TREATMENT, ALCOHOLICS ANONYMOUS AND ALCOHOL CONTROLS DURING THE DECREASE IN ALCOHOL PROBLEMS IN ALBERTA: 1975-1993t

Alcohol & Alcoholism Vol. 33, No. 3, pp. 265-272, 1998 TREATMENT, ALCOHOLICS ANONYMOUS AND ALCOHOL CONTROLS DURING THE DECREASE IN ALCOHOL PROBLEMS IN ALBERTA: 1975-1993t REGILD G. SMART* 1 and ROBERT E. MANN 12 'Clinical, Social and Evaluation Research Department, Addiction Research Foundation, Toronto and department of Behavioural Science, University of Toronto, Toronto, Canada (Received 28 July 1997; in revised form 7 November 1997; accepted 20 November 1997) Abstract In this study, the trends in alcohol consumption, alcohol-related problems, alcohol availability and treatment efforts were examined for the province of Alberta, for the period 1975-1993. Most of the trends previously observed in Ontario were also observed in Alberta. We found: (1) stabilization followed by important declines in per capita consumption of alcohol; (2) large decreases in most measures of problems such as cirrhosis mortality and traffic fatalities related to drinking; (3) increases in treatment and Alcoholics Anonymous membership rates; (4) increases in measures of physical availability of alcohol. One problem, impaired driving arrest rate, increased substantially during the years examined. INTRODUCTION Most Western countries, including Canada, experienced large increases in alcohol consumption and related problems in the 30-year period after the second world war (Bruun et al., 1975; Smart, 1989). However, around 1975 alcohol consumption and alcohol-related problems began to decrease in Canada and many other countries (Smart, 1988, 1989). In some Canadian provinces, these decreases were very large; for example, in Ontario, liver cirrhosis death rates decreased by 25.1% (1975-1983) and the rate of drinking drivers involved in fatal accidents fell by 21.6% (Smart and Mann, 1987). Previously, we showed that the decreases in liver cirrhosis mortality and morbidity in both Canada and the USA were associated with increased levels of treatment for alcoholism (Mann et al., 1988), increased funding for alcoholism treatment (Smart et al., 1996), and increased membership of Alcoholics Anonymous (AA) (Mann et al, 1991). fthe opinions expressed in this paper are those of the authors and do not necessarily reflect the views or policies of the Addiction Research Foundation. *Author to whom correspondence should be addressed at: Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada M5S 2S1. Recently, we examined evidence from Ontario for the period 1975-1992 which showed: (i) a stabilization and gradual decline in per capita consumption; (ii) large decreases in such problems as cirrhosis and drink-driving mortality rates; (iii) important increases in prevention measures; (iv) large increases in the number of alcoholics treated (treatment and in AA membership); (v) alcohol availability remained the same or increased (Smart and Mann, 1995). While this study used simple description which cannot prove a link between increased prevention and treatment activities and the reduction in alcohol-related problems, changes in treatment levels and prevention were more consistent with recent declines in alcohol use and problems than changes in availability measures in Ontario. We argued that research on determinants of alcohol consumption and related problems should include prevention and treatment activities as well as data on alcohol availability. We also pointed out the need to determine if similar patterns in treatment and prevention activities and other alcohol-related measures have occurred in jurisdictions other than Ontario. In this paper, we report data from Alberta, another Canadian province, on trends in alcohol consumption and problems, as well as treatment levels and AA membership. The Alberta data cover the years 1975 to 1993 and include information on changes 265 1998 Medical Council on Alcoholism

