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

Description

• Proportion of the population aged 19 and over that exceed the low-risk alcohol drinking guidelines (LRADG), (1) i.e.:
• males that drank more than 15 drinks per week, females that drank more than 10 drinks per week OR
• males that drank more than 3 drinks per day, females that drank more than 2 drinks per day OR
• males or females with less than 2 non-drinking days a week OR
• males or females that drank 5 or more drinks on any one occasion in the previous year

* Note: This indicator excludes pregnant women and breastfeeding women.

• Proportion of the total population 19 and over that exceed LRADG #1 (guideline #1)
• Proportion of the total population 19 and over that exceed LRADG #2 (guideline #2)
• Proportion of the total population 19 and over that exceed LRADG #1 AND/OR #2 (guideline #1 and/or #2)

*See "Definitions" section for description of LRADG #1 and #2. 

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.  

• Societal Outcome (Prevention of Injury and Substance Misuse): There is reduced incidence and severity of substance misuse and substance-related injuries, hospitalizations, disabilities and deaths
• Societal Outcome (Prevention of Injury and Substance Misuse): Members of the public have an increased capacity to prevent injury and substance misuse.
• Societal Outcome (Prevention of Injury and Substance Misuse): Sustained behaviour change by the public contributes to the prevention of injury and substance misuse.

Assessment and/or Surveillance Requirements  

• 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).

http://www.ontario.ca/publichealthstandards

Corresponding Health Indicator(s) from Statistics Canada and CIHI 

• Prevalence of alcohol consumption in excess of LRADG #1
• Prevalence of alcohol consumption in excess of LRADG #2

Note: The Canadian Alcohol and Drug Use Monitoring Survey, (CADUMS) (2), reports on the population aged 15 and over and uses the Canadian Community Health Survey (CCHS) module "Alcohol Use in the Past Week (ALW)" to calculate exceedance of both LRADG #1 and LRADG #2. This APHEO Core Indicator will use the CCHS ALW module to calculate exceedance of LRADG #1, and the "Alcohol Use (ALC)"  module (i.e., alcohol consumption in the past 12 months) to calculate exceedance of LRADG #2. 

Centers for Disease Prevention and Control (3):

• Prevalence of binge drinking (5 or more and 4 or more drinks on one occasion during the last 30 days for males and females respectively)
• Prevalence of heavy drinking (male respondents aged 18 years and older who report an average of more than 2 drinks per day and female respondents aged 18 years and older who report an average of more than 1 drink per day in the past 30 days).

Australian Bureau of statistics (4):

• Proportion of persons 18 years and older who exceeded lifetime risk alcohol guidelines 
• Proportion of persons who exceeded single occasion risk alcohol guidelines

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

The indicator is derived from several modules. A syntax file (Stata) is available to run on all years of CCHS data (see Analysis Check List for details). The syntax file is based on the following information:

• Alcohol use during the past year.
• Available from the module Alcohol Use. This module was core content in 2003, 2005, 2007-08, 2009-10 and 2011-12. Formerly, this question was in the Alcohol module in 2000/01 (core). Both current and non-drinkers are included in the denominator of the indicator.
• Alcohol use during the past week:
• Available from the module Alcohol use during the past week. This module was optional content in 2007-08, 2009-10, and 2011-12. Formerly, these questions were core content in the Alcohol Use module in 2003 and 2005, and the Alcohol module in 2000/01.
• Pregnancy status:
• Available from the module Height and Weight - Self-reported. This module was core content in 2007-08, 2009-10 and 2011-12. Formerly, these questions were core content in the Mammography module in 2000/01, 2003, 2005.
• Breastfeeding/lactation status:
• Available from the module Maternal experiences - Breastfeeding. This module was core content in 2007-08, 2009-10 and two year core (two year biennial common content for all health regions) in 2011-12. Formerly, these questions were core content in the Maternal experiences module in 2003 and 2005, and the Breastfeeding module in 2000/01.

