Strategies to Reduce the Harmful Use of Alcohol World Health Organization submission

Strategies to Reduce the Harmful use of Alcohol
Submission to the World Health Organization – Public Hearing
November 14, 2008

Thank you for the opportunity to provide input to the World Health Organization (WHO) public hearing on strategies to reduce the harmful use of alcohol.

The Centre for Addiction and Mental Health (CAMH), in addition to being a hospital, is an organization with a provincial mandate to conduct research, engage in public education health promotion, and participate in the development of healthy public policy in the area of addictions and mental health. CAMH has access to the most current evidence on: alcohol availability and its effects on consumption, drinking and driving, reducing aggression and injury in bars, harm reduction, alcohol management policies for municipalities, and the effects of measures designed to reduce health and social problems.

CAMH supports and endorses the National Alcohol Strategy (NAS) – a collaboration of different sectors of the alcohol stakeholder community that provides direction and recommendations about reducing alcohol-related harm in Canada. The NAS endorses four strategic areas of action. These include health promotion, prevention and education; health impacts and treatment; availability of alcohol; and safer communities. CAMH is currently working in all four strategic areas, whether through providing support to other organizations or taking an organizational lead where research and policy development is required.

1. What are your views on effective strategies to reduce alcohol-related harm?

Drinking Driving Policies and Countermeasures
CAMH believes that the reduction of deaths and injuries from drunk driving is a public health priority. Currently, in Canada it is a criminal offence to drive with a Blood Alcohol Content (BAC) over 80 mg%. In Ontario, alone this BAC level has been associated with an on-going reduction of 18% in drinking and driving fatalities. Evidence shows that driving skills are significantly impaired at levels of 50 mg% and below, and that collision risks are significantly elevated at BAC levels of 50 mg% CAMH supports lowering the legal BAC limit from 80 mg% to 50 mg% in an effort to educate the public about the hazards of driving or operating motorized vehicles of any kind after excessive alcohol consumption.

CAMH also recommends random breath testing (RBT). RBT allows police to request a breath sample without probable cause. RBT operates as a general deterrent, as it increases the average driver’s perception of being processed by the police if he/she drives while impaired. Evaluations and reviews, including a World Health Organization study, of RBT have supported its effectiveness in reducing alcohol related collisions and fatalities.

Addressing the Availability, Pricing and Marketing of Alcohol
Alcohol monopolies with a strong regulatory agenda play a key role in preventing alcohol related harm. Evidence demonstrates that a privatized system with little government regulation and open competition among private retailers typically leads to an increased number of outlets, longer opening hours, and increased consumption . And, higher consumption rates are strongly related to an increase in drinking related problems. CAMH recommends implementing alcohol monopolies with policies on alcohol that control sales, promote public health, curtail risk and reduce drinking related harm. Density restrictions that outline the maximum number of licensed outlets and number of occupants per region is an excellent example of a policy proven to control alcohol sales. CAMH urges the inclusion of public health objectives in government mandates and policies on alcohol.

Pricing is an important determinant of alcohol consumption. CAMH recommends adopting a minimum retail social reference price for alcohol and indexed to the Consumer Price Index. A move towards alcohol volumetric pricing based on the volume of ethyl alcohol in alcohol products is also recommended. Volumetric pricing should be priced within each beverage class.

The marketing of alcoholic beverages, especially to young people, is of concern to CAMH. In order to reduce drinking related harm, it is essential that promotional, marketing and alcohol management strategies be assessed from a public health perspective and controls on volume, placement and content of alcohol advertising be implemented. CAMH, however, strongly encourages a social marketing campaign that focuses on a culture of moderation, such as the National Drinking Guidelines supported by the Centre for Addiction and Mental Health and partner organizations, as a health promotion and prevention tool.

Harm Reduction and Health Promotion
CAMH strongly endorses harm reduction interventions and health promotion strategies to reduce the harms of alcohol. A range of interventions to reduce alcohol related harm in and around licensed premises has been developed and evaluated. Requiring bars to develop prevention polices to reduce alcohol related problems due to over-service/over-consumption is strongly recommended. These policies should be based on evaluated safety measures. CAMH’s ‘Safer Bars Program’ has been fully evaluated and has demonstrated effectiveness in reducing alcohol related violence in licensed establishments. Other interventions include implementing penalties for illegal services, (such as overcrowding, serving to people who are underage or intoxicated), and implementing server training programs as a pre-condition for receiving and/or renewing licenses for serving alcohol.

Excessive alcohol use leads to long-term health consequences. The harms to physical health is well documented and includes cirrhosis of the liver, cancer, a range of diseases affecting the heart, including stroke and hypertension, fetal harm and mental health problems. Despite the growing body of evidence concerning the role of alcohol in chronic disease it has received little attention from government bodies and non-government organizations. CAMH strongly encourages alcohol to be consistently included in policies and programs focused on chronic disease. In addition, collaboration with other national organizations in the area of chronic disease to improve the prevention of alcohol related chronic disease is strongly recommended.