266 R. G. SMART and R. E. MANN in alcohol controls, such as price and number of outlets, as well as on levels of treatment and AA membership. The purpose of this paper was to present descriptive and correlational information on the trends in levels of treatment and self-help for alcohol problems, as well as changes in alcohol controls, such as price and physical availability. Several studies suggest the importance of treatment for alcohol problems in the decline of such problems (Mann et al., 1988, 1991, 1996; Smart and Mann, 1991). Much of the work has been done in Ontario. However, studies have also been performed in the USA (Holder and Parker, 1992), Sweden (Romelsjo, 1987), and Norway (Norstrom, 1995). There is little evidence on trends in government controls on availability during the period when alcohol consumption and problems have declined. The large declines in alcohol problems in Ontario and Alberta may represent important opportunities to observe such effects. Unfortunately in Alberta we have no data on health promotion programmes, as with Ontario. However, there are good data on treatment for alcohol problems and alcohol controls, and reliable official statistics on alcohol consumption and problems. The Single Distribution Theory and related perspectives (e.g. Ledermann, 1956; Seeley, 1960; Bruun et al., 1975; Popham et al., 1976; Skog, 1980) propose a close relationship between mean alcohol consumption and problems, with the clear expectation that heavy alcohol consumption and problems such as liver cirrhosis will not decline without declines in mean alcohol consumption. Also, according to these models, the only predictable means of achieving such declines are to increase controls on alcohol availability by increasing prices and by reducing the number and type of outlets (e.g. Popham et al., 1976; Rush et al., 1986). However, others have argued that there are no set relationships between alcohol availability, mean alcohol consumption, and heavy consumption (Duffy and Cohen, 1978; Fitzgerald and Mulford, 1992). The recent study by Smart and Mann (1995) showed that in Ontario small declines in alcohol consumption were associated with large declines in alcohol-related problems and with increased levels of prevention and treatment programmes, while the availability of alcohol increased. This paper attempts to see whether this same picture was seen in Alberta during the period of decline in alcohol consumption. METHODS Data were obtained from a variety of sources on alcohol consumption and alcohol problems in Alberta for the years 1975-1993. Per capita alcohol consumption was determined from sales figures as collected by Statistics Canada. As usual, per capita consumption figures were expressed as litres of absolute alcohol for the population aged 15 years and over. Hospital separation (equivalent to discharge) rates per 100 000 aged 20 years and over were estimated for cases with a diagnosis of 'alcohol-dependence' syndrome as defined by the ICD criteria. These figures do not include most of the data reported by treatment centres shown below, because very few of them are hospitals. Death rates for chronic liver disease and cirrhosis due to alcohol were obtained from Statistics Canada publications and were expressed as rates per 100 000 population aged 20 years and over. Drink-driving data were obtained from Statistics Canada publications and from the Statistical Unit of the Addiction Research Foundation. Driving while impaired charges, and drink-drivers involved in fatal accidents were expressed as rates per 100000 total population. Data on the availability of alcohol in Alberta were derived from various government reports. Data on the number of on-premise drinking establishments were drawn from yearly reports of the Liquor Control Board of Alberta. The increase in on-premise drinking is mainly due to increases in the number of restaurants having licences. The number of 'liquor' stores was determined by examining the yearly reports of the Liquor Control Board of Alberta. It should be noted that, although such stores are termed 'liquor' stores in that they are the only outlet for spirits, they also sell most of the wine bought in Alberta and about 10% of the beer. Data on the cost of 101 of absolute alcohol as a percentage of disposable income were obtained from the Statistical Information Unit of the Addiction Research Foundation, which uses Statistics Canada data to make the necessary computations. Data on the relative cost of alcohol are not available for the years 1976-1982, nor are data available for different beverage types separately.

