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Will alcohol go the way of cigarettes? What one public health battle can tell us



You’ve probably seen the video by now. An apoplectic St. Catharines man seemed to strike a chord recently after being asked about his drinking habits outside a liquor store where he’d just purchased 12 tall boys.

“Two drinks a week?” he responded to a reporter, asking about new drinking guidelines released in January by the Canadian Centre on Substance Use and Addiction.

“That’s just not feasible. Not in this country … Why you gotta tell me how much I can drink at home?”

To many, the short clip was hilarious; it quickly went viral.

But the outspoken patron may also be remembered someday as an early face of the resistance to a public health establishment that appears to be slowly setting its sights on alcohol, after successfully slashing smoking rates.

Robert Schwartz with the University of Toronto’s Dalla Lana School of Public Health says while it’s true that antismoking and public-health campaigns have had an impact, it took decades, and in that time, many have died. Nearly 50,000 people die annually, even now, from tobacco-related causes in Canada.

“We got all upset with the pandemic (which was) killing less people,” he said. “But because this is something chronic, people don’t get upset about it so much, even if you put the figures in front of their faces.”

In the 1990s especially, when smoking indoors started to get rooted out, the argument that held the most sway was that second-hand smoke hurt innocent bystanders. How is it fair that people not smoking were having their health put at risk just so a restaurant customer could enjoy a puff after an omelette?

When looking at alcohol, there are also such “externalities,” said Schwartz — drinking and driving, violence, and dependence, to name a few. There are broader impacts on the health-care system and the economy as well.

“I think that we are going to see, gradually, a change in attitudes toward alcohol,” he said. “You know, it is still far more normative to use alcohol than it has been to use cigarettes for a long time.”

Yet habits change; alcohol sales, as measured by volume, decreased by 1.2 per cent last year in Canada, the largest drop in over a decade. And alcohol is becoming more widely known now as something that’s associated with cancer and “that’s huge,” said Schwartz.

“It’s going to be probably an even tougher battle for public health than tobacco,” he said. “Practically everybody uses alcohol. It’s pervasive in our media, it’s advertised; the government is even more in bed with industry on alcohol (compared to tobacco).

“It is what we do to celebrate. It is what we do to mourn. It is what we do when we come home from work.”

Meanwhile, public health authorities often struggle with one crucial part of their jobs, he said: talking to the public. In that sense, the new alcohol guidelines were a missed opportunity, added Schwartz.

It was once recommended that men consume no more than 15 drinks in a week and women no more than 10. That’s been dramatically cut, to two drinks per week, at least when it comes to keeping your risk at the lowest level.

“People are laughing at it,” Schwartz said. “That’s not the effect that you want to have. You need to gently and slowly educate the public, not to come up with such a drastic guideline all at once.”

About 80 per cent of Canadians over the age of 15 reported having at least one alcoholic drink in 2019. It’s the most commonly used drug in the country, and contributes to roughly 15,000 deaths per year.

If a push begins to curtail alcohol consumption, arguments will no doubt surface warning of the rise of an interfering, overreaching nanny-state. People will demand the government stay out of their personal health decisions. Businesses reliant on the sale of alcohol will advocate for its continued use and the mammoth industry will defend itself.

Dan Malleck, a health sciences professor at Brock University, argues that the new guidelines themselves are already doing damage. He said the Canadian Centre on Substance Use and Addiction’s “job is to look for harm” and doesn’t take into account any positives that arise from drinking alcohol, like socialization, creating community and stress relief.

Without the two-drink guidelines, a responsible drinker is typically seen as someone who doesn’t drink and drive, doesn’t go home and beat their partner, or doesn’t get so drunk they throw up over the side of a bridge, Malleck said.

“But now the responsible drinker is someone who drinks two drinks a week,” he said. “That’s a problem because it’s creating this expectation of behaviour that a lot of people don’t want to meet.”

