DRINKING PATTERNS AND PERSPECTIVES ON ALCOHOL POLICY: RESULTS FROM TWO ONTARIO SURVEYS

NORMAN GIESBRECHT*, ANCA IALOMITEANU and LISE ANGLIN

Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario M5S 2S1, Canada

* Author to whom correspondence should be addressed at: Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario M5S 2S1, Canada. Tel.: +1 416 535 8501 (ext. 6895); Fax: +1 416 595 6899; E-mail: Norman_giesbrecht{at}camh.net

(Received 16 July 2004; first review notified 9 August 2004; accepted in revised form 25 October 2004)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: Previous research has shown that heavier drinkers, in comparison to light drinkers or abstainers, are more likely to favour increased access to alcohol and relaxation of control policies. Often, studies have not examined whether attitudes to alcohol policies vary according to a respondent's pattern of drinking. This study examined the association between drinking variables and views on policy, using six drinking variables and six topics on alcohol policy. Methods: Data were available from two Ontario surveys conducted in 2000 and 2002, which took representative samples of adults, aged 18 and older, selected by random digit dialling, who participated in interviews over the telephone (n = 1294 and 1206, respectively). Drinking variables include drinking status, drinking frequency, usual number of drinks, typical weekly volume, frequency of 5+ drinks per occasion and Alcohol Use Disorders Identification Test (AUDIT) scores. Six policy items were examined: alcohol taxes, warning labels, density of retail alcohol outlets, privatization of government liquor stores, alcohol advertising and consultation with health experts on decisions on alcohol policy. Logistic regression analyses included five demographic variables: gender, age, marital status, education and income. Results: Among males, there was strong support for increased access to alcohol and fewer controls over alcohol policies. This relationship, although not as strong, also emerged for frequent consumers, high volume drinkers and those with a higher AUDIT score. Conclusion: Whether it is intentional or not, government policies that tend to make alcohol more available cater to young, heavy-drinking males who possibly experience problems in connection with their drinking behaviour.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Social science literature on public opinion relating to alcohol policies has grown steadily in the past 15 years. This literature emerges from many countries, including Australia (Hawks et al., 1993Go; Shanahan and Hewitt, 1999Go), Canada (Giesbrecht and Kavanagh, 1999Go; Anglin et al., 2004Go), Finland (Ahlström and Österberg, 1992Go), Ireland (Hope, 2003Go), New Zealand (Casswell et al., 1989Go; Sellman and Ariell, 1996Go), the UK (Alcohol Policy, 2000; Lancaster and Dudleston, 2001Go; Kara and Hutton, 2003Go), the USA (Schmidt et al., 1990Go; Wagenaar and Streff, 1990Go; Hilton and Kaskutas, 1991Go; Room et al., 1995Go; Wagenaar et al., 2000Go; Harwood et al., 2002Go; Latimer et al., 2003Go) and six European countries (Hemstrom, 2002Go).

The rationale for such research is varied. In some cases the focus is on rank ordering of support across alcohol policy topics. In the North American context, there is a rough rank order of level of support across alcohol policies, with typically greater generalized support for those policies that are more narrowly focused, such as interventions by alcohol servers to cut off service to persons perceived to be intoxicated; unobtrusive, such as warning labels about the risks of drinking placed on beverage containers; and generic and vague, such as increased prevention and treatment interventions (Kaskutas, 1993aGo). There is usually less support for those policies that control access to alcohol and potentially affect all consumers, such as higher taxes on alcoholic beverages, reduced density of outlets and shorter hours of sale (Giesbrecht and Greenfield, 1999Go).

Another aim of such research is to identify demographic groups that tend to support or oppose certain policies (Anglin et al., 2001Go). Older adults and women are found to be more supportive of policies on alcohol control than are younger adults and men.

