Meeting Date: February 6, 2019
Report No.: BH.01.FEB0619.R06
Prepared By: Katie Junkin, Health Promotion Specialist, Healthy Communities and Public Policy; Amy Estill, Manager, Healthy Communities and Public Policy
Approved By: Dr. Matthew Tenenbaum, Physician Consultant
Submitted By and Signature: Dr. Nicola J. Mercer, MD, MBA, MPH, FRCPC Medical Officer of Health & CEO
It is recommended that the Board of Health:
- Receive this report for information.
- Alcohol is the most common drug consumed in Canada, with 77% of Canadians and 81% of Wellington-Dufferin-Guelph (WDG) residents reporting consuming alcohol within the past year.1,2,3
- Over 49% of drinkers in WDG report drinking more than Canada’s Low-Risk Drinking Guideline (LRDGs) limits, putting them at risk for alcohol related health issues.3
- Alcohol consumption is a leading risk factor for death, disease and disability in Canada and worldwide.1,4,5 It is associated with over 200 health conditions, as well as with injury, violence, child neglect, impaired driving, property damage and workplace absenteeism.1,2,5 Certain groups experience more alcohol-related harms than others based on factors such as their socioeconomic status, education, sex, ethnicity and place of residence.
- In 2014, alcohol related harm cost $14.6 billion, or 38.1 percent of the total costs of substance use in Canada. This represents a cost more than four times that of opioids and cannabis.6
- Alcohol policies can reduce the risks and harms of alcohol in a community, can protect the vulnerable (i.e. youth and high-risk populations) and can address the greater burden of alcohol-related harms faced by marginalized groups.7,8
- Public Health can support municipalities to develop and implement policies to reduce alcohol-related harms in their communities.
Alcohol consumption is one of the three leading risk factors for global disease burden, contributing to more than 200 health conditions.1,5 Alcohol is a leading factor for death, disease and disability in Canada and is also associated with social harms including: injury, violence, child neglect, impaired driving, property damage and workplace absenteeism.2,4
A person’s risk of alcohol-related harm increases with the number of alcoholic beverages they consume. Canada’s Low-Risk Drinking Guidelines (LRDGs) recommend consuming no more than 10 drinks per week for women (15 for men) and no more than 3 drinks for women (4 for men) on any single occasion.9 High-risk or ‘heavy’ drinking, which refers to consumption that exceeds these limits, increases a person’s risk of alcohol-related harms, both immediately and over the longer term. Immediate risks include: violence, risky sexual behaviours, alcohol poisoning, unintentional injuries and self-harm.9 Longer-term problems associated with high risk alcohol use include: cardiovascular events, the development of certain cancers, negative mental health outcomes, stroke, liver cirrhosis, digestive issues and negative social outcomes such as loss of employment, finances and social connections.2,9,10
Table 1: Canada’s Low Risk Drinking Guidelines9
|1 When Zero is the Limit||
When operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; living with mental or physical health problems; doing dangerous physical activity; responsible for the safety of others; or making important decisions
|2 Chronic Effects||
No more than 10 standard drinks per week
No more than 15 standard drinks per week
|3 Immediate Effects||
No more than 3 standard drinks on an occasion
No more than 4 standard drinks on an occasion
|4 When Pregnant||
The safest option during pregnancy or when planning to become pregnant is to not drink alcohol at all
|5 Young People||
Uptake of drinking by youth should be delayed at least until the late teens
While harmful alcohol use is one of the four most modifiable and preventable risk factors for non-communicable diseases, the relationship between alcohol consumption and harm is complex.4 It is affected by individual factors, cultural factors and social factors, including social norms. It is also affected by governmental alcohol policy and strategies aimed to prevent or reduce alcohol-related harms.4,11
In 2014, the cost of substance use in Canada, including: healthcare, criminal justice, loss of productivity and other direct costs, was $38.4 billion dollars. The cost of alcohol-related harm was highest among all substances, surpassing smoking and contributing $14.6 billion or 31.8% of the total costs of substance use in Canada. This reflects an increase of 11.6% from 2007 to 2014, and a cost of more than four times that of opioids and six times that of cannabis.6 While alcohol is also a source of revenue for governments, the costs to society are higher than the revenue generated for most provinces and territories, creating a net deficit.12
