The Chief Public Health Officer's Report on the State of Public Health in Canada, 2015: Alcohol Consumption in Canada

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Organization: Public Health Agency of Canada

Date published: 2016-02-03

A message from Canada's Chief Public Health Officer

Alcohol is a socially accepted part of everyday life for most Canadians. Almost 80 percent of us drink.

Many Canadians associate drinking with pleasurable social events such as music festivals, watching sports, parties, and relaxing. Celebrations and milestones like weddings, anniversaries, and awards are often "toasted" with alcohol.

Our society condones, supports, and in some cases promotes drinking such as through "drink of the day" specials, sale prices on certain brands, and associating alcohol with fun and sophistication.

Although handled more like a food in Canada, alcohol is a mind-altering drug and there are health risks associated with drinking. Our low-risk drinking guidelines do not mean that alcohol is harmless.

At least three million drinking Canadians risk acute illness, such as injury and at least four and half million risk chronic conditions such as liver disease and cancer.

Our children grow up seeing alcohol in many aspects of their environment and around 3,000 are born with fetal alcohol spectrum disorder each year.

I hope this report will raise awareness and stimulate frank conversations between Canadians, especially with their loved ones, and helps us reflect on how our society deals with this mind-altering drug.

Dr. Gregory Taylor

Chief Public Health Officer of Canada

Table of Contents

Acknowledgements:

Many individuals and organizations have contributed to the development of The Chief Public Health Officer's Report on the State of Public Health in Canada, 2015: Alcohol Consumption in Canada.

I would like to express my appreciation to the consultants who provided invaluable expert advice:

  • David Mowat, MBChB, MPH, FRCPC, FFPH, former Medical Officer of Health, Region of Peel, Ontario;
  • Daryl Pullman, PhD, Professor of Medical Ethics, Division of Community Health and Humanities, Memorial University;
  • Don Mahleka, member of the Mental Health Commission's Youth Advisory Council and the Children and Youth in Challenging Context's youth advisory committee;
  • Jeff Reading, MSc, PhD, FCAHS, Professor, School of Public Health and Social Policy, Faculty of Human and Social Development, University of Victoria;
  • John Frank, MD, Director, Scottish Collaboration for Public Health Research and Policy; Chair, Public Health Research and Policy, University of Edinburgh; Professor Emeritus, Dalla Lana School of Public Health, University of Toronto;
  • Michael Routledge, BSc (Med), MD, CCFP, MSc , FRCPC, Chief Provincial Public Health Officer, Manitoba;
  • Peter Glynn, PhD, Health Systems Consultant; and,
  • Tim Stockwell, PhD, Director of the Centre for Addictions Research of British Columbia; Professor, Psychology, University of Victoria.

In addition, I would also like to recognize contributions made by partners and stakeholders who were consulted on the report under tight timelines, including Health Canada, the Council of Chief Medical Officers of Health, the Canadian Centre on Substance Abuse, the Centre for Addiction and Mental Health, the Centre for Addictions Research of British Columbia, Mothers Against Drunk Driving, the Canadian Public Health Association.

I would also like to sincerely thank the many individuals and groups within the Public Health Agency of Canada for all of their efforts and dedication, notably my report unit team, my support staff and members of the 2015 Core Advisory Group.

KEY MESSAGES:

This report aims to increase Canadians' awareness about the health impacts of alcohol consumption.

  • Humans have a long history with mind altering drugs, such as alcohol. Consuming alcohol is ingrained in Canadian culture. In 2013, an estimated 22 million Canadians, almost 80 percent of the population, drank alcohol in the previous year. At least 3.1 million Canadians drank enough to be at risk for immediate injury and harm with at least 4.4 million at risk for chronic health effects, such as liver cirrhosis and various forms of cancer.

  • Drinking patterns matter - how much and how often a person drinks alcohol are key factors that increase or decrease health impacts. Canada's Low-Risk Alcohol Drinking Guidelines provide guidance on risky drinking patterns, including avoidance of alcohol in pregnancy. Low risk does not equal no risk.

  • Social situations, family contexts and messaging influence drinking patterns. Exposure to alcohol through families and friends as well as through entertainment and advertising can strongly influence people's motives for drinking alcohol and their drinking patterns. For many Canadians, drinking is associated with many positive situations including important celebrations, forming friendships, positive mood and relaxation. However, risky drinking can increase the risk for family conflict, violence, crime including rape, and traffic accidents through impaired driving.

  • Our understanding of the dose-dependent health effects of alcohol continues to evolve. Recent research questions the health benefits of low to moderate alcohol consumption. Studies suggest that women are at increased risk for breast cancer even at one drink per day. The International Agency for Research on Cancer's World Cancer Report 2014 and the Canadian Cancer Society state that there is no "safe limit" of alcohol consumption when it comes to cancer prevention.

  • Youth are particularly at risk for negative impacts from drinking alcohol. Teenage brains are more vulnerable to the effects of alcohol. Families, friends, and all Canadians who care for or work with youth can play a positive role if they recognize their influence on youth's drinking patterns and support their healthy physical, mental and emotional development.

  • How we deal with alcohol in part defines our society. Approaches such as a regulated alcohol industry, policies on pricing and taxation, controls on sales and availability, and minimum age laws help reduce the impact on Canadians, especially youth . These approaches vary across the country and may not be realizing their full potential. No single approach can address the large variations in the needs and drinking patterns of Canadians.

  • The story of alcohol is complicated. Despite the large of amount of information available, there are significant gaps in our understanding of drinking patterns, risk factors, alcohol's impacts on health and the effectiveness of approaches to reduce these impacts.

What this report is about

This report explores how consuming alcohol, a common mind-altering drug, is an important public health issue for Canadians. In 2013, an estimated 22 million Canadians, almost 80% of the population, reported that they drank alcohol in the previous year.Footnote 1Footnote 2

Mind-altering drugs or substances contain psychoactive chemicals that act on the brain to change thinking, mood, consciousness, and behaviour and whose use can sometimes lead to dependence and abuse. Footnote 3

Under the Food and Drugs Act , alcohol is identified as a food. However, alcohol contains psychoactive chemicals making it a psychoactive drug or substance in terms of impacts on health. Footnote 3

Many Canadians who consume alcohol do so responsibly. However, alcohol consumption is linked to over 200 different diseases, conditions and types of injuries. Footnote 4 Of those who choose to drink, a significant number of Canadians (at least 3.1 million) drink enough to risk immediate injury and harm, including alcohol poisoning in some cases. At least 4.4 million are at risk for longer term negative health effects. Footnote 1

Canadians are subjected to mixed messages about alcohol's benefits and harms. Alcohol consumption is a complex public health issue that can have a wide range of health impacts. Various factors contribute to the effects of alcohol, including how much people drink, how often they drink, what they are doing while they are drinking, as well as their underlying state of health.

Is alcohol consumption the same as alcohol abuse? No. Paying attention to drinking patterns, knowing what factors contribute to health risks, and recognizing warning signs can help reduce or prevent health risks, risky drinking,alcohol abuse, alcohol dependence, alcohol use disorders and their associated harms.

Why focus on alcohol?

Canadians have a long history with alcohol that has shaped drinking patterns over time. Alcohol is widely available and promoted in Canada. Footnote 5 Canadians are exposed to messages and images about alcohol through advertising and marketing of alcoholic beverages and in TV shows, movies and literature, as well as through alcohol retail outlets within their neighbourhood. With the majority of Canadians choosing to drink, people are exposed to alcohol through their friends and family, in their neighbourhoods, at social gatherings and through social media. Generally speaking, increased exposure and access to alcohol are linked to increased drinking. Footnote 10-36

This report focuses on alcohol consumption at the population level in Canada, in order to raise awareness of the evidence regarding health risks. Canadians take health risks every day. Behaviours like how physically active people are, how many servings of fruit and vegetables or how much salt and fat is in the food people eat and how much alcohol people consume can all carry some degree of health risk. Many people who drink underestimate how much they drink. Footnote 37-39 Knowing the shorter- and longer-term risks to health may help some Canadians pay closer attention to their drinking and prevent negative impacts on their health and the health of others.

What are Canadians using?

Alcohol, tobacco, caffeine, marijuana, cocaine, heroin, hallucinogens, and various prescription drugs are all examples of psychoactive drugs. In Canada, alcohol is the most widely consumed psychoactive drug (see Figure 1)Footnote 1 except for caffeine. After water, coffee (which contains caffeine) is the second most consumed beverage in Canada.Footnote 40

Figure 1: What psychoactive drugs are Canadians using?

Estimated percentage
Alcohol Tobacco Marijuana Other illicit drugs
Total 75.9 14.6 10.6 1.6
Men 80.6 16 13.9 2.4
Women 71.2 13.3 7.4 0.8

Estimated percentage of Canadians 15 years of age and older in 2013 who consumed alcohol, marijuana and other illicit drugs in the past year and/or regularly smoke tobacco. Footnote 1

How can alcohol be harmful? Drinking alcohol was the third highest risk factor for global disease burden in 2010, moving up from being ranked sixth in 1990. It was also the top risk factor for poor health in people ages 15 to 49 years.Footnote 41

A snapshot of alcohol's impacts on Canadians:

  • In 2002, 4,258 deaths in Canada were related to alcohol abuse, representing 1.9% of all deaths. Footnote 6
  • Costs related to alcohol in Canada equalled approximately $14.6 billion in 2002. Footnote 6
  • From April 2013 to March 2014, $20.5 billion worth of alcohol was sold in Canada. Footnote 7
  • In 2008, impaired driving was the leading cause of criminal death in Canada. Footnote 8
  • Among psychoactive drugs, alcohol-related disorders were the top cause of hospitalizations in Canada in 2011. Footnote 9

Risky drinking can result in a wide range of negative impacts on society, including increased rates of premature death, disability and disease, impaired driving, reduced productivity, a burdened health care system, and high financial burden to both the individual and society. e.g.,Footnote 6Footnote 8Footnote 9Footnote 42-48

Globally, alcohol was linked to over 3 million deaths per year in 2012, slightly more than lung cancer and HIV/AIDS combined. Footnote 48-50

At the individual level, alcohol affects a wide variety of biological systems in a dose-dependent manner, leading to impacts on health, well-being, and behaviour over both the short and long term (see Table 1).

For example, the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO) has classified alcoholic beverages, ethanol in alcoholic beverages and acetaldehyde associated with the consumption of alcoholic beverages as carcinogenic to humans. This means that alcohol consumption is capable of increasing the incidence of cancer in a population. It can also reduce the length of time cancer is present but inactive in the body, increase cancer's severity, and increase the number of tumours or types of cancer present. Footnote 51

The IARC's World Cancer Report 2014 and the Canadian Cancer Society state that there is no "safe limit" of alcohol consumption when it comes to cancer prevention.

Infographic 1: Dose-dependent health effects
Figure 1
Figure 1 - Text Equivalent

This image depicts the dose-dependent health effects of drinking alcohol by indicating that with each additional drink, there is an increase in health risk.

Table 1: An overview of the dose-dependent health and behavioural impacts of alcohol consumption

Direct effects

Risky drinking can cause:

  • Alcohol use disorders
  • Amnesia (e.g., Korsakoff's syndrome)
  • Memory loss and blackouts
  • Delirium due to a severe form of withdrawal
  • Fetal Alcohol Spectrum Disorder (FASD)
Disease and Conditions

Drinking alcohol is linked to:

  • Other drug use disorders
  • Brain damage
  • Liver disease
  • Various cancers
  • Pancreatitis
  • Mental health disorders
  • Suicide
  • Stomach ulcers
  • Hypertension
  • Stroke
  • Cardiovascular disease
  • Diabetes
  • Sexually transmitted infections
Functions and Systems

Drinking alcohol can affect the following systems:

  • Immune
  • Stress
  • Memory, cognition
  • Digestion
  • Heart, blood, lungs
  • Brain
  • Hormones
  • Muscles
  • Fertility
  • Skin
  • Development
Behaviour

Risky drinking can lead to:

  • Risky behaviour
  • Impulsivity
  • Violence
  • Injury
  • Poor memory
  • Impaired decision-making
  • Lack of coordination
  • Poor academic performance
  • Impaired social and occupational functioning

References: Footnote 4, Footnote 42, Footnote 49, Footnote 51-127

Infographic 2: Examples of potential health impacts
Figure 2

References: Footnote 4, Footnote 42, Footnote 46-49, Footnote 51-127.

Infographic 2 - Text Equivalent

This image depicts two human bodies surrounded by a list of the potential short- and long-term impacts of alcohol on health. Short-term impacts include: intoxication, delirium, disinhibition, psychosis, risky behaviour, alcohol poisoning, injury, motor control, depression, anxiety, vision, decision-making and memory. Long-term impacts include: brain damage, stroke, mental health, heart disease, hypertension, pancreatitis, stomach ulcers, fatty liver disease, hepatitis, cirrhosis, fertility, skin, muscles, hormones, immune system, stress system, cancer, sexually transmitted infections, alcohol and other drug use disorders, injury, motor control, depression, anxiety, memory and decisions-making.

Many factors influence how alcohol affects a person's health, including how much and how often a person drinks, that person's specific risk factors and what they are doing while they are drinking. Although controversial, studies have shown that alcohol may have beneficial effects. However, benefits are dose-dependent and apply to a select set of diseases, conditions, situations, and segment of the population.Footnote 53Footnote 54Footnote 56Footnote 57Footnote 59Footnote 61Footnote 63-65Footnote 69Footnote 73Footnote 76-80Footnote 84Footnote 87Footnote 89Footnote 90-92 Given that many people who drink underestimate how much they drink, Footnote 38Footnote 39Footnote 128-130, their perceived potential for harm or benefit may also be inaccurate.

What this report covers:

This report focuses on the health impacts of alcohol consumption, including how they develop and are modified by drinking patterns and risk factors. Included in this report are the following sections:

  1. Impacts on Canadians explores how much Canadians are drinking and what are the resulting major impacts on health and society, including potential benefits.
  2. Pathways to impacts: From brain to behaviour describes low-risk drinking patterns and how drinking alcohol can lead to impacts on the brain and through behaviour.
  3. Influencing factors describes how different risk and protective factors can influence the risks for impacts from alcohol consumption.
  4. Population health perspective provides three examples of specific populations in Canada: youth, women, and Aboriginal populations.
  5. Reducing health impacts provides highlights on how public health can address the issue of alcohol consumption in Canada, with a focus on primary prevention.

Impacts on Canadians

Identifying how much and how often people drink is a first step in understanding consequences, benefits, and harms of alcohol consumption on a particular population. Currently, data on alcohol consumption and related costs and harms, particularly for trends, are limited in Canada. This makes it difficult to capture a true picture of the impact on Canadians.

Risky Drinking: The impacts of alcohol are dose-dependent. In 2011, the Canadian Centre on Substance Abuse released Canada's Low-Risk Alcohol Drinking Guidelines . These guidelines identify how much is too much: Footnote 42

  • Drinking more than 15 standard drinks a week for men or 10 a week for women with more than 3 drinks a day for men or 2 for women on most days increases the risk for long-term negative impacts on health.
  • Drinking more than 4 standard drinks for men or 3 for women in an occasion increases the risks for short-term injury and harm.

