摘要：Objectives. We report impacts on alcohol consumption following new and increased minimum alcohol prices in Saskatchewan, Canada. Methods. We conducted autoregressive integrated moving average time series analyses of alcohol sales and price data from the Saskatchewan government alcohol monopoly for 26 periods before and 26 periods after the intervention. Results. A 10% increase in minimum prices significantly reduced consumption of beer by 10.06%, spirits by 5.87%, wine by 4.58%, and all beverages combined by 8.43%. Consumption of coolers decreased significantly by 13.2%, cocktails by 21.3%, and liqueurs by 5.3%. There were larger effects for purely off-premise sales (e.g., liquor stores) than for primarily on-premise sales (e.g., bars, restaurants). Consumption of higher strength beer and wine declined the most. A 10% increase in minimum price was associated with a 22.0% decrease in consumption of higher strength beer (> 6.5% alcohol/volume) versus 8.17% for lower strength beers. The neighboring province of Alberta showed no change in per capita alcohol consumption before and after the intervention. Conclusions. Minimum pricing is a promising strategy for reducing the public health burden associated with hazardous alcohol consumption. Pricing to reflect percentage alcohol content of drinks can shift consumption toward lower alcohol content beverage types. The contribution of both individual- and population-level alcohol consumption to increased risk of a range of serious chronic diseases (e.g., cancers, liver diseases) and adverse acute events (e.g., injuries, poisonings) is well documented. 1,2 In the World Health Organization Region of the Americas report, alcohol is identified as the single leading cause of the preventable loss of disability-adjusted life years. 1 Globally, hazardous and harmful alcohol use has been found to be the leading contributing cause of death among young adults, involving especially, deaths from road trauma, homicide, and suicide. 3 Successive comprehensive and systematic reviews of published research conclude that governments have a number of proven strategies to reduce the burden of illness from alcohol. 4,5 The evidence is strongest for universal policies that control price 6,7 and physical availability. 8,9 In many instances, however, policies with the least evidence of effectiveness (e.g., public awareness campaigns, alcohol education in schools) attract the greatest public support whereas the most effective policy—raising the price of alcohol—is consistently less popular. 10 A recent Canadian study found that provinces with higher levels of per capita alcohol consumption were more likely to oppose effective public health measures. 11 We previously identified specific alcohol pricing policies that may have higher levels of public acceptability and political viability without compromising effectiveness: (1) setting prices and taxes that reflect the ethanol content of beverages, thereby encouraging consumption of lower alcohol content varieties; (2) setting minimum prices to eliminate availability of cheap alcohol often favored by young adults and other high-risk drinkers; (3) creating earmarked taxes applied to a standard drink of any alcoholic beverage to raise funds for alcohol prevention and treatment programs (e.g., “a nickel a drink” tax); and (4) indexing all price and tax rates to the cost of living. 12,13 Elements of these policies have been endorsed under Canada’s National Alcohol Strategy 14 and formally advocated by the Public Health Officer of British Columbia, 15 and the Scottish government recently passed legislation to introduce a fixed minimum price per “unit” of ethanol. 16 Some US states have previously set mandatory minimum liquor prices (e.g., Washington), but the great majority sell alcohol at substantially lower prices than in Canada. 17 We have seen examples of spirits and fortified wine for sale in California liquor stores sold at approximately Can $0.25 per Canadian standard drink, less than half the price of the cheapest alcohol available in Canada. 18 We evaluated the impacts on alcohol consumption and government revenue of 2 of the aforementioned policies (1 and 2) as recently implemented in a Canadian province. On April 1, 2010, the Saskatchewan Liquor and Gaming Authority (SLGA) introduced a comprehensive set of new and increased minimum prices on alcohol. The SLGA has a monopoly on alcohol distribution and a partial monopoly on the sale of alcohol in liquor stores. Their minimum prices apply directly to liquor store retail prices and also to the prices at which the SLGA sells liquor to bar and restaurant owners; hence, they also indirectly affect on-premise retail prices, but likely to a smaller degree. Minimum prices were first introduced for spirits other than brandy and cognac in 2003, beer in 2005, wine in 2008, and higher strength coolers, brandy, and cocktails on April 1, 2010. Effective minimum prices calculated in Canadian dollars per standard Canadian drink (17.05 mL ethanol) are summarized in Table 1 . As shown in the supplementary online material (Appendix A, available as a supplement to this article at http://www.ajph.org ), the minimum price increase in 2010 impacted just 216 (8.5%) of the 2542 alcoholic products then sold by the SLGA, ranging from 0% of liqueurs to 17.0% of premixed cocktails. TABLE 1— Average Minimum Prices for Different Types of Alcoholic Beverage per Standard Drink (17.05 mL ethanol): Saskatchewan, July 