Rising per capita alcohol consumption and drinking-related harm:Suggestions for meeting the challenge¹

Norman Giesbrecht

Alcohol consumption and high risk drinking

After a long period of gradual decline in per capita consumption in Canada, around the mid-1990s the official sale of alcohol per capita began to slowly increase. For example, it rose from 7.3 litres of absolute alcohol per adult (aged 15+) in 199

A likely outcome of a rising rate of consumption is an increase in drinking-related damage, as indicated by extensive international research², including recent work in Europe³ and Canada. Publications by Skog and Ramstedt, focusing on Canada, note that as consumption increases one can expect an increase in motor vehicle crash mortality⁴ and liver cirrhosis mortality⁵. Other research, also focusing on Canada’s experience over the past five decades, points to strong associations between changes in the rate of consumption and death classified as due to drinking, and other types of harm, including suicides, homicides and mortality from all causes.₆

There are also signals from at least one Canadian province, Ontario, that with an increase in consumption, high-risk drinking is not becoming less common. In the 1998 general population survey, 61.3% of drinkers reported having had 5 or more drinks on at least one occasion in the past 12 months, and 15.2% reported that this was at least weekly; for 2002 the percentages were 66.5% and 14.4%, respectively.⁷

Trends in consumption and drinking patterns

There are signs that alcohol consumption will continue to increase in Canada. The Canadian economy is strong and with a high disposable income per capita and no sign of a significant increase in alcohol prices, rates of drinking will probably continue to rise. Although the change in total alcohol outlets per capita has been modest, the direction of this change, and several others, such as hours and days of sale, involves more rather than less access, and probably contributes to stimulating alcohol sales.⁸ There is extensive marketing of alcohol products, both by most provincial liquor boards and alcohol producers.⁹ While evidence on the contribution of marketing and promotion to consumption rates is subject to debate,¹⁰ these marketing initiatives signal that alcohol is a normalized ordinary commodity. Such marketing practices dramatically overshadow the occasional public message that raises concerns about drinking-related risks. Furthermore, it appears that those who manage alcohol distribution and sales are not concerned about rising rates of consumption, but instead are oriented to stimulating sales.¹¹

An accurate understanding of the multiple factors behind changing rates of consumption and patterns of drinking is elusive. Yet there is a strong body of knowledge, research and experience about appropriate goals of prevention and effective interventions. The dismantling of alcohol controls with the resultant increased access to alcohol in many western countries in the past few decades, has ironically contributed to a better knowledge of measures which reduce damage at the population level.¹²

Based on recent WHO estimates of the global burden of death, disease and disability from alcohol, it has been projected¹³ that if alcohol policy and interventions do not become more effective, damage from alcohol will be likely to increase. In order to reduce the harm from alcohol, prevention strategies need to be based on evidence of impact and, as an interim step, reduce both the population-level drinking rate and frequency of high-risk consumption.

Goals of prevention

Three general goals of alcohol-related prevention strategies are to promote health,¹⁴ to reduce damage and disability, and to prolong life. With regard to damage and disability, this includes chronic and acute physical problems associated with drinking, as well as relevant social harms and economic hardship.¹⁵ In assessing the effectiveness of different interventions, it is appropriate to use their harm reduction impact at individual and population levels as criteria.

Intervening Variables and Interventions

Several interim steps are associated with the desired outcomes, for example,

(1) reducing overall rates of drinking in the population;

(2) reducing the frequency of heavy-drinking occasions;

(3) reducing binge drinking;

(4) separating alcohol use from certain behaviours -- such as driving motor vehicles, operating boats or snowmobiles, and raising awareness of the associated risks with alcohol consumption.

In Canada, more attention is paid to the two latter intervening variables and less to the three first broader ones, even though the broader variables are critical to promoting health and reducing harm.¹⁶ Information and persuasion campaigns generally raise awareness about the risks of heavy drinking and drinking in connection with activities (e.g., driving) or conditions (e.g., pregnancy), or contexts (e.g., workplace), or offer a counter message that challenges the promotion of alcohol through marketing, advertising and sponsorship. Health or safety messages may encourage health-oriented dialogue about risks of drinking and delineate personal options in handling pressures to drink. However, the evidence suggests they are unlikely to reduce consumption or drinking-related harm.¹⁷

Despite their popularity, information and education campaigns are the weakest of the interventions noted above. The extensive resources devoted to them are likely to have little, if any, impact on drinking rates or damage from alcohol use.

