Risk of Injury: The Implications of Mental Health, Alcohol and Gender

Each year, hundreds of thousands of deaths occur due to intentional and unintentional injuries related to alcohol use. Alcohol impairs coordination as well as our ability to perceive and respond to hazardous situations, making it more likely that we will get hurt. Research shows the risk for injury increases as the amount of alcohol use increases. For example, someone consuming five or more drinks on one occasion is 10 times more likely to get injured in the following six hours. But are certain people more likely to get injured when they drink? Are there additional factors associated with alcohol use that could further increase your risk of injury?

In my Master’s thesis, I looked at how alcohol use, mental health symptoms and gender contributed to the risk of injury for British Columbians. I used data from the Alcohol and Other Drugs Monitoring Study, which collects data from people who are admitted to the Emergency department at the Royal Jubilee Hospital in Victoria and Vancouver General Hospital.

I found that the risk for injury increased as the amount of alcohol use increased. The greatest risk of injury is for men, and those consuming six or more drinks in the six-hour period prior to the injury event. I also found that mental health symptoms such as anxiety or depression exacerbated the effect of alcohol and the likelihood of injury among women. Women who consumed alcohol and had mental health symptoms were almost twice as likely to be injured compared to women without mental health symptoms.

Why would the presence of mental health symptoms place women at a greater risk for experiencing injury from alcohol use? It could be that women experiencing mental health issues are more likely to drink as a form of self-medication; however, it is difficult to determine the direction of this effect, as long-term alcohol use has been known to lead to the development of depression and anxiety. Another possible explanation is that because women with mental health symptoms are more likely to take medication to treat the symptoms, the alcohol may be interacting with the medication and resulting in detrimental effects. Finally, higher levels of impulsivity are found among individuals experiencing depression, and it may be that the combination of impulsivity and alcohol use could result in someone engaging in more risk-taking behaviors, thereby placing them at a greater risk of injury.

How can we use this information to help prevent future injuries? It is important that health care providers are aware of the combined effect of mental health symptoms and alcohol on risk of injury. If individuals presenting injuries at the emergency departments could be quickly screened for mental health symptoms such as anxiety and depression, the treatment of these symptoms could potentially result in a reduction of risky alcohol use and help to prevent future injuries. For future research, we hope to continue to look at the inter-relationships between these three factors on risk of injury. In particular, we want to look at whether the risk may differ when comparing violent to non-violent related injuries.

audra roemer

Author: Audra Roemer, Centre for Addictions Research of BC

Audra Roemer completed her Masters Degree in Clinical Psychology at the University of Victoria in July 2014 and will be starting her PhD in September 2014. She studied at the University of British Columbia for her Bachelors degree; her research interests include: substance use, family and individual risk factors, gender, prevention, violence and injury, and child and adolescent development.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Will minimum prices work to minimize harm?

The recent changes to pricing rules in alcohol-serving establishments across BC have been met by applause, discontentment, indifference — and confusion. In effect, two changes were announced: the fact that restaurants and bars can now have happy hour drink specials, allowing them to change the price of alcoholic drinks throughout the day, and the introduction of province-wide minimum drink prices, which apply at all times, not just during happy hour.

BC's new minimum prices for standard alcoholic drinks in booze-serving establishments.

BC’s new minimum prices for standard alcoholic drinks in booze-serving establishments.

Minimum unit pricing is not a new concept. All provinces, except Alberta and Quebec, have some type of minimum pricing policy. Even prior to these new changes, BC had minimum pricing policies in place in liquor stores, though prices were much lower than many other provinces. These new requirements will bring the rest of the province in line with municipalities such as Victoria, which have had minimum unit pricing policies and bylaws in bars and restaurants for quite some time to reduce violence and other late-night order problems.

While the new requirement to charge at least $3 per standard drink may cause prices to increase at some establishments, many British Columbians will likely not notice the implementation of the minimum unit pricing—and in some instances, happy-hour specials will make booze cheaper than it was before. I can’t remember a time when I paid less than $5 for a beer at an establishment; $3 sounds like a steal. But minimum pricing isn’t really about getting “a good deal;” this bold move by the BC government is a step towards reducing alcohol-related harms in our province.