There are no health benefits to alcohol consumption for youth. The potential health benefits from alcohol do not begin until middle age.

The evidence used to develop these guidelines can be found at this link.

Drinking in Canada

In 2013, an estimated 22 million Canadians 15 years of age and older, almost 80% of the population, drank alcohol in the previous year, with the highest percentage of past year drinkers found in 30 to 34 year olds (see Figure 2a). The highest percentage of risky drinkers, based on drinking over the previous week, was found in young adults (ages 20 to 29) (see Figure 2b). Footnote 1 These data only capture risky drinking in the week previous to the survey, meaning it is a limited snapshot. Footnote 1

Figure 2a: Drinking rates in Canada in 2013

Estimated percentage
AGE GROUPS 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
Past year 60.3 83.2 76.8 86.3 80.2 80.5 79.7 78 73.8 74.9 67.7

Estimated percentage of Canadians 15 years of age and older who had consumed alcohol in the year previous to a 2013 survey. Footnote 1

Figure 2b: Risky drinking rates in Canada in 2013

Estimated percentage
AGE GROUPS 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
risk for short-term impacts 2013 15 23.1 21.4 18.7 17.1 15.3 14.2 15 11.7 8.8 7.9
risk for long-term impacts 2013 19.9 29.1 28 25.9 23.1 21.3 19.9 23.6 20 13.4 10.2

Estimated percentage of Canadians 15 years of age and older who had consumed alcohol in the week prior to a 2013 survey in amounts that exceeded the guidelines for risks for short- or long-term impacts. Footnote 1

From April 2013 to March 2014, Canadians bought almost 76 litres of beer, 16 litres of wine, 5 litres of spirits, and 4 litres of other alcoholic beverages per person. Footnote 7 Proportionally, Canadians drink more beer (51%) than spirits (27%) or wine (22%) (see Figure 3). Footnote 48

Figure 3 : Type of drink consumed by Canadians in 2010 (percentage of alcohol consumption per capita in litres). Footnote 48

Percentage of alcohol consumption per capita in litres
beer wine spirits
percent 51 22 27

Drinking is more common in men than women, as is risky drinking. For every year between 2003 and 2010, approximately one in three men and one in five women aged 15 years and older who drink reported that they drank risky amounts of alcohol at least once a month. In the same period, approximately 50% of young men and women (ages 18 to 24) who drank reported undertaking risky drinking on a monthly basis.Footnote 131

Risky drinking is currently on the rise among women, especially those 35 years of age and older. In 2013, 56% of women aged 15 years and older reported binge drinking (four drinks or more in one sitting) at least once in the previous year compared to 44% in 2004. Footnote 1Footnote 2Footnote 132 Rates of past-year drinking among Canadians aged 15 years and older have been decreasing, from 79% in 2004 to 76% in 2013. For Canadians ages 15 to 24, rates of past year drinking dropped from 78% in 2004 to 73% in 2013. Footnote 1Footnote 2Footnote 132 An estimated 24% of Canadians - almost 7 million - aged 15 years and older reported that they did not drink in 2013. Footnote 1Footnote 2

How much alcohol do Canadians really drink? Most people tend to under-report how much alcohol they drink. Not only do people tend to underestimate how much they and others drink, they also tend to underestimate how harmful alcohol is. Footnote 37-39Footnote 129Footnote 133-148 In some cases, drinking on special occasions, which is not well captured by many surveys, can partially explain this discrepancy. Footnote 149 Some surveys only capture a short period of consumption (e.g., one week), leading to a limited picture of consumption. Footnote 1

Surveys also tend to focus on drinking of regulated alcoholic beverages (e.g., beer, wine, liquor), meaning data on consumption of home brew and other sources of alcohol are not captured. Estimates on the proportion of home brew consumed as part of the total consumption of alcohol in Canada vary widely and depend on the source of data used and how data are analysed. Footnote 150-152

Attempts have been made to account for under-reporting. e.g.,Footnote 37Footnote 129Footnote 153-155 In Canada, under-reporting occurred more often for spirits than for beer or wine. Canadians under the age of 45 were more likely to under-report their alcohol consumption as were low-risk drinkers of any age. Men and women were similar in terms of the extent to which they under-report their consumption of alcohol. Footnote 129

Adjusted rates for risky drinking: To adjust Canadian drinking data from 2008 to 2010 for under-reporting, data on drinking over the previous year and sales data were incorporated. These adjusted data suggest that: Footnote 155

  • Estimates of the average rates of past-year risky drinking among Canadians ages 15 years and older who drink rose from 16.7% to 38.6% for short-term harm and from 6.8% to 27.3% for long-term harm.
  • Most underage drinking and drinking by young adults occurs in bouts of heavy drinking (i.e., exceeding the short-term guidelines) rather than in a low level of drinking spread out over several days.

How much does alcohol contribute to daily caloric intake? Unlike many other drugs, alcohol can count towards daily caloric intake (see Table 2). Footnote 45 The National Institutes of Health in the United States has an alcohol calorie calculator for a variety of different types of alcohol. For example:

  • 1 drink of regular beer (12 ounces) is 153 calories.
  • 1 drink of red wine (5 ounces) is 125 calories, while 1 glass of white wine (5 ounces) is 121 calories.
  • 1 drink of gin, rum, vodka, whisky, or tequila (1.5 ounces) is 97 calories. This does not account for calories in added ingredients, such as carbonated beverages or juice.
Table 2: Examples of how daily consumption of alcohol can contribute to recommended daily caloric intake.
Quantity Consumed Calories Approximate % of recommended daily caloric intake
For men between the ages of 19 to 50 years who are somewhat active (recommend daily calories: 2600-2700)
Note: These calculations are based on recommendations from Canada's Low-Risk Alcohol Drinking Guidelines and Canada's Food Guide.
4 drinks of regular beer 612 23%
4 drinks of red wine 500 19%
4 drinks of white wine 484 18%
4 drinks of gin, rum, vodka, whisky, or tequila 388 14.5%
For women between the ages of 19 to 50 years who are somewhat active (recommended daily calories: 2000-2100)
3 drinks of regular beer 459 22.5%
3 drinks of red wine 375 18.5%
3 glasses of white wine 363 17.5%
3 glasses of gin, rum, vodka, whisky, or tequila 291 14%

Costs of alcohol in Canada

Costs related to alcohol consumption can be explored through sales and the overall cost to society. Sales can provide an indirect measure of consumption and cost to the individual, while overall cost shows the high financial burden of alcohol in Canada.

Sales of alcoholic beverages: Sales of alcoholic beverages can indirectly reflect how much Canadians are drinking. They also show how much Canadians are spending on alcoholic beverages. Sales continue to increase in Canada. From April 2013 to March 2014, Canadians bought $20.5 billion worth of alcohol, which was 1.1% higher than the previous year. Sales of ciders, coolers, and other refreshment alcoholic beverages accounted for most of this increase, although sales of wine and spirits are also increasing. Beer remains the most popular alcoholic beverage in Canada. Footnote 7

The alcohol industry ensures that regulated alcoholic beverages are available to Canadians while sales contribute to the Canadian economy. For example, production and sales provide employment while taxes and pricing provide revenue for provincial and federal governments. Footnote 156 Net income and government revenue from the control and sale of alcoholic beverages was $10.5 billion in 2013/2014. Footnote 7 In most provinces, revenue from alcohol does not exceed societal costs from drinking. Footnote 156

Overall costs: The estimated cost of alcohol abuse in Canada in 2002 was $14.6 billion (see Figure 4). Footnote 6 This information is dated and the cost has likely changed over time. In fact, more recent data show that the cost of hospitalizations for substance use disorders from psychoactive drugs has been increasing, reaching $267 million in 2011, over half of which was due to alcohol.Footnote 9 These data do not fully capture hospitalizations from alcohol consumption as they are limited to alcohol use disorders.Footnote 9

Figure 4: Breakdown of estimated costs of alcohol abuse in Canada in 2002
Administrative costs Health care Fire damage Law enforcement Losses associated with workplace damage Lost productivity Prevention and research Traffic accident damage
$ billion 0.0658 3.3062 0.1565 3.0722 0.017 7.1264 0.053 0.7569
Breakdown of estimated costs of alcohol abuse in Canada in 2002Footnote 6
  $ billion
Lost productivity 7.1264
Health care 3.3062
Law enforcement 3.0722
Traffic accident damage 0.7569
Fire damage 0.1565
Administrative costs 0.0658
Prevention and research 0.053
Losses associated with workplace damage 0.017
Total 14.554

Impaired driving also creates a high financial burden, through both law enforcement and damage from accidents. When the health and social costs for deaths, injuries and damage to vehicles are included, costs related to impaired driving (including alcohol and other drugs) were estimated at over $20.6 billion a year in 2010. Footnote 157

Alcohol-related mortality and morbidity in Canada

In Canada, alcohol is one of the top ten risk factors for disease among all Canadians and the top risk factor for Canadians aged 15 to 49 years.Footnote 158 In 2002, 4,258 deaths in Canada were related to alcohol abuse.Footnote 6 The majority of these deaths were due to alcoholic liver disease, motor vehicle accidents and alcohol-related suicides.Footnote 6

Globally, alcohol contributes to: Footnote 48

  • 100% of deaths and disability from alcohol use disorders and fetal alcohol spectrum disorder;
  • 50% of deaths and disability for liver disease;
  • 20-30% of deaths and disability from oral/pharynx cancer, laryngeal cancer, oesophageal cancer, pancreatitis, violence or self-harm;
  • 10-15% of deaths and disability from liver cancer, tuberculosis, epilepsy, haemorrhagic stroke, unintentional injuries, falls, traffic injuries, drowning or fires;
  • less than 10% of deaths and disability from breast cancer, heart disease, ischaemic stroke, lower respiratory infections or HIV.

In terms of health, consuming alcohol can have long- and short-term effects on the body with each having different underlying, although sometimes overlapping, causes. Drinking can also impact well-being over both the short and long term.

Long-term impacts

Long-term impacts can be caused by a variety of mechanisms that are usually disease-specific. Outlined below are examples of long-term impacts of alcohol consumption, most of which are dose-dependent:

What about binge drinking and long-term health?

The impact of binge drinking (or heavy episodic drinking) on long-term health is a complex and evolving story. Evidence suggests that binge drinking is linked to negative impacts on the liver, the brain, cancer and cardiovascular health. Footnote 189-192 In some cases, the impacts of binge drinking are no different than drinking the same amount over a longer period. Footnote 193Footnote 194 Binge drinking is also linked to higher rates of behaviours that put people's health at risk (e.g., smoking). Footnote 189Footnote 193

Alcoholic liver disease: The number of deaths in Canada from alcoholic liver disease has been increasing, from 1,104 in 2000 to 1,535 in 2011. Footnote 159 Risk factors for developing alcoholic liver disease include dose, frequency of drinking, type of drink, genetics, and the presence of other disorders. Footnote 160-162

Fetal alcohol spectrum disorder (FASD): FASD is a lifelong chronic disorder that is the leading known cause of preventable developmental disability in Canada. Footnote 163Footnote 164 It is estimated that more than 3,000 babies are born with FASD every year in Canada and that more than 330, 000 people in Canada are affected. Footnote 165Footnote 166 Estimates suggest that 2% to 5% of people in western countries may be affected by FASD. Footnote 167 Higher rates have been estimated for some Aboriginal communities in Canada. Footnote 168

Alcohol is a teratogen (i.e., a substance that crosses the placenta in a pregnant woman to the baby and can cause malformation of an embryo) that can permanently affect the development of the fetus, resulting in a child born with FASD. FASD includes physical and central nervous system defects with impacts ranging from mild to severe. The greatest effects are on the brain, resulting in cognitive, behavioural and emotional impacts. Footnote 169

People with FASD experience difficulties with judgment, planning, memory, impulsivity, communication, and other impairments. As a result, they are at greater risk for experiencing problems at school, mental health issues, problems with alcohol and other drugs, employment challenges, and involvement with the criminal justice system. Footnote 170

Experts recommend that the safest choice is to not drink any type of alcohol at any time during pregnancy or when planning to become pregnant. Footnote 42 This recommendation may be difficult to follow as 50% of pregnancies are unplanned. Footnote 171 Mothers are also advised to limit alcohol consumption while breastfeeding and plan their breastfeeding schedule to ensure that alcohol is eliminated from their system before breastfeeding. Footnote 172Footnote 173

Cancer: Cancer is linked to 30% of all Canadian deaths, making it the leading cause of death in Canada. An estimated 40% of Canadians will develop cancer at some point during their lifetime. Footnote 174 Alcohol is considered to be carcinogenic and is strongly associated with an increased risk for certain types of cancer such as colorectal cancer, breast cancer, some cancers of the central nervous system, and cancers of the larynx, pharynx, oesophagus, and liver. Footnote 4Footnote 48Footnote 49Footnote 52Footnote 72Footnote 82Footnote 83Footnote 88Footnote 175-181

Heavy drinking increases the risk for oral, pharyngeal, and oesophageal cancers by five times, for laryngeal cancer by two and a half times, and for colorectal and breast cancers by 50%. Footnote 182Footnote 183 There are sex differences in these effects. For example, men have a higher risk for alcohol-related colorectal cancer than women. Recent research shows that one drink a day may increase the risk for breast cancer in women. Footnote 183Footnote 184-188 Every additional drink per day may further increase the risk for breast cancer as does the number of years a woman has consumed alcohol. Footnote 183Footnote 184Footnote 186

Cardiovascular disease: Some evidence suggests that the effects of alcohol on the cardiovascular system are dose-dependent. Low to moderate doses can be beneficial in some cases. Footnote 42Footnote 63Footnote 89Footnote 200 These beneficial effects may not be directly due to alcohol consumption with recent research raising many questions about this association. Footnote 200-203 Heavy drinking can lead to increased mortality, coronary heart disease, peripheral artery disease, heart failure, stroke, hypertension and abnormal amounts of cholesterol or fat in the blood. Footnote 56Footnote 63Footnote 204-206 The effects on stroke depend on type - low to moderate drinking may only protect against ischemic stroke (blood clots) and not other types of stroke, while heavy drinking increases the risk for all types of stroke. Footnote 205Footnote 207

Examples of how alcohol consumption leads to disease: Footnote 96Footnote 109Footnote 115Footnote 127Footnote 189Footnote 195-199

  • Alcohol is toxic for the liver, heart, pancreas and nervous system.
  • Alcohol has a dose-dependent effect on the immune system with low doses being beneficial and higher doses being detrimental.
  • There are many ways that alcohol might lead to cancer. For example, some metabolic by-products that result from drinking can cause tumours. This effect may depend on genetics.
  • Evidence suggests that alcohol impacts various aspects of the cardiovascular system, some being direct (e.g., increased cell death in the heart) and some being indirect (e.g., through damage to the liver).

