National Preventative Health Taskforce

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1 Prevetative Health Taskforce Natioal Prevetative Health Taskforce Techical Report No 3 Prevetig Alcohol-related Harm i Australia: a widow of opportuity Prepared for the Natioal Prevetative Health Taskforce by the Alcohol Workig Group

2 Techical Report No 3: Prevetig alcohol-related harm i Australia: a widow of opportuity Prepared for the Natioal Prevetative Health Taskforce by the Alcohol Workig Group ISBN: Olie ISBN: Publicatios Approval Number: P Paper-based publicatios (c) Commowealth of Australia 2008 This work is copyright. Apart from ay use as permitted uder the Copyright Act 1968, o part may be reproduced by ay process without prior writte permissio from the Commowealth. Requests ad iquiries cocerig reproductio ad rights should be addressed to the Commowealth Copyright Admiistratio, Attorey-Geeral s Departmet, Robert Garra Offices, Natioal Circuit, Barto ACT 2600 or posted at Iteret sites This work is copyright. You may dowload, display, prit ad reproduce this material i ualtered form oly (retaiig this otice) for your persoal, o-commercial use or use withi your orgaisatio. Apart from ay use as permitted uder the Copyright Act 1968, all other rights are reserved. Requests ad iquiries cocerig reproductio ad rights should be addressed to Commowealth Copyright Admiistratio, Attorey-Geeral s Departmet, Robert Garra Offices, Natioal Circuit, Barto ACT 2600 or posted at

3 Ackowledgemets The techical report o alcohol was prepared o behalf of the Natioal Prevetative Health Taskforce: Professor Rob Moodie, Chair Professor Mike Daube, Deputy Chair Ms Kate Carell AO Dr Christie Coors Mr Shau Larki Dr Ly Roberts AM Professor Leoie Segal Dr Lida Selvey Professor Paul Zimmet AO The report was prepared with advice from the Natioal Prevetative Health Taskforce Alcohol Workig Group: Professor Rob Moodie (Chair) Professor Steve Allsop Ms Kate Carell AO Mr David Crosbie Professor Margaret Hamilto AO Mr Todd Harper Professor Leoie Segal Dr Lida Selvey Associate Professor Ted Wilkes Professor Paul Zimmet AO Writer: Mr Bria Vadeberg We would also like to thak the followig people for their cotributios to the report: Professor Robi Room (Director), ad Mr Michael Livigsto, AER Cetre for Alcohol Policy Research ad Turig Poit, Alcohol & Drug Cetre Melboure Ms Meriel Schultz, Adviser, Natioal Prevetative Health Taskforce Ms Michelle Scollo, Seior Adviser, Cacer Coucil Victoria The Populatio Health Strategy Uit ad the Publicatios Uit ad Commuicatios Brach, Australia Govermet Departmet of Health ad Ageig

4 Cotets 1 Itroductio: chagig the drikig culture i Australia Purpose The drikig culture i Australia Determiats of drikig behaviour Alcohol policy ad programs i Australia Recet developmets i Australia 4 2 Key treds i alcohol cosumptio Alcohol cosumptio i Australia ad other coutries Drikig patters amog Australias Product prefereces Alcohol prices ad cosumer spedig 9 3 Key treds i alcohol-related harm Health impacts Social impacts Health iequalities 15 4 Best practice i prevetio Curret activity Regulatig the physical availability of alcohol Taxatio ad pricig Drik-drivig coutermeasures Treatmet ad early itervetio Alterig the drikig cotext Regulatig promotio Educatio ad persuasio 35 ii

5 5 Policy Imperatives The state of alcohol policy i Australia The best mix of itervetios Challeges i implemetatio Opportuities for actio Priorities 43 Refereces 45 iii

6 1. Itroductio: chagig the drikig culture i Australia 1.1 Purpose This paper has bee prepared for the Natioal Prevetative Health Taskforce to provide upto-date ad evidece-based iformatio o policies ad programs to prevet alcoholrelated harm i Australia. While the paper is iteded as a overview of the most relevat ad geerally available evidece, i the iterests of brevity it covers may issues i summary oly. The paper attempts to aswer three questios: What are the key treds i alcohol cosumptio ad related harm i Australia? What are the most effective approaches to prevetig ad reducig alcoholrelated harm? What are the gaps ad opportuities for prevetative actio i Australia? The paper is iformed by the most curret ad readily available iformatio o alcohol cosumptio ad related harm, ad the scietific literature o approaches to prevetig ad reducig alcohol-related harm. It draws upo evidece ad examples of approaches from both withi Australia ad iteratioally. The paper summarises ad ackowledges prevetative work addressig alcohol-related harm already uder way i Australia, ad icludes some commetary o its effectiveess, ad also attempts to highlight gaps ad opportuities for further prevetative actio. The rage of itervetios that are reviewed i some detail i the paper iclude: Regulatig physical availability Taxatio ad pricig Drik-drivig coutermeasures Treatmet ad early itervetio Alterig the drikig cotext Regulatig promotio Educatio ad persuasio. A emergig theme from the paper is that there is curretly a uique widow of opportuity i Australia for a sigificat expasio of activity i the prevetio of alcohol-related harm. I part, this opportuity grows from icreased commuity ad political cocer about the harmful cosumptio of alcohol (especially focused o youth drikig) ad a heighteed willigess from all levels of govermet to take actio i the area. Furthermore, there is a icreasigly solid base of evidece upo which policy decisios ca be made eve from the brief review preseted i this paper, it is clear which of the various policies ad programs hold the most promise of beig effective, ad those which offer the least. It is also apparet that there are potetial syergies with other public health efforts to address tobacco, obesity ad a rage of chroic diseases. 1

7 The priorities for prevetative actio that are suggested i this paper are reflected i the overarchig discussio paper Australia: the Healthiest Coutry by The drikig culture i Australia Alcohol plays may roles i cotemporary Australia society as a relaxat, as a accompaimet to socialisig ad celebratio, as a source of employmet ad exports, ad as a geerator of tax reveue. It is itrisically part of Australia culture. The majority of Australias who regularly drik, do so i moderatio. Aroud three-quarters (72.6%) of Australias drik below levels for log-term risk of harm.[1] However, short-term cosumptio of alcohol at harmful levels, while oly occasioal, is also a promiet feature of the drikig culture i Australia. Oe i five Australias (20.4%) drik at short-term risky/high-risk levels at least oce a moth.[2] Put aother way, this equates to more tha 42 millio occasios of bige drikig i Australia each year. While overall levels of alcohol cosumptio ad drikig patters have ot chaged markedly over the past decade, there is a icreasig commuity awareess of the problem of harmful cosumptio of alcohol. These patters cotiue to produce substatial costs to the health of Australias. Alcohol cosumptio accouts for 3.2% of the total burde of disease ad ijury i Australia: 4.9% i males ad 1.6% i females. [3] Beyod its impacts o the health ad wellbeig of idividuals ad commuities, the harmful cosumptio of alcohol also impacts sigificatly across a rage of other areas, icludig workforce productivity, healthcare services such as hospitals ad ambulaces, road accidets, law eforcemet, property damage ad isurace admiistratio. The aual cost to the Australia commuity from alcohol-related harm is estimated to be more tha $15 billio.[4] I Australia, cocer i the geeral commuity about alcohol s adverse health ad social effects is growig. A recet survey of Australias revealed that 84% of people are cocered about the impact of alcohol o the commuity.[5] 1.3 determiats of drikig behaviour The curret atioal alcohol strategy[6] observes that Australia s drikig cultures are drive by a mix of powerful, itagible social forces, such as habits, customs, images ad orms, ad other iterlockig ad equally powerful tagible forces relatig to the social, ecoomic ad physical availability of alcohol, icludig promotio ad marketig, age restrictios, price, outlets, hours of access ad service practices[6] (see Fig. 1). Certaily, there is o sigle factor that determies why people drik at harmful levels. Health-damagig behaviours related to poor diet, iadequate exercise, cigarette smokig, excessive drikig ad illicit drug use appear to be embedded i a complex etwork of social determiats ad risk ad protective factors, ad behaviours are also mediated by cultural iflueces.[7] 2

