The Prevention of Substance Misuse Working Group would like to thank program staff from Public Health Units for their contribution of program examples to the development of this Guidance Document.
Guidance and editorial support from the project Steering Committee members, Cancer Care Ontario and Ontario Ministry of Health Promotion staff was also greatly appreciated.
Under Section 7 of the Health Protection and Promotion Act (HPPA), the Minister of Health and Long-Term Care published the Ontario Public Health Standards (OPHS) as guidelines for the provision of mandatory health programs and services by the Minister of Health and Long-Term Care. Ontario’s 36 boards of health are responsible for implementing the program standards, including any protocols that are incorporated within a standard. An Order in Council (OIC) has assigned responsibility to the Ministry of Health Promotion (MHP) for four of these standards: (a) Reproductive Health; (b) Child Health; (c) Prevention of Injury and Substance Misuse; and (d) Chronic Disease Prevention. The Ministry of Children and Youth Services has an OIC pertaining to responsibility for the administration of the Healthy Babies Healthy Children components of the Family Health standards.
The OPHS are guided by the following four principles: need; impact; capacity; and partnership and collaboration. One Foundational standard focuses on four speciﬁc areas: (a) population health assessment; (b) surveillance; (c) research and knowledge exchange; and (d) program evaluation. These principles and the Foundational standard should be utilized in conjunction with this Guidance Document.
The MHP has worked collaboratively with local public health experts to draft a series of Guidance Documents. These Guidance Documents will assist boards of health to identify issues and approaches for local consideration and implement the standards. While the OPHS and associated protocols published by the Minister under Section 7 of the HPPA are legally binding, Guidance Documents that are not incorporated by reference to the OPHS are not enforceable by statute. These Guidance Documents are intended to be resources to assist professional staff employed by local boards of health as they plan and execute their responsibilities under the HPPA and the OPHS. Both the social determinants of health and the importance of mental health are also addressed.
In developing the Guidance Documents, consultation took place with staff of the Ministries of Health and Long-Term Care, Children and Youth Services, Transportation and Education. The MHP has created a number of Guidance Documents to support the implementation of the four program standards for which it is responsible, e.g.:
This particular Guidance Document provides speciﬁc advice about the OPHS Requirements related to the PREVENTION OF SUBSTANCE MISUSE.
Section 2 of this Guidance Document provides background information relevant to the prevention of substance misuse, including the signiﬁcance and burden of this speciﬁc public health issue, a brief overview about provincial policy direction, strategies to reduce the burden and the evidence and rationale supporting the direction. The background section also addresses mental well-being and social determinants of health considerations in the public health approach to the issue.
Section 3 provides a statement of each program requirement in the OPHS (2008) and discusses evidence-based practices, innovations and priorities within the context of situational assessment, policy, program and social marketing and evaluation and monitoring. Examples of how this has been done in Ontario or other jurisdictions are provided. Crossover areas with other programs are identiﬁed, including identiﬁcation of opportunities for multilevel partnerships, suggested roles at each level (provincial, municipal/board of health, community agencies and others) and identiﬁcation of collaborative opportunities with other strategies and programs such as the Smoke-Free Ontario Strategy and Healthy Babies Healthy Children. Section 3 also identiﬁes key tools and resources that may assist staff of local boards of health to implement the respective program standards and to evaluate their interventions.
Section 4 provides further explanation of the alcohol requirements under Chronic Disease Prevention in the OPHS (2008) and discusses evidence-based practices, innovations and priorities within the context of situational assessment, policy, program and social marketing and evaluation and monitoring, with examples.
Section 5 is the conclusion.
This Guidance Document is intended to be a tool that identiﬁes key concepts and practical resources that public health staff may use in health promotion planning. It provides advice and guidance to both managers and front-line staff in supporting a comprehensive health promotion approach to fulﬁ ll the OPHS Requirements (i.e., Chronic Disease Prevention, Prevention of Injury and Substance Misuse, Reproductive Health, Child Health).
In the event of any conﬂict between this Guidance Document and the Ontario Public Health Standards (2008), the Ontario Public Health Standards will prevail.
The prevention of substance misuse has been a focus of intervention for public health units since prior to the 1997 Mandatory Guidelines. The Ontario Public Health Standards (2008) and the creation of this Guidance Document provide a further opportunity for health units across Ontario to work together to effectively and comprehensively apply best and promising practices in their efforts to prevent substance misuse.
According to the Canadian Centre on Substance Abuse, the economic burden of alcohol approaches that of tobacco. (1) A recent Canadian cost study, based on 2002 data, estimated the overall social cost of substance misuse to be $39.8 billion, representing a cost of $1,267 for every Canadian. Tobacco accounts for about $17 billion (42.7% of the total estimate), alcohol accounts for about $14.6 billion (36.6%) and illegal drugs for about $8.2 billion (20.7%). The social costs included in the 2006 study encompass the direct costs of health care, enforcement, research and prevention and the indirect costs of lost productivity in the workplace or at home. The evidence shows that a signiﬁcant toll of death, injury and illness could be reduced for future generations by implementing effective interventions to prevent substance misuse.
In Ontario, alcohol misuse costs were estimated at $5.3 billion, or 37.2%, of all costs (tobacco, alcohol and illegal drugs) and illegal drugs accounted for $2.9 billion, or 20.4%, of all costs.
Alcohol is a drug that is readily accessible and legal to consume. Illicit drugs are illegal and although the use of illegal drugs presents signiﬁcant health risks, the direct costs of alcohol present a more substantial issue for Ontarians. As epidemiological evidence and research suggests that public health efforts focusing on reducing the rates of alcohol consumption are required, this Guidance Document will primarily focus on evidence-based research to reduce rates of alcohol use.
Substance use refers to the ingestion or administration of any substance that is psychoactive (i.e., alters consciousness). (2,3) Psychoactive substances include alcohol, tobacco, caffeine, illegal drugs, some medications, solvents and glues. The use of psychoactive substances is an almost universal human cultural behaviour since the beginning of recorded human history.
Substance use may range from beneﬁcial to problematic, depending on the quantity, frequency, method or context of use. Substance misuse refers to instances or patterns of substance use not consistent with legal or medical guidelines associated with physical, psychological, economic or social problems, or use that constitutes a risk to health, security or the well-being of individuals, families or communities. (4) This includes potentially harmful types of behaviours that may not constitute clinical disorders, such as impaired driving, using a substance while pregnant, heavy consumption and routes of administration (i.e., ways of taking a substance into one’s body) that increase harm. Substance misuse also includes substance use disorders (e.g., clinical conditions deﬁned by medical diagnostic criteria, including dependence or addiction). Substance misuse is not solely related to the legal status of the substance used, but to the amount used, the pattern of use, the context in which it is used and, ultimately, the potential for harm. (4)
Heavy drinking or binge drinking is deﬁned as 5 or more drinks on one occasion, at least once a month in the past 12 months. (4,5) All current Canadian professional standards of practice recommend that there is no known safe level of alcohol consumption during pregnancy. (2)
Underage drinking can also be considered a form of misuse because it is both illegal and often involves consumption in quantities and settings that can lead to serious immediate and long-term consequences. (6)
Substance use falls within a continuum of potentially problematic behaviours based on frequency, intensity and degree of dependency. (2) This continuum includes the following range of types of use:
Substance dependence can be physical, psychological, or both. (7) Physical dependence consists of tolerance (needing more of the substance for the same effect) or tissue dependence (cell tissue changes so the body needs the substance to stay in balance). Psychological dependence occurs when people feel they should use the substance in particular situations or to function effectively. There are degrees of dependence that range from mild to compulsive, with the latter being characterized as addiction.
While illegal drugs create much public concern and discussion, the literature indicates that legal substances such as tobacco and alcohol usually cause the greatest amount of individual and societal harm. (8) These are followed (in terms of burden of disease) by prescription and illegal drug use. (2) Substances that contribute the greatest harm can be identiﬁed from the distribution of their burden of disease; alcohol accounts for 10% of the burden of disease and illegal substances account for 2%.
