Description | Specific Indicators | Ontario Public Health Standards | Corresponding Health Indicators from Statistics Canada and CIHI |  Data Sources |  Survey Questions | Analysis Check List | Method of Calculation |  Basic Categories | Indicator Comments | Definitions |  Cross-References to Other Indicators | Cited References | Changes Made | Acknowledgements

Description

• Proportion of the population, aged 12 and over, who reported drinking 5 or more drinks on at least one occasion per month in the past 12 months.

Specific Indicators

• Proportion of the population with a heavy drinking episode on at least one occasion per month

Ontario Public Health Standards

• The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.

Outcomes Related to this Indicator

• Societal Outcome (Chronic Disease Prevention): There is increased adoption of behaviours and skills associated with reducing the risk of chronic diseases of public health importance.
• Societal Outcome (Prevention of Injury and Substance Misuse): Sustained behaviour change by the public contributes to the prevention of injury and substance misuse.
• Societal Outcome (Prevention of Injury and Substance Misuse): There is a reduced incidence and severity of substance misuse and substance-related injuries, hospitalizations, disabilities and deaths.

Assessment and/or Surveillance Requirements Related to this Indicator

• The board of health shall conduct epidemiological analysis of surveillance data...in the area of alcohol use (Chronic Disease Prevention Program).
• The board of health shall conduct epidemiological analysis of surveillance data...in the area of alcohol and other substances (Prevention of Injury and Substance Misuse Program).

http://www.ontario.ca/publichealthstandards

Corresponding Health Indicators from Statistics Canada and CIHI

• Frequency of Drinking (Heavy Drinking): Population aged 12 and over who are current drinkers and who reported drinking 5 or more drinks on at least one occasion per month in the past 12 months.

http://www.statcan.gc.ca/

Click on "Publications"
Type "Health Indicators" into search box
Scroll down and click on the html version of "Health Indicators"
Click on "Data tables and maps" and then "Frequency of drinking"

Note: As of June 25, 2009, Statistics Canada Health Indicators will be changing their definition to include the total population in the denominator. This will match the APHEO Core Indicator. Previously, the indicator was based only on current drinkers.

Data Sources

Numerator & Denominator: Canadian Community Health Survey (CCHS)
Original source: Statistics Canada
Distributed by:
1. Ontario Ministry of Health and Long-Term Care
2. Statistics Canada
Suggested citation (see Data Citation Notes):
1. Canadian Community Health Survey [year], Statistics Canada, Share File, Ontario Ministry of Health and Long-Term Care
2. Canadian Community Health Survey [year], Statistics Canada, Public Use Microdata File, Statistics Canada

Survey Questions

The Canadian Community Health Survey (CCHS) has an Alcohol Use module (core content) that includes a question about the frequency of having five or more drinks on one occasion.