8 Modifiable Determiats: Cultural Place ad Availability: Price Outlet locatios Opeig hours Miimum purchase age Service practices Law eforcemet Promotio Social orms & values Target Bahaviours: Drikig to Itoxicatio: (BAC > 0.08) Log Term Heavy Drikig Outcomes: Public Safety ad Ameity: Violece Property damage Ati-social behaviour Perceptios of safety Public Safety ad Ameity: Road ijuries Assaults Drowig Suicides Falls Fire/smoke ijuries Sexually trasmitted ifectios Log-term (Chroic) Health Impacts: Cacers Cirrhosis of the liver Depedece Metal Illess Figure 1: Alcohol-related harm: determiats, behaviours ad outcomes Source: Natioal Alcohol Strategy [6] 1.4 alcohol policy ad programs i Australia Support whole-of-commuity iitiatives to reduce alcohol-related health problems Prevetig alcohol-related harm is a resposibility shared amog all levels of govermet. The Australia Govermet ad the states ad territories are workig together through the mechaisms of the Miisterial Coucil o Drug Strategy to implemet iitiatives as part of the Natioal Alcohol Strategy [6] The strategy is a pla for actio developed collaboratively betwee govermets, idustry ad commuity parters. Key actio areas iitially idetified for the strategy iclude: Moitor ad review of alcohol promotios Icrease commuity awareess ad uderstadig of the extet ad impacts of itoxicatio Improve eforcemet of liquor licesig regulatios Develop ad implemet social marketig campaigs to reduce alcohol-related harms. At a state ad territory level, key alcohol policy ad program resposibilities iclude law eforcemet, licesig regulatio, the provisio of treatmet services ad drug educatio i schools. Additioally, all states ad territories have strategic plas to address alcohol, which vary i scope ad fudig. Give the diverse rage of adverse outcomes of drikig ofte experieced at a local commuity level, local govermets also play a importat role, icludig their fuctios i evirometal health, plaig, commuity developmet, waste disposal ad youth services. 3

9 Local govermets ca cotribute to the maagemet of the physical availability of alcohol ad the creatio of safer drikig settigs, ad egage i evirometal desig ad plaig that cotributes to ad supports commuity wellbeig. There are may examples of iovative, locally resposive measures i Australia, i part to respod to the moder pheomea of ight-time ecoomies.[8] Throughout Australia, there is also a cosiderable amout of commuity-based activity uder way i prevetig alcohol-related harm, some of which is govermet fuded ad some of which is led by charitable groups. The cotributio of commuity-level actio is sigificat, ad is itegral to the effective implemetatio of federal, state ad local govermet polices ad programs. Overall, while rhetoric is aimed at prevetio, ad there is curretly a mood to address the egative side of alcohol use, there is great difficulty i gaiig coheret, cooperative, strategic ad effective actio. This situatio might be compared to the place of ad resposes to tobacco smokig i Australia i the 1960s. 1.5 Recet developmets i Australia Natioal Bige Drikig Strategy O 28 March 2008, the Prime Miister aouced a ew atioal strategy to address the bige drikig epidemic amog youg Australias.[9] Coucil of Australia Govermets (COAG) Bige Drikig Agreemet The Coucil of Australia Govermets (COAG) recetly agreed o the importace of tacklig the harmful cosumptio of alcohol amog youg people ad asked the Miisterial Coucil o Drug Strategy to report to it i December 2008 o optios to reduce bige drikig, icludig i relatio to closig hours, the resposible service of alcohol, reckless secodary supply ad the alcohol cotet i ready-to-drik beverages. The Australia New Zealad Food Regulatio Miisterial Coucil is to request Food Stadards Australia New Zealad to cosider madatory health warigs o packaged alcohol.[10] Miisterial Coucil o Drug Strategy (MCDS) The work of the Miisterial Coucil o Drug Strategy (MCDS) icludes a focus o the assessmet of late-ight lock-outs for licesed premises ad the developmet of a preferred framework to more effectively target police resources o bige drikig hot spots. It is also focused o a atioal policy framework for the resposible service of alcohol, a preferred regulatory model to address the secodary supply of alcohol to miors, optios for reducig the alcohol cotet i products (icludig those aimed at youg people), possible stadards ad cotrols for alcohol advertisig targetig youg people, ad advice regardig the impact of health warigs o alcohol products.[11] Norther Territory iitiative ad other Aborigial ad Torres Strait Islader specific iitiatives Perhaps the most radical experimets i respodig to problems, especially amog Aborigial Australias, have bee carried out i the Norther Territory. Most recetly, the Norther Territory Iitiative was implemeted by the the Miister for Aborigial Affairs of the previous Australia govermet, ad is soo to be reviewed after oe year of implemetatio. This is a complex area ad this paper will ot attempt to summarise itervetios specific to Idigeous Australias or presume to provide comprehesive iformatio i this area. 4

10 2. Key treds i alcohol cosumptio 2.1 alcohol cosumptio i Australia ad other coutries Iformatio o levels ad patters of alcohol cosumptio is diverse, ad it ca be difficult to idetify the key features for the purposes of moitorig treds i drikig ad related harm, ad the possible opportuities for itervetio. Ufortuately, i Australia at the curret time, some of the most sigificat ad valuable data is ot readily available to the public health field. [12] For example, alcohol sales data, while it is kow to be collected ad aalysed by the alcohol beverage idustry, is ot available for the purposes of this paper, or ideed is it easily accessed for public health research purposes i geeral. The Taskforce otes with some cocer that the cotiuatio of the most accessible data sets o alcohol cosumptio levels i Australia, collected ad compiled by the Australia Bureau of Statistics (ABS), is curretly uder review. Efforts are therefore urgetly required to seek the cotiuatio of these valuable data sets. Per capita cosumptio of alcohol is a importat measure from a public health perspective because it is to a cosiderable extet, related to the prevalece of heavy use, which i tur is associated with egative effects.[13] Total per capita cosumptio of alcohol i Australia alcohol grew rapidly i the 1970s ad has ot retured to low levels sice the; i 2007 it was estimated to be 9.88 litres of alcohol per capita (see Fig. 2). Amog the differet alcoholic beverage categories, there have bee sigificat chages i per capita cosumptio over the past 70 years. Sice peakig at over 6.4 litres of alcohol per capita i the mid-1970s, per capita cosumptio of beer has steadily declied ad is ow at a level similar to that of the late 1950s. This reductio partly reflects chages i cosumer tastes towards wie, ad the icrease i the availability of relatively low-priced wie. Cosumptio of wie has icreased almost fourfold sice the late 1940s, whe itake was 0.77 litres of alcohol per capita. I 2005 wie cosumptio i Australia reached a all time record of 3.13 litres of alcohol per capita. Whe iterpretig the tred i per capita cosumptio i Australia, it should be oted that the data does ot take ito accout the ageig of the populatio; as people age, they geerally cosume less alcohol. Hece, as the Australia populatio cotiues to age over the comig decades, it is expected that per capita alcohol cosumptio will most likely decrease. Figure 2: Apparet per capita cosumptio of alcohol (litres of alcohol), Australia persos aged 15+ years, 1994 to 2007 (years edig 30 Jue) Source: ABS upublished data ad ABS 2008 Per capita cosumptio of alcohol i Australia is high by world stadards. Australia is raked withi the top 30 highest alcohol-cosumig atios, out of a total of 180 coutries. Table 1 shows Australia s level of per capita alcohol cosumptio (9.02 litres of pure alcohol) ad rakig (#30) compared to other selected coutries i More recet estimates of per capita alcohol cosumptio for Australia (9.88 litres of pure alcohol i 2007) suggest that our iteratioal rakig is ow likely to be eve higher. 5