They are not sufficiently geared towards the special needs of the high-risk drinkers and may be more commonly viewed by the ‘converted’, that is the modest drinkers or abstainers. Their potential may be enhanced by using them as a supplement to interventions with a demonstrated impact, rather than as stand alone initiatives. They could also be refocused to offer the public a rationale for changes in alcohol policy, encouraging dialogue about alcohol promotion, marketing, and other activities of the alcohol industry.¹⁸ While changing social norms about alcohol appears, in principle, to be an important step, it is unclear how this is done without using effective policies or regulatory measures. Nor is it necessarily the case that changes in social norms need to precede a change in alcohol policy.

Telling people to avoid high-risk drinking is unlikely to produce results in the absence of other initiatives. These include, for example, server intervention programs – including instructions on server liability for over-serving, serving to minors, and allowing intoxicated customers to drive away, and active enforcement of other on-premise regulations.¹⁹ Unfortunately, it is not yet a requirement that all persons who serve alcohol either in an off-premise or on-premise venue, including special occasion permit events, are required to take a server intervention program. Other strategies include managing access to alcohol by controlling days and hours of sale, density of outlets or having prices of alcoholic beverages at least keep pace with consumer prices indices.

The Canadian provincial and federal governments appear to have made significant strides in tackling drinking and driving. There is a national legal BAC threshold of 0.08, administrative license suspension for lower thresholds in most provinces, and graduated licence programmes for first time licensees of motor vehicles.²⁰ Periodic roadside spot checks, which are common during the Christmas holiday season, are frequently implemented in most parts of Canada. These efforts facilitate the separation of driving from drinking. It is feasible that they may eventually have a broader beneficial impact in reducing high-risk drinking in general.

Next Steps

This overview has made a case for phasing out or refocusing some interventions, such as education campaigns, and for giving more attention to others, such as controls on access to alcohol and on-site interventions involving the service and sales of alcohol. The next paragraphs propose several steps forward, grouped into four categories: perceptions, structures, research, and action.

Perceptions: There is a noteworthy contrast between the messages about alcohol that dominate the media and public opinion among Canadians about alcohol policy topics. The promotional material in the media and in-store displays, as well as promotions and other inducements, conveys the message that this is a benign product, suitable for almost any occasion, that might be integrated into daily activities without major risks. In contrast, surveys of representative adults show that almost half would like to see advertising banned,²¹ most are not in favour of greater access to alcohol,²² and the majority are concerned about over-service to intoxicated customers.²³

A more costly and possibly less effective option is to provide sufficient resources and advertising talents in order to raise awareness about the burden of disease, death and disability from alcohol. These “counter” messages might also outline the impacts of alcohol promotion upon views of youth about alcohol,²⁴ and the relative effectiveness of alcohol polices and intervention strategies.²⁵ Furthermore, through debate about policy options and their enforcement, perceptions among the public and policy leaders may also be encouraged to become more oriented to health and safety agendas. However the impact of counter-advertising is likely to be modest. A more cost-effective approach is to implement alcohol control policies and other interventions noted by Babor and colleagues.²⁶

Structures: Several changes at the organisational level are proposed that will likely facilitate a more effective response to alcohol problems. Currently, most provincial liquor control boards report to a provincial Ministry that is responsible for commercial agendas. Although the liquor boards have a mandate to control harm, in at least some provinces the commercial, marketing and aggressive retailing functions have dominated their activities in recent years. This transformation seems to be influenced by the threat of privatisation on the one hand, and desire to generate higher government revenue each year on the other, combined with an apparent desire to excel in state-of-the art marketing practices. One way of reinforcing a more balanced view²⁷ is to change the reporting arrangements, so that liquor boards report directly to a small cabinet committee with an alcohol management mandate and representation from ministries responsible for health, traffic, public safety and commerce, or to the Ministry of Health for each province.

Federal and provincial governments would benefit from establishing alcohol advisory groups²⁸ with diverse representation, for example, from public health and safety organisations, research community and business and retailing sectors. The mandate of these advisory groups should include the review of developments in drinking-related harm in the relevant jurisdiction as well as proposals for changes in regulation and policy. Their mandate might include that of commissioning background papers to assess the potential impacts of proposed changes and sponsoring evaluations of pilot experiments in alcohol policy and alcohol distribution arrangements.

