Alcohol consumption in Ontario has grown at a relatively rapid pace during the post-war period; per capita consumption of alcohol, expressed in terms of 100 per cent ethanol, has increased from 5.4 litres in 1950 to 9.0 litres in 1978. The locus of alcohol control policy is at the provincial level. The province regulates the marketing and distribution of alcoholic beverages, while the federal government has jurisdiction over the manufacture, importation, exportation and interprovincial trade in alcoholic beverages. The distilling industry is also highly concentrated in a few firms which are mainly subsidiaries or affiliates of multinational corporations. The wine industry is much smaller than the brewing or distilling industries. The most frequently cited attempt to quantify the costs associated with alcohol consumption in Ontario is the study by Holmes in 1976, entitled 'The Demand for Beverage Alcohol in Ontario, 1953 to 1973, and the Cost-Benefit Comparison for 1971'.

Smoking causes health and social problems such as sickness, death, fire, injury, pain and suffering. This paper provides an estimate of the economic burden imposed by the adverse health and social consequences of smoking in Ontario in 1992. The cost-of-illness method, in particular, the human-capital approach is used to estimate the prevalence-based economic costs of smoking. The direct and indirect components of smoking-related costs are estimated and the total cost in Ontario is US$2.91 billion. Associated with these economic costs are health-related harms: 69,318 hospital separations; 1,007,647 days stay in hospitals; 11,648 deaths resulting in more than 171,443 person-years lost.

A coalition of provincial, national and international addictions agencies has sponsored a series of symposia leading to the developing of international guidelines for estimating the costs of substance abuse. These guidelines have now been used in national studies in four continents, with more consistent and comparable results than in previous studies. Although the bottom-line results have been used to argue for alcohol and drug issues having a higher place on the public policy agenda, the real value in such studies lies in the detailed results regarding mortality and morbidity attributable to substance abuse, the relative contribution of acute versus chronic conditions to overall problem levels and the role of substance misuse in adverse social consequences, such as crime and economic productivity. There is a variety of factors which undermine the robustness of the findings, including lack of data, layering of assumptions and changes in the epidemiological knowledge base. It is argued that economic cost estimates should nonetheless be conducted and continually refined, as the detailed findings are of great utility to the design and targeting of prevention programming and policy. The presentation concludes on a personal note of farewell, as this is the author's final conference presentation.

This presentation describes a recently developed set of guidelines for estimating the economic costs of substance abuse, summarizes the findings from a Canadian study that utilized these guidelines, and discusses the implications to the potential development of guidelines for estimating the costs and benefits of gambling. The guidelines for estimating the costs of substance abuse present a general framework of costs to be included and discuss methodological issues such as the definition of abuse; determination of causality; comparison of the demographic and human capital approaches; the treatment of private costs; the treatment of nonworkforce mortality and morbidity; the treatment of research, education, law enforcement costs, the estimation of avoidable costs and budgetary impact of substance abuse, and the significance of intangible costs. Utilizing these guidelines, a study was undertaken to estimate the economic costs of alcohol, tobacco, and illicit drugs to Canadian society in 1992. Based on this experience, it is argued that cost/benefit research should be conducted by multidisciplinary teams, that the real value of such work lies more in the detailed findings than in the bottom line results, and that focus should be placed on developing an ongoing process for developing consensus on how to conduct studies of the costs and benefits of gambling, rather than attempting to find a precise methodology that everyone agrees upon.

The Canadian federal government has promised legislation that will decriminalize the simple possession of cannabis by the summer of 2003. This paper will first review the socio-historical context as it pertains to the criminalization of cannabis use in Canada. Specifically, it will discuss the numerous (unsuccessful) legal and political attempts at cannabis-control reform in the past 30 years, called "the saga of promise, hesitation and retreat" by Giffen, Endicott, and Lambert (1991: 571). It will then review some distinct forces in the current cannabis law reform debate, namely a series of high-profile court cases, patterns of public opinion, and the recommendations of two federal inquiries, all of which contribute to the momentum for reform. After summarizing the diverse landscape of cannabis-control regimes in other Western countries, this paper will examine more closely the actual options that exist for cannabis decriminalization in Canada and their possible effects and implications. Specifically, making simple cannabis possession a civil offence, as suggested, would provide for both discretionary interpretations and net-widening effects in law enforcement and would, in addition, leave the cannabis supply question unresolved.