Every year in BC, there are more than 80,000 alcohol-related crimes, 1,800 alcohol-related deaths, and 18,000 alcohol-related hospitalizations. While many of us enjoy alcohol without incident, these staggering numbers remind us of how many of our fellow British Columbians are negatively affected by alcohol use. The introduction of minimum prices could reduce these numbers.

There is strong evidence that minimum alcohol pricing avoids punishing the majority of responsible drinkers while having the greatest impact on the behaviour and health of those most at-risk. Using BC hospital data, a recent study published in the American Journal Public Health found that for every 10 percent increase in minimum prices there was an immediate 9 percent reduction in hospital admissions for injuries and poisonings ‒ and a similar reduction in serious illnesses caused by alcohol (such as liver cirrhosis and cancers) two to three years later. Similarly, we have found immediate and delayed effects from minimum price increases on alcohol-related deaths. Is $3 really such a steep cost for reducing harm?

The BC government has listened to the strong research evidence supporting minimum prices and has taken a step in the right direction by implementing these prices for bars, restaurants and other establishments that serve alcohol. It is refreshing to see decisions being made will protect British Columbians while also respecting that alcohol is an important part of our culture and economy. However, in order to fully realize the harm-reduction potential of minimum pricing policies and offset the potential impact of happy hours, government needs to follow through on updating and overhauling minimum pricing in liquor stores. According to our research, this will have a much larger impact on high-risk consumption and related harms.

Kara Thompson, CARBC

Author: Kara Thompson, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

21st century drinking in BC: more convenience, more government revenue and reduced harms?

On Friday January 31, 2014 the BC government endorsed all 73 recommendations contained in John Yap’s landmark review of liquor laws with the stated goal of modernizing BC’s approach to managing alcohol. Modern drinking in British Columbia will mean consumers are able to purchase and consume more types of alcohol and in more places. Bars, nightclubs and restaurants will be able to compete aggressively on price by offering happy hours; Canucks fans will be able to consume hard liquor while watching a game; festivalgoers will be able to purchase alcohol and wander freely as they drink it; shoppers will be able to buy alcohol with their groceries and parents will be allowed to bring their children into pubs.

The government heralds these and other measures as a way to free businesses and charities from cumbersome, out of date regulations. Interestingly, the media release is relatively silent on an encouraging swathe of other recommendations in the report that, while less politically appealing, make BC’s approach to alcohol also more responsive to health concerns. Mr Yap clearly heard the messages delivered during the review by individuals and groups concerned with health and safety, including those summarised in the CARBC submission.

We congratulate Mr Yap on his acknowledgement that alcohol is a major health issue and not just a matter for the economy, for tourism and government revenue. His very first recommendations concern the need to communicate the serious health effects of alcohol more effectively to British Columbians along with active promotion of the national drinking guidelines. The report even mentions the word “cancer”. This is critically important: at the present time the BC Liquor Distribution Branch has absolutely no mandate to acknowledge, address or monitor the health and safety consequences of the product it so efficiently distributes across our province. It will now be required to collaborate with health experts to design educational materials and, more importantly, consider how to price the many thousands of its alcoholic products so that: a) they are not too cheap and b) their price reflects their degree of potential harmfulness i.e. alcoholic strength.

Perhaps wisely, the government press release has not trumpeted the recommendations on alcohol pricing. It has used only cautious language stating rather timidly that the BC Liquor Distribution Branch should “consider” setting minimum prices according to the ethanol content of drinks and whether they are at “an appropriate level”. Such policies, while possibly the most effective available to government to reduce alcohol-related harm, are undoubtedly not quite as popular as the introduction of happy hours and less red tape for small business.

For the past eight years CARBC has been collecting and reporting indicators of alcohol consumption and related harms across 89 local areas of the province as part of the Alcohol and Other Drug (AOD) Monitoring Project. When Mr Yap’s report asserts that in 2011 there were 20,542 alcohol-related hospital admissions and 1191 alcohol-related deaths, those estimates were calculated by the AOD project team. They were also the basis of research published in the American Journal of Public Health identifying the significant positive impacts of minimum alcohol prices on BC hospital admissions. This same paper also identified negative but smaller impacts on hospital admissions from the increased availability of alcohol associated with the large increase in private liquor outlets that occurred between 2002 and 2006.