Both provincial and federal governments would be well advised to collaborate in developing an Action Plan with regard to alcohol. Experiences from Europe provide a very useful model. Several phases of a European Alcohol Action Plan were approved by the WHO, starting in 1995, and provided guidance to countries and communities with regard to goals and interventions designed to reduce drinking rates, high risk drinking and related damage.²⁹ While this proposed action plan is not in itself a structural change, it might provide a vision and a pulling together of resources in ways that are more effective in reducing harm than is currently the case.³⁰

Monitoring and research: Further work is needed to understand how alcohol policy decisions are made and what determines the allocation of resources for their enforcement. Studies that monitor the activities of the alcohol industry are rare but would be useful in understanding the dynamics of alcohol policy priorities. Of particular interest are trade agreements³¹ and the position of federal and provincial agencies with regard to the protection of alcohol as a unique and high-risk commodity.³² Other work might look at changes in access to alcohol and alcohol promotion and their impacts on consumption rates, drinking patterns and alcohol-related problems. Case studies of community experiences in harm reduction have not been systematically documented. Annual monitoring of drinking patterns, drinking-related harm and public opinion on alcohol issues – at the provincial level -- would provide a resource for assessing the effect of policy changes and prevention efforts.³³ Research conducted elsewhere on the proportion of total alcohol consumed by high-risk drinkers³⁴ also might be undertaken with regard to Canadian experiences in order to explore what proportion of total sales is linked to chronic or sporadic heavy consumption.

It is uncommon to find a priori social impact assessments in the alcohol field with regard to policy changes.³⁵ If this were to become the standard protocol prior to the implementation of proposed changes in access to alcohol, a very useful resource would be created for the advisory committees proposed above, and for policy-makers. Natural experiments with baseline and post-change data also provide a basis for assessing the impact of policy changes.

Finally, the means of disseminating key findings to policy advisors and decision makers and other interested persons needs to be enhanced in all provinces. A useful model is the Alcohol Policy Network in Ontario.³⁶ Other provinces may wish to develop similar networks with links to a national network.

Action: An important interim goal is that of reducing per capita consumption.³⁷ If effective action is to be taken towards reducing the harm associated with alcohol, it will require an acknowledgement by governments that both rising rates of alcohol sales as well as high risk drinking patterns are matters of concern. While changing the rate of consumption will not necessarily reduce all types of harm related to drinking, it has been linked to a wide range of acute and chronic damage from alcohol use, and the international evidence indicates that it is an important intervening step in effective prevention.³⁸

A recent WHO-sponsored publication offers the following list of best practices: minimum purchase age, government monopoly of retail sales, restrictions on hours and days of sale, outlet density restrictions, higher alcohol taxes, sobriety check-points, lowered BAC limits, administrative licence suspension, graduated licensing for novice drinkers and brief interventions for hazardous drinkers.³⁹ This analysis provides concrete and practical guidance moving us beyond mere lip service to the term “evidence-based”. The strategies outlined deserve more resources and attention. If the central intent of prevention is to reduce harm from drinking, then those strategies with a demonstrated track record should receive the highest profile.

There are encouraging signals at several levels. For example, senior staff of the Federal department of Foreign Affairs and International Trade recently indicated that they were not planning to give in to pressures to encourage the dismantling of alcohol monopolies that might arise from international trade discussions.⁴⁰

Through deliberations about new research opportunities⁴¹ it is hoped that further studies of the impacts of alcohol policies and analyses of policy development experiences will be funded.

Although the province of Alberta privatised their alcohol retailing system in 1993, so far, no other province has completely followed this lead. Nevertheless, partial privatisation is underway in British Columbia, and there have been occasional threats of this option being undertaken in Ontario and Nova Scotia. Thus the potential for a liquor board with a strong control mandate exists in most provinces, although a rediscovery of their control and harm reduction agendas would be a worthy priority.⁴² What is worrisome is that marketing and promotion, using state-of-the-art techniques, appear to be a dominant activity of some provincial liquor boards.⁴³

In many municipalities and cities there are citizen’s groups and town councils that seek to control drinking-related problems by implementing alcohol policies and seeking to limit the number of outlets or encouraging responsible sales and service. However, the municipalities often lack the power to enact the most effective interventions relevant to all sales in their jurisdiction while being expected to deal with the damage from heavy drinking. Robin Room has stated:

Ensuring that communities and local government are not hamstrung at state, national or supranational levels from responding to their local problems is thus a more and more pressing issue. It is counterproductive and even cynical to assign communities the responsibility for preventing the problems while denying them the policy tools needed for effective action.⁴⁴

Experiences in tackling drinking and driving in Canada and elsewhere, and the central role that policies and law enforcement played in successfully reducing this rate, provide a useful model for addressing other chronic and acute problems related to drinking.

