CITY OF TORONTO DEPARTMENT OF PUBLIC HEALTH
Proposal for An Alcohol Abuse Prevention Program

September 2, 1992

Origin: Board of Health, June 25, 1992 (c34hlth92084:133)

RECOMMENDATIONS:

1. That the Department of Public Health increase emphasis on alcohol in its health promotion and public awareness campaigns to raise community awareness regarding alcohol and health.

2. That the Department of Public Health increase emphasis on alcohol in its school and community educational programs and in individual counselling.

3. That the Department of Public Health work with the Board of Health Subcommittee on Substance Abuse, health professionals, the Addiction Research Foundation and similar organizations to promote public awareness of the health, social and fiscal costs of alcohol abuse.

4. That the Board of Health request City Council to direct appropriate staff to review city legislation and policies on alcohol issues (e.g., serving alcohol at civic functions or on city property, rules for special occasion permits, and employee assistance programs) to ensure that city requirements allow only low-risk consumption of alcohol.

5. That the Board of Health recommend that the federal government, within the context of a comprehensive strategy integrating both environmental and individual risk factors:

(a) develop legislation that will require all alcohol products to carry clear health warning labels that include easily understood alcohol content descriptions and identify the health risks associated with alcohol use;

(b) prohibit all advertising of alcoholic beverages on broadcast media as approved by City Council Report Number 1, Clause 16 (January 15, 1991), and further, to develop mechanisms to limit advertising of alcoholic beverages in print media;

6. That the Board of Health recommend that the provincial government, within the context of a comprehensive strategy integrating both environmental and individual risk factors, develop legislation that will require all places where alcohol is sold to post clear signs that warn about a wide range of risks associated with alcohol use. The Department of Public health will offer to work with the Province to ensure appropriate content of such warning signs.

7. That the Board of Health recommend that the provincial and federal governments use their powers of taxation to:

(a) increase the cost to the consumer of alcoholic beverages by tying alcohol taxes to the consumer price index;

(b) implement a schedule of regular tax increases over and above the rate of inflation; and,

(c) equalize the price of different forms of alcohol according to pure alcohol content.

8. That the Board of Health recommend that the Liquor Licence Board of Ontario develop mechanisms to ensure mandatory server intervention/education programs in all licensed establishments in order to improve enforcement of existing provincial legislation prohibiting the sale of alcohol to underage and intoxicated individuals.

SUMMARY:

This report summarizes recent information on alcohol consumption and its effect on individuals and communities. It describes the variety of programs and activities underway and suggests a new approach and related initiatives to reduce alcohol consumption to a level of minimal risk.

BACKGROUND:

At its meeting of June 25, 1992, the Board of Health requested a background paper on the topic for discussion by the Board's Subcommittee on Substance Abuse; it forms the basis of this report.

This report also stemmed from discussions at the Board of Health on September 8, 1991 concerning the possibility of developing a by-law requiring the posting of a health warning sign in all licensed premises. This matter was brought to the Board's attention by Councillor Kay Gardner in relation to Fetal Alcohol Syndrome (FAS). At its September 8, 1991 meeting, the Board of Health received a report, Proposal for a City of Toronto By-law to Make Provisions for the Warning of Fetal Alcohol Syndrome, prepared by Department of Public Health staff and heard deputations from concerned organizations and groups. These discussions highlighted the need for a review of the City's alcohol abuse prevention program and initiated the planning process for a comprehensive health promotion approach to alcohol use which resulted in the attached document.

COMMENTS:

This report proposes a comprehensive strategy to reduce alcohol consumption, utilizing a health risk continuum model. The strategy builds on prior Board of Health actions and Departmental activities. The Department of Public Health looks forward to continuing to work with the Board of Health and its Subcommittee on Substance Abuse to reduce the negative health consequences of alcohol consumption.

EK/sm David J. McKeown, MDCM, MHSc, FRCPC, FACPM

Acting Medical Officer of Health

City of Toronto Department of Public Health

ALCOHOL ABUSE PREVENTION

David J. McKeown, MDCM, MHSc, FRCPC, FACPM Acting Medical Officer of Health

September 1992

PROFILE OF ALCOHOL USE

Recent statistics suggest a general decrease in the prevalence, frequency and amount of alcohol use. Nevertheless, alcohol is the most widely-used drug in Toronto and all Canada. A 1989 national survey reported that approximately 78% of Canadians, 15 years of age and over, are current drinkers, and an additional 16% are former drinkers (1). The Community Health Survey, 1988, found that 85% of Toronto residents aged 15 and over do drink. According to an earlier Community Health Survey, 85% of Torontonians also drank in 1983 (2).