Alcohol is the most widely used psychoactive drug. In Ontario, 82% of adults 18 years and over report using alcohol in the past 12 months. (9)
In 2002, the World Health Organization (WHO) identiﬁed alcohol as a leading risk factor for chronic disease and ranked it third overall with respect to Disability Adjusted Life Years (DALYS) in developed countries. (1)
There is a growing body of evidence linking alcohol to (10,11):
Major alcohol-related health conditions contributing to morbidity and mortality (11,12) include:
Alcohol consumption by women during their childbearing years can cause signiﬁcant harm, placing them at risk for adverse perinatal and fetal outcomes. Fetal Alcohol Spectrum Disorder (FASD) is the leading cause of preventable developmental disability among Canadian children.
Worldwide, alcohol causes 1.8 million deaths and 58.3 million DALYs. Alcohol consumption has increased in recent decades (mainly in developing countries).
Heavy drinking also increases the risk of violence, (14) vandalism, (15) sexual assault and unprotected sexual encounters with the potential for unplanned pregnancy or infection from sexually transmitted infections. (16)
Alcohol misuse is associated with signiﬁcant economic impacts (17):
The literature points to several key developmental periods that provide opportunities to enhance protective factors and thus reduce vulnerabilities to substance misuse (19):
According to Statistics Canada, 16% of the Ontario population aged 12 and over are considered heavy drinkers (22% males and 9% females). Heavy drinking is deﬁned as ﬁve or more drinks on one occasion, at least once a month in the past 12 months. (20,21)
In 2007, 37% of Ontarians aged 20 years and older reported consuming at least ﬁve or more drinks on at least one occasion in the last 12 months. Based on 36 public health units in Ontario, the highest proportion of heavy drinkers in the last 12 months was 54% and the lowest was 24% of adults aged 20 years and older. (17)
It is estimated that 10% of all deaths in Ontario directly or indirectly result from alcohol misuse. (22) Alcohol misuse is involved in about 40% of all trafﬁc collisions (23) and results in a large number of potential years of life lost because of the relatively young age of those killed. (24)
According to the Ontario Trauma Registry Report: Major Injury in Ontario, 2007-2008, (25) in 2007/2008, there were 4,354 cases hospitalized with major trauma in 11 participating facilities across 14 sites in Ontario. More than half of these cases (56%) qualiﬁed for blood alcohol testing, which is recommended by the Trauma Advisory Committee on all trauma patients older than 10 years of age when the patient is admitted within 12 hours of the incident. Of those tested, 706 (29%) had a blood alcohol concentration greater than zero and 22% had an alcohol concentration deﬁned as greater than or equal to 17.4 mmol/L, reﬂecting the legal positive blood alcohol limit. Among these cases, 50% were admitted due to motor vehicle collisions, 26% were admitted due to unintentional falls and 19% were admitted due to injury purposely inﬂicted by another person.
Although the 2005 CAMH Monitor survey has found that fewer adults use cannabis than alcohol, the reported use of cannabis has increased from 9% in 1996 to 14% in 2005. (26) This increase is evident for both men and women and among all age groups. A substantial increase in cannabis use has also occurred among 18-29 year olds, from 18% in 1996 up to 38% in 2008.
Although a small percentage of adults and youth self-identify use of illicit drugs and misuse of prescription drugs, there is growing anecdotal evidence that, in some Ontario communities, use of methamphetamines and oxycodone by adults is more common than stimulant drugs such as ecstasy and cocaine. (27) Adults are also more likely to use prescription drugs for non-medical reasons and to binge drink.
Misuse of prescription medications is also a cause for concern and can lead to signiﬁcant harm. (28) Problems related to medications stem from a variety of inappropriate uses, such as under-treatment, over-treatment, use for reasons other than as prescribed and adverse effects of the medication even if given according to recommendations. In one British Columbia study, it was found that the pattern of utilization of benzodiazepines appears inconsistent with the recommendations of educational groups, regulators and manufacturers.
There are a variety of risk factors that contribute to substance misuse, and addiction may develop if these factors act together. (2) Risk factors for substance misuse include a genetic, biological, or physiological predisposition, as well as external psychosocial factors (e.g., community attitudes including school, values and attitudes of peers or social group and family situation) and internal factors (e.g., poor coping skills and lack of resources).
Factors such as social environment, culture, income and social status have an impact on rates of use. (9) Groups at high risk for substance misuse include youth and adults who are homeless, lesbian, gay, bisexual and transgendered, Aboriginal people, people with concurrent disorders, sex workers and people in jail.
There is little known about certain groups who use alcohol and other drugs, especially those who are vulnerable or do not come in contact with the service system. This can also include people who have the resources to acquire and use drugs in private. It is suspected that many people use substances without their family or friends ever knowing.
In 2008, the Ontario government made a commitment to strengthen mental health and addiction services in the province and a Mental Health and Addictions Strategy is currently under development. The goals of the strategy are to:
The strategy will outline a comprehensive approach to mental health and addiction, leading to better services for Ontarians by transforming mental health and addiction services and promoting healthy communities and resiliency. It will look beyond health and will include collaboration across ministries, including Health Promotion, Education, Community and Social Services, Citizenship and Immigration, Community Safety and Correctional Services and the Attorney General.
Research in the United States has suggested that the prevalence of alcohol dependence in those with psychiatric disorders is almost twice as high as in the general population; similar levels are reported for the UK. (30) Similarly, research shows that people with alcohol dependency are more at risk of suicide (31) and have higher levels of depressive and affective problems, schizophrenia and personality disorders. (32)
While mental health is correlated with addictions, it is also important to note that individuals are predisposed to risk through behaviours such as binge drinking and heavy drinking.
The Low-Risk Dinking Guidelines were developed to minimize the risk for problematic substance use and consist of the following (4):
The guidelines do not apply if the individual:
For men and women, almost one in three drinkers (32%) consume alcohol at levels exceeding the Low-Risk Drinking Guidelines. (4) While these guidelines help prevent alcohol misuse, to prevent chronic diseases such as cancer and diabetes, alcohol consumption guidelines actually may be lower.
Strategies that help reduce the burden of illness attributed to alcohol misuse are outlined in recommendations from the National Alcohol Strategy and consist of the following broad areas (33):
Due to the burden of illness resulting from alcohol misuse, experts have stressed the need to create a culture of moderation with relation to alcohol consumption. (34)
The following policy strategies contribute to a culture of moderation and are effective in creating a safer drinking environment (37,38):
Research has established that effective public health strategies and interventions to reduce the harms associated with alcohol misuse are needed to inﬂuence levels of consumption in the general population, as well as those that inﬂuence high-risk behaviours that are associated with alcohol-related problems. (11)
Within a broader community context, and to impact the underlying causes of alcohol misuse, methods must be linked very closely to initiatives promoting emotional well-being and resiliency (e.g., community-based interventions, programs in schools, parenting initiatives, healthy public policy that modify drinking environments and Low-Risk Drinking Guidelines and treatment interventions to develop a comprehensive approach or developing evidence informed initiatives in targeted communities). (11) It is well known that comprehensive approaches are required to reduce substance misuse rather than stand alone programs or social marketing.
Of all forms of substance misuse, alcohol has the highest impact in terms of human harm and ﬁnancial costs. Many of these harms and costs are preventable. While this Guidance Document has intentionally focused on alcohol, health units should also identify the scope, scale and patterns of drug use in their communities to best address their local issues. This includes working with partners in the community to develop a comprehensive approach, or developing evidence-informed initiatives in targeted communities.
The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) in the areas of:
The use of substances, such as alcohol and other drugs, and the associated personal, social and economic harms are a concern for the community, for health and social services, for law enforcement ofﬁcials and for government. http://www.toronto.ca/health/drugstrategy/
Public health units have utilized data and information on substance misuse from the following sources:
Linkages with other programs can be found in Appendix A.