With regard to tobacco, another legal product with addictive and harmful side effects, Canada has seen remarkable progress, despite some setbacks, in implementing effective policies. These experiences also offer lessons for the alcohol field.

It is also worthwhile to observe alcohol promotion and prevention initiatives in Europe, the United States and other jurisdictions. The relevance of the European Alcohol Action Plan has been noted above. In the United States, for example, alcohol distribution and promotion are more aggressively pursued than they are in Canada; at the same time community activism in promoting effective alcohol policies and law enforcement also appear to be more advanced. More generally, the newly formed Global Alliance offers a venue where Canadians can share their experiences and, in turn, find out about developments in other countries and global regions in promoting effective alcohol policies.

In conclusion, several inter-related action steps are recommended:

• get a place at the policy-making table;

• strengthen and expand partnerships intent on using the most effective interventions to reduce drinking-related harm;

• increase public awareness of alcohol as not an ordinary commodity and draw attention to its potential to inflict damage;

• reduce high risk drinking and per capita consumption;

• support enforcement of effective regulations designed to reduce drinking-related damage;

• assess the expected impacts of policy changes prior to decisions to implement them;

• direct resources and attention to the most effective prevention strategies.

The challenges are significant and so are the human resources required to meet them. However, there are some positive signals, useful lessons to draw on, and guidance with regard to which interventions have a demonstrated track record. Public opinion is supportive of effective interventions. With appropriate vision and leadership from those who influence policy decisions and manage resources, one can imagine a time when rates of drinking, high risk drinking events and alcohol-related harm are measurably reduced.

Dr Norman Giesbrecht is a Senior Scientist with the Centre for Addiction and Mental Health, Toronto, Ontario, Canada

References

1 This paper is based, in part, on a presentation at the a meeting of the Global Alcohol Policy Alliance, Westminister College, Cambridge, England, September 24, 2003. Thanks are extended to Lise Anglin for providing information and copy-editing suggestions, and to Peter Anderson, Colleen Anne Dell, Jürgen Rehm and Patrick Smith for providing information cited here. The views and opinions expressed herein are those of the author.

2 Bruun, K., Edwards, G., Lumio, M., Mäkelä, K., Pan, L., Popham, R.E., Room, R., Schmidt, W., Skog, O.-J., Sulkunen, P. & Österberg, E. (1975) Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, volume 25. Edwards, G. Anderson, P., Babor, T.F., Casswell, S., Ferrence, R., Giesbrecht, N., Godfrey, C., Holder, H.D., Lemmens, P., Mäkelä, K., Midanik, L.T., Norström, T., Österberg, E., Romelsjö, A., Room, R., Simpura, J. and Skog, O.-J. (1994) Alcohol Policy and the Public Good. Oxford: Oxford University Press. Babor, T. , Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., Grube, J., Gruenewald, P., Hill, L., Holder, H., Romel, R., Österberg, E., Rehm, J., Room, R. & Rossow, R. (2003) Alcohol, No Ordinary Commodity: Research and Public Policy. Oxford: Oxford University Press.

3 Norström, T. (1999) European Comparative Alcohol Study – ECAS. Project presentation. Nordic Studies on Alcohol and Drugs 16 (English Supplement), 5-6. Norstrom, T. (2001) Per capita consumption and all-cause mortality in 14 European countries. Addiction, 96 (Supplement 1), S113-S128.
4 Skog, O-J. (2002) Alcohol consumption and fatal accidents in Canada, 1950-1998. Addiction, 98 (7), 883-894.

5 Ramstedt. M. (2002) "Per capita alcohol consumption and liver cirrhosis mortality--the case of Canada." Paper presented at the Seminar: Canadian Alcohol Experiences & Nordic Perspectives. December 12-13, 2002, Voksenåsen Hotel, Oslo

6 Norström, T., (2002) "Per capita alcohol consumption and all-cause mortality in Canada, 1950-1998." Paper presented at the Seminar: Canadian Alcohol Experiences & Nordic Perspectives. December 12-13, 2002, Voksenåsen Hotel, Oslo. Ramstedt, M. (2002) "Are suicide rates in Canada related to changes in alcohol consumption? A time series analysis of postwar experience." Paper presented at the Seminar: Canadian Alcohol Experiences & Nordic Perspectives. December 12-13, 2002, Veksenasen Hotel, Oslo. Ramstedt. M. (2002) "Alcohol consumption and alcohol-related mortality in Canada -- a regional analysis of the postwar period." Paper presented at the Seminar: Canadian Alcohol Experiences & Nordic Perspectives. December 12-13, 2002, Voksenåsen Hotel, Oslo. Rossow, I. (2002) "Alcohol consumption and homicides in Canada 1950-1999." Paper presented at the Seminar: Canadian Alcohol Experiences & Nordic Perspectives. December 12-13, 2002, Voksenåsen Hotel, Oslo.