2003–April 2010 Beverage Type (Volume) and % Alcohol Content July 2003, $ January 2005, $ June 2005, $ January 2007, $ February 2007, $ January 2008, $ March 2008, $ January 2009, $ April 2010, $ Spirits (750 mL) 35% to ≤ 44.9% 1.23 1.25 1.30 1.29 1.30 1.37 45% to ≤ 54.9% 1.03 1.05 1.09 1.09 1.09 1.45 ≥ 55% 0.66 0.67 0.70 0.70 0.70 1.18 All spirits 1.23 1.25 1.30 1.29 1.30 1.39 Liqueurs (750 mL) ≤ 22.9% 1.84 23% to ≤ 34.9% 1.59 All liqueurs 1.79 Wine (750 mL) ≤ 15.9% 1.32 1.41 ≥ 16% 0.82 1.20 All wine 1.28 1.39 Beer (6 pack, 2.046 L) ≤ 6.5% 1.28 1.32 1.36 1.40 1.56 > 6.5% to ≤ 7.5% 1.00 1.03 1.06 1.10 1.72 > 7.5 to ≤ 8.5% 0.75 0.77 0.80 0.82 1.46 ≥ 8.5% 0.64 0.67 0.69 0.71 1.39 All beers 1.27 1.32 1.35 1.40 1.56 Cocktails (1 L) ≤ 7% 1.71 > 7% to ≤ 13.7% 1.16 > 13.7 to ≤ 22.9% 1.49 23% to ≤ 34.9% 1.44 ≥ 35% 1.46 All cocktails 1.50 Coolers (6 pack, 2.046 L) ≤ 5.99% 1.48 ≥ 6% 1.29 All coolers 1.33 Open in a separate window Note . The effective minimum prices per standard drink introduced in April 1, 2010, were calculated in Canadian dollars for each beverage strength category after calculating a typical beverage strength within each strength category (L of beverage divided by L of ethanol) and after applying all applicable sales taxes (goods and services tax and liquor consumption tax). The outcome of the new policy was a set of minimum prices for alcohol that, depending on beverage type and strength, ranged between $1.16 and $1.84 per standard drink and that are now among the highest of all Canadian provinces. 19 Although minimum prices per standard drink were still lower for the low alcohol content beverage types after April 1, 2010 ( Figure 1 ), the new pricing structure shifted Saskatchewan’s alcohol pricing regime significantly toward the public health ideal represented by Scotland’s forthcoming fixed minimum price for a unit of ethanol. 15 Open in a separate window FIGURE 1— Trends in seasonally adjusted indices of age 15 years or older per capita consumption of beers, spirits, coolers, cocktails, and liqueurs 2 years before and after the minimum price increase: Saskatchewan, Canada, April 2008–March 2012. Note . 100 = mean per capita ethanol for each fiscal year. In most Canadian provinces, some Nordic countries, and some US states, governments are the leading retailers of alcohol, and so minimum prices can potentially serve fiscal as well as public health goals. In countries such as the United Kingdom and in most of the United States, where alcohol retailing is managed by private businesses, most increased profits from minimum pricing will flow to private retailers. In all jurisdictions, however, raising the minimum price of alcohol also creates the opportunity for additional government revenue whether through sales taxes or simultaneous adjustments to excise taxes or government-set markups. There is suggestive evidence that minimum alcohol pricing should have public health benefits. Meta-analyses have linked increases in overall alcohol prices to significant reductions in both alcohol consumption 6,7 and related harms. 20 There is evidence from the United States 21 and the United Kingdom 22 that the higher-risk drinkers tend to purchase the cheapest alcohol. Evidence from Sweden suggests that consumers of cheap alcohol are more price sensitive than are those who drink more expensive varieties mainly because they cannot substitute down to still cheaper beverages when prices go up. 23,24 The potential impacts of setting minimum alcohol prices on health and social costs have been modeled for the United Kingdom with significant and larger effects for younger and heavier alcohol consumers. 22,25 In the first empirical test of the impact of changes in minimum alcohol prices in a Canadian province, it was estimated that a 10% increase in the minimum price of any beverage resulted in a 3.4% decrease in total alcohol consumption. 26 There is also a strong rationale for encouraging the consumption of lower alcohol content products as a strategy for reducing related harms. A US study demonstrated how providing unlabeled 3% alcohol strength beer at a college party resulted in similar volumes of beer being consumed but with significantly lower blood alcohol concentrations in drinkers than when unlabeled 7% beer was provided. 27 A Canadian study found that young male beer drinkers were unable to reliably differentiate between low (3.7%) and high (5.6%) alcohol content beer and reported similar levels of enjoyment and subjective intoxication after consuming each type. 28 The new measures introduced in Saskatchewan in April 2010 substantially reduced incentives for selecting higher alcohol content beverages by introducing proportionately larger increases in minimum price for higher alcohol content products ( Table 1 ). We report autoregressive integrated moving average (ARIMA) time series analyses of SLGA sales and price data for different types and strengths of alcoholic beverages to examine the size and significance of changes after the increase in minimum liquor prices in April 2010. We hypothesized that the changes implemented by the SLGA would lead to: an overall reduction in alcohol consumption across all beverage types, greater reductions in consumption of high versus low alcohol content varieties of each beverage type, and greater effect sizes for off-premise sales (liquor stores) compared with sales from venues licensed to sell alcohol for on-premise consumption (bars, nightclubs, restaurants).