On the basis both of local and international research, if the government proceeds with only the more popular recommendations in the report, the net effect will be upward pressure on levels of alcohol consumption and increased harms. If the key recommendations for higher minimum prices based on ethanol content are fully implemented, the net effect will be reduced alcohol-related harms and increased government revenues. Maybe this is what 21st century drinking should be: more choices, more responsibility, more convenience and more financial incentives to produce, promote and consume less harmful products. Perhaps also more funds for treatment and prevention. We at CARBC will continue to watch and hope that the easier and popular policy changes will not be implemented in advance of those which are less popular but more effective in terms of protecting health and safety. Either way, we will observe and report the outcomes as they unfold.

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Authors (left to right): Tim Stockwell, Dan Reist, Kara Thompson, Gerald Thomas, & Kate Vallance

What happens now? Reflecting on the BC Liquor Act Review 2013

After nearly 80 days, the BC liquor policy review wraps up today. For the last 8 weeks we have followed the comments and tweets and have heard thoughts and opinions from the public on how to change liquor policy in BC.  In reviewing the comments on John Yap’s blog, several main themes continued to emerge. First, it is clear that many British Columbian’s feel the current liquor laws are outdated (i.e., “our liquor laws can only be described as archaic – insulting, too”). We agree – in the last decade we have learned much about effective alcohol policy internationally, as well as the costs and benefits of alcohol, which are not reflected in the current laws.

Second, the overwhelming majority of comments centered on a desire for increased convenience and access, both for sale and purchase of alcohol and offered suggestions such as selling alcohol in grocery stores, allowing minors to eat in pubs, and having fewer licensing regulations. Many felt that these changes would help boost local economy and tourism revenue (i.e., “Canada is one of the only countries in the world that restricts the sale of beer and wine to liquor stores. This is a huge inconvenience for consumers, hurts tourism, limits competition, and does not help our economy in any way”), while others cautioned against the harms potentially caused from alcohol, with a particular concern about increasing access to minors (i.e., “Long-term, it will encourage young people to consume more alcohol”). Further, many comments emphasized personal responsibility and suggested that liquor regulations should not punish the majority of responsible drinkers for the irresponsible few (i.e., “Why not stop punishing people for wanting to have a beer at the beach with some friends, and instead punish those who are drinking irresponsibly”). In our alcohol policy blog series we have tried to respond to these comments and offer evidence to facilitate an informed discussion around some of these issues such as balancing harms and costs,  privatization, and increased accessibility.

John Yap’s announcement Tuesday indicates that BC may well go forward with some initiatives to increase consumer convenience in BC, such as selling alcohol in grocery stores. We understand the value placed on convenience in our busy lives and appreciate also the desire  from people in the business sector to improve the viability of their enterprises in a challenging economic environment. We hope to see more announcements that respond to the desire for convenience while addressing British Columbian’s desire to minimize the number of deaths, hospitalization, and injuries caused by alcohol in BC every year.  We know from a recent random survey of people in BC that 84% are in support of using liquor laws to reduce these types of problems that are associated with alcohol use. Research in British Columbia suggests that influencing the price of the cheapest products is of far greater significance when it comes to improving health and safety outcomes than are the number of liquor outlets. Furthermore, maintaining minimum alcohol prices protects the profits of many sectors of the alcohol industry, enhances government revenue and impacts mostly on the heaviest alcohol consumers – with substantial health benefits resulting for that group. A modern approach to liquor regulation in the 21st-century involves allowing consumers more responsibility, providing them with better information to make choices and further encouraging those choices through a  price structure which favors lower alcohol content beverages. These changes may help reduce any increases in alcohol-related problems that could arise from loosening restrictions in order to increase convenience. With the right balance, maybe it is possible to increase convenience while using evidence-based strategies to simultaneously reduce the substantial harms from alcohol.

 

***Tune in next week for the first post in our next Blog series “The cannabis question: where do we go from here?

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Authors: Kara Thompson, PhD and Tim Stockwell, Director, Centre for Addictions Research of BC

Initiatives for evolving safer public drinking environments

A significant portion of alcohol-related harm is associated with a small number of licensed establishments that fail to meet acceptable standards of responsible beverage service. These places are more likely to serve minors and intoxicated patrons. The facilities may be poorly designed or staff poorly trained, leading to clients becoming upset or getting into altercations. Excessively noisy entertainment and narrow passageways are just a couple of common problems that can contribute to aggressive or damaging behaviour.