The Rapid Risk Factor Surveillance System (RRFSS) Alcohol Use module was optional content in 2001 and 2003-2005, core in 2002 and has been rotating core since 2006.
Note: a rotating core module in RRFSS is a module that, within a two year cycle, is core in one year but optional in the other. The RRFSS indicator measures the percent of adults (18+) who are low risk drinkers or non-drinkers of alcohol, defined as males who drink 14 or fewer drinks per week and women who drink 9 or fewer drinks per week.

• It is recommended that ‘total population' be used as the denominator. ‘Total number of current drinkers' (ALCn_1 = 1) may be considered for the denominator for a supplemental indicator. In this case, exclude respondents who have not had an alcoholic drink in the past year.
• The syntax file (Stata) "Low-Risk Alcohol Drinking Guidelines" calculates the proportion of respondents who have exceeded or adhered to the low risk drinking guidelines in Ontario for CCHS 2000/01-2010. After running the syntax file, categories 98 (those pregnant or lactating and respondents aged <19) and 99 (Not stated, Don't Know, Refused may be excluded (see note below).
• 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.
• Not applicable respondents should be excluded; however, it is important to understand who these respondents are from the questionnaire skip patterns to be able to describe the relevant population.
• 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 full text copy of the Statistics Canada article entitled "Mode effects in the Canadian Community Health Survey: a Comparison of CAPI and CATI".

RRFSS

Users should refer to the most recent RRFSS Manual of Operations for a complete list of RRFSS analysis guidelines.
Denominator Data - cell size less than 30 not to be released (based on unweighted data).
Numerator Data - cell size less than 5 not to be released (based on unweighted data).
Coefficients of variation (CV) should be calculated for every estimate. The following categories determine the release of the data:
• CV between 0 and 16.5: estimate can be released without qualification.
• CV between 16.6 and 33.3: estimate can be released with qualification: interpret with caution. High variability.
• CV greater than 33.3: estimate should not be released, regardless of the cell size.
95% confidence intervals should accompany all released estimates. If estimates are close to 0 or 100% and a simple computation confidence intervals include values less than zero or greater than 100 then the Fleiss 2^nd edition computation for skewed estimates should be employed.
Weighting:
• General household weight will be applied for questions related to the individual.
• Household weight is to be applied for questions about households when we wish to determine the population/number of people affected.
• Household weight is not to be applied for child proxy questions (bicycle helmet use, car seat safety), dog and cat immunization modules, or other questions that relate to the household rather than the respondent.
• Household weights are not required to be recalculated for sub-population based questions; for example mammography in women ages 35+ years and 50-74 years.
• If the weights supplied with the data set (health unit wave specific, health unit cumulative total, all health units combined wave specific, all health units combined cumulative total) are not appropriate for the required analysis, then a time-specific weight must be calculated. For example, a new weight is required for all seasonal modules.
If the cell size of ‘Don't Know' responses is 5% or greater, ‘Don't Know' responses should be included in the denominator of the analyses and reported separately.
If the cell size of ‘Refusal' responses is 5% or greater, ‘Refusal' responses should be included in the denominator of the analyses and reported separately.
When an indicator is being compared between groups (e.g. health units, time periods, gender), if any one group has ‘Don't Know' and/or ‘Refusal' responses that are 5% or greater, ‘Don't Know' and/or ‘Refusal' responses should be included in the denominator of the analyses and reported separately for all groups.
A provincial sample is not available with the RRFSS.
Refer to the RRFSS Data Dictionaries for more information about module questions and indicators: http://www.rrfss.ca/

• Ages: 19-24, 25-44, 45-64, 65+. It may be necessary to aggregate data based on age groups to produce stable rates. (Refer to Document: Methods for Calculating Moving Averages).
• Sex: male, female and total
• Geographic areas for:
• CCHS - Public Health Units
• RRFSS - all RRFSS participating health units

