Political and Social Affairs Division
28 June 2006
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After tobacco, alcohol is the psychoactive substance that causes the greatest harms in terms of health, legal, social and economic costs and problems. A recent study estimated the total social costs (death, illness and economic cost) of substance abuse in Canada to be $39.8 billion in 2002. Alcohol accounted for 36.6% ($14.6 billion) of the total estimate, whereas tobacco accounted for 42.7% ($17 billion) and illegal drugs for 20.7% ($8.2 billion).(2)
This paper summarizes the most recent information on the prevalence of alcohol use and abuse in Canada and its related harms. Statistical data are drawn primarily from the 2004 Canadian Addiction Survey(3) and other data collected through the Northwest Territories Addiction Survey (NWT Survey 2004), the 2005 Ontario Student Drug Use Survey, the Canadian Community Health Survey (CCHS, 2002), the Health Behaviour in School-Aged Children Survey (2001-2002) and the National Longitudinal Survey of Children and Youth (NLSCY, 1998-1999). The document also includes a brief section on reducing alcohol-related harms and best overall policy practices and activities undertaken by the federal government in addressing the harms caused by alcohol in Canada.
The control and sale of alcohol in Canada is regulated by provincial and territorial governments. Different models range from total government control to a sharing of responsibility by both the government and private-sector stakeholders.(4) In 2003-2004, sales of alcoholic beverages in Canada totalled $16.1 billion (50.7% of sales attributed to beer, 24.7% to spirits and 24.6% to wine), up 4.9% from the previous year. The total net income of provincial and territorial liquor authorities and government revenue from the control and sale of alcohol (not including revenue from provincial sales taxes) reached $4.3 billion in 2003-2004, up from $4 billion the previous year.(5)
According to the 2004 Canadian Addiction Survey, 79.3% of the Canadian population aged 15 years and older consumed alcohol in the year prior to the survey. Most Canadians drink in moderation. Of those who reported drinking alcohol in the past year, 44% indicated drinking at least once a week and 9.9% consumed alcohol four or more times a week. The pattern of drinking of 16% of those who drank in the previous year was associated with an increased risk of developing alcohol-related problems (usual pattern of consuming five or more drinks in a drinking day). The survey also revealed that 6.2% of past-year drinkers engaged in heavy drinking (five drinks or more in a single sitting for males and four or more drinks for females) at least once a week and 25.5% reported this pattern of drinking at least once a month. Moreover, based on the Alcohol Use Disorder Identification Test, which identifies hazardous patterns of alcohol use and indications of alcohol dependency, 17% of current drinkers were considered high-risk drinkers. Most heavy and hazardous drinkers were young males under the age of 25.(6)
As to the prevalence of alcohol dependence, the 2002 Canadian Community Health Survey revealed that 2.6% of Canadians aged 15 and over (3.8% males and 1.3% females) reported symptoms consistent with alcohol dependence, at some time during the 12 months prior to the survey.(7) Of those reporting heavy drinking at least monthly, 26.9% admitted being drunk or hungover at work or school, or while caring for children. Some 26.2% reported taking alcohol in larger amounts or for longer periods than intended. Almost 17% stated that they had been in a situation while drunk or hungover that increased their probability of injury, and slightly over 16% indicated that they had developed an increased tolerance to alcohol.(8)
The prevalence of heavy and hazardous drinking is much higher in the Northwest Territories than in the provinces. According to the 2004 Northwest Territories Addiction Survey, of the 77.9% of respondents 15 years of age and older who indicated they had drunk alcohol in the year prior to the survey, 46.4% reported that they had consumed five or more drinks on a single occasion at least once a month and 14.6% stated that they had engaged in such heavy drinking at least once a week. Another 40% of current drinkers indicated that they normally consumed five or more drinks on a typical drinking day. Based on the Alcohol Use Disorder Identification Test, 41.3% of current drinkers in the Northwest Territories had engaged in hazardous drinking in the 12 months prior to the survey. As reported in the rest of Canada, heavy drinkers were more likely to be young males than females.(9)
With regard to alcohol consumption by youth under the legal drinking age, data from the 1998-1999 National Longitudinal Survey of Children and Youth showed that 42% of children aged 12 to 15 reported that they had consumed at least one drink of alcohol in the past, and 22% stated that they had been drinking to intoxication at least once.(10) Data from the Health Behaviour in School-Aged Children survey showed that 34% of boys and 23% of girls in grade 10 reported weekly alcohol use in 2002. Furthermore, 46% of boys and 42% of girls in grade 10 indicated that they had been “really drunk” at least twice.(11) The children surveyed were age 15 or younger and thus below the legal age for purchasing and consuming alcohol in Canada.
