Preventing Alcohol-related Harm in Australia - Department of Health

Preventative Health TaskforceNational PreventativeHealth TaskforceTechnical Report No 3Preventing Alcohol-related Harm in Australia:a window of opportunityPrepared for the National Preventative Health Taskforceby the Alcohol Working Group

AcknowledgementsThe technical report on alcohol was prepared on behalf ofthe National Preventative Health Taskforce:Professor Rob Moodie, ChairProfessor Mike Daube, Deputy ChairMs Kate Carnell AODr Christine ConnorsMr Shaun LarkinDr Lyn Roberts AMProfessor Leonie SegalDr Linda SelveyProfessor Paul Zimmet AOThe report was prepared with advice from the NationalPreventative Health Taskforce Alcohol Working Group:Professor Rob Moodie (Chair)Professor Steve AllsopMs Kate Carnell AOMr David CrosbieProfessor Margaret Hamilton AOMr Todd HarperProfessor Leonie SegalDr Linda SelveyAssociate Professor Ted WilkesProfessor Paul Zimmet AOWriter: Mr Brian VandenbergWe would also like to thank the following people for their contributions to the report:Professor Robin Room (Director), and Mr Michael Livingston, AER Centre for Alcohol Policy Researchand Turning Point, Alcohol & Drug Centre MelbourneMs Meriel Schultz, Adviser, National Preventative Health TaskforceMs Michelle Scollo, Senior Adviser, Cancer Council VictoriaThe Population Health Strategy Unit and the Publications Unit and Communications Branch,Australian Government Department of Health and Ageing

Contents1 Introduction: changing the drinking culture in Australia 11.1 Purpose 11.2 The drinking culture in Australia 21.3 Determinants of drinking behaviour 21.4 Alcohol policy and programs in Australia 31.5 Recent developments in Australia 42 Key trends in alcohol consumption 52.1 Alcohol consumption in Australia and other countries 52.2 Drinking patterns among Australians 62.3 Product preferences 82.4 Alcohol prices and consumer spending 93 Key trends in alcohol-related harm 113.1 Health impacts 113.2 Social impacts 133.3 Health inequalities 154 Best practice in prevention 174.1 Current activity 174.2 Regulating the physical availability of alcohol 234.3 Taxation and pricing 274.4 Drink-driving countermeasures 274.5 Treatment and early intervention 284.6 Altering the drinking context 304.7 Regulating promotion 324.8 Education and persuasion 35ii

5 Policy Imperatives 375.1 The state of alcohol policy in Australia 375.2 The best mix of interventions 385.3 Challenges in implementation 405.4 Opportunities for action 425.5 Priorities 43References 45iii

1. Introduction:changing thedrinking culturein Australia1.1 PurposeThis paper has been prepared for the NationalPreventative Health Taskforce to provide upto-dateand evidence-based information onpolicies and programs to prevent alcoholrelatedharm in Australia. While the paper isintended as an overview of the most relevantand generally available evidence, in theinterests of brevity it covers many issues insummary only.The paper attempts to answer three questions:nnnWhat are the key trends in alcoholconsumption and related harm in Australia?What are the most effective approachesto preventing and reducing alcoholrelatedharm?What are the gaps and opportunities forpreventative action in Australia?The paper is informed by the most currentand readily available information on alcoholconsumption and related harm, and thescientific literature on approaches to preventingand reducing alcohol-related harm. It drawsupon evidence and examples of approachesfrom both within Australia and internationally.The paper summarises and acknowledgespreventative work addressing alcohol-relatedharm already under way in Australia, andincludes some commentary on its effectiveness,and also attempts to highlight gaps andopportunities for further preventative action.The range of interventions that are reviewed insome detail in the paper include:nnnnnnnRegulating physical availabilityTaxation and pricingDrink-driving countermeasuresTreatment and early interventionAltering the drinking contextRegulating promotionEducation and persuasion.An emerging theme from the paper is that thereis currently a unique window of opportunity inAustralia for a significant expansion of activityin the prevention of alcohol-related harm. Inpart, this opportunity grows from increasedcommunity and political concern about theharmful consumption of alcohol (especiallyfocused on youth drinking) and a heightenedwillingness from all levels of government to takeaction in the area.Furthermore, there is an increasingly solid baseof evidence upon which policy decisions canbe made – even from the brief review presentedin this paper, it is clear which of the variouspolicies and programs hold the most promise ofbeing effective, and those which offer the least.It is also apparent that there are potentialsynergies with other public health efforts toaddress tobacco, obesity and a range ofchronic diseases.1

The priorities for preventative action that aresuggested in this paper are reflected in theoverarching discussion paper Australia: theHealthiest Country by 2020.1.2 The drinking culture in AustraliaAlcohol plays many roles in contemporaryAustralian society – as a relaxant, as anaccompaniment to socialising and celebration,as a source of employment and exports, and asa generator of tax revenue. It is intrinsically partof Australian culture. The majority of Australianswho regularly drink, do so in moderation.Around three-quarters (72.6%) of Australiansdrink below levels for long-term risk of harm.[1]However, short-term consumption of alcoholat harmful levels, while only occasional, is alsoa prominent feature of the drinking culture inAustralia. One in five Australians (20.4%) drink atshort-term risky/high-risk levels at least once amonth.[2] Put another way, this equates to morethan 42 million occasions of binge drinking inAustralia each year.While overall levels of alcohol consumption anddrinking patterns have not changed markedlyover the past decade, there is an increasingcommunity awareness of the problem of harmfulconsumption of alcohol. These patterns continueto produce substantial costs to the health ofAustralians. Alcohol consumption accounts for3.2% of the total burden of disease and injuryin Australia: 4.9% in males and 1.6% in females.[3] Beyond its impacts on the health andwellbeing of individuals and communities, theharmful consumption of alcohol also impactssignificantly across a range of other areas,including workforce productivity, healthcareservices such as hospitals and ambulances, roadaccidents, law enforcement, property damageand insurance administration.The annual cost to the Australian communityfrom alcohol-related harm is estimated to bemore than $15 billion.[4] In Australia, concernin the general community about alcohol’sadverse health and social effects is growing.A recent survey of Australians revealed that 84%of people are concerned about the impact ofalcohol on the community.[5]1.3 Determinants of drinking behaviourThe current national alcohol strategy[6] observesthat Australia’s drinking cultures are drivenby a mix of powerful, intangible social forces,such as habits, customs, images and norms,and other interlocking and equally powerfultangible forces relating to the social, economicand physical availability of alcohol, includingpromotion and marketing, age restrictions, price,outlets, hours of access and service practices[6](see Fig. 1). Certainly, there is no single factorthat determines why people drink at harmfullevels. Health-damaging behaviours relatedto poor diet, inadequate exercise, cigarettesmoking, excessive drinking and illicit drug useappear to be embedded in a complex networkof social determinants and risk and protectivefactors, and behaviours are also mediated bycultural influences.[7]2

ModifiableDeterminants:Cultural Place and Availability:• Price• Outlet locations• Opening hours• Minimum purchase age• Service practices• Law enforcement• Promotion• Social norms & valuesTargetBahaviours:Drinking to Intoxication:(BAC > 0.08)Long TermHeavy DrinkingOutcomes:Public Safety and Amenity:• Violence• Property damage• Anti-social behaviour• Perceptions of safetyPublic Safety and Amenity:• Road injuries• Assaults• Drowning• Suicides• Falls• Fire/smoke injuries• Sexually transmittedinfectionsLong-term (Chronic)Health Impacts:• Cancers• Cirrhosis of the liver• Dependence• Mental IllnessFigure 1: Alcohol-related harm: determinants, behaviours and outcomesSource: National Alcohol Strategy 2006–2009[6]1.4 Alcohol policy andprograms in AustralianSupport whole-of-community initiatives toreduce alcohol-related health problemsPreventing alcohol-related harm is a responsibilityshared among all levels of government. TheAustralian Government and the states andterritories are working together through themechanisms of the Ministerial Council onDrug Strategy to implement initiatives as partof the National Alcohol Strategy 2006–2009.[6] The strategy is a plan for action developedcollaboratively between governments, industryand community partners. Key action areasinitially identified for the strategy include:nnnMonitor and review of alcohol promotionsIncrease community awareness andunderstanding of the extent and impactsof intoxicationImprove enforcement of liquorlicensing regulationsnDevelop and implement socialmarketing campaigns to reducealcohol-related harms.At a state and territory level, key alcohol policyand program responsibilities include lawenforcement, licensing regulation, the provisionof treatment services and drug education inschools. Additionally, all states and territorieshave strategic plans to address alcohol, whichvary in scope and funding. Given the diverserange of adverse outcomes of drinking oftenexperienced at a local community level,local governments also play an importantrole, including their functions in environmentalhealth, planning, community development,waste disposal and youth services.3

Local governments can contribute to themanagement of the physical availability ofalcohol and the creation of safer drinkingsettings, and engage in environmental designand planning that contributes to and supportscommunity wellbeing. There are many examplesof innovative, locally responsive measures inAustralia, in part to respond to the modernphenomena of ‘night-time economies’.[8]Throughout Australia, there is also aconsiderable amount of community-basedactivity under way in preventing alcohol-relatedharm, some of which is government fundedand some of which is led by charitable groups.The contribution of community-level actionis significant, and is integral to the effectiveimplementation of federal, state and localgovernment polices and programs.Overall, while rhetoric is aimed at prevention,and there is currently a mood to address thenegative side of alcohol use, there is greatdifficulty in gaining coherent, cooperative,strategic and effective action. This situationmight be compared to the place of andresponses to tobacco smoking in Australiain the 1960s.1.5 Recent developments in AustraliaNational Binge Drinking StrategyOn 28 March 2008, the Prime Ministerannounced a new national strategy to addressthe binge drinking epidemic among youngAustralians.[9]Council of Australian Governments(COAG) Binge Drinking AgreementThe Council of Australian Governments (COAG)recently agreed on the importance of tacklingthe harmful consumption of alcohol amongyoung people and asked the MinisterialCouncil on Drug Strategy to report to it inDecember 2008 on options to reduce bingedrinking, including in relation to closing hours,the responsible service of alcohol, recklesssecondary supply and the alcohol contentin ready-to-drink beverages. The AustraliaNew Zealand Food Regulation MinisterialCouncil is to request Food Standards AustraliaNew Zealand to consider mandatory healthwarnings on packaged alcohol.[10]Ministerial Council onDrug Strategy (MCDS)The work of the Ministerial Council on DrugStrategy (MCDS) includes a focus on theassessment of late-night lock-outs for licensedpremises and the development of a preferredframework to more effectively target policeresources on binge drinking hot spots. It is alsofocused on a national policy framework forthe responsible service of alcohol, a preferredregulatory model to address the secondarysupply of alcohol to minors, options for reducingthe alcohol content in products (including thoseaimed at young people), possible standards andcontrols for alcohol advertising targeting youngpeople, and advice regarding the impact ofhealth warnings on alcohol products.[11]Northern Territory initiative and otherAboriginal and Torres Strait Islanderspecific initiativesPerhaps the most radical experiments inresponding to problems, especially amongAboriginal Australians, have been carried outin the Northern Territory. Most recently, theNorthern Territory Initiative was implementedby the then Minister for Aboriginal Affairs of theprevious Australian government, and is soon tobe reviewed after one year of implementation.This is a complex area and this paper will notattempt to summarise interventions specific toIndigenous Australians or presume to providecomprehensive information in this area.4

2. Key trends in alcoholconsumption2.1 Alcohol consumption in Australiaand other countriesInformation on levels and patterns of alcoholconsumption is diverse, and it can be difficultto identify the key features for the purposes ofmonitoring trends in drinking and related harm,and the possible opportunities for intervention.Unfortunately, in Australia at the current time,some of the most significant and valuable datais not readily available to the public health field.[12] For example, alcohol sales data, while it isknown to be collected and analysed by thealcohol beverage industry, is not available forthe purposes of this paper, nor indeed is it easilyaccessed for public health research purposes ingeneral. The Taskforce notes with some concernthat the continuation of the most accessibledata sets on alcohol consumption levels inAustralia, collected and compiled by theAustralian Bureau of Statistics (ABS), is currentlyunder review. Efforts are therefore urgentlyrequired to seek the continuation of thesevaluable data sets.Per capita consumption of alcohol is animportant measure from a public healthperspective because it is ‘to a considerableextent, related to the prevalence of heavyuse, which in turn is associated with negativeeffects’.[13] Total per capita consumption ofalcohol in Australia alcohol grew rapidly in the1970s and has not returned to low levels sincethen; in 2007 it was estimated to be 9.88 litresof alcohol per capita (see Fig. 2). Among thedifferent alcoholic beverage categories, therehave been significant changes in per capitaconsumption over the past 70 years. Sincepeaking at over 6.4 litres of alcohol per capitain the mid-1970s, per capita consumptionof beer has steadily declined and is now ata level similar to that of the late 1950s.This reduction partly reflects changes inconsumer tastes towards wine, and the increasein the availability of relatively low-priced wine.Consumption of wine has increased almostfourfold since the late 1940s, when intake was0.77 litres of alcohol per capita. In 2005 wineconsumption in Australia reached an all timerecord of 3.13 litres of alcohol per capita. Wheninterpreting the trend in per capita consumptionin Australia, it should be noted that the datadoes not take into account the ageing of thepopulation; as people age, they generallyconsume less alcohol. Hence, as the Australianpopulation continues to age over the comingdecades, it is expected that per capita alcoholconsumption will most likely decrease.Figure 2: Apparent per capita consumption of alcohol (litres ofalcohol), Australian persons aged 15+ years, 1994 to 2007 (yearsending 30 June)Source: ABS unpublished data and ABS 2008Per capita consumption of alcohol in Australia ishigh by world standards. Australia is ranked withinthe top 30 highest alcohol-consuming nations, outof a total of 180 countries. Table 1 shows Australia’slevel of per capita alcohol consumption (9.02 litresof pure alcohol) and ranking (#30) comparedto other selected countries in 2003. More recentestimates of per capita alcohol consumptionfor Australia (9.88 litres of pure alcohol in 2007)suggest that our international ranking is now likelyto be even higher.5