The problems associated with alcohol use were once largely considered to be primarily due to long-term heavy intake of ethanol. The major causes of death and hospitalization attributed to alcohol use were thought to be chronic diseases such as cirrhosis and alcohol dependence. Until recently, this view was largely supported by available research. The health benefits of alcohol consumption were not well established, and prevailing estimates of alcohol-related mortality indicated chronic disease accounted for most alcohol-related deaths. Based on results of a 1984 Health Canada expert committee regarding the attribution of alcohol to major causes of death, 1 it was estimated that 80% of alcohol-attributable deaths were due to chronic disease and alcohol dependence. 2 Youthful drinking was viewed with benign neglect ‐ although there were concerns that consumption rates established in youth influence lifelong drinking patterns, youthful drinking in itself was not seen as a major component of alcohol-attributable mortality. We now know differently. More recent estimates indicate that acute causes contribute a great deal more to overall levels of alcohol-related mortality than previously thought. 3,4 Unlike earlier results, these estimates are based on specific disease categories controlling for age and gender. They show that accidents, suicide and other acute causes actually account for approximately one half of the deaths caused by alcohol misuse. 5 Furthermore, because such deaths often involve young persons, acute causes account for two thirds of years of potential life lost due to alcohol misuse. 3 Mitic and Greschner’s timely analysis of the role of alcohol in the deaths of British Columbia youth and children 6 corroborate these findings. One could raise questions regarding their exact findings ‐ only a subset of youthful fatalities are available for analysis and, as the authors are well aware, the attribution of causality based solely on whether or not drinking had taken place, is subject to criticism. But combined with evidence from other sources, the primary conclusion of their analysis is undeniable: alcohol plays a major role in the premature death of our children and youth. Given the significance of alcohol to youthful mortality, the key issue is what should be done to enhance the effectiveness of prevention policy and programming. Not long ago, when the primary problems associated with alcohol were chronic conditions stemming from long-term drinking, the answer to this question would have focused on controls over alcohol availability and preventive programming emphasizing the message that drinking less is better. The use of tax policy and availability controls to reduce alcohol problems has certain advantages. Such population-based measures are relatively easy to implement. There is reasonably good evidence that they can reduce levels of drinking and alcohol problems. 7-9 Tax

Two key methodological issues underlying different methods for calculating estimates of the number of alcohol-caused deaths are identified and recommendations suggested for future work. 1. How to adjust alcohol aetiologic fractions across time and place to reflect different levels of risky drinking. A common approach is outlined for both acute and chronic alcohol-related conditions. In the absence of consistent, reliable and regionally specific measures of the prevalence of risky alcohol consumption from national surveys, the use of per capita consumption data as a means of adjusting alcohol population aetiologic fractions over time and across regions is recommended. 2. Whether abstainers or low-risk drinkers should be used as the reference group when assessing the impact of alcohol consumption and how the resulting information is best presented. It is recommended that when abstainers are used as the reference group, the costs and benefits for both 'low-risk' and 'risky/high-risk' drinking should be identified. Using this approach, it was estimated that for Australia in 1998 there was a net benefit of 5,100 lives saved due to low-risk drinking, while there was a net loss of 2,737 lives due to risky/high-risk drinking. On its own, the figure of a net saving of 2,363 lives per year is a simplistic and potentially misleading picture of alcohol as a net benefit to public health and safety. For public health communications, there is still value in providing estimates using the low-risk drinking contrast, of the number of lives saved if risky/high-risk drinkers all became low-risk drinkers (n = 3,292 in 1998). The use of the abstinence contrast, however, allows the more complex picture of alcohol's impact on public health to be apparent, e.g. including the estimated 1,505 deaths associated with low-risk drinking (mostly from cancer).