A positive association has been found between alcohol consumption and income and education; language spoken at home, employment and marital status are other factors that affect alcohol consumption (3). Gender and age are also important. At all ages, men are more likely to drink than women. According to a 1989 Ontario survey, 81.9% of men 18 years of age and older used alcohol in the past year, with 68.2% occasionally consuming five or more drinks at a single sitting and 13.3% using alcohol daily. The corresponding statistics for women are 76.9%, 40.9% and 6.7% respectively (4). The 1991 Ontario Student Drug Use Survey found that 66.2%, or 1.7 million, highschool students used alcohol at

least once in the year preceding the survey and 23.9% of this group had consumed five or more drinks on one occasion. In the four weeks before the survey 16.6% of students had been drunk (5). In 1990, Toronto street youth aged 13 to 24 were surveyed to learn about alcohol and other drug use. Ninety-five percent of street youth contacted had used alcohol at least once in the year before the study and 63% reported consuming five or more drinks at a single sitting in the four weeks directly preceding the survey (6).

In the Community Health Survey, 1988, 11% of Toronto drinkers surveyed in 1988 drank heavily (2) (defined by the Ministry of Health as more than 12 drinks/week (7). Health, social and legal problems mainly occur with heavy drinking. For instance, 30% or more of violent crimes are alcohol related and about 20% of Canadians have been assaulted by someone who has been drinking. Furthermore, an estimated one-third of child abuse cases involve alcohol. In Canada, approximately one in ten deaths is the result of alcohol (8). (See Appendix 1 for more detail on the health and social consequences of alcohol abuse.)

DISCUSSION

Alcohol abuse is one of the most significant substance abuse problems of the 1990s (1) and a major public health concern. The chronic problems caused by alcohol abuse continue; individual, family, societal and fiscal costs have not diminished. Prevention efforts must be comprehensive and based on a solid understanding of the current patterns of alcohol use and the associated consequences, and on the popular beliefs that underlie alcohol use. Given the recent report of the House of Commons Subcommittee (9), it is timely for the Board of Health and the Department of Public Health to recommit to alcohol use reduction programming.

The mission of the City of Toronto Department of Public Health is ". . .to enable all people in the City of Toronto to be as healthy as they can be" (10). The Ontario Ministry of Health mandates the Department of Public Health, under the direction of the Board of Health, ". . .to improve the health of the population by reducing the abuse of substances that pose a risk to health" (11). The Healthy Toronto 2000 report (12), which forms a blueprint for the Department of Public Health for the 1990s, is congruent with the province's mandate. The report directs the Department to produce a comprehensive, data-based substance abuse prevention strategy to address root causes, plan community-based programs, and encourage inter-agency and intersectoral cooperation.

In 1985 the Department proposed a formal approach to alcohol abuse prevention (13). A 1987 report to the Board of Health (14) detailed an enhanced educational program, just beginning to be implemented, which aimed to promote knowledgeable decision-making about alcohol use through focused activities such as school-based education for children, community-based support, advocacy and health promotion, and inter-agency and inter-sectoral cooperation. The program's goal was " . . .a low health risk use of alcohol by Torontonians that would result in no preventable deaths or disability from the use of alcohol" (14). The program was designed as part two of the comprehensive Substance Abuse Prevention Program. Part one, dealing with tobacco issues was already well-established, and part three, dealing with licit and illicit drugs, was, in the mid-80s, in the planning stages.

Increasing knowledge about HIV and AIDS in the 1980s meant that the Department and Board drew attention from other programs, including alcohol, to start-up appropriate HIV-related interventions. More recently, community and political concerns regarding the use of illicit drugs led to the swift development of the Department's Drug Abuse Prevention Program (DAPP). This program generally follows the outline of a comprehensive, multifaceted, community-based program consistent with part three of the Substance Abuse Prevention Program. The acute problems that the rise in illicit drug use brings to individuals, families and communities has led to an increase in resources and publicity for the Drug Abuse Prevention Program.