Analysis Check List

CCHS

• Combine responses 3 to 6 to get a frequency of heavy drinking of at least once per month in the past 12 months.
• It is recommended that ‘total population' be used as the denominator. Therefore, non-drinkers (i.e. those who are ‘Not Applicable') need to be added to the denominator. ‘Total number of current drinkers' (ALCn_1 = 1) may be considered for the denominator for a supplemental indicator.
• It is recommended that public health units use the Share File provided by the Ministry of Health and Long-Term Care rather than Public Use Microdata File (PUMF) provided by Statistics Canada. The Share File has a slightly smaller sample size because respondents must agree to share their information with the province to be included; however, the share file has more variables and fewer grouped categories within variables. The Share File is a cleaner dataset for Ontario analysis because all variables that were not common content, theme content or optional content for Ontario have been removed.
• There may be slight differences between results from the share file and data published on the Statistics Canada website for the Health Indicators because rates calculated for Health Indicators use the master CCHS data file.
• Users need to consider whether or not to exclude the ‘Refusal, 'Don't Know' and ‘Not Stated' response categories in the denominator. Rates published in most reports, including Statistics Canada's publication Health Reports generally exclude these response categories.  In removing not stated responses from the denominator, the assumption is that the missing values are random, and this is not always the case.  This is particularly important when the proportion in these response categories is high.
• Estimates must be appropriately weighted (generally the share weight for the CCHS) and rounded.
• Users of the CCHS Ontario Share File must adhere to Statistics Canada's release guidelines for the CCHS data when publishing or releasing data derived from the file in any form. Refer to the appropriate user guide for guidelines for tabulation, analysis and release of data from the CCHS. In general, when calculating the CV from the share file using the bootstrap weights, users should not use or release weighted estimates when the unweighted cell count is below 10. For ratios or proportions, this rule should be applied to the numerator of the ratio.  Statistics Canada uses this approach for the tabular data on their website. When using only the Approximate Sampling Variability (CV) lookup tables for the share file, data may not be released when the unweighted cell count is below 30. This rule should be applied to the numerator for ratios or proportions.  This provides a margin of safety in terms of data quality, given the CV being utilized is only approximate.
• Before releasing and/or publishing data, users should determine the CV of the rounded weighted estimate and follow the guidelines below:
• Acceptable (CV of 0.0 - 16.5) Estimates can be considered for general unrestricted release. Requires no special notation. 
• Marginal (CV of 16.6 - 33.3) Estimates can be considered for general unrestricted release but should be accompanied by a warning cautioning subsequent users of the high sampling variability associated with the estimates. Such estimates should be identified by the letter E (or in some other similar fashion). 
• Unacceptable (CV greater than 33.3) Statistics Canada recommends not to release estimates of unacceptable quality. However, if the user chooses to do so then estimates should be flagged with the letter F (or in some other fashion) and the following warning should accompany the estimates: "The user is advised that...(specify the data)...do not meet Statistics Canada's quality standards for this statistical program. Conclusions based on these data will be unreliable and most likely invalid". These data and any consequent findings should not be published. If the user chooses to publish these data or findings, then this disclaimer must be published with the data.
• Caution should be taken when comparing the results from Cycle 1.1 (2000/01) to subsequent years of the survey, due to a change in the mode of data collection.  The sample in Cycle 1.1 had a higher proportion of respondents interviewed in person, which affected the comparability of some key health indicators.  Please refer to http://www.statcan.gc.ca/imdb-bmdi/document/3226_D16_T9_V1-eng.pdf for a full text copy of the Statistics Canada article entitled "Mode effects in the Canadian Community Health Survey: a Comparison of CAPI and CATI".

Method of Calculation

Prevalence of heavy drinking episodes:

Weighted number of respondents aged 12+ who reported drinking 5 or more drinks on at least one occasion per month during the past 12 months Weighted total population aged 12+

X 100

Basic Categories

• Age groups for age-specific rates: 12-19 (teens), 20-44, 45-64, 65+, 20+ (adults), 12-18 (underage)
• Sex: male, female
• Geographic areas for: CCHS - all 36 Public Health Units

Indicator Comments

• Most studies define heavy drinking episodes as occasions on which five or more drinks were consumed; however, this number is used mainly because of tradition rather than empirical study. Risk appears to increase in a roughly linear manner with the amount consumed.¹
• In Canada, one "standard drink" is equal to 13.6 grams of alcohol.  Alcohol is found in different amounts in different kinds of drinks (i.e. regular strength beer, table wine, fortified wine, liquor).²
• The Low-Risk Drinking Guidelines recommend that individuals of legal drinking age drink no more than 2 standard drinks on any one day.³
• Current drinkers who engage in episodes of heavy drinking are at higher risk of developing alcohol-related problems. These people may not drink frequently and may have a relatively low daily average consumption; however, they tend to drink excessively on some occasions.
• This indicator is sometimes referred to as binge drinking. Since the clinical definition of binge drinking is quite different, the indicator was renamed to episodes of heavy drinking.
• Since heavy drinkers are generally more difficult to reach in surveys, the proportion may be underestimated and overall drinking profile skewed.
• The perception of social approval/disapproval by respondents may affect the responses to survey questions on heavy drinking habits.
• One of the consequences of heavy drinking is intoxication, which can result in violent encounters, unintentional injuries and impaired-driving collisions. The largest number of alcohol-related deaths (more than from chronic diseases) stem from impaired-driving collisions. These collisions also result in a large number of potential years of life lost because of the relatively young age of people killed in alcohol-related traffic collisions.^4,5
• Alcohol consumption over the Low-Risk Drinking Guidelines, including episodic heavy drinking, increases the risk of several chronic diseases and toxic effects (e.g., tissue damage leading to liver cirrhosis, acute brain damage, or long-term effects, such as cancer, caused by continuous exposure).  In addition, alcohol is a major contributor to suicide.^5,6,7
• There is a complex relationship between alcohol dependence and depression. Longitudinal data from the National Population Health Survey suggests that depression is both a precursor and an outcome of drinking heavily more than once a week.^5,8
• Heavy drinking is significantly more likely to be reported by males and younger adults.¹
• Individuals react differently to the same alcohol levels depending upon sex, body size and alcohol tolerance.  Surveys of drinking behaviour cannot capture individual differences in the health effects of heavy drinking.
• Based on the CCHS Cycle 3.1 (2005) Share File, 13.2% of Ontarians aged 12-19 and 17.4% aged 20+ engaged in heavy drinking monthly during the past 12 months. Not stated were excluded. Not applicable (those who had not had a drink in the past year) were coded as not engaging in heavy drinking and included in the denominator.