The board of health shall work with community partners, using a comprehensive health promotion approach, to inﬂuence the development and implementation of healthy policies and programs and the creation or enhancement of safe and supportive environments that address the following:
The term “supportive environment” refers to both physical and social aspects. It includes where people live, their local community, their home and where they work and play. (35) Action to create supportive environments has many dimensions, including physical, social, spiritual, economic and political. Each of these dimensions is inextricably linked to the others in a dynamic interaction. (36) Safe and supportive environments in relation to alcohol and other substances focus on strategies that modify the environment in which these substances are used. Modiﬁcation of the environment can be achieved through policy, community-based efforts, enforcement and legislation.
Speciﬁc characteristics of persons or places in an area may encourage problems; (38) for example, the layout of a neighbourhood can contribute to criminal activity. (38) Community-based interventions that focus on neighbourhood-speciﬁc strategies are effective. In order to incorporate a social determinants of health framework in activities related to substance misuse, it is useful to build partnerships between public health, community members, service providers and crime prevention to address the social and physical contexts that contribute to substance misuse. Public health staff should develop relationships with community partners who understand the neighbourhood mechanisms thought to account for community variation in outcomes, (38) such as a crime prevention committee and other service providers.
5 “Funded by the Canadian Institutes of Heath Research, the overall objective of the 2004 Canadian Campus Survey is to build understanding regarding the individual, social and environmental determinants of hazardous drinking. This preliminary report describes the prevalence of alcohol use, other drug use, mental health and gambling problems among Canadian undergraduates interviewed in 2004, relationships between these outcomes and student characteristics, and whether such outcomes have changed since 1998.” http://www.camh.net/Research/Areas_of_research/ Population_Life_Course_Studies/CCS_2004_report.pdf.
6 An overview of CAMH population life course studies: http://www.camh.net/research/areas_of_research/Population_life_course_studies/population_life_course.html
7 Information about the Ontario Trauma Registry is available at (http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=services_otr_e) Alcohol and Gaming Commission of Ontario, http://www.agco.on.ca/
Using surveillance data, identify and foster collaborative partnerships with local, provincial and national community partners, such as, but not limited to:
Health unit staff members should seek out additional relevant local data sources, either those collected by local organizations, or those collected locally by external organizations at the provincial or federal level. Where local data are lacking or limited, staff should seek to engage local partners in improving data collection or sharing relevant data.
Using surveillance data, public health units can identify local policies, programs and environmental supports being developed or implemented within the community, focusing on those that modify the drinking environment.
Public health role:
(34) There are a variety of systems changes that can maintain current systems of control over alcohol sales. (P/T governments) Under these systems, it will be important to:
Although several of these recommendations are primarily provincial actions, local boards of health, together with community partners, can advocate that the province acts in accordance with these recommendations.
There is evidence that community actions can reduce problems related to alcohol use and youth substance use. (38) Coalitions and partnerships have become a popular vehicle for community action. The following examples are evaluated community-based programs:
Community Trials Intervention to Reduce High-Risk Drinking is a multi-component, community-based program developed to alter the alcohol use patterns and related problems of people of all ages. (39) The program incorporates a set of environmental interventions that assist communities in:
The Midwestern Prevention Project helps youth recognize the tremendous social pressures to use drugs and provides training skills in how to avoid drug use and drug use situations. These skills are initially learned in the school program and reinforced through the parent, media and community organization components. (Cross-over ﬂ ag: School Health Guidance Document)
The MPP disseminates its message through a system of well-coordinated, community-wide strategies: mass media programming, a school program and continuing school boosters, a parent education and organization program, community organization and training and local policy change regarding tobacco, alcohol and other drugs. (40) These components are introduced to the community in sequence at a rate of one per year, with the mass media component occurring throughout all the years. The central component for drug prevention programming, however, is the school.
Safer Bars is an evidence-based CAMH program shown to reduce alcohol-related violence in bars, clubs and other licensed establishments. (41) The program involves a bar risk assessment, the provision of information on alcohol liability and the law and violence prevention training for bar management and staff. Since the fall of 2006, an ad hoc group with representatives from the Toronto Drug Strategy Secretariat, Toronto Public Health, the Toronto Police Service, the Alcohol and Gaming Commission of Ontario, the city’s Community Safety Secretariat and CAMH have met to develop strategies to promote Safer Bars with a starting focus on Toronto’s entertainment district. For more information, visit http://www.camh.net\About_camh\health_promotion\community_health_promotion\ strat_prevalcprob_bars04.pdf
Substance misuse information can be augmented through local cross-sectoral collaborative partnerships that share data in order to determine success measures and methods for monitoring. Partnerships with police services and municipal licensing will enhance this activity.
A strategy should be developed to address local issues that facilitate partnerships and the establishment and evaluation of outcome measures (e.g., municipal drug strategy). The Federation of Canadian Municipalities (FCM) has published the Municipal Drug Strategy Phase III report, A Summary Evaluation of Pilot Projects, outlining recommendations that draw from lessons learned from nine communities. This approach requires municipal government support, as well as the involvement of community stakeholders. (42) The key to a good strategy is to agree on a common mission and an action plan derived from local priorities. The FCM has prepared an evaluation framework that provides guidance to evaluate municipal drug strategy.
In 2001, Durham Region Health Department conducted a focus group with stakeholders in the community on risk factors associated with alcohol misuse. Results indicated that interventions were required at the source of alcohol intake and with those serving alcohol. Licensed establishments were also surveyed, and they identiﬁ ed alcohol intake and violence as key problems. The Durham Region Safer Bars and Communities Coalition was created to address these issues. As a member of the coalition, the Health Department facilitated the implementation of an integrated approach involving skill-development, supportive environments, capacity building and policy development.
The coalition consists of representatives from a wide variety of disciplines, including government regulatory bodies, enforcement services, researchers, alcohol prevention advocates, municipalities, commercial host liability experts and service industry professionals. Interventions for the Durham Region Safer Bars Strategy include:
Community groups across the province have adapted coalition resources and activities as templates for their own communities. For further information, please contact the Durham Region Health Department.
The City of Toronto is currently exploring by-laws that would require the Safer Bars Program as a requirement of licence renewal and new licences. (43) Once a response is made public, it would be up to individual health units to undertake a similar initiative in their catchment area. The Toronto backgrounder is available electronically at http://www.toronto.ca/legdocs/mmis/2009/ls/bgrd/backgroundﬁ le-17944.pdf
Public health role:
In Ontario, in 2009, the Minister’s Advisory Group on Mental Health and Addictions released a discussion paper on the development of a ten-year strategy for mental health and addictions in the province: Every Door is the Right Door. (29) The paper will be followed with online and in-person consultation.
The following organizations contribute to prevention efforts in Ontario.
Centre for Addiction Mental Health
Alcohol Policy Network
Healthy Communities Consortium – Ontario Drug Awareness Partnership (ODAP)
Parent Action on Drugs (PAD)
Public health units should be familiar with the many recommendations proposed in the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada and should monitor developments to which they could contribute. For more information, visit http://www.nationalframework-cadrenational.ca/index_e.php?orderid_top=2
City of Vancouver’s Four Pillars Drug Strategy Program; for more information, visit http://www.vancouver.ca/fourpillars/
The Health Communication Unit’s Developing Health Promotion Policies Workbook, pg. 49-50 http://www.mdfilestorage.com/thcu/pubs/539372877.pdf
Canadian Centre on Substance Abuse’s National Framework for Action to Reduce the Harms Associated with Alcohol, Other Drugs and Substances in Canada; for more information, visit http://www.ccsa.ca/Eng/Partnerships/Pages/OtherDrugsandSubstances.aspx
The board of health shall use a comprehensive health promotion approach to increase the capacity of priority populations to prevent injury and substance misuse by:
This Requirement is consistent with evidence-based practice and should be considered when planning public health activities to implement the priority population requirement. To be considered comprehensive, any intervention directed at a priority population must take into consideration environmental factors. For example, an intervention aimed at delaying the age of onset of ﬁrst use of alcohol through enhancements to the school curriculum will be hampered if there are no additional interventions directed at the adult population outside the school system; at alcohol marketing practices in the community; at retail sales of alcohol; or at the availability of social supports. This is the community systems approach, where alcohol and other drug problems are viewed as the outcomes of processes driven and sustained by the community at large (not just individuals). The intention is to reduce the collective risk to populations through appropriate interventions affecting these processes. (38)
Youth, deﬁned as individuals from 12-24 years of age, are a priority population because youth who use substances predispose themselves to a number of risks, such as injury and other chronic diseases. (44) They are an important focus for substance misuse because delaying the age when youth begin to use substances is a critical harm reduction strategy.