Sometimes the goal is to plot changes in public opinion over time (Kaskutas, 1993bGo; Room et al., 1995Go; Giesbrecht et al., 2001Go), with certain core items used repeatedly to monitor trends. In the USA, there is evidence of gradual declining support for most alcohol policies examined in surveys between the late 1980s and 1990s (Kaskutas, 1993bGo; Room et al., 1995Go; Giesbrecht and Kavanagh, 1999Go; Giesbrecht et al., 2001Go).

The research also explores the relationship between public opinion and actual policy (e.g. Room et al., 1995Go; Giesbrecht and Kavanagh, 1999Go; Anglin et al., 2003Go). Researchers ask whether public opinion influences policy or vice versa (Casswell et al., 1989Go; Kaskutas, 1993aGo), and what accounts for differences in opinion across countries (Giesbrecht and Greenfield, 1999Go) and variations over time in public opinion as policies change (Ahlström and Österberg, 1992Go).

The views of the respondents on alcohol policies may relate to their self-reported drinking, such as drinking status, level of alcohol consumption and drinking patterns. In some studies, the heaviest drinkers were least likely to support alcohol policies, particularly those policies that reduce access to alcohol (Kaskutas, 1993bGo; Wagenaar et al., 2000Go; Anglin et al., 2001Go).


    RATIONALE AND PREVIOUS STUDIES
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
This paper focuses on the last theme: the association between the drinking patterns of respondents and their views on alcohol policy. The topic has both technical and practical dimensions. One question is whether the association between drinking and views on policy is consistent across drinking variables. If not, what might explain the differences with regard to a specific policy item or across policy items?

A frequent rationale for increasing access to alcohol and for reducing checks and balances is that of perceived consumer demand (Liquor Control Board of Ontario [LCBO], 2003bGo). Therefore, a second question is whether support for greater convenience and access is evident among all types of consumers or mainly among the prolific buyers of alcohol.

The drinking variables that are considered in connection with views on alcohol policy can be grouped into several categories. These include: typical drinking frequency in the past 12 months; drinking volume (number of drinks on drinking occasions or in the past 30 days); higher-risk drinking (frequency of drinking five or more drinks on an occasion); and various combinations of drinking frequency and drinking volume (graduated frequency scale). [For an analysis of various measures of alcohol consumption, see Room (1990)Go, Dawson et al. (1998)Go and Poikolainen et al. (2002)Go].

This study extends the examination of the association between drinking variables and views on policy by including questions that tapped at least indirectly into both past and current drinking-related problems. We wanted to know whether or not variations in the association between a policy question and drinking behaviour would be detected, if the measure of drinking pattern included several variables, such as drinking frequency, usual number of drinks, typical weekly volume, frequency of 5+ drinks per occasion and Alcohol Use Disorders Identification Test (AUDIT) scores.


    METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In this paper, the alcohol consumption measures are based on standard drinking questions included in recent years in the Centre for Addiction and Mental Health (CAMH) annual CAMH monitor survey. They included some of the quantity/frequency variables noted in the previous paragraph, plus two other variables that are less commonly used in this literature, namely a drinking status variable and the AUDIT score. The drinking status variable has three values: current drinker (past 12 months), lifetime abstainer and former drinker. Although it is a reasonable conjecture that the last group would probably include those who once drank heavily, this cannot be demonstrated, since only those who had been drinking in the past 12 months were asked questions about their drinking frequency, volume of drinking, peak drinking or those from the AUDIT.

The data are based on two probability surveys, in each case using representative samples from the Ontario survey, with comparable design, interviewing and data preparation techniques. The surveys are the 2000 and 2002 cycles of the CAMH Monitor, a repeated cross-sectional telephone survey of Ontario adults (aged 18 or older), conducted by CAMH and administered by the Institute for Social Research, York University. The surveys employ random-digit-dialling methods via computer assisted telephone interviewing. Each cycle consists of 12 independent monthly samples with ~200 completions. Monthly effective response rates ranged from 58 to 61%. (For sampling design details see Adlaf and Ialomiteanu, 2001Go; 2003Go). The items on alcohol policy were included in the surveys for the 6 month period from July to December, for both survey years.