11 Table 1: Per capita cosumptio of alcohol by coutry ad rak (out of 180 coutries), selected coutries* Rak Coutry Per capita cosumptio Rak Coutry Per capita cosumptio 1 Luxembourg Greece Irelad USA Germay Italy UK Japa Spai South Africa Frace Swede Russia Federatio Thailad Netherlads Chia New Zealad Papua New Guiea Australia Idoesia 0.09 * Values are for various years before ad icludig 2003 Per capita alcohol cosumptio (litres of pure alcohol) amog adults Source: WHO 2008[14] 2.2 drikig patters amog Australias It is estimated that 83% of Australias are drikers, ad that 1.4 millio Australias cosume alcohol o a daily basis.[2] I 2007, males (10.8%) were almost twice as likely as females (5.5%) to drik daily. Two i every five Australias drik o a weekly basis. However, there is a sizable proportio of the populatio (10.1% i 2007) who, for various reasos, have ever druk ay alcohol (see Table 2). Table 2: Frequecy of alcohol cosumptio, proportio of the populatio aged 14+ years, Australia, 1991 to 2007 Frequecy Daily Weekly Less Ex-driker Never Source: AIHW, Natioal Drug Strategy Household Surveys,[2] various years Almost three-quarters (72.6%) of Australias drik below levels that would icur log-term risk of harm. However, amog youg adults (aged years), the prevalece of drikig at levels posig log-term risk of harm is sigificatly higher (16%) tha amog other age groups (see Fig. 3). This patter of drikig is the equivalet of cosumig 29 or more stadard driks per week for males ad 15 or more stadard driks per week for females. Amog Australia teeagers i 2007, this drikig patter was cosiderably higher amog females (10.6%) tha amog males (7%). 6

12 Figure 3: Drikig at risky/high risk of harm i the log term by age ad year, proportio of the populatio aged 14+ years, Australia, 2007 Source: AIHW Natioal Drug Strategy Household Survey[2] While almost half (48.3%) of the Australia populatio drik at low risk levels, oe i five Australias (20.4%) drik at short-term risky/highrisk levels at least oce a moth. This patter of drikig is the equivalet of cosumig seve or more stadard driks o ay oe day for males, ad cosumig five or more stadard driks o ay oe day for females. I short, this geerally equates to drikig to the poit of itoxicatio, or what is ofte termed as bige drikig. This sort of drikig is most prevalet amog adults aged years, oe-quarter (24.9%) of whom do so o at least a mothly basis. Overall, Australia males are more likely tha females to drik at short-term risky/high-risk levels o regular (at least oce a moth) occasios (17.1% of females compared to 23.6% of males). However, amog teeagers, females are more likely tha males to regularly drik at levels of risky/high-risk of harm i the short term: 28.3% of female teeagers compared to 24.5% of male teeagers (see Figs. 4 ad 5). Betwee 2001 ad 2007 there were oly slight chages i the prevalece of drikig at risky/high risk of harm i the short term across the age groups. Figure 4: Mothly drikig at risky/high risk of harm i the short term* by age ad year, proportio of the male populatio aged 14+ years, 2001 to 2007 Source: AIHW Natioal Drug Strategy Household Survey[2] Figure 5: Mothly drikig at risky/high risk of harm i the short term* by age ad year, proportio of the female populatio aged 14+ years, 2001 to 2007 Source: AIHW Natioal Drug Strategy Household Survey[2] (*Risky/high-risk drikig i the short term = seve or more stadard driks o ay oe day for males; five or more stadard driks o ay oe day for females.) 7

13 2.3 Product prefereces The most preferred types of alcoholic beverages amog Australia female drikers, i descedig order, are bottled wie, bottled spirits ad liqueurs, ready-to-drik beverages (RTDs) i a bottle ad RTDs i a ca. Over the 2001 to 2007 period, the preferece for bottled wie had the greatest icrease amog females, growig from 57.3% to 63.8%. Amog males, the most preferred types of alcoholic beverages, i descedig order, are full-stregth beer, bottled wie, bottled spirits ad liqueurs, ad RTDs i a ca. Over the 2001 to 2007 period, the preferece for RTDs i a ca had the greatest icrease amog males, growig from 18.2% to 24.3% (see Figs. 9 ad 10). With regard to which types of alcoholic beverages are most commoly ivolved i the harmful cosumptio of alcohol, Stockwell et al. have estimated[16] that straight spirits (79.7%), alcoholic cider (78.9%), pre-mixed spirits (71.8%) ad regular stregth beer (72.6%) are the top four types of beverages cosumed by Australia drikers o days whe they drak at risky/high-risk levels. Amog 12- to 17-year-olds, the top three types of beverages are straight spirits (98.9%), regular beer (78.9%) ad RTDs (76.7%). Spirit-based beverages held the highest market share, represetig 62.7% of total alcohol cosumptio amog this age group, with slightly more cosumed as straight spirits tha as RTDs. Figure 9: Preferece for selected alcoholic beverages by year, proportio of the male populatio, Australia, 2001 to 2007 Source: AIHW[15] Figure 10: Preferece for selected alcoholic beverages by year, proportio of the female populatio, Australia, 2001 to 2007 Source: AIHW[15] 8

14 2.4 alcohol prices ad cosumer spedig The real price of alcohol i Australia has remaied relatively low compared to other commodities, ad i some cases has dropped. For example, a glass of wie costig $1 i Jue 1999 dropped i real terms to $0.90 i March 2008 (see Fig. 6). The affordability of alcohol i Australia today is reflected i the fact that, o average, Australia households are spedig proportioately less o alcohol owadays compared to the amout they spet 20 years ago, despite total per capita cosumptio of alcohol chagig little over the same period. The proportio of average weekly expediture by Australia households o alcoholic beverages i 1984 was 3.4% ($12.30), compared to 2.6% ($23.32) i (ABS 2005).[17] Figure 6: Prices of alcoholic beverages relative to other cosumptio (Jue 1999 $1.00), Australia, September 1980 to March 2008 Source: ABS, various years 9

15 3. Key treds i alcoholrelated harm 3.1 Health impacts It is importat to cosider both the shortterm ad log-term health impacts of the harmful cosumptio of alcohol, as both result i sigificat morbidity ad mortality. The typical effects of moderate alcohol cosumptio are those o the brai, such as feeligs of relaxatio, wellbeig ad loss of ihibitios. However, as itake icreases, pleasat effects are lesseed by adverse effects such as drowsiess, loss of balace, ausea ad vomitig, ad other more serious harmful effects such as aggressive behaviours, ucosciousess, kidey failure ad icreased risk of accidets ad ijury [18]. Overall, more people die from the acute effects of alcohol tha the log-term or chroic effects.[18] Alcohol cosumptio accouts for 3.2% of the total burde of disease ad ijury i Australia: 4.9% i males ad 1.6% i females.[19] It should be oted that although this percetage is lower tha the cotributio from tobacco smokig (7.8%) ad high body mass (7.5%), there remais some debate over the method to calculate the disease burde attributable to alcohol. That the Australia figure may be a uderestimate is suggested by the higher reported burde of disease from alcohol for New Zealad (10% for me ad 4% for wome).[20] Alcohol has bee causally liked to more tha 60 differet medical coditios.[13] I Australia, alcohol was liked to 3430 deaths per year ad 85,435 disability-adjusted life years (DALYs) per year.[3] I the 10 years betwee 1992 ad 2001, more tha 31,000 Australias died from alcoholattributable ijury ad disease a greater umber died from acute (usually i the cotext of acute itoxicatio) rather tha chroic coditios (ofte related to loger term depedece o alcohol). Table 3: Deaths ad burde (DALYs) attributable to alcohol by specific cause, Australia, 2003 Specific cause Number Deaths Proportio of total (%) Number DALYs Proportio of total (%) Alcohol abuse % 34, % Suicides & self-iflicted ijuries % 12, % Road traffic accidets % 11, % Oesophagus cacer % 4, % Breast cacer % 4, % Other 1, % 19, % Total harm 3, % 85, % Source: Begg et al The most commo cause of death due to itoxicatio was road crash ijury, ad amog the chroic coditios alcohol-related liver cirrhosis accouted for the majority of deaths.[21] Deaths from acute causes are most commo amog youg people, particularly those aged years, while deaths from alcoholattributable chroic diseases are more commo amog people aged over 45 years. 11