Young people express their independence by testing their limits and developing their own social networks. Although many adults are concerned about adolescent experimentation with illegal psychoactive substances, the most common patterns of risky substance use are with more familiar substances such as tobacco and alcohol. The use of these socially sanctioned substances has generated increasing concern, especially due to evidence of increased “binge” drinking by teenagers in Canada, the United Kingdom, Europe and Australia. (45–48) There has also been a marked increase in these countries in the use of cannabis, ecstasy and injectable drugs, such as heroin, cocaine and various amphetamine-type drugs, over the past three decades. (46)
High risk/vulnerable youth are an important priority population requiring speciﬁc attention. (49) Vulnerable youth are deﬁned as those with a history of family member misusing substances, those with behavioural, mental health or social problems, those that are excluded from school, young offenders, those who are homeless, those involved in commercial work and those from minority ethnic groups. Vulnerable youth are at greater risk of substance misuse and require targeted interventions.
Reducing the patterns of harmful drinking among youth will require inﬂuencing key transitions, such as the move from elementary to secondary school and secondary to post-secondary education. A range of prevention strategies and services is necessary and should be carried out in collaboration with government, school and community partners to address protective and risk factors at critical points along the lifespan. Efforts should be in partnership with school boards and community groups for children and youth and should focus on smooth transitions to school, middle school, high school and post-secondary education. (50) Universal approaches to preventing substance misuse are essential to ensure that all young people, not just those at risk, are the focus of prevention efforts.
The literature on healthy youth development recommends a shift toward interventions that enhance and facilitate adaptive qualities in youth and away from interventions that reduce risk factors and negative behaviour. (51) Protective factors that buffer risky environments and lead to resilience among youth include the development of competence across domains, conﬁdence in oneself, connections to all elements of the community, character and moral commitment and a sense of caring and compassion. (49) Healthy boundaries, constructive use of time and social competencies are additional developmental assets. (2,29) Efforts should focus on resiliency and protective factors. (50)
Key developmental stages are highlighted in the literature as opportunities to enhance protective factors and reduce vulnerabilities. Many of the protective factors at key developmental stages reduce vulnerabilities and are also the basis for mental health promotion. As a result, there is a need for strong linkages with new MOHLTC mental health and addictions strategy, particularly in examining risk factors for youth and ensuring that activities proposed within the strategy are aligned with activities at a local level. For more information, visit http://www.health.gov.on.ca/english/public/program/mentalhealth/minister_advisgroup/minadvis_faq.html
There are speciﬁc groups of youth who are at much higher risk than their peers for heavy use, multi-drug use and substance misuse. These include runaway and street-involved youth, youth in custody, adolescents with co-occurring disorders, sexually-abused and exploited youth, gay, lesbian, bisexual and questioning teens and First Nation, Inuit and Métis youth. Fortunately, not all youth exposed to these higher risks end up with chronic substance misuse or dependence disorders. There is growing evidence that protective factors and assets in the lives of even the most vulnerable may buffer their risk and support resilience and healing. Connectedness to school, positive relationships with caring adults within or outside of the family and supportive peers seem to reduce the likelihood of the distress and difﬁculties in coping that lead to problem substance use. For more information, visit http://www.ccsa.ca/2007%20CCSA%20Documents/ccsa-011522-2007-e.pdf
Partnerships are the same as Requirement 2 with the following additions:
Building assets (U.S. terminology) and resiliency (Canadian terminology) in youth, as well as providing youth opportunities to be engaged, are protective factors that promote positive youth development and prevent youth from engaging in risk taking behaviours. (57)
The Search Institute in the United States has developed a framework of 40 Developmental Assets – positive experiences, relationships, opportunities and personal qualities that help young people grow up healthy, caring and responsible. Created in the 1990s, the framework is grounded in research on child and adolescent development, risk prevention and resiliency. The Search Institute’s research shows that the more assets young people have, the less likely they are to engage in risky behaviours. Three common themes have emerged from numerous ﬁ ndings, which indicate assets:
Because of its basis in research and its proven effectiveness, the Developmental Assets framework has become the single most widely used approach to positive youth development in the United States. Studies of more than 2.2 million young people consistently show that the more assets young people have, the less likely they are to engage in a wide range of high-risk behaviours and the more likely they are to thrive. (57) Assets have power for all young people, regardless of their gender, economic status, family, or race/ethnicity. Furthermore, levels of assets are better predictors of high-risk involvement and thriving than poverty or being from a single-parent family.
Youth who experience more assets are less likely to get into trouble, use drugs and engage in sexual activity, violence, gambling and other high-risk behaviours. They are also more likely to be successful, do well in school and help others. By building assets, youth can be prepared to make good decisions when faced with difﬁ cult situations.
In alignment with the U.S., Resiliency Initiatives has developed a resiliency assessment and evaluation protocol that provides a statistically sound and research-based approach to understanding the strengths related to long-term resiliency. Working from this strength-based model of understanding child, youth and adult development, Resiliency Initiatives emphasizes the positive aspects of individual differences in understanding what extrinsic and intrinsic strengths contribute to optimal human development. For more information, visit http://www.resiliencycanada.ca
A resiliency focus allows individuals to be seen as being “at promise” instead of “at risk.” The focus is on facilitating rather than ﬁxing, pointing to health rather than dysfunction and turning away from limiting labels to wholeness and well-being. (58)
Building assets (resiliency) through youth engagement enhances protective factors and is associated with a reduction in risky youth behaviour, including the use of alcohol and other drugs. Youth engagement is deﬁned as the meaningful and sustained involvement of a young person in an activity focusing outside the self. Full engagement consists of a cognitive component, an affective component and a behavioural component – head, heart and feet. For more information, visit http://www.engagementcentre.ca/
Assess regional and local needs to establish priorities for planning initiatives for both universal and targeted initiatives.
In many countries, signiﬁcant investments have been made into prevention programs and their evaluation. Recent reviews of interventions for prevention of substance use and its harms (2,11,38) have documented what can be learned from the global experience. These reviews have identiﬁed key elements that inﬂuence substance use patterns and contribute to or mitigate harms:
Of the policies related to substance misuse, the following are most effective for youth in Ontario (38):
Restricting access to alcohol by minors include (59):
These recommendations are also supported by findings in the Community Preventative Services Guide; for more information, visit http://www.thecommunityguide.org/adolescenthealth/index.html
Public health role:
This section focuses on youth, schools and post-secondary institutions. The School Health Guidance Document provides information on how to effectively implement a comprehensive health promotion approach in a school setting, including opportunities for alignment with the education sector.