Table 1: Per capita consumption of alcohol by country and rank (out of 180 countries),selected countries*RankCountryPer capitaconsumption † Rank CountryPer capitaconsumption †1 Luxembourg 15.56 31 Greece 9.012 Ireland 13.69 33 USA 8.617 Germany 11.99 37 Italy 8.028 UK 11.75 42 Japan 7.5910 Spain 11.68 52 South Africa 6.7214 France 11.43 63 Sweden 5.9620 Russian Federation 10.32 70 Thailand 5.5923 Netherlands 9.68 74 China 5.2024 New Zealand 9.68 120 Papua New Guinea 1.6230 Australia 9.02 168 Indonesia 0.09* Values are for various years before and including 2003† Per capita alcohol consumption (litres of pure alcohol) among adultsSource: WHO 2008[14]2.2 Drinking patternsamong AustraliansIt is estimated that 83% of Australians aredrinkers, and that 1.4 million Australiansconsume alcohol on a daily basis.[2] In 2007,males (10.8%) were almost twice as likely asfemales (5.5%) to drink daily.Two in every five Australians drink on a weeklybasis. However, there is a sizable proportionof the population (10.1% in 2007) who, forvarious reasons, have never drunk any alcohol(see Table 2).Table 2: Frequency of alcohol consumption, proportion of the population aged 14+ years,Australia, 1991 to 2007Frequency 1991 1993 1995 1998 2001 2004 2007Daily 10.2 8.5 8.8 8.5 8.3 8.9 8.1Weekly 41.0 39.9 35.2 40.1 39.5 41.2 41.3Less 30.4 29.5 34.3 31.9 34.6 33.5 33.5Ex-drinker 12.0 9.0 9.5 10.0 8.0 7.1 7.0Never 6.5 13.0 12.2 9.4 9.6 9.3 10.1Source: AIHW, National Drug Strategy Household Surveys,[2] various yearsAlmost three-quarters (72.6%) of Australiansdrink below levels that would incur long-termrisk of harm. However, among young adults(aged 20–29 years), the prevalence of drinkingat levels posing long-term risk of harm issignificantly higher (16%) than among otherage groups (see Fig. 3).This pattern of drinking is the equivalent ofconsuming 29 or more standard drinks per weekfor males and 15 or more standard drinks perweek for females. Among Australian teenagersin 2007, this drinking pattern was considerablyhigher among females (10.6%) than amongmales (7%).6

Figure 3: Drinking at risky/high risk of harm in thelong term by age and year, proportion of thepopulation aged 14+ years, Australia, 2007Source: AIHW National Drug Strategy Household Survey[2]While almost half (48.3%) of the Australianpopulation drink at low risk levels, one in fiveAustralians (20.4%) drink at short-term risky/highrisklevels at least once a month. This pattern ofdrinking is the equivalent of consuming seven ormore standard drinks on any one day for males,and consuming five or more standard drinks onany one day for females. In short, this generallyequates to drinking to the point of intoxication,or what is often termed as ‘binge drinking’.This sort of drinking is most prevalent amongadults aged 20–29 years, one-quarter (24.9%) ofwhom do so on at least a monthly basis. Overall,Australian males are more likely than femalesto drink at short-term risky/high-risk levels onregular (at least once a month) occasions(17.1% of females compared to 23.6% of males).However, among teenagers, females are morelikely than males to regularly drink at levels ofrisky/high-risk of harm in the short term: 28.3% offemale teenagers compared to 24.5% of maleteenagers (see Figs. 4 and 5). Between 2001and 2007 there were only slight changes in theprevalence of drinking at risky/high risk of harmin the short term across the age groups.Figure 4: Monthly drinking at risky/high riskof harm in the short term* by age and year,proportion of the male population aged 14+years, 2001 to 2007Source: AIHW National Drug Strategy Household Survey[2]Figure 5: Monthly drinking at risky/high riskof harm in the short term* by age and year,proportion of the female population aged 14+years, 2001 to 2007Source: AIHW National Drug Strategy Household Survey[2](*Risky/high-risk drinking in the short term =seven or more standard drinks on any one dayfor males; five or more standard drinks on anyone day for females.)7

2.3 Product preferencesThe most preferred types of alcoholicbeverages among Australian female drinkers,in descending order, are bottled wine, bottledspirits and liqueurs, ready-to-drink beverages(RTDs) in a bottle and RTDs in a can. Over the2001 to 2007 period, the preference for bottledwine had the greatest increase among females,growing from 57.3% to 63.8%. Among males, themost preferred types of alcoholic beverages,in descending order, are full-strength beer,bottled wine, bottled spirits and liqueurs, andRTDs in a can. Over the 2001 to 2007 period, thepreference for RTDs in a can had the greatestincrease among males, growing from 18.2% to24.3% (see Figs. 9 and 10).With regard to which types of alcoholicbeverages are most commonly involved inthe harmful consumption of alcohol, Stockwellet al. have estimated[16] that straight spirits(79.7%), alcoholic cider (78.9%), pre-mixed spirits(71.8%) and regular strength beer (72.6%) arethe top four types of beverages consumed byAustralian drinkers on days when they drank atrisky/high-risk levels. Among 12- to 17-year-olds,the top three types of beverages are straightspirits (98.9%), regular beer (78.9%) and RTDs(76.7%). Spirit-based beverages held the highestmarket share, representing 62.7% of total alcoholconsumption among this age group, with slightlymore consumed as straight spirits than as RTDs.Figure 9: Preference for selected alcoholicbeverages by year, proportion of the malepopulation, Australia, 2001 to 2007Source: AIHW[15]Figure 10: Preference for selected alcoholicbeverages by year, proportion of the femalepopulation, Australia, 2001 to 2007Source: AIHW[15]8

2.4 Alcohol prices andconsumer spendingThe real price of alcohol in Australia hasremained relatively low compared to othercommodities, and in some cases has dropped.For example, a glass of wine costing $1 in June1999 dropped in real terms to $0.90 in March2008 (see Fig. 6).The affordability of alcohol in Australia today isreflected in the fact that, on average, Australianhouseholds are spending proportionatelyless on alcohol nowadays compared to theamount they spent 20 years ago, despite totalper capita consumption of alcohol changinglittle over the same period. The proportion ofaverage weekly expenditure by Australianhouseholds on alcoholic beverages in 1984was 3.4% ($12.30), compared to 2.6% ($23.32) in2003–2004 (ABS 2005).[17]Figure 6: Prices of alcoholic beverages relativeto other consumption (June 1999 $1.00),Australia, September 1980 to March 2008Source: ABS, various years9

3. Key trends in alcoholrelatedharm3.1 Health impactsIt is important to consider both the shorttermand long-term health impacts of theharmful consumption of alcohol, as bothresult in significant morbidity and mortality.The typical effects of moderate alcoholconsumption are those on the brain, suchas feelings of relaxation, wellbeing and lossof inhibitions. However, as intake increases,pleasant effects are lessened by adverseeffects such as drowsiness, loss of balance,nausea and vomiting, and other more seriousharmful effects such as aggressive behaviours,unconsciousness, kidney failure and increasedrisk of accidents and injury [18]. Overall, morepeople die from the acute effects of alcoholthan the long-term or chronic effects.[18]Alcohol consumption accounts for 3.2% of thetotal burden of disease and injury in Australia:4.9% in males and 1.6% in females.[19]It should be noted that although thispercentage is lower than the contributionfrom tobacco smoking (7.8%) and high bodymass (7.5%), there remains some debate overthe method to calculate the disease burdenattributable to alcohol. That the Australianfigure may be an underestimate is suggestedby the higher reported burden of disease fromalcohol for New Zealand (10% for men and 4%for women).[20]Alcohol has been causally linked to more than60 different medical conditions.[13] In Australia,alcohol was linked to 3430 deaths per year and85,435 disability-adjusted life years (DALYs) peryear.[3]In the 10 years between 1992 and 2001, morethan 31,000 Australians died from alcoholattributableinjury and disease – a greaternumber died from acute (usually in the contextof acute intoxication) rather than chronicconditions (often related to longer termdependence on alcohol).Table 3: Deaths and burden (DALYs) attributable to alcohol by specific cause, Australia, 2003Specific causeNumberDeathsProportion oftotal (%)NumberDALYsProportionof total (%)Alcohol abuse 918 0.7% 34,116 1.3%Suicides & self-inflicted injuries 553 0.4% 12,245 0.5%Road traffic accidents 396 0.3% 11,121 0.4%Oesophagus cancer 368 0.3% 4,594 0.2%Breast cancer 184 0.1% 4,152 0.2%Other 1,012 0.8% 19,207 0.7%Total harm 3,430 2.6% 85,435 3.2%Source: Begg et al. 2005The most common cause of death due tointoxication was road crash injury, and amongthe chronic conditions alcohol-related livercirrhosis accounted for the majority of deaths.[21]Deaths from acute causes are most commonamong young people, particularly thoseaged 15–29 years, while deaths from alcoholattributablechronic diseases are morecommon among people aged over 45 years.11

More males than females died from both acuteand chronic alcohol-attributable conditions [21.]Over half a million hospitalisations were causedby risky and high-risk drinking in Australia in theeight years between 1993/94 and 2000/01.[21]The most numerous conditions among thesehospitalisations were for alcohol dependence(87,186), injuries caused by assault (76,115), roadcrash injuries (47,167) and attempted suicide(20,374). As many as 10,094 hospitalisations wereattributed to some form of ‘alcoholic overdose’from very high blood alcohol levels, includingalcohol poisoning and aspiration vomitus.Overall, the majority of hospitalisations were foracute conditions (67.8%).[21]Future projections of the leading causes ofdisease burden predict that the proportiondue to alcohol will remain stable and within thetop 14 leading causes among Australian malesby 2023 (see Fig. 7). The proportion of diseaseburden caused by anxiety and depression isalso expected to remain stable by 2023, whileischaemic heart disease and lung cancerare expected to decline. Type 2 diabetes ispredicted to be the leading cause of diseaseburden among Australian males by 2023.Figure 7: Leading causes of burden (DALYs) inmales, Australia, 1993 to 2023Source: Begg et al. 2007[19]At low levels of consumption, alcohol mayalso have some benefits – various studieshave found reductions in some forms of heartdisease (particularly in middle-aged and oldermales) and ischaemic stroke (in older females),diabetes, gallstones and dementia.The extent and even the existence of suchbenefits remain controversial.[22, 23] In terms ofpopulation, health, heart disease and stroke arethe most important of these potential benefits.Nearly all the potential benefits are confinedto males over the age of 45 and women pastmenopause, and can be gained with a drinkingpattern of as little as one drink every secondday. Since alternative means of preventingheart and vascular disease are available, theclinical consensus is that people need not takeup or maintain drinking for health benefits.Drinking during pregnancyRecent data show that 59% of Australianwomen drank alcohol at some time duringtheir pregnancy and that 14% reporteddrinking five or more drinks in a sitting inthe three months prior to pregnancy – 58%during the first and second trimester and54% in the third trimester.[18] Maternalalcohol consumption can result in aspectrum of harms to the fetus. Althoughthe risk of birth defects is greatest with high,frequent maternal alcohol intake during thefirst trimester, alcohol exposure throughoutpregnancy (including before a pregnancy isconfirmed) can have consequences for thedevelopment of the fetal brain. It is not clearwhether the effects of alcohol are relatedto the dose of alcohol and whether thereis a threshold above which adverse effectsoccur.[24] This uncertainty is reflected inpolicy regarding alcohol use in pregnancywithin Australia and overseas.[25] Althoughthe risks from low-level drinking (such as oneor two drinks per week) during pregnancyare likely to be low, a ‘no-effect’ level hasnot been established, and limitations in theavailable evidence make it impossible toset a ‘safe’ or ‘no-risk’ drinking level forwomen to follow in order to avoid causingharm to their unborn baby.12

In 2005–2006 there were a total of 145,000drug treatment episodes recorded in Australia,of which 56,000 (or 39%) were for alcoholproblems.[15] While this figure is high, it isperhaps relatively low given the estimated585,000 Australians who drink at levelsconsidered to be high risk to health in thelong term, many whom might be consideredthe potential target group for treatment.[15]Females accounted for 31% of alcoholtreatment episodes in 2005–2006. Personsaged 20–29 years received 22% of treatmentepisodes. For persons aged 10–19 yearsreceiving treatment, the proportion treatedfor alcohol problems has increased from 15%to 23% between 2001–2002 and 2005–2006.The interactions between other drugs(tobacco, illicit and prescription) and alcoholare complex. Australian studies reveal a closeassociation between heroin overdose andalcohol consumption at harmful levels at thetime of overdose. Australian research has alsofound that among cannabis users, alcohol wasalmost universally used on a regular basis, withmost users consuming alcohol at harmful levels.There are also parallels in aetiological researchregarding the uptake of one psycho-activesubstance increasing the likelihood of use ofothers. There has also been some work doneregarding parents’ attitudes and behaviour asa factor in influencing tobacco, alcohol andother drug use. For all of these substances, itis important that prevention efforts focus ondelaying the uptake of regular use. This paperdoes not attempt to deal with the obviouscrossover between mental health issues andthe harmful consumption of alcohol, and theincreasing problem of poly-drug use, but anypreventative action needs to bear these factorsin mind.3.2 Social impactsThe effects of alcohol consumption go beyonddiseases, accidents and injuries to a rangeof adverse social consequences, both forthe drinker and for others in the community.These consequences include harm to familymembers (including children) and to friendsand workmates, as well as to bystanders andstrangers. Alcohol-related disturbance andassault ranges from acts of vandalism, offensivebehaviour and disruption to far more seriousantisocial behaviour, which can result inviolence or injury to others.[18,23] While it isnot a perfect description of the wider socialimpacts of the harmful consumption of alcohol,some commentators have coined the term‘passive drinking’, akin to passive smoking, torefer to the impact of drunken behaviour onthird parties.13