Alcohol-related programming has proceeded as an integrated component of the day-to-day work of staff in their roles as counsellors, educators, health assessors, promoters and advocates. Advocacy actions have related to alcohol content and sales of stomach bitters and low alcohol content beverages, pricing of alcohol, hours and locations of alcohol sales, and advertising of alcoholic products. At an area level, teaching continues at elementary schools as part of our Substance Abuse Prevention Program, currently being evaluated. The Eastern Health Area also is piloting a classroom-based program for grades 7 and 8. Currently, a multidisciplinary committee is developing a strategy to link education for adolescents about drugs, alcohol and sexuality.

The Ministry of Health's report, Ideas for Action on Alcohol, released in 1990, is consistent with Board of Health philosophy and Department programming. It includes a framework (see Appendix 2) that provides a practical and concrete tool with which to reassess and organize our alcohol abuse prevention programming. Certain approaches that have been identified as priorities by the Department of Public Health but not by the Ministry framework (such as cultural sensitivity, strengthening communities and addressing inequities in access to the basic health prerequisites) must be integral components of our alcohol abuse prevention program. Congruency with the Department's program focus initiative is also required. An alcohol component should be included in healthy parents/healthy children, healthy children/healthy adolescents and healthy adults/healthy seniors programs.

A CONTINUUM APPROACH FOR DEPARTMENT ACTIVITIES

From 1930 onward, the disease concept of alcoholism dominated popular thinking. (See Appendix 3 for an overview of this concept.) Current thinking on alcohol use and alcohol-related problems has, however, moved from a concentration on the "alcoholic" to the realization that many health, social, legal and economic problems relating to alcohol use are caused by drinkers who are not alcoholics or "alcohol-dependent", but who have drunk heavily and/or inappropriately. This has led to a change in strategies for dealing with alcohol problems. The focus has shifted from fixating on the alcoholic individual to a more complex and comprehensive approach with strategies also aimed at the agent (alcohol) and the social, cultural, legal, political and economic context in which drinking occurs.

A simple and graphic way of looking at the main cause of alcohol problems (i.e., alcohol consumption) is to use the Risk Continuum Model (see Appendix 4). This model associates increased risk of health, social, legal and economic problems with increased amounts of alcohol consumed. Using a continuum indicates that there is no definite point at which alcohol consumption changes from harmless to harmful. Drinking is a dynamic situation, dependent on the physical, emotional and mental state of the individual and the context in which drinking occurs. However, looking at categories of relative risk is useful for program planning purposes.

The risk continuum makes it possible to define a series of program and service categories into which any population can be separated. Four categories are identified: no-risk, low-risk, moderate-risk and high-risk. For planning purposes, each can be considered a separate target group characterized by its relative level of risk. Programs and services can then be developed in line with each category and shaped by a distinct set of objectives and strategies.

Most Department of Public Health activity will lie within the health promotion end of the continuum, ranging from preconception and prenatal education to school-based programs and communitybased health promotion activities. Minimal intervention activities such as promoting self-help materials, brief assessment and referral programs could also be included. A continuum of programs would attempt to move people from high-risk to low or no-risk. Legislative, educational and community support initiatives are having an influence on alcohol consumption as attested to by recent Ontario statistics that show that people are beginning to drink less (1); this should give momentum to the City's programs.

ALCOHOL CONTROL

Society has long recognized the need to control alcohol use by developing codes of behaviour, or by passing laws governing production, sale, and use. In the early 1900s the Temperance Movement in Canada blamed alcohol for almost all crime, divorce, poverty, prostitution and family problems. In Ontario, prohibition began in 1916 and lasted until 1923. However, although illegal, alcohol was soon available from underground sources for all who wanted it. Since the end of prohibition, the production, distribution, sale, and use of alcohol have been controlled by the federal and provincial governments. Many restrictions were removed in the 1960s and liberalization has continued (15,16).