A combination of population-based interventions that engage all members of society and targeted strategies are required to reduce the harm associated with youth use of alcohol and other drugs. Comprehensive approaches to reduce the rate of alcohol use include policy that restricts access to alcohol, as previously described in this document, in conjunction with social marketing strategies. In addition to these initiatives, school, post-secondary and community-based interventions are also essential components to achieve a comprehensive approach. (38)
School drug education programs with a behavioural orientation have shown short- to medium-term success. Educational strategies should also increase knowledge, explore attitudes, develop decision-making, increase self esteem and raise awareness of how media, peers and parents inﬂuence alcohol consumption and drug use. Strategies should also introduce a “whole school” approach and help parents to develop their parenting skills. Where appropriate, it is useful to offer brief one-on-one advice and referrals to external resources. (49)
The Canadian Centre on Substance Abuse (CCSA) and the Public Health Agency of Canada (PHAC) have identiﬁ ed important ingredients that should be included in alcohol-related programs. Examples of detailed programs can be found in New standards for school-based youth substance abuse prevention: Building on Our Strengths Canadian Standards for School-based Youth Substance Abuse Prevention CCSA’ s Drug Prevention Strategy for Canada’s Youth 2009, available at http://www.ccsa.ca/2009%20CCSA%20Documents/ccsa-newrel-20090519e.pdf
Essential ingredients for programs:
Assessment of alcohol and drug use in post-secondary students in Canada has been sporadic. The Centre for Addiction and Mental Health (CAMH) has conducted two campus surveys over a decade, releasing the last survey in 2004. Post-secondary students have their own patterns of harmful drinking that can be signiﬁ cantly curtailed by interventions on campus. Campus interventions, however, should be supported by community initiatives that deal with licensed establishments who cater to this target group. For more information, visit http://www.camh.net/Research/Areas_of_research/Population_Life_Course_Studies/CCS_2004_report.pdf
Similar studies outside of Canada can shed light on substance misuse among post-secondary students. For example, the Harvard School of Public Health College Alcohol Study surveyed students from a nationally representative sample of US colleges four times between in 1993 and 2001. More than 50,000 students at 120 colleges took part in the study. The study reviewed college drinking and the implications for prevention, including the need to focus on lower drink thresholds, the harm produced at this level of drinking, the secondhand effects experienced by other students and neighborhood residents, the continuing extent of the problem and the role of the college alcohol environment in promoting heavy drinking. The survey also highlighted the roles of campus culture, alcohol control policies, enforcement of policies, access, availability and pricing, marketing and special promotions of alcohol.
A Matter of Degree is an evaluation report on environmental prevention strategies from the Harvard School of Public Health study for post-secondary setting. The document can be viewed at http://www.hsph.harvard.edu/cas/What-We-Learned-08.pdf
The Centre for Addictions Research of BC provided the Canadian context by releasing, in 2008, Alcohol on Campus: Programs and Policies: Review and Recommendations. This document presents a situational assessment of the consumption patterns of post-secondary students and includes a call to action for speciﬁ c interventions that would reduce alcohol-related harms. The document can be viewed at http://www.carbc.ca/Portals/0/PropertyAgent/2111/Files/20/AlcoholOnCampus.pdf
Educational strategies in the post-secondary setting are recommended. Although these measures demonstrate modest impact in isolation, when woven together in a concerted initiative – especially one that involves both committed internal staff, faculty and student representatives and external off-campus resource personnel – they have the potential to affect meaningful and important changes such as:
Further evidence, summaries and detailed interventions are provided in Alcohol on Campus: Programs and Policies Review and Recommendations from the Centre for Addictions Research of BC, revised July 2008. Available at http://www.carbc.ca/Portals/0/PropertyAgent/2111/Files/20/AlcoholOnCampus.pdf
Research stresses the importance of efforts by post-secondary institutions to develop programs and policies that respond to problems of excessive substance use on campus. Campus policies and programs should be holistic and address the unique needs of their population. In their review of drug prevention strategies for college students, Larimer et al. (60) strongly recommend that campuses collaborate with surrounding communities to implement efﬁcient and effective individual and environmental preventive and intervention strategies. The Alberta Alcohol and Drug Abuse Commission (AADAC) report (61) underlines that the binge drinking environment also includes the communities surrounding the campus and stresses that it is important for campus administrators to collaborate and work with the community in order to target, prevent and intervene in case of excessive use of alcohol among college students. (54)
Public awareness campaigns in the mass media on their own have been shown to have limited effect; however, media strategies appear to be effective when complemented by on-the-ground regulations and other interventions. (38)
Colleges and universities should develop and implement effective policies that will prevent the misuse of alcohol by students. (62,63) Policy components must be accessible to students and provide clear information about laws and regulations regarding alcohol use. These policies should include (63,64):
Further details are provided at http://www.apolnet.ca/thelaw/policies/ReviewOfAlcoholPolicies.pdf
Brief interventions are a recommended best practice for post-secondary settings (65) and are recommended by CAMH in many of their documents. According to one study, brief alcohol interventions are among the top ﬁ ve most cost-effective preventatives and are as at least as effective as Pap smears or bowel cancer screening. (54) A brief intervention can range from a brief conversation to up to ﬁve counselling sessions. Even brief interventions lasting three to ﬁve minutes have been shown to be effective.
Brief interventions can take place in settings such as primary health care and can be implemented by a variety of trained behavioural and primary health care providers. Brief interventions consist of feedback about personal risk, explicit advice to change behaviour, patient’s responsibility for change and ways to affect change. (66)
One recent document that examines the brief intervention technique from a public health perspective is Screening and Brief Intervention: Making a Public Health Difference, 2008, available at http://www.jointogether.org/ aboutus/ourpublications/pdf/sbi-report.pdf
BASICS is an intervention designed for college students 18 to 24 years old who drink heavily and have experienced negative consequences as a result. Sixty-seven percent of students receiving the BASICS signiﬁcantly improved their behaviour from baseline to follow-up four years later, compared to 55% of a control group (a statistically signiﬁ cant 12% difference). Positive results were documented in controlled studies at three different universities. (67)
Summary of BASICS as a model program is available at http://nrepp.samhsa.gov/ViewIntervention.aspx?id=124
School-based strategies should be augmented by community-based interventions. (38) This Guidance Document includes examples of community trials in Requirement 2.
An example of a community-based program is SHAHRP (School Health and Alcohol Harm Reduction Project), Preparing for the Drug Free Years and Preventing substance abuse among Aboriginal youth: http://www.cancer.ca/manitoba/prevention/mb-knowledge%20exchange%20network/~/media/CCS/Manitoba/KEN/mb_youth-alcohol_en.ashx
Strengthening Families for the Future is a prevention program for families with children between the ages of 7 and 11 who may be at risk for substance use problems, depression, violence and school failure. The program’s goals are to:
Further information is available at http://www.camh.net/Publications/CAMH_Publications/strengthen_families.html
This Australian parenting program focuses on parents of adolescent children. Eighteen sites were involved in an extensive evaluation. The program used a broad-based strategy that promoted mental health, well-being and connectedness in families and local communities. Local service providers were trained to run the program. Parents and adolescents were recruited from Grades 7/8 in targeted schools and through a broad range of community strategies. A program description and ordering information is provided at http://www.mhws.agca.com.au/mmppi_detail.php?id=27
The Australian program has been evaluated (68) and short videos are available that document the challenge of recruiting parents and encouraging them to attend, as well as the labour intensive nature of interventions that work. The abstract with the evaluation is available at http://www.ncbi.nlm.nih.gov/pubmed/12225740
Monitoring alcohol use can be facilitated by:
Programs should be evaluated, and systems to monitor youth alcohol and substance use should be developed. Tool kits and services are available.
Examples of how this has been done in Ontario:
Opportunities for Partnership
Identification of Key Linkages to Other OPHS and Government Strategies and Programs
For substance misuse prevention tool kits in schools, including policy, community partners, higher risk youth and classroom education; for more information visit http://www.jcsh-cces.ca/
Alcohol, Trauma and Impaired Driving, 3rd edition http://madd.ca/english/research/real_facts.pdf
Alcohol, No Ordinary Commodity http://www.racp.edu.au/download.cfm?DownloadFile=58652CD1-9BE2-4D4E-55490E849F199F90
The board of health shall increase public awareness of the prevention of injury and substance misuse in the following areas:
These efforts shall include:
A systematic review conducted by the Alcohol Policy Network found that advertising has an impact on youth substance use. In addition, observational studies have shown an association for adolescents. Communication should be part of a comprehensive approach and support local initiatives. For more information visit http://www.apolnet.ca/resources/pubs/rpt_Effectiveness-Dec05.pdf
Numerous studies have shown that alcohol advertising and promotion increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol. For more information, visit http://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds%5b%5d=citjournalarticle_94003_1
The prevention of substance misuse requires a comprehensive health promotion approach. Comprehensive approaches include education and awareness, skill-building, policy, environmental support and community action. To be effective, communication and social marketing strategies should be sustained over time.