Short-term impacts

Short-term impacts are often a result of being intoxicated ("being drunk") or drinking enough to impair judgement. In extreme cases, alcohol poisoning can occur. Outlined below are examples of short-term impacts of alcohol consumption:

What is intoxication? According to the World Health Organization, intoxication is a condition that results from taking a psychoactive drug. It depends on the dose taken and a person's unique characteristics, such as level of tolerance. For alcohol, intoxication is often called 'being drunk' and can lead to feeling flushed, slurred speech, lack of coordination, euphoria, being more active and talkative, disorderly behaviour, slower reactions, and impaired judgement.

Alcohol poisoning: When levels of alcohol in the brain are high or toxic enough to have an impact on areas important for essential functions, alcohol poisoning can occur. Footnote 208Footnote 209 Symptoms include: confusion, stupor, coma, inability to wake up, vomiting, seizures, slowed breathing, irregular breathing, hypothermia, and suppressed vital functions. Footnote 209 Between 2009 and 2011, an average of 232 deaths per year from alcohol poisoning occurred in Canadians 15 years of age and older. Footnote 210

Homicide: Homicide has been decreasing substantially over time. In 2013, it constituted approximately 0.1% of all violent crimes in Canada, resulting in 505 homicides in 2013. Footnote 211 Alcohol and other drug use is common in homicides in Canada, for both the accused and the victim. In 2013, an estimated 40% of accused and 32% of victims involved in a homicide in Canada had used alcohol at the time of the crime. Footnote 211

Impaired driving: Impaired driving is the leading cause of criminal death in Canada. Footnote 8 In 2012, 523 Canadians died in fatal accidents involving alcohol, which is a decrease from 1,296 in 1995. Footnote 212Footnote 213 In 2012, this accounted for a third of all fatalities in motor vehicle accidents in Canada. Footnote 213

The Criminal Code of Canada's section 253 describes the offence of operating a vehicle while impaired and includes a threshold for blood alcohol levels. As levels of alcohol in a driver's bloodstream increase, so does the risk for vehicle accidents. Footnote 214 Provinces and territories also have legislation and programs to reduce impaired driving. Footnote 5

Since the 1980s, incidents of impaired driving have decreased substantially. In 1998, there were over 87,000 incidents of impaired driving linked to alcohol. The number of incidents have fluctuated over the years, reaching a low of over 76,000 incidents in 2006 before increasing again to a high of over 86,000 in 2009. More recently, the number of incidents has again decreased to over 72,000 in 2014.Footnote 2 Footnote 215

Who is drinking and driving in Canada? Footnote 1Footnote 8

  • Most people charged with impaired driving are men, but the gap has been closing recently with the rate of women being charged with impaired driving increasing since 2005.
  • Rates of impaired driving are highest in the Northwest Territories, the Yukon, and Saskatchewan and lowest in Ontario and Quebec.
  • Rates of impaired driving are lowest in metropolitan areas.
  • Impaired driving incidents happen most often during weekends and soon after bars close.
  • For licensed drivers, rates of impaired driving are highest in 20 to 24 year olds followed by 25 to 34 year olds.
  • However, the third highest rate of impaired driving is found in 16 to 19 year olds despite the fact that fewer people in this age group drink than any other age group.

Impacts on mental health

Alcohol is a risk factor for several mental illnesses while some mental illnesses precede heavy drinking. Footnote 216-219 At the same time, many of the risk and protective factors are the same for both, meaning that mental illness and drinking may be driven by other factors. Footnote 220

In Canada, rates of death from alcohol-related suicide are linked to drinking patterns within a population.Footnote 221 Data from the early 2000s show that approximately 25 to 30% of suicides in Canada were linked to alcohol.Footnote 221 However, the link between alcohol and suicide is part of the broader and complex connection between alcohol and mental health.

Depression: Alcohol and depression are strongly linked. Footnote 222Footnote 223 Rates of alcohol use are higher in people with depression. Heavy drinking per occasion is linked to an increased risk for major depression, especially for women. Footnote 222Footnote 224-226Some evidence suggests that alcohol abuse or dependence could lead to depression. Footnote 225

Post-traumatic stress disorder (PTSD): A link exists between alcohol use disorders and PTSD. Footnote 227-232 Alcohol is sometimes used to cope with the symptoms of PTSD, despite the fact that drinking is associated with the onset of PTSD and the severity of its symptoms. Footnote 230Footnote 232Footnote 233

Anxiety: Anxiety is linked to alcohol use. Footnote 234-239 In the short-term, alcohol can reduce anxiety and panic, but withdrawal from alcohol can increase anxiety. Footnote 234 Women are more likely to drink to cope with social anxiety than are men. Footnote 240

Personality disorders: Alcohol is linked to a variety of personality disorders, including antisocial personality disorder and narcissistic personality disorder. Footnote 241-245

Alcohol and families: Problems with drinking tend to run in families due to a complicated interaction among alcohol consumption, genetics, and the social/family environment. Footnote 246-248 For example:

  • The earlier people start drinking, the more likely genetics plays a role in the development of alcohol dependence. Footnote 246
  • Children of parents who drank heavily per occasion tended to have their first drink earlier, drink more as they get older and experience more negative life events in adulthood. Footnote 19Footnote 36
  • University students with a family history of problems with alcohol have a higher risk for harm from drinking alcohol. Footnote 249

These intergenerational effects interact to create a complicated web of impact on children and future generations. Footnote 250

Health benefits from drinking alcohol

Some evidence suggests that alcohol may be beneficial for a limited portion of the population, with the effect being most associated with wine.Footnote 251-256 Research indicates that youth do not benefit from alcohol at any dose.Footnote 42 Low to moderate levels of alcohol consumption have been linked to reduced mortality from some diseases and lower rates of diseases such as diabetes, cardiovascular problems, and cognitive impairments. However, this is a complex story, as growing evidence suggests that the benefits from alcohol consumption may not be directly due to alcohol and are not relevant for all individuals, at all ages or in all situations. Benefits could also be due to other factors or based on research with methodological issues.Footnote 53Footnote 54Footnote 56Footnote 57Footnote 59Footnote 61Footnote 63-65Footnote 69Footnote 73Footnote 76-80Footnote 84Footnote 87Footnote 89Footnote 90-92Footnote 256-261

Social Benefits: Drinking alcohol may also have social benefits, such as being part of some cultural traditions. Footnote 266 Drinking alcohol is strongly tied to being social, enjoyment and positive social experiences. Footnote 31Footnote 32Footnote 267

Alcohol consumption can be a powerful social motivator that can help form new friendships and strengthen existing ones. Footnote 32Footnote 268Footnote 269 For some people, drinking is associated with positive mood, relaxation and in some cases, positive mental well-being. However, these benefits may be culturally specific and can occur at the same time as negative outcomes on other measures of health. Footnote 267 Footnote 270Footnote 271

In addition, it is possible that the benefits are not from alcohol per se, but rather the positive social expectations and experiences associated with drinking. Footnote 271

Moreover, risks and benefits can occur at the same time. While low and moderate levels of alcohol consumption may be beneficial in some situations, one drink more than the recommended amounts can increase the risk for several types of chronic illnesses. Footnote 42Footnote 184Footnote 186Footnote 187Footnote 262 There are other less risky behaviours that can be adopted to achieve the reported health benefits of low to moderate alcohol consumption, such as a healthy diet and physical activity. e.g.,Footnote 263-265

Pathways to impacts: From brain to behaviour

Alcohol can have a variety of direct immediate or short-term effects on biology that can result in impacts on health, well-being, and behaviour. In order to understand how alcohol creates social impacts, it is important to understand drinking patterns and alcohol's pathway from the brain to behaviour.

Importance of drinking patterns

How much and how often an individual drinks are key factors that increase or decrease the risk for impacts from alcohol. Abstinence prevents all direct alcohol-related impacts on an individual. Some negative health impacts are temporary and can be reversed or reduced once a person stops drinking or drinks within recommended guidelines. e.g.,Footnote 272Footnote 273

The impacts of drinking patterns are complicated. Alcohol's impacts are dose-dependent (e.g., volume consumed), but also depend on type of drink and the pattern of consumption over time (e.g., drinking patterns). To that end, experts have developed low-risk drinking guidelines to help Canadians understand how much is too much. Footnote 42

Canada's Low-Risk Alcohol Drinking Guidelines recommend that:

To reduce risks of short-term injury and harm:

  • Women should have no more than 3 standard drinks on any single occasion.
  • Men should have no more than 4 standard drinks on any single occasion.

To reduce long-term health risks:

  • Women should have no more than 10 standard drinks a week, with no more than 2 drinks a day on most days.
  • Men should have no more than 15 standard drinks a week, with no more than 3 drinks a day on most days.
What is a standard drink?
What is a standard drink?
Figure 3 - Text Equivalent

This image describes a standard drink for regular beer, wine, fortified wine, and hard liquor.

  • A standard drink of regular beer is 341 mL or 12 ounces and 5% alcohol.
  • A standard drink of wine is 142 mL or 5 ounces and 12% alcohol.
  • A standard drink of fortified wine is 85 mL or 3 ounces and 16 to 18% alcohol.
  • A standard drink of hard liquor is 43 mL or 1.5 ounces and 40% alcohol.

Due to the health risks involved, abstinence is recommended:

  • During pregnancy, when planning to become pregnant, and before breastfeeding;
  • Before and while driving or using machinery and tools;
  • When complications with medications or other drugs are possible;
  • When living with mental or physical health problems; and
  • Before and during any activities that need judgment, physical skill, balance and endurance.

Youth should delay drinking alcohol as long as possible, at least until reaching the legal drinking age.

Alcohol use disorders: Alcohol use disorders are associated with heavy drinking, but are not diagnosed by use alone. The Diagnostic and Statistical Manual of Mental Disorders, 5thedition (DSM-V) is a diagnostic tool used by health care professionals to diagnose and determine treatment for mental health disorders. Footnote 274 Previous editions defined problems with psychoactive substances through two distinct categories of abuse (based on risky use and the resulting social and occupational impairments) and dependence (based on resulting health problems, physiological dependence, cravings, lack of control over use, and time spent seeking, using or recovering from use). Footnote 275 In 2012, approximately 5 million Canadians (or 18 % of the population) aged 15 years and older met the criteria for alcohol abuse or dependence at some point in their lifetime. Footnote 276

Categories of diagnostic criteria: Footnote 274

  • Risky use
  • Lack of control over use
  • Social and occupational impairment
  • Needing more drug over time to have an effect (i.e. tolerance) and/or experiencing withdrawal symptoms

The DSM-V defines substance use disorders along a continuum of severity rather than as distinct conditions. For diagnosis, there are a variety of criteria that must be met, with severity being gauged by how many criteria a person fits. Substances use disorders are defined for nine groups of psychoactive substances: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics and anxiolytics; stimulants; tobacco; and, other substances. Footnote 274

From brain to behaviour

As a psychoactive drug, alcohol acts on the brain, leading to changes in behaviour.

Alcohol's effects are dose-dependent and differ from individual to individual. Generally, alcohol initially acts as a stimulant then a depressant. Footnote 277 Alcohol interacts with two widespread chemicals in the brain: gamma-aminobutyric acid (GABA) and glutamate. Alcohol stimulates GABA receptors (which are inhibitory) and inhibits glutamate receptors (which are excitatory), leading them to work together to suppress activity in certain areas of the brain. Footnote 45Footnote 100

Drinking alcohol acts on the brain to create a pleasant feeling and has a reinforcing effect on the brain's reward (dopamine) system with the help of other brain chemicals (e.g., opioids, stress hormones). Alcohol's effect on the reward system is thought to be the mechanism by which addiction to alcohol develops. Footnote 45Footnote 95Footnote 124Footnote 262Footnote 278-280

Alcohol easily reaches the brain and at a certain amount, can adversely affect processes that are essential for healthy brain growth and functioning. At higher amounts, it can also damage a wide range of areas in the brain that are important for learning, memory, decision making, motor control, and emotion. Footnote 100Footnote 208Footnote 281Footnote 282

Stress and alcohol

A healthy response to stress is essential for good health. Footnote 283 Drinking alcohol can negatively affect how the body reacts to stress, Footnote 284-291, which in turn, may underlie some of alcohol's effects on health and well-being. Footnote 290

From behaviour to social impacts

Over the short term, alcohol consumption can decrease inhibitions and increase risky behaviour. e.g.,Footnote 93Footnote 291-293 This can lead to a variety of potential impacts (see Figure 5) including risky decisions such as deciding to drive after drinking or having unprotected sex. Footnote 93Footnote 294 Drinking patterns are also linked to unwanted sex and rape among students.Footnote 296-298 Alcohol can be considered a date rape drug. Footnote 296 Drinking alcohol can also be used to help ease sexual interactions in consensual situations.Footnote 299

Alcohol dependence can also increase emotional reactivity and lead to an inability to interpret emotions, language and humour. Footnote 300-302 In some cases, heavy drinking is associated with increased social rejection and smaller, less diverse social networks. Footnote 303Footnote 304 Families can also be affected by alcohol. For example, how much a person drinks can influence how much their partner drinks. Footnote 305 Marital dissatisfaction and divorce can result when one partner drinks heavily. Footnote 305-307 An increased risk for partner violence, negative interactions, aggression, and child abuse and neglect is also linked to heavy use of alcohol. Footnote 248Footnote 307-313

Figure 5: A schematic of the widespread impacts of alcohol on risky behaviour
Figure 5
Figure 5 - Text Equivalent

This image depicts how drinking alcohol can lead to widespread impacts through risky behaviour. Drinking alcohol can lead to decreased inhibitions which can lead to risky behaviour. Risky behaviour can lead to drinking more, accidents, aggression, unwanted or unprotected sex, impaired driving and use of other drugs. Drinking more can lead to alcohol poisoning and other short-term impacts. Alcohol poisoning can lead to hospitalization and/or fatalities. Other short-term impacts can lead to an increased risk of long-term impacts. Aggression can lead to abuse and violence, which are interconnected and can both lead to crime. Impaired driving can lead to crime and accidents. Unwanted or unprotected sex can lead to unplanned pregnancy and sexually transmitted infections. Use of other drugs can lead to overdose which can lead to hospitalization and/or fatalities.

References: Footnote 4 Footnote 6 Footnote 9 Footnote 42-44, Footnote 86 Footnote 93 Footnote 125 Footnote 146 Footnote 208-210, Footnote 214 Footnote 294 Footnote 309 Footnote 311 Footnote 312 Footnote 315-327.

Summary of alcohol's impacts on behaviour

  • Alcohol-induced disinhibition can facilitate risky behaviour which can lead to a variety of negative outcomes such as impaired driving, accidents, rape, sexually transmitted infections, aggression, and violence.
  • Alcohol's effect on cognition can affect a person's ability to learn and work effectively, leading to poor academic performance and impaired occupational functioning. In turn, this can lead to dropping out of school or unemployment.
  • Alcohol can have a negative impact on relationships with family and friends. Parents, other adults and older siblings can act as role models for children and youth, passing on risky drinking patterns to the next generation.
  • Impaired motor skills from drinking alcohol can lead to an inability to drive safely, leading to a higher risk for accidents that can affect the drinker and other Canadians.