16 More males tha females died from both acute ad chroic alcohol-attributable coditios [21.] Over half a millio hospitalisatios were caused by risky ad high-risk drikig i Australia i the eight years betwee 1993/94 ad 2000/01.[21] The most umerous coditios amog these hospitalisatios were for alcohol depedece (87,186), ijuries caused by assault (76,115), road crash ijuries (47,167) ad attempted suicide (20,374). As may as 10,094 hospitalisatios were attributed to some form of alcoholic overdose from very high blood alcohol levels, icludig alcohol poisoig ad aspiratio vomitus. Overall, the majority of hospitalisatios were for acute coditios (67.8%).[21] Future projectios of the leadig causes of disease burde predict that the proportio due to alcohol will remai stable ad withi the top 14 leadig causes amog Australia males by 2023 (see Fig. 7). The proportio of disease burde caused by axiety ad depressio is also expected to remai stable by 2023, while ischaemic heart disease ad lug cacer are expected to declie. Type 2 diabetes is predicted to be the leadig cause of disease burde amog Australia males by Figure 7: Leadig causes of burde (DALYs) i males, Australia, 1993 to 2023 Source: Begg et al. 2007[19] At low levels of cosumptio, alcohol may also have some beefits various studies have foud reductios i some forms of heart disease (particularly i middle-aged ad older males) ad ischaemic stroke (i older females), diabetes, gallstoes ad demetia. The extet ad eve the existece of such beefits remai cotroversial.[22, 23] I terms of populatio, health, heart disease ad stroke are the most importat of these potetial beefits. Nearly all the potetial beefits are cofied to males over the age of 45 ad wome past meopause, ad ca be gaied with a drikig patter of as little as oe drik every secod day. Sice alterative meas of prevetig heart ad vascular disease are available, the cliical cosesus is that people eed ot take up or maitai drikig for health beefits. Drikig durig pregacy Recet data show that 59% of Australia wome drak alcohol at some time durig their pregacy ad that 14% reported drikig five or more driks i a sittig i the three moths prior to pregacy 58% durig the first ad secod trimester ad 54% i the third trimester.[18] Materal alcohol cosumptio ca result i a spectrum of harms to the fetus. Although the risk of birth defects is greatest with high, frequet materal alcohol itake durig the first trimester, alcohol exposure throughout pregacy (icludig before a pregacy is cofirmed) ca have cosequeces for the developmet of the fetal brai. It is ot clear whether the effects of alcohol are related to the dose of alcohol ad whether there is a threshold above which adverse effects occur.[24] This ucertaity is reflected i policy regardig alcohol use i pregacy withi Australia ad overseas.[25] Although the risks from low-level drikig (such as oe or two driks per week) durig pregacy are likely to be low, a o-effect level has ot bee established, ad limitatios i the available evidece make it impossible to set a safe or o-risk drikig level for wome to follow i order to avoid causig harm to their ubor baby. 12

17 I there were a total of 145,000 drug treatmet episodes recorded i Australia, of which 56,000 (or 39%) were for alcohol problems.[15] While this figure is high, it is perhaps relatively low give the estimated 585,000 Australias who drik at levels cosidered to be high risk to health i the log term, may whom might be cosidered the potetial target group for treatmet.[15] Females accouted for 31% of alcohol treatmet episodes i Persos aged years received 22% of treatmet episodes. For persos aged years receivig treatmet, the proportio treated for alcohol problems has icreased from 15% to 23% betwee ad The iteractios betwee other drugs (tobacco, illicit ad prescriptio) ad alcohol are complex. Australia studies reveal a close associatio betwee heroi overdose ad alcohol cosumptio at harmful levels at the time of overdose. Australia research has also foud that amog caabis users, alcohol was almost uiversally used o a regular basis, with most users cosumig alcohol at harmful levels. There are also parallels i aetiological research regardig the uptake of oe psycho-active substace icreasig the likelihood of use of others. There has also bee some work doe regardig parets attitudes ad behaviour as a factor i ifluecig tobacco, alcohol ad other drug use. For all of these substaces, it is importat that prevetio efforts focus o delayig the uptake of regular use. This paper does ot attempt to deal with the obvious crossover betwee metal health issues ad the harmful cosumptio of alcohol, ad the icreasig problem of poly-drug use, but ay prevetative actio eeds to bear these factors i mid. 3.2 Social impacts The effects of alcohol cosumptio go beyod diseases, accidets ad ijuries to a rage of adverse social cosequeces, both for the driker ad for others i the commuity. These cosequeces iclude harm to family members (icludig childre) ad to frieds ad workmates, as well as to bystaders ad stragers. Alcohol-related disturbace ad assault rages from acts of vadalism, offesive behaviour ad disruptio to far more serious atisocial behaviour, which ca result i violece or ijury to others.[18,23] While it is ot a perfect descriptio of the wider social impacts of the harmful cosumptio of alcohol, some commetators have coied the term passive drikig, aki to passive smokig, to refer to the impact of druke behaviour o third parties. 13

18 Families ad childre It is a reality that the most visible effects of drikig o others, icludig childre, result from accidets ad ijury (icludig violece) durig or after drikig occasios.[18, 23) Whe families have to deal with a relative s alcoholism, violece, ijury or eve death, these serious cosequeces ca cause great sufferig.[18, 30) Drikig withi families is a importat cosideratio because, depedig upo the circumstaces, it ca be either a positive or egative ifluece o the drikig behaviour of youg people. It is estimated that 13% of Australia childre aged twelve years or less are exposed to a adult who is a regular bige driker.[26] It has bee estimated that 31% of parets ivolved i substatiated cases of child abuse or eglect experiece sigificat problems with alcohol use.[27] I Australia, it is estimated that 47% of all perpetrators of assault ad 43% of all victims of assault were itoxicated prior to the evet.[28] It has also bee reported that 34% of homicide perpetrators ad 31% of homicide victims were alcohol affected at the time of the homicide. I additio, it has bee estimated that alcohol is a importat factor i 50% of cases of domestic physical ad sexual violece.[29] I a sigle year ( ), there were 8661 people admitted to Australia hospitals with ijuries from alcohol-related assaults; 62,534 alcoholrelated assaults were reported to police i the same year, ad it is estimated that may more wet ureported. Of the hospitalisatios with ijuries from alcohol-related assaults, 74% were male ad two-thirds were aged years.[30] A importat factor i alcohol-related violece is the settig where drikig occurs. Australia studies have geerally cofirmed that alcoholrelated violece most commoly occurs i ad aroud ier-city hotels, i the early hours of Saturday ad Suday morigs, ad usually amog youg adult males.[31] Furthermore, it has bee show that the majority of alcohol-related icidets occur i a miority of high-risk licesed veues.[32] It is ot surprisig that much of the time ad resources of policig i Australia is related to icidets ivolvig alcohol. Oe study reported that alcohol is ivolved i 62% of all police attedaces, 73% of assaults, 77% of street offeces, 40% of domestic violece icidets ad 90% of late-ight calls, from 10.00pm to 2.00am.[31] The total social cost of the harmful cosumptio of alcohol is estimated to be more tha $15 billio each year.[4] The majority of these costs are for tagible social costs such as crime ($1.6 billio), health ($1.9 billio), productivity i the workplace ($3.5 billio), productivity i the home ($1.5 billio) ad road accidets ($2.2 billio) (see Table 4). Table 4: Estimated social costs of alcohol abuse, Australia, Type of cost $m Reductio i workforce ad abseteeism 3,579 Labour i the household 1,571 Medical 541 Hospital 662 Nursig homes 401 Pharmaceuticals 298 Ambulaces 75 Road accidets 2,202 Police 747 Crimial courts 86 Prisos 142 Property 67 Isurace admiistratio 14 Productivity of prisoers 368 Resources used i abusive cosumptio 1,689 Loss of life 4,135 Pai ad sufferig (road accidets) 354 Source: Collis & Lapsley 2008[4] 14