The author of the present article explores factors that account for variation in drug use and drug-related harm over time. A model of a drug system is presented, consisting of dependent variables, proximate causes and underlying determinants. The dependent variables concern drug use (level and pattern), adverse health consequences and drug-related crime. The major proximate causes of drug use and drug-related harm include drug availability (price and physical availability), attitudes towards use (fear of legal sanctions, health beliefs regarding risks and cultural beliefs) and alternatives to the illicit market (home cultivation and legal intoxicants for users, alternative career and income prospects for sellers). The underlying determinants that influence those proximate causes include policy (drug laws, preventive education and risk management programming) and environmental factors (geographical isolation, climate and fauna, and threat of acquired immunodeficiency syndrome (AIDS) and other infectious diseases). Despite recent improvements in the measurement of problematic patterns of drug use, there is still a paucity of data on patterns of use and drug-related harm. The viability of drug policy is thus often measured in terms of changes in levels of drug use and/or changes in the number of persons detected and charged with drug crimes. Until valid and reliable data are available on its key variables, any model of drug systems will have very limited applicability.

BACKGROUND:In 1996 the number of deaths and admissions to hospital in Canada that could be attributed to the use of alcohol, tobacco and illicit drugs were estimated from 1992 data. In this paper we update these estimates to the year 1995.METHODS:On the basis of pooled estimates of relative risk, etiologic fractions were calculated by age, sex and province for 90 causes of disease or death attributable to alcohol, tobacco or illicit drugs; the etiologic fractions were then applied to national mortality and morbidity data for 1995 to estimate the number of deaths and admissions to hospital attributable to substance abuse.RESULTS:In 1995, 6507 deaths and 82,014 admissions to hospital were attributed to alcohol, 34,728 deaths and 194,072 admissions to hospital were attributed to tobacco, and 805 deaths and 6940 admissions to hospital were due to illicit drugs.INTERPRETATION:The use and misuse of alcohol, tobacco and illicit drugs accounted for 20.0% of deaths, 22.2% of years of potential life lost and 9.4% of admissions to hospital in Canada in 1995.

Evidence is growing that alcohol consumption confers health benefits beyond protection from ischemic heart disease. We review this evidence with regard to cerebrovascular disease, peripheral vascular disease, diabetes, cholelithiasis (gallstones), cognitive functioning, and stress reduction and subjective psychosocial benefits. Other possible benefits are briefly considered. The weight of evidence suggests that low-level alcohol consumption offers some protection against ischemic stroke. The evidence that moderate alcohol consumption protects against diabetes and gallstones is also fairly strong. The possibility of other health benefits cannot be dismissed. For all the conditions considered, more research is indicated. The application of more appropriate statistical techniques, studies of patterns of drinking, and experimental approaches to delineating underlying mechanisms should enable firmer conclusions to be drawn. A better understanding of both the benefits and the risks of alcohol use for individuals and populations will facilitate the development of appropriate program and policy interventions to promote health.

This paper summarises and compares the impacts of cannabis decriminalisation measures in two countries. In Australia, an expiation model of decriminalisation succeeded in avoiding the imposition of criminal convictions for many offenders, but substantial numbers of offenders received criminal convictions because of a general "net-widening" in cannabis offence detections, and the failure of many offenders to pay expiation fees and thus avoid criminal prosecution. Despite these problems, the expiation approach has been cost-effective, reducing enforcement costs without leading to increased cannabis use. In the United States, cannabis decriminalisation similarly reduced enforcement costs, with enforcement resources generally redirected toward trafficking and other illicit drugs. There were no increases in cannabis use or substantial problems that could be ascribed to decriminalisation. The implications for other countries are discussed, with particular attention to the importance of implementation issues, monitoring, and evaluation. Although decriminalisation has succeeded in reducing enforcement and other costs without increasing the problems associated with cannabis use, the same impacts would not necessarily result from the legalisation of cannabis or the decriminalisation of other illicit drugs.

This paper provides an overview of the context, definition, and key features of the harm reduction approach, and provides several examples of current programs in various countries. Both licit and illicit drugs are included in these illustrations. Some of the critical issues, and the strategies needed to advance harm reduction, are discussed. [Translations are provided in the International Abstracts Section of this issue.]

There is a strong interest in many countries regarding the development of scientifically valid, credible estimates of the economic costs of tobacco as well as other forms of substance abuse. The costs of drugs is an issue of key interest to stakeholders, policy makers and the media. Knowledge of the costs of resources associated with drug abuse informs decisions related to funding and to interventions which are designed to reduce abuse. Relatively few countries have attempted to estimate the costs of substance abuse. Such estimates are fraught with methodological difficulties resulting in widely varying estimates.