Current provincial legislation and municipal by-laws do address such issues. For example, the Serving it Right training program is mandatory for managers and servers. Also, local zoning requirements regulate acceptable floor plans and stipulate crowd limits. Periodic examination of the premises and monitoring of performance by government authorized personnel (e.g., inspectors, police officers, pseudo-shoppers) are important enforcement mechanisms for confirmation of continuing compliance with conditions intended to ensure security and enjoyment for patrons in these settings.

What more can local communities and citizens do to ensure local establishments are safe and enjoyable places to be? We could plaster our communities with “responsible use” messages. But evidence suggests that on their own such strategies have minimal impact. We could adopt a health protection approach with more frequent surveillance and tighter enforcement of regulations. Indeed some element of this is no doubt needed, and it can be effective. But is there more that can be done? Can we also apply the health promotion principle of self-regulation to entities such as licensed establishments?

This has been attempted, first in Australia in the 1990s with promising initial results in reduction of disorderly conduct and violent encounters. The idea was to form an agreement among local operators of licensed establishments to uphold and monitor acknowledged standards for safe and comfortable premises and quality service that consumers could confidently count on. Subsequent programs have not all been so successful, but the principle of supporting self-regulation in preventing harm inspired a 2003 initiative in Manchester England under the moniker of Best Bar None that has spread in the UK with encouraging impact. It has since been positively adopted in Alberta and Ontario.

The program involves the hospitality industry and government authorities (including local police) reaching consensus on appropriate criteria that licensed establishments must meet to gain and retain recognized accreditation in the program. Qualifying applicants are entitled to display the credentials in their promotion and are potentially eligible for awards conferred on those retail outlets who demonstrate the most consistent maintenance of the standards committed to. And citizens get to make informed choices about what establishments they wish to frequent when wanting a safe and enjoyable night out. The program as implemented in Alberta appears to be an approach that merits serious consideration here in BC.

As almost always, the magic is in finding the balance. Health promotion, regulation and education work best when they work together. The enforcement of regulations is required for those that won’t or can’t regulate themselves. In fact, some level of monitoring and enforcement is needed to keep us all honest. Education has a critical role in building shared understanding and evolving social norms. Nonetheless, engaging the operators of licensed establishments together with other members of the community and providing a range of incentives to encourage responsible behaviour is also an important part of building healthy communities.

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Authors: Tim Dyck (left), Dan Reist (right)

Public opinion and alcohol policy in BC

As the BC government’s public consultation on liquor control and licensing laws draws to a close at the end of this month we wish to highlight findings from a province-wide opinion survey conducted last month for MADD Canada and CARBC. While telephone surveys have their limitations we believe the results are indicative of broad support across BC for some fundamental principles: that a major purpose of liquor laws should be to reduce alcohol-related harm (84% support); that consumers need to be better informed about risks, e.g. through labeling (71%); and that some kinds of pricing can be used to reduce harm (62% to 65%).

In this blog, we will mainly address the issue of public support for alcohol pricing policies because the strong evidence behind this approach is not widely known. The scientific evidence shows that alcohol consumption decreases when alcohol prices increase – and, more importantly, there are associated reductions in premature deaths, admissions to hospital and accidents on our roads. However, opinion research has found that most people do not believe heavy drinkers will reduce their drinking if prices are increased.

Furthermore, in the many hundred comments on the public consultation website and the blog series from the parliamentary secretary for the review, John Yap, a common sentiment is expressed: why punish the responsible majority for the behaviour of a small minority who misuse alcohol? While this viewpoint overlooks the existence of risks from moderate drinking (e.g. cancers), widespread occasional heavy consumption and harm from others drinking, this is a critical objection to address in discussions of policies like pricing.

Setting a minimum or floor price on alcoholic beverages is a policy that the BC government has implemented for the last 25 years, though BC minimum prices tend to be lower than most other provinces and are considerably lower than some (e.g. Saskatchewan). This type of policy is well targeted towards heavier drinkers as several studies have shown that those who drink low cost alcohol tend to consume higher amounts.

So do BC minimum prices provide any public health or safety benefit? Using BC hospital data, a recent study published in the American Journal Public Health found that for every 10% increase in minimum prices there was an immediate 9% reduction in hospital admissions for injuries and poisonings ‒ and a similar reduction in serious illnesses caused by alcohol (e.g., liver cirrhosis, cancers) 2 to 3 years later. Similarly, we have found immediate and delayed effects from minimum price increases on alcohol-related deaths.