Families and childrenIt is a reality that the most visible effectsof drinking on others, including children,result from accidents and injury(including violence) during or afterdrinking occasions.[18, 23) When familieshave to deal with a relative’s alcoholism,violence, injury or even death, theseserious consequences can cause greatsuffering.[18, 30) Drinking within familiesis an important consideration because,depending upon the circumstances, it canbe either a positive or negative influenceon the drinking behaviour of young people.It is estimated that 13% of Australianchildren aged twelve years or less areexposed to an adult who is a regular bingedrinker.[26] It has been estimated that 31%of parents involved in substantiated casesof child abuse or neglect experiencesignificant problems with alcohol use.[27]In Australia, it is estimated that 47% of allperpetrators of assault and 43% of all victims ofassault were intoxicated prior to the event.[28]It has also been reported that 34% of homicideperpetrators and 31% of homicide victims werealcohol affected at the time of the homicide. Inaddition, it has been estimated that alcohol isan important factor in 50% of cases of domesticphysical and sexual violence.[29] In a singleyear (1998–1999), there were 8661 peopleadmitted to Australian hospitals with injuriesfrom alcohol-related assaults; 62,534 alcoholrelatedassaults were reported to police in thesame year, and it is estimated that many morewent unreported. Of the hospitalisations withinjuries from alcohol-related assaults, 74% weremale and two-thirds were aged 15–34 years.[30]An important factor in alcohol-related violenceis the setting where drinking occurs. Australianstudies have generally confirmed that alcoholrelatedviolence most commonly occurs in andaround inner-city hotels, in the early hours ofSaturday and Sunday mornings, and usuallyamong young adult males.[31]Furthermore, it has been shown that themajority of alcohol-related incidents occurin a minority of high-risk licensed venues.[32]It is not surprising that much of the time andresources of policing in Australia is related toincidents involving alcohol. One study reportedthat alcohol is involved in 62% of all policeattendances, 73% of assaults, 77% of streetoffences, 40% of domestic violence incidentsand 90% of late-night calls, from 10.00pm to2.00am.[31]The total social cost of the harmful consumptionof alcohol is estimated to be more than$15 billion each year.[4] The majority of thesecosts are for tangible social costs such as crime($1.6 billion), health ($1.9 billion), productivityin the workplace ($3.5 billion), productivity inthe home ($1.5 billion) and road accidents($2.2 billion) (see Table 4).Table 4: Estimated social costs of alcohol abuse,Australia, 2004–2005Type of cost $mReduction in workforce and absenteeism 3,579Labour in the household 1,571Medical 541Hospital 662Nursing homes 401Pharmaceuticals 298Ambulances 75Road accidents 2,202Police 747Criminal courts 86Prisons 142Property 67Insurance administration 14Productivity of prisoners 368Resources used in abusive consumption 1,689Loss of life 4,135Pain and suffering (road accidents) 354Source: Collins & Lapsley 2008[4]14

3.3 Health inequalitiesGeographicThere are variations in alcohol consumptionacross Australia and different impacts onspecific high-risk population groups. Per capitaalcohol consumption varies significantlybetween urban and rural areas, and betweenAustralian states and territories. For instance,while the prevalence of drinking at short-termrisky/high-risk levels at least monthly is 18.7%in New South Wales and 19.4% in Victoria, itis 28.4% in the Northern Territory.[1] Alcoholconsumption levels (and alcohol-attributablemortality and morbidity) are consistently foundto be lower for people living within majorcities when compared to outer regions. In2004 it was estimated that the proportion ofAustralians who drank at risky/high-risk levelsfor short-term harm, residing in outer regional(24%) and remote/very remote (28%) locationswas between 20% and 40% greater than forresidents of major cities. The proportion ofthe population residing in outer regional andremote/very remote locations who drank atrisky/high-risk levels for long-term harm were11% and 16% respectively, compared to 9.5%in major cities. Not surprisingly, there are alsogeographic differences in the rates of alcoholrelatedharm in Australia. The Northern Territoryhas the highest rate of alcohol-attributabledeaths and hospitalisations in the country.Indigenous AustraliansIndigenous Australians are about twice as likelyto abstain from alcohol as non-IndigenousAustralians, but those who do drink may beup to six times more likely to drink at high-risklevels than non-Indigenous people.[34] A surveyestimated that 38% of Indigenous people aged14 and over drank at risky/high-risk levels foracute harm, compared to 20% among non-Indigenous people; and that 23% drank at risky/high-risk levels for chronic harm, comparedto about 10% of non-Indigenous people.[35]However, a less recent, but better designed,Indigenous-specific survey of substancemisuse found that about 58% of all Indigenousrespondents drank at risky/high-risk levels.[36]Among Indigenous people who live in remoteparts of Australia, levels of alcohol consumptionare particularly high.In 2002–2003 the rate of hospital admissionamong Indigenous males for conditions relatedto high levels of alcohol use was betweentwo and seven times greater than for non-Indigenous males. Such conditions includeacute alcohol intoxication, alcoholic liverdisease, harmful use and alcohol dependence.In addition, between 1999 and 2003 about71% of Indigenous homicides occurred insituations where both the perpetrator andvictim were drinking (as opposed to 19% ofnon-Indigenous homicides).[29] Other studieshave shown that the rates of death from whollyalcohol-caused conditions among residentsof Western Australia, South Australia and theNorthern Territory are almost eight times greaterfor Indigenous males than for non-Indigenousmales and 16 times greater for Indigenousfemales than for other females.[37] The levelof alcohol-attributable death among youngIndigenous Australians (15–24 years) has alsobeen shown to be almost three times greaterthan for their non-Indigenous counterparts– with the divergence between the twopopulations apparently increasing in recentyears.[38]15

Young AustraliansRates of risky drinking in Australia peakamongst young people,[2] and alcoholrelatedharm is substantial for both adolescentsand young adults. Drinking contributes tothe three leading causes of death amongadolescents – unintentional injuries, homicideand suicide – along with risk-taking behaviour,unsafe sex choices, sexual coercion andalcohol overdose.[18] A recent study of selfreportedharm found that drinkers under theage of 15 years are much more likely thanolder drinkers to experience risky or antisocialbehaviour connected with their drinking, andthe rates are also somewhat elevated amongdrinkers aged 15–17 years.[39] Furthermore,initiation of alcohol use at a young age mayincrease the likelihood of negative physicaland mental health conditions, social problemsand alcohol dependence. Regular drinkingin adolescence is an important risk factor forthe development of dependent and riskypatterns of use in young adulthood. Childhoodand adolescence are critical times for braindevelopment and the brain is more sensitive toalcohol-induced damage during these times,while being less sensitive to cues that couldmoderate alcohol intake.Like adolescents, young adults continue to begreater risk takers than older adults, but theirdecision-making skills remain undeveloped –factors that are reflected in the high levels ofinjuries sustained by this age group. Alcoholaffects brain development in young people;thus, drinking, particularly ‘binge drinking’, atany time before brain development is complete(which is not until around 25 years of age) mayadversely affect later brain function. In addition,young adults are also the adult age group mostlikely to take mood-altering drugs.[2]Trends in youth drinking are unclear, withneither school survey data (ASSADS) nor theNational Drug Strategy Household Survey(NDSHS) demonstrating clear trends in drinkingamongst adolescents or young adults in thelast decade. While a recent examination ofVictorian data relating to young people agedbetween 12 and 24 found no clear trend inrates of risky drinking, it revealed that rates ofhospitalisation and presentation at emergencydepartments have increased dramaticallyover recent years. The study suggests that therelationship between survey-derived estimatesof alcohol consumption and rates of alcoholrelatedharms is not as clear-cut as expected,and raises concerns about the sensitivity ofpopulation surveys in detecting changes inharmful drinking patterns.[40]Drinking can also lead to poorer outcomes forpeople who have a mental health condition,whether it is a high-prevalence condition suchas depression or a low-prevalence conditionsuch as schizophrenia.There has been little analysis of the patternsof consumption and trends in alcohol-relateddysfunction or harm in older people in Australia.Older people are more vulnerable to theeffects of alcohol due to changes in their bodycomposition, decreased metabolic capacity,the presence of co-morbid conditions and themedications that regulate these conditions.Older people express concern about reducedperceptions of safety associated with publicplace drinking. Women in the baby boomer agegroup, now aged in their 50s to 70s, are morelikely than their parents to be alcohol consumersand it might be anticipated that this will producean increase in alcohol-related morbidity in theirolder years, but this is yet to be documented.Certain occupational groups are also known toregularly drink at risky/high-risk levels, especiallytradespeople and unskilled workers, and thoseworking in the hospitality, agricultural andmining industries.16

4. B est practicein prevention4.1 Current activityConsiderable activity aiming to preventalcohol-related harm is currently under way inAustralia. The extent to which the considerablepreventative desire and activity (planned orunder way) is likely to be effective, and howwell this activity reflects an evidence-basedapproach, is considered in the next section ofthis paper. In general, the measures that aremost often called for by community memberstend to be the least effective, while the mosteffective measures are the least popular and arethus probably the most difficult for governmentsto introduce, usually requiring strong leadershipand well-planned implementation.What is prevention in this area?The stated aim of Australia’s current NationalDrug Strategy is to ‘prevent the uptakeand minimise the harmful effects of druguse in Australian society’. Known as ‘harmminimisation’, this approach has been definedas encompassing:nnnSupply reduction strategies designedto restrict the harmful supply of drugsDemand reduction strategies designedto prevent the uptake of harmful drug useHarm reduction strategies to reducedrug-related harm for individualsand communities.The approach of harm minimisation, whilecomplex and requiring continuing supportfrom public advocates, is based on scientificevidence and underpins the definition ofprevention adopted for the review of alcoholrelatedinterventions in this paper. It canencompass universal as well as targetedinterventions (both selective: particular highrisksub-populations; and indicated: those withemerging problems).Though not explored in detail in this paper, theconcept of the prevention paradox assists inunderstanding prevention approaches in theareas of public health and public safety. Thisapproach suggests that more (net) harm maybe prevented through universal interventions –focusing on the majority who are less seriouslyinvolved in harmful alcohol/drug use, ratherthan through interventions that only target thesmaller proportion of high-risk users.What works in alcoholrelatedprevention?The following discussion is informed by recentreviews of the available research evidence.This includes:nnnthe World Health Organization’s (WHO)international review of alcohol-relatedresearch and public policy[13]a recent Australian research monographon the prevention of substance use, riskand harm[7]a recent update of the latter, witha focus on prevention interventionstargeting adolescents.[41]Other recent reviews have also been drawn upon,to a lesser extent, including Stockwell 2004,[42]Loxley et al. 2005[7, 43] and NDRI 2007.[36]The conclusions reached in the WHO report[13]with regard to the respective strengths andweaknesses of different types of interventions,according to the available international researchevidence, are summarised in Table 6. Included inthis table are Australian-authored evaluations ofthe equivalent interventions provided by Loxleyet al.[7] and Toumbourou et al.[41] The scalesused to rate the interventions by the respectiveauthors are summarised in Table 5 below.17

Table 5: Key to the rating scales shown in Table 6RatingEvidence ofeffectivenessBreadth ofresearch supportTest across culturesAustralianevaluation0 Lack of effectiveness No studies undertaken Not tested Limited investigation★ Limited effectiveness 1 well-designed studycompletedTested in 1 countryEvidence forimplementation★ ★ Moderate effectiveness 2–4 studies completed Tested in 2–4 countries Evidence for outcomeeffectiveness★ ★ ★High degree ofeffectiveness5+ studies completed Tested in 5+ countries Evidence for effectivedissemination? No evidence available N/A●✖Warrants furtherresearchEvidence iscontra-indicativeThis rating scale applies to the WHO’sinternational review [13] and Australianreviews.[14].Of the 39 interventions listed in Table 6, at leasthalf of these are universal (targeted at the wholepopulation) and approximately half are targetedat high-risk groups. The international reviewby Babor et al. concludes that interventionstargeting the whole population generally havehigher effectiveness ratings and are less costlyto implement and maintain, on average, thanthose targeting high-risk groups.[13] In general,the types of interventions that are consideredmost effective according to the ratings are,in order:1. Regulating physical availability.2. Taxation and pricing.3. Drink-driving countermeasures.4. Treatment and early intervention.The types of interventions for which there issomewhat less evidence of effectivenessare, in order:5. Altering the drinking context6. Regulating promotion7. Education and persuasionThere are differences in the ratings of someinterventions between the internationalreview[13] and the Australian review.[7](for example, the treatment of alcoholproblems and mass media campaigns).Also, importantly, it should be recognisedthat although the effectiveness of someinterventions do not rate highly, in somecases this may be due to the limitedresearch evidence that is available toinform the rating (for example, advertisingcontent controls).18