Recently, a number of Canadian cities and municipalities have begun to develop alcohol management policies. In Ontario, 11 communities have officially adopted alcohol control policies (17). These include: Guelph, Simcoe, Thunder Bay, Sault Ste. Marie, Elliot Lake, Walden, Chapleau, Schreiber, Sturgeon Falls, and Tehkummah and Manitowaning on Manitoulin Island. Other Ontario communities, such as North Bay, Mattawa, Moosonee and Moose Factory, are in the process of developing similar policies. These communities have worked closely with the Addiction Research Foundation to negotiate and draft alcohol control policies. Principally, these policies focus on municipally-owned facilities where alcohol use is not permitted and those facilities where alcohol use is permitted under Special Occasion Permits. The City of Toronto Department of Parks and Recreation is preparing a report for City Council about control of alcohol consumption on City properties.

As a consequence of the constitutional division of powers, the federal government has jurisdiction over advertising and labelling of alcohol, whereas provincial governments control licensing of establishments and regulation of all aspects of the selling and serving of alcohol. Laws controlling the advertising of alcoholic beverages are currently under discussion. Presently, liquor (distilled spirits) advertisements are not allowed on television, but beer and wine ads are permitted. Advertisements are restricted in that they must highlight the product, not the consumer. The report of the Subcommittee on Health Issues of the House of Commons Standing Committee on Health and Welfare entitled Foetal Alcohol Syndrome: A Preventable Tragedy, released in June of this year, recommends a complete ban on lifestyle advertising of alcohol products on television and radio (9). A complete TV and radio advertising ban was called for by the Canadian Medical Association earlier this year (18).

The Subcommittee report also recommends the institution of health warning labels on all alcohol sold in Canada. Health and Welfare Canada is currently planning pilot projects to test warning labels on alcohol in certain jurisdictions. The United States has already enacted laws requiring producers of alcoholic beverages to put health warning labels on all their products. Some state and local jurisdictions have also passed legislation requiring warning signs where alcohol is sold. This strategy was brought to the Board of Health's attention in early August 1991 by Councillor Kay Gardner. On September 8, 1991, the Board of Health received a report, Proposal for a City of Toronto By-law to Make Provisions for the Warning of Fetal Alcohol Syndrome, considering the development of a by-law requiring proprietors of all premises licensed to sell alcoholic beverages to post a sign

warning of the dangers of drinking alcohol during pregnancy. A number of deputations were made to the Board at this meeting. This issue highlighted the need for a review of the City's alcohol abuse prevention programs and initiated the planning process for a comprehensive health promotion approach to alcohol.

The federal Subcommittee on Health Issues recommends that the federal government initiate discussions with the provinces to require warning signs in establishments serving or selling alcohol. The Subcommittee recommendations about warning labels and signs are specific to fetal alcohol effects and fetal alcohol syndrome. The Addiction Research Foundation, which has also called for warning labels and signs, recommends a more comprehensive program dealing with warnings about a range of ill effects of alcohol use (19).

ALCOHOL ABUSE PREVENTION PROGRAM GUIDELINES

Alcohol will be recognized as a drug and addressed as part of the Substance Abuse Prevention Program. It will be acknowledged that alcohol, like tobacco, plays a leading role as a gateway drug to illegal drug use. Alcohol is the drug of choice for the majority of citizens; it is crucial that Department programs reflect this. The Department's alcohol abuse prevention efforts can build upon the successes of the Smoking Prevention Program, the Drug Abuse Prevention Program and ongoing alcohol abuse prevention initiatives.

Simple, clear, health-based guidelines for alcohol consumption and low-risk drinking practices will be developed and disseminated. It will be emphasized that not drinking alcohol is always an option. Not drinking is advised for youth, pregnant women, people operating vehicles or machinery and people with health problems that alcohol might exacerbate.

A comprehensive program is needed to address the complex social, cultural, medical and economic factors involved in alcohol use and public health. It will incorporate individual counselling; group education; mass media campaigns; policy and legislative initiatives at the City level; advocacy for provincial and federal legislation; community-based projects; coalition building and developing partnerships and programs with family physicians, the Addiction Research Foundation and other organizations working on substance abuse prevention.

APPENDIX 1

HEALTH AND SOCIAL CONSEQUENCES OF ALCOHOL ABUSE

Alcohol and Health

Alcohol affects the brain and the central nervous system. Many people use alcohol because the short-term effects make them feel less nervous, more confident and socially competent, but the after-effects often leave the drinker up-tight, irritable and anxious. The effects of alcohol on other parts of the body are not immediately apparent to the drinker. Yet, alcohol use affects blood pressure, the digestive system, the liver, and the endocrine and immune systems (20).