Use of Alcohol in Canada and WDG
Alcohol is by far the most common drug used by Canadians, with over 77% of the population reporting consumption of alcohol within the past year, and a National consumption rate of 13.8L of alcohol per capita/per year.1,2,9 Alcohol consumption has become a part of Canadian culture and while most Canadians drink in moderation, many drink in a high-risk way.4 In 2015, 20% of drinkers exceeded the LRDGs for chronic effects, while just over 15% exceeded the guideline for immediate risk.2 Males were more likely to exceed both guidelines than females and young adults age 19-24 had the highest rates of risky consumption, exceeding the chronic and immediate risk guidelines by 26.5% and 22.1%, respectively.2
Within WDG, 81% of the population consumed alcohol in 2013 and 49% exceeded at least one of the LRDG’s. These local rates are statistically significantly higher than provincial rates of alcohol consumption.3 Results from the 2015 community survey indicate that most WDG residents were not familiar with the LRDGs or many of the health and pregnancy alcohol-related risks.13
Current Policy Environment in Ontario
Restrictions on the sale of alcohol in Ontario have loosened substantially since 2014. Beer, cider and wine are now sold in select grocery stores and cider and wine can be sold at farmer’s markets.14 The provincial government has announced an interest in further expanding sales in grocery stores, big box stores and corner stores in 2019.15 The provincial government has also recently reduced the minimum price of beer with the ‘Buck-a-beer’ policy, increased LCBO hours of sale on Sundays and slowed the planned yearly alcohol tax increase to match inflation.16,17,18
These provincial policy changes make alcohol easier to access for Ontario residents. Additionally, these changes have occurred notwithstanding substantial evidence that increasing alcohol availability increases alcohol-related harms, and likewise, that reducing availability through strengthened policy, reduces alcohol-related harms.19
Opportunities for Municipal Alcohol Policy
In 2016, Liem Strategic Integration Inc., in coordination with Wellington-Dufferin-Guelph Public Health (WDGPH), Thunder Bay District Health Unit and Durham Region Health Department conducted an alcohol policy feasibility review for municipalities and public health units; Alcohol Policy Review: Opportunities for Ontario Municipalities. The review identified local policy options across Canada and internationally to reduce alcohol-related risk and harm at the community level and assessed their feasibility for Ontario municipalities. Recommendations were made to support municipal leaders, public health practitioners and other community stakeholders in their policy development efforts and are made in the context of the Ontario Municipal Act and other provincial legislation.20
Recommended actions are proposed in six (6) areas:
- Licensing & enforcement;
- Regulating physical access through density and location restrictions;
- Hours of sale limitations;
- Pricing strategies;
- Marketing; and
- Information sharing.20
These six (6) areas of policy recommendation are supported by evidence that:
- Injuries resulting from accidents, violence and self-induced harm are increased in areas of high alcohol availability;
- Increased hours of sale correspond with an increase of alcohol-related harms, including road traffic casualties, alcohol-related diseases, injury and assaults, whereas restricting hours of sale for two or more hours is associated with reduced alcohol-related harms;
- Pricing strategies, including reducing affordability of alcohol can reduce alcohol consumption rates, particularly among heavy alcohol consumers, and decrease overall alcohol-related harms;
- Crime and alcohol-related deaths and hospitalizations due to intoxication decline with increases in minimum alcohol prices; and
- Policies restricting alcohol exposure through marketing and advertisements reduce first time alcohol use and alcohol-related harms.20
1) Licensing & Enforcement
The Alcohol and Gaming Commission of Ontario (AGCO) is responsible for assessing liquor license applications, but municipalities may update and/or revise municipal licensing by-laws to strengthen the protection of public safety and property standards.