Table 6: Ratings of policy-relevant strategies and interventionsStrategy or intervention EffectivenessBreadth ofresearchCrossculturaltestingCost toimplementRegulating physical availability Total ban on sales ★ ★ ★ ★ ★ ★ ★ ★ High ★ ★AustralianevaluationMinimum legal purchase age ★ ★ ★ ★ ★ ★ ★ ★ LowHours and days of sale restrictions ★ ★ ★ ★ ★ ★ Low ★ ★Restrictions on density of outlets ★ ★ ★ ★ ★ ★ ★ Low ●Staggered closing times for bars and clubs ✖Server liability ★ ★ ★ ★ ★ Low ★Different availability by alcohol strength ★ ★ ★ ★ ★ LowTaxation and pricing Alcohol taxes ★ ★ ★ ★ ★ ★ ★ ★ ★ Low ★ ★Hypothecated tax to pay for treatment / prevention ★ ★ ★Setting floor prices / banning discounting ★ ★Drink-driving countermeasures Sobriety checkpoints ★ ★ ★ ★ ★ ★ ★ ★ ModerateRandom breath testing ★ ★ ★ ★ ★ ★ Moderate ★ ★ ★Lowered BAC limits ★ ★ ★ ★ ★ ★ ★ ★ LowAdministrative licence suspension ★ ★ ★ ★ ★ ★ ModerateLow BAC for young drivers ★ ★ ★ ★ ★ ★ Low ★Graduated licensing for novice drivers ★ ★ ★ ★ ★ ★ LowDesignated drivers and ride services 0 ★ ★ Moderate ★Ignition interlocks ★Treatment and early intervention Brief intervention in primary health settings ★ ★ ★ ★ ★ ★ ★ ★ Moderate ★ ★ ★Alcohol problems treatment ★ ★ ★ ★ ★ ★ ★ High ★ ★ ★Thiamine supplementation ★ ★Workplace interventions ●Mutual help/self-help attendance ★ ★ ★ ★ LowMandatory treatment of repeat drink drivers ★ ★ ★ ★ ModerateAltering the drinking context Bans on serving intoxicated persons ★ ★ ★ ★ ★ ★ ModerateTraining staff to prevent intoxication / aggression ★ ★ ★ Moderate ★ ★ (✖ if not enforced)Voluntary codes of bar practice 0 ★ ★ Low ★ ★ (✖ if not enforced)Enforcement of on-premises regulations and laws ★ ★ ★ ★ ★ HighPromoting alcohol-free events 0 ★ ★ ★ HighCommunity mobilisation ★ ★ ★ ★ ★ High ★ ★Plastic or tempered-glass serving containers ★Food service ★Regulating promotion Advertising bans ? ● ● LowAdvertising content controls ? ● ● Low ●Education and persuasion Alcohol education in schools 0 ★ ★ ★ ★ ★ High ★College student education 0 ★ ★ HighParent education ? ● ● Moderate ●Public service messages / Mass media campaigns ● ● ● Moderate ★Warning labels / National drinking guidelines 0 ★ ★ Low ★Source: Adapted from Babor et al. (2003),[13] Loxley et al. (2004),[7] Toumbourou et al. (2007)[41]19

4.2 Regulating the physicalavailability of alcoholRegulating physical availability refers to theaccessibility or convenience of the alcoholproducts, and relates to policies that aim toprevent alcohol-related harm through controlson the condition of sale to the drinker as aretail customer.[13] In Australia, there has beena recent review of the evidence for restrictingthe sale and supply of alcohol by the NationalDrug Research Institute.[36] While regulationof the ‘economic’ availability of alcohol (i.e.the price of alcohol) is, currently, exclusively afederal responsibility in Australia, via measuressuch as taxation, the physical availability ofalcohol is generally regulated by state andterritory governments, and to a limited extentby local governments.Restricting the hours and days of sale of alcoholis a standard component of alcohol policyand regulation, and there is a substantial bodyof international and Australian work that hasexamined the impact of changes to tradinghours for licensed premises on levels of alcoholconsumption and rates of related harms. MostAustralian studies have shown that increasedtrading hours have been accompaniedby significantly increased levels of alcoholconsumption and/or harms.[36] A recentAustralian study by Chikritzhs and Stockwell[44]found that small extensions of trading hoursfor licensed hotels in Perth, Western Australia,significantly increased the numbers of drinkdriverroad crashes. More specifically, this studydemonstrated that the relationship betweentrading hours and increased drink-driver roadcrashes was mediated by the quantity ofalcohol purchases. The National Drug ResearchInstitute (NDRI) reports that several studies haveindicated that young males and regular heavydrinkers are especially likely to take advantageof longer trading hours.[36]Restrictions on density of outlets can beachieved by requiring minimum distancesbetween outlets or limiting the number ofoutlets in a particular location.Liquor licensing systems or planning controlscan potentially be used to limit the numberof places where alcohol can be sold. Inrecent years in Australia there has been asignificant liberalisation of licensing laws anda corresponding growth in outlets, both onandoff-premises. Recent research from threestates,[45-49] has demonstrated consistent linksbetween the availability of alcohol in a regionand the alcohol-related problems experiencedthere. In particular, these studies have linkedrates of violence to density of alcohol outlets. Alongitudinal study in Melbourne has highlightedthat changes in the number of outlets in anarea are directly related to changes in therates of night-time assaults occurring there.The links between outlet density and otheroutcomes are less clear cut, although someinternational evidence suggests higher outletdensity is related to higher rates of: risky alcoholconsumption,[50] motor vehicle accidents,[51]risky sexual behaviour,[52] pedestrian injury,[53]child maltreatment[54] and neighbourhoodamenity problems.[55] The results of thisresearch are clear: liberalising alcoholavailability is likely to increase alcohol-relatedproblems. The results certainly call into questionthe general assumption behind actions inrecent decades that have been made inaccordance with National Competition Policysuch as the state-led liberalisation of liquorlicensing regimes – that the number of a typeof outlet should be determined by marketdemand for the product, without considerationof community amenity or impacts.Apart from issues of outlet density, there is thequestion of whether particular types of outletsor their design and location are particularlylikely to cause problems. There is goodevidence that certain premises contributedisproportionately to problems,[32] highlightingthe need to further examine the types of outletsthat are related to assaults. Further data, suchas alcohol sales, opening hours, capacity andvenue style, could provide substantial insightsinto how different outlets contribute to theeffect of outlet density on assault.20

Growth in alcohol outletsWhile not completely deregulated, liquorlicensing laws and regulations in mostjurisdictions have been significantly relaxedover the past decade, generally coincidingwith the required reviews under the NationalCompetition Policy. One of the effects of thishas been a proliferation in the number ofnew licensed premises in some jurisdictions(see Fig. 8).Along with an increase in the total numberof licensed premises, there has beenan increase in the numbers of premiseswith extended trading hours, the numbersof licences to sell packaged liquor(i.e. take away) and over time, an increasedconcentration of licences held by just afew businesses.Figure 8: Number of liquor licences by year,Victoria, 1986 to 2006Source: Consumer Affairs Victoria, unpublished dataRestricting availability by alcohol strength isknown to be an effective intervention, bothinternationally and in Australia. In Australia,it has been estimated that full-strength beermakes the largest single contribution to all riskyand high-risk alcohol consumption (39%).[21]The National Drug Research Institute (NDRI)reports that studies that have examined therelationship between alcoholic beverage typeand levels of alcohol-related harm have foundincreasing evidence that beer consumption ismore commonly associated with drink-driving.[36] The NDRI also observes that while moststudies identify wine as a comparatively low-riskbeverage, a study by Stockwell et al. (1998)[56] found that certain types of wine that offerhigh alcohol content at a relatively low pricewere strongly associated with hospitalisationsfor alcohol-related road injuries, falls, assaultsand suicides. Some small regional or remotecommunities in Australia, with relatively largeIndigenous populations, have introduced salesbans on cask wine and cask fortified wine.According to the NDRI,[36] evaluations of someof these bans show that such restrictions canresult in reduced alcohol-related harm in thecommunities where the bans exist.The issue of the server liability for injuries tointoxicated people or third parties affected bythe actions of a person affected by alcohol isa complex and controversial area of the law.[57] In the US, ‘Dram Shop’ laws and courtdecisions under common law in many statesallow people injured through the actions of anintoxicated person to recover damages froma licensee or licensed premises owner. Suchlicensees are, in most Dram Shop legislation,also vicariously liable for their employees’actions in serving an (intoxicated) patron.[57]Loxley et al. report[7] that studies show DramShop laws have a modest deterrent effect, andthat the underlying rationale for discouragingservice of intoxicated persons is sound andthere is no likelihood of adverse consequences.A recent Australian review of the key aspectsof law and the implications of recent courtdecisions has reported that there is now a lessonerous duty of care imposed on licensees andtheir staff with regard to the consequences ofserving alcohol.[58] (See also the discussion ofresponsible service of alcohol (RSA) interventionsin Section 4.6 of this paper).Minimum legal purchase age refers to the ageat which alcohol can actually be purchasedby a person. This is distinct from the age atwhich alcohol can be consumed, sometimesreferred to as the legal drinking age.21

The distinction is important because while allstate and territory laws in Australian prohibita minor from purchasing alcohol, they do notnecessarily prohibit consumption in certaincircumstances. Babor et al. emphasise thatconsistent enforcement of laws regardingpurchase age is critical if reduced alcoholconsumption and related harm among youngpeople is to be achieved.[13] Although theminimum legal purchase age for alcohol in allAustralian jurisdictions is 18 years, the averageage at which Australians have their first fullserve of alcohol is 17 years, and as detailedearlier in this paper, there is a high prevalenceof underage drinking that has not changedsignificantly in the past 20 years. In the US,where the minimum legal purchase age forsome time ranged between 18 and 21 years,several studies have found that increasing theage limit is an effective means of reducingroad crash death and injury among teenagersand young adults. The NDRI reports[36] thatsome studies have also found that the higherlegal minimum drinking age is associated withreductions in alcohol consumption amongyoung people. There is, therefore, someevidence that raising the purchase age to21 can reduce teenage drinking, as well asharms. Kypri’s account[59] of recent attemptsto increase the minimum purchase age inNew Zealand to 20 demonstrated that populardebate convinced a majority of the public thatraising the age would be an appropriate wayto reduce young people’s harm from drinking.Toumbourou et al. here in Australia haverecommended that a first step in this directionwould be better monitoring of alcohol-relateddevelopmental harms using longitudinal andother developmental research.[41]It must be acknowledged that consumptionof alcohol by children and adolescents in thehome and in certain social settings is oftensanctioned by parents, often in the belief thatit is relatively harmless or might be helpful ineducating young people about alcohol.[60]The majority of young Australians who reportdrinking at home also report parents as beingthe primary suppliers of their alcohol.[61]In New South Wales, it is now an offence tosupply alcohol to minors in a private homewithout the direct approval of a parent orguardian. This has often been referred to as theNSW secondary supply law. While the impactof this law on youth drinking is not yet known,legislation of this kind has been welcomedby advocates against alcohol-related harmand there is currently considerable lobbyingof government to support the introduction ofsimilar laws in other Australian jurisdictions.[60]Another example of restrictions on the physicalavailability of alcohol, which is known to beeffective in reducing alcohol-related harmin some Australian Indigenous communities,is referred to as dry community declarations.[36] Some remote Indigenous communities inWestern Australia, the Northern Territory andSouth Australia have declared themselves ‘dry’,using provisions of state/territory legislation.The key element of such dry area declarationsis a combination of Indigenous communitycontrol and statutory authority, along withpolice enforcement for ensuring that drycommunity declarations reach their potential.Evidence suggests that although there areshortcomings (for example, sly grogging) andassociated costs to this approach, overallthere are reductions in consumption andalcohol-related harm. It should be notedthat dry community declarations are distinctfrom local dry area alcohol bans, as the latterrelate to restrictions on drinking in designatedpublic places and are usually imposedwhere there are high rates of alcohol-relatedpublic disorder.[36] While local dry area banshave been found to decrease public orderproblems in designated areas, overall it is notyet fully known if they reduce public orderoffences, alcohol-related hospitalisations orpolice detentions of intoxicated persons. Oftendry area restrictions simply displace drinkersto other areas where there are no, or fewer,restrictions, and dry area declarations are oftenseen as inherently discriminatory because ofthe negative impacts on Indigenous peoplealready at risk of alcohol problems.[36]22

