The role of alcohol control policies in the reversal of alcohol consumption levels and resulting attributable harms in China.

Yearly adult per capita consumption of alcohol in China between 2016 and 2019 decreased by 2.4 litres of pure alcohol, or 33%. According to the World Health Organization, this decrease in consumption was accompanied by reductions in alcohol-attributable mortality of 23% between 2015 and 2019. This paper examines the contribution of alcohol control policies in China to these public health gains. A systematic search of the literature was conducted on alcohol control policies and their effectiveness in China as part of a larger search of all countries in WHO Western Pacific Region. In addition to articles on empirical evidence on the impact of such alcohol control policies, we also searched for reviews. The plausibility of changes of traditional alcohol control policies (taxation increases, availability restrictions, restriction on advertisement and marketing, drink-driving laws, screening and brief interventions) in explaining reductions of consumption levels and attributable mortality rates was explored. There was some progress in the successful implementation of strict drink-driving policies, which could explain reductions in traffic injuries, including fatalities. Other traditional alcohol control policies seem to have played a minimal role in reducing alcohol consumption and attributable harms during the time period 2016-2019. However, an anti-corruption campaign was extensive enough to have substantially contributed to these reductions. The campaign prohibited the consumption of alcoholic beverages in everyday life of government officials and thus contributed to a de-normalization of alcohol. While this anti-corruption campaign was the only policy to potentially explain marked decreases in levels of alcohol consumption and attributable mortality, more detailed research is required to determine exactly how the campaign achieved these decreases.

Changes in medical cannabis use in Ontario, Canada (2014 to 2019): Trajectory of trends, medical authorization patterns and association with recreational cannabis legalization.

Objectives: We characterized trends in medical cannabis use; examined characteristics associated with medical cannabis use without medical authorization; and examined the association between recreational cannabis legalization and medical cannabis use in Ontario, Canada. Methods: Data were from a repeated, population-based, cross-sectional survey of adults (N = 19,543; 2014-2019). Cannabis use was categorized as either medical cannabis use, recreational cannabis use or no cannabis use. The analytical strategy included jointpoint regression, logistic regression and multinomial logistic regression. Results: Medical cannabis use increased from 4 % to 11 % (Annual Percentage Change [APC]: 25 %, 95 % Confidence Interval [CI]: 17 %-33 %) and recreational cannabis use increased from 9 % to 15 % (APC: 9 %, 95 % CI: 3 %-15 %) between 2014 and 2019. Being 18 to 29 years old compared with being 65+ years old was associated with an increased likelihood of medical cannabis use without medical authorization (Odds Ratio [OR]: 4.05, 95 % CI: 2.12-7.72), while being of fair or poor self-perceived health compared with excellent, very good or good self-perceived health (OR: 0.61, 95 % CI: 0.40-0.95) was associated with a decreased likelihood of medical cannabis use without medical authorization. Recreational cannabis legalization was associated with an increased likelihood of medical cannabis use compared with no cannabis use (OR: 1.48, 95 % CI: 1.19-1.85) and of recreational cannabis use compared with no cannabis use (OR: 1.35, 95 % CI: 1.11-1.65). Conclusions: Although medical cannabis use increased, it was largely used without medical authorization. Guidance and education that encourages medical usage under clinical supervision is recommended, and mitigation of known barriers to medical cannabis authorization.

The effect of an annual temporary abstinence campaign on population-level alcohol consumption in Thailand: a time-series analysis of 23 years.

