Jinhui Zhao

Does minimum pricing reduce alcohol consumption? The experience of a Canadian province

AIMS Minimum alcohol prices in British Columbia have been adjusted intermittently over the past 20 years. The present study estimates impacts of these adjustments on alcohol consumption. DESIGN Time-series and longitudinal models of aggregate alcohol consumption with price and other economic data as independent variables. SETTING British Columbia (BC), Canada. PARTICIPANTS The population of British Columbia, Canada, aged 15 years and over. MEASUREMENTS Data on alcohol prices and sales for different beverages were provided by the BC Liquor Distribution Branch for 1989-2010. Data on household income were sourced from Statistics Canada. FINDINGS Longitudinal estimates suggest that a 10% increase in the minimum price of an alcoholic beverage reduced its consumption relative to other beverages by 16.1% (P < 0.001). Time-series estimates indicate that a 10% increase in minimum prices reduced consumption of spirits and liqueurs by 6.8% (P = 0.004), wine by 8.9% (P = 0.033), alcoholic sodas and ciders by 13.9% (P = 0.067), beer by 1.5% (P = 0.043) and all alcoholic drinks by 3.4% (P = 0.007). CONCLUSIONS Increases in minimum prices of alcoholic beverages can substantially reduce alcohol consumption.

Non-response bias in alcohol and drug population surveys.

INTRODUCTION AND AIMS This proposed study was to assess non-response bias in the 2004 Canadian Addictions Survey (CAS). DESIGN AND METHODS Two approaches were used to assess non-response bias in the CAS which had a response rate of only 47%. First, the CAS sample characteristics were compared with the 2002 Canadian Community Health Survey (CCHS, response rate 77%) and the 2001 Canada Census data. Second, characteristics of early and late respondents were compared. RESULTS People with lowest income and less than high-school education and those who never married were under-represented in the CAS compared with the Census, but similar to the CCHS. Substance use was more prevalent in the CAS than the CCHS sample, but most of the CAS and CCHS estimates did not exceed +/-3% points. Late respondents were also significantly more likely to be male, young adult, highly educated, used, have high income, live in different provinces and report substance use. Multivariate logistic regression found significant non-response bias for lifetime, past 12 months, chronic risky, acute risky and heavy monthly alcohol use, lifetime and past year cannabis use, lifetime hallucinogen use, any illicit drug uses of lifetime and past year. Adjustment for non-response bias substantially increased prevalence estimates. For example, the estimates for lifetime and past 12 month illicit drug use increased by 5.22% and 10.34%. DISCUSSION AND CONCLUSIONS It is concluded that non-response bias is a significant problem in substance use surveys with low response rates but that some adjustments can be made to compensate.

The relationship between minimum alcohol prices, outlet densities and alcohol‐attributable deaths in British Columbia, 2002–09

AIM To investigate relationships between periodic increases in minimum alcohol prices, changing densities of liquor stores and alcohol-attributable (AA) deaths in British Columbia, Canada. DESIGN Cross-section (16 geographic areas) versus time-series (32 annual quarters) panel analyses were conducted with AA deaths as dependent variables and price, outlet densities and socio-demographic characteristics as independent variables. SETTING AND PARTICIPANTS Populations of 16 Health Service Delivery Areas in British Columbia, Canada. MEASUREMENTS Age-sex-standardized rates of acute, chronic and wholly AA mortality; population densities of restaurants, bars, government and private liquor stores; minimum prices of alcohol in dollars per standard drink. FINDINGS A 10% increase in average minimum price for all alcoholic beverages was associated with a 31.72% [95% confidence interval (CI): ± 25.73%, P < 0.05] reduction in wholly AA deaths. Significantly negative lagged associations were also detected up to 12 months after minimum price increases for wholly but not for acute or chronic AA deaths. Significant reductions in chronic and total AA deaths were detected between 2 and 3 years after minimum price increases. Significant but inconsistent lagged associations were detected for acute AA deaths. A 10% increase in private liquor stores was associated with a 2.45% (95% CI: ± 2.39%, P < 0.05), 2.36% (95% CI: ± 1.57%, P < 0.05) and 1.99% (95% CI: ± 1.76%, P < 0.05) increase in acute, chronic and total AA mortality rates. CONCLUSION Increases in the minimum price of alcohol in British Columbia, Canada, between 2002 and 2009 were associated with immediate and delayed decreases in alcohol-attributable mortality. By contrast, increases in the density of private liquor stores were associated with increases in alcohol-attributable mortality.