ALCOHOL CONSUMPTION, TREATMENT AND CONTROL TRENDS IN ALBERTA 1975-1993 267 Year Table 1. Per capita alcohol consumption and problem indicators in Alberta: 1975-1993 Alcohol consumption* 1 (I/year) % Road fatalities with positive BAC b Impaired driving charges 0 Alcohol-dependence syndrome hospital separations' 1 (rate/100 000) Liver cirrhosis mortality (rate/100 000) 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Percentage change first to last year 12.1 12.5 12.6 13.3 13.1 10.9 13.2 12.5 11.6 11.1 11.1 10.5 10.0 9.7 9.3 9.0 8.9 8.4-30.6 62 51 58 55 41 64 57 63 52 59 45 44 44 49 41 33 40 42 27-56.5 12 988 14 494 18 139 21612 22 875 24 717 27 308 28 012 27 086 27 306 27 904 26 279 27 075 27 093 29 875 29 260 30 666 24 418 22 372 + 72.3 249.5 250.7 208.0 211.1 166.6 151.8 147.5 140.5 147.1 149.6 157.3 152.1 71.3 67.4 75.2 62.0 60.0 54.5-78.2 9.2 10.0 10.1 10.1 10.5 10.4 10.4 9.5 9.0 8.7 6.5 6.7 6.3 6.4 6.1 7.4 7.1-22.8 a Per capita litres of ethanol per year for total population aged 15 years and over; data are for fiscal years; b BAC = blood-alcohol concentration; = not available; c data are for fiscal years 1975-1992; d per 100000 population aged 20 years and over. Information on levels of treatment in Alberta was gathered from the annual reports of the Alberta Alcohol and Drug Addiction Commission. Every specialized alcoholism treatment facility (including those in hospitals and in the community) in the province was asked to provide information on the number of cases treated for the fiscal years 1975-1992, among other measures; data were collected from all facilities identified. Persons treated by private physicians were not included. The data shown are for the total number of patients treated, not new cases only, as such data are not available. AA membership data for Alberta were kindly provided by the AA General Service Board Central Office in New York, USA. The Central Office surveys AA groups every 3 years; individual groups are asked to provide the number of members who regularly attend meetings. These data may be subject to inaccuracies, e.g. due to failure of some groups or individuals to respond, but we have no reason to suspect any systematic or year to year bias. AA membership figures are highly correlated with the number of groups and we show both. Although membership figures may be over- or under-estimated, it is unlikely that the number of groups is seriously in error. Unfortunately, the years for which AA membership data were available did not correspond exactly to the years for which treatment data were available. In this paper we present a descriptive analysis of the data and correlations among the measures. Such analyses are useful for identifying the more obvious trends in the data; however, the data are insufficient for more complex time-series analyses. Our goal was therefore to provide an overall impression of these trends and, hence, we also included information on percentage increases and decreases. RESULTS Table 1 presents the data on alcohol consumption and related alcohol problems for the years

268 R. G. SMART and R. E. MANN Year Table 2. Physical and economic availability of alcohol in Alberta: 1976-1993 Cost of 101 of absolute alcohol (% personal disposable income) Total no. of licensed establishments Total no. of liquor stores 1976 1977 1978 1979 1980 1981 1982 1983 2.56 1984 2.57 1985 2.41 1986 2.47 1987 2.66 1988 2.60 1989 2.56 1990 2.60 1991 2.66 1992 2.73 1993 % Change first to last year of data +6.6 = not available. a Change in legislation. 2827 3022 3277 3537 4091" 3457 4101 4490 4787 5099 5337 5581 5754 5893 6019 6151 6299 6655 + 135.4 178 183 190 191 192 183 193 197 199 199 212 212 224 211 211 207 222 295 + 65.7 Table 3. Total admissions Year 1980 1982 1983 1984 1985 1986 1987 1988 1989 1991 1992 % Change 1982-1992 for alcohol and drug problems in Alberta 1980-1992 Cases treated 8 16 638 17 720 20 326 21313 25 074 20 802 22 310 21689 22 258 + 33.8 and Alcoholics Anonymous (AA) membership: No. of AA members 3950 4963 5559 625 l b + 58.2 No. of AA groups 316 393 432 495 b + 56.6 = not available. a Cases treated are for fiscal years for 1982-1989; b this number is estimated based on the 1992 data and an interpolation of probable changes between 1986 and 1992. 1975-1993. The data for per capita consumption show a stable period in the early part of the series followed by a steady decline beginning in the early 1980s. Overall there is a 30.6% decrease between 1975 and 1992. This decrease is considerably greater than the 19.1% found in Ontario between 1975 and 1990. Inspection of the data on alcohol problems also shows mostly steady declines, again with some exceptions. The rate of hospital separations (discharges) from alcohol dependence declined by 78.2% and liver cirrhosis mortality by 22.8%. The percentage of fatally injured drivers with a positive blood-alcohol concentration (BAC)