Specifically, municipalities are encouraged to:
- Investigate public concerns (nuisances, property standard violations) in areas with a high number of liquor license establishments;
- Continue to work with enforcement authorities during a liquor licence application process (concerns may be identified by police and public health inspector reports);
- Establish new business license conditions through a municipal by-law on the basis of protecting public interests and minimizing nuisances, where warranted (e.g. using a license application questionnaire that assesses how businesses intend to manage nuisances, protect the safety of patrons and the community and reduce risk;); and
- Create a new business license category that includes supermarket retailers licensed to sell alcohol. This would include establishing specific requirements for the application to go through a rezoning process and including a public hearing (e.g. establishing zoning by-laws that impose density and proximity conditions and minimum size of floor space).
- Continue to report potential liquor license infractions to the AGCO and police, and where applicable, participate in a task force with municipalities and local law enforcement to support a multi-pronged enforcement approach.
Examples of this approach include:
- The City of Vaughn has established a business license by-law that restricts the sale of liquor to businesses that are established as eating establishments, thereby preventing salons, barber shops, etc. from serving liquor; and
- The City of Barrie requires businesses to complete a liquor license questionnaire addressing social responsibility considerations as part of the Liquor License Application process.
2) Regulating Physical Access through Density and Location Restrictions
To regulate physical access to alcohol through density and location restrictions, municipalities are encouraged to:
- Introduce site-specific zoning to control the location of establishments, including restrictions to protect sensitive land uses (e.g. schools, parks and hospitals) and minimum distance requirements between alcohol outlets.
- Introduce zoning that restricts where outdoor patios can be located, regulates hours of operation and serving, and regulates the sale of alcohol in grocery stores.
- Create policy restrictions that establish limits for the number of liquor licensed establishments by neighbourhood, and that limit the number of business licenses for late night entertainment and establishments.
- Update municipal zoning by-laws to establish a minimum floor area requirement that is at least greater than the provincial requirement for sale in grocery stores.
- Request that the AGCO not issue liquor licenses within a municipality until the municipality has had the opportunity to undertake a formal review process to determine conditions that would protect public interest.
- Educate stakeholders about the importance of provincial policies that:
- Allow local jurisdictions the authority to block on- and off-premise licenses in areas where there is a high degree of crime or socioeconomic disparity;
- Develop a separation distance between alcohol retailers.
- Encourage municipalities to establish restrictions to control alcohol retail density.
- Participate in municipal strategic planning to inform the municipal approach to retail services, business development, tourism and culture (e.g. tourism plans).
- Work with municipalities to identify priority neighbourhoods in which to limit alcohol retailers and licensed establishments.
- Continue to use mapping to monitor the location of alcohol retail outlets and licensed establishments.
Example: Richmond, BC amended its zoning by-law and developed a policy framework to establish consistency in evaluating and approving liquor license applications from grocery stores. The amendment requires grocery stores to enter a re-zoning process, requiring a larger minimum retail floor space to ensure that the provision of liquor in grocery stores is directed at larger community shopping centers. The municipality also conducts a neighbourhood survey and seeks council input for new applications or for permanent changes to liquor licenses.
3) Hours of Sale Limitations
Regulating the hours of operation of licensed facilities is under provincial authority through the Liquor License Act.
In Ontario, municipalities can only limit the hours of sale by:
- Issuing site-specific conditions to address issues of public concern and nuisances, where applicable.
- Provide municipalities with best practices research and evidence regarding the risks and alcohol-harms associated with hours of sale.
- Educate stakeholders about the importance of stronger provincial regulations that allow municipalities greater authority to restrict hours or service.
Example: The City of Toronto has additional by-laws for cafes that prohibit outdoor music or amplified sound and reduced hours of operation (11pm).
4) Pricing Strategies
In Ontario, the provincial government is responsible for regulating the sale and pricing of alcohol for both on-and-off premise alcohol retailers through the Liquor Control Act. Currently, the AGCO sets a minimum price of $2.00 (including taxes) for a standard drink sold at licensed establishments.21 The AGCO provides flexibility for licensees to change their drink prices throughout the day, if prices do not fall below the minimum. Within Ontario the Municipal Act does not allow municipalities, other than the City of Toronto, to impose alcohol taxes. However, provincial policy does not prohibit municipalities from setting minimum alcohol prices that exceed those set by the ACGO.