RATIONALE: A small number of earlier studies have suggested an effect of temporary abstinence campaigns on alcohol consumption. However, all were based on self-reported consumption estimates. OBJECTIVES: Using a time series of 23-year monthly alcohol sales data, this study examined the effect of an annual temporary abstinence campaign, which has been organised annually since 2003 during the Buddhist Lent period (spanning 3 months), on population-level alcohol consumption. METHODS: Data used in the analysis included a time series of monthly alcohol sales data from January 1995 to September 2017 and the midyear population counts for those years. Generalised additive models (GAM) were applied to estimate trends as smooth functions of time, while identifying a relationship between the Buddhist Lent abstinence campaigns on alcohol consumption. The sensitivity analysis was performed using a seasonal autoregressive integrated moving average with exogenous variables (SARIMAX) model. INTERVENTION: The Buddhist Lent abstinence campaign is a national mass media campaign combined with community-based activities that encourages alcohol abstinence during the Buddhist Lent period, spanning 3 months and varying between July and October depending on the lunar calendar. The campaign has been organised annually since 2003. MAIN OUTCOME: Per capita alcohol consumption using monthly alcohol sales data divided by the midyear total population number used as a proxy. RESULTS: Median monthly per capita consumption was 0.43 (IQR: 0.37 to 0.51) litres of pure alcohol. Over the study period, two peaks of alcohol consumption were in March and December of each year. The significant difference between before-campaign and after-campaign coefficients in the GAM, -0.102 (95% CI: -0.163 to -0.042), indicated an effect of the campaign on alcohol consumption after adjusting for the time trend and monthly seasonality, corresponding to an average reduction of 9.97% (95% CI: 3.65% to 24.18%). The sensitivity analyses produced similar results, where the campaign was associated with a decrease in consumption of 8.1% (95% CI: 0.4% to 15.7%). CONCLUSIONS: This study demonstrated that the temporary abstinence campaign was associated with a decrease in population-level alcohol consumption during campaign periods. The finding contributed to a growing body of evidence on the effectiveness of emerging temporary abstinence campaigns.

The prevalence of gambling and problematic gambling: a systematic review and meta-analysis.

BACKGROUND: Gambling behaviours have become of increased public health interest, but data on prevalence remain scarce. In this study, we aimed to estimate for adults and adolescents the prevalence of any gambling activity, the prevalence of engaging in specific gambling activities, the prevalence of any risk gambling and problematic gambling, and the prevalence of any risk and problematic gambling by gambling activity. METHODS: We performed a systematic review and meta-analysis. We systematically searched for peer-reviewed literature (on MEDLINE, Embase, and PsycInfo) and grey literature to identify papers published between Jan 1, 2010, and March 4, 2024. We searched for any gambling, including engagement with individual gambling activities, and problematic gambling data among adults and adolescents. We included papers that reported the prevalence or proportion of a gambling outcome of interest. We excluded papers of non-original data or based on a biased sample. Data were extracted into a bespoke Microsoft Access database, with the Joanna Briggs Institute Critical Appraisal Tool used to identify the risk of bias for each sample. Representative population survey estimates were firstly meta-analysed into country-level prevalence estimates, using metaprop, of any gambling, any risk gambling, problematic gambling, and by gambling activity. Secondly, population-weighted regional-level and global estimates were generated for any gambling, any risk gambling, problematic gambling, and specific gambling activity. This review is registered on PROSPERO (CRD42021251835). FINDINGS: We screened 3692 reports, with 380 representative unique samples, in 68 countries and territories. Overall, the included samples consisted of slightly more men or male individuals, with a mean age of 29·72 years, and most samples identified were from high-income countries. Of these samples, 366 were included in the meta-analysis. Globally, 46·2% (95% CI 41·7-50·8) of adults and 17·9% (14·8-21·2) of adolescents had gambled in the past 12 months. Rates of gambling were higher among men (49·1%; 45·5-52·6) than women (37·4%; 32·0-42·5). Among adults, 8·7% (6·6-11·3) were classified as engaging in any risk gambling, and 1·41% (1·06-1·84) were engaging in problematic gambling. Among adults, rates of problematic gambling were greatest among online casino or slots gambling (15·8%; 10·7-21·6). There were few data reported on any risk and problematic gambling among adolescent samples. INTERPRETATION: Existing evidence suggests that gambling is prevalent globally, that a substantial proportion of the population engage in problematic gambling, and that rates of problematic gambling are greatest among those gambling on online formats. Given the growth of the online gambling industry and the association between gambling and a range of public health harms, governments need to give greater attention to the strict regulation and monitoring of gambling globally. FUNDING: Australian National Health and Medical Research Council.

Feasibility and effectiveness of extended-release buprenorphine (XR-BUP) among correctional populations: a systematic review.