Social marketing alone is rarely enough to bring about change. A variety of strategies should be applied if change is to occur. Social marketing works best when policies are modiﬁed and communities are mobilized. The combined approach can change conditions, as well as socio-economic and environmental systems. Ultimately, this will have an impact on both individual behaviour and health determinants. (73)
It has been shown that media-based campaigns that are pursued in conjunction with complementary and reciprocal community actions are more effective than media campaigns alone in changing both attitudes towards substances and use itself. (74,75)
According to the World Health Organization:
Ingredients of a successful communication campaign include (WHO):
Public service announcements (PSAs) are messages prepared by non-governmental organizations, health agencies and media organizations that promote responsible drinking, and share the hazards of drinking and driving and related topics. Despite their good intentions, PSAs are an ineffective antidote to the much more frequent high-quality paid advertisements that promote alcohol consumption.
Counter-advertising decreases the appeal and use of harmful products such as tobacco and alcohol by disseminating information about these products, their effects and the industry that promotes them. Tactics include health-warning labels on product packaging, as well as prevention messages in magazines and on television.
In 2005, Miller and Associates (76) reported evidence and best practices for a communication campaign on alcohol that speciﬁcally targeted youth. Even for ﬁndings related to youth:
Communication strategies should target policy and decision-makers. Media messages addressing health and safety issues are rare. Currently, health messages to youth and the general population about the risks associated with alcohol relate mostly to impaired driving – and are delivered at the local level. While some regions of the province have identiﬁed messaging and campaigns that address other risks and safety strategies, there has been no coordinated provincial campaign. For more information, visit http://www.apolnet.ca/Index.html.
Social marketing should be used as part of a comprehensive approach to advocate for or inﬂ uence policy development. This ﬁts into Step 5 – “Build Support for a Policy” of The Health Communication Unit’s (THCU) Policy Development at a glance – Eight Steps to Developing a Health Promotion Policy. For more information, see http://www.mdfilestorage.com/thcu/pubs/489887946.pdf
Building Networks to Support Municipal Alcohol Policy Development: The Simcoe County Experience An example of Step 5 – “Building Support for a Policy” is Building Networks to Support Municipal Alcohol Policy Development: The Simcoe County Experience. In this program, health unit staff partnered with the local FOCUS community project and CAMH to mount a campaign aimed at encouraging municipalities in Simcoe County to adopt municipal alcohol policies. (77) The objectives of the campaign were to:
A range of strategies were employed by the campaign to convey the importance of implementing MAPs, including presentations to municipal councils, displays in the community, radio and TV appeals and special events. Public health nurses taking part in the campaign carried out a proactive outreach strategy with local municipalities, connecting with interested municipalities to offer support for MAP development and recognizing municipalities that had MAPs in place through the presentation of awards at community events. Smart Serve, a responsible alcohol beverage service training program, was offered to community groups and businesses throughout Simcoe County. The campaign appeared to be successful in encouraging municipal governments to adopt MAPs. By November 2001, four new MAPs had been adopted in Simcoe County and an additional four were in progress. (75) The Simcoe County experience illustrates how a comprehensive awareness and advocacy campaign can bring about healthy policy change. (78)
Social marketing can be used to inﬂuence behaviour by raising awareness about new or changed policy and legislation. Before being enforced, campus policies must be well disseminated. (38) For more information, see http://www.carbc.ca/Portals/0/PropertyAgent/2111/Files/20/AlcoholOnCampus.pdf
Eight Steps to Developing a Health Promotion Policy stresses the importance of raising awareness and effectively communicating information about a new policy. For more information, see http://www.mdﬁ lestorage.com/thcu/ pubs/497736921.pdf
The following organizations develop communication campaigns on alcohol use:
Rethinking Drinking is an example of a campaign designed to change the culture of alcohol use and to provide tools and resources in print and online. This website and booklet from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is designed to help people reduce their risk for alcohol problems. The materials present evidence-based information about risky drinking patterns, the alcohol content of drinks and the signs of an alcohol problem, along with information about medications and other resources to help people who choose to cut back or quit drinking.
A similar site and campaign in BC called Alcohol Reality Check can be found at http://www.alcoholreality.ca
The Australian Government’s National Alcohol Campaign called Where Are Your Choices Taking You? and It’s Your Choice took place from 1998–99 to 2002–03. This program included two PSA TV spots (one aimed at males; one at females), a print pocket card, brochure for parents, magazine ads, print ads for parents of non-English speaking backgrounds and inserts in major Sunday papers. The three phases of the campaign were focused on youth ages 15–17, parents of children aged 12–17 and young people aged 18–24. All phases were effective and campaign awareness levels were very high. There was an increase in the proportion of respondents who reported that the central campaign message was related to choices about whether to drink alcohol. Respondents continued to rate commercials as thought provoking, believable and relevant. The campaign also made the target group think about the negative effects of drinking too much, the beneﬁts of not drinking too much and the choices they made about drinking. Alcohol consumption decreased in the three months prior to the evaluation.
This comprehensive National Youth Alcohol Campaign aims to contribute, along with a range of initiatives, to a reduction in harms associated with drinking to intoxication by young Australians. For more information, visit http://www.drinkingnightmare.gov.au.
National Anti-Drug Strategy: Youth Drug Prevention Campaign Parent component 2007-2009 http://www.hc-sc.gc.ca/ahc-asc/activit/marketsoc/camp/nads-sna-eng.php
The objective is to mobilize youth-marketing and youth-service organizations around a drug prevention campaign by creating task-speciﬁc alliances that result in the ongoing delivery of consistent, evidence-informed messages designed to increase awareness and understanding among youth aged 10–24 of illicit drugs and their related harms. A recent initiative was launched at http://www.xperiment.ca that addresses cannabis, ecstasy and cocaine.
The board of health shall use a comprehensive health promotion approach in collaboration with community partners, including enforcement agencies, to increase public awareness of and adoption of behaviours that are in accordance with current legislation related to the prevention of injury and substance misuse in the following areas:
Active enforcement of regulations is related to serving intoxicated or underage clients and related health and safety issues.
A detailed overview of legislative and regulatory bodies was produced by the Alcohol Policy Network in 2006. In addition, an updated overview of regulatory bodies was provided by the Alcohol Policy Network in 2008. These overviews are of importance to public health units because regulatory changes should be monitored and assessed against best practices for their impact on the health of Ontarians.
Legislative changes in Ontario have both enabled and challenged the work of public health units in achieving substance misuse prevention.
Overviews of legislative changes and regulatory bodies are described in: http://www.apolnet.ca/resources/pubs/rpt_Priorities2006.pdf http://www.apolnet.ca/thelaw/WhoResponsible.html
Provincially elected ofﬁcials develop liquor legislation governing the sale and distribution of alcohol in Ontario.
Pieces of the Liquor License Act and other relevant legislation will be discussed in more detail in the Policy and Program sections below.
Enforcement of the Act is primarily conducted by police forces (federal, provincial and municipal) and by Alcohol and Gaming Commission of Ontario (AGCO) inspectors.
This requirement recommends that health units work with enforcement agencies to raise awareness and the adoption of behaviours that are in accordance with current legislation. Health units should develop the capacity to transfer knowledge to the general public about the origins of speciﬁc legislation, beneﬁts, pros and cons and effectiveness in preventing mortality or disability.
The Smart Serve Training Program has been developed by Smart Serve Ontario, a division of the Hospitality Industry Training Organization of Ontario (HITOO), and is endorsed by the AGCO.
Smart Serve training is mandatory for the following individuals (81):
Government policies regarding alcohol services have the greatest impact if they are combined with active enforcement. (13) As mentioned above, this is also important in post-secondary environments. Schools that permit the operation of a licensed establishment on campus can and should monitor operations, to ensure operations honour contractual terms, including obligations for responsible beverage service (e.g., hours of business and other agreements). (38) For more information visit http://www.carbc.ca/Portals/0/PropertyAgent/2111/Files/20/AlcoholOnCampus.pdf.