Currently receiving considerable attentionin some Australian jurisdictions are measuresrelated to restricting the hours of sale of alcohol,known as lockouts. These do not restrict tradinghours per se, however, because outlets arepermitted to continue trading until their usualclosing times. However, after a certain time,such as 2:00am or 3:00am, new patrons andthose wishing to re-enter the premises are notpermitted to do so. Lockouts aim to reduce themovement of people between clubs after acertain time, since it is this movement of peoplebetween venues that police have reportedas being a major cause of alcohol-relatedincidents late at night. There are examplesof lockout programs in operation in locationsthroughout Australia, such as in Ballarat andBendigo in Victoria, and across Queensland,where a 3.00am lockout now applies to alllate-night licensed premises. The Victoriangovernment has also trialled a 2.00am lockoutthroughout four inner-city municipalities ofMelbourne. The NDRI reports[36] that, asyet, there is limited formal evidence of theeffectiveness of lockout programs, in partbecause they often occur as one elementwithin a range of programs aimed at reducinglate-night alcohol-related problems (forexample, CCTV cameras, street lighting, publictransport, police presence).While they are not usually focused solely onissues that relate to the physical availabilityof alcohol, community-based preventionprograms have become increasinglypopular in recent years because of emergingunderstandings of how environmental andsocial conditions contribute to alcoholproblems.[7] A detailed discussion on therange and scope effects of community basedprograms is not provided here, but can beobtained elsewhere (see Loxley et al. 2007:[7]pp166–167).4.3 Taxation and pricingThe price of alcohol clearly impacts onconsumption patterns. There are more than50 studies from around the world showingthat when alcohol increases in price,consumption is reduced.[12, 39-42] The WorldHealth Organization (WHO) is one of manyinternational and national health organisationsthat strongly endorse the use of increasedalcohol taxation (higher prices for alcoholproducts) as an effective preventative strategyto reduce alcohol-related harm.[62] At thesame time, it is important to recognise thatthere is a complex relationship between priceand consumption.[63, 64] Patterns of alcoholconsumption can vary considerably accordingto individual factors such as the age, sex andincome levels of the drinker. Other factors suchas availability, the cultural setting, the marketingand image of the product are also important.Studies consistently show that lower socioeconomicgroups and people with limiteddisposable income (young people, Indigenousgroups and heavy drinkers) are more directlyimpacted by the price of alcohol products.Higher income drinkers tend to drink moreexpensive alcohol, and while price may leadthem to reduce their consumption marginally,they are also able to alter drinking preferencesto cheaper alternatives.[65, 66] The natureof the alcohol product is also a key variable.An Australian study identified considerablevariations in price elasticity (the amount thatprice needs to change before it impacts onconsumption) for different alcohol products.It concluded that spirits are twice as pricesensitive as wine and beer.[67]Given the complexity of the relationshipbetween alcohol price and consumption,increasing alcohol taxation does not necessarilylead to a linear reduction in the levels ofalcohol-related harm. It is important that therelationship between the price of individualalcohol products and consumption amongstparticular groups of drinkers is carefullymodelled against known price elasticity andexisting consumption patterns.23

While increasing the price through taxationis likely to lead to a reduction in per capitaconsumption, increasing the price of individualproducts may not necessarily achieve this goal.In some cases, product-based changes cancreate opportunities for new products anddrinking patterns that increase levels of harm.[68] In this context, it is important to recognisethat the production costs of alcohol productsvary considerably between product types(eg spirits are relatively inexpensive tomanufacture compared to beer and wineproducts) which in turn has a bearing on thecost price to consumers.Australia’s alcohol tax system can best beunderstood as a constantly changing reflectionof the history of alcohol consumption in Australia,and the status of various alcohol products.It also reflects changing powers of taxationbetween state and territory governments andthe Australian Government. As a consequence,different products – wine, spirits, beer, ciders,fortified wines – are all taxed differently. Theexcise duties arrangements can generally bedescribed as a volumetric tax system, becausethe amount of excise duty depends on thevolume of alcohol contained in the particularproduct. Wine equalisation tax can be describedas an ad valorem tax system, because the rateof tax depends on the value of the retail sellingprice of the particular product. Customs dutiesare a combination of both volumetric and advalorem systems. GST is set at a fixed rate of 10%of the product price, on top of all other taxes(see Table 7).Within some categories there are variousconcessions and exceptions. Smaller wineries,for instance, are largely exempt from their valueadded tax (the Wine Equalisation Tax) for allcellar door sales.Recent estimates show that the AustralianGovernment will collect over $6 billion as aresult of the production and consumption ofalcohol during the 2008/09 financial year.[68, 4]However, a substantial disparity exists betweenthe amount of tax revenue received by theAustralian Government from risky drinkingcompared with the overall amount spent inattempting to prevent harmful consumptionof alcohol. For example, it has been estimatedthat Australian adolescents (aged 12–17 years)spent approximately $217 million on alcoholicbeverages in 2002, netting the AustralianGovernment approximately $112 million in taxrevenue.[69] This means that for every dollarspent on alcohol interventions aimed atadolescents, the government receives around$7 in alcohol tax revenue.[69]The current taxation rates translate into a widevariety of taxation per standard drink of alcohol(see Fig. 13). For those who argue that alcoholshould be taxed according to the amount ofalcohol in each product and container, thecurrent system represents a massive distortionof this principle.Table 7: Summary of the types of alcohol taxesapplied by category of alcohol productBeer Spirits & RTDs Wine CiderGST Yes Yes Yes YesExcise duty Yes Yes No NoWET No No Yes YesCustoms duty (ad valorem) No Yes (imported) Yes (imported) NoCustoms duty (volumetric) Yes (imported) Yes (imported) No No24

$1.00$0.90$0.81$0.87$0.87Excise or WET payable per standard drink:$0.80$0.70$0.60$0.50$0.40$0.30$0.20$0.10$0.04$0.05$0.16$0.17$0.19$0.26$0.28$0.32$0.39$0.52$-Light beeron tapCask Wine Port, Sherry Mid strengthbeer on tapPackagedlight beerBottled Wine1Full strengthbeer on tapPackagedmid strengthbeerPackagedfull strengthbeerBottled Wine2BrandyPre-mixedspirits /RTDsWhistky,Rum,Vodka,LiqueursTypical ABV:2 12.5 20 3 2 14 5 3 5 14 37 3.0 - 9.0 22 - 43Figure 13: Tax payable per standard drink*of alcohol, various products, Australia, as at1 August 2008*Note: *Includes a 1.15% ABV excise-free concession for beer. WET payableper standard drink of wine is based on a four-litre cask of wine sellingfor $13 (incl. GST) [‘Cask Wine’], a 750ml bottle of wine selling for $15(incl. GST) [‘Bottled Wine 1’], a 750ml bottle of wine selling for $30(incl. GST) [‘Bottled Wine 2’] and a 750ml bottle of port selling for $13(incl. GST) [‘Port, Sherry’]. A standard drink is equal to 0.001267 litres or10 grams of pure alcohol.As noted above, Australia has been througha continuous process of change in relationto the taxation and pricing of various alcoholproducts. There are three changes that areparticularly interesting to note. In the late 1980s,states and territories adopted various formsof licensing for all alcohol sales. As part of thissystem, most jurisdictions offered low-alcoholbeer (less than 3.5% alcohol by volume) fora significant concession in fees. The licensefee concession translated into cheaper lowalcoholbeer and, in combination with intensemarket competition in the beer market andthe introduction of harm-reduction measuressuch as random breath testing, createdan ideal environment for low-alcohol beer.Producers recognised the benefit of investingconsiderable developmental and marketinginvestment into low-alcohol beer.As a consequence, low-alcohol beer increasedits sales very significantly and capturedapproximately 20% of the total Australianbeer market.[70]The Northern Territory’s ‘Living with Alcohol’program provides another example of howchanges in price through government taxationincreases contributed to a reduction in percapita consumption. In 1992, the NorthernTerritory government used a hypothecationapproach by placing a levy of 5 cents perstandard drink on the sale of alcohol productswith more than 3% alcohol by volumeand used the revenue to fund a range ofalcohol-prevention measures in the territory.[71] Evaluations of the ‘Living with Alcohol’program found that the increase in price hadcontributed to a major reduction in the levelof alcohol-related harm within the NorthernTerritory.[72, 73]Over the last 15 years, there have been a seriesof changes in the level of excise and taxationapplied to various forms of the ready to drink(RTD) product segment of the Australianalcohol market.25

These changes have resulted in major shifts indrinking patterns across Australia, particularly inrelation to brown spirit pre-mixed drinks (mostlyaround 5% alcohol by volume in 375ml cans)and white spirit pre-mixed bottled drinks (mostlyaround 5% alcohol by volume in 375ml bottles).With each price change, sales of these RTDshave increased or decreased quite significantly.While there is considerable evidence that theseincreases and decreases in sales representshifts in product preferences (market share)rather than shifts in per capita drinking, thepatterns of consumption have clearly beendirectly influenced by taxation and pricing.There is substantive evidence that the higherthe price, the lower the consumption of theseproducts, and the lower the price, the higherthe consumption of these products. Perhapsjust as importantly, the shifts in consumptionpatterns are more marked amongst the youngand lower social-economic groups.[2, 68, 74]The principle of alcohol taxation reform mostoften discussed by public health advocatesis usually that of applying excise taxes to allcategories of alcoholic beverages. That is,taxing the beverages on their alcohol content,as a mild discouragement of consumption.Along with taxation reform of this kind, therehave been calls to raise the price of thecheapest forms of alcohol. This is referred toas the floor price of alcohol. Given that priceis being used as the lever, it is the floor pricethat should be given more attention in order toachieve a real shift in per capita consumption,rather than just product preference. Within thiscontext, it is important to acknowledge thatthe impact of any increase in the floor pricefor alcohol will impact more on young people,Indigenous communities, heavy drinkers andlower socio-economic groups.It appears that the most likely model thatcan effectively reduce alcohol-related harmwould be based on an across-the-boardexcise model that also includes regulating thefloor (minimum) price, especially with regardto small containers. The excise tax couldbe scaled within different product types toensure there were strong financial incentivesfor the production of lower alcohol products(for example, low-strength beer, wine andRTDs), and so that the highest-risk alcoholproducts (i.e. spirits, which can more easilycause overdose) are taxed at an appropriatelyhigher rate. In combination with a volumetrictaxation system, in which all products are taxedaccording to alcohol content, all productscould effectively have a floor price based ontheir alcohol content in a 300ml container.Modelling this alcohol taxation system would bea very challenging exercise, particularly whenhealth advocates have very limited access toactual sales data. As noted above, competingin the alcohol market requires extensive markettesting and monitoring. This generates a levelof detailed information that is not availableto health researchers and policy makers.Perhaps just as importantly, this model wouldhave a negative impact on some segments– particularly cask wine and cider – whileadvantaging other market segments – spiritsand spirit-based RTD products. It would be verydifficult to gain broad political support for sucha model, given the level of public and politicalopposition from powerful alcohol producers.There has been some modelling undertakenthat considered a range of alcohol taxationscenarios that would move the alcohol exciseand taxation system closer to a true volumetricbase, while remaining revenue neutral withineach market segment. These models are publiclyavailable, but have attracted limited supportas they increase the price of cask wine andciders while more expensive wines are reducedin price.[36] Until public health researchers andadvocates have access to accurate sales data,and economic modelling can be implementedon the combination of floor price and a morevolumetric approach to alcohol taxation, itis difficult to strongly put forward a particularmodel. At the same time, there is a substantivehistory in Australia that illustrates the danger ofchanging taxation levels of particular productswithout considering the implications both onconsumption patterns and the developmentand marketing of alternative alcohol products.26

4.4 Drink-driving countermeasuresDrink-driving laws and the associated programsof enforcement and social marketing areconsidered to be one of the great publichealth success stories of the late 20th century. InAustralia, state and territory laws allow a BloodAlcohol Content (BAC) of up to 0.05% whiledriving for full licence holders, 0.00% for learnerdrivers and 0.00 per to 0.02% for provisionaldrivers, depending on the state or territory. Thosewho operate commercial aircraft, public orheavy vehicles, commercial vessels, machineryand mobile plant or farm equipment mustobserve the BAC restrictions required by theiremployer, as well as those required by law. Formost adults, drinking no more than two standarddrinks on an occasion will maintain their BACbelow 0.05%. The evidence for the deterrenteffect of such laws is strong, although the effectscan erode over time and hence some countrieshave continued to lower BAC limits.[13] From the1970s, Australian states world leaders in drivingdown rates of drink-driving through randombreath tests and other means.There is some evidence, albeit tentative, thathaving lower BAC limits for young driversreduces the risk of road fatalities, especially ifthe BAC limit is 0.00%.[7] More broadly, there isgood evidence that lower BAC limits, delayedaccess to full licence and curfews for youngdrivers can be effective in reducing drink drivingamong young people; graduated licensingschemes can potentially incorporate all of thesemeasures within a single system.[13]Random breath testing (RBT) has been shownto be effective in several countries, includingAustralia, in reducing road crashes, injuries andfatalities.[7] The defining feature of RBT is thatany motorist at any time may be required totake a breast test, and there is nothing theycan do to influence their chances of beingtested.[13] Research suggests that there is astrong tendency for motorists to comply withdrink-driving laws in jurisdictions that use RBTprograms because of the uncertainty aboutthe real risk of detection.[13] Herein lies part ofthe impressive cost effectiveness of randombreath testing. RBT is considered a superiormethod of enforcing drink-driving laws thansobriety checkpoints, which only check driverswho are judged to have been drinking.[13] InAustralia, creating the public perception thatthere is a high chance of being caught drinkdriving through RBT has been achieved by acombination of high-visibility policing (roadblocks, ‘booze buses’) and frequent socialmarketing campaigns that emphasise thelikelihood of drink drivers being detected.[7]Among the range of punishments for drinkdriving, the penalty that appears to havehad the most consistent impact is licencesuspension.[13] Increasing the severity of finesand imposing penalties such as imprisonmentfor drink driving have not been shown to result inreduced rates of drink driving or car accidents.[13] However, it is estimated that up to 70% ofpeople who lose their licence continue to drivewhile unlicensed, as the risk of apprehensionis relatively low.[43] The major concerns withdisqualified drivers continuing to drive arethat it undermines the effectiveness of licencesuspension and is also linked to a range ofother high-risk behaviour such as repeateddrink driving and speeding.[43] Court diversionof drink drivers to educative and mandatorytreatment interventions and the incapacitationof vehicles using ignition interlock devices areregarded as effective means of increasingcompliance with licence suspension andreducing recidivism.[7, 13]While there is no evidence that on-premisedesignated driver programs produce negativeeffects, the impact of such programs is verymodest and even with concerted promotionsthey only produce a small positive effect.[13]An Australian review of these schemes wassomewhat more supportive, pointing to researchfindings that the programs do have somepositive influence on the behaviour of youngpeople in selecting a sober driver, and thatgiven the cost of such programs is usually borneby licensed premises, there is no opportunitycost in recommending such schemes.[7]27