Background: Medications for opioid use disorder (MOUD) reduce risks for overdose among correctional populations. Among other barriers, daily dosing requirements hinder treatment continuity post-release. Extended-release buprenorphine (XR-BUP) may therefore be beneficial. However, limited evidence exists.Objectives: To conduct a systematic review examining the feasibility and effectiveness of XR-BUP among correctional populations.Methods: Searches were carried out in Pubmed, Embase, and PsychINFO in October 2023. Ten studies reporting on feasibility or effectiveness of XR-BUP were included, representing n = 819 total individuals (81.6% male). Data were extracted and narratively reported under the following main outcomes: 1) Feasibility; 2) Effectiveness; and 3) Barriers and Facilitators.Results: Studies were heterogeneous. Correctional populations were two times readier to try XR-BUP compared to non-correctional populations. XR-BUP was feasible and safe, with no diversion, overdoses, or deaths; several negative side effects were reported. Compared to other MOUD, XR-BUP significantly reduced drug use, resulted in similar or higher treatment retention rates, fewer re-incarcerations, and was cost-beneficial, with a lower overall monthly/yearly cost. Barriers to XR-BUP, such as side effects and a fear of needles, as well as facilitators, such as a lowered risk of opioid relapse, were also identified.Conclusion: XR-BUP appears to be a feasible and potentially effective alternative treatment option for correctional populations with OUD. XR-BUP may reduce community release-related risks, such as opioid use and overdose risk, as well as barriers to treatment retention. Efforts to expand access to and uptake of XR-BUP among correctional populations are warranted.

Impact of health spending on hospitalization rates in Baltic countries: a comparative analysis.

INTRODUCTION: This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020. METHOD: We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita. RESULTS: Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models. CONCLUSIONS: The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts.

Classifying national drinking patterns in Europe between 2000 and 2019: A clustering approach using comparable exposure data.

BACKGROUND AND AIMS: Previously identified national drinking patterns in Europe lack comparability and might be no longer be valid due to changes in economic conditions and policy frameworks. We aimed to identify the most recent alcohol drinking patterns in Europe based on comparable alcohol exposure indicators using a data-driven approach, as well as identifying temporal changes and establishing empirical links between these patterns and indicators of alcohol-related harm. DESIGN: Data from the World Health Organization's monitoring system on alcohol exposure indicators were used. Repeated cross-sectional hierarchical cluster analyses were applied. Differences in alcohol-attributable harm between clusters of countries were analyzed via linear regression. SETTING: European Union countries, plus Iceland, Norway and Ukraine, for 2000, 2010, 2015 and 2019. PARTICIPANTS/CASES: Observations consisted of annual country data, at four different time points for alcohol exposure. Harm indicators were only included for 2019. MEASUREMENTS: Alcohol exposure indicators included alcohol per capita consumption (APC), beverage-specific consumption and prevalence of drinking status indicators (lifetime abstainers, current drinkers, former drinkers and heavy episodic drinking). Alcohol-attributable harm was measured using age-standardized alcohol-attributable Disability-Adjusted Life Years (DALYs) lost and deaths per 100 000 people. FINDINGS: The same six clusters were identified in 2019, 2015 and 2010, mainly characterized by type of alcoholic beverage and prevalence drinking status indicators, with geographical interpretation. Two-thirds of the countries remained in the same cluster over time, with one additional cluster identified in 2000, characterized by low APC. The most recent drinking patterns were shown to be significantly associated with alcohol-attributable deaths and DALY rates. Compared with wine-drinking countries, the mortality rate per 100 000 people was significantly higher in Eastern Europe with high spirits and 'other' beverage consumption [ ß ^ $$ \hat{\beta} $$ = 90, 95% confidence interval (CI) = 55-126], and in Eastern Europe with high lifetime abstainers and high spirits consumption ( ß ^ $$ \hat{\beta} $$ = 42, 95% CI = 4-78). CONCLUSIONS: European drinking patterns appear to be clustered by level of beverage-specific consumption, with heavy episodic drinkers, current drinkers and lifetime abstainers being distinguishing factors between clusters. Despite the overall stability of the clusters over time, some countries shifted between drinking patterns from 2000 to 2019. Overall, patterns of drinking in the European Union seem to be stable and partly determined by geographical proximity.

Alcohol rehabilitation and cancer risk: a nationwide hospital cohort study in France.