ALCOHOL CONSUMPTION, TREATMENT AND CONTROL TRENDS IN ALBERTA 1975-1993 269 decreased by 56.5%, but driving while impaired charges increased by 72.3%. The increase for impaired charges contrasted with the decrease seen in Ontario, but all other changes were of a similar direction and magnitude in the two provinces. Data on the availability of alcohol are shown in Table 2. It can be seen that the number of onpremise drinking establishments increased greatly in Alberta between 1976 and 1993. The increase of 135.4% is due largely to changes in alcohol control policy which made it easier for restaurants to obtain beer and wine licences. The number of liquor stores increased by 65.7%, which is far higher than the increase seen in Ontario between 1975 and 1990. Table 2 also shows that the relative cost of alcohol was fairly stable between 1980 and 1992, with a 6.6% increase between the first and last year of data. Table 3 shows the data for changes in levels of treatment and AA membership. The numbers in formal treatment and AA showed increases of 33.8% and 56.6% respectively, which were less than those in Ontario; these numbers increased by a factor of three for treatment and two for persons attending AA. The correlations among the variables (except AA membership, for which too few data points were available) are presented in Table 4 (for these analyses, impaired driving arrests, numbers of licensed establishments, and numbers of provincial liquor stores were translated into rates per 100 000 population aged 20 years and over). The relationship of rate of treatment with cirrhosis mortality rates was significant and negative. Its relationships with other problem measures were in the expected direction, although not significant. Per capita consumption demonstrated the predicted positive and significant relationship with three of the four problem measures, but not with rate of impaired driving arrest rate. The cost of alcohol demonstrated the expected negative relationship with all four problem measures, though significance was only demonstrable with alcohol dependence rates. The measures of physical availability, rates of provincial liquor outlets and licensed establishments demonstrated an unexpected pattern of relationships with problem measures. Only one correlation in the expected positive direction was significant (liquor stores and alcohol dependence rate). However, four of the eight relationships (licensed establishments with percentage of dead drivers who were BAC positive, alcohol dependence rates, cirrhosis mortality rates; and provincial liquor stores with rate of impaired driving arrests) were significant and negative. DISCUSSION The present data provide an important perspective on recent developments in alcohol use and problem measures, and on efforts to reduce those problems. Similarly to what was previously done for Ontario (Smart and Mann, 1995), we have assembled as comprehensive as possible a set of data on alcohol-related measures for a major North American jurisdiction, the province of Alberta. These data are of great interest, because of the breadth of measures available. They also permit a preliminary evaluation of whether the same trends observed in Ontario would be observed in another location. In general, most of the trends observed in Ontario were also observed in Alberta, with one notable difference. In particular, we noted: (1) stabilization followed by important declines in per capita consumption of alcohol; (2) large decreases in most measures of problems such as cirrhosis mortality and traffic fatalities related to drinking; (3) increases in treatment and AA membership rates; (4) increases in measures of physical availability of alcohol. This makes our earlier findings for Ontario more reliable, although more jurisdictions should be studied. One problem measure, impaired driving arrest rate, increased substantially during the years examined here. During the period of time covered by this study, government policy changed to give drink-driving arrests a higher priority, by increasing arrest rates and making more dririk-driving programmes available. This probably accounts for the difference in trends in drink-driving arrests in Alberta and Ontario. These data must be interpreted with caution, as they represent an overview of recent developments in alcohol use, problem levels, and problem prevention efforts in Alberta and associations between different measures. However, for some of the data (e.g. AA membership, treatment rates, cost) a full series is not available. Also, the correlational strategy cannot probe causation, and