4.5 Treatment and early interventionThis paper considers treatment and earlyintervention as essential components ofa preventative approach to the harmfulconsumption of alcohol. While treatment andprevention are traditionally viewed as separateand sometimes unrelated activities, it is criticalthat they be embraced as part of a holisticapproach to tackling alcohol problems froma public health perspective. While treatmentsare primarily designed to serve the needs ofindividuals, there are a number of ways thattreatment can also have a positive impactat a whole-of-population level:nnnnBy raising public awarenessof alcohol problemsInfluencing national andcommunity agendasInvolving health professionals inadvocacy for preventionProviding secondary benefits for families,employers and road users.[13]Brief interventions in primary health settings. Forearly-stage alcohol problems, brief interventionsare consistently identified as a key ingredient ina comprehensive alcohol-prevention strategybecause they are regarded as relativelyinexpensive, they take very little time andthey can be implemented by a wide rangeof health and welfare professionals.[7] Theirbenefit as preventative measures arises fromthe relative effectiveness in treating early-stageproblem drinking, obviating the need for latermore intense and costly treatment.[43] Briefinterventions are designed to motivate high-riskdrinkers to moderate their alcohol consumption,and typically involve one to three sessions beforeor soon after the onset of problem drinking.[13]In Australia, brief interventions, as yet, are arelatively untapped opportunity, due in partto the need for greater recognition of the rolethat the primary health workforce can play.[43] Efforts during the 1980s and early 1990s tointroduce more systematic screening, earlyidentification and potentially brief or extendedresponses were variously tried.These included the Coordinator of Alcohol andDrug Education in Medical Schools (CADEMS)that supported curriculum development forundergraduate medical students, a rangeof General Practice trials (especially in NewSouth Wales, sometimes in association withother specific interventions including tobaccoand even efforts to develop a combined riskscreeninginstrument for a number of conditions)and studies of the use of screening instruments(especially AUDIT) in hospital settings. Follow-uphas been patchy, and even where the uptakeand utility under experimental conditions waspromising, the longer term effort and costrequired to achieve widespread involvement hasnot been sustained. With a sense of déjà vu, theauthors note a recent study of the effectivenessof brief interventions in hospital emergencydepartments, which suggests that these canpotentially reduce subsequent alcohol-relatedinjuries significantly.[75] For assessments andbrief interventions to become part of routinepractice of doctors, nurses and other healthprofessionals, an approach at the healthsystem level accompanied by fundingand promotion is needed. It is unrealisticto expect overstretched health serviceproviders to implement brief interventionswithout reimbursement or other recognition.While this paper especially addresses primaryprevention, it is worth noting that there remainsa serious lack of accessible and availableevidence-based treatment services for laterstage alcohol dependence and other alcoholrelateddisorders across Australia (in private andpublic as well as in city and remote locations).With a still evolving specialist clinical workforce,there remains a relative vacuum for trainingand professional development at senior clinicallevels, and it is this group that ultimately set thestandard and nature of practice in any field.A comment from a senior clinician on the morerecent development of Medicare support forprivate practice GPs and clinical psychologistsis pertinent: ‘it means that I get all these patientstreated under the mental health items withfundamental alcohol-related problemswhere alcohol was not properly managed’.28

Workplace interventions. Australian workplacesare another setting with great potential for briefinterventions with at risk drinkers. There are twomain rationales for workplace interventionswith regard to the harmful consumptionof alcohol: to improve productivity; and toimprove workplace safety.[7] In the Australiancontext, approaches to workplace alcoholissues are influenced by occupational healthand safety laws and polices, and devisingprevention strategies must be considered inthis context. Historically, alcohol problems inthe workplace have been dealt with throughemployee assistance programs (EAPs) andemployers’ policies on alcohol and drug use;however, there has been insufficient researchto determine the effectiveness of EAPs inresponding to and/or preventing alcoholissues in the workplace.[7] Nonetheless, EAPsdo provide the potential opportunity forinterventions that are known to be effective,such as brief interventions for high-risk drinkers.A recent study of alcohol consumptionby Australian workers and the impact onabsenteeism has pointed to the need forworkplace education to influence youngemployees’ attitudes and behaviours regardingalcohol use.[76] The study also suggests thatthere is a need to take a whole-of-workplaceapproach when designing and implementingprevention strategies that target both ‘problemdrinkers’ and workers who drink at short-termrisk levels, even infrequently, because thelatter have an elevated risk of alcohol-relatedworkplace absenteeism.[76] Others havepointed to the need for addressing structuralfactors in the workplace as a more sustainableprevention measure, such as reducing stressfulworking conditions that may lead to healthdamagingbehaviour such as the harmfulconsumption of alcohol.[77]Alcohol problem treatment. Internationally, andparticularly in Australia, the evidence base withregard to the treatment of alcohol problems isvery well developed and is now at the stageof determining what is best practice ratherthan attempting to determine if treatmentcan work.[7] Effective alcohol treatmentoptions include motivational interviewing, briefinterventions, social skills training, communityreinforcement approach, relapse preventionand some aversion therapies.[7] There isevidence that mutual help programs such as12-Step Facilitation Therapy, which encouragesattendance at Alcoholics Anonymous (AA)meetings, are particularly effective for severelydependent drinkers with low levels of socialsupport.[7] Although popular and widelyused, there are also treatments that have littleevidence of efficacy, including insight-orientatedpsychotherapy, confrontation counselling,relaxation training, general ‘alcoholismcounselling’, education and milieu therapy.[7]Pharmacotherapies for alcohol dependenceinclude disulfiram, naltrexone and acamprosate.Reviews have found that naltrexone andacamprosate are the safest and most effectiveof the three pharmacotherapies in the longand intermediate terms, respectively.[7]Thiamine supplementation. A uniquepreventative measure to address the risk ofserious brain damage from thiamine deficiency(known as Wernicke-Korsakoff’s syndrome)that can result from heavy consumption ofalcohol over many years, along with poornutrition, is thiamine supplementation. Since1991, all baking flour in Australia has beensupplemented with thiamine as a universalmethod to increase thiamine levels in the dietof at risk populations.[7] This is included hereas an example of a preventative measurethat requires ongoing consideration, as therehas since been advocacy for the removal ofsupplements (including thiamine) by the purefood advocates and there is concern that thereach of thiamine in bakers flour might not bethe most cost-effective population measure inpreventing this condition.[78]Since the 1980s, sobering-up centres havebeen established in many parts of Australia,particularly Indigenous communities, ashumane forms of care for publicly intoxicatedindividuals, and as an alternative to individualsbeing arrested and held in police cells andwatch houses.[34]29

number of RSA training programs have beenevaluated in Australia.[36] In addition to trainingbar staff in the responsible service of alcohol,there have also been programs designed totrain staff in managing aggressive behaviour,given the reality that some patrons may havebecome already intoxicated elsewhere andthat some aggressive behaviour may not benecessarily alcohol-related at all.[13] There havebeen very few evaluations of such programs,although there is evidence that they canimprove staff and patron interactions generally,but the long-term sustainability of theseimprovements relies on maintaining trainingand standards of practice.[13]Proactive policing or intelligence-led policinghas been successful in some parts of theworld and has been partially adopted insome Australian jurisdictions.[13] It involvesmonitoring alcohol-related incidents in andaround licensed premises, combined withregular police visits to the licensed premisesthat are most often linked to alcohol problems.For example, the New South Wales policehave adopted a system of enforcing liquorlaws through the collection of data such asfeedback to police about alcohol-relatedcrimes that have followed drinking at aspecific licensed premises.[83] Known as the‘Alcohol Linking Program’, the intelligence-ledenforcement system has been shown to reducealcohol-related crime, and similar approachesare now being trialled and implemented inother jurisdictions.Voluntary codes of bar practice typically takethe form of ‘liquor accords’ in Australia. Theemergence of liquor accords as a means ofreducing alcohol-related problems in late-nightentertainment centres began in Victoria in theearly 1990s, and since then there has been arapid proliferation throughout several states.[36]Accords are local, community-basedinitiatives to involve licensees, other businesses,local government authorities, communityrepresentatives and police, but which areimplemented and largely coordinated bythe latter to reduce alcohol-related harmin the late-night drinking environment.[36]There are many possible components ofaccords, such as RSA, drink discounting bans,trained security personnel, provisions of food,use of safe glassware and alcohol containers,and environmental modifications to reduceconflict and thereby reduce the risk of violence.[7] Few accords have been formally evaluated,and among those that have, most havebeen unable to demonstrate effectivenessin either the short- or (particularly) long-termreduction of alcohol-related harms.[36] Theappeal of accords probably rests more on thedevelopment of local communication networks,the facilitation of local input, a sense of local‘control’ and improving public relations throughopen negotiations than in the actual reductionof harm. Even so, improved communicationand participation may also be perceived asdesirable and worthwhile outcomes in somecircumstances. Loxley et al. acknowledgethat there is no doubt that accords can bean effective vehicle for introducing someharm-reducing practices into licenseddrinking venues; however, it is recommendedthat voluntary regulation such as this isaccompanied by effective law enforcement.[7]The promotion of alcohol-free events, whilepopular in many countries, including Australia,has not been found on its own to be effectivein reducing alcohol problems.[36] Alcoholrestrictions for large sporting and leisure eventshave usually been implemented as part ofa range of initiatives, making it difficult todetermine their specific impact.[36] Based onevidence that some injuries from alcohol-relatedviolence were linked to the use of drinkingglasses and bottles as weapons, a number oflicensed premises around the world now servealcohol only in toughened glass or plasticcontainers.[13] However, the soundness of thisapproach has been called into question by astudy that found that injuries to bar staff actuallyincreased when toughened glass was used.[13]Providing food service on premises that servealcohol, as a way of encouraging eatingwhile drinking and hence reducing the effectsof alcohol, is a popular element in liquoraccords.[7]31

However, the specific contribution of makingfood available on licensed premises as away of preventing intoxication has not beendetermined, and in the case of certain foods(for example, salty snacks) there may actuallybe a risk of the opposite effect on alcoholconsumption.[7]Community mobilisation has been used toraise awareness of problems associated withon-premises drinking, develop specific solutionsto problems and pressure licensees to takeresponsibility for some of the impacts on thelocal community, such as noise, litter and antisocialbehaviour.[13] There is no set formula bywhich community action projects operate, aseach project has differing aims and objectives,often in response to localised problems.[36]Studies overseas support the view that whencommunity mobilisations are implemented ascomprehensive, evidence-based strategiesand are well funded, they can influence serverbehaviour, drinking behaviour and levels ofalcohol-related harms associated with licensedpremises.[36] Although some relatively smallcommunity mobilisation projects are currentlyunder way in Australia, results from evaluativestudies are yet to be published.[36] In general,community mobilisation approaches have atleast a temporary effect on licensed premises interms of serving practices and patron behaviourbut in the longer term they often tend not to beimplemented in a systematic way, and prove tobe expensive and difficult to sustain.[13]4.7 Regulating promotionAlcohol marketing and promotion is aglobal activity, with the largest corporationspromoting their products across the world.[13]Marketing strategies include an integratedmix of advertising on television, radio, printmedia, point of sale promotions, productdesign (including the packaging and namingof alcohol beverages) and the internet.Sponsorship of sports and cultural events is alsoa common marketing strategy used by alcoholcompanies, particularly in Australia. The keyquestions from a public perspective are:nnwhat is the impact of marketing andpromotion on overall consumptionand particularly the misuse of alcoholin the community?what are the most effective measures forpreventing the adverse impacts of alcoholmarketing and promotion?Total alcohol advertising expenditure inAustralia in 2007 was reported to be $128 million(see Table 8). However, this figure is highlyconservative, given that it generally relatesto the advertising of products rather than ofalcohol outlets, for which alcohol advertisingexpenditure is now very significant. Nordoes it include sponsorship, ‘below the line’advertising or internet advertising, the latterbeing a significant growth area in recent years.In Australia, the main sectors in which alcoholadverting expenditure occurs, and throughwhich the greatest exposure is achieved, arethrough commercial television advertising (38%)and outdoor advertising (32%). Globalisedalcohol manufacturers (for example, Diageo;Pernod Ricard Pacific) are among the biggestspending advertisers in Australia. The amountspent on advertising by spirits and wineproducers combined, now equals that of thetraditionally dominant beer market in Australia,reflecting an increasingly competitive alcoholbeverage market.32