BACKGROUND: Even though alcohol consumption is an established risk factor for cancer, evidence regarding the effect of a reduction or cessation of alcohol consumption on cancer incidence is scarce. Our main study aim was to assess the effect of alcohol rehabilitation and abstinence on cancer incidence in people with alcohol dependence. METHODS: We conducted a nationwide hospital retrospective cohort study which included all adults residing in mainland France and discharged in 2018-21. Multivariable Cox proportional hazards models were used to estimate the effect of rehabilitation treatment at hospital or a history of abstinence versus alcohol dependence without rehabilitation or abstinence on the risk for incident alcohol-associated cancers by sex, controlled for potential confounding risk factors. FINDINGS: 10 260 056 men and 13 739 369 women were discharged from French hospitals in 2018-21. Alcohol dependence was identified in 645 720 (6·3%) men and 219 323 (1·6%) women. Alcohol dependence was strongly related to alcohol-associated cancer sites in both sexes (hepatocellular carcinoma and oral, pharyngeal, laryngeal, oesophageal, and colorectal cancers), except for breast cancer. Rehabilitation treatment or abstinence was associated with significantly lower risks compared with alcohol dependence without rehabilitation or abstinence (adjusted hazard ratios: 0·58, 99·89% CI 0·56-0·60 in men and 0·62, 0·57-0·66 in women). Relative risk reductions were significant for each alcohol-associated cancer site in both sexes and supported by all subgroup and sensitivity analyses. INTERPRETATION: Our study results support the clear benefits of alcohol rehabilitation and abstinence in reducing the risk for alcohol-associated cancers. As only two in five patients with alcohol dependence were recorded with a history of rehabilitation treatment or abstinence, a large untapped potential exists for reducing cancer incidence. FUNDING: European Union's EU4Health programme.

Effect of alcohol health warning labels on knowledge related to the ill effects of alcohol on cancer risk and their public perceptions in 14 European countries: an online survey experiment.

BACKGROUND: Alcohol health-warning labels are a policy option that can contribute to the reduction of alcohol-related harms, but their effects and public perception depend on their content and format. Our study aimed to investigate the effect of health warnings on knowledge that alcohol causes cancer, the perceptions of three different message topics (responsible drinking, general health harm of alcohol, and alcohol causing cancer), and the role of images included with the cancer message. METHODS: In this online survey experiment, distributed in 14 European countries and targeting adults of the legal alcohol-purchase age who consumed alcohol, participants were randomly allocated to one of six label conditions using a pseudorandom number generator stratified by survey language before completing a questionnaire with items measuring knowledge and label perceptions. Effect on knowledge was assessed as a primary outcome by comparing participants who had increased knowledge after exposure to labels with the rest of the sample, for the six label conditions. Label perceptions were compared between label conditions as secondary outcomes. FINDINGS: 19 110 participants completed the survey and were eligible for analysis. Our results showed that a third of the participants exposed to the cancer message increased their knowledge of alcohol causing cancer (increase for 1131 [32·5%, 95% CI 29·8 to 35·2] of 3409 participants [weighted percentage] for text-only message; increase for 1096 [33·3%, 30·4 to 36·2] of 3198 [weighted percentage] for message inlcuding pictogram; and increase for 1030 [32·5%, 29·6 to 35·4] of 3242 [weighted percentage] for message including graphic image), compared with an increase for 76 (2·4%, -1·2 to 6·0) of 3018 participants who viewed the control message. Logistic regression showed that cancer messages increased knowledge compared with the control label (odds ratio [OR]text only 20·20, 95% CI 15·88 to 26·12; ORpictogram 21·16, 16·62 to 27·38; ORgraphic-image 20·61, 16·19 to 26·68). Cancer messages had the highest perceived impact and relevance, followed by general health harm and responsibility messages. Text-only and pictogram cancer messages were seen as clear, comprehensive, and acceptable, whereas those including an image of a patient with cancer had lower acceptability and the highest avoidance rating of all the labels. The only identified interaction between perceptions and experimental conditions (with gender) indicated higher comprehensibility and acceptability ratings of cancer labels than responsibility messages and control labels by women, with the results reversed in men. INTERPRETATION: Health warnings are an effective policy option to increase knowledge of alcohol causing cancer, with a generalisable effect across several countries. Europeans consider alcohol health-warning labels to be comprehensible and acceptable, with cancer-specific health warnings having the highest perceived impact and relevance. FUNDING: EU4Health.

Alcohol, No Ordinary Commodity: policy implications for Canada.

Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity, and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it.

A burden of proof study on alcohol consumption and ischemic heart disease.