7 Anglin, L., Giesbrecht, N., Ialomiteanu, A., Grand, L., Mann, R. & McAllister, J. (2003) Public Opinion on Current Alcohol Policy Issues: International Trade Agreements, Advertising and Access to Alcohol. Findings from a 2002 Ontario Survey. CAMH Research Document Series No. 201. Toronto: Centre for Addiction and Mental Health.

8 Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 117-139, Oxford: Oxford University Press.

9 Giesbrecht, N. (in press) Challenges to Reducing Drinking-Related Harm Through Social Policies. The Globe

10 Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 173-188, Oxford: Oxford University Press. Hill, L. & Casswell, S. (2001) Alcohol advertising and sponsorship: Commercial freedom or control in the public interest, pp. 823-846. In: N. Heather, T.J. Peters & T. Stockwell (Eds.) International Handbook of Alcohol Dependence and Problems. Chichester: John Wiley & Sons Ltd.

11 LCBO Corporate Communications (2002) LCBO Annual Report 2001-2002 - Our seventh straight record year. Toronto: LCBO Corporate Communications.

12 Room, R. (1999) The idea of alcohol policy. Nordic Studies on Alcohol and Drugs (English Supplement) 16, 7-20.

13 Rehm, J. (2003) “Alcohol and the burden of disease – epidemiology and policy implications.” Keynote address at the Annual Meeting of the Ontario Public Health Association, Windsor, Ontario, November 3, 2003.

14 Centre for Addiction and Mental Health (2000) Enhancing Health Promotion and Prevention: Final Report. Toronto: Centre for Addiction and Mental Health.

15 Recent WHO sponsored estimates of disability adjusted life years (DALYs) are conservative in that they do not take into account social and family disruption and economic hardships arising from alcohol use. World Health Organization (2003) (editor) Alcohol policy and the Global Burden of Disease – A layperson’s guide. (manuscript).

16 Rehm, R., Room, R., Monteiro, M, Gmel, G., Graham, K., Rehn, N., Sempos, C.T. & Jernigan, D. (2003) Alcohol as a risk factor for global burden of disease. European Addiction Research 9(4): 157-164. Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 263-276, Oxford: Oxford University Press.
17 Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 189-207. Oxford: Oxford University Press.
18 Giesbrecht N. & Grube, J. (2003) “Good intentions or effective prevention in reducing alcohol-related problems. Can we afford both? Paper presented at the 46 International Conference. International Council on Alcohol and Addictions. Toronto, Ontario, October 19-24, 2003.

19 Graham, K. (2000) Preventive interventions for on-premise drinking: A promising but under-researched area of prevention. Contemporary Drug Problems 27, 593-668.

20 Mann, R., Macdonald, S., Stoduto, G., Bondy, S., Jonah, B. & Shaikh, A. (2001) The effects of introducing or lowering legal per se blood alcohol limits for driving: an international review. Accident Analysis and Prevention 33, 569-583. Degutis, L., Giesbrecht, N., Stoduto, G. & Sayward, H. (2002) “A comparison of driving while intoxicated laws in the United States and Canada.” Presented at the International Congress on Alcohol, Drugs and Traffic Safety, Montreal, August 2002.

21 Giesbrecht, N. & Kavanagh, L. (1999) Public opinion and alcohol policy: Comparisons of two Canadian general population surveys. Drug and Alcohol Review 18, 7-19.

22 Anglin, L. et al. (2003) Public Opinion on Current Alcohol Policy Issues: International Trade Agreements, Advertising and Access to Alcohol. Findings from a 2002 Ontario Survey. CAMH Research Document Series No. 201. Toronto: Centre for Addiction and Mental Health.

23 Anglin, L., Kavanagh, L. & Giesbrecht, N. (2001) Alcohol-related policy measures in Ontario: who supports what and to what degree? Canadian Journal of Public Health 92(1): 24-28. Giesbrecht, N., Ialomiteanu, A., Room, R. & Anglin, L. (2001) Trends in public opinion on alcohol policy measures: Ontario 1989-1998. Journal of Studies on Alcohol 62(2): 142-149

24 Grube, J. W. & Nygard, P. (2002) Adolescent drinking and alcohol policy. Contemporary Drug Problems, 28, 87-132.

25 Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 263-276. Oxford, Oxford University Press.