Table 8: Alcohol advertising in Australia by sector, advertiser and beverage category, 2007SectorPercentageshareRank Advertiser$millionsAnnualchangeBeveragecategoryPercentageshareMetro TV 33% 1 Diageo 19.1 29% Beer 47%Regional TV 5% 2 Carlton & United14.4 -24% Spirits 26%BeveragesMetro press 5% 3 Tooheys Brewery 14.0 10% Wine 21%Regional1% 4 Boag J & Son 9.9 13% Premix /6%pressciderMagazines 14% 5 Pernod Ricard6.9 60%PacificRadio 5% 6 Beringer Blass Wine 5.3 93%EstatesCinema 5% 7 Southcorp Wines 4.8 191%Outdoor 32% 8 Suntory 4.8 421%Direct mail 1% 9 Carlton Special4.7 238%Beverages10 Heineken 3.9 36%Others not in top 10 39.9 -5%Source: Nielsen Media Research AdEx 2008The impact of advertising on individuals can beseen as having both immediate effects, suchas influencing decision making with regard tobrand preference, as well as longer term effectssuch as reinforcing pro-drinking messages.[13] Inthis way, it is both the content and frequency ofexposure to advertising that can have an impacton individuals’ attitudes and behaviours. Theimpact of alcohol advertising on young peopleis an area where there has been considerableresearch, but of somewhat poor quality, yieldingconflicting results that range from positiveassociations between young people whohave been exposed to and/or enjoy alcoholadvertising and an increased risk of harmfulconsumption of alcohol, to negative associationsor inconclusive results.[7] Numerous studieshave found a link between alcohol advertisingand alcohol-related knowledge, beliefs andintentions of young people.[84]Unlike tobacco advertising, which was bannedin Australia in 1995, there are no alcoholadvertising bans in Australia, although somerestrictions, including advertising contentcontrols, do apply (see further below). InAustralia, alcohol advertising is subject to anumber of different laws and codes of practice.The Australian Association of NationalAdvertisers Code of Ethics covers generaladvertising issues. Other applicable laws andcodes include:nnnnnThe Trade Practices ActState and territory fair trading legislationThe Commercial Television IndustryCode of PracticeThe Commercial Radio Code of PracticeThe Outdoor Advertising Code of Ethics.The Commercial Television Industry Code ofPractice states that advertisements can onlybe shown during M, MA or AV classificationperiods. However, on weekends and publicholidays, alcohol advertisements can be shownas an accompaniment to the live broadcastof a sporting event. Alcohol advertising iscovered in detail by the Alcohol BeveragesAdvertising Code (ABAC) Scheme. The mainaims of the scheme are to ensure that alcoholadvertising presents a responsible approachto drinking, and does not have appeal tochildren or adolescents. Among other rules inthe code, the administration of the followingis often questioned by community members:‘Advertisements for alcohol beverages must notdepict the consumption or presence of alcohol33

everages as a cause of or contributing tothe achievement of personal, business, social,sporting, sexual or other success’ (ABAC 2008,Clause C (i)).[85]The ABAC Scheme is funded and administeredentirely by the alcohol industry. Commonwealthand state and territory governments are involvedthrough one government representative on theABAC Management Committee.Despite the ABAC Scheme’s rules, whichdiscourage advertising that has ‘strong orevident appeal to children or adolescents’,research shows that a substantial amount ofalcohol advertising is communicated to youngpeople. For example, several advertisements foralcoholic beverages screened on television inmetropolitan Melbourne were found to be morelikely to reach 13- to 17-year-olds than adults(see Table 9).Table 9: Advertising on metro Melbournetelevision, year to March 2005said or shown. It is estimated that only 3% of thetotal adult population are aware of the existingABAC scheme and know what it relates to.[87]Among the 30% of people who reported beingconcerned about any alcohol advertising,only 2% had made a formal complaint. Someof the reasons why those who were concerneddid not make a complaint included the beliefthat it would not achieve anything (30%), nothaving time (25%) and not knowing who/how/where to complain (15%). ABAC currently hasno powers to sanction advertisers who breachthe code rules; however, a Senate Committeeinquiry currently under way is consideringproposed federal legislation that wouldintroduce sanctions on advertisers who breachthe code, which would be determined by anindependent adjudicating panel.[88]In 2003, the Ministerial Council on Drug Strategyconsidered a report on the effectiveness ofthe ABAC Scheme that identified the followingissues of concern:ProductHeinekenLagerCougarBourbonArchersSpriSchnappsBundabergRum Dry &Lime MixOrlandoJacobsCreekSparklingRoseTotalannualspendSource: King, Taylor and Carroll (2005)[86]Frequencyof adsRelativeexposure(of 13–17-years-oldsVs 18–29-year-olds)$ 94,000 110 1.12$ 45,000 103 1.04$ 57,000 110 1.04$ 36,000 88 1.06$ 89,000 34 1.11As a self-regulatory scheme, ABAC’seffectiveness largely depends on theindependence of its complaints body withthe powers to sanction.[43] Recent researchhas revealed that less than three in 10 (28%)people surveyed reported an awarenessof restrictions or regulations covering theadvertising of alcohol, in terms of what can bennnnnThe current system does not address publichealth concerns about alcohol advertisingand use. In particular, most complaintsabout alcohol advertising are dealt withunder the general advertising complaintsresolution system rather than the alcoholspecificsystem.The high dismissal rate for complaints aboutalcohol advertisements heard by the ASBdoes not engender community confidencein the complaint system and maydiscourage people from making complaintsabout alcohol advertisements.The general public is largely unaware ofthe complaint resolution system and, inparticular, how to make complaints.The system lacks transparency. In particular,there is insufficient reporting of theoutcomes of complaints.The current system does not apply to allforms of advertising; for example, packaging,electronic advertising, sponsorships, point ofsale advertising and promotions.34

nThe effectiveness of the current systemis compromised by the amount of timetaken to resolve complaints (MCDS 2003,unpublished).While some of these concerns have beenaddressed, pressure remains to move to a moretightly regulated advertising environment withstrict government controls. The WHO recentlyrecommended that governments be supported:nnnto effectively regulate the marketing ofalcoholic beverages, including effectiveregulation or banning of advertising and ofsponsorship of cultural and sports events,in particular those that have an impact onyounger peopleto designate statutory agencies to beresponsible for monitoring and enforcementof marketing regulationsto work together to explore establishing amechanism to regulate the marketing ofalcoholic beverages, including effectiveregulation or banning of advertising andsponsorship, at the global level.One of the most formidable obstacles toeffective education and persuasion strategiesregarding alcohol (which are discussed in thenext section below) is product advertising by thealcohol industry that intentionally promotes prodrinkingmessages to the general population,much of which also reaches young people. Inresponse, the governments of some countrieshave sponsored counter-advertising programs.[13] These might include public servicesannouncements, or warning messages withinactual product advertisements. However,studies suggest that counter-advertising usuallyhas only limited effectiveness, often becauseit is communicated at low frequencies and inpoorer quality productions compared to alcoholbeverage advertising.[13] In contrast, counteradvertising in the tobacco field is of proveneffectiveness, primarily because in that contexthard-hitting messages were possible (essentiallythat the tobacco industry was not in businessfor the consumer’s good). Counter advertisingmay be a more politically realistic option thanbanning advertising altogether, and shouldbe strongly supported from a public healthperspective, but it is important that its messagenot be compromised. Although rare, there areexamples of well-planned and implementedcounter-advertising programs that have hadsome success, particularly in building support forpublic health-oriented alcohol controls,[13] andthere is very strong evidence from other publichealth areas such as tobacco about the valueof such approaches.4.8 Education and persuasionInternational reviews of education andpersuasion strategies suggest that even withadequate resources, such approaches havelimited potential for success on their own.[13]Part of the reason for this is the counter effectof powerful forces that underpin unsafe andunhealthy drinking cultures, such as the price,availability and promotion of alcohol products.Recent Australian research for the developmentof a national alcohol social marketing initiativereports that ‘the challenge for communicationis that intoxication is closely linked to alcoholper se. When we simply asked participantsabout their earliest memories in relation toalcohol there was an overwhelming tendencyto leap to their first drunk experience. Further,these experiences were recalled with a senseof pride and nostalgia, even though the storiesinevitably involved some embarrassment.’[89]A key element to the success of socialmarketing in the public health area is effectiveintegration with and reinforcement by othercomplementary strategies.[7] For instance,the success of social marketing in promotingquitting smoking and road safety, includinganti-drink-driving campaigns, is indicative thateducation and persuasion strategies can beeffective when coupled with other measuressuch as support services, changes to theenvironment, regulation and enforcement.Throughout the world, alcohol education inschools is an enormously popular approach toaddressing the issue of harmful consumption ofalcohol among young people. The traditionalalcohol education programs that are based35

on an informational approach, while still verycommon, have not been shown to prevent orreduce the harmful consumption of alcohol byyoung people, and in some cases have actuallybeen counterproductive by stimulating aninterest in drinking among young people.[13]In recent years, there has been a shift towardsnormative education, which aims to correctyoung people’s perceptions about their peers’drinking and thus de-normalise the harmfulconsumption of alcohol.[13] While this makesintuitive sense, it has been found that suchschool-based educational interventions, ingeneral, produce only modest results that areshort-lived unless accompanied by ongoingbooster sessions. Importantly, given there areconsiderable risks involved in school-basededucation, it has been recommended thatinvestment in such programs be accompaniedby a proportionate investment in evaluation.[7]There are some examples of sound outcomesbut these are relatively unusual. These generallyinvolve whole-of-community efforts and theyare usually associated with a close evaluationthat ensures they are implemented (withmodifications through feedback) as planned. InAustralia, these include the School Health andHarm Reduction Project (SHAHRP) in WesternAustralia[43] and the Gatehouse Project inVictoria, whose primary target was reducedschool bullying but where the side benefit wasa comparative reduction in the use of tobaccoand alcohol.[90] Related to alcohol educationprograms for school students are parenteducation programs. While some reviews citepromising signs of effectiveness, in general thereremains a lack of research to fully determine thevalue of such programs.[7]Low-risk drinking guidelines have beenadopted in many countries, including Australia,to provide advice on the health risks andbenefits of drinking at various levels for thegeneral adult population, and for particularsub-groups. Despite their popularity, thereis very little research that demonstrates theeffectiveness of guidelines.[13]However, guidelines do potentially fulfil animportant function as supporting informationfor other measures known to be effective,such as brief interventions in primary care, andas the basis for health promotion messagesand social marketing campaigns. In Australia,the current alcohol guidelines.[91] are underreview. New draft guidelines prepared forpublic consultation are due to be finalised andreleased in late 2008. The new draft guidelineshave been informed by updated modellingon the health risks of drinking, which haveproduced new estimates of the lifetime risksof alcohol-related harm. Emerging evidencealso indicates that previous studies claimingthe significant health benefits of alcoholconsumption have tended to overestimate theeffects. The consultation draft indicates themain changes are expected to include a newsimplified, universal guideline level for alcoholintake for both short-term and long-term risks,a new guideline with special precautions forchildren and adolescents, and a new guidelinefor pregnant or breastfeeding women.[18]Warning labels on alcohol products, while notrequired in Australia, have a high level of publicsupport. Evaluations of alcohol warning labelsare generally limited to the US experience,where labels were implemented in 1989. Whilethere is some evidence of effects on knowledgeand attitudes, there is no evidence that warninglabels influence drinking behaviour.[92] Bycontrast, the tobacco labelling experienceoffers strong evidence that warning labels canbe effective, not only in increasing informationand changing attitudes but also in changingbehaviour. These successes of tobacco warninglabels suggest that alcohol warning labelsshould be graphic and attention-getting,should occupy a considerable portion of thepackage surface, and should involve rotatingand changing messages.[92] Perhaps mostimportantly, they should complement and becomplemented by a wider range of strategiesaimed at changing drinking behaviour.36

5. Policy imperatives5.1 The state of alcoholpolicy in AustraliaA recent report by the WHO warns that ‘thedifference between good and bad alcoholpolicy is not an abstraction, but very often amatter of life and death’.[13] Nonetheless, it isacknowledged internationally that ‘alcoholpolicy is often the product of competinginterests, values and ideologies’, and henceis not always based entirely on scientificevidence.[13] More specifically, the culturalsignificance of alcohol in many societies,along with its economic importance andthe political influence wielded by the globaland domestic alcohol beverage industries,create a hostile environment for public healthpolices, especially those aimed at reducingconsumption overall as a way of preventingand reducing alcohol-related harm.While we can see that it is politically necessaryto have ‘collaborative and cohesive’ alcoholpolicy where all interested parties areincluded, this poses significant impedimentsto the implementation of the most effectivepreventative interventions. Notwithstandingthis, Australia has been assessed as beingcomparatively progressive and among the bestin the world in terms of evidence-based alcoholpolicy.[93] In a recent commentary on nationalalcohol control policies in 18 countries, Baborand Winstanley [94] report that ‘contrary tothe generally pessimistic reports about alcoholpolicies, the case of Australia provides causefor optimism’. This assessment probably speaksto the relative low level of well-integratedpolicies globally, rather than an opportunity forcomplacency in Australia.Stockwell (2004:[42]) has judged that whilethere are ‘some significant disappointments’,there are also ‘some wonderful examples ofsuccessful Australian public policies aroundalcohol from the past two decades’. Amongthe population-wide strategies that havebeen successful in reducing alcohol-relatedharm in Australia, Stockwell highlights taxationand drink-driving legislation/enforcement. Forhigh-risk groups, the compulsory fortification ofbakers flour with thiamine and liquor licensingrestrictions in some Indigenous communitiesare considered as successes. Among thestrategies not likely to have been effective,Stockwell points to the dissemination ofnational drinking guidelines, the introductionof standard drink labelling on alcoholcontainers, and efforts to encourage GPs todeliver brief interventions and advice aboutlow-risk drinking. Stockwell also underlinessome significant ‘setbacks’ in Australianalcohol policy, such as the relaxation ofliquor licensing laws, which has led to theproliferation of outlets in many Australianjurisdictions; changes to the tax rate on wine,which has encouraged the production andharmful consumption of cheap wine; and,since 1997, the inability of states and territoriesin Australia to collect levies on the sale ofalcohol products.The recent review of alcohol policies in 30OECD nations rated Australia as fifth overall,behind Norway (1st), Poland, Iceland andSweden.[93] The study rated the state ofalcohol policy in each of the 30 countries bycreating a composite score based on theextent to which the country had adoptedpolices in various policy domains such as thephysical availability of alcohol, prices, drinkingcontext, alcohol advertising and road safety.37