The risk of health damage from alcohol, as from any other drug, depends on the dose and the characteristics of the person taking it. Generally, the amount and frequency of any drug consumed directly relates to the harmful effects. This is true for alcohol. Alcohol is highly toxic (poisonous) in very high doses. Heavy long-term drinking (five or more drinks per day) has been linked to liver disease, heart disease, some cancers, brain damage, a weakened immune system and a host of other potentially fatal health problems (20,21). Children born to mothers who drink heavily during pregnancy are more likely to show fetal alcohol effects or to have fetal alcohol syndrome. Mental retardation, growth problems, head and facial deformities, joint and limb abnormalities and heart defects are, in differing degrees, characteristic of these conditions (22,23).

Heavy consumption can result in major problems of dependency and disruption of life. Twelve percent of current Canadian drinkers have experienced a physical health problem at sometime in their life due to their drinking. An estimated one in ten deaths in Canada is the result of alcohol (24). In Ontario, alcohol is believed to indirectly cause an estimated ten percent of cancer deaths (or 1,740 deaths/year) and five percent of deaths due to heart disease and stroke (or 1,510 deaths/year). Alcohol is a major contributor to accidents that result in injury and death because it modifies behaviour, alters perceptions, judgement, and response time. Alcohol plays a role in at least 50% of traffic fatalities and 30 to 40% of falls, drownings and fires. In 1985, 6,506 deaths were directly or indirectly caused by the use of alcohol (25).

Drinking and Driving

In Ontario in 1987, 18,737 car crashes involved drinking drivers. Where car crashes involved driving under the influence, drivers were predominantly male and young (16-34 years old). Research has shown that the more people drink, the more likely they are to drink and drive (26). Thirty-three percent of Toronto drivers drive after drinking. The practice is more common among men than women, 38% versus 24% (27).

Seven percent of Canadian drivers drink and drive frequently. More than one-third of Canadians have been passengers in a motor vehicle (car, truck, motorcycle, all-terrain vehicle, boat or snowmobile) with a drunk driver. Drinking drivers place themselves, their passengers and the people around them at risk of death, injury and physical disability. Drinking drivers face criminal charges that can lead to higher insurance fees, high legal fees, jail time and fines. With a criminal record, they may lose job opportunities and have trouble travelling outside Canada (28,29).

Alcohol and Society

Alcohol use has become pervasive in our society with strong cultural, economic and recreational components. The social costs of heavy alcohol use can be seen at the individual, family and community levels.

Roughly 30% to 50% of violent crimes are alcohol-related. About 20% of Canadians have been assaulted by someone who had been drinking (29). An estimated one-third of child abuse cases involve alcohol (28). Children of alcoholic parents pay in yet another way. They are more likely to become alcohol or drug dependent and adopt high-risk patterns of drinking. Children of alcoholics are also seen at an increased risk for a variety of reasons including, genetic or other physiological factors, psychological and social factors (30).

Seven percent of Canadians report that drinking has affected their happiness at some time. Six percent feel that it has harmed their marriage or home life; one in six divorces is associated with heavy alcohol use. About one-fifth of Canadians have had family problems because of others' drinking. Eleven percent of Canadians report that alcohol has caused problems with friendships or social life, and 16% of Canadians have lost friends. More than half of adult Canadians have been insulted by someone who has been drinking, and nearly half have been disturbed by loud parties or the behaviour of people drinking at a party (31).

In Ontario in 1981, alcohol abuse cost society approximately $1.8 billion a year in extra health, law enforcement and social welfare services (32). Alcohol abuse reduces productivity, increases absenteeism, lowers morale and causes accidents at the workplace. Employers who require licensed drivers have gone bankrupt due to crashes caused by impaired employees. Four percent of Canadians believe that alcohol use has caused harm to their work-related abilities, employment or studies. Similarly, five percent report that their drinking has harmed their financial position, and three percent have had financial difficulties because of others' drinking. Eight percent of Canadians have had property vandalized, yet another cost to society (29).

APPENDIX 2

A FRAMEWORK FOR ACTION ON ALCOHOL

An effective plan for action on alcohol consists of three APPROACHES carried out in six SITES aimed at many TARGET GROUPS (35).