Increasing public knowledge about alcohol and chronic illness should be a health priority. A public awareness campaign, which promotes consistent and clear messaging on alcohol related health and safety issues, emphasizing the strong link to chronic disease is recommended. A start would be to promote the National Drinking Guidelines through a social marketing campaign encouraging a culture of moderation. Although CAMH supports a culture of moderation, we also recognize that abstinence is a legitimate option, especially for underage youth, alcoholics, and those who abstain from alcohol for health or religious reasons.

Research shows that providing information through media campaigns and educational programs, as stand-alone interventions, will not reduce harm from alcohol, and should not be considered in isolation. CAMH is in favour of a greater emphasis on alcohol policy and regulatory measures with education/information as a supplement.

Health Sector Response
A health sector response is critical in reducing alcohol related harms. CAMH supports the development of integrated and culturally sensitive screening, brief intervention and referral tools and strategies for persons experiencing issues with alcohol. Making use of other health professionals, such as nurses and social workers to screen for problems with alcohol and begin brief intervention programs is recommended. Screening, brief intervention and referral tools, however, must be culturally and linguistically sensitive. A focus on marginalized and high-risk populations, such as Aboriginals, concurrent disorders, etc. is recommended.

2. From a global perspective, what are the best ways to reduce problems related to harmful use of alcohol?

a) Pressure governments to implement drinking and driving polices to reduce alcohol related fatalities.

Two proven effective strategies include lowering the legal BAC content and implementing random breath testing. However, research shows that laws can be unsuccessful in achieving reductions in collisions and fatalities if they are not enforced or if resources are not available to support their implementation and enforcement.

b) Encourage governments to implement alcohol monopolies and reject the privatization of alcohol sales.

A review of both international and Canadian evidence indicates that retail alcohol monopolies with strong public health agendas combined with regulations governing alcohol have the potential to contribute significantly to the prevention of alcohol related problems.

CAMH suggests:

i) Governments should consider density restrictions on the availability of alcohol.
ii) Develop incentives to encourage healthier consumer choices whether through tax or price adjustments on reduced-alcohol beer, wines and spirits.

c) Promote governments to consistently include alcohol in policies and programs focused on chronic disease.

CAMH suggests:

i) Collaborate with other national organizations in the area of chronic disease to improve the prevention of alcohol related chronic disease.

d) Develop a framework convention on alcohol control.

Develop a framework convention on alcohol control similar to the 2005 framework on tobacco control. A framework convention would place restraint on international trade in alcohol, encourage a call to action by all governments and society, and aid legislators and government to develop effective policies on alcohol control.

3. In what ways can you or your organization contribute to reduce harmful use of alcohol?

CAMH is positioned to reduce the harmful use of alcohol in several ways:

1. Develop integrated and culturally sensitive screening, brief intervention and referral tools and strategies.

CAMH is exploring the opportunity to partner with other organizations in developing integrated and culturally sensitive screening, brief intervention and referral tools. CAMH has a long history in researching and disseminating screening, brief interventions and referral tools and partnering with other organizations on a variety of projects.

2. Ensure that alcohol is consistently included in policies and programs to chronic disease.

CAMH has a strong proven track record in conducting research, providing advice and working with others to advocate that greater attention be drawn to alcohol-related chronic disease. CAMH will develop:

-A synthesis [secondary analysis] report in partnership with experts in other centres, drawing from recent studies and data focusing on Canada that highlights the dimensions of alcohol-related chronic disease and links with drinking patterns and overall consumption.

-A summary document outlining the types of population-level policies considered to be most effective in controlling alcohol-related chronic disease.

CAMH will:

-Collaborate with the Chronic Disease Prevention Alliance of Canada and others to improve the prevention of alcohol related chronic disease including implementation of a public awareness campaign.

3. Maintain current systems of control over alcohol sales (Provincial/Territorial government).

CAMH will partner with non-government organizations and government to:
a) Require liquor control boards to maintain a social responsibility frame of reference for all matters pertaining to their operations and governance, and to maintain or increase their spending an programming in this area;
b) Enhance staff training at outlets and implement ongoing enforcement compliance programs to ensure that alcohol is consistently sold in a socially responsible way and in accordance with the law; and,

CAMH will:

· Work to monitor the social responsibility mandate, programming and spending of provincial/territorial jurisdictions across Canada.

For more information, please contact:

Barney Savage
Director of Public Policy
Centre for Addiction and Mental Health
1001 Queen Street West
Toronto, ON
M6J 1H4

barney_savage@camh.net