Municipalities are encouraged to address pricing through:
- Participating in advocacy for stronger provincial regulations in controlling access and affordability to alcohol.
- Exploring the development of minimum pricing standards for alcoholic beverages as a condition of a business license application.
- Educate stakeholders about the importance of stronger alcohol pricing interventions at the provincial level to reduce alcohol-related harms.
Example: The City of Kamloops, BC created a by-law for the minimum sale of alcohol in serving establishments at $3 for a standard drink.
Various guidelines regulate advertisements that promote liquor, including the Canadian Radio-Television Telecommunications Commission (CRTC) code, the Liquor License Act and Regulations, and the AGCO and LCBO guidelines. Currently, there are no guidelines governing marketing on social media, event sponsorship and merchandising.
Municipalities have jurisdiction to control the promotion of alcoholic beverages on municipally-owned lands and facilities through Municipal Alcohol Policies.
Municipalities are encouraged to:
- Develop policies that prohibit the promotion and sale of alcohol on municipally owned lands of facilities, including public transit.
Public health can continue to educate stakeholders about the importance of stronger provincial and federal policies to restrict alcohol marketing and advertising.
Example: The City of King County in Washington created a policy that prohibits the marketing of any alcohol related material on their transit system.
6) Information Sharing
Collaboration and information sharing regarding alcohol-related incidents is a means of monitoring high-risk areas to inform Municipal policy development and/or targeted police and by-law enforcement.
Municipalities are encouraged to:
- Access and utilize available local data and collaborate with public health and legal counsel to seek access to AGCO data and police data.
- Share the findings of this policy review with municipalities and encourage the adoption of a policy approach to reducing alcohol risk and harm.
- Work with the provincial government to create policies that allow freer access to alcohol sales data that can support policy development.
Alcohol is the most popular drug, in Canada, and it is also the most costly. Alcohol not only contributes to the costs of healthcare, the criminal justice system, loss of productivity and other direct costs, it is also associated with crime, domestic violence, self-harm, injury and over 200 health conditions.1,2,6
The costs of alcohol are incurred at all levels, including the municipal level. Some of these costs include increased policing (i.e. nuisance reports, drinking and driving monitoring, reports of crime or violence etc.), municipal clean up and property damage.7
Alcohol policies can reduce the risks and harms of alcohol in a community, can protect the vulnerable (i.e. youth and high-risk populations) and can reduce alcohol-related health inequities.7,8 While some alcohol policy is governed at the provincial level, municipalities can address alcohol-related risk and harm on municipally-owned property through Municipal Alcohol Policies (MAPs), and off municipally-owned property through by-laws, zoning, and licensing restrictions.20
WDGPH can act as a resource to municipalities to share information relevant to policy development and can also encourage the provincial government to strengthen alcohol policy for the reduction of alcohol related-risks and harms (e.g. increase in minimum pricing, strengthen policies around marketing, access to establishment sales information beyond LCBO).20
Municipalities, WDGPH and other relevant stakeholders (e.g. police, business owners) can work together to develop new municipal policies to create safer communities with less alcohol-related impact and burden.20
Ontario Public Health Standard
Substance Use and Injury Prevention Requirements:
2. The board of health shall collect and analyze relevant data to monitor trends over time, emerging trends, priorities, and health inequities related to injuries and substance use and report and disseminate the data and information in accordance with the Population Health Assessment and Surveillance Protocol, 2018 (or as current).