Thus, there is strong evidence that minimum alcohol pricing avoids punishing the majority of responsible drinkers while having the greatest impact on the behaviour and the health of those most at-risk. We would love to know how public opinion would change if these facts were more widely known. We believe British Columbians would tolerate price increases on the very cheapest, often high strength alcohol products if they actually believed this would prevent fellow citizens becoming seriously ill, injured or dying from the effects of alcohol.

Because minimum prices here are relatively low and, unlike in Saskatchewan, they are not adjusted to reflect alcoholic strength, there are some products that cost less than 75 cents per “standard drink” (i.e., 17.05 mL ethanol or the amount of alcohol in a 12oz can of 5%beer). This makes it possible to exceed Canada’s Low-Risk Drinking Guidelines while spending less than three dollars per day – usually less than a loaf of bread.

Would you accept increasing the price of the cheapest alcohol to $1.50 per standard drink if you knew that it would save a few lives each year and reduce health care costs?

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Author: Tim Stockwell, Director, CARBC

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Author: Gina Martin

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Author: Andy Murie, CEO MADD Canada

Should the minimum legal drinking age of 19 years old in British Columbia be reduced?

Alcohol use is the largest contributor to injury, disability, and death among adolescents and young adults aged 10-24 years old. As a result, Canada and other countries worldwide have implemented minimum legal drinking age (MLDA) legislation for many decades now, and drinking-age laws are considered a cornerstone of alcohol-control policies designed to reduce harms among young people. In Canada, the minimum legal drinking age is 18 years of age in Alberta, Manitoba, Québec, and 19 years of age in the rest of the country.

No other alcohol policy has generated more research or debate than minimum legal drinking age legislation. Usually the debates about the most appropriate drinking age involve competing views about how society should assign importance to the harms versus the benefits of such legislation. Some people put more emphasis on the importance of individual choice in alcohol consumption, while other people place more value on restricting alcohol consumption in some age groups so as to safeguard young adults and improve overall public health. And so, there is a healthy tension between individual rights and the greater public good underlying debates about the minimum legal drinking age, and where individuals sit on this continuum will often affect how they interpret the scientific findings.

The large majority of the scientific evidence on this topic, however, is consistent and clear: raising the MLDA is associated with reductions in alcohol-related harms (such as motor vehicle collisions, injuries, assaults, and deaths), and lowering the MLDA is associated with increases in alcohol-related harms.

Advocates for lowering the MLDA might argue that most MLDA studies rely on United States’ data from the 1970s and 1980s, and usually have fatal/nonfatal motor vehicle collisions as their most harmful outcomes. And, critics of MLDA legislation might continue, the large MLDA impacts on motor vehicle collisions observed in the 1970s and 1980s might be substantially diminished in the contemporary British Columbia context due, in large part, to advances in both traffic safety and other alcohol policies (e.g., improvements in road safety/motor vehicle safety; introduction of provincial graduated driver licensing legislation; increases in the severity of penalties for drinking and driving).

Could it be that the MLDA has lost much of its effectiveness in reducing alcohol-related harms among young people in British Columbia?

In four recent studies, my colleagues and I have demonstrated that drinking-age legislation continues to have a powerful impact on alcohol-related harms among young people in Canada. Relative to youth slightly younger than the minimum legal drinking age, young adults just older than the MLDA incur immediate and significant increases in a range of serious alcohol-related harms, including: motor vehicle collisions; inpatient/Emergency Department admissions for alcohol-use disorders, attempted suicides, injuries, assaults; and death. An example of our work was published recently in the American Journal of Public Health.

Along with the prior MLDA literature, our Canadian studies provide up-to-date and persuasive evidence that lowering the MLDA will likely result in significant increases in serious alcohol-related harms among young people in British Columbia. Proponents of a lower MLDA in BC will need to make an even more convincing argument that such substantial damages to youth in British Columbia will be outweighed by the benefits of lowering the drinking age in our province.

Authors:

Dr. Russ Callaghan, PhD (Russ.Callaghan@UNBC.ca); Jodi Gatley, BSc (jgatley@gmail.com)

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Jodi Gatley