More recent data from the 2005 Ontario Student Drug Use Survey (OSDUS) showed that 62% of students in grades 7 to 12 reported drinking alcohol in the previous year, ranging from 31.4% of grade 7 students to 81.8% of students in grade 12. These percentages are high but are lower than the previous data of 66% recorded in 2003. The prevalence of consumption of alcohol does not differ between males and females. Among those who reported drinking, 39% indicated that they drank only on special occasions and 16% reported drinking at least once a week. Twenty-three percent of students engaged in binge drinking at least once during the month prior to the survey; 8% reported binge drinking two to three times during the same period; and another 5% reported drinking four or more times. More males than females reported binge drinking (25% and 20%, respectively). Overall, 16% of students reported drinking at a hazardous level. The early onset of alcohol use has, however, significantly decreased since 2003 when 42% of students reported having used alcohol by grade 6, whereas 29% of students reported using alcohol at such a young age in 2005.(12)
Research has shown that alcohol, when taken in moderation, has some health benefits, such as reducing the risk of cardiovascular problems, particularly for men over the age of 45.(13) However, a recent meta-analysis of benefit studies has challenged the widely accepted cardiac benefit assertions. The findings of this analysis suggest “that the cardiac protection afforded by alcohol may have been overestimated.”(14) On the other hand, research has clearly shown that heavier alcohol consumption(15) is linked to a number of health problems, such as liver cirrhosis and damage to other organs (e.g., heart, lungs, and kidneys); alcohol dependence syndrome; neuropsychiatric diseases; diabetes; cardiovascular and gastrointestinal diseases; and various forms of cancer. Long-term, regular consumption and even moderate drinking with occasional heavy drinking episodes may also lead to health problems.
Alcohol consumption affects the nervous system, impairs judgement, concentration and coordination, and lowers inhibitions. Drinking to intoxication and binge drinking increase the risk of alcohol poisoning; accidents and injuries (e.g., falls, fires, motor vehicle accidents, accidents in the workplace); violent and criminal behaviour;(16) suicide; unsafe sex; unwanted pregnancies; and the use of other psychoactive substances, as well as the probability of problems in the workplace (e.g., absenteeism, arriving late for work or making mistakes due to a hangover or impairment). In 2002, the costs of alcohol abuse in Canada were estimated at $14.6 billion in additional health care, law enforcement, and loss of productivity in the workplace or at home.(17)
Alcohol use during pregnancy can cause birth defects, Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE) and alcohol-related neurodevelopmental disorders (ARND) that have lifelong consequences for individuals, their families and society as a whole. These physical and/or mental disabilities related to prenatal exposure to alcohol are grouped under the umbrella term of Fetal Alcohol Spectrum Disorder (FASD).
According to the study on the costs of substance abuse in Canada, it is estimated that alcohol abuse accounted for $3.3 billion in direct health care costs in 2002.(18) Hospitalizations and deaths are two key indicators that show the toll of alcohol abuse on Canadian society.