Cohort and case-control data have suggested an association between low to moderate alcohol consumption and decreased risk of ischemic heart disease (IHD), yet results from Mendelian randomization (MR) studies designed to reduce bias have shown either no or a harmful association. Here we conducted an updated systematic review and re-evaluated existing cohort, case-control, and MR data using the burden of proof meta-analytical framework. Cohort and case-control data show low to moderate alcohol consumption is associated with decreased IHD risk - specifically, intake is inversely related to IHD and myocardial infarction morbidity in both sexes and IHD mortality in males - while pooled MR data show no association, confirming that self-reported versus genetically predicted alcohol use data yield conflicting findings about the alcohol-IHD relationship. Our results highlight the need to advance MR methodologies and emulate randomized trials using large observational databases to obtain more definitive answers to this critical public health question.

A dose-response meta-analysis on the relationship between average amount of alcohol consumed and death by suicide.

BACKGROUND: To determine whether sub-clinical levels of drinking may contribute to suicide risk, and whether the risk differs by sex, we aimed to evaluate the relationship between average amount of alcohol consumed per day and death by suicide. METHODS: A systematic literature search was performed in Embase, Medline, PsycINFO, PubMed, and Web of Science from database inception up to April 27, 2022. The search strategies incorporated a combination of medical subject headings and keywords for "alcohol use" and "suicide". One-stage dose-response meta-analyses using a restricted maximum likelihood random-effect estimator were conducted to explore the relationship between average alcohol volume consumed and suicide, by sex. Three different shapes of the dose-response relationship-linear (on the log-scale), quadratic, and restrictive cubic splines-were tested. RESULTS: A total of eight studies were included (three studies for females (n=781,205), and eight studies for males (n=1,215,772)). A linear dose-response relationship between average alcohol volume consumed and the log-risk of suicide was identified for both males and females. For males and females, a relative risk (RR) of 1.11 (95% CI: 1.05, 1.18) and 1.64 (95% CI: 1.07, 2.51) for suicide when consuming an average of 10 g of pure alcohol per day compared to lifetime abstention, 1.38 (95% CI: 1.14, 1.66) and 4.39 (95% CI: 1.21, 15.88) for 30g/day, and 1.71 (95% CI: 1.25, 2.33) and 11.75 (95% CI: 1.38, 100.33) for 50g/day, respectively. CONCLUSIONS: As consumption increases, the risk of suicide increases proportionally. The risk of suicide associated with average daily alcohol consumption may be elevated for females, compared with males. Albeit, more research is needed, particularly among females.

Designing and implementing an experimental survey on knowledge and perceptions about alcohol warning labels.

OBJECTIVES: This paper describes the design and implementation of an online survey experiment to investigate the effects of alcohol warning labels on alcohol-related knowledge, risk perceptions and intentions. METHOD: The survey collected self-reported data from 14 European countries through two waves of data collection with different recruitment strategies: dissemination via social media and public health agencies was followed by paid-for Facebook ads. The latter strategy was adopted to achieve broader population representation. Post-stratification weighting was used to match the sample to population demographics. RESULTS: The survey received over 34,000 visits and resulted in a sample size of 19,601 participants with complete data on key sociodemographic characteristics. The responses in the first wave were over-representing females and higher educated people, thus the dissemination was complemented by the paid-for Facebook ads targeting more diverse populations but had higher attrition rate. CONCLUSION: Experiments can be integrated into general population surveys. Pan-European results can be achieved with limited resources and a combination of sampling methods to compensate for different biases, and statistical adjustments.

Navigating the nexus between British Columbia's public consumption and decriminalization policies of illegal drugs.

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province's primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC's overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

Germany's cannabis act: a catalyst for European drug policy reform?

With the enforcement of the Cannabis Act on 1 April 2024, Germany has adopted one of the most liberal legal approaches to cannabis on the continent. The German model prioritises a non-profit approach and precludes legal market mechanisms. We believe these are the main drivers for increasing cannabis use and related health problems, based on observations following cannabis legalisation in Canada and many states in the U.S. Although legalising cannabis possession and cultivation may not immediately eliminate the illegal market, it is expected to serve public health goals. Despite the overall positive evaluation of the Cannabis Act in Germany, there are three potential areas of concern: the potential for misuse of the medical system, the normalization of cannabis use, and the influence of the cannabis industry. The German model may herald the beginning of a new generation of European cannabis policies, but concerted efforts will be required to ensure that these policy reforms serve rather than undermine public health goals.