In 1997 the Addiction Research Foundation of Ontario and Canadian Centre on Substance Abuse released updated guidelines for low-risk alcohol consumption. This paper presents the scientific rationale behind this statement. Important comprehensive overviews on the consequences of alcohol use were studied. Formal meta-analyses on morbidity and mortality were examined wherever possible. Individual elements from similar guidelines were investigated for their scientific foundation. Limited original analyses defined risk levels by average weekly consumption. The evidence reviewed demonstrated that placing limits on both daily intake and cumulative intake over the typical week is justifiable for the prevention of important causes of morbidity and mortality. Gender-specific limits on weekly consumption were also indicated. In these updated guidelines intended for primary prevention, days of abstinence are not necessarily recommended. Intoxication should be avoided and abstinence is sometimes advisable. Available evidence does not strongly favour one alcoholic beverage over another for cardiovascular health benefits.

Substance abuse not only adversely affects the health of users, but also imposes economic and other burdens on those around them and the society at large. Estimates of the economic costs of substance abuse are in demand by health planners, policy makers and researchers. This paper estimates selected economic consequences of substance abuse in Ontario in 1992.The cost-of-illness method, in particular, the human capital approach, is used. In addition to employment earnings, employee fringe benefits and the value of housekeeping for both men and women in and outside of the labour force are taken into account when computing productivity losses due to premature death. The costs of hospital care plus productivity losses associated with premature death are estimated to be Cdn $4.42 billion in 1992 for the province of Ontario. It is also found that the harm associated with substance abuse is higher for men than for women.

OBJECTIVESThis study estimated morbidity and mortality attributable to substance abuse in Canada.METHODSPooled estimates of relative risk were used to calculate etiologic fractions by age, gender, and province for 91 causes of disease or death attributable to alcohol, tobacco, or illicit drugs.RESULTSThere were 33,498 deaths and 208,095 hospitalizations attributed to tobacco, 6701 deaths and 86,076 hospitalizations due to alcohol, and 732 deaths and 7095 hospitalizations due to illicit drugs in 1992.CONCLUSIONSSubstance abuse exacts a considerable toll on Canadian society in terms of morbidity and mortality, accounting for 21% of deaths, 23% of years of potential life lost, and 8% of hospitalizations.

BACKGROUND:There are no standardized ways to assess alcohol consumption in epidemiological studies. The main objective of the present study was to compare three widely used methods for assessing alcohol consumption with respect to resulting prevalence estimates for high risk drinking and harm as defined by morbidity and mortality indicators.METHODS:A within-subjects design was used to compare a quantity frequency, a graduated frequency, and a weekly drinking recall measure. Data consisted of a representative sample of 3961 adult residents of the province of Ontario, Canada, who participated in a multi-wave cross-sectional survey between 1990-1994. Cross-tabulation, Spearman correlation, and standard methodologies for prevalence-based cost-of-illness studies were used.RESULTS:The graduated frequency measure consistently yielded higher estimates of the prevalences of high risk drinking and harm. Differences were marked on all indicators, but were most pronounced for harmful drinking as defined by consuming an average of >60 g pure alcohol per day for males, and >40 g per day for females. Prevalence estimates of harmful drinking were almost five times higher for graduated frequency versus weekly drinking measures, and almost three times higher for graduated frequency versus quantity frequency measures.CONCLUSIONS:The characteristics of different measures of alcohol consumption should be considered in future research in epidemiology.

Welcome to the Harm Reduction Digest, where in each regular edition of Thug and Alcohol Review invited co-authors will contribute to pieces on the theory and practice of harm reduction. While the focus of subsequent HR Digests will be accounts of the practice of harm reduction interventions, programmes and policies from around the world, it was decided that the first Digest ought to address the definition of Harm Reduction. Consequently the style of this digest is probably more formal than most that will follow it. Many of you will have read DAR's special issue on harm reduction (1995, 14(3)) where Alex Wodak, Bill Saunders, Patricia Erickson, Eric Single and Nick Heather all addressed the issue of definition in their respective contributions. Since this there have been a handful of papers and reports which have also grappled with the issue of definition. Co-author of this piece is Professor Eric Single, from the Department of Public Health Sciences at the University of Toronto. Eric addressed issues around the definition of harm reduction in the 1996 Dorothy Black lecture in London and, with Professor Timothy Rohl, as independent evaluators of Australia's National Drug Strategy, wrote on the topic in their report ‘Mapping the Future’.