Examples from Ontario Public Health Units:
Alcohol Liability and/or Policy workshops for golf courses and/or bars and other licensed establishments have been organized by many health units across Ontario.
These workshops have included experts on alcohol liability (e.g., Prof. Robert Solomon, Shelley Timms and Larry Grand) who share information about the Liquor Licence Act and provide case law examples. The workshops stress the importance of effective policy development with enforcement to help reduce the risk of liability. Some health units have followed up and provided further resources to participating establishments to assist them in raising awareness of their policies and consequences. Policy writing workshops guide licensed establishments through the process of developing effective policy.
The Ontario Public Health Association (OPHA) has written letters to the AGCO providing input on proposed reforms to the Liquor Licence Act. Amongst other important recommendations, the OPHA recommends doubling the amount of liquor inspectors in the province and instituting minimum liquor prices. More details are available at http://www.apolnet.ca/news/ITW/ITW-Oct08.html.
The letters to the AGCO are available at http://www.opha.on.ca/our_voice/letters_a-d.shtml#alcohol.
Kingston’s post-secondary working group decided to act on Alcohol Delivery Services after discussions with staff at Queen’s University residences, who were concerned about some of the delivery practices, etc. The public health role was mainly one of connecting the partners (Queen’s, AGCO, Kingston Police), and Queen’s contacted the delivery companies, with assurances from the Kingston Police that they would follow up as required. The end result was that delivery services were ofﬁcially banned from the Queen’s campus. Letters from the university were sent to the delivery service companies informing them that deliveries to student residents were prohibited and any violations would be reported to police.
Legal drinking age (Liquor Licence Act)
Best Practice Recommendation: There is sufficient evidence for enhanced enforcement of laws prohibiting sale of alcohol to minors in order to limit underage alcohol purchases. Further research will be required to assess the degree to which these changes in retailer behaviour affect underage drinking. Effective actions include:
Public health can partner with the AGCO and other enforcement agencies and community partners to raise awareness amongst licensed establishment owners and staff of local enforcement activities, in an effort to increase compliance with local by-laws and the Liquor Licence Act. Information about local enforcement activities could also be shared with the public (targeting those who frequent licensed establishments), so that they are aware that inappropriate behaviour, such as intoxication, will not be tolerated. This can help to shift social norms.
The most promising approaches to reduce aggression and violence in licensed premises include community-focused interventions such as interventions to improve the effectiveness of bar staff and approaches that include increased policing. (38)
Many interventions, especially broad-based community interventions, have shown signiﬁcant reductions in violence
in licensed premises. Rigorous evaluations, however, have been rare and a wide range of strategies showing promising results are worthy of further study. These include targeted policing strategies, training programs for staff (especially security staff) and multi-component strategies targeting a range of known risk factors for violence. (38) Community approaches tend to produce the largest and most signiﬁcant effects, but are more expensive than other approaches and have shown difﬁculties with sustainability.
Holding servers legally liable for the consequences of providing more alcohol to persons who are already intoxicated, or to those underage, has shown consistent beneﬁt as a policy measure in the U.S. Wagenaar and Holder (84) found that when one state deliberately distributed publicity about the legal liability of servers, there was a 12% decrease in single-vehicle night time injury-producing trafﬁc crashes. (13)
Public health is encouraged to facilitate the adoption and implementation of these promising practices and to ensure programs are evaluated.
The evaluation included systematic observations by trained researchers, incident recording by security staff and police data. Environmental data (e.g., social and physical environment, serving and drinking practices) were collected. The evaluation indicated the interventions were associated with a reduction in violence and there was evidence of improvement in environmental risk factors. Analysis of system changes (some years later) revealed signiﬁcant increases in the capacity of the formal regulatory system. (65)
Details about these community approaches are well documented in the literature. (40, 87–92)
Comprehensive community-based approaches can also apply to post-secondary environments. In addition to acting as a watchdog, groups representing healthy alcohol programs and policy action on campus can seek to build a rapport and basis for cooperation with a campus pub. (38)
A community coalition within an educational institution can address concerns about licensed retail outlets in the area, and also address the impact of student consumption in off-campus residential settings. Students attending or hosting local parties could be advised in advance about liability issues in relation to service to minors and those who leave intoxicated, about what neighbourhood standards are in regard to annoyance and grounds for complaint and about procedures followed and possible sanctions issued in the event of behaviour that provokes complaint. A campus may see ﬁt to make clear to its students and the surrounding community the extent that it is committed to support area residents and exercise disciplinary jurisdiction over off-campus disturbances caused by students, under the inﬂuence or not. (93)
In partnership with Kingston Police, the Kingston Public Health Unit will arrange for an education session for student leaders prior to orientation about alcohol law and liability.
See details from the examples used in the section Program and Social Marketing, which included evaluation as part of their interventions.
Information from the AGCO
The AGCO Licence Line http://www.agco.on.ca/en/whatwedo/licence_line_archive.aspx
Responsible Service Tip Sheets
Alcohol Frequently Asked Questions (FAQs)
The Community Guide
Preventing Excessive Alcohol Use: Regulation of Alcohol Outlet Density
City of Vancouver
Four Pillars Drug Strategy Program
NOTE: Only Requirements 4 (Workplace Health) and 7 (Community Partners) related to alcohol use are included in this section under Chronic Disease Prevention (CDP), as the focus of this Guidance Document is on the Substance Misuse requirements. See the Healthy Eating, Physical Activity and Healthy Weights; Comprehensive Tobacco Control; and School Health Guidance Documents for detailed information on other components of the Chronic Disease Prevention program standard.
The board of health shall use a comprehensive health promotion approach to increase the capacity of workplaces to develop and implement healthy policies and programs and to create or enhance supportive environments to address the following topics:
Alcohol use is a contributing factor in some workplace injuries, absenteeism, attrition, disciplinary problems, theft, poor morale and lower productivity. (102) Bennett and Lehman (94) identiﬁed that alcohol misuse in the workplace causes approximately 40% of co-workers to experience at least one negative consequence in association with a person’s substance misuse.
The Alcohol Policy Network provides a comprehensive situational assessment in their resource entitled Let’s Take Action on Alcohol Policies in the Workplace, 2004. For more information see http://www.apolnet.ca/resources/pubs/LTA-Workplace.pdf
Presently, some health units offer technical support to workplaces in policy development, frequently through educational sessions targeting employees, or “train the trainer” events for occupational health nurses. The most useful Ontario resource is provided by the Alcohol Policy Network, and is titled Let’s Take Action on Alcohol Policies in the Workplace, 2004. This resource can be printed and provided to workplaces that have an interest in developing a policy. For more information, see http://www.apolnet.ca/resources/pubs/LTA-Workplace.pdf
The Centre for Addiction and Mental Health (CAMH) has also developed materials to support the development of workplace policies on substance use. These can be accessed at http://www.apolnet.ca/thelaw/policies/wkpl_policy_worksheet-CAMH.pdf. The provided worksheet contains a checklist that a workplace can use to develop an overall substance use policy.
In addition to the proper handling of employees with substance misuse problems and exploring how the workplace can contribute to the prevention of problems, workplaces have also been interested in avoiding civil litigation as the result of social events where alcohol is served. Keeping Good Company: An Employer’s Guide to Understanding and Avoiding Alcohol Liability, produced by MADD Canada in 2006, is a good resource for health units interested in supporting workplaces in providing responsible social events. For more information, see http://www.madd.ca/ english/research/liability_employer.pdf
There are best practices in promoting and developing workplace policies consistent with other settings. Simply developing and implementing a written policy on how the workplace views and will respond to alcohol and other drug problems is an effective strategy in itself and provides a good foundation for further interventions. An effective policy should address the following development and content issues:
The Effectiveness of Workplace Interventions to Reduce Substance Misuse, Effective Public Health Practice Project, McMaster University School of Nursing, May 2008 http://www.mhp.gov.on.ca/en/healthy-communities/public-health/guidance-docs/PreventionOfSubstanceMisuse.PDF
Evidence about the effectiveness of information and education programs is inconsistent. Some programs have achieved short-term change, but this change was not sustained. Education can help employees understand why alcohol and drug use can be a problem in the workplace, and this understanding can provide a foundation and rationale for more targeted programs.