• Alcohol consumption is associated with a number of risks and health problems, as well as potential benefits. The three intermediate mechanisms are dependence, intoxication and biochemical effects (toxic and beneficial) (5). The major burden of morbidity and mortality related to alcohol use falls into two main categories: injuries and chronic disease.
• According to studies by the World Health Organization, alcohol consumption is a leading contributor to chronic diease and is recognized as a strong risk factor affecting health in developed countries (6 - 8).
• Both the volume of alcohol consumed and high-risk drinking patterns were found to contribute to chronic disease and disability (9). High-risk drinking patterns impact chronic disease, especially ischemic or other cardiovascular disease categories (10).
• The health benefits associated with low-risk drinking are mostly relevant from middle-aged onwards (when risk of cardiac illness increases). It is not recommended to start drinking or to drink more to achieve health benefits, as health benefits can be better achieved through other means (11).
• The World Cancer Research Foundation (WCRF) and the American Institute for Cancer Research (AICR) maintain "there is no level of consumption of alcoholic drinks below which there is no increase in the risk of cancers it causes", but recognize there may be a protective effect of alcohol against coronary artery disease (12). The WCRF/AICR recommends:
  • no more than two drinks a day for men and one drink a day for women

• Canada's Low Risk Alcohol Drinking Guidelines, intended for Canadians of legal drinking age who choose to drink alcohol, are informed by the most recent and best scientific research and evidence (1). They are intended to provide consistent information across the country to help Canadians moderate their alcohol consumption and reduce their immediate and long-term alcohol-related harm. For more information on Canada's Low-Risk Alcohol Drinking Guidelines see http://www.ccsa.ca/eng/priorities/alcohol/canada-low-risk-alcohol-drinking-guidelines/pages/default.aspx
• Five specific guidelines that identify three distinct types of risk from drinking were developed (1):
• Guideline 1: increased long-term risk of chronic diseases caused by the consumption of alcohol over a number of years (e.g., liver disease, some cancers);
• Guideline 2: increased short-term risk of injury or acute illness due to the overconsumption of alcohol on a single occasion; and
• Guidelines 3-5: risk associated with situation-specific or individual circumstances that are particularly hazardous (e.g., woman who are pregnant or planning to become pregnant, teenagers, persons on medication) and for which abstinence or only occasional light intake is advised.
• A relative risk approach was used to establish the guidelines, i.e., a level of average daily consumption was identified at which the potential health risk and benefits exactly of alcohol consumption cancelled each other and the net risk of premature death was the same as that of a lifetime abstainer (11, 13). This zero-net risk point compared with lifetime abstainers was two drinks on average per day for women and three for men (11, 13).
• This Core Indicator addresses:
• guideline #1 (long-term risk) which provides sex-specific daily and weekly limits for alcohol consumption and recommends at least two non-drinking days every week, and
• guideline #2 (short-term risk) which provides sex-specific limits for alcohol consumption on special occasions. Guideline #1 is assessed using alcohol use in the past week (i.e., using CCHS "Alcohol use during the past week" (ALW) module) to measure daily and weekly consumption; and guideline #2 is being assessed using binge drinking episodes in the past year (i.e., using CCHS "Alcohol use" (ALC) module) to measure consumption on special occasions.
• Note: The Canadian Alcohol and Drug Use Monitoring Survey (14) reports on the population aged 15 and over and uses the Canadian Community Health Survey (CCHS) module ALW to calculate exceedance of both guideline #1 and guideline #2. 
• While guideline #2 specifies that females should not consume 4 or more drinks on one occasion, the CCHS asks both males and females if they have consumed 5 or more drinks on one occasion. Since the exact definition of exceedance of guideline #2 cannot be calculated for females, this Core Indicator will underestimate the proportion that exceeded guideline #2. A conversion factor has been proposed to convert this proportion from 5 or more drinks to 4 or more drinks for females (15)
• Additional risk categorization for those exceeding moderate risk drinking on special occasions (i.e., 5+ drinking occasions weekly or more often in the past year) has been suggested (15). Although not included in this Core Indicator, this further detail of risk categorization may be useful.
• The LRADGs also address drinking for teens and young adults up to age 24 (1). It is recommended that if teens choose to drink, they should do so under parental guidance; never consume more than 1-2 drink at a time; and never more than 1-2 times per week.  The daily and weekly limits should never be exceeded. 
• This Core Indicator defines low-risk drinking using CCHS data, which are based on self-reported alcohol consumption in the previous week. For some respondents this consumption may be more or less than their typical pattern of alcohol intake, but discrepancies should even out over the whole year and over the population. 
• The perception of social approval or disapproval by respondents may affect the responses to survey questions on drinking habits.
• This indicator excludes pregnant and lactating women because Canada's Low Risk Alcohol Drinking Guidelines state that for pregnant females, those planning to become pregnant, or about to breastfeed, the safest choice is to abstain from alcohol (1). 
• Note: Cancer Care Ontario alcohol consumption indicator, based on WCRF/AICR recommendations, currently excludes pregnant females but includes lactating females (16).
• In 2011 Cancer Care Ontario (CCO), introduced a new definition for their alcohol consumption indicator to align with WCRF/AICR recommendations for cancer prevention:
• Proportion of adults (19+) exceeding the cancer prevention maximum for alcohol drinking, i.e., No more than 1 drink per day for women; No more than 2 drinks per day for men.
• In 2013, CCO began to calculate exceedance of this guideline based on average weekly consumption (16). Prior to 2013, exceedance of the guideline was based on maximum number of alcoholic drinks consumed on any day in the previous week, which resulted in a higher estimates.