Influencing factors

A variety of factors play an important role in whether or not alcohol impacts an individual or population. Some factors are risk factors and some are protective; however, many are linked to the social determinants of health. The social determinants of health play a role in health inequities and help define an individual's or a population's social, economic, and physical environment, as well as an individual's characteristics and behaviours.Footnote 328Footnote 329

History

Humans have a long history and, arguably, fascination with mind-altering drugs, including alcohol. Footnote 266Footnote 330Footnote 331 Not long ago, alcohol was illegal in many jurisdictions and remains highly regulated in some areas of the world today. Footnote 48

Prohibition of alcohol in the early 1900s in North America arose out of concerns for its negative impacts. Based on data from the United States, prohibition of alcohol initially decreased drinking rates. These rates returned to pre-Prohibition levels in the decade following the end of Prohibition. Footnote 332

Like other psychoactive drugs, alcohol was explored for its medical qualities. More specifically, the idea that moderate drinking could have health benefits started in the 19thcentury. Footnote 333 Until recently; however, it was less clear what defined the difference between low- and high-risk drinking. Footnote 42

Social acceptability: When a drug is socially acceptable, people are more likely to use it and pressure others to use it too. Alcohol is an example of a drug that is socially acceptable in some areas of the world despite its risks for harm. Alcohol is most often consumed for enjoyment, to be social, and to celebrate despite awareness of the risks involved. Footnote 31Footnote 32Footnote 267 In some situations drinking alcohol is not acceptable, such as when it leads to violence, before and while driving, when underage or during pregnancy. Footnote 42

Stigma and discrimination: Despite being socially acceptable, the use of alcohol can also lead to stigma and discrimination, particularly for those who are being treated for alcohol use disorders. Footnote 304Footnote 334-337On the other hand, stigma is also attached to abstinence. Non-drinkers can be reluctant to disclose their non-drinking status because of this stigma and in order to be socially accepted. Footnote 336Footnote 338

Local context

Drinking patterns differ across the world, shaped by the local context of where people live, including: local laws, regulations, and policies related to alcohol; history, cultural and religious beliefs, and attitudes; and, the social determinants of health. Footnote 31Footnote 48Footnote 331 In addition, major political, economic, and social events can influence a country's drinking pattern. Footnote 339-341

Drinking around the world: Globally, developed countries show the highest rates of alcohol use while eastern Mediterranean countries have very low rates. Footnote 48 In many developed countries, rates of risky drinking are increasing in young people, particularly in young women. Footnote 342 Other shifts in drinking rates are occurring in different areas of the world. For example, India and China are currently seeing large increases in drinking. These increases are strongly influencing the overall picture of global drinking patterns. Footnote 48 There are also shifts in alcohol consumption being experienced in the United Kingdom and France, areas of the world with specific stereotypes related to alcohol. In the United Kingdom, rates of binge drinking have been decreasing while in France, rates of binge drinking have been increasing in youth. Footnote 343-345

Canada and the world Footnote 48

From 2008 to 2010, average alcohol consumption per person in Canada was below the alcohol consumption of many developed countries.

Canada

  • Canadians reported drinking 8.2 litres of pure alcohol per year.
  • 23% of drinkers drink heavily.

United States

  • Americans reported drinking 8.7 litres of pure alcohol per year.
  • 24.5% of drinkers drink heavily.

United Kingdom

  • People from the UK reported drinking 10.4 litres of pure alcohol per year.
  • 33.4% of drinkers drink heavily.

Australia

  • Australians reported drinking 10.4 litres of pure alcohol per year.
  • 13% of drinkers drink heavily.

* Annual consumption was averaged from 2008 to 2010 and measured in pure alcohol per capita in Canadians aged 15 years and older.

** For these data, heavy drinking was defined as consuming at least 60 grams or more of pure alcohol on at least one occasion in the previous month.

Note: 10 litres of pure alcohol is equivalent to over 580 drinks of regular beer (at 5% alcohol and 341 mL per drink).

Drinking patterns across Canada:

Even within a country, drinking patterns can differ. In 2013, rates of past year use of alcohol were highest in Quebec and lowest in Newfoundland and Labrador. However, rates of risky drinking among drinkers were highest in Newfoundland and Labrador and lowest in QuebecFootnote 1 (see Figure 6). Other surveys show that people in the Maritimes drink more alcohol in a sitting while people in the Prairies drink less, both in terms of amount and frequency. People from Quebec, Ontario and British Columbia drink more frequently and drink most often during a meal.Footnote 346

Figure 6a : What percentage of Canadians drank alcohol in the previous year in 2013?

Estimated percentage
BC Ab Sk Mb On Qc NB NS PEI NL Canada
Estimated percentage 75.3 74.5 75.5 74.8 72.7 82.8 73.9 76.2 74.6 72.5 75.9

Estimated percentage of Canadians 15 years of age and older who had consumed alcohol in the year previous to a 2013 survey. Data from the territories were not collected. Footnote 1

Figure 6b : What percentage of Canadians undertook risky drinking in 2013?

Estimated percentage
BC Ab Sk Mb On Qc NB NS PEI NL Canada
risk for short-term impacts 15.7 16.8 15.1 14.6 14.7 13.7 16.9 16.7 15.2 20.3 15
risk for long-term impacts 22 23.4 20.3 20.4 20.3 19.7 21.9 21.9 20.4 25.3 20.9

Estimated percentage of Canadians 15 years of age and older who had consumed alcohol the week prior to a 2013 survey in amounts that exceeded the guidelines for risks of immediate impacts or long-term impacts. Data from the territories were not collected. Footnote 1

Statistics Canada also collects data on drinking that exceeds the guidelines for short-term risks (i.e., 5 drinks or more for men and 4 drinks or more for women on one occasion at least once a month in the previous year). This provides a more comprehensive picture of risky drinking than asking about drinking in the previous weekFootnote 347.

In 2014, almost 18% of Canadians reported drinking heavily. Footnote 347 Ontario and British Columbia consistently had rates below the overall Canadian rate (both approximately 16% in 2014) while data from Nunavut suggest similarly lower rates. The Northwest Territories (32.7%), the Yukon (27.8%) and Newfoundland and Labrador (25.4%) had the highest rates (see Table 3). Footnote 347

Table 3: Rates of heavy drinking in 2014
Provence Total Men Women
Estimated percentage of Canadians 12 years of age and older in 2014 who had reported drinking heavily on one occasion at least once a month in the previous year. Heavy drinking was defined as drinking 5 drinks or more for men and 4 drinks or more for women. Footnote 347

* Data should be used with caution. Footnote 347

British Columbia 15.8 19.9 11.8
Alberta 18.9 23.1 14.6
Saskatchewan 19.5 25.7 13.3
Manitoba 17.8 22.5 13.2
Ontario 16.2 20.7 11.8
Quebec 20.2 25.8 14.8
New Brunswick 21.4 27.8 15.3
Nova Scotia 20.1 24.5 15.9
Prince Edward Island 16.9 21.0 13.1
Newfoundland and Labrador 25.4 33.2 18.0
Yukon 27.8 32.6 22.7
Northwest Territories 32.7 39.1 26.3
Nunavut 14.3* 17.4* 11.0*
Canada 17.9 22.7 13.2

Individual factors

Drinking patterns not only differ significantly across populations, they also vary widely between individuals. There are several factors that influence how much people drink and their risk for impacts from drinking alcohol.

How do expectations influence alcohol's effects?

The effects of alcohol are mediated by the expectations of the drinker. People are poor at judging how intoxicated they are, leading to the belief that they are more capable of doing certain activities such as driving safely, than they actually are. Footnote 353Footnote 354

Motives for drinking define why people drink alcohol. Generally, there are four main reasons why people drink: to be social, to create a positive mood, to cope, or to conform.Footnote 348-350 Coping and conforming are considered negative motives, with drinking to cope more likely to be associated with alcohol use disorders.Footnote 348-351 How alcohol is linked to a person's identity and self-image plays a role in the impact that motives have on drinking patterns. Footnote 349

Heavy drinking among young adults is often the result of intending to drink heavily. Many factors influence this decision-making process, including social norms and future plans. Footnote 352 Factors that occur during a drinking episode can also change how much is consumed, including available funds, behaviour of friends, mood and transportation options. Footnote 352

Cues that are unique to an individual and related to alcohol, such as certain friends or specific locations, can increase the need for alcohol as well as the potential for negative consequences. Footnote 355Footnote 356 How a person feels while drinking can affect their subsequent alcohol use. When heavy drinkers drink alcohol, they experience a more intense stimulating effect and a less intense depressive effect than do light drinkers. This effect was linked to an increased risk of binge drinking among heavy drinkers at a later date and of developing an alcohol use disorder. Footnote 357-359

Different locations can strongly influence drinking patterns. Generally speaking, certain locations are associated with drinking and tend to increase the potential for heavy drinking. Footnote 360-364 Drinking at locations such as pubs and off-campus housing can lead to more drinking among university students. Footnote 365Footnote 366 Drinking at a friend's house or in a restaurant is associated with lower levels of drinking among adults. Footnote 364Footnote 367 Becoming a parent is related to decreased drinking, which is likely at least partially due to less time spent at locations where heavy drinking is more prevalent (e.g., bars). Footnote 364

Friends strongly influence drinking habits. Drinking alcohol is strongly linked to being social. In fact, young people will emphasize positive social experiences associated with drinking to compensate for the negative impacts. Footnote 267 Drinking patterns within a social network have an important impact on useFootnote 26.Having more friends who drink is linked to heavy drinking, although loneliness is also linked to heavy use. Footnote 365Footnote 366 Social support can sometimes decrease how much alcohol is consumed. Footnote 365Footnote 367-370

Context is also important - drinking alcohol with meals tends not to lead to the same negative impacts as drinking alcohol at other times. Footnote 428Footnote 429 When many people are intoxicated together or drinking games are involved, more alcohol tends to be consumed. Footnote 360

Some personality traits have been linked to increased risk for impacts from alcohol. Impulsivity and sensation seeking are associated with increased alcohol consumption. In turn, these traits are linked to increased alcohol-related negative health impacts, including alcohol use disorders. Footnote 98Footnote 104Footnote 107Footnote 116Footnote 430-435

For some people, stress can trigger a need for alcohol as a method of coping, which can create a cycle of stress and alcohol use. Footnote 348Footnote 367Footnote 404Footnote 406-411Footnote 414Footnote 415Footnote 417Footnote 419Footnote 423Footnote 427Footnote 436

Various events that happen over a person's lifespan affect drinking patterns and the risk for impacts from alcohol. Footnote 93Footnote 305-307Footnote 348-427 For example:

  • Poor academic performance
  • Problems at school
  • Dropping out
  • Moving from high school to university/college
  • Unemployment
  • Stress at work
  • Divorce
  • Marital conflict/dissatisfaction
  • Partner who drinks heavily
  • Stressful life events
  • Marriage
  • Becoming a parent
  • Retirement
  • Aging

Modifying risk factors

In addition to personal triggers, there are other risk factors that can result in some people being more at risk for negative impacts than others. These include:

  • Genetics and Epigenetics: Genetics play a strong role in becoming dependent on alcohol, Footnote 437-442, with some evidence suggesting that genetics contribute approximately 50%. Footnote 438Footnote 440 Genetics affect the risk for impacts from alcohol through a variety of mechanisms. For example, genes can affect how people metabolize alcohol or the development of personality traits that are linked to alcohol use. Footnote 443-445

    Epigenetics looks at how different factors can turn genes on or off and how these changes in gene activation can be passed on to future generations. Footnote 446 This is still a growing area of research, including for alcohol. Footnote 447-449 The epigenetic effects of alcohol can be seen through the impacts of drinking before conception. For example, heavy drinking during the preconception period by a mother or father can affect the development of their child. Footnote 450Footnote 451 Epigenetics also plays a role in a variety of risk factors that influence the use of alcohol such as stress and early development. Footnote 452-457

  • Biology: Alcohol is most often consumed as a beverage and enters the bloodstream via the digestive tract. Blood levels of alcohol depend on a person's metabolism and increase when more alcohol is consumed, when people have a higher body fat content, when less food is present in the digestive system and with the use of some medications. Footnote 45Footnote 100
  • Underlying health conditions: Alcohol can exacerbate poor health. Generally, alcohol impairs the immune system, although it does so in a dose-dependent manner.Footnote 96Footnote 109Footnote 115Footnote 127 Alcohol's impacts on the immune system could make existing health conditions worse.Footnote 96Footnote 109Footnote 115Footnote 127 Alcohol also contributes to the development and progression of non-alcoholic fatty liver disease, which is largely caused by obesity.Footnote 467 It can also hasten the progression of HIV and hepatitis C.Footnote 468-473 Alcohol can modify the effectiveness of various medications, including drugs for conditions such as arthritis, diabetes, heart disease, enlarged prostate, high cholesterol, heartburn, indigestion, high blood pressure, infections, depression, anxiety, epilepsy, seizures, attention deficit/hyperactivity disorder, blood clots, nausea, insomnia, and allergies. Other examples include pain killers, cough syrups, anti-cancer drugs, and anti-retrovirals.Footnote 474-476
  • Socioeconomic status (SES): SES is a factor that is based largely on income, education and employment. Footnote 477 As a risk factor for problems with alcohol, the link between SES and alcohol is complex and influenced by other factors, such as drinking pattern, age, gender, parental/childhood SES, neighbourhood characteristics and country of residence. Footnote 478-493 In Canada, men and women with high SES are more likely to drink and undertake risky drinking than those with low SES. Footnote 342 In general, people with low SES are more likely to experience negative impacts from drinking. Footnote 490Footnote 492Footnote 493
  • Occupation: Beyond its role in SES, employment can modify alcohol's impacts on health. In Canada, different types of jobs were not linked to risky drinking. Footnote 494 Characteristics of work or the labour market rather than the job per se were more likely to affect drinking patterns. For example, social support, job motivation, and job satisfaction were related to low alcohol consumption. Stress, overwork, long hours, harassment, and job insecurity were linked to risky drinking. Control over decisions was linked to both high and low alcohol consumption. Footnote 495-506 Factors outside the workplace seem to have a greater impact on drinking patterns than work-related factors. Footnote 494

    Certain types of jobs or activities involve a sub-culture of drinking alcohol. For example, alcohol is an integral part of life for musicians, as is job insecurity, stress, and the need to socialize for work, all of which are linked to risky drinking. Footnote 507Footnote 508 Alcohol is also a part of sports culture. Student athletes are more likely to drink than student non-athletes, although this depends on time of year (e.g., on- versus off-season), sex, level of competition, and type of sport in some situations. Footnote 509-519 In addition, students who were fans of sports at college were more likely to drink and drink heavily. Footnote 520 There is some evidence that teenagers' involvement in sports may lead to heavier drinking later on. Footnote 521Footnote 522

