It’s a political football. Whenever the prospect of privatizing the Liquor Control Board of Ontario (LCBO) is placed on the agenda, the result is a heated and polarized debate.

Tax revenues, employment, competition and consumer convenience—these are the concerns that dominate discussion.

But when it comes to any changes in alcohol policy, explicit consideration of the health impact of changes is typically absent.  “It’s a kind of chronic blindness,” says Norman Giesbrecht, senior scientist with the public health and regulatory policy division of the Centre for Addiction and Mental Health in Toronto.

“Look through media coverage of these debates over the years and you rarely see any reference to health.”

Alcohol second only to tobacco as health risk, says the WHO

The absence of discussion of health is striking. Alcohol ranks second only to tobacco in terms of leading risk factors for death and disability in high income countries, according to the World Health Organization.

Two LCBO related initiatives have recently attracted commentary.

Progressive Conservative Tim Hudak, leader of the opposition in Ontario, has called for an end to the LCBO monopoly.

LCBO expansion plans

Meanwhile, under the Liberal government, the LCBO is expanding. Last August, the Ontario Ministry of Finance announced that the LCBO would open “approximately 70 new stores” over two years (there are now 620 retail outlets in the province). The planned expansion is in addition to the 13 new stores opened in 2011-12. Those new stores, together with two renovations, resulted in $14.5 million in additional sales, according to a press release from the Ontario Ministry of Finance.

And last month, in a move widely perceived to be a response to Hudak’s call for private liquor outlets in corner and grocery stores, the ministry announced the creation of LCBO “express” stores in 10 large grocery stores.

While several columnists and editorial writers have weighed in, the potentially negative health effects have only barely been touched on in the public debate.

Too High a Cost, A Public Health Approach to Alcohol Policy in Canada, a 2011 report from the Canadian Public Health Association, called for a moratorium on the new retail outlets pending careful review of the public health and public safety implications.

10% of adults consume more than 50% of alcohol, survey reveals

But neither the Ontario Ministry of Health and Long-Term Care nor Public Health Ontario was represented during the decision-making process about the LCBO expansion, according to ministry spokesperson David Jensen and Public Health Ontario spokesperson Nicole Helsberg.

While moderate drinking may not have a negative effect on health, high consumption and binge drinking are undoubtedly harmful. About 10% of the Canadian population consumes more than 50% of the alcohol consumed in Canada, according to an analysis of a 2004 Canadian survey. As well, the majority of alcohol consumed in Canada is consumed in ways that increase the health and safety risks of drinkers, the survey analysis states.

And although tobacco use is associated with a far higher mortality rate, the negative effects of alcohol lead to earlier deaths than do the effects of tobacco smoking, according to Jürgen Rehm, director of social and epidemiological research at CAMH.

In Canada, about 7% of deaths before age 70—or about 4,500 deaths—are due to alcohol-related events and illnesses (injuries, liver disease, digestive diseases and cancer), he told a recent seminar.

Rehm and other researchers have published research calculating the rates of mortality and years of life lost in Canada due to alcohol and well as the burden of disease and injury that can be attributed to alcohol.

Burden of harm from alcohol can be reduced

These burdens could be substantially reduced if effective public health policies were implemented, the researchers note. A set of such policies were recommended in the 2007 National Alcohol Strategy and in Too High a Cost.

Developments in other provinces are instructive. In British Columbia, a team of researchers has tracked the effects of a policy decision to allow partial privatization of liquor sales. The expansion of private outlets there began in 1988, but picked up after 2002.

Tim Stockwell, director of the Centre for Addictions Research of British Columbia, and fellow researchers analysed the five-year period from 2003-04 to 2007-08. They found that the expansion led not only to higher alcohol sales but also higher rates of alcohol-related mortality.

The higher mortality rate was associated with the increased density of liquor stores.

“In Canada there is hardly and conversation”

Stockwell says the impact on crime is the subject of a soon-to-be published paper, and adds that his team is doing further analysis of the situation with grant support from the U.S. National Institutes of Health. “The Americans are very interested in this because of the explosion of private liquor stores there. In Canada there is hardly any conversation.”

Despite the touted financial benefits of privatization, even provincial ministries of finance should be wary. Alberta privatized liquor sales in the early 1990s and, according to a study by economist Greg Flanagan, provincial revenues from alcohol sales went down even as alcohol consumption and retail prices rose.

The LCBO states that even with the proposed expansion of stores over the next two years Ontario will have significantly fewer retail outlets per capita than other jurisdictions in Canada. A couple of years ago, the number of retail alcohol sales outlets in Ontario was 2.17 per 10,000 population 15 years and older, or the 2nd lowest outlet density among the provinces, according to CAMH figures.

A spokesperson clarified that of the 70 “new” stores heralded in a press release from August 2012, about two-thirds are replacements of old stores, with the balance being new stores. Still, many of those replacement stores are larger than the originals, and the volume of sales is expected to increase. (The LCBO did not respond to requests for their estimate of how much sales would increase as a result of the expansion.)

Lack of ongoing monitoring of alcohol-related harm

The 2007 National Alcohol Strategy, developed by a wide range of stakeholders, noted that in 2002, “the cost of alcohol-related harm totaled $14.6 billion, or $463 for every living Canadian. This included $7.1 billion for lost productivity due to illness and premature death, $3.3 billion in direct health care costs, and $3.1 billion in direct law enforcement costs.” The CAMH’s Rehm notes that there’s been no new study of the epidemiology of alcohol-related health and social costs since 2002.

Without regular ongoing monitoring of these impacts, it’s difficult to draw attention to the issues, observes Gerald Thomas, senior research and policy analyst with the Canadian Centre for Substance Abuse.

Advertising and the media promote an almost exclusively positive image of drinking, and many people drink alcohol safely and enjoyably, Thomas notes. “But people also understand the dark side of alcohol, and yet there is almost a social denial about responding to it.”