3. The board of health shall develop and implement a program of public health interventions using a comprehensive health promotion approach that addresses risk and protective factors to reduce the burden of preventable injuries and substance use in the health unit population.
a. The program of public health interventions shall be informed by:
i. An assessment of the risk and protective factors for, and distribution of, injuries and substance use;
ii. Consultation and collaboration with local stakeholders in the health, education, municipal, non-governmental, and other relevant sectors, including LHINs;
iii. An assessment of existing programs and services within the area of jurisdiction of the board of health to build on community assets and minimize duplication;
iv. Consideration of the following topics based on an assessment of local needs: Alcohol
v. Evidence of the effectiveness of the intervention employed.
b. The program of public health interventions shall be implemented in accordance with relevant guidelines, including the Health Equity Guideline, 2018 (or as current); the Injury Prevention Guideline, 2018 (or as current); the Mental Health Promotion Guideline, 2018 (or as current); and the Substance Use Prevention and Harm Reduction Guideline, 2018 (or as current).
WDGPH Strategic Direction(s)
✓ Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.
Service Centred Approach: We are committed to providing excellent service to anyone interacting with WDG Public Health.
✓ Building Healthy Communities: We will work with communities to support the health and well-being of everyone.
Certain groups are affected more by alcohol-related harms than others.7 In Canada, rates of heavy drinking are higher among vulnerable populations, including Indigenous peoples and people with mental health issues.7,8
Young adults, including students, have the highest rates of heavy or risky drinking. Males have higher rates of alcohol consumption, and subsequent alcohol-related hospitalizations than females. However, the gap is narrowing with continually increasing rates of consumption among females.2,10
Alcohol consumption has been shown to increase incrementally with income, meaning that individuals with higher income tend to consume more alcohol than individuals with lower income.9 However, groups of lower socioeconomic status experience higher rates of alcohol-related harms. This is an example of the ‘alcohol paradox’ phenomenon, which reflects international evidence that less affluent groups experience greater alcohol-related harms than more affluent groups, even if usage patterns are similar.21 This occurs due to interactions between alcohol consumption and other variables (e.g. available social supports, stress levels and access to health services) that can modify the risk of health and social harms.4 Other factors, such as education and insecure housing can also worsen the impact of alcohol-related harms.7
When considering alcohol policy options through an equity lens, it is important to consider how changes will impact those of highest risk and greatest vulnerability. Policy options that reduce baseline harms, but target those who are most vulnerable, will have
the greatest impact. Some of these policy options include increasing the price of alcohol, reducing availability, including zoning and licensing measures that ensure disadvantaged areas are not exposed to higher density of alcohol outlets, and restricting alcohol marketing and promotion. Research has found that people in lower socioeconomic groups engaging in harmful drinking can disproportionately benefit from population-based measures, such as restricting hours of sale and reducing alcohol availability.7
As was recommended within the Alcohol Policy Review: Opportunities for Municipalities, health units can provide evidence to inform where high-risk populations and neighbourhoods are located, and in collaboration with municipalities, police and other local stakeholders, can help to identify which policy options may be most appropriate for their populations to reduce alcohol-related harm inequities.20
- World Health Organization. Global status report on alcohol and health 2018. [Internet]. [cited January 3 2019]. Available from: http://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng….
- Canadian Centre on Substance Use and Addiction. Canadian drug summary- alcohol. [Internet]. 2017 [cited January 3 2019]. Available from: http://www.ccsa.ca/Resource%20Library/CCSA-Canadian-Drug-Summary-Alcohol….
- Wellington-Dufferin-Guelph Public Health. A Report on Alcohol in Wellington, Dufferin and Guelph. [Internet]. August 2015 [cited January 3 2019]. Available from: https://www.wdgpublichealth.ca/sites/default/files/file-attachments/repo….
- Canadian Institute for Health Information. Alcohol harm in Canada, Examining hospitalizations entirely caused by alcohol and strategies to reduce alcohol harm. Available from: https://www.cihi.ca/sites/default/files/document/report-alcohol-hospital….
- World Health Organization. Global status report on alcohol and health 2014. [Internet] [cited September 7 2018]. Available from: http://apps.who.int/iris/bitstream/handle/10665/112736/9789240692763_eng….
- Canadian Centre on Substance Use and Addiction. Canadian Substance Use Costs and Harms, 2007-2014. [Internet]. 2018 [cited January 3 2019]. Available from: http://www.ccsa.ca/Resource%20Library/CSUCH-Canadian-Substance-Use-Costs….