  • Alcohol and Other Drugs: Drugs are often discussed in isolation, but in reality, some are frequently used together (known as polydrug use). The risks for harm increase with polydrug use. Footnote 97Footnote 318Footnote 324Footnote 326Footnote 523 For example:
    • Alcohol and caffeine is a combination that is a public health concern, particularly with respect to youth and the use of energy drinks. Footnote 524Footnote 525 Caffeine and alcohol together may increase the risks for harm from alcohol. People who combine alcohol and caffeine often increase their consumption of alcohol and report feeling less tired and more alert, as well as feeling less intoxicated than they actually are. Footnote 525-532 Mixing alcohol and caffeine is also often associated with increased risky behaviour. Footnote 533Footnote 534
    • When combined, alcohol and marijuana can increase motor control problems, leading to higher risks for motor vehicle accidents than the use of either drug alone. Footnote 535 This is likely due to the fact that alcohol increases marijuana metabolites in the bloodstream, increasing the impacts of marijuana on behaviour. Footnote 536Footnote 537
    • Separately, alcohol and tobacco can strongly impact long-term health. Together, they can further increase this impact. For example, the risk for oral and pharyngeal cancers in people who both drink heavily and smoke tobacco is 300 times higher than for people who neither drink nor smoke.Footnote 538

Sex: Women and men tend to differ in body fat percentage and in how they metabolize alcohol. Reduced amounts of certain enzymes and other sex differences in metabolism lead to more alcohol entering the bloodstream in women than men when the same amount is consumed. Footnote 45Footnote 100

Aging: With age, risks from alcohol may increase as people become more sensitive and less tolerant to alcohol. Footnote 386Footnote 458-464As a result, alcohol has a greater impact on people who are older than 65. People tend to drink less alcohol as they age, although this may be changing. Footnote 465

Stress, depression, and life events and transitions linked to aging such as death of a spouse or divorce, loss of social networks, a change in health status or retirement can impact drinking patterns. Footnote 466

Protective factors

Certain factors can protect against the negative impacts of alcohol, notably reducing consumption. Many protective factors are the same for adolescents as they are for young adults. Footnote 539 Attending religious services or activities, being more attached to parents, having high levels of family support, strong family management (e.g., rules, monitoring, consistent discipline, reinforcing good behaviour), having good social skills, and sense of morality, social conformity and being prosocial (e.g., working hard at school, helping at home, being involved in community activities, etc.) are all factors that are linked to reduced drinking among youth and young adults. Footnote 539Footnote 540 Protective and risk factors are not the same everywhere, with differences contributing to drinking rates and patterns. Footnote 541 Some traits, such as self-esteem, can also have an impact on alcohol consumption, although the effect is complex and can depend on drinking motives or context.Footnote 542Footnote 543

Certain strategies can also help protect against the negative impacts from alcohol, including setting limits, adjusting limits to recognize risk factors (e.g., age, body weight), drinking slowly, alternating between alcoholic and non-alcoholic drinks and eating before and while drinking. Footnote 544

Population health perspective

Based on existing information, alcohol consumption is discussed in three specific populations below - youth, women and Aboriginal populations:

Youth

Alcohol is a public health concern for youth because:

  • Drinking patterns established during adolescence are important predictors of drinking patterns and their impacts in adulthood. The younger a person starts drinking, the higher their risk for poor health and problems with alcohol later in life. Footnote 545-555
  • Girls may experience more impacts from alcohol on the brain than boys. Footnote 556 While drinking rates for girls are lower than for boys, rates of becoming intoxicated are similar. Footnote 555
  • Teenage brains, particularly those of teenage girls, are more vulnerable to the effects of alcohol, resulting in various impacts on developing cognition and behaviour. Footnote 281Footnote 555-567Howthe brain influences drinking behaviour may differ between teenaged boys and girls. Footnote 556Footnote 568
  • Youth who drink heavily can have trouble with attention, memory and decision-making and can experience social, emotional, and behaviour problems.Footnote 559Footnote 565 Problems with alcohol can lead to poor academic performance, dropping out, poorer job possibilities, and social isolation. Footnote 93Footnote 105Footnote 299Footnote 342Footnote 569-572
  • Youth are strongly influenced by friends and family. For example, when youth believe that their friends are drinking heavily, they drink heavily too. Also, when friends and parents approve of drinking alcohol, youth are more likely to drink and suffer negative impacts from drinking.Footnote 571

Why do youth try alcohol? Footnote 431Footnote 467Footnote 560-564Footnote 568Footnote 573-576

  • Youth tend to be more impulsive, seek out new experiences and take more risks.
  • Youth also tend to have trouble with self-control and deal with stress differently than adults.
  • Areas in the brain related to decision-making, motivation, emotion, and reward are still developing. In fact, brain development continues into young adulthood.

Where does parenting fit in?

  • Parents can have a negative influence on their children's future use of alcohol, health and well-being through abuse, neglect, and stress. Footnote 94Footnote 99Footnote 101Footnote 305Footnote 575-582
  • Parental drinking predicts alcohol use in youth. Footnote 583-585 Parental motives, rules, and attitudes also affect children's drinking. Footnote 585-590
  • Positive family relationships and parenting practices are linked to reduced drinking by teenagers, while negative family relationships, including divorce and family violence, are associated with more or earlier drinking. Footnote 591-598

Data on youth and alcohol consumption in Canada: The age at which youth take their first drink in Canada has been increasing. Footnote 599 An estimated 60% of Canadians aged 15 to 19 years drank alcohol in 2013. An estimated 15% of these youth drank enough to exceed the adult low-risk drinking guidelines for acute effects, while almost 20% exceeded the adult guidelines for chronic impacts. Footnote 1

Many Canadians begin drinking before the age of 15. The phenomenon of students binge drinking or "getting drunk" is infrequent in lower grades and becomes much more common in higher grades (see Figure 7). Footnote 555Footnote 599 By grades 10 to 12, almost 60% of teenagers reported having had a drink in the previous year while about 46% reported having undertaken binge drinking in 2012-2013. This is a decrease from previous years. For example, over 70% of students in Grades 10 to 12 reported drinking in the past year with almost 60% binge drinking in 2008-2009. Footnote 599-601 In 2012-2013, about 50% of youth reported having had their first drink of alcohol between the ages of 12 and 14. Footnote 602

Rates of drinking at least once a week by students in Grades 6,8, and 10 have decreased, particularly for beer. However, rates of becoming intoxicated have been relatively stable since 1994. Footnote 555

In every grade, boys consistently drink more beer than do girls, while consumption of wine, liquor and coolers is more similar across sexes. Consumption of beer increases across grades, while the consumption of wine and liquor is more stable. Footnote 555

About 60% of students in Grades 6 to 10 think drinking "once in a while" carries little to no risk. Regular drinking is thought to be risky by around 80% of boys and 87% of girls in Grades 6 to 10.Footnote 602 Binge drinking (i.e., drinking 5 or more drinks in a single occasion for boys and 4 or more drinks for girls) in the previous year was linked to more emotional and behaviour problems, particularly in those who undertook binge drinking most often.Footnote 602

Figure 7a: What percentage of students drank alcohol in 2012-2013?

Estimated percentage
Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
Estimated percentage 8.4 18.7 36.9 49.6 63 67.3

Estimated percentage of Canadians in Grades 7 to 12 who consumed alcohol in the year prior to the Youth Smoking Survey 2012-2013. Footnote 599

Figure 7b: What percentage of students undertook binge drinking in 2012-2013?

Estimated percentage
Grade 7-9 Grade 10-12
Estimated percentage 12.1 46.2

Estimated percentage of Canadians in Grades 7 to 12 who undertook binge drinking (5 or more drink on one occasion) in the year prior to the Youth Smoking Survey 2012-2013. Footnote 599

Key facts about students and alcohol: Footnote 11Footnote 555Footnote 599Footnote 603-611

  • Rates of drinking increase considerably from lower grades to higher grades and even more so after the transition to university and college.
  • Many university and college students experience negative outcomes from their drinking, such as hangovers, fights, and poor academic performance.
  • Some students rate negative impacts such as hangovers and blackouts as neutral or positive, which is more likely to lead them to drink more and experience negative health impacts.
  • For some students, alcohol can have positive effects, such as making events or celebrations more fun. Positive impacts have a stronger effect on subsequent drinking than negative impacts.
  • Drinking games are popular in high school and university/college and can lead to many negative impacts.
  • Holidays and special events such as celebrating being legal age to drink, spring break, and athletic events, can increase drinking, even in students who tend to normally drink lower amounts.

Women

Alcohol is a public health concern for women because:

  • As a population, women are less at risk for negative impacts from alcohol because they tend to drink less than men. As individuals, women are more at risk for harm from alcohol due to biological and social factors.Footnote 1Footnote 2Footnote 45Footnote 100Footnote 342
  • Because more women are undertaking risky drinking over time, this increases the risk that with time, women will be more impacted by alcohol as a population. Footnote 1Footnote 2Footnote 342
  • Women can be more vulnerable to sexual assault or other violence when drinking beyond their capacity. Footnote 298Footnote 299
  • Alcohol consumption can affect fertility. While moderate levels of drinking are linked to more sexual activity, they may also reduce the ovary's ability to release healthy eggs (which is essential for conception) in pre-menopausal women. Footnote 108Footnote 612
  • Although the impacts of drinking during pregnancy are well known, over 10% of women in 2006-2007 who gave birth reported they drank while pregnant. Footnote 613 Drinking before conceiving can also have detrimental effects on the development of offspring. Footnote 450Footnote 451 It is estimated that 50% of pregnancies are unplanned, meaning women may consume alcohol before knowing they are pregnant. Footnote 171
  • Alcohol's effects on women may be moderated by the impact of alcohol on hormones. For example, estrogen levels in women increase with every drink of alcohol, although the link between alcohol and estrogen is complex. Footnote 112Footnote 117Footnote 614 These changes in estrogen may be linked to alcohol-related effects on breast cancer and fertility.Footnote 102Footnote 111Footnote 615-617

Data on sex differences in alcohol consumption in Canada: In Canada, a higher percentage of men than women drink alcohol both in general and in terms of risky drinking (see Figure 8). Footnote 1 However, risky drinking by women in Canada has increased, Footnote 1Footnote 131Footnote 132Footnote 342, particularly in women above the age of 35. Footnote 1Footnote 132

Men tend to begin drinking and undertaking risky drinking at an earlier age than do women, Footnote 1Footnote 618, although women progress more quickly from abuse to physical dependence and to treatment for problem use than men. Footnote 619 Men also tend to drink more for the positive effects and social aspects of alcohol than women do. Footnote 620

Figure 8a: What percentage of Canadians undertook risky drinking in 2013?

Estimated percentage
men women
Estimated percentage 80.6 71.2

Estimated percentage of Canadians 15 years of age and older who consumed alcohol in the week prior to a 2013 survey in amounts that exceed the low-risk drinking guidelines. Footnote 1

Figure 8b: What percentage of Canadians drank alcohol in 2013?

Estimated percentage
men women
risk for short-term impacts 14.6 8
risk for long-term impacts 18.8 12.7

Estimated percentage of Canadians 15 years of age and older who consumed alcohol in the year previous to a 2013 survey. Footnote 1

Aboriginal populations

Alcohol is a public health concern for some Aboriginal populations in Canada because:

  • · Many Aboriginal populations face major challenges that affect their health and well-being such as high unemployment, poverty, poor access to education, poor housing, being located far from health services, the displacement of Aboriginal language and culture, and social and economic marginalization. Footnote 621-629
  • In order to address health issues, there is a need to understand how Aboriginal social determinants of health affect and contribute to a holistic view of health. For Aboriginal populations, historically and culturally specific factors play a particularly important role.Footnote 621Footnote 622Footnote 625

Key determinants of health for Aboriginal populations: Footnote 621-623Footnote 625Footnote 627Footnote 630

  • Community readiness
  • Economic development
  • Employment
  • Environmental stewardship
  • Gender
  • Historical conditions and colonialism
  • Housing
  • Land and resources
  • Language, heritage, and strong cultural identity
  • Legal and political equity
  • Lifelong learning
  • Living on- and off-reserve
  • Racism and discrimination
  • Self-determination and non-dominance
  • Social services and supports
  • Living in urban and rural areas

Data on Aboriginal populations and alcohol consumption in Canada: Findings from the First Nations Regional Health Survey (2008-10) indicate that the rate of reported alcohol consumption for First Nations living on reserve is lower compared to the general Canadian population. However, the rate of reported heavy drinking is higher than the Canadian rate. Approximately 35% of First Nations adults living in First Nations communities did not drink in the past year, but of those who did drink, more than 60% drank heavily. First Nations youth living in First Nations communities are less likely to drink, with approximately 60% saying they did not drink in the past year. For those youth who did drink, approximately 50% drank heavily. Footnote 631 In addition, use and abuse of alcohol and drugs was ranked by First Nations on-reserve as the top challenge for community wellness. Footnote 631

According to the 2012 Aboriginal Peoples Survey, 33% of Inuit 15 years of age and older did not drink in the previous year, although 26% drank heavily.Footnote 632 According to the 2007-2010 Canadian Community Health Survey, 27% of Métis aged 12 years and older drank heavily in the previous year. Footnote 633

Reducing health impacts

Drinking alcohol is ingrained in Canadian culture. Because there are multiple levels and types of influence on drinking patterns (see Figure 9), many actors play a role in promoting responsible drinking and healthy behaviours. Many primary prevention strategies aim to reduce risky drinking and potential negative impacts of alcohol consumption; however, none of these are universally effective. The amount of variability across individuals, communities, and societies means that there is no single way to reduce impacts of alcohol use on individuals and populations. Footnote 5Footnote 342

Types and levels of influence on alcohol consumption

Individual

Reaction to alcohol:
  • Stimulating
  • Metabolism
  • Genetics
  • Expectations
Life transitions:
  • Going to school
  • Finding or losing a job
  • Getting married
  • Getting divorced
  • Becoming a parent
  • Retiring
Stress:
  • Coping
  • Makes alcohol more rewarding
Personality:
  • Impulsive
  • Sensation seeking

Family and Friends

Family:
  • Role models
  • Parenting
  • Abuse, stress, family violence
  • Beliefs and attitudes toward alcohol
  • Letting children try alcohol
Friends:
  • Drinking patterns
  • Peer pressure
  • Behaviour
  • Social support

Community and Society

Availability:
  • Cost
  • Ease of access
  • Retail outlets
Social acceptability:
  • Social expectations
  • Acceptable in certain situations (e.g., parties, celebrations, university/college)
  • Not acceptable in other situations (e.g., pregnancy, before/while driving, when underage, when violence occurs)
  • Stigma for those who do not drink
Exposure:
  • Widely promoted
  • On tv, on the radio, in movies, in literature
  • On social media, websites

Addressing individual factors

Not all factors that influence drinking can be addressed at the individual level. Individuals can reduce their drinking by recognizing factors that influence them to drink and that increase their risk for harm.