Based on data collected by the Canadian Institute for Health Information (CIHI), there were 27,084 hospital admissions involving alcohol-related conditions in 2000-2001. The vast majority of the patients were men (19,067) and most were hospitalized for disease conditions such as alcohol dependence or abuse, alcoholic psychosis, liver-related diseases and other (15,447).(19)
CIHI data also revealed that in 2002-2003 more than half (783) of the alcohol-related severe trauma hospitalizations in Canada were the result of motor vehicle collisions. The other two causes of alcohol-related severe trauma were falls (21%) and assaults and homicides (18%). Of those admitted to a specialized trauma hospital due to alcohol-related injuries, 27% were between the ages of 10 and 24, and another 22% were aged 25 to 29 years old.(20) Other data from the CIHI showed that young adults under the age of 25 were involved in over 30% of alcohol-related motor vehicle collisions in 2002-2003. “Among youth, 62% of severe trauma deaths related to alcohol were the result of a motor vehicle collision, and 30% of these fatalities occurred in people younger than the legal drinking age.”(21)
As for deaths attributed to alcohol-related road crashes, the Traffic Injury Research Foundation of Canada estimated that 1,055 persons died in alcohol-related road crashes in Canada in 2002. The vast majority were men (80%). Over two-thirds were the drivers of the vehicle (68.3%).(22) The number of motor vehicle deaths directly involving a drinking driver was estimated to be 850, down significantly from the 1,296 estimated deaths in a similar study conducted in 1995.(23)
Alcohol also plays a key role in snowmobile accidents. According to the CIHI, alcohol was a factor in almost half of the hospitalizations for snowmobile-related trauma in 2003-2004. “Of those with positive alcohol levels, 91% were driving the snowmobile. More than one in three (39%) of these individuals required mechanical ventilation and on average stayed in hospital more than three times as long (33 days) as those who had no alcohol in their blood and were admitted to a specialized trauma unit with snowmobile-related injuries.”(24)
According to data on the causes of deaths recorded in Canada in 2003, 666 people died as a result of mental and behavioural disorders due to the use of alcohol. The main cause of death was alcohol dependence syndrome (328 deaths); followed by deaths caused by the harmful use of alcohol (155 deaths) and deaths caused by acute intoxication (77 deaths). The vast majority of people who died of alcohol-related mental and behavioural disorders in 2003 were men (507 males, 159 females). That same year, another 818 people died of alcoholic cirrhosis of the liver. Again more males than females died (615 as opposed to 203), and the vast majority (81.5%) were 50 years and older. A little over 58% of deaths attributed to alcoholic cirrhosis of the liver involved people between the ages of 50 and 69. Finally, poisoning by and exposure to alcohol was the cause attributed to another 106 deaths.(25)
Close to 79,000 incidents of impaired driving were reported by Canadian police forces in 2004,(26) a rate 33% lower than a decade ago.(27) Although the number of impaired driving offences has been generally declining for over two decades, these offences accounted for two-thirds of all Criminal Code traffic offences in 2004. In Canada, impaired driving is prohibited under the Criminal Code. If convicted, impaired drivers face various penalties ranging from a mandatory minimum driving prohibition period and a fine and/or jail term that could be up to life imprisonment, depending on the seriousness of the offence committed and whether the person convicted of the offence is a repeat offender. As well, license suspensions and other sanctions (e.g., vehicle impoundment, mandatory participation in a rehabilitation program) can be imposed in various jurisdictions across the country.(28)
Even though surveys reveal that the prevalence of impaired driving has been declining over the last decade, a small percentage of Canadian drivers still pose a serious threat to their personal safety and that of others on the road. The Road Safety Monitor 2005 said that 3% of Canadian drivers would account for the vast majority of all impaired driving trips. In 2005, 14.7% of Canadian drivers reported that they had driven a vehicle within two hours of consuming alcohol during the month prior to the survey, down from 16.7% from 2001. As well, 6.7% of drivers indicated that in the past year they had driven when they were probably over the legal blood alcohol content (BAC) limit, down from 7.3% in 2001.(29)
As for young drivers, findings from the 2005 Ontario Student Drug Use Survey showed that 13.6% of all drivers in grades 10 to 12 reported driving within an hour of consuming two or more drinks at least once in the previous year. Contrary to findings in the adult population, rates of drinking and driving among youth have remained stable since 1999. However, there has been a significant decline compared to the late 1970s and early 1980s. Another 28.8% percent of students in grades 7 to 12 indicated being a passenger at least once in the previous year in a vehicle driven by someone who had been drinking alcohol, which is not significantly lower than the 30.9% rate reported in 2001.(30)
Fetal Alcohol Spectrum Disorder (FASD) is a leading cause of preventable birth defects resulting in developmental and cognitive disabilities among Canadian children. A recent study of the direct and indirect costs associated with FASD estimated that the “cost of FASD annually to Canada of those 1 to 21 years old, was $344,208,000.”(31)
Little is known as to the prevalence of FASD in Canada as there are no official national statistics. Most researchers and stakeholders agree however that FASD is grossly under-diagnosed and under-reported. Research in the United States estimates the incidence of FASD to be one to nine per 1,000 live births. Health Canada suggests that the prevalence of FASD in Canada would be similar to that in the United States. The prevalence of Fetal Alcohol Syndrome/Fetal Alcohol Effects among high-risk populations, including First Nations and Inuit communities and other populations living in chronic poverty or marginalized conditions, is estimated to be much higher. However, until more data are available, we cannot establish the overall prevalence of FASD in Canada or determine its incidence within any population subgroups.