• Guideline 1: To reduce long-term  health risks (chronic disease)
• Males: 0 - 3 standard* drinks per day. No more than 15 standard *drinks per week
• Females: 0 - 2 standard*drinks per day. No more than 10 standard* drinks per week
• Always have some non-drinking days per week to minimize tolerance and habit formation

• Guideline 2: Maximum special occasion alcohol consumption to reduce short-term risks (injury or acute effects associated with excess alcohol consumption)
• Males: 4 standard* drinks in one day in any 3 hour period
• Females: 3 standard* drinks in one day  in any 3 hour period

*Standard drink -  see below

Alcoholic drink:

• CCHS (17) -  defined 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. 
• RRFSS (18) - one drink is defined as 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor.

These definitions are not as precise as the definition of standard drink.

Standard drink (1) - quantities of different alcoholic beverages that contain roughly the same amount of alcohol. The the Canadian Centre on Substance Abuse (CCSA) defines one standard drink as 17.05 ml or 13.45 g of pure alcohol. This is roughly equivalent to:

• 341 mL (12 oz.) bottle of 5% beer, cider or cooler  
• 142 mL (5 oz.) glass of 12% wine
• 43 mL (1.5 oz) shot of 49% spirits

Heavy drinking (20)  - consumption of 5 or more alcoholic drinks on at least one occasion per month in the past 12 months.

Short-term of "acute" effects (11) from drinking are associated with the 'dose' taken on one occasion and the degree of impairment

Long-term or "chronic" effects (11) from drinking are associated with the volume of alcohol consumed in the longer term and result from its effects mainly on the central nervous and digestive systems.

Lifetime abstainer (11) - a person who has never had even one drink of alcohol. 

• Alcohol-related injury and mortality from motor vehicle traffic collisions (Section 4C: Injury Prevention and Substance Abuse Prevention)
• Underage Alcohol Drinking (Section 5B: Alcohol)
• Heavy Drinking Episodes (Section 5B: Alcohol)
• Drinking and Driving Prevalence (Section 5B: Alcohol) 

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12. World Cancer Research Fund (WCRF); American Institute for Cancer Research (AICR). Food, nutrition, physical activity and the prevention of cancer: a global perspective Washington, DC: AICR; 2007 [cited 2013 June 5]. Available from: http://eprints.ucl.ac.uk/4841/1/4841.pdf.
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