Treatment rate Consumption Cost Rate of licensed establishments Rate of provincial liquor stores Impaired driving arrest rate % of drivers killed who were BAC positive Alcohol dependence rate Cirrhosis mortality rate Table 4. Correlations among measures of treatment, alcohol use and cost, physical activity and alcohol problems Treatment rate -0.4126 0.1523 (8) 0.5935 0.5781-0.3071-0.5511-0.0206-0.7517* (8) Consumption -0.8277** -0.9320** 0.4607-0.1717 0.6207** 0.8302** 0.8375** BAC = blood-alcohol concentration. Sample size is shown in parentheses. * P <0.05; ** P < 0.01. "Hospital separations. Cost 0.8170** -0.1416-0.3589-0.3730-0.7908** -0.4671 Rate of licensed establishments 0.1417 0.0985-0.7944** -0.8368** -0.8877** Rate of provincial liquor stores -0.8399** -0.0521 0.7299** 0.4007 Impaired driving arrest rate 0.0428-0.5591* -0.2985 % Drivers killed who were BAC positive 0.6118** 0.6323** Alcohol Cirrhosis dependence mortality rate" rate 0.6918** TO P on s> 70 H 3 Q. TO P 3 >

ALCOHOL CONSUMPTION, TREATMENT AND CONTROL TRENDS IN ALBERTA 1975-1993 271 a stronger analytical strategy, such as time-series analysis, was precluded by the restricted times involved. Keeping these restrictions in mind, it is interesting to note the significant negative relationship between treatment rates and cirrhosis mortality rates. This observation is similar to the relationship observed in Ontario (Mann et al, 1988; Smart and Mann, 1995) and in the USA (Smart et al, 1996). Holder and Parker (1992) have also observed this relationship in the state of North Carolina. The general trends involving treatment measures (treatment and AA rates) are also similar to those observed in Ontario for a similar time period (Smart and Mann, 1995) and support the suggestion that treatment and AA, if they reach a sufficient level of intensity, can reduce population rates of cirrhosis (Mann et al, 1988; Holder and Parker, 1992; Noble et al., 1993; Edwards et al, 1994; Smart and Mann, 1995; Smart et al., 1996). It should be noted that modest changes in drinking levels of treated alcoholics can reduce their risk of death from cirrhosis; abstinence is not necessary. For example, Borowsky et al. (1981) found that alcoholics who were abstinent after treatment had higher survival rates than those who continued drinking. However, those who had moderate binges (five drinks a day) had the same survival rates as the abstinent group. The relationships observed among alcohol consumption, alcohol cost, and problem measures are also consistent with much previous research, which demonstrated that as cost increases and consumption decreases, problems tend to decrease (Seeley, 1960; Bruun et al, 1975; Popham et al, 1976; Skog, 1980; Smart, 1987; Mann and Anglin, 1988, 1990; Mann et al, 1996). This observation forms the empirical basis for the current public health approach to alcohol problems (Edwards et al, 1994) and forms the basis of the Single Distribution Theory. The relationships between physical availability measures and problem levels shown here are perplexing. Increased physical availability has previously been linked to increased problem levels (Bruun et al, 1975; Edwards et al, 1994). However, in the present research, the relationships between physical availability and problem levels were, for the most part, counter to what is expected from the Single Distribution Theory. Assuming that these observations are not simply due to chance, two explanations can be suggested. First, the measures of physical availability used here may not reflect all aspects of physical availability, and a broader measure of physical availability might show the expected relationship. Second, the influence of physical availability on problems may be modified or obscured by other variables, such as prevention and treatment activities. Unfortunately, the available data do not yet permit an evaluation of either hypothesis. Perhaps the Single Distribution Theory requires modification to include prevention and treatment considerations. Finally, it is important to reiterate the descriptive and correlational nature of these observations. A simple interpretation of these observations is that some measures of alcohol use, availability and treatment (e.g. per capita consumption and price) demonstrated the strong relationships with alcohol problems that previous research would predict, whilst measures of physical availability did not demonstrate the predicted relationships. This situation is very similar, but not identical, to that observed for Ontario (Smart and Mann, 1995). However, the restrictions on the available data and limitations of the analysis performed do not allow causative conclusions to be drawn. Further research is necessary to validate these observations and elucidate any mechanisms which might be involved. REFERENCES Borowsky, S. A., Stome, S. and Lott, E. (1981) Continued heavy drinking and survival in alcoholic cirrhosis. Gastroenterology 80, 1405-1409. Bruun, K., Edwards, G., Lumio, M., Makela, K., Pan, L., Popham, R. E., Room, R., Schmidt, W., Skog, O.