19 3.3 Health iequalities Geographic There are variatios i alcohol cosumptio across Australia ad differet impacts o specific high-risk populatio groups. Per capita alcohol cosumptio varies sigificatly betwee urba ad rural areas, ad betwee Australia states ad territories. For istace, while the prevalece of drikig at short-term risky/high-risk levels at least mothly is 18.7% i New South Wales ad 19.4% i Victoria, it is 28.4% i the Norther Territory.[1] Alcohol cosumptio levels (ad alcohol-attributable mortality ad morbidity) are cosistetly foud to be lower for people livig withi major cities whe compared to outer regios. I 2004 it was estimated that the proportio of Australias who drak at risky/high-risk levels for short-term harm, residig i outer regioal (24%) ad remote/very remote (28%) locatios was betwee 20% ad 40% greater tha for residets of major cities. The proportio of the populatio residig i outer regioal ad remote/very remote locatios who drak at risky/high-risk levels for log-term harm were 11% ad 16% respectively, compared to 9.5% i major cities. Not surprisigly, there are also geographic differeces i the rates of alcoholrelated harm i Australia. The Norther Territory has the highest rate of alcohol-attributable deaths ad hospitalisatios i the coutry. Idigeous Australias Idigeous Australias are about twice as likely to abstai from alcohol as o-idigeous Australias, but those who do drik may be up to six times more likely to drik at high-risk levels tha o-idigeous people.[34] A survey estimated that 38% of Idigeous people aged 14 ad over drak at risky/high-risk levels for acute harm, compared to 20% amog o- Idigeous people; ad that 23% drak at risky/ high-risk levels for chroic harm, compared to about 10% of o-idigeous people.[35] However, a less recet, but better desiged, Idigeous-specific survey of substace misuse foud that about 58% of all Idigeous respodets drak at risky/high-risk levels.[36] Amog Idigeous people who live i remote parts of Australia, levels of alcohol cosumptio are particularly high. I the rate of hospital admissio amog Idigeous males for coditios related to high levels of alcohol use was betwee two ad seve times greater tha for o- Idigeous males. Such coditios iclude acute alcohol itoxicatio, alcoholic liver disease, harmful use ad alcohol depedece. I additio, betwee 1999 ad 2003 about 71% of Idigeous homicides occurred i situatios where both the perpetrator ad victim were drikig (as opposed to 19% of o-idigeous homicides).[29] Other studies have show that the rates of death from wholly alcohol-caused coditios amog residets of Wester Australia, South Australia ad the Norther Territory are almost eight times greater for Idigeous males tha for o-idigeous males ad 16 times greater for Idigeous females tha for other females.[37] The level of alcohol-attributable death amog youg Idigeous Australias (15 24 years) has also bee show to be almost three times greater tha for their o-idigeous couterparts with the divergece betwee the two populatios apparetly icreasig i recet years.[38] 15

20 Youg Australias Rates of risky drikig i Australia peak amogst youg people,[2] ad alcoholrelated harm is substatial for both adolescets ad youg adults. Drikig cotributes to the three leadig causes of death amog adolescets uitetioal ijuries, homicide ad suicide alog with risk-takig behaviour, usafe sex choices, sexual coercio ad alcohol overdose.[18] A recet study of selfreported harm foud that drikers uder the age of 15 years are much more likely tha older drikers to experiece risky or atisocial behaviour coected with their drikig, ad the rates are also somewhat elevated amog drikers aged years.[39] Furthermore, iitiatio of alcohol use at a youg age may icrease the likelihood of egative physical ad metal health coditios, social problems ad alcohol depedece. Regular drikig i adolescece is a importat risk factor for the developmet of depedet ad risky patters of use i youg adulthood. Childhood ad adolescece are critical times for brai developmet ad the brai is more sesitive to alcohol-iduced damage durig these times, while beig less sesitive to cues that could moderate alcohol itake. Like adolescets, youg adults cotiue to be greater risk takers tha older adults, but their decisio-makig skills remai udeveloped factors that are reflected i the high levels of ijuries sustaied by this age group. Alcohol affects brai developmet i youg people; thus, drikig, particularly bige drikig, at ay time before brai developmet is complete (which is ot util aroud 25 years of age) may adversely affect later brai fuctio. I additio, youg adults are also the adult age group most likely to take mood-alterig drugs.[2] Treds i youth drikig are uclear, with either school survey data (ASSADS) or the Natioal Drug Strategy Household Survey (NDSHS) demostratig clear treds i drikig amogst adolescets or youg adults i the last decade. While a recet examiatio of Victoria data relatig to youg people aged betwee 12 ad 24 foud o clear tred i rates of risky drikig, it revealed that rates of hospitalisatio ad presetatio at emergecy departmets have icreased dramatically over recet years. The study suggests that the relatioship betwee survey-derived estimates of alcohol cosumptio ad rates of alcoholrelated harms is ot as clear-cut as expected, ad raises cocers about the sesitivity of populatio surveys i detectig chages i harmful drikig patters.[40] Drikig ca also lead to poorer outcomes for people who have a metal health coditio, whether it is a high-prevalece coditio such as depressio or a low-prevalece coditio such as schizophreia. There has bee little aalysis of the patters of cosumptio ad treds i alcohol-related dysfuctio or harm i older people i Australia. Older people are more vulerable to the effects of alcohol due to chages i their body compositio, decreased metabolic capacity, the presece of co-morbid coditios ad the medicatios that regulate these coditios. Older people express cocer about reduced perceptios of safety associated with public place drikig. Wome i the baby boomer age group, ow aged i their 50s to 70s, are more likely tha their parets to be alcohol cosumers ad it might be aticipated that this will produce a icrease i alcohol-related morbidity i their older years, but this is yet to be documeted. Certai occupatioal groups are also kow to regularly drik at risky/high-risk levels, especially tradespeople ad uskilled workers, ad those workig i the hospitality, agricultural ad miig idustries. 16

21 4. B est practice i prevetio 4.1 Curret activity Cosiderable activity aimig to prevet alcohol-related harm is curretly uder way i Australia. The extet to which the cosiderable prevetative desire ad activity (plaed or uder way) is likely to be effective, ad how well this activity reflects a evidece-based approach, is cosidered i the ext sectio of this paper. I geeral, the measures that are most ofte called for by commuity members ted to be the least effective, while the most effective measures are the least popular ad are thus probably the most difficult for govermets to itroduce, usually requirig strog leadership ad well-plaed implemetatio. What is prevetio i this area? The stated aim of Australia s curret Natioal Drug Strategy is to prevet the uptake ad miimise the harmful effects of drug use i Australia society. Kow as harm miimisatio, this approach has bee defied as ecompassig: Supply reductio strategies desiged to restrict the harmful supply of drugs Demad reductio strategies desiged to prevet the uptake of harmful drug use Harm reductio strategies to reduce drug-related harm for idividuals ad commuities. The approach of harm miimisatio, while complex ad requirig cotiuig support from public advocates, is based o scietific evidece ad uderpis the defiitio of prevetio adopted for the review of alcoholrelated itervetios i this paper. It ca ecompass uiversal as well as targeted itervetios (both selective: particular highrisk sub-populatios; ad idicated: those with emergig problems). Though ot explored i detail i this paper, the cocept of the prevetio paradox assists i uderstadig prevetio approaches i the areas of public health ad public safety. This approach suggests that more (et) harm may be preveted through uiversal itervetios focusig o the majority who are less seriously ivolved i harmful alcohol/drug use, rather tha through itervetios that oly target the smaller proportio of high-risk users. What works i alcoholrelated prevetio? The followig discussio is iformed by recet reviews of the available research evidece. This icludes: the World Health Orgaizatio s (WHO) iteratioal review of alcohol-related research ad public policy[13] a recet Australia research moograph o the prevetio of substace use, risk ad harm[7] a recet update of the latter, with a focus o prevetio itervetios targetig adolescets.[41] Other recet reviews have also bee draw upo, to a lesser extet, icludig Stockwell 2004,[42] Loxley et al. 2005[7, 43] ad NDRI 2007.[36] The coclusios reached i the WHO report[13] with regard to the respective stregths ad weakesses of differet types of itervetios, accordig to the available iteratioal research evidece, are summarised i Table 6. Icluded i this table are Australia-authored evaluatios of the equivalet itervetios provided by Loxley et al.[7] ad Toumbourou et al.[41] The scales used to rate the itervetios by the respective authors are summarised i Table 5 below. 17