- Loring B. Alcohol and inequities: guidance for addressing inequities in alcohol-related harm. [Internet] 2014 [cited January 3 2019]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0003/247629/Alcohol-and-I….
- Key inequalities in Canada: a national portrait- executive summary. [Internet] 2018 [cited January 3 2019]. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publicati….
- Butt, P., Beirness, D., Gliksman, L., Paradis, C. & Stockwell, T. Alcohol and health in Canada: a summary of evidence and guidelines for low risk drinking. [Internet] 2011 [cited September 7 2018]. Available from: http://www.ccsa.ca/Resource%20Library/2011-Summary-of-Evidence-and-Guide….
- The Chief Public Health Officer’s Report on the State of Public Health in Canada 2015. Alcohol Consumption in Canada. [Internet] 2016 [cited January 3, 2018]. Available from: https://www.canada.ca/content/dam/canada/health-canada/migration/healthy….
- GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for Global Burden of Disease Study 2016. The Lancet [Internet]. 2017 [Cited September 7 2018];392,1015-1035. Available from: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931310-2.
- Canadian Centre for Substance Use and Addiction. Alcohol Price Policies Series Report 2 of 3: Analysis of beverage alcohol sales in Canada. [Internet] November 2012 [cited January 9 2019]. Available from: http://www.ccsa.ca/Resource%20Library/CCSA-Analysis-Alcohol-Sales-Polici…
- World Health Organization. Global strategy to reduce the harmful use of alcohol. [Internet] 2010 [cited September 5 2018]. Available from: http://apps.who.int/iris/bitstream/handle/10665/44395/9789241599931_eng…..
- Government of Ontario. Newsroom: Wine, cider and fruit wines coming to grocery stores and Farmers’ Markets across Ontario. [Internet] February 19 2016
- [cited January 10 2019]. Available from: https://news.ontario.ca/omafra/en/2016/02/wine-cider-and-fruit-wines-com….
- Government of Ontario. Newsroom: Ontario launches consultations on alcohol choice and convenience, review of beverage alcohol sales includes opportunity for public input. [Internet] December 13 2018 [cited January 10 2019]. Available form: https://news.ontario.ca/mof/en/2018/12/ontario-launches-consultations-on….
- Government of Ontario. Newsroom: Premier Doug Ford announces return of ‘Buck-a-Beer’ to Ontario. [Internet] August 7 2018 [cited January 10 2019]. Available from: https://news.ontario.ca/opo/en/2018/08/premier-doug-ford-announces-retur….
- Alcohol and Gaming Commission of Ontario. Info Bulletin No. 54: Changes to permitted Sunday retail sale hours. [Internet] November 15 2018 [cited January 10 2019].
- Government of Ontario. Newsroom: Premier Ford announces halt to beer tax hike, Government for the people will leave more money in consumers’ pockets. [Internet] October 12 2018 [cited January 10 2019]. Available from: https://news.ontario.ca/opo/en/2018/10/premier-ford-announces-halt-to-be….
- Centre for Addiction and Mental Health. Research Snapshot: Raising alcohol prices and decreasing availability reduces alcohol-related harms. [Internet] December 2018 [cited January 3 2019]. Available from: http://eenet.ca/sites/default/files/2018/Research%20Snapshot%20-%20Alcoh….
- Liem Strategic Integration Inc. Alcohol Policy Review: Opportunities for Ontario Municipalities. [Internet] 2018 [cited January 3 2019]. Available from: http://opha.on.ca/getmedia/4e8f860f-6e34-4036-9fa6-a1311a35852e/Alcohol-….
- Alcohol and Gaming Commission of Ontario. You and the Liquor Laws: A Guide for Liquor Sales Licensed Premises. [Internet] January 2018 [cited January 28 2019]. Available from: https://agco.ca/sites/default/files/yll_en-lr_0.pdf.
- Bellis MA. The alcohol harm paradox: using a national survey to explore how alcohol may disproportionately impact health in deprived individuals. BMC Public Health [Internet]. 2016 [cited 2019 Jan 24];16:111. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-27….