The raising of minimum alcohol prices in Saskatchewan, Canada: Impacts on consumption and implications for public health.

OBJECTIVES We report impacts on alcohol consumption following new and increased minimum alcohol prices in Saskatchewan, Canada. METHODS We conducted autoregressive integrated moving average time series analyses of alcohol sales and price data from the Saskatchewan government alcohol monopoly for 26 periods before and 26 periods after the intervention. RESULTS A 10% increase in minimum prices significantly reduced consumption of beer by 10.06%, spirits by 5.87%, wine by 4.58%, and all beverages combined by 8.43%. Consumption of coolers decreased significantly by 13.2%, cocktails by 21.3%, and liqueurs by 5.3%. There were larger effects for purely off-premise sales (e.g., liquor stores) than for primarily on-premise sales (e.g., bars, restaurants). Consumption of higher strength beer and wine declined the most. A 10% increase in minimum price was associated with a 22.0% decrease in consumption of higher strength beer (> 6.5% alcohol/volume) versus 8.17% for lower strength beers. The neighboring province of Alberta showed no change in per capita alcohol consumption before and after the intervention. CONCLUSIONS Minimum pricing is a promising strategy for reducing the public health burden associated with hazardous alcohol consumption. Pricing to reflect percentage alcohol content of drinks can shift consumption toward lower alcohol content beverage types.

Minimum Alcohol Prices and Outlet Densities in British Columbia, Canada: Estimated Impacts on Alcohol-Attributable Hospital Admissions

OBJECTIVES We investigated whether periodic increases in minimum alcohol prices were associated with reduced alcohol-attributable hospital admissions in British Columbia. METHODS The longitudinal panel study (2002-2009) incorporated minimum alcohol prices, density of alcohol outlets, and age- and gender-standardized rates of acute, chronic, and 100% alcohol-attributable admissions. We applied mixed-method regression models to data from 89 geographic areas of British Columbia across 32 time periods, adjusting for spatial and temporal autocorrelation, moving average effects, season, and a range of economic and social variables. RESULTS A 10% increase in the average minimum price of all alcoholic beverages was associated with an 8.95% decrease in acute alcohol-attributable admissions and a 9.22% reduction in chronic alcohol-attributable admissions 2 years later. A Can

Impact on alcohol‐related mortality of a rapid rise in the density of private liquor outlets in British Columbia: a local area multi‐level analysis

0.10 increase in average minimum price would prevent 166 acute admissions in the 1st year and 275 chronic admissions 2 years later. We also estimated significant, though smaller, adverse impacts of increased private liquor store density on hospital admission rates for all types of alcohol-attributable admissions. CONCLUSIONS Significant health benefits were observed when minimum alcohol prices in British Columbia were increased. By contrast, adverse health outcomes were associated with an expansion of private liquor stores.

Changes in per capita alcohol sales during the partial privatization of British Columbia's retail alcohol monopoly 2003-2008: A multi-level local area analysis

AIMS To study relationships between rates of alcohol-related deaths and (i) the density of liquor outlets and (ii) the proportion of liquor stores owned privately in British Columbia (BC) during a period of rapid increase in private stores. DESIGN Multi-level regression analyses assessed the relationship between population rates of private liquor stores and alcohol-related mortality after adjusting for potential confounding. SETTING The 89 local health areas of BC, Canada across a 6-year period from 2003 to 2008, for a longitudinal sample with n = 534. MEASUREMENTS Population rates of liquor store density, alcohol-related death and socio-economic variables obtained from government sources. FINDINGS The total number of liquor stores per 1000 residents was associated significantly and positively with population rates of alcohol-related death (P < 0.01). A conservative estimate is that rates of alcohol-related death increased by 3.25% for each 20% increase in private store density. The percentage of liquor stores in private ownership was also associated independently with local rates of alcohol-related death after controlling for overall liquor store density (P < 0.05). Alternative models confirmed significant relationships between changes in private store density and mortality over time. CONCLUSIONS The rapidly rising densities of private liquor stores in British Columbia from 2003 to 2008 was associated with a significant local-area increase in rates of alcohol-related death.