22 Table 5: Key to the ratig scales show i Table 6 Ratig Evidece of effectiveess Breadth of research support Test across cultures Australia evaluatio 0 Lack of effectiveess No studies udertake Not tested Limited ivestigatio Limited effectiveess 1 well-desiged study completed Tested i 1 coutry Evidece for implemetatio Moderate effectiveess 2 4 studies completed Tested i 2 4 coutries Evidece for outcome effectiveess High degree of effectiveess 5+ studies completed Tested i 5+ coutries Evidece for effective dissemiatio? No evidece available N/A Warrats further research Evidece is cotra-idicative This ratig scale applies to the WHO s iteratioal review [13] ad Australia reviews.[14]. Of the 39 itervetios listed i Table 6, at least half of these are uiversal (targeted at the whole populatio) ad approximately half are targeted at high-risk groups. The iteratioal review by Babor et al. cocludes that itervetios targetig the whole populatio geerally have higher effectiveess ratigs ad are less costly to implemet ad maitai, o average, tha those targetig high-risk groups.[13] I geeral, the types of itervetios that are cosidered most effective accordig to the ratigs are, i order: 1. Regulatig physical availability. 2. Taxatio ad pricig. 3. Drik-drivig coutermeasures. 4. Treatmet ad early itervetio. The types of itervetios for which there is somewhat less evidece of effectiveess are, i order: 5. Alterig the drikig cotext 6. Regulatig promotio 7. Educatio ad persuasio There are differeces i the ratigs of some itervetios betwee the iteratioal review[13] ad the Australia review.[7] (for example, the treatmet of alcohol problems ad mass media campaigs). Also, importatly, it should be recogised that although the effectiveess of some itervetios do ot rate highly, i some cases this may be due to the limited research evidece that is available to iform the ratig (for example, advertisig cotet cotrols). 18

23 Table 6: Ratigs of policy-relevat strategies ad itervetios Strategy or itervetio Effectiveess Breadth of research Crosscultural testig Cost to implemet Regulatig physical availability Total ba o sales High Australia evaluatio Miimum legal purchase age Low Hours ad days of sale restrictios Low Restrictios o desity of outlets Low Staggered closig times for bars ad clubs Server liability Low Differet availability by alcohol stregth Low Taxatio ad pricig Alcohol taxes Low Hypothecated tax to pay for treatmet / prevetio Settig floor prices / baig discoutig Drik-drivig coutermeasures Sobriety checkpoits Moderate Radom breath testig Moderate Lowered BAC limits Low Admiistrative licece suspesio Moderate Low BAC for youg drivers Low Graduated licesig for ovice drivers Low Desigated drivers ad ride services 0 Moderate Igitio iterlocks Treatmet ad early itervetio Brief itervetio i primary health settigs Moderate Alcohol problems treatmet High Thiamie supplemetatio Workplace itervetios Mutual help/self-help attedace Low Madatory treatmet of repeat drik drivers Moderate Alterig the drikig cotext Bas o servig itoxicated persos Moderate Traiig staff to prevet itoxicatio / aggressio Moderate ( if ot eforced) Volutary codes of bar practice 0 Low ( if ot eforced) Eforcemet of o-premises regulatios ad laws High Promotig alcohol-free evets 0 High Commuity mobilisatio High Plastic or tempered-glass servig cotaiers Food service Regulatig promotio Advertisig bas? Low Advertisig cotet cotrols? Low Educatio ad persuasio Alcohol educatio i schools 0 High College studet educatio 0 High Paret educatio? Moderate Public service messages / Mass media campaigs Moderate Warig labels / Natioal drikig guidelies 0 Low Source: Adapted from Babor et al. (2003),[13] Loxley et al. (2004),[7] Toumbourou et al. (2007)[41] 19

24 4.2 Regulatig the physical availability of alcohol Regulatig physical availability refers to the accessibility or coveiece of the alcohol products, ad relates to policies that aim to prevet alcohol-related harm through cotrols o the coditio of sale to the driker as a retail customer.[13] I Australia, there has bee a recet review of the evidece for restrictig the sale ad supply of alcohol by the Natioal Drug Research Istitute.[36] While regulatio of the ecoomic availability of alcohol (i.e. the price of alcohol) is, curretly, exclusively a federal resposibility i Australia, via measures such as taxatio, the physical availability of alcohol is geerally regulated by state ad territory govermets, ad to a limited extet by local govermets. Restrictig the hours ad days of sale of alcohol is a stadard compoet of alcohol policy ad regulatio, ad there is a substatial body of iteratioal ad Australia work that has examied the impact of chages to tradig hours for licesed premises o levels of alcohol cosumptio ad rates of related harms. Most Australia studies have show that icreased tradig hours have bee accompaied by sigificatly icreased levels of alcohol cosumptio ad/or harms.[36] A recet Australia study by Chikritzhs ad Stockwell[44] foud that small extesios of tradig hours for licesed hotels i Perth, Wester Australia, sigificatly icreased the umbers of drikdriver road crashes. More specifically, this study demostrated that the relatioship betwee tradig hours ad icreased drik-driver road crashes was mediated by the quatity of alcohol purchases. The Natioal Drug Research Istitute (NDRI) reports that several studies have idicated that youg males ad regular heavy drikers are especially likely to take advatage of loger tradig hours.[36] Restrictios o desity of outlets ca be achieved by requirig miimum distaces betwee outlets or limitig the umber of outlets i a particular locatio. Liquor licesig systems or plaig cotrols ca potetially be used to limit the umber of places where alcohol ca be sold. I recet years i Australia there has bee a sigificat liberalisatio of licesig laws ad a correspodig growth i outlets, both oad off-premises. Recet research from three states,[45-49] has demostrated cosistet liks betwee the availability of alcohol i a regio ad the alcohol-related problems experieced there. I particular, these studies have liked rates of violece to desity of alcohol outlets. A logitudial study i Melboure has highlighted that chages i the umber of outlets i a area are directly related to chages i the rates of ight-time assaults occurrig there. The liks betwee outlet desity ad other outcomes are less clear cut, although some iteratioal evidece suggests higher outlet desity is related to higher rates of: risky alcohol cosumptio,[50] motor vehicle accidets,[51] risky sexual behaviour,[52] pedestria ijury,[53] child maltreatmet[54] ad eighbourhood ameity problems.[55] The results of this research are clear: liberalisig alcohol availability is likely to icrease alcohol-related problems. The results certaily call ito questio the geeral assumptio behid actios i recet decades that have bee made i accordace with Natioal Competitio Policy such as the state-led liberalisatio of liquor licesig regimes that the umber of a type of outlet should be determied by market demad for the product, without cosideratio of commuity ameity or impacts. Apart from issues of outlet desity, there is the questio of whether particular types of outlets or their desig ad locatio are particularly likely to cause problems. There is good evidece that certai premises cotribute disproportioately to problems,[32] highlightig the eed to further examie the types of outlets that are related to assaults. Further data, such as alcohol sales, opeig hours, capacity ad veue style, could provide substatial isights ito how differet outlets cotribute to the effect of outlet desity o assault. 20