Definitions

• CCHS defines an alcoholic drink as: one bottle or can of beer or a glass of draft, one glass of wine or a wine cooler, one drink or cocktail with 1 and a 1/2 ounces of liquor.  This is not as precise as the definition from the Centre for Addiction and Mental Health (CAMH) which defines one standard drink as 13.6 g of alcohol or:
• 5 oz or 142 mL of wine (12% alcohol)
• 1.5 oz or 43 mL of spirits (40% alcohol)
• 12 oz or 341 mL of regular strength beer (5% alcohol)

Cross-References to Other Indicators

• Alcohol-Related Injury and Mortality from Motor Vehicle Traffic Collisions (Section 4C: Injury Prevention and Substance Abuse Prevention)
• Underage Alcohol Drinking (Section 5B: Alcohol)
• Drinking in Excess of the Low-Risk Drinking Guidelines (Section 5B: Alcohol)
• Drinking and Driving Prevalence (Section 5B: Alcohol)
• Smoking During Pregnancy (Section 6B: Reproductive Health)

Cited References

1. Bondy SJ, Rehm J. Ashley MJ, Walsh G, Single E, Room R. Low-risk drinking guidelines: the scientific evidence. Can J Public Health 1999; 90(4):264-70.
2. Adlaf EM, Ialomiteanu A, Rehm J. CAMH Monitor eReport: Addiction and Mental Health Indicators among Ontario Adults, 1977 - 2005. Centre for Addiction and Mental Health Research Document Series #24. Available online at: http://www.camh.net/Research/camh_monitor.html (Accessed May 14, 2009).
3. Centre for Addiction and Mental Health. Low - Risk Drinking Guidelines, 2008. Available online at: http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction_Information/low_risk_drinking_guidelines.html (Accessed May 14, 2009).
4. Single E, Rehm J, Robson L, Van Truong M. The relative risk and etiologic fractions of different cause of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. Can Medical Association J 2000;162(12):1669-1675. 
5. Roerecke M, Haydon E, Giesbrecht N. Alcohol and Chronic Disease: An Ontario Perspective. Toronto: The Alcohol Policy Network and Ontario Public Health Association, 2007.  Available online at: http://www.apolnet.ca/resources/pubs/rpt_ChronicDisease.pdf (Accessed May 14, 2009).
6. Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos CT. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction 2003; 98(9):1209-28.
7. Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube J, Gruenewald P, Hill L, Holder H, Romel R, Österberg E, Rehm J, Room R, Rossow R. Alcohol, No Ordinary Commodity: Research and Public Policy. Oxford: Oxford University Press, 2003.
8. Tjepkema M. Alcohol and illicit drug dependence. Health Reports Special Issue, Supplement to Volume 15, 2004:9-19. Statistics Canada Cat. No. 82-003-SPE. Available online at: http://www.statcan.gc.ca/pub/82-003-s/2004000/pdf/7447-eng.pdf (Accessed May 14, 2009).

Changes Made

Acknowledgements