Influence of pre-diagnostic cigarette smoking on colorectal cancer survival: overall and by tumour molecular phenotype

AIM To investigate the independent effects on liquor sales of an increase in (a) the density of liquor outlets and (b) the proportion of liquor stores in private rather than government ownership in British Columbia between 2003/4 and 2007/8. DESIGN The British Columbia Liquor Distribution Branch provided data on litres of ethanol sold through different types of outlets in 89 local health areas of the province by beverage type. Multi-level regression models were used to examine the relationship between per capita alcohol sales and outlet densities for different types of liquor outlet after adjusting for potential confounding social, economic and demographic factors as well as spatial and temporal autocorrelation. SETTING Liquor outlets in 89 local health areas of British Columbia, Canada. FINDINGS The number of private stores per 10,000 residents was associated significantly and positively with per capita sales of ethanol in beer, coolers, spirits and wine, while the reverse held for government liquor stores. Significant positive effects were also identified for the number of bars and restaurants per head of population. The percentage of liquor stores in private versus government ownership was also associated significantly with per capita alcohol sales when controlling for density of liquor stores and of on-premise outlets (P < 0.01). CONCLUSION The trend towards privatisation of liquor outlets between 2003/04 and 2007/08 in British Columbia has contributed to increased per capita sales of alcohol and hence possibly also to increased alcohol-related harm.

Should alcohol policies aim to reduce total alcohol consumption? New analyses of Canadian drinking patterns

Background:Smoking is a risk factor for incident colorectal cancer (CRC); however, it is unclear about its influence on survival after CRC diagnosis.Methods:A cohort of 706 CRC patients diagnosed from 1999 to 2003 in Newfoundland and Labrador, Canada, was followed for mortality and recurrence until April 2010. Smoking and other relevant data were collected by questionnaire after cancer diagnosis, using a referent period of ‘2 years before diagnosis’ to capture pre-diagnosis information. Molecular analyses of microsatellite instability (MSI) status and BRAF V600E mutation status were performed in tumour tissue using standard techniques. Multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with Cox proportional hazards regression, controlling for major prognostic factors.Results:Compared with never smokers, all-cause mortality (overall survival, OS) was higher for current (HR: 1.78; 95% CI: 1.04–3.06), but not for former (HR: 1.06; 95% CI: 0.71–1.59) smokers. The associations of cigarette smoking with the study outcomes were higher among patients with ⩾40 pack-years of smoking (OS: HR: 1.72; 95% CI: 1.03–2.85; disease-free survival (DFS: HR: 1.99; 95% CI: 1.25–3.19), those who smoked ⩾30 cigarettes per day (DFS: HR: 1.80; 95% CI: 1.22–2.67), and those with microsatellite stable (MSS) or MSI-low tumours (OS: HR: 1.38; 95% CI: 1.04–1.82 and DFS: HR: 1.32; 95% CI: 1.01–1.72). Potential heterogeneity was noted for sex (DFS HR: 1.68 for men and 1.01 for women: P for heterogeneity=0.04), and age at diagnosis (OS: HR: 1.11 for patients aged <60 and 1.69 for patients aged ⩾60: P for heterogeneity=0.03).Conclusions:Pre-diagnosis cigarette smoking is associated with worsened prognosis among patients with CRC.

Is alcohol consumption a risk factor for prostate cancer? A systematic review and meta–analysis

We investigated whether high-risk drinking patterns are restricted to a few high-volume drinkers or are evenly distributed across the population to inform discussion regarding the optimal mix of targeted versus universal prevention strategies. Drinking patterns reported in the 2004 Canadian Addiction Survey (CAS, n = 13,909) were assessed against various low-risk drinking guidelines. Under-reporting was assessed against known alcohol sales for 2004. Non-response bias due to the low response rate (47%) was investigated through comparisons with the 2002 Canadian Community Health Survey (CCHS). Self-reported alcohol consumption for the past week and past year accounted for between 31.9% and 37.0%, respectively of official alcohol sales data. Comparisons with the 2002 CCHS suggested only limited non-response bias. Many more respondents regularly placed themselves at risk of short-term harm (20.6%) than exceeded guidelines for avoiding long-term health problems (3.9%). Ten percent of respondents consumed more than 50% of total self-reported consumption. Most alcohol (73.4%) consumed by the sample in the previous week was drunk in excess of Canadian low-risk drinking guidelines – for 19 to 24 year olds this figure was 89.4%. These data provide support both for universal prevention strategies (e.g. reducing economic and physical availability of alcohol) as well as targeted interventions for risky drinkers (e.g. screening and brief interventions in primary health care settings).