Reducing consumption: The amount of alcohol consumed plays a large role in the risk for both short- and long-term impacts. Footnote 42 Once an individual determines how much he or she drinks, Canada's Low-Risk Alcohol Drinking Guidelines can help determine whether or not the amount consumed is putting the individual and his or her family and friends at risk for harm. Some countries, including the United Kingdom, are currently revising their low-risk guidelines. Footnote 634

Brief interventions for alcohol: Following a screening process, brief interventions aim to target at-risk individuals through personalized feedback and counselling to set goals, find effective strategies to change behaviour, and provide information and guidance. Interventions can range from one short session to multiple sessions depending on the individual's needs. Individuals can be identified for and referred to treatment through this process. Footnote 635

Brief interventions have been noted as an important component for reducing the impacts of alcohol on individuals and act as a bridge between prevention and treatment.Footnote 635-637 A number of randomized trials in several countries have demonstrated that brief interventions are effective in many settings.Footnote 636 Brief interventions can reduce drinking, decrease mortality rates and improve health.Footnote 638-640

Although brief interventions are effective, social norms interventions (i.e., providing information on how much other people are drinking) are largely ineffective. Footnote 641Footnote 642

Recognizing and addressing risk: Addressing risk factors that influence drinking is an important step in reducing the potential for impacts. For example, why people drink is an important factor in determining what approach would work best for an individual. Footnote 643 For those who use alcohol to cope with stress, healthy coping skills and lifestyles can help reduce drinking and related impacts. Footnote 644-646 Using protective behaviours such as eating before drinking, alternating non-alcoholic with alcohol drinks and pacing drinks, can decrease the negative impacts from alcohol. Footnote 647

Attitudes and beliefs are also important considerations. For example, skills that help youth learn how to say no to alcohol seem only to help youth who already disapprove of drinking. Footnote 648 Evidence also suggests that changing parental attitudes on underage drinking by making them stricter can reduce heavy drinking in adolescents. Footnote 649-651 Changing parental behaviour seems to be a necessary component for reducing youth drinking over the long term, particularly for high risk youth. Footnote 652-655

Other risk factors are more difficult to address. For example, interventions that target personality traits have mixed effects with some showing promise and some being largely ineffective. Footnote 656-658

Health professionals can also influence people to recognize their risk for harm from alcohol. For example, educating women of child-bearing age about potential risks from alcohol to their health and the health of their developing baby is important. Footnote 659

Addressing availability and exposure

Laws, regulations and policies aim to keep Canadians safe and help mitigate harm from alcohol by contributing to changing behaviour. They also contribute to variability in drinking patterns across different jurisdictions, including across provinces. Footnote 5 Many of these are related to controlling availability. For example:

  • Pricing and taxation are tools that can discourage people from buying alcohol. As a consequence, this can reduce alcohol-related health and social impacts, including for impaired driving and alcohol-related crime. Footnote 660-663 Increasing the minimum price of alcohol is one of the more effective approaches that successfully decreases consumption, alcohol-related death and hospital admissions. Footnote 660Footnote 662-665Most provinces have introduced minimum pricing; however, policies on indexation and pricing on alcohol content are not well implemented across every Canadian province (data on territories were not analyzed). Footnote 5
  • Control of sales and availability also reduces the impacts of alcohol use by restricting eligibility to purchase and sell alcohol as well as restricting the number of alcohol outlets and days/hours of sale.Footnote 666 When alcohol sales are not controlled, there tends to be higher availability, more drinking, more alcohol related problems and increased acceptability of alcohol use.Footnote 5Footnote 128Footnote 666-673 Currently, alcohol is widely available across Canada.Footnote 5 The number of locations that are allowed to sell alcohol in an area is largely decided at the municipal level; however, provinces implement various other means of controlling sales and availability.Footnote 5
  • Minimum age laws also restrict availability of alcohol by legally defining at what age people can buy and drink alcohol. When enforced, it is the most effective means of reducing drinking among underage youth. Footnote 678 Consequently, the impacts of alcohol on measures like mortality, overdoses, injuries, vehicle accidents and use of the health care system are also reduced. Footnote 679-684 In Canada, rates of fatalities, including from motor vehicle accidents, increase at the minimum legal drinking age, more so for men than women. Footnote 681 The legal drinking age is 19 years of age in Canada, except in Quebec, Manitoba, and Alberta where it is 18. Footnote 685
  • Alcohol advertising: In Canada, advertising of alcohol is regulated by a variety of federal and provincial statutes and regulations, including the Food and Drugs Act , Television Broadcasting Regulations, and Radio Regulations . Commercial messages are also to observe the Code for Broadcast Advertising of Alcoholic Beverages.

    There is very limited research on the effects of alcohol advertising on Canadians. Based on research from the United States, evidence has found that alcohol marketing reaches a wide audience, including underage youth.Footnote 686-688 Some elements of alcohol ads are particularly appealing to a youth audience and exposure to particular brands do increase the likelihood that youth will drink that brand.Footnote 687Footnote 689-691However, research is mixed on if or how alcohol advertising affects drinking patterns. Some results suggest that advertising increases drinking in youth who are already more receptive to this type of advertising or more likely to undertake risky behaviour.Footnote 692-694 Other research suggests that there is a dose response to advertising - the greater the exposure to alcohol advertising, the more youth drink.Footnote 695 Promoting alcohol also occurs through other means. For example, in the United States, the alcohol industry sponsors a large number of events linked to sports and music. Brands that are popular with youth are more likely to sponsor such events.Footnote 696

Programs that aim at improving safety at drinking establishments (e.g., Safer Bars Program) show promise in reducing violence and physical aggression. Footnote 674Footnote 675

Responsible beverage server training is also effective in reducing risky drinking. Footnote 676Footnote 677 Examples include SmartServe in Ontario and Serving it Right in British Columbia.

Changing behaviour: Reducing risky drinking involves a change in behaviour. To change behaviour, it is important to understand:

  • what is risky drinking; and
  • how to reduce alcohol consumption.

The Canadian Centre on Substance Abuse and Educ'alcool have a variety of tools to help use Canada's Low-Risk Alcohol Drinking Guidelines as well as tips and resources to drink responsibly.

Strategies and tools have been developed to help people reduce their drinking. For example:

Safe alcohol, safe drinking: Liquor control boards and commissions and the alcohol industry, including producers, restaurants, bars, and night clubs, play an important role in reducing risks associated with drinking alcohol. The safety of alcohol is regulated by various pieces of legislation, including through the Food and Drugs Act. Footnote 697 In addition, the alcohol industry in Canada works in collaboration with government, non-governmental organizations and other groups to promote responsible drinking. For example:

Addressing social acceptability

Perhaps the most challenging aspect to tackle in terms of reducing the negative impacts of alcohol consumption is social acceptability. Addressing social acceptability must involve action at the individual, family, community, and societal levels.

Stigma: Addressing stigma for both people who do not drink and those who are in treatment is important. For information on addressing stigma, see the Mental Health Commission of Canada.

Strategies on Alcohol: Alcohol is a recognized public health issue both globally and within Canada.

  • The World Health Organization has developed the Global Strategy to Reduce the Harmful Use of Alcohol that outlines ten areas for national action: leadership, awareness and commitment; health services response; community action; drink-driving policies and countermeasures; availability of alcohol; marketing of alcoholic beverages; pricing policies; reducing the negative consequences of drinking and alcohol intoxication; reducing the public health impact of illicit alcohol and informally produced alcohol; and, monitoring and surveillance.
  • Developed in 2007 in collaboration with a variety of alcohol stakeholders, Reducing Alcohol-Related Harm in Canada: Toward a Culture of Moderation identified a range of recommendations to form the basis of a National Alcohol Strategy.

Canada's National Alcohol Strategy: Formed in 2008, the National Alcohol Strategy Advisory Committee (NASAC) leads the implementation, monitoring and evaluation of the National Alcohol Strategy. The committee is co-chaired by the Canadian Centre on Substance Abuse, Mothers Against Drunk Driving Canada, and the Nova Scotia Department of Health and Wellness and consists of experts from across Canada including federal and provincial government representatives, non-governmental organizations, public health including medical officers of health, First Nations, Inuit and Métis service providers, and the alcohol industry.

Some progress has been made on a number of the recommendations, including: the development of Canada's Low-Risk Alcohol Drinking Guidelines launched in 2011; staff and server training programs; policies and programs for deterring underage drinking; and, community alcohol awareness campaigns.

In addition to the progress made on the Strategy, the Public Health Agency of Canada and Health Canada have also made progress on addressing fetal alcohol spectrum disorder.

Awareness campaigns: Developing messages about alcohol that resonate is challenging, making it difficult to create effective awareness campaigns. Footnote 342 Interestingly, alcohol is one of the few health-related topics where mass media campaigns are rarely effective. Footnote 698 Awareness campaigns have had the most success for impaired driving, Footnote 698-701, suggesting that specific and tangible topics where messages and actions are clear may benefit most from awareness campaigns.

Awareness campaigns are important for increasing knowledge and changing attitudes, but they do not always change drinking behaviour or the intention to drink.Footnote 342Footnote 699 There is a lack of awareness among Canadians about the full impact of alcohol on health. For example, in 2008, almost 70% of Canadians were not aware that alcohol was linked to cancer, while almost half were not aware of its links to heart disease and diabetes.Footnote 702

Public health awareness campaigns that either use scare tactics or promote responsible drinking can increase drinking while knowledge of drinking guidelines does not always reduce risky drinking. Footnote 703-705

Increasing knowledge and shifting attitudes is a key first step in the difficult process of changing societal views on drinking alcohol. This means awareness campaigns are an important component of a multi-faceted approach for reducing the negative impacts of alcohol consumption.

Closing comments

My role as Canada's Chief Public Health Officer is to engage Canadians and this report is meant to support a public health dialogue about drinking and its risks. The evidence gathered in this report provides an overview of public health impacts within our Canadian culture that normalises drinking. Information is organized in a way that recognizes that people may choose to read only certain sections as it is web-based.

As noted by the Canadian Public Health Association in their 2011 position paper on alcohol , tackling the problematic use of alcohol requires a combination of factors, including leadership and a broad base of support at all levels.

Since our National Alcohol Strategy was developed in 2007, there is emerging evidence on increased risks of cancers at low levels of drinking and a growing skepticism on alcohol's benefits. Our knowledge and understanding of alcohol consumption, drinking patterns, the effectiveness of current approaches, and the health impacts of alcohol in Canada is inadequate.

I suggest that Canadians and our institutions take a closer look at our current approach and reflect if we are doing enough to reduce the harms associated with drinking alcohol.

References

Data and information for this report were collected using a variety of methods, including key words searches through PubMed and Google Scholar as well as consultations with Canadian public health experts. The most up to date data and information available were used, with all research and data cited in this report being from peer-reviewed scientific articles and trusted data sources, such as Statistics Canada. Terminology on drinking, such as heavy drinking, alcohol abuse, alcohol dependence, and alcohol use disorders, were used as appropriate and matched the terminology being used in the research and data being cited. Care was taken to not use terms such as alcohol abuse, alcohol dependence, and alcohol use disorders unless relevant, as these conditions are clinically diagnosed.

Footnotes

What this report is about

Footnote 1

Health Canada (2015). Canadian Tobacco, Alcohol and Drugs Survey, 2013. All computations on these microdata were prepared by the Public Health Agency of Canada and the responsibility for the use and interpretation of these data is entirely that of the author(s).

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Footnote 2

Statistics Canada. (2015-09-28). Table 051-0001 - Estimates of population, by age group and sex for July 1, Canada, provinces and territories, annual (persons unless otherwise noted) [Data File]. Retrieved on December 2, 2015, from http://www5.statcan.gc.ca/cansim/pick-choisir?lang=eng&p2=33&id=0510001.

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Footnote 3

The World Health Organization: definition of psychoactive substances. http://www.who.int/substance_abuse/terminology/psychoactive_substances/en/

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Footnote 4

Rehm, J., Mather, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y., Patra, J. (2009). Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, 373, 2223-2233.

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Footnote 5

Giesbrecht, N., Wettlaufer, A., April, N., Asbridge, M., Cukier, S., Mann, R., McAllister, J., Murie, A., Plamondon, L., Stockwell, T., Thomas, G., Thompson, K., Vallance, K. (2013). Strategies to reduce alcohol-related harms and costs in Canada: a comparison of provincial policies. Toronto, ON: Centre for Addiction and Mental Health.

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Footnote 6

Rehm, J., Ballunas, D., Brochu, S., Fischer, B., Gnam, W., Patra, J., Popova, S., Sarnocinska-Hart, A., Taylor, B. (2006). The costs of substance abuse in Canada 2002. Canadian Centre on Substance Abuse.

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Footnote 7

Statistics Canada (2015). Control and sales of alcoholic beverages, for the year ending March 31, 2014. Ottawa ON: Statistics Canada.

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Footnote 8

Perreault, S. (2013). Impaired driving in Canada, 2011. Ottawa ON: Statistics Canada.

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Footnote 9

Young, M.M., Jesseman, R. (2014). The impact of substance use disorders on hospital use. Ottawa, ON: Canadian Centre on Substance Abuse.

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Footnote 10

Anderson, P., De Bruijn, A., Angus, K., Gordon, R., Hastings, G. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies. Alcohol and Alcoholism, 44(3), 229-243.

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Footnote 11

Borsari, B., Read, J.P., Neighbors, C., White, H.R. (2013). An update of research examining college student alcohol-related consequences: new perspectives and implications for interventions. Alcoholism: Clinical and Experimental Research, 37(5), 709-716.

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Footnote 12

Drapkin, M.L., Eddie, D., Buffington, A.J., McCrady, B.S. (2015). Alcohol-specific coping styles of adult children of individuals with alcohol use disorders and association with psychosocial functioning. Alcohol and Alcoholism, epub.

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Footnote 13

Engels, R.C., Hermans, R., van Baaren, R.B., Hollenstein, T., Bot, S.M. (2009). Alcohol portrayal on television affects actual drinking behaviour. Alcohol and Alcoholism, 44(3), 244-249.

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Footnote 14

Gommans, R., Stevens, G.W., Finne, E., Cillessen, A.H., Boniel-Nissim, M., ter Bogt, T.F. (2015). Frequent electronic media communication with friends is associated with higher adolescent substance use. International Journal of Public Health, 60(2), 167-177.

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Footnote 15

Gordon, R., Harris, F., Marie Mackintosh, A., Moodie, C. (2011). Assessing the cumulative impact of alcohol marketing on young people's drinking: cross-sectional data findings. Addiction Research and Therapy, 19(1), 66-75.

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Footnote 16

Heath, D. (2000). Drinking occasions: Comparative perspectives on alcohol and culture. Philadelphia: Brunner/Mazel.