While health units are not usually invited to assist a workplace in developing drug testing policies, health units can provide the evidence available on the ineffectiveness of drug testing in response to employer queries.
In Canada, drug testing may be unreasonable and discriminatory and thus conﬂicts with the Canadian Charter of Rights and Freedoms. Some studies have indicated that testing programs reduced drug use and increased productivity, but their methodology was weak and the ﬁndings should be interpreted with caution. Many of the claims cited to justify pre-employment drug screening have been exaggerated.
Please see previous Evaluation and Monitoring sections of this Guidance Document for further information.
The Health Communication Unit (THCU) Virtual Community home page on Workplace
THCU Workplace Health Promotion Project http://www.thcu.ca/Workplace/Workplace.html
Alberta Health Services (now merged with former Alberta Alcohol and Drug Abuse Commission-AADAC) It’s Our Business – Workplace Information Series: http://www.aadac.com/542_1609.asp
SAMHSA’s Drug Free Workplace Kit – resources and tools that workplaces can use to develop drug-free workplace policies and programs
Dr. Graham Lowe
National Quality Institute (NQI)
The board of health shall increase the capacity of community partners to coordinate and develop regional/local programs and services related to:
These efforts shall include:
Alcohol has been identiﬁed as a risk factor for chronic disease, including stroke, diabetes and some cancers. (96,97) Exceeding the Ontario Low-Risk Drinking Guidelines (more than 1-2 drinks per day, with weekly maximums of 14 for men and 9 for women) and heavy drinking can double the risk of ischemic stroke and increase the risk of hemorrhagic stroke two-to-three–fold. (100) Excessive alcohol consumption increases the risk of stroke by raising the blood pressure and contributing to obesity. (98) About 7% of Ontarians aged 45 and over drink at unhealthy levels. Excessive alcohol consumption is a signiﬁ cant, modiﬁable risk factor for stroke and other chronic diseases. One of the recommendations of the Ontario Stroke Strategy is that a population health approach to reducing excessive alcohol consumption and associated health risks be developed and implemented as part of existing health promotion programs.
Alcohol consumption is signiﬁcantly associated with cancer risk. Individuals who consume more than one drink of alcohol per day are at 1.4 times greater risk for breast or colorectal cancer than non-drinkers. (99) If more than two drinks per day are consumed (versus none), the relative risk is greater than one for breast, colorectal, esophagus, liver, pharynx, prostate and stomach cancer. According to Cancer 2020, approximately 25% of men and 10% of women in Ontario drink in a manner that increases their risk of cancer either acutely or over the long run. If the proportion of people consuming alcohol in Ontario were to be reduced by half, an estimated 3.5% of alcohol-related cancers could be eliminated each year, translating into approximately 3,000 less cases over a ﬁve-year period.
Alcohol has gradually been added to the agenda for chronic disease prevention in Ontario.
Men and Women: (104)
Almost one in three drinkers (32%) consumes alcohol at levels exceeding the low risk drinking guidelines.
18-29 year olds:
Weekly heavy drinking increased from 11% in 1995 to 26% in 2007.
Hazardous or harmful drinking increased from 22% in 2002 to 39% in 2007.
Past-year drinking increased from 72% in 1998 to 78% in 2007.
Daily drinking increased from 2.6% in 2001 to 5.3% in 2007.
Hazardous or harmful drinking increased from 5% in 1998 to 8% in 2007.
For chronic disease, the appropriate level of alcohol consumption may be lower than current drinking guidelines. Based solely on the evidence related to cancer, even small amounts of alcoholic drinks should be avoided. Other than abstinence, there is no recommended level of alcohol consumption to reduce the risk of cancer. (101)
Higher costs for alcoholic drinks and more stringent marketing and sale policies contribute to lower levels of consumption and a corresponding lighter burden of public health problems including the incidence of various cancers. (105)
(102) The role of alcohol in chronic disease is particularly important in light of the alcohol consumption habits of the Canadian population. Recorded alcohol consumption increased in Canada from 7.3 litres of absolute alcohol per person aged 15 and over in 1997 to 7.9 litres in 2004. (103)
As discussed previously, alcohol screening and brief intervention can lead to behaviour change. According to a study published in Addiction, the majority of people are comfortable with physician inquiries into their drinking habits, and with advice to cut down where warranted. Very few respondents, however, indicated that their own physician had ever asked about their drinking, provided them with advice on cutting down or provided assistance with alcohol drinking problems. This suggests that public health efforts to engage physicians in recognizing the importance of alcohol consumption on overall health and engaging in brief intervention are valuable. (105)
The National Alcohol Strategy suggests that it is important to encourage health professionals such as doctors, nurses, social workers and allied health professionals to screen and treat those at risk of developing alcohol-related problems. It states that early intervention with problem drinkers would yield enough future savings to health and social services, and to law enforcement and justice, to offset the initial costs. In addition, primary care providers are often the ﬁrst resource that people turn to for help with their alcohol issues. Providing primary care providers with information and resources on alcohol risks can support their uptake and use of health promotion information and tools to help to combat chronic diseases such as stroke and cancer.
Screening and Brief Intervention: Making a Public Health Difference, 2008
Alcohol Screening and Brief Intervention: A Guide for Public Health Practitioners, APHA, 2008
Evidence-based information package from Canadian Cancer Society on effective primary care alcohol interventions for adults: Effective primary care alcohol interventions for adults http://www.cancer.ca/manitoba/prevention/mb-knowledge%20exchange%20network/~/media/CCS/Manitoba/Files%20List/English%20files%20heading/pdf%20not%20in%20publications%20section/KEN%20-%20Adults%20alcohol_1509131489.ashx
Screening and Brief Intervention
This Guidance Document is one of a series that have been prepared by the Ontario Ministry of Health Promotion to provide guidance to boards of health as they implement health promotion programs and services that fall under the 2008 Ontario Public Health Standards (OPHS). This Guidance Document has provided background information speciﬁc to prevention of substance misuse, including its signiﬁcance and burden.
In addition, this Guidance Document has provided information about situational assessments for each OPHS Requirement relevant to prevention of substance misuse, and includes related information about policies, program/ social marketing, evaluation and monitoring issues and the social determinants of health. It also suggests policy direction and strategies for consideration, and examines evidence and rationale.
Achieving overall health goals and societal outcomes will depend on the efforts of boards of health working together with many other community partners, such as non governmental organizations, local and municipal governments, government-funded agencies and the private sector. By working in partnership towards a common set of requirements, Ontario can better accomplish its health goals by reaching for higher standards and adequately measuring the processes involved.
The health of individuals and communities in Ontario is signiﬁ cantly inﬂuenced by complex interactions between social and economic factors, the physical environment and individual behaviours and conditions. Addressing the determinants of health and reducing health inequities will also ensure that boards of health are successful in their efforts.
CH = Child Health
CTC = Comprehensive Tobacco Control
FS = Food Safety
HEHWPA = Healthy Eating, Healthy Weights and Physical Activity
HHPM = Health Hazard Prevention and Management
IDPC = Infectious Diseases Prevention and Control
PHEP = Public Health Emergency and Preparedness
PI = Prevention of Injury
PSM = Prevention of Substance Misuse (including alcohol)
R = Requirement
RH = Reproductive Health
RPC = Rabies Prevention and Control
SH = School Health
SHSTIBI = Sexual Health, Sexually Transmitted Infections, and Blood-borne Infections (including HIV)
SW = Safe Water
TPC = Tuberculosis Prevention and Control
VPD = Vaccine Preventable Diseases
The key subjects for the linkages are:
1) Surveillance; 2) Community Partners; 3) Priority Populations; and 4) Public Education and Social Marketing.
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