The first three opinion items on alcohol policy were included in the 2000 cycle of the survey (n = 1294) and asked whether: (i) taxes on alcoholic beverages should be increased, decreased or remain the same; (ii) alcoholic beverages should have warning labels (yes or no); and (iii) the government should prohibit wine, liquor and beer advertising on TV (yes or no). The other three items were included in the 2002 cycle of the survey (n = 1206) and asked whether: (iv) the number of places where alcohol can be bought in the community is too few, too many or about right; (v) governments should be required to consult with health experts before making legislation or policy changes in the way alcohol is sold (strongly agree, somewhat agree, somewhat disagree, strongly disagree); and (vi) the Ontario government should close all LCBO stores (i.e. government retail outlets) and allow privately run stores to sell alcohol (strongly agree, somewhat agree, somewhat disagree, strongly disagree). Thus, the policy questions included a combination of items used numerous times since 1989 when asked initially as part of Canada's National Alcohol and Other Drugs Survey (NADS) (Eliany et al., 1992Go) (items i to iv) as well as two new questions (items v and vi) asked in the Ontario CAMH Monitor.

Demographic factors employed in our analysis include gender, age, marital status, education and income. Alcohol measures included drinking status, drinking frequency in the past 12 months, usual number of drinks consumed on those days when the respondent drank, weekly volume of drinks consumed (derived from the product of drinking frequency and the usual number of drinks), frequency of consuming five or more drinks on one occasion in the past 12 months and the AUDIT, designed to detect problem drinkers at the less severe end of the spectrum of alcohol problems (see Saunders et al., 1993Go; Reinert and Allen, 2002Go). The 10 AUDIT items focus on drinking frequency, volume, heavy consumption and frequency of various disruptive experiences due to alcohol. We use the generally accepted cut-off score of 8 or more on the AUDIT as an indication of problem drinking (Reinert and Allen, 2002Go; Carey et al., 2003Go).

The results are based on 'valid' responses (n) such that missing data (i.e. 'don't know' and refusals) are excluded. The percentages reported are based on weighted sample sizes and are considered representative for the population surveyed.

Logistic regression analyses were conducted to assess the impact of alcohol factors on public views on alcohol policy when controlling for demographic factors (gender, age, marital status, education and income). To avoid excessive inter-correlation among alcohol measures, the following drinking variables were included: (i) weekly volume of drinks consumed (computed from the product of drinking frequency and usual number of drinks), (ii) frequency of consuming five or more drinks on one occasion in the past 12 months (used to assess episodic heavy drinking) and (iii) an AUDIT score of 8 or more (used to assess high-risk drinking and drinking-related disruptions).


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The frequencies, based on all valid responses, indicate that there was considerable variation in the level of support for either increased access to alcohol or relaxation of control measures.

Demographic characteristics and views on alcohol policy
We present cross-tabulations between demographic characteristics of respondents and six alcohol policy questions. We focus on the proportion that were opposed to interventions, health messages and controls or favoured increased access to alcohol. A minority was opposed to the policy interventions examined here, with the exception of a ban on alcohol advertising on television and radio where a majority was opposed (see above, also Table 1). A greater proportion of males than females was in favour of greater access to alcohol and opposed to interventions. The variation based on age was not significant, with the exception of the item on banning advertising, where less than half the respondents aged 65 and older were opposed, compared with 60–70% for younger age groups. Those aged 18–29 were more likely to be opposed to a ban on alcohol advertising than those aged 65 and older. Marital status was significantly related to views on warning labels: the never married and those widowed were most likely to oppose them. Those who were divorced or separated were least likely to oppose a ban on alcohol advertising.


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Table 1. Alcohol policy items by demographic characteristics among total sample

 
The proportion supporting decreased taxes on alcohol was significantly higher among the less educated than among those with a university degree. The opposite pattern emerged with regard to the warning label question: the proportion opposed was greatest among those with a higher education. The association between views on alcohol policy and income was significant for the warning label and advertising questions. The proportion opposed to warning labels was higher among those with a higher income level; a similar pattern is evident with regard to opposition to a ban on alcohol advertising.