Malleck added that it hurts the credibility of the public health industry “because this is so extreme” and people may shrug it off. He has also been publicly critical of the new guidelines, questioned the methodology, and criticized how the researchers reached their conclusions.

Arguments against research and government action have long been commonplace as the walls have continued to close in around smokers over the years — earlier this month, some vacationers groaned when Ottawa advised travellers heading to the beaches in Mexico that the country had banned smoking in public spaces.

Other countries are going further. New Zealand has heavily restricted where cigarettes can be sold, and forbidden anyone born on or after Jan. 1, 2009 to buy them, signalling that the government intends to make those who came before then the last generation of smokers.

Canada has already made much headway, too. In 1965, roughly half the population of Canada smoked. That share had dropped to about a third of the country in 1987, a quarter in 2000, and below 15 per cent in 2017.

Nowadays, the country has roughly three million smokers, perhaps 10 per cent of the population. The federal government aims to get that down under five per cent by 2035.

Tobacco is a formidable adversary: Even though the harm caused by cigarettes has been known since the 1960s, smokers, consumer-rights advocates, businesses — and, of course, tobacco companies — entrenched themselves in a battle that raged in the late 1980s and 1990s, especially regarding public health measures.

Smoking was seen as a staple of masculinity for a time and was commonplace in Hollywood movies. Lighting a romantic interest’s cigarette, or just sharing a light, in a movie could be filmed as a deeply intimate gesture; think of Lauren Bacall and Humphrey Bogart in “To Have and Have Not.” (A heavy smoker and drinker in real life, Bogart died of esophageal cancer.)

Later, tobacco was also marketed toward women as part of the feminist movement. In the 1980s, rates of smoking among young women actually increased.

In 1987, Canada was tied for seventh globally in overall cigarette consumption per capita, and it was estimated that 33,000 Canadians were dying each year from smoking-related causes. One in every four billboards featured tobacco ads, also prominent in newspapers and magazines. The country’s tobacco industry spent nearly $80 million every year pumping those ads out.

Those companies argued that they weren’t trying to create new smokers but win over current smokers to their brands. It was also perfectly legal to sell and buy cigarettes, and smokers and companies argued for their rights to buy and sell.

Then, in the 1990s, the battle reached a fever pitch.

Governments banned smoking in many public areas. Some critics made comparisons with dictatorships and pushed back on research that began showing the dangers around second-hand smoke.

Restaurants and bars could still permit smoking indoors, but only in areas that were cordoned off and ventilated. Owners had to section off designated smoking areas at costs that sometimes exceeded $100,000 — and then years later advancing regulation forbade those areas, too.

“This is awful,” Siva Bala, owner of Shoeless Joe’s in Toronto, told the Star in 2006. “It cost me $30,000 to build. If I knew I only had until 2006 I wouldn’t have put it up … And I’ll have to spend another $10,000 to break down the room.”

Some consumers also objected; diners and partiers declared they’d stop going out if they couldn’t enjoy a ciggy with a drink in their favourite restaurant or pub.

The slippery-slope argument arose, too. What about obesity, some critics asked — will the government also control where we eat chocolate and cheesecake?

Peter Selby, a senior scientist at The Centre for Addiction and Mental Health, says that trying to reduce people’s use of a dangerous substance comes down to one powerful force: social norms. “You look at generations of young people that are less likely to get behind a wheel and drive if they’re drinking,” he said.

“I think there will be this conversation around alcohol and … restrictions like labelling on bottles,” Selby added. “Most people don’t know alcohol is a carcinogen. They just don’t know.”

The lesson he draws from decades of cigarette use among people is that if society lets market forces sell addictive substances, “you will end up with harm,” he said.

“You need to mitigate that harm, and tobacco control efforts have been relatively successful in getting it down to a fairly low level of prevalence of smoking.”

Selby said whatever vice you tackle, it’s crucial to have a “multi-pronged” public health approach that includes reducing demand and cutting availability in a way that doesn’t result in more dangerous consumption.