26 Babor T. et al. (2003) Alcohol No Ordinary Commodity, pp. 263-276, Oxford, Oxford University Press.

27 Centre for Addiction and Mental Health (2003) Retail Alcohol Monopolies and Regulation: Preserving the Public Interest – A position paper.

28 Centre for Addiction and Mental Health (2003) Alcohol Policy Framework for Reducing Alcohol-Related Problems. (Draft Manuscript, November 21, 2003).

29 World Health Organization Europe (1999) European Alcohol Action Plan 2000-2005. Copenhagen: WHO Regional Office for Europe.

30 Some recent developments provide a resource for developing such a plan: for example, Ontario Public Health Association (2003) Promoting Healthy Communities – A Framework for Alcohol Policy and Public Health in Ontario. A position paper adopted by the Ontario Public Health Association (OPHA). Centre for Addiction and Mental Health (2003) Retail Alcohol Monopolies and Regulation: Preserving the Public Interest – A position paper. Centre for Addiction and Mental Health (2003) Alcohol Policy Framework for Reducing Alcohol-Related Problems. (Draft Manuscript, November 21, 2003). A Report on the Forum on Alcohol and Illicit Drugs Research in Canada, October 2-4, 2003, Kanata, Ontario. Health Canada, Canadian Institutes for Health Research, Canadian Centre on Substance Abuse & Canadian Executive Council on Addictions

31 Grieshaber-Otto, J. & Schacter, N. (2002) The GATS: impacts of the international “services” treaty on health-based alcohol regulation. Nordic Studies on Alcohol and Drugs, 19 (English supplement), 50-68.

32 Lee, J. (2003) Public health issues involving alcohol in GATS and FTAA treaty negotiations. Letter addressed to the Honourable Pierre Pettigrew, Minister for International Trade, on behalf of the Ontario Public Health Association, September 3, 2003. Garfinkel, P. (2003) Proposed erosion of restrictions on alcohol. Letter address to Suzanne Vinet, Director General, Foreign Affairs and International Trade, Government of Canada, on behalf of the Centre for Addiction and Mental Health, April 11, 2003.

33 For additional suggested research questions see World Health Organization (2003) (editor) Alcohol policy and the Global Burden of Disease – A layperson’s guide. (manuscript)

34 Greenfield, T. K. & Rogers, J.D. (1999) Who drinks most of the alcohol in the U.S.? The policy implications. Journal of Studies on Alcohol, 60, 1, 78-89.

35 Giesbrecht, N., Her, M., Room, R. & Rehm, J. (1999) Impacts of privatization: what do we know and where should we go? Response to commentaries on Her et al. Addiction, 94, 8, 1141-1153. See also, World Health Organization (2003) (editor) Alcohol policy and the Global Burden of Disease – A layperson’s guide. (manuscript).

36 See http://apolnet.org/

37 World Health Organization Europe (1999) European Alcohol Action Plan 2000-2005. Copenhagen: WHO Regional Office for Europe, p. 3.

38 Edwards, G. et al. (1994) Alcohol Policy and the Public Good. Oxford: Oxford University Press. Babor, T. et al. (2003) Alcohol No Ordinary Commodity. Oxford, Oxford University Press. World Health Organization (2003) (editor) Alcohol policy and the Global Burden of Disease – A layperson’s guide. (manuscript).

39 Alcohol and Public Policy Group (2003) Alcohol: No Ordinary Commodity. A summary of the report. Addiction, 98, 1342-1349. See also, Babor, T. et al. (2003) Alcohol No Ordinary Commodity, pp. 263-276, Oxford: Oxford University Press.

40 Lee, J. (2003) and Garfinkel, P. (2003) [see endnote 33]

41 A Report on the Forum on Alcohol and Illicit Drugs Research in Canada, October 2-4, 2003, Kanata, Ontario. Health Canada, Canadian Institutes for Health Research, Canadian Centre on Substance Abuse & Canadian Executive Council on Addictions

42 Centre for Addiction and Mental Health (2003) Retail Alcohol Monopolies and Regulation: Preserving the Public Interest – Position paper

43 LCBO Corporate Communications (2002) LCBO Annual Report 2001-2002 - Our seventh straight record year. Toronto: LCBO Corporate Communications.

44 Room, R. (2003) Rethinking alcohol, tobacco and other drug control. Addiction, 98, 715.