Drinking patterns and views on policy
The cross-tabulations summarized in Table 2 show a statistically significant relationship between each drinking variable and each policy question. (This is in contrast to Table 1 where most relationships between demographic variables and policy items were not statistically significant.) In most cases the pattern is linear, with the highest support for greater access to alcohol, for example, found among those who drink most often, drink the largest volumes, have more than five drinks on an occasion most often or score 8+ on the AUDIT scale.


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Table 2. Alcohol policy items by drinking characteristics among total sample

 
The drinking status variable shows that current drinkers are more likely than former drinkers to favour greater access to alcohol and oppose interventions with regard to alcohol taxes, an advertising ban and warning labels. However, 15% of former drinkers versus 11% of current drinkers wanted more bars. Moreover, the former drinkers were more likely than current drinkers to favour the closing of LCBO and full privatization.

In contrast to infrequent drinkers, those who drank frequently were more likely to favour a decrease in alcohol taxes, oppose warning labels, oppose a ban on advertising, claim that there were not enough bars, favour the closing of LCBO stores and disagree on government consulting with health experts on questions on alcohol policy. A similar generalized pattern is evident for the questions focusing on usual number of drinks and weekly drinking volume (derived variables based on typical frequency and typical volume).

Similarly, those who had five or more drinks per occasion on a weekly basis were more likely than other respondents to favour greater access to alcohol and be opposed to controls or interventions. The results for those scoring 8+ on the AUDIT are also in line with this pattern.

Logistic regression analyses
The logistic regression analyses (Table 3) indicate that the results from the cross-tabulations are a good signal of what to expect. Taking into account the confidence intervals, the odds ratios are significant for gender for four policy items, with males more likely than females to support greater access or reduced policy interventions. The odds ratios are noteworthy for age only with regard to two items. There is a significant relationship between being aged 65+ and not being opposed to a ban on alcohol advertising. In contrast, there appears to be a weak association between being aged 50 or more and being in favour of closing LCBO stores. Compared with those who had never married, married respondents were least likely to oppose warning labels. In general, education and income were not significantly associated with views on alcohol policies, with two exceptions: those with a university degree were opposed to warning labels and those with an income of $50 000 to $79 000 were opposed to a ban on alcohol advertising.


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Table 3. Alcohol policy items and drinking—logistic regression

 
For several of the models, the odds ratios are significant for the three drinking variables used in these analyses, although in all cases this is at the P < 0.05 level and the confidence intervals suggest that it is a tenuous association in most instances. Support for lower taxes on alcohol was evident among those who drank five or more drinks per occasion weekly, had a high weekly volume or scored 8+ on the AUDIT. With regard to opposition to warning labels, there was an association with regard to those who had five or more drinks per occasion weekly or had a high weekly volume. There is an association between a high AUDIT score and an opposition to a ban on alcohol advertising. Those having five plus drinks weekly were likely to be opposed to consulting with health experts before government policy decisions are made. There is an association between a high weekly volume and the view that LCBO stores should be closed and a private system initiated.

In summary, there is a strong association between gender and views on alcohol policies, particularly with regard to taxation, warning labels and alcohol advertising variables: in comparison to females, males are supportive of greater access to alcohol or fewer controls. The odds ratios also show an association between heavier drinkers and support for greater access or fewer controls. This is evident for several of the six drinking and policy combinations with regard to both five plus drinks on an occasion and weekly alcohol volume. The odds ratios are also significant for two of the six combinations in the comparisons involving AUDIT scores and policy variables (Table 3).