“Humans being human, when you communicate to somebody (that) something is less harmful, there’s a tendency to risk compensate, which means you use more of it because you feel it’s safer,” said Selby.

This happened with “mild” and “light” cigarettes when they were introduced, he continued. Some people just didn’t quit because they figured they were safer.

Selby noted that the conversation around alcohol will be different than that regarding cigarettes. The number of people who get addicted to alcohol has remained “relatively stable” and there are many who enjoy alcohol responsibly.

In 2018, according to Statistics Canada, nearly 20 per cent of Canadians reported consumption that could be classified as heavy drinking: men having five or more drinks, and women having four or more drinks, on at least one occasion per month.

In 2019, the Canadian Alcohol and Drugs Survey asked respondents if they’d experienced harm due to drinking. It listed five harms: being unable to stop drinking once starting, failing to do what was expected of you due to drinking, needing a drink in the morning after a heavy night of drinking, blacking out because of alcohol, or having a feeling of guilt or remorse after drinking.

It found that 21 per cent of people experienced at least one of those in the past year.

“When you have more people consuming alcohol you get more harms from alcohol,” Selby said. “In fact, most people who have impaired driving charges are not people who meet the traditional alcoholic definition or alcohol use disorder definition.”

He said labelling on alcohol bottles is likely to be discussed in the near to medium term — “There’s more information on a can of Coke then there is on a bottle of wine or your vodka that you’re having.”

No big change appears to be in the offing right away, though a federal tax on all beer, wine and spirits rises by 6.3 per cent on April 1. Prohibition was a distinct failure and if anything, despite the habit’s harms, Canadian governments have been liberalizing access to alcohol over the last 40 years. For example, Alberta privatized liquor retail; B.C. let grocery stores sell beer; and Ontario extended last call and allowed drinks in cinemas — and permitted fans at Blue Jays and Maple Leafs games to drink, after years of reluctance.

And notwithstanding the efforts of the Canadian Centre on Substance Use and Addiction and its new alcohol guidelines, many on social media mocked the suggestion that two drinks per week would be optimal.

Peter Butt, the co-chair of the group that put out the alcohol guidance, said that he found the attention paid to the research gratifying and that it “generally has been positive.” But he also said that the two-drinks-per-week guideline was taken a bit out of context.

The researchers wanted to introduce the idea of “risk zones,” he said: One or two drinks per week brings a risk similar to “other voluntary activities,” which could result in one premature death out of 1,000 people.

For a one in 100 risk — the threshold usually used for looking at alcohol consumption — the researchers have it at six standard drinks per week (one standard drink in Canada has 13.45 grams of alcohol). This would be considered a moderate risk.

Meanwhile, in Australia, the guidance is the equivalent of seven standard Canadian drinks per week and in the United Kingdom, it’s eight, said Butt.

“We didn’t tell people to not drink more than two standard drinks a week,” he continued, “we said, here are the risk zones. Less is better. Situate your drinking, reflect on it, and decide where you think you would like to be within this spectrum of risk and make an informed decision.”

But some similarities to the tobacco battle are already apparent, Butt added: researchers funded by the alcohol industry as well as the companies themselves are pushing back on the notion that alcohol is risky at all consumption levels.

“The industry is more subtle in their approach,” he said. “They know better than to attack public health directly. So, the way that they do it is to undermine the scientific credibility of the evidence.”

When it comes to putting warning labels on alcohol, the feds look to be taking a “low-key approach,” said Butt, and signalling that they want the industry to self-regulate.

“It’s a class one carcinogen … it causes birth defects. Why is it not labelled? You would expect that of every other commodity that is intended to be ingested that has that level of toxicity.”

In the coming years and decades, Butt says he hopes to see less cultural indulgence given to binge drinking and a shift toward “something that is more moderate and it’s more about the company that we’re sharing when we socialize, rather than the chemical.

“This is going to be a process. It’s not an event.”


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