25 Growth i alcohol outlets While ot completely deregulated, liquor licesig laws ad regulatios i most jurisdictios have bee sigificatly relaxed over the past decade, geerally coicidig with the required reviews uder the Natioal Competitio Policy. Oe of the effects of this has bee a proliferatio i the umber of ew licesed premises i some jurisdictios (see Fig. 8). Alog with a icrease i the total umber of licesed premises, there has bee a icrease i the umbers of premises with exteded tradig hours, the umbers of liceces to sell packaged liquor (i.e. take away) ad over time, a icreased cocetratio of liceces held by just a few busiesses. Figure 8: Number of liquor liceces by year, Victoria, 1986 to 2006 Source: Cosumer Affairs Victoria, upublished data Restrictig availability by alcohol stregth is kow to be a effective itervetio, both iteratioally ad i Australia. I Australia, it has bee estimated that full-stregth beer makes the largest sigle cotributio to all risky ad high-risk alcohol cosumptio (39%).[21] The Natioal Drug Research Istitute (NDRI) reports that studies that have examied the relatioship betwee alcoholic beverage type ad levels of alcohol-related harm have foud icreasig evidece that beer cosumptio is more commoly associated with drik-drivig. [36] The NDRI also observes that while most studies idetify wie as a comparatively low-risk beverage, a study by Stockwell et al. (1998) [56] foud that certai types of wie that offer high alcohol cotet at a relatively low price were strogly associated with hospitalisatios for alcohol-related road ijuries, falls, assaults ad suicides. Some small regioal or remote commuities i Australia, with relatively large Idigeous populatios, have itroduced sales bas o cask wie ad cask fortified wie. Accordig to the NDRI,[36] evaluatios of some of these bas show that such restrictios ca result i reduced alcohol-related harm i the commuities where the bas exist. The issue of the server liability for ijuries to itoxicated people or third parties affected by the actios of a perso affected by alcohol is a complex ad cotroversial area of the law. [57] I the US, Dram Shop laws ad court decisios uder commo law i may states allow people ijured through the actios of a itoxicated perso to recover damages from a licesee or licesed premises ower. Such licesees are, i most Dram Shop legislatio, also vicariously liable for their employees actios i servig a (itoxicated) patro.[57] Loxley et al. report[7] that studies show Dram Shop laws have a modest deterret effect, ad that the uderlyig ratioale for discouragig service of itoxicated persos is soud ad there is o likelihood of adverse cosequeces. A recet Australia review of the key aspects of law ad the implicatios of recet court decisios has reported that there is ow a less oerous duty of care imposed o licesees ad their staff with regard to the cosequeces of servig alcohol.[58] (See also the discussio of resposible service of alcohol (RSA) itervetios i Sectio 4.6 of this paper). Miimum legal purchase age refers to the age at which alcohol ca actually be purchased by a perso. This is distict from the age at which alcohol ca be cosumed, sometimes referred to as the legal drikig age. 21

26 The distictio is importat because while all state ad territory laws i Australia prohibit a mior from purchasig alcohol, they do ot ecessarily prohibit cosumptio i certai circumstaces. Babor et al. emphasise that cosistet eforcemet of laws regardig purchase age is critical if reduced alcohol cosumptio ad related harm amog youg people is to be achieved.[13] Although the miimum legal purchase age for alcohol i all Australia jurisdictios is 18 years, the average age at which Australias have their first full serve of alcohol is 17 years, ad as detailed earlier i this paper, there is a high prevalece of uderage drikig that has ot chaged sigificatly i the past 20 years. I the US, where the miimum legal purchase age for some time raged betwee 18 ad 21 years, several studies have foud that icreasig the age limit is a effective meas of reducig road crash death ad ijury amog teeagers ad youg adults. The NDRI reports[36] that some studies have also foud that the higher legal miimum drikig age is associated with reductios i alcohol cosumptio amog youg people. There is, therefore, some evidece that raisig the purchase age to 21 ca reduce teeage drikig, as well as harms. Kypri s accout[59] of recet attempts to icrease the miimum purchase age i New Zealad to 20 demostrated that popular debate coviced a majority of the public that raisig the age would be a appropriate way to reduce youg people s harm from drikig. Toumbourou et al. here i Australia have recommeded that a first step i this directio would be better moitorig of alcohol-related developmetal harms usig logitudial ad other developmetal research.[41] It must be ackowledged that cosumptio of alcohol by childre ad adolescets i the home ad i certai social settigs is ofte sactioed by parets, ofte i the belief that it is relatively harmless or might be helpful i educatig youg people about alcohol.[60] The majority of youg Australias who report drikig at home also report parets as beig the primary suppliers of their alcohol.[61] I New South Wales, it is ow a offece to supply alcohol to miors i a private home without the direct approval of a paret or guardia. This has ofte bee referred to as the NSW secodary supply law. While the impact of this law o youth drikig is ot yet kow, legislatio of this kid has bee welcomed by advocates agaist alcohol-related harm ad there is curretly cosiderable lobbyig of govermet to support the itroductio of similar laws i other Australia jurisdictios.[60] Aother example of restrictios o the physical availability of alcohol, which is kow to be effective i reducig alcohol-related harm i some Australia Idigeous commuities, is referred to as dry commuity declaratios. [36] Some remote Idigeous commuities i Wester Australia, the Norther Territory ad South Australia have declared themselves dry, usig provisios of state/territory legislatio. The key elemet of such dry area declaratios is a combiatio of Idigeous commuity cotrol ad statutory authority, alog with police eforcemet for esurig that dry commuity declaratios reach their potetial. Evidece suggests that although there are shortcomigs (for example, sly groggig) ad associated costs to this approach, overall there are reductios i cosumptio ad alcohol-related harm. It should be oted that dry commuity declaratios are distict from local dry area alcohol bas, as the latter relate to restrictios o drikig i desigated public places ad are usually imposed where there are high rates of alcohol-related public disorder.[36] While local dry area bas have bee foud to decrease public order problems i desigated areas, overall it is ot yet fully kow if they reduce public order offeces, alcohol-related hospitalisatios or police detetios of itoxicated persos. Ofte dry area restrictios simply displace drikers to other areas where there are o, or fewer, restrictios, ad dry area declaratios are ofte see as iheretly discrimiatory because of the egative impacts o Idigeous people already at risk of alcohol problems.[36] 22

27 Curretly receivig cosiderable attetio i some Australia jurisdictios are measures related to restrictig the hours of sale of alcohol, kow as lockouts. These do ot restrict tradig hours per se, however, because outlets are permitted to cotiue tradig util their usual closig times. However, after a certai time, such as 2:00am or 3:00am, ew patros ad those wishig to re-eter the premises are ot permitted to do so. Lockouts aim to reduce the movemet of people betwee clubs after a certai time, sice it is this movemet of people betwee veues that police have reported as beig a major cause of alcohol-related icidets late at ight. There are examples of lockout programs i operatio i locatios throughout Australia, such as i Ballarat ad Bedigo i Victoria, ad across Queeslad, where a 3.00am lockout ow applies to all late-ight licesed premises. The Victoria govermet has also trialled a 2.00am lockout throughout four ier-city muicipalities of Melboure. The NDRI reports[36] that, as yet, there is limited formal evidece of the effectiveess of lockout programs, i part because they ofte occur as oe elemet withi a rage of programs aimed at reducig late-ight alcohol-related problems (for example, CCTV cameras, street lightig, public trasport, police presece). While they are ot usually focused solely o issues that relate to the physical availability of alcohol, commuity-based prevetio programs have become icreasigly popular i recet years because of emergig uderstadigs of how evirometal ad social coditios cotribute to alcohol problems.[7] A detailed discussio o the rage ad scope effects of commuity based programs is ot provided here, but ca be obtaied elsewhere (see Loxley et al. 2007:[7] pp ). 4.3 Taxatio ad pricig The price of alcohol clearly impacts o cosumptio patters. There are more tha 50 studies from aroud the world showig that whe alcohol icreases i price, cosumptio is reduced.[12, 39-42] The World Health Orgaizatio (WHO) is oe of may iteratioal ad atioal health orgaisatios that strogly edorse the use of icreased alcohol taxatio (higher prices for alcohol products) as a effective prevetative strategy to reduce alcohol-related harm.[62] At the same time, it is importat to recogise that there is a complex relatioship betwee price ad cosumptio.[63, 64] Patters of alcohol cosumptio ca vary cosiderably accordig to idividual factors such as the age, sex ad icome levels of the driker. Other factors such as availability, the cultural settig, the marketig ad image of the product are also importat. Studies cosistetly show that lower socioecoomic groups ad people with limited disposable icome (youg people, Idigeous groups ad heavy drikers) are more directly impacted by the price of alcohol products. Higher icome drikers ted to drik more expesive alcohol, ad while price may lead them to reduce their cosumptio margially, they are also able to alter drikig prefereces to cheaper alteratives.[65, 66] The ature of the alcohol product is also a key variable. A Australia study idetified cosiderable variatios i price elasticity (the amout that price eeds to chage before it impacts o cosumptio) for differet alcohol products. It cocluded that spirits are twice as price sesitive as wie ad beer.[67] Give the complexity of the relatioship betwee alcohol price ad cosumptio, icreasig alcohol taxatio does ot ecessarily lead to a liear reductio i the levels of alcohol-related harm. It is importat that the relatioship betwee the price of idividual alcohol products ad cosumptio amogst particular groups of drikers is carefully modelled agaist kow price elasticity ad existig cosumptio patters. 23