However, in contrast to the association between gender and views on alcohol policy, these latter associations are not as strong. The finding that the levels of significance are typically at P < 0.05, and that odds ratios show lower confidence intervals near 1.0 or less, suggests weak associations between drinking variables and views on alcohol policy in these analyses. The findings with regard to the drinking status variable (Table 2) indicate that former drinkers tend to be less supportive of greater access to alcohol than current drinkers.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
These outcomes suggest that among those who might have experienced drinking-related problems at one time and decided to quit, i.e. the former drinkers, there may be less enthusiasm for greater access to alcohol or reduction in controls. However, we do not know the causal vectors from this cross-sectional data. For example, did an increase in awareness of personal drinking-related harm and problems contribute to a change in perspective on alcohol policy? Or, alternatively, did a change in perspective on policy, due to factors other than personal drinking-related problems, lead to increased awareness of personal experiences of harm from alcohol? Future research might examine these questions in more detail. For example, it would be interesting to see the variation in views on policy among former and current heavy drinkers, differentiated further by those with or without drinking-related problems. This exploration might be pursued by means of a pilot study or key informant methodology.

It is noteworthy that the odds ratios for drinking variables and policy questions do not approach the high levels evident for gender, where five of the six comparisons were significant. Males typically show more support for higher access to alcohol and reduced controls. The one exception was that of consulting with health experts. Here the odds ratio for males and opposition to consulting with health experts was elevated but not significant.

Significantly higher odds ratios are evident for both gender and drinking variables for the item about taxes, followed by the item on warning labels. In contrast, the item about consulting with health experts did not produce significantly higher odds ratios, with the exception of those having five plus drinks weekly.

It appears that gender and drinking pattern predict views on several topics on alcohol policy. However, this does not mean that the drinking variables are interchangeable. As Table 3 indicates, the odds ratios were consistently higher for the five plus drinks weekly variable than the weekly alcohol volume variable. Those with frequent peak drinking events are likely to support lower taxes, be opposed to warning labels and be opposed to consulting with health experts about options on alcohol policy.

One criticism against general measures on alcohol policy is that they potentially impact the total population and thus unnecessarily interfere with the consumption of light and moderate drinkers. In contrast, our results suggest that it is the heavier drinkers who are most opposed to (and therefore, by inference, inconvenienced by) some of these general measures, and not the light and moderate drinkers.

There are many decisions that the government of a Canadian province makes about access to alcohol: changing prices, changes in the density of outlets, whether to privatize liquor retailing systems and whether to introduce warning labels on alcoholic beverage containers. One interpretation is that measures such as extending hours of sale, increasing outlet density and extensive marketing and promotion of alcohol outlets and products are, in part, in response to consumer demand and will be of special benefit to the social and responsible drinker (LCBO, 2003bGo). A related perspective is that such changes do not increase high-risk drinking or raise the population level of damage due to alcohol. However, a general goal of these changes in access and promotion appears to be that of generating greater sales and revenues (LCBO, 2002Go, 2003bGo) and to do so in a way that caters to the most loyal customers (LCBO, 2003aGo).

Thus, there appears to be reciprocity among several changes in the distribution system, the drinking culture and the views of those who drink the most or most frequently. For example, a UK national opinion poll conducted in 2000 found that the majority (59%) said it would be a 'bad thing' to extend drinking hours at night. However, it was also noted that a substantial majority of those who habitually drink beyond the safe limits 'thought extended hours was a good thing' (Alcohol Policy, 2000, p. 14). And, as is the case elsewhere, there also appears to be strong reciprocity between deregulation of alcohol controls in the UK and the interests of various sectors of the alcohol industry (Appleby, 2000Go; Drummond, 2000Go; 2004Go).

It is also conceivable that increasing access to alcohol through increased density of outlets, longer hours of sale and greater promotion and marketing has an impact on cultural views of alcohol and thus, perpetuates support for further erosion of controls. Although it is hard to assess this idea from cross-sectional data, results from surveys over 11 years point to a gradual erosion of public support for effective health-oriented alcohol policies. This erosion occurred during a period when access to alcohol was increasing in Ontario (Giesbrecht et al., 2001Go).