-J., Sulkunen, P. and Osterberg, E. (1975) Alcohol Control Policies in Public Health Perspective, Vol. 25. Finnish Foundation for Alcohol Studies, Helsinki (distributed by Rutgers Center of Alcohol Studies, New York). Duffy, J. C. and Cohen, G. R. (1978) Total alcohol consumption and excessive drinking. British Journal of Addiction 73, 259-264. Edwards, G., Anderson, P., Babor, T. F., Casswell, S., Ferrance, R., Giesbrecht, N., Godfrey, C, Holder, H., Lemmens, P., Makela, L. T., Norstrom, T., Osterberg, E., Romelsjo, A., Room, R., Simpura, J. and Skog, O.-J. (1994) Alcohol Policy and the Public Good. Oxford University Press, Oxford. Fitzgerald, J. L. and Mulford, H. A. (1992) Consequences of increasing alcohol availability: The Iowa

272 R. G. SMART and R. E. MANN experience. British Journal of Addictions 87, 267-274. Holder, H. D. and Parker, R. N. (1992) Effect of alcoholism treatment on cirrhosis mortality: A 20- year multivariate time series analysis. British Journal of Addictions 87, 1263-1274. Ledermann, S. (1956) AIcool, Alcoolisme, Alcoolisation Donnee's scientifiques de Charactiere Physiologique, Economique el Social. Presses Universitaires de France, Paris. Mann, R. E. and Anglin, L. (1988) The relationship between alcohol-related traffic fatalities and per capita consumption of alcohol, Ontario 1957-83. Accident Analysis and Prevention 20, 441^146. Mann, R. E. and Anglin, L. (1990) Alcohol availability, per capita consumption, and the alcohol-crash problem. In Wilson, R. J. and Mann, R. E. eds, Drinking and Driving: Advances in Research and Prevention, pp. 205-225. Guilford, New York. Mann, R. E., Smart, R. G., Anglin, L. and Rush, B. R. (1988) Are decreases in liver cirrhosis rates a result of increased treatment for alcoholism? British Journal of Addiction 83, 683-688. Mann, R. E., Smart, R. G., Anglin, L. and Adlaf, E. M. (1991) Reductions in cirrhosis deaths in the United States. Associations with per capita consumption and AA membership. Journal of Studies on Alcohol 52, 361-365. Mann, R. E., Smart, R. G. and Anglin, L. (1996) Alcohol-related measures as factors in traffic fatalities. Journal of Studies on Alcohol 57, 646-651. Noble, J. A., Fe Caces, M., Steffens, R. A. and Stinson, F. S. (1993) Cirrhosis hospitalization and mortality trends. Public Health Reports 108, 192-197. Norstrom, T. (1995) Prevention strategies and alcohol policy. Addiction 90, 515-524. Popham, R. E., Schmidt, W. and delint, J. (1976) The effects of legal restraint on drinking. In Kissin, B. and Begleiter, H. eds, The Biology of Alcoholism, Vol. 4, Social Aspects of Alcoholism, pp. 579-625. Plenum Press, New York. Romelsjo, A. (1987) Decline in alcohol-related inpatient care and mortality in Stockholm County. British Journal of Addiction 82, 653-663. Rush, B. R., Gliksman, L. and Brook, R. (1986) Alcohol availability, alcohol consumption and alcohol-related damage. I. The distribution of consumption model. Journal of Studies on Alcohol 47, 1-10. Seeley, J. R. (1960) Death by liver cirrhosis and the price of beverage alcohol. Canadian Medical Association Journal 83, 1361-1366. Skog, O.-J. (1980) Liver cirrhosis epidemiology: Some methodological problems. British Journal of Addiction 75, 227-243. Smart, R. G. (1987) Socio-economic, lifestyle and availability factors in the stabilization of alcohol consumption in Canada. Canadian Journal of Public Health 78, 176-180. Smart, R. G. (1988) Recent international reduction and increases in liver cirrhosis deaths. Alcoholism: Clinical and Experimental Research 12, 239-242. Smart, R. G. (1989) Is the postwar drinking binge ending? Cross-national trends in per capita alcohol consumption. British Journal of Addiction 84, 743-748. Smart, R. G. and Mann, R. E. (1987) Large decreases in alcohol related problems following a slight reduction in alcohol consumption in Ontario 1975-83. British Journal of Addiction 82, 285-291. Smart, R. G. and Mann, R. E. (1991) Factors in recent reductions in liver cirrhosis deaths. Journal of Studies on Alcohol 52, 232-240. Smart, R. G. and Mann, R. E. (1995) Treatment, health promotion and alcohol controls and the decrease of alcohol consumption and problems in Ontario, 1975-1991. Alcohol and Alcoholism 30, 337-343. Smart, R. G., Mann, R. E. and Lee, S. L. (1996) Does increased spending on alcoholism treatment lead to lower liver cirrhosis death rates? Alcohol and Alcoholism 31, 487^91.