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Footnote 17

Jennings, J.M., Milam, A.J., Greiner, A., Furr-Holden, C.D., Curriero, F.C., Thornton, R.J. (2014). Neighborhood alcohol outlets and the association with violent crime in one mid-Atlantic City: the implications for zoning policy. Journal of Urban Health, 91(1), 62-71.

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Footnote 18

Jernigan, D.H., Ostroff, J., Ross, C.S., Naimi, T.B., Brewer, R.D. (2007). Youth exposure to alcohol advertising in magazines - United States, 2001-2005. Morbidity and Mortality Weekly Report, 56(30), 763-766.

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Footnote 19

Klostermann, K., Chen, R., Kelley, M.L., Schroeder, V.M., Braitman, A.L., Mignone, T. (2011). Coping behavior and depressive symptoms in adult children of alcoholics. Substance Use and Misuse, 46(9), 1162-1168.

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Footnote 20

Koordeman, R., Anschutz, D. J., Engels, R. C. (2011). Exposure to alcohol commercials in movie theaters affects actual alcohol consumption in young adult high weekly drinkers: an experimental study. The American Journal on Addictions, 20(3), 285-291.

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Footnote 21

Koordeman, R., Anschutz, D. J., van Baaren, R. B., Engels, R. C. (2011). Effects of alcohol portrayals in movies on actual alcohol consumption: an observational experimental study. Addiction, 106(3), 547-554.

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Footnote 22

Koordeman, R., Kuntsche, E., Anschutz, D. J., van Baaren, R. B., Engels, R.C. (2011). Do we act upon what we see? Direct effects of alcohol cues in movies on young adults' alcohol drinking. Alcohol and Alcoholism, 46(4), 393-398.

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Footnote 23

Koordeman, R., Anschutz, D. J., Engels, R. C. (2012). The effect of alcohol advertising on immediate alcohol consumption in college students: an experimental study. Alcoholism, Clinical and Experimental Research, 36(5), 874-880.

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Footnote 24

Koordeman, R., Anschutz, D. J., Engels, R. C. (2015). Self-control and the effects of movie alcohol portrayals on immediate alcohol consumption in male college students. Frontiers in Psychiatry, 5, 187.

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Footnote 25

Martinic, M., Meashams, F. (eds.) (2008). Swimming with crocodiles: the culture of extreme drinking. New York: Routledge.

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Footnote 26

McCutcheon, V.V., Lessov-Schalgger, C.N., Steinley, D., Bucolz, K.K. (2014). Social network drinking and family history contribute equally to first-onset dependence in high risk adults. Drug and Alcohol Dependence, 141, 145-148.

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Footnote 27

Milam, A., Furr-Holden, C., Bradshaw, C., Webster, D., Cooley-Strickland, M., Leaf P. (2013). Alcohol environment, perceived safety and exposure to alcohol, tobacco and other drugs in early adolescence. Journal of Community Psychology, 41(7), 867-883.

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Footnote 28

Milam, A.J., Furr-Holden, C.D., Cooley-Strickland, M.C., Bradshaw, C.P., Leaf, P.J. (2014). Risk for exposure to alcohol, tobacco, and other drugs on the route to and from school: the role of alcohol outlets. Prevention Science, 15(1), 12-21.

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Footnote 29

Pasch, K.E., Komro, K.A., Perry, C.L., Hearst, M.O., Farbakhsh, K. (2007). Outdoor alcohol advertising near schools: what does it advertise and how is it related to intentions and use of alcohol among young adolescents? Journal of Studies on Alcohol and Drugs, 68(4), 587-596.

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Footnote 30

Scull, T.M., Kupersmidt, J.B., Erausquin, J.T. (2014). The impact of media-related cognitions on children's substance use outcomes in the context of parental and peer substance use. Journal of Youth and Adolescence, 43(5), 717-728.

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Footnote 31

Smith, L.A., Foxcroft, D.R. (2009). The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. BMC Public Health, 9, 51.

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Footnote 32

Snyder, L.B., Milici, F.F., Slater, M., Sun, H., Strizhakova, Y. (2006) Effects of alcohol advertising exposure on drinking among youth. Archives of Pediatrics and Adolescent Medicine, 160(1) 18-24.

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Footnote 33

Stacy, A.W., Zogg, J.B., Unger, J.B., Dent, C.W. (2004). Exposure to televised alcohol ads and subsequent adolescent alcohol use. American Journal of Health Behavior, 28(6), 498-509.

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Footnote 34

Stoolmiller, M., Wills, T.A., McClure, A.C. (2012). Media and family predictors of drinking onset and binge drinking among US adolescents. BMJ Open, 2.

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Footnote 35

Treno, A.J., Grube, J.W., Martin, S.E. (2003). Alcohol availability as a predictor of youth drinking and driving: a hierarchical analysis of survey and archival data. Alcoholism, Clinical and Experimental Research, 27(5), 835-840.

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Footnote 36

Vermeulen-Smit, E., Koning, I.M., Verdurmen, J.E., Van der Vorst, H., Engels, R.C., Vollebergh, W.A. (2012). The influence of paternal and maternal drinking patterns within two-partner families on the initiation and development of adolescent drinking. Addictive Behaviors, 37(11), 1248-1256.

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Footnote 37

Boniface, S., Shelton, N. (2013). How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario. European Journal of Public Health, 23(6), 1076-1081.

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Footnote 38

Caetano, R. (2001). Non-response in alcohol and drug surveys: a research topic in need of further attention. Addiction, 96, 1541-1545.

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Footnote 39

Stockwell, T., Donath, S., Cooper-Stanbury, M., Chikritzhs, T., Catalano, P., Mateo, C. (2004). Under-reporting alcohol consumption in household surveys: a comparison of quantity-frequency, graduated-frequency and recent recall. Addiction, 99(8), 1024-1033.

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Mares, S.H., Lichtwarck-Aschoff, A., Engels, R.C. (2013). Intergenerational transmission of drinking motives and how they relate to young adults' alcohol use. Alcohol and Alcoholism, 48(4), 445-451.

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King, K.M., Chassin, L. (2004) Mediating and moderated effects of adolescent behavioral undercontrol and parenting in the prediction of drug use disorders in emerging adulthood. Addictive Behaviors, 18, 239-249.

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Moore, G.F., Rothwell, H., Segrott, J. (2010). An exploratory study of the relationship between parental attitudes and behaviour and young people's consumption of alcohol. Substance Abuse Treatment, Prevention, and Policy, 5, 6.

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Waldron, M., Grant, J.D., Bucholz, K.K., Lynskey, M.T., Slutske, W.S., Glowinski, A.L., Henders, A., Statham, D.J., Martin, N.G., Heath, A.C. (2014). Parental separation and early substance involvement: results from children of alcoholics and cannabis dependent twins. Drug and Alcohol Dependence, 134, 78-84.

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Waldron, M., Vaughan, E.L. Bucholz, K.K., Lynskey, M.T., Sartor, C.E., Duncan, A.E., Madden, P.A., Heath, A.C. (2014). Risks for early substance involvement associated with parental alcoholism and parental separation in an adolescent female cohort. Drug and Alcohol Dependence, 138, 130-136.

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Freeman, J.G., King, M., Pickett, W. (2011). The health of Canada's young people: a mental health focus. Ottawa ON: Public Health Agency of Canada.

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Borsari, B., Murphy, J.G., Barnett, N.P. (2007). Predictors of alcohol use during the first year of college: implications for prevention. Addictive Behaviors, 32, 2062-2086.

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Park, C.L. (2004). Positive and negative consequences of alcohol consumption in college students. Addictive Behaviors, 29, 311-321.

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Mallett, K.A., Bachrach, R.L., Turrisi, R. (2008). Are all negative consequences truly negative? Assessing variations among college students' perceptions of alcohol related consequences. Addictive Behaviors, 33, 1375-1381.

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Patrick, M.E., Maggs, J.L. (2011). College students' evaluations of alcohol consequences as positive or negative. Addictive Behaviors, 36, 1148-1153.

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Borsari, B., Bergen-Cico, D., Carey, K.B. (2003). Self-reported drinking-game participation of incoming college students. Journal of American College Health, 51(4), 149-154.

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Cameron, J.M., Heidelberg, N., Simmons, L., Lyle, S.B., Mitra-Varma, K., Correia, C. (2010). Drinking game participation among undergraduate students attending National Alcohol Screening Day. Journal of American College Health, 58(5), 499-506.

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Johnson, T.J., Stahl, C. (2004). Sexual experiences associated with participation in drinking games. The Journal of General Psychology, 131(3), 304-320.

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Perdersen, E.R., Labrie, J. (2008). Normative misperceptions of drinking among college students: a look at the specific contexts of prepartying and drinking games. Journal of Studies on Alcohol and Drugs, 69(3), 406-411.

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Zamboanga, B.L., Leitkowski, L.K., Rodriguez, L., Cascio, K.A. (2006). Drinking games in female college students: more than just a game? Addictive Behaviors, 31(8), 1485-1489.

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Battaglia, C., Battaglia, B., Mancini, F., Nappi, R.E., Paradisi, R., Venuroli, S. (2011). Moderate alcohol intake, genital vascularization and sexuality in young, healthy eumenorrheic women. A pilot study. The Journal of Experimental Medicine, 8(8), 2334-2343.

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Public Health Agency of Canada (2009). What Mothers Say: The Canadian Maternity Experience Survey. Ottawa ON: Public Health Agency of Canada.

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Rohwer, R.D., Liu, S., You, N.C., Buring, J.E., Manson, J.E., Song, Y. (2015). Interrelationship between alcohol intake and endogenous sex-steroid hormones on diabetes risk in postmenopausal women. Journal of the American College of Nutrition, 34(4), 273-280.

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Augustynska, B., Ziolkowski, M., Odrowaz-Sypniewska, G., Kielpinski, A., Gruszka, M., Kosmowski, W. (2007). Menstrual cycle in women addicted to alcohol during the first week following drinking cessation - changes in sex hormones levels in relation to selected clinical features. Alcohol and Alcoholism, 42(2), 80-83.

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Suzuki, R., Ye, W., Rylander-Rudqvist, T., Saji, S., Golditz, G.A., Wolk, A. (2005). Alcohol and postmenopausal breast cancer risk defined by estrogen and progesterone receptor status: a prospective cohort study. Journal of the National Cancer Institute, 97(21), 1601-1608.

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Suzuki, R., Orsini, N., Mignone, L., Saji, S., Wolk, A. (2008). Alcohol intake and risk of breast cancer defined by estrogen and progesterone receptor status - a meta-analysis of epidemiological studies. International Journal of Cancer, 122(8), 1832-1841.

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Lewis, B., Nixon, S.J. (2014). Characterizing gender differences in treatment seekers. Alcoholism, Clinical and Experimental Research, 38, 275-284.

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Kuntsche, E., Knibbe, R., Gmel, Engels., R. (2006). Who drinks and why? A review of socio-demographic, personality and contextual issues behind the drinking motives in young people. Addictive Behaviours, 31(10), 1844-1857.

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Assembly of First Nations (2006). First Nations Public Health: A Framework for Improving the Health of our People and our Communities. Ottawa ON: Assembly of First Nations.

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Assembly of First Nations (2013). First Nations Wholistic Policy and Planning: a transitional discussion document on the social determinants of health. Ottawa ON: Assembly of First Nations.

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Dion Tout, M., Kipling, G. (2003) Aboriginal People, Resilience and the Residential School Legacy. Ottawa ON: The Aboriginal Healing Foundation.

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Greenwood, M.L., de Leeuw, S.N. (2012). Social determinants of health and the future well-being of Aboriginal children in Canada. Paediatrics and Child Health, 17(7), 381-384.

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Health Canada, Assembly of First Nations, National Native Addiction Partnership Foundation (2011). Honouring Our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada. Ottawa ON: Health Canada, Assembly of First Nations and National Native Addiction Partnership Foundation.

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Health Canada, the Assembly of First Nations (2015). First Nations Mental Wellness Continuum Framework. Ottawa ON: Health Canada and the Assembly of First Nations.

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Inuit Tapiriit Kanatami (2014). Social Determinants of Inuit Health in Canada. Ottawa ON: Inuit Tapriit Kanatami.

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Kumar, M.B., Wesche, S., McGuire, C. (2012). Trends in Metis-related health research (1980-2009): identification of research gaps. Canadian Journal of Public Health, 103(1), 23-28.

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Sheppard, A.J., Hetherington, R. (2012). A decade of research in Inuit children, youth, and maternal health in Canada: areas of concentrations and scarcities. International Journal of Circumpolar Health, 71.

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Young, T.K. (2003). Review of research on Aboriginal populations in Canada: relevance to their health needs. BMJ, 327(7412), 419-422.

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First Nations Information Governance Centre (FNIGC) (2012). First Nations Regional Health Survey (RHS) 2008/10: National report on adults, youth and children living in First Nations communities. Ottawa ON: FNIGC.

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Wallace, S. (2014). Inuit health: selected findings from the 2012 Aboriginal Peoples Survey. Ottawa ON: Statistics Canada.

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Gionet, L., Roshanafshar, S. (2013). Select health indicators of First Nations people living off reserve, Métis and Inuit. Ottawa, ON: Statistics Canada.

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The Government of the United Kingdom (2012). The Government's Alcohol Strategy. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcohol-strategy.pdf.

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Moyer, A., Finney, J.W. (2015). Brief interventions for alcohol misuse. Canadian Medical Association Journal, 187(7), 502-506.

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Babor, T.F., Higgins-Biddle, J.C. (2001). Brief intervention: for hazardous and harmful drinking. World Health Organization.

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Berger, D., Bradley, K.A. (2015). Primary care management of alcohol misuse. The Medical Clinics of North America, 99(5), 989-1016.

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Cuijpers, P., Riper, H., Lemmers, L. (2004). The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction, 99(7), 938-945.

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USPSTF (2004). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Annals of Internal Medicine, 140(7), 554-56.

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Whitlock, E.P., Polen, M.R., Green, C.A., Orleans, T., Klein, J., US Preventive Services Task Force (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine, 140(7), 557-568.

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Foxcroft, D.R., Moreira, M.T., Almeida Santimano, N.M., Smith, L.A. (2015). Social norms interventions to reduce alcohol misuse in university or college students. The Cochrane Database of Systematic Reviews, epub.

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Moreira, M.T., Smith, L.A., Foxcroft, D. (2009). Social norms interventions to reduce alcohol misuse in university or college students. The Cochrane Database of Systematic Reviews, 8(3).

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Linden, A.N., Kite, B.A., Braitman, A.L., Henson, J.M. (2014). Protective behavioral strategy use and motivations for drinking: exploring alternatives to drinking strategies. Addictive Behaviors, 39, 469-472.

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Mason, A.E., Boden, M.T., Cucciare, M.A. (2014). Prospective associations among approach coping, alcohol misuse and psychiatric symptoms among veterans receiving a brief alcohol intervention. Journal of Substance Abuse Treatment, 46(5), 553-560.