However, an extensive promotion of alcohol and easy access to alcohol products might also contribute to a contrary reaction. A cross-sectional comparison of Canada and the USA with regard to public opinion on alcohol policies suggests some support for this alternative interpretation. In the USA, for example, there are fewer controls on alcohol advertising. Given the modest levels of taxation on alcohol, real prices also tend to be lower than in Canada. Nevertheless, in 1990 the proportions supporting a ban on advertising and higher alcohol taxes were greater in the USA than in Canada (Giesbrecht and Greenfield, 1999Go).

By the mid-1990s alcohol management in Ontario was already placing a strong emphasis on alcohol marketing, promotion and retailing techniques. Although this orientation expanded what had been undertaken some years earlier, it appears to have been particularly stimulated by the threat of privatization when the Progressive Conservatives were elected in 1995. In addition, this perspective was probably reinforced by an assumption that privatization was a definite possibility if there was not increased revenue from alcohol sales.

These changes included a further commitment to create a modernized and aggressively run liquor management system using highly sophisticated marketing and retailing techniques. For example, senior staff were hired at the LCBO with extensive generic skills in retailing, promotion and marketing. These retailing methods were applied to marketing alcoholic products and produced an expanded and enhanced approach to advertising, promotion and retailing of products sold in the government liquor board stores. During these years there was an increase in alcohol-related revenue for the provincial government (LCBO, 2002Go, 2003aGo). Nevertheless, full privatization, though periodically mentioned, has not occurred.

It is likely that these developments are also seen favourably by those who use alcohol products most frequently (heavier drinkers). Given that ~50% of the alcohol is consumed by ~10% of the population (Greenfield and Rogers, 1999Go), one wonders whether a primary goal of these changes in access is really limited to that of providing products in a more convenient way to be used responsibly by moderate social drinkers. Is it possible that these changes are also oriented to those consumers who contribute to such a large share of overall sales, revenue and total consumption levels? In light of the substantial rates of death and damage from alcohol, one wonders whether in an age of consumerism those who make alcohol policy pay sufficient attention to public health interests (see Babor et al., 2003Go, p. 263; Dunning, 2004).

The fact that some consumers derive more benefit from, and support, certain policy changes more than others does not necessarily prove that the so-called best customers (the minority who purchase the most alcoholic beverages) are a prime target of marketing campaigns and new operational strategies. Nevertheless, what are the policy and public health implications if the support for policies is particularly evident among those who are most likely to experience alcohol related harm themselves and to inflict it upon others from alcohol consumption? Should there not be careful analyses, prior to policy changes, which look at the social and health impact of such initiatives both at the aggregate and individual levels?

In any case, at least some of the heavy consumers appear to be dissatisfied with the changes so far and look towards privatization—possibly expecting greater competition, even higher density of alcohol outlets and lower prices, with a dramatic change in the system. For example, in this study, those who support the closing of government liquor stores and privatizing are mainly the heavy drinkers (Tables 2 and 3). Despite the increased access to alcohol, extensive promotion and greater convenience that has emerged under a modernized and commerce-oriented government-run system, particularly in the past decade, for some consumers there is less loyalty to the system than to the product.


    ACKNOWLEDGEMENTS
 
This is a revised version of a paper presented at the 30th Annual Meeting of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol, University of Helsinki, Finland, May 31st to June 3rd, 2004. It is based on the CAMH Monitor survey conducted by Edward Adlaf and his colleagues at the Centre for Addiction and Mental Health. Each year the alcohol policy questions are chosen—either from a list of previously asked questions, or new draft questions—by members of the CAMH Alcohol Policy and Research Group. We are pleased to acknowledge the contributions of Janet McAllister and her colleagues for their input in developing some of the policy questions reported here. Thomas Greenfield and Pia Mäkelä also provided advice and comments. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the persons acknowledged or the policies of CAMH.


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 RATIONALE AND PREVIOUS STUDIES
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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