, Griffiths, et al.. A Summary of Alcohol Policy and the Public Good. A Guide for Action. Oxford, England: Oxford University Press and WHO Eurocare, December 1995.

English, D. R., et al. The quantification of drug caused morbidity and mortality in Australia. Canberra: Australian Government Publishing Service, 1995.

Erickson, Patricia G. "Harm Reduction: What It Is and Is Not." Drug and Alcohol Review, Vol 14 (1995): 283-285.

Giesbrecht, Norman and Paulette West. Alcohol Policy, Consumption Patterns, and Related Harmful Effects of Drinking: Preliminary Report: Ontario 1994 Survey. Toronto: Addiction Research Foundation, 1994.

Giesbrecht, Norman. Proposed Privatization of Retail Alcohol Sales in Ontario: Health, Social, Economic and Safety Implications. Toronto: Addiction Research Foundation, 1995.

Giesbrecht, Norman, Jacqueline Ferris and Paulette West. Alcohol Policy Perspectives and Public Opinion: Trends and Patterns in Ontario. Toronto: Addiction Research Foundation, 1993.

Health Canada. Canada's Alcohol and Other Drugs Survey, 1994. Ottawa: Minister of Supply and Services, 1995.

Health Canada. Canada's Drug Strategy. Ottawa: Minister of Supply and Services, 1992.

Holder, Harold D. The State Monopoly as a Public Policy Approach to Consumption and Alcohol Problems: A Review of Research Evidence, paper presented at Symposium on Alcohol Monopolies and Social/Health Issues, Toronto, October 27-30, 1992.

Homel, Ross. "Experiences of Australia in Achieving Reductions in Drinking and Driving Through Legal Measures," a paper presented at the conference Drinking and Driving - An Avoidable Evil? Strategies Against Alcohol-Related Traffic Accidents and Their Legal and Technical Implemention, Bonn, Germany, September 14-15, 1995.

James, D. Alcohol Availability and Control: A Review of the Research Literature. Alberta Alcohol and Drug Abuse Commission: Edmonton, Alberta, 1994.

Jazairi, Nuri T. The Impact of Privatizing the Liquor Control Board of Ontario. Toronto: Ontario Liquor Boards Employees' Union, September, 1994.

Lauzon, Léo-Paul and Michel Bernard. Contribution of the Liquor Control Board of Ontario to Public Finances, and Risks Associated with Privatization. Montreal: University of Quebec, November 1995.

Laxer, Gordon, Duncan Green, Trevor Harrison and Dean Neu. Out of Control - Paying the Price for Privatizing Alberta's Liquor Control Board. Ottawa: Canadian Centre for Policy Alternatives, September 1994.

Liquor Control Board of Ontario. Taking on Tomorrow: LCBO Annual Report, 1993-94. Toronto, 1994.

Liquor Licence Board of Ontario (LLBO). You and the Liquor Laws: Licensee Information. Seminar booklet. Toronto: LLBO, 1995.

MacKinnon, David P. "Review of the Effects of the Alcohol Warning Label." In Alcohol, Cocaine, and Accidents. Totowa, New Jersey: Human Press (1995): 131-162.

Mayhew, Daniel R. Prevention Measures for Young or Novice Drivers: A Safety Initiative of Private Insurance in Canada. Paris, France: OECD, 1992.

McKeown, David. Proposed Privatization of the Sale of Alcohol in Ontario. Toronto: City of Toronto Public Health Department, 1996.

Mosher, James F. and Rose M. Works. Confronting Sacramento. State Preemption, Community Control and Alcohol-Outlet Blight in Two Inner City Communities. San Rafael, California: Marin Institute for the Prevention of Alcohol and Other Drug Problems, December, 1994.

Moskowitz, Joel. "The Primary Prevention of Alcohol Problems: A Critical Review of the Research Literature." Journal of Studies on Alcohol, Vol. 50, No. 1 (1989): 54 - 88.

"Municipal Alcohol Policies in Ontario: A Survey." Municipal World, Vol. 106, No. 1 (1996): 4 - 5.

National Centre for Research into the Prevention of Drug Abuse. The Measurement of Alcohol Problems for Policy Project. A first report of work in progress. Perth, Australia: Curtin University, 1995.

Ontario Ministry of Health. Partners in Action: Ontario's Substance Abuse Strategy. Toronto: Queen's Printer for Ontario, 1993.

Ontario Progressive Conservative Party. Setting the Rules. A Common Sense Approach to the Modernization of the Liquor Control Board of Ontario, backgrounder, Ontario PC.

Ontario Ministry of Health. Ideas for Action on Alcohol. Toronto: Queen's Printer for Ontario, 1990.

Ross, H.E., "DSM-IIIR Alcohol Abuse and Dependence and Psychiatric Comorbidity in Ontario: Results from the Mental Health Supplement to the Ontario Health Survey.," Drug and Alcohol Dependence, Vol. 39 (1995): 111-128.

Single, Eric. "Harm Reduction and Alcohol" in The International Journal of Drug Policy, Vol. 6, No. 1, 1995.

Single, Eric, Anne MacLennan and Patricia MacNeil. Horizons 1994: Alcohol and Other Drug Use in Canada. Ottawa: Health Canada and the Canadian Centre on Substance Abuse, 1994.

Single, Eric and Scott Worley. "Drinking in Various Settings as It Relates to Sociodemographic Variables and Level of Consumption: Findings from a National Survey in Canada, Journal of Studies on Alcohol, Vol. 54 (1993): 590-599.

Single, Eric, Lynda Robson, Xiaodi Xi and Jurgen Rehm. The Costs of Substance Abuse in Canada, Highlights of a Major Study of the Health, Social and Economic Costs Associated with the Use of Alcohol, Tobacco and Illicit Drugs. Ottawa: CCSA, 1996.

Single, Eric, et al.. Alcohol and Drug Use: Results from the General Social Survey, 1993. Ottawa: Health Promotion Directorate, Health Canada, 1994.

Smart, Reginald G. "Health Warning Labels for Alcoholic Beverages in Canada." Canadian Journal of Public Health, Vol. 81(1990): 280-284.

Smith, Ian. "Effect of Low Proscribed Blood Alcohol Levels (BALs) on Traffic Accidents Among Newly-licensed Drivers," Medical Science Law, Vol. 26, No. 2 (1986): 144 - 148.

Solomon, Robert M. Alcohol and Legal Grief: A Guide to Municipal Alcohol Policy. London, Ontario: University of Western Ontario, 1993.

Traffic Injury Research Foundation. Dealing with DWI Offenders in Canada: Final Report, July 1994. Ottawa: Traffic Injury Research Foundation, 1994.

Traffic Injury Research Foundation of Canada. Alcohol Ignition Interlocks: Their Function and Role in Preventing Impaired Driving. Ottawa: Traffic Injury Research Foundation, 1991.

Wagenaar, Alexander C. and Harold D. Holder. "Changes in Alcohol Consumption Resulting from the Elimination of Retail Wine Monopolies: Results from Five U.S. States," Journal of Studies on Alcohol, Vol. 56, No. 5, (Sept. 1995): 566 - 572.

West, Paulette, Norman Giesbrecht and Benita Pius. Alcohol Policy, Consumption Patterns, Access to Alcohol, and Harmful Effects of Drinking. Preliminary Report: Based on the 1995 Ontario Alcohol and Other Drugs Opinion Survey. Toronto: Addiction Research Foundation, 1995.

Williams, Bob. Canadian Profile: Alcohol, Tobacco & Other Drugs 1995. Toronto: ARF and CCSA,1995.

Wine Council of Ontario. The Privatization Experience in North America: An Overview. St. Catharines, Ontario: Wine Council of Ontario, October, 1994.

The Ontario Public Health Association would like to thank the members of the OPHA Substance Abuse Work Group: Karen Bays-Woods, Brian Hyndman, Maria Lee, Eliseo Martell, Michael McCulloch and Paula Neves (staff) for their assistance in developing this paper. A special thanks to Susan Bondy of the Addiction Research Foundation for writing a substantial portion of the Key Assumptions Section.