28 While icreasig the price through taxatio is likely to lead to a reductio i per capita cosumptio, icreasig the price of idividual products may ot ecessarily achieve this goal. I some cases, product-based chages ca create opportuities for ew products ad drikig patters that icrease levels of harm. [68] I this cotext, it is importat to recogise that the productio costs of alcohol products vary cosiderably betwee product types (eg spirits are relatively iexpesive to maufacture compared to beer ad wie products) which i tur has a bearig o the cost price to cosumers. Australia s alcohol tax system ca best be uderstood as a costatly chagig reflectio of the history of alcohol cosumptio i Australia, ad the status of various alcohol products. It also reflects chagig powers of taxatio betwee state ad territory govermets ad the Australia Govermet. As a cosequece, differet products wie, spirits, beer, ciders, fortified wies are all taxed differetly. The excise duties arragemets ca geerally be described as a volumetric tax system, because the amout of excise duty depeds o the volume of alcohol cotaied i the particular product. Wie equalisatio tax ca be described as a ad valorem tax system, because the rate of tax depeds o the value of the retail sellig price of the particular product. Customs duties are a combiatio of both volumetric ad ad valorem systems. GST is set at a fixed rate of 10% of the product price, o top of all other taxes (see Table 7). Withi some categories there are various cocessios ad exceptios. Smaller wieries, for istace, are largely exempt from their value added tax (the Wie Equalisatio Tax) for all cellar door sales. Recet estimates show that the Australia Govermet will collect over $6 billio as a result of the productio ad cosumptio of alcohol durig the 2008/09 fiacial year.[68, 4] However, a substatial disparity exists betwee the amout of tax reveue received by the Australia Govermet from risky drikig compared with the overall amout spet i attemptig to prevet harmful cosumptio of alcohol. For example, it has bee estimated that Australia adolescets (aged years) spet approximately $217 millio o alcoholic beverages i 2002, ettig the Australia Govermet approximately $112 millio i tax reveue.[69] This meas that for every dollar spet o alcohol itervetios aimed at adolescets, the govermet receives aroud $7 i alcohol tax reveue.[69] The curret taxatio rates traslate ito a wide variety of taxatio per stadard drik of alcohol (see Fig. 13). For those who argue that alcohol should be taxed accordig to the amout of alcohol i each product ad cotaier, the curret system represets a massive distortio of this priciple. Table 7: Summary of the types of alcohol taxes applied by category of alcohol product Beer Spirits & RTDs Wie Cider GST Yes Yes Yes Yes Excise duty Yes Yes No No WET No No Yes Yes Customs duty (ad valorem) No Yes (imported) Yes (imported) No Customs duty (volumetric) Yes (imported) Yes (imported) No No 24

29 $1.00 $0.90 $0.81 $0.87 $0.87 Excise or WET payable per stadard drik: $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 beer o tap Cask Wie Port, Sherry Mid stregth beer o tap Packaged light beer Bottled Wie 1 Full stregth beer o tap Packaged mid stregth beer Packaged full stregth beer Bottled Wie 2 Brady Pre-mixed spirits / RTDs Whistky, Rum, Vodka, Liqueurs Typical ABV: Figure 13: Tax payable per stadard drik* of alcohol, various products, Australia, as at 1 August 2008* Note: *Icludes a 1.15% ABV excise-free cocessio for beer. WET payable per stadard drik of wie is based o a four-litre cask of wie sellig for $13 (icl. GST) [ Cask Wie ], a 750ml bottle of wie sellig for $15 (icl. GST) [ Bottled Wie 1 ], a 750ml bottle of wie sellig for $30 (icl. GST) [ Bottled Wie 2 ] ad a 750ml bottle of port sellig for $13 (icl. GST) [ Port, Sherry ]. A stadard drik is equal to litres or 10 grams of pure alcohol. As oted above, Australia has bee through a cotiuous process of chage i relatio to the taxatio ad pricig of various alcohol products. There are three chages that are particularly iterestig to ote. I the late 1980s, states ad territories adopted various forms of licesig for all alcohol sales. As part of this system, most jurisdictios offered low-alcohol beer (less tha 3.5% alcohol by volume) for a sigificat cocessio i fees. The licese fee cocessio traslated ito cheaper lowalcohol beer ad, i combiatio with itese market competitio i the beer market ad the itroductio of harm-reductio measures such as radom breath testig, created a ideal eviromet for low-alcohol beer. Producers recogised the beefit of ivestig cosiderable developmetal ad marketig ivestmet ito low-alcohol beer. As a cosequece, low-alcohol beer icreased its sales very sigificatly ad captured approximately 20% of the total Australia beer market.[70] The Norther Territory s Livig with Alcohol program provides aother example of how chages i price through govermet taxatio icreases cotributed to a reductio i per capita cosumptio. I 1992, the Norther Territory govermet used a hypothecatio approach by placig a levy of 5 cets per stadard drik o the sale of alcohol products with more tha 3% alcohol by volume ad used the reveue to fud a rage of alcohol-prevetio measures i the territory. [71] Evaluatios of the Livig with Alcohol program foud that the icrease i price had cotributed to a major reductio i the level of alcohol-related harm withi the Norther Territory.[72, 73] Over the last 15 years, there have bee a series of chages i the level of excise ad taxatio applied to various forms of the ready to drik (RTD) product segmet of the Australia alcohol market. 25

30 These chages have resulted i major shifts i drikig patters across Australia, particularly i relatio to brow spirit pre-mixed driks (mostly aroud 5% alcohol by volume i 375ml cas) ad white spirit pre-mixed bottled driks (mostly aroud 5% alcohol by volume i 375ml bottles). With each price chage, sales of these RTDs have icreased or decreased quite sigificatly. While there is cosiderable evidece that these icreases ad decreases i sales represet shifts i product prefereces (market share) rather tha shifts i per capita drikig, the patters of cosumptio have clearly bee directly iflueced by taxatio ad pricig. There is substative evidece that the higher the price, the lower the cosumptio of these products, ad the lower the price, the higher the cosumptio of these products. Perhaps just as importatly, the shifts i cosumptio patters are more marked amogst the youg ad lower social-ecoomic groups.[2, 68, 74] The priciple of alcohol taxatio reform most ofte discussed by public health advocates is usually that of applyig excise taxes to all categories of alcoholic beverages. That is, taxig the beverages o their alcohol cotet, as a mild discouragemet of cosumptio. Alog with taxatio reform of this kid, there have bee calls to raise the price of the cheapest forms of alcohol. This is referred to as the floor price of alcohol. Give that