Until recently, there was no comprehensive approach to diagnosing FASD-related conditions in Canada. In March 2005, the first Canadian guidelines for the diagnosis of FASD prepared by the Subcommittee of the Public Health Agency of Canada’s National Advisory Committee on Fetal Alcohol Spectrum Disorder were published. These guidelines were based on vast consultations with stakeholders and experts in the field.(32) The implementation of these guidelines should facilitate the collection of data on FASD in Canada.
Some data are currently available on the levels of awareness of FASD and on alcohol use during pregnancy. According to the Canadian Perinatal Health Report 2003, the percentage of self-reported alcohol consumption during pregnancy declined from 17.4% in 1994-1995 to 14.6% in 1998-1999. The prevalence rate varied across regions from a low of 7.7% in the Atlantic provinces to a high of 25.1% in Quebec. As to levels of awareness, a national survey of women aged 18 to 40 and their partners conducted in March 2002 on behalf of Health Canada revealed that the vast majority (98%) of respondents knew that the more alcohol a woman drinks during pregnancy, the more harm that could be done to the baby. The safety of drinking in moderation during pregnancy was not so clear. Sixty-eight percent of respondents indicated that they believe any amount of alcohol use during pregnancy can harm the baby. Sixty-two percent of women surveyed stated that they would stop drinking alcohol if they were to become pregnant. Another 9% of women indicated that they would lower their intake of alcohol and 5% reported that they would not modify their alcohol use.(33)
In Canada, many levels of governments, stakeholders, non-governmental organizations, researchers, policy analysts and the alcohol industry share the responsibility for creating and implementing initiatives and measures that will prevent and reduce alcohol-related harms. There are two basic approaches: “1) the population health approach, which targets overall drinking rates and 2) the harm reduction approach, which targets high-risk drinking patterns at the individual level.”(34) These approaches complement each other and are part of a mix of policies employed by most countries to address alcohol-related harms. Ten best practices reflecting these approaches have been identified in a recent study conducted by an international project team of 15 researchers who reviewed 31 public policies aimed at reducing alcohol-related harms.(35) These best practices are:
At the federal level, Canada’s Drug Strategy includes a number of activities to reduce alcohol-related harms to individuals, families and communities. In cooperation with the provinces and territories, Health Canada contributes $14 million each year toward the development of substance abuse treatment and rehabilitation through its Alcohol and Drug Treatment and Rehabilitation Program.(37) Alcohol and drug abuse treatments are also offered to inmates in federal correctional institutions. Health Canada’s First Nations and Inuit Health Branch oversees the National Native Alcohol and Drug Abuse Program, which spends approximately $30 million in support of alcohol and other drug abuse community-based prevention programs targeted at First Nations People and Inuit.(38)
Alcohol prevention programs are also funded under the Drug Strategy Community Initiatives Fund. As well, funding provided under the strategy has led to the creation of a Web site targeted specifically at youth. Be Drug Wise provides easily accessible facts about drugs and alcohol, their impact, and related laws. Finally, Canada’s Drug Strategy provides funding for public awareness campaigns, surveys, research, and the dissemination of knowledge and best practices.(39)
As to the development of specific alcohol-related public policies, Health Canada and the Canadian Centre on Substance Abuse co-hosted a National Thematic Workshop on Alcohol Policy in November 2004. Major stakeholder groups have identified priority areas for a collaborative approach to alcohol policy. These areas are:
A National Alcohol Strategy Working Group (NASWG) was established to address priority issues identified during the workshop. This group is co-chaired by Health Canada, the Alberta Alcohol and Drug Abuse Commission and the Canadian Centre on Substance Abuse. Its membership include non-governmental organizations, federal partners in Canada’s Drug Strategy, representatives of provincial and territorial governments, retail alcohol monopolies and regulators, and the alcohol industry, as well as academics and researchers. The NASWG was expected to unveil a national alcohol strategy in the summer of 2006.(41)
Other round tables on substance use and abuse were also held across Canada in 2004. These consultations led to the presentation of a National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada at a national forum held in June 2005. Stakeholders present at the forum agreed on the principles, goals and priorities outlined in this framework. Individuals who took part in the drafting of the framework are now seeking its endorsement by their ministers, boards and governing bodies. A meeting to discuss progress made in this regard is expected early in 2007.(42)
Key stakeholders who participated in the 2004 National Thematic Workshop on Alcohol Policy identified FASD as an area requiring further action. Thus far, the Government of Canada is involved through several initiatives. It created a National FASD Initiative in 1999, followed by the establishment of a National Advisory Committee on Fetal Alcohol Syndrome/Fetal Alcohol Effects in May 2000. In December 2003, following consultations with organizations across the country, Health Canada published a guide for future action on FASD in Canada entitled Fetal Alcohol Spectrum Disorder (FASD): A Framework for Action. Since its creation in September 2004, the Public Health Agency of Canada has overseen the implementation of the FASD initiative. Health Canada’s First Nations and Inuit Health Branch also delivers a program aimed at reducing the incidence of FASD births and improving the quality of life of those affected in First Nations persons living on reserves and in Inuit communities. As well, Health Canada funding made possible the creation of a National Database of FASD and Substance Use during Pregnancy Resources administered by the Canadian Centre on Substance Abuse. More recently, under Canada’s Drug Strategy, $2 million ($1 million in 2004-2005 and another million in 2005-2006) in additional funding was invested in the National FASD Initiative “to accelerate the development and dissemination of diagnostic guidelines and screening tools, as well as training and education resources for health care providers.”(43)
As noted earlier in this paper, the sale of alcohol clearly contributes to the national economy of Canada. Moderate alcohol consumption may also have some health benefits, particularly in terms of prevention of cardiovascular diseases. However, as this hypothesis is now under review, policy makers and other stakeholders should give pause before accepting that moderate alcohol use has a cardiac protection benefit. On the other hand, alcohol use and abuse also contribute to a number of social, legal, economic and health problems. Alcohol consumption is a factor in the development of numerous diseases, as well as being a cause of injuries, disability, and premature deaths. Alcohol abuse affects not only those who drink to excess but also those close to them and society as a whole. The cost of alcohol abuse in Canada has recently been estimated at $14.6 billion annually.
Research on impaired driving, its related harms, and public policies has shown that some policies can significantly reduce the occurrence of alcohol-related harms. Major groups of stakeholders from all sectors of Canadian society have recently agreed on priority areas that should be the target of alcohol policy development and action. They established a National Alcohol Strategy Working Group, which is currently developing a comprehensive, integrated, and inclusive national approach to alcohol in Canada. A national alcohol strategy is expected to be released in 2006. This strategy will be an important step toward a more coordinated approach to the use and control of alcohol in Canada that will likely promote a responsible use of alcohol and assist in reducing alcohol-related harms.