THREE APPROACHES

The approaches used to reduce alcohol use and influence behaviour are:

- EDUCATION: A first step in this approach is to give people facts on alcohol use and problems. Information makes people more aware of the issue, increases knowledge and changes attitudes towards alcohol. A second step in the EDUCATION APPROACH is skills development. People need to learn skills to change or avoid high-risk practices. Skills and information are both necessary for behaviour change to occur.

- POLICIES: Health-oriented policy measures, such as restricting the supply of alcohol, place barriers in the way of risk drinking and make it easier to engage in no/low-risk drinking.

- ENVIRONMENTAL SUPPORT: This approach creates opportunities and an environment that supports healthy behaviours. It includes programs and services, access to information and services, promotions and advertising, and the existence of self-help and support groups as well as related interest groups.

SIX SITES

Action to reduce alcohol problems must take place in many settings. Community projects should include programs, activities and policies in many sites:

- Community-at-large: Media, both small (e.g., neighbourhood newsletters, posters, flyers), and mass (e.g., radio, television, print), community organizations such as youth clubs, social service agencies, and community facilities such as recreation facilities and parks are all places where alcohol messages can reach large numbers of people.

- Home: People spend more time at home than anywhere else, and drinking behaviour is often shaped by practices and attitudes in the home.

- Educational settings: Statistics show that young people begin to experiment with alcohol very early. Programs in elementary and secondary schools, community colleges and universities may help students develop low-risk drinking habits and responsible attitudes towards alcohol.

- Health-care settings: Offices of physicians, dentists and other health professionals (e.g., pharmacists, chiropractors, therapists), hospitals, emergency departments, visiting nurses, community health centres and public health units are all places where people turn for health information.

- Workplaces: An effective place to reach adults is the workplace. As employers pay a high price for problem drinkers (e.g., lost productivity), they are likely to be receptive to workplace programs on alcohol.

- Licensed Premises: Places that serve alcohol for consumption on-premise can have a strong impact on people's drinking habits. They can be used to encourage low-risk drinking.

APPENDIX 3

THE DISEASE CONCEPT OF ALCOHOLISM AND RECENT CONCEPTUAL CHANGES

Chronic heavy drinking was first connected with ill health in the late 1700s. In the 19th century, Matthew Huss, a Swedish doctor, coined the word "alcoholism" to describe the chronic health effects of continual heavy drinking. In the 1930s, Otto Jellinek, an American physician, promoted a new disease concept of alcoholism. He defined alcoholics as people whose dependence on alcohol interfered with their health, social functioning or economic well-being. Jellinek's work had tremendous influence on medical, scientific and popular thinking about alcohol use, and in 1952 the World Health Organization adopted this definition (33).

Whereas early ideas focused on "the demon alcohol", the disease concept saw the problem as lying not so much in the alcohol as in the person, or in certain people who had developed a disease called alcoholism which made them unable to control their drinking. This disease concept was politically and commercially acceptable because it allowed alcohol to be portrayed as beneficial for most people, apart from those who were afflicted with "alcoholism". It also removed the moral stigma from drunkards: they were neither bad nor evil, but sick. In a landmark 1960 paper, Jellinek defined alcoholism in terms of harm to the individual and to society. Jellinek's ideas underlie the belief that alcoholism is a chronic disease and that the sole treatment is to abstain. General acceptance of Jellinek's ideas led to the success and world-wide spread of Alcoholics Anonymous. Originating in the United States, this self-help initiative is based on the belief that alcoholism is an incurable disease that can be controlled by abstinence, spiritual awareness and fellowship (34).

Recent conceptual changes have been accompanied by changes in terminology. People who are physically and psychologically reliant on alcohol are now described as "alcohol dependent", and "alcohol abuse" is used to describe the behaviour of people who experience health or social problems because of their alcohol use habits. A further classification is made up of "social drinkers" or "alcohol users": people who drink, but have no serious health or social consequences. It is now recognized that people do not fit neatly into one category and that individuals who are usually social drinkers may, on occasion, be involved in accidents or incidents related to a single occurrence of heavy drinking and risk-taking behaviour.

Thus there is no clear line delineating alcohol use, alcohol abuse and alcohol dependence. There is no evidence of an inevitable sequence of behaviour and systems leading from one classificati