The study also examined the relationshipbetween each country’s score and per capitaalcohol consumption, and found a strongnegative correlation that implied a decreasein consumption of 1 litre of alcohol per yearfor each 10-point increase in the score. Inother words, as alcohol policies increasedin strength (i.e. effectiveness), alcoholconsumption decreased.Since the late 1980s, Australia has adoptedseveral national strategies to tackle the harmfulconsumption of alcohol. Australia’s first nationalalcohol strategy was completed in 1989 [95]followed by subsequent inerations in 1996, [96]2001, [97] and most recently in 2006.[6] If thesuccess of these strategies is to be measured onthe basis of any change in rates of overall percapita drinking, rates of adult binge drinking,rates of underage drinking, and outcomessuch as hospitalisations and crime, then thesestrategies appear to have had only modestsuccess. One Australian commentator hassaid that ‘while these documents provide thebasis for a coherent and legitimate nationalapproach to alcohol there has been poorfollow-through on implementation’.[98]A recent summary of the state of alcohol policyin Australia reported that ‘what is needednow is not so much an understanding of whatworks, but an appreciation of how to makeit work in the various contexts in which it isimplemented’[43] [emphasis added]. Essentially,even the most effective strategies in the worldwill not be effective if they are not properlyimplemented as intended.5.2 The best mix of interventionsWhile some interventions are more effectivethan others, there is no single strategy thatcan offer a ‘quick fix’ or ‘silver bullet’ to theprevention of harmful consumption of alcohol.The review undertaken by Babor et al. (2003)[13] concludes that an integrated approachis required that includes a combination ofthe strategies that are known to be effectiveand suitable for the particular context inwhich they are to be implemented. The NDRIemphasises[36] that it is important to considerthe quality, rather than the quantity, ofinterventions. For example, ‘a single targetedrestriction (for example, hotel closing atmidnight) may be more effective than anentire suite of half-heartedly implemented,watered-down or ill-considered restrictions’.[36]Importantly, choosing high-quality interventionsdoes not mean choosing the most expensive. Infact, many of the most effective strategies arethe cheapest.A recent analysis of studies into the costeffectiveness of various alcohol-preventionmeasures found that there are very substantialdifferences in costs and effects, both betweeninterventions and between world regions.See Table 10.[99] Random breath testing (dueto the need for regular sobriety checkpointsadministered by police) and brief advice inprimary care (the intervention itself, plus costsassociated with training) are the most costlyinterventions to achieve equivalent savings inyears of health, expressed as disability-adjustedlife years (DALYs) With regard to taxation, costeffectiveness appears to depend in part on theefficiency of the tax system and the degree ofanti-drinking sentiment. In the Americas andEurope, where like Australia, the prevalence ofheavy drinking is high, taxation was the mosteffective and cost-efficient strategy. However,by contrast, tax is actually least effective andleast efficient in South East Asia, where lowrates of heavy drinking appear to favour moretargeted approaches such as random breathtesting and brief physician advice.[99]38

Table 10: Cost-effectiveness (average cost per DALY) of interventions for reducing the burden ofalcohol in three WHO sub-regions (at different levels of economic development)Intervention Americas Europe South East AsiaBrief physician advice 776 2,612 856Random breath testing 1,919 2,741 701Excise tax (current) 364 370 5,420Excise tax (current + 20%) 326 321 7,414Excise tax (current + 50%) 297 287 9,418Reduced retail access 484 1,208 1,406Comprehensive ad ban 536 660 1,807Source: Chisholm et al. (2006)[99]A more recent, Australian-based study hasidentified the interventions for which strongAustralian or international evidence exists as totheir potential benefits, and has attempted toevaluate these benefits in terms of the reductionin the social costs of alcohol-related harm itwould be possible to achieve.[100] Interventionsidentified as being effective and for whichbenefits are quantifiable, include:nHigher alcohol taxation, includingdifferential tax rates on forms of alcoholthat are particularly subject to abuseThe study estimates that through the adoptionof these interventions it would be possible toachieve a 48% reduction in alcohol-attributabledeaths, along with significant reductionsin the social costs of alcohol-related harm.These include a $5.94 billion saving from higheralcohol taxation, a $5.83 billion saving from briefinterventions, a $2.45 billion saving from partialadvertising and marketing controls, and a$0.94 billion saving from greater enforcementof drink-drive laws.nnnPartial or complete bans on theadvertising and promotion of alcoholMeasures to reduce drink driving: moreintensive enforcement of random breathtesting and lowering the legal bloodalcohol concentration (BAC) levelBrief interventions by primary carephysicians to reduce hazardousalcohol consumption.39

5.3 Challenges in implementationAustralia’s international score card in thearea of alcohol policy appears to be quiteimpressive, as the reviews mentioned abovetestify, and many would argue that incrementalpolicy change, rather than radical approaches,is the most appropriate way to proceed.However, some have cautioned against takingcomfort in this approach because of the‘cultural inertia’ surrounding alcohol policy inAustralia, which can be a formidable barrierto meaningful policy changes. ‘Drinking formspart of the Australian legend, and there is goodprecedent in Australian history to suggest that aradical alcohol reform agenda could provokecommunity backlash – beware the ‘wowser’label’.[98] An example of radical policy changethat has been successful is the introduction ofrandom breath testing, thanks in part to theaccompanying social marketing campaignsthat have highlighted both the seriousness ofthe problem and the effectiveness of the policyresponse. The level of public support in Australiafor new alcohol policy interventions and/or theextension of existing interventions is encouragingin some areas (see Fig. 14); for example, the levelof public support for measures known to beeffective, such as the strict monitoring of latenightlicensed premises (75%), is relatively high.While support for measures such as increasingtax on alcohol to pay for health, education andthe treatment of alcohol-related problems isrelatively lower (41%), it is a reasonably sufficientbase of public support on which to buildthrough public education and social marketingabout the rationale and potential benefits ofsuch a measure.Figure 14. Support for alcohol measures,proportion of the population aged14+ years, Australia, 2007Source: AIHW 2008[2]40

There are some specific challenges that gobeyond public understanding and attitudes.These have been raised throughout this paperand include:nnnNational Competition Policy, as it relates toliquor licensing systems, regulating alcoholprices and restricting alcohol promotionsThe division of responsibilities between levelsof governments for key alcohol policy areasand the historic complexity in achievingcoordinated actionThe economic and political importance,and thus influence, of the alcohol beverageand related industries.These challenges arise in the context of broad,community-wide changes in the nature of work,education and social connectedness, andoccur at a time when:nnnAlcohol sponsorship of sporting andcultural activities has replaced and isnow prominent in many areas previouslyoccupied by the tobacco industry.Alcohol consumption is symbolicallyassociated with positive and pleasurablelife in portrayals of Australia’s history andculture, including the ongoing promotionof alcohol as a necessary ingredient ofentertainment, celebration and all ‘rite ofpassage’ life course transitions.The ‘menu’ of psychoactive andperformance-enhancing substancesis increasing in scope and complexitywithin a society that is encouraged tofocus on pleasure and performance, andwhere alcohol is seen, comparatively,as the ‘known’ commodity and thus‘unchallengeable’ (or at least acceptable).nnnnnThe debate regarding the positive healthbenefits of small doses of alcohol makesforthright messages for social marketingpurposes awkward and less memorable,and where compromise is extracted inevery effort to implement effective alcoholharm prevention measures.Intoxicated behaviour is regarded by manycommunity members as ‘normal’ and bymany young people as desirable.The significantly lower life expectancy ofIndigenous people is intrinsically linkedto layered aetiology, including historicand structural issues, social and serviceexclusion, patterns of alcohol consumption,where there is great sensitivity to progressingevidence-based approaches in somecommunities and where the consequentimmobilisation and inaction from thebroader society is the most ready response.There is a parallel dilemma of too muchtoo fast, and the possibility of even greaterbroad dysfunction if not managed carefully.‘Consumer’ is a complex concept in thisfield. It can include both alcohol consumers(who generally seek liberal access to theirfavoured drug) and service users who arevery often extremely reluctant to seek ‘help’.Those who experience the ‘second-hand’effects of harmful consumption of alcoholare a somewhat untapped group (includingparents, who are the most identifiable group,but extending well beyond this sub-category).The extent and level of detail of dataavailable precludes the evaluation ofthe outcomes of the incremental andplanned changes to the levers thatinfluence alcohol-consumption patterns,and patterns of related harm over the pastdecades, and similarly make effectivemodelling or assessment of the likely impactof future directed changes incomplete andthus less reliable.41

nnWhile there are few well-qualifiedspecialists, there are many middlemanaginghealth and welfare personnelimplementing interventions that theysometimes have little faith in, and theconcomitant low expectations of successwith patients or clients can be self-fulfilling.In this context there is now good evidenceof what works and we know that treatment,for example, can be successful. Althoughmany will agree with this statement, few inthe responding industry seem to believe itor lack the skills to utilise the most effectivemeans to achieve it.The views of community members tend tobe closer to the alcohol beverage industries’preferred preventative approaches, such asadvocating for measures including schoolbasedalcohol education, the responsibleservice of alcohol training, parent supportand information, and education programsfor specific target populations on fetalalcohol effects.5.4 Opportunities for actionReflecting on the evidence regarding thedeterminants of harmful consumption ofalcohol, as gleaned from the review ofinterventions earlier in this paper, is perhapsa starting point for considering what thepriorities for action should be. In general:nnnnWhen alcohol availability increases,alcohol-related harms are likely to increaseWhen alcohol availability decreases,alcohol-related harms are likely to decreaseWhen alcohol prices decrease in real terms,alcohol-related harms are likely to increaseWhen alcohol prices increase in realterms, alcohol-related harms are likelyto decrease.In summary, changing the physical andeconomic availability of alcohol is probably themost effective and reliable way of reducing theharmful consumption of alcohol.As the NDRI (2007) suggests, ‘where the ultimateaim of decision makers is to minimise or reducethe negative impact of alcohol on the publichealth, safety and amenity of a population,best practice is that which is evidence-basedand at very least, avoids implementingchanges likely to increase overall availabilityabove the current status quo’.Government decision making relating to theavailability in Australia, whether it be liquorlicensing decisions or changes to the exciserates of particular alcohol products, tends tobe reactionary. As an alternative, NDRI (2007)suggests that ‘authorities and decision makersmight consider adopting a pro-active style –one which acknowledges the links betweenalcohol availability and harms and which plansaccordingly. Optimally, such an approachwould: include policy and strategies basedon sound research evidence for efficacyand/or have a solid theoretical grounding;include processes which support the ongoing,systematic collection of detailed objective datafor monitoring and evaluation purposes; employevaluation findings to inform and supportfuture evidence-based decisions and reliablemonitoring of community sentiment.’Of course, ‘supply reduction’ measures thatrestrict availability are not the single solutionto addressing the harmful consumptionof alcohol – harm reduction and demandreduction measures are also important andvery necessary. Maintaining and buildingon Australia’s impressive track record indrink-driving countermeasures is an obviouselement to include in an overall preventativestrategy, but it should not be taken for granted,especially given the powerful cultural forcessurrounding alcohol in Australia that couldundermine, stall or, worse still, reverse thegains made in preventing and reducingalcohol-related road injuries and fatalities. Briefinterventions are known to be one of the mosteffective preventative measures and more workis needed to examine the most appropriatesetting for such an approach. Along with theusual health settings considered, workplacesprovide a window of opportunity for reaching42

thousands of Australians at the early stagesof problematic drinking. This also opens anopportunity for novel partnerships. The success ofprevention in other areas of public health, suchas tobacco control, tells us that social marketingis a key element that is necessary to inform targetaudiences, shift attitudes and positively reinforcebehaviour changes being driven by othercomplementary measures, such as restrictionson availability, regulation and enforcement.5.5 PrioritiesThe intent of this paper has been to providebackground information about alcohol-relatedharm in Australia, and summarise internationalbest practice in alcohol-prevention policiesand programs, rather than to articulate aparticular course of action. However, somepriorities for preventative policies and programs,and for research, are most important and mosturgent, and should be singled out, becausethey represent a gap in current practiceor knowledge in Australia or because theywould enhance and/or inform existing andnew practices. In the first instance, the majorimperatives for Australia are to:1. Reshape consumer demand towardssafer drinking through:nnManaging both the physical availability(access) and economic availability(price). The high accessibility of alcohol– in terms of outlet opening hours, densityof alcohol outlets and discountingof alcohol products – is an issue in manyAustralian communities.Addressing the cultural place of alcohol.Carefully planned, targeted andresearch-based social marketing andpublic education are required, and willbe more effective if the marketing ofalcoholic beverages is restricted, includingcurbing advertising and sponsorshipof cultural and sporting events.2. Reshape supply towards lower-riskproducts through:nnChanges to the current taxation regimeto stimulate the production andconsumption of low-alcohol products.Improved enforcement of current legislativeand regulatory measures (such asResponsible Serving of Alcohol or banson serving intoxicated persons andminors, or continuing to lower the bloodalcohol content in drink-driving laws).3. Strengthen, skill and support primaryhealth care to help people in makinghealthy choices:nSupporting brief interventions as part ofroutine practice by health professionalsand other health workers in primaryhealthcare settings can assist changesin drinking behaviour and attitudesto alcohol consumption. This supportshould include consideration of buildingappropriate reimbursements and otherincentives into health system funding.4. Close the gap for disadvantagedcommunities:nThere is a need for tailored approachesand services to reach Indigenous andother disadvantaged groups.5. Improve the evaluation ofinterventions through:nnMonitoring and evaluation of regulatorymeasures and other programsto underpin the further evolution ofprevention strategies directed at inappropriatealcohol consumption.Developing effective models of saferpatterns of alcohol consumption in differentcommunities through changesto alcohol taxation arrangements, andan understanding of the impact of differenttypes of alcohol outlets and theirdensity on hospitalisation, violenceand crime rates.43

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