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Melnyk, B.M., Jacobson, D., Kelly, S., Belyea, M., Shaibi, G., Small, L., O'Haver, J., Marisglia, F.F. (2013). Promoting healthy lifestyles in high school adolescents: a randomized controlled trial. American Journal of Preventive Medicine, 45(4), 407-415.

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Stappenbeck, C.A., Luterek, J.A., Kaysen, J.A., Rosenthal, C.F., Gurrad, B., Simpson, T.L. (2015). A controlled examination of two coping skills for daily alcohol use and PTSD symptom severity among dually diagnosed individuals. Behaviour Research and Therapy, 66, 8-17.

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Ray, A.E., Turrisi, R., Abar, B., Peters, K.E. (2009). Social-cognitive correlates of protective drinking behaviors and alcohol-related consequences in college students. Addictive Behaviors, 34(11), 911-917.

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Stephens, P.C., Sloboda, Z., Stephens, R.C., Teasdale, T., Grey, S.F., Hawthorne, R.D., Williams, J. (2009). Universal school-based substance abuse prevention programs: modelling targeted mediators and outcomes for adolescent cigarette, alcohol and marijuana use. Drug and Alcohol Dependence, 102(1-3), 19-29.

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Koutakis, N., Stattin, H., Kerr, M. (2008). Reducing youth alcohol drinking through a parent-targeted intervention: the Orebro Prevention Program. Addiction, 103(10), 1629-1637.

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Ozdemir, M., Koutaski, N. (2015). Does promoting parents' negative attitudes to underage drinking reduce adolescents' drinking? The mediating process and moderators of the effects of the Orebro Prevention Program. Addiction, epub.

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Pettersson, C., Ozdemir, M., Eriksson, C. (2011). Effects of a parental program for preventing underage drinking - the NGO program strong and clear. BMC Public Health, 11, 251.

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Koning, I.M., Verdurmen, J.E., Engels, R.C., van den Eijnden, R.J., Vollebergh, W.A. (2012). Differential impact of a Dutch alcohol prevention program targeting adolescents and parents separately and stimultaneously: low self-control and lenient parenting at baseline predict effectiveness. Prevention Science, 13(3), 278-287.

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Koning, I.M., van den Eijnden, R.J., Verdurmen, J.E., Engels, R.C., Vollebergh, W.A. (2013). A cluster randomized trial on the effects of a parent and student intervention on alcohol use in adolescents four years after baseline; no evidence of catching-up behavior. Addictive Behaviors, 38(4), 2032-2039.

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Footnote 654

Koning, I.M., Maric, M., MacKinnon, D., Vollebergh, W.A. (2015). Effects of combined parent-student alcohol prevention program on intermediate factors and adolescents' drinking behavior: a sequential mediation model. Journal of Consulting and Clinical Psychology, 83(4), 719-727.

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Footnote 655

Verdurmen, J.E., Koning, I.M., Vollebergh, W.A., van den Eijnden, R.J., Engels, R.C. (2014). Risk moderation of a parent and student preventive alcohol intervention by adolescent and family factors: a cluster randomized trial. Preventive Medicine, 60, 88-94.

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Conrod, P.J., O'Leary-Barrett, M., Newton, N., Topper, L., Castellanos-Ryan, N., Mackie, C., Girard, A. (2013). Effectiveness of a selective, personality-targeted prevention program for adolescent alcohol use and misuse: a cluster randomized controlled trial. JAMA Psychiatry, 70(3), 334-342.

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O'Leary-Barrett, M., Mackie, C.J., Castellanos-Ryan, N., Al-Khudhairy, N., Conrod, P.J. (2010). Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers. Journal of the American Academy of Child and Adolescent Psychiatry, 49(9), 954-963.

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Lammers, J., Goossens, F., Conrod, P., Engels, R., Wiers, R.W., Kleinjan, M. (2015). Effectiveness of a selective intervention program targeting personality risk factors for alcohol misuse among young adolescents: results of a cluster randomized controlled trial. Addiction 110(7), 1101-1109.

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Footnote 659

The Society of Obstetricians and Gynaecologists of Canada (2010). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology Canada, 32(8), S1-S32.

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Stockwell, T., Zhao, J., Giesbrecht, N., Macdonald, S., Thomas, G., Wettlaufer, A. (2012). The raising of minimum alcohol prices in Saskatchewan, Canada: impacts on consumption and implications for public health. American Journal of Public Health, 201(12), 103-110.

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Footnote 661

Stockwell, T., Zhao, J., Marzell, M., Gruenewald, P.J., Macdonald, S., Ponicki, W.R., Martin, G. (2015). Relationships between minimum alcohol pricing and crime during the partial privatization of a Canadian Government alcohol monopoly. Journal of Studies on Alcohol and Drugs, 76(4), 628-634.

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Wagenaar, A.C., Salois, M.J., Kmoro, K.A. (2009). Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction, 104(2), 179-190.

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Xu, X., Chaloupka, F.J. (2011). The effects of prices on alcohol use and its consequences. Alcohol Research and Health, 34(2), 236, 245.

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Stockwell, T., Zhao, J., Martin, G., Macdonald, S., Vallance, K., Treno, A., Ponikci, W., Tu, A., Buxton, J. (2013). Minimum alcohol prices and outlet densisties in British Columbia, Canada: estimated impacts on alcohol-attributable hospital admissions. American Journal of Public Health, 103(11), 2014-2020.

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Zhao, J., Stockwell, T., Martin, G., Macdonald, S., Vallance, K., Treno, A., Ponikci, W.R., Tu, A. Buxton, J. (2013). The relationships between minimum alcohol prices, outlet densities and alcohol-attributable deaths in British Columbia, 2002-2009. Addiction, 108(6), 1059-1069.

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Callaghan, R.C., Sanches, M., Gatley, J.M. (2013). Impacts of the minimum legal drinking age legislation on in-patient morbidity in Canada, 1997-2007: a regression-discontinuity approach. Addiction, 108(09), 1590-1600.

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Footnote 670

Popova, S., Giesbrecht, N., Bekmuradov, D., Patra, J. (2009). Hours and days of sale and density of alcohol outlets: impacts of alcohol consumption and damage: a systematic review. Alcohol and Alcoholism, 44(5), 500-516.

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Footnote 671

Stockwell, T., Zhao, J., Macdonald, Pakula, B., Gruenewald, P., Holder, H. (2009). 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. Addiction, 104(11), 1827-1836.

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Footnote 672

Stockwell, T., Zhao, J., Macdonald, S., Vallance, K., Gruenewald, P., Ponicki, W., Holder, H. Treno, A. (2011). Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: a local are multi-level analysis. Addiction, 106(4), 768-776.

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Trolldal, B. (2005). An investigation of the effect of privatization of retail sales of alcohol on consumption and traffic accidents in Alberta, Canada. Addiction, 100, 662-671.

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Graham, K., Osgood, D.W., Zibrowski, E., Purcell, J., Gliksman, L., Leonard, K., Pernanen, K., Saltz, R.F., Toomey, T.L. (2004). The effect of the Safer Bars programme on physical aggression in bars: results of a randomized controlled trial. Drug and Alcohol Review, 23(1), 31-41.

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Patra J., Rehm, J., Popova, S. (2011). Avoidable alcohol-attributable criminality and its costs due to selected interventions in Canada. The International Journal on Drug Policy, 22(2), 109-119.

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Howard-Pitney, B., Johnson, M.D., Altman, D.G., Hopkins, R., Hammond, N. (1991). Responsible alcohol service: a study of server, manager and environmental impact. American Journal of Public Health, 81, 197-199.

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Lang, E., Stockwell, T., Rydon, P., Beel, A. (1998). Can training bar staff in responsible serving practices reduce alcohol-related harm? Drug and Alcohol Review, 17, 39-50.

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Wagenaar, A.C., Toomey, T.L. (2002). Effects of minimum drinking age laws: review and analyses of the literature from 1960 to 2000. Journal of Studies on Alcohol, 14, 206-225.

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Footnote 679

Callaghan, R.C., Sanches, M., Gatley, J.M. (2013). Impacts of the minimum legal drinking age legislation on in-patient morbidity in Canada, 1997-2007: a regression-discontinuity approach. Addiction, 108(09), 1590-1600.

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Footnote 680

Callaghan, R.C., Sanches, M., Gatley, J.M., Cunningham, J.K. (2013). Effects of the minimum legal drinking age on alcohol-related health service use in hospital settings in Ontario: a regression-discontinuity approach. American Journal of Public Health, 130(12), 2284-2291.

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Footnote 681

Callaghan, R.C., Gatley, J.M., Sanches, M., Asbridge, M. (2016). Impacts of drinking-age legislation on alcohol-impaired driving crimes among young people in Canada, 2009-2013. Addiction, epub.

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Footnote 682

Callaghan, R.C., Sanches, M., Gatley, J.M., Stockwell, T. (2014). Impacts of drinking-age laws on mortality in Canada, 1980-2009. Drug and Alcohol Dependence, 138, 137-145.

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Fell, J.C., Fisher, D.A., Voas, R.B., Blackman, K., Tippets, A.S. (2009). The impact of underage drinking laws on alcohol-related fatal crashes of young drivers. Alcoholism, Clinical and Experimental Research, 33(7), 1208-1219.

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Footnote 684

Green, R., Jason, H., Ganz, D. (2015). Underage drinking: does the minimum age drinking law offer enough protection? International Journal of Adolescent Medicine and Health, 27(2), 117-128.

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Footnote 685

Canadian Centre on Substance Abuse. Legal Drinking Age for Alcohol in Canada. http://www.ccsa.ca/eng/topics/alcohol/pages/legal-Drinking-Age-for-Alcohol-in-Canada.aspx .

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Footnote 686

Barry, A.E., Johnson, E., Rabre, A., Darville, G., Donovan, K.M., Efunbumi, O. (2015). Underage access to online alcohol marketing content: a YouTube case study. Alcohol and Alcoholism, 50(1), 89-94.

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Footnote 687

Jernigan, D., O'Hara, J. (2004). Alcohol advertising and promotion. In Bonnie, R.J., O'Connell, M.E. (eds). Reducing Underage Drinking: A Collective Responsibility. Washington D.C.: The National Academies Press.

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Footnote 688

Ross, C.S., Ostroff, J., Siegel, M.B., DeJong, W., Naimi, T.S., Jernigan, D.H. (2014). Youth alcohol brand consumption and exposure to brand advertising in magazines. Journal of Studies on Alcohol and Drugs, 75(4), 615-622.

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Footnote 689

Ross, C.S., Maple, E., Siegel, M., DeJong, W., Naimi, T.S., Ostroff, J., Padon, A.A., Borzekowski, D.L., Jernigan, D.H. (2014). The relationship between brand-specific alcohol advertising on television and brand-specific consumption among underage youth. Alcoholism, Clinical and Experimental Research, 38(8), 2234-2242.

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Footnote 690

Ross, C.S., Maple, E., Siegel, M., DeJong, W., Naimi, T.S., Padon, A.A., Borzekowski, D.L., Jernigan, D.H. (2015). The relationship between population-level exposure to alcohol advertising on television and brand-specific consumption among underage youth in the US. Alcohol and Alcoholism, 50(3), 358-364.

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Footnote 691

Tanski, S.E., McClure, A.C., Li, Z., Jackson, K., Morgenstern, M., Li, Z., Sargent, J.D. (2015). Cued recall of alcohol advertising on television and underage drinking behavior. JAMA Pediatrics, 169(3), 264-271.

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Footnote 692

Siegel, M., DeJong, W., Cioffi, D., Leon-Chi, L., Naimi, T.S. Padon, A.A., Jernigan, D.H., Xuan, Z. (2015). Do alcohol advertisements for brands popular among underage drinkgers have greater appeal among youth and young adults? Substance Abuse: Research and Treatment, epub.

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Footnote 693

Henriksen, L., Feighery, E.C., Schleicher, N.C., Fortmann, S.P. (2008). Receptivity to alcohol marketing predicts initiative of alcohol use. Journal of Adolescent Health, 42, 28-35.

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Footnote 694

McClure, A.C., Stoolmiller, M., Tanksi, S.E., Worth, K.A., Sargent, J.D. (2009). Alcohol-branded merchandise and its association with drinking attitudes and outcomes in US adolescents. Archives of Pediatrics and Adolescent Medicine, 163, 211-217.

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Footnote 695

Morgenstern, M., Sargent, J.D., Sweeting, H., Faggiano, F., Mathis, F., Hanewinkel, R. (2014). Favourite alcohol advertisements and binge drinking among adolescents: a cross-cultural cohort study. Addiction, 109(12), 2005-2015.

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Footnote 696

Belt, O., Stamatakos, K., Ayers, A.J., Fryer, V.A., Jernigan, D.H., Siegel, M. (2014). Vested interests in addiction research and policy. Alcohol brand sponsorship of events, organizations and causes in the United States, 2010-2013. Addiction, 109(12), 1977-1985.

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Footnote 697

Food and Drugs Regulations: http://laws-lois.justice.gc.ca/eng/regulations/C.R.C.,_c._870/index.html .

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Footnote 698

Wakefield, M.A., Loken, B., Hornick, R.C. (2010). Use of mass media campaigns to change health behavior. Lancet, 376 (9748), 1261-1271.

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Footnote 699

Glock, S., Klapproth, F., Muller, B.C. (2015). Promoting responsible drinking? A mass media campaign affects implicit but not explicit alcohol-related cognitions and attitudes. British Journal of Health Psychology, 20(3), 482-497.

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Footnote 700

Elder, R.W., Shults, R.A., Sleet, D.A., Nichols, J.L., Thompson, R.S., Rajab, W., Task Force on Community Preventive Services (2004). Effectiveness of mass media campaigns for reducing drinking and driving and alcohol-involved crashes: a systematic review. American Journal of Preventive Medicine, 27(1), 57-65.

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Footnote 701

Tay, R. (2005). Drink driving enforcement and publicity campaigns: are the policy recommendations sensitive to model specification? Accident; Analysis and Prevention, 37(2), 259-266.

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Footnote 702

Canadian Partnership Against Cancer (2011).Alcohol Use and Cancer in Canada. Cancer Control Snapshot 5: http://www.cancerview.ca/idc/groups/public/documents/webcontent/rl_crc_snapshot_5.pdf

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Footnote 703

Jessop, D.C., Wade, J. (2008). Fear appeals and binge drinking: a terror management theory perspecitve. British Journal of Health Psychology, 13(4),773-788.

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Footnote 704

Moss, A.C., Dyer, K.R., Albery, I.P. (2009). Knowledge of drinking guidelines does not equal sensible drinking. The Lancet, 347 (9697), 1242.

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Footnote 705

Moss, A.C., Albery, I.P., Dyer, K.R., Frings, D., Humphreys, K., Inkelaar, T., Harding, E., Speller, A. (2015). The effects of responsible drinking messages on attentional allocation and drinking behaviour. Addictive Behavior, 44, 94-101.

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