1. 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

2. 2 Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences * Independent of intoxication or dependence Source: T. Babor et al. 2003

3. 3 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 mortality Developed countries Developing countries

4. 4 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

5. 5 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

6. 6 Ratings of policy-relevant strategies and interventions Policy - strategy EffectivenessBreadth 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

7. 7 Best Practices & Practices with Good Support & Feasibility Alcohol taxes Alcohol taxes Minimum legal purchase age Minimum legal purchase age Government monopoly of retail sales Government monopoly of retail sales Sobriety check points Sobriety check points Lowered BAC limits Lowered BAC limits Administrative license suspension Administrative license suspension Graduated licensing for novice drivers Graduated licensing for novice drivers Restrictions on hours and days of sale Restrictions on hours and days of sale Restrictions on outlet density Restrictions on outlet density Enforcement of on- premise regulations Enforcement of on- premise regulations Brief interventions for high risk drinkers Brief interventions for high risk drinkers Source: T. Babor et al. 2003, chapter 16

8. 8 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

9. 9 Lessons from Tobacco Control 1. 1. There are no “magic bullets” 2. 2. Health behaviour is social behaviour 3. 3. Combine scientifically valid interventions and social movements 4. 4. Multi-faceted, multi-level approaches are needed 5. 5. Research, monitoring and evaluation must be integral 6. 6. Dose matters; investment is essential * * * (courtesy of John Garcia, PhD)

10. 10 Lessons from Tobacco Control...continued 7. 7. Public Health infrastructure is essential 8. 8. Take advantage of inter-dependence of strategies to achieve multiple ends 9. 9. Prevention among youth requires societal approach, as opposed to a narrowly targeted approach 10. 10. Leadership is essential 11. 11. A long-term perspective is needed 12. 12. Gains can be reversed * * * * Key considerations

11. 11 Challenges 1. Bridging perspectives that are based on values rather than evidence 2. Generating political leadership 3. Securing resources and sustainability 4. Negotiating the divide between public health and community safety 5. Shifting policy environment across levels

12. 12 Elements for Success 1. (Political) leadership and support 2. Multi-sector involvement, including major NGOs and government 3. Use of evidence to inform policy 4. Relevance/resonance 5. A focus on health 6. A provincial/national advocacy network 7. Dedicated staff/support

13. 13 Role for the Public Health Community Advocacy skills Experience in partnerships Understanding of the need to be comprehensive Leadership Implementing some of the recommendation

14. 14 Some specific activities for the Public Health Community: 1. 1. Engage in development of Municipal Alcohol Policies 2. 2. Analyze learnings from tobacco use prevention and apply to alcohol 3. 3. Stop doing ineffective activities 4. 4. Promote Low-Risk Drinking Guidelines and combine with controls on alcohol and partner with advocates for other health issues 5. 5. Hone advocacy skills 6. 6. Advocate for and support municipal, provincial and national drug/alcohol strategies through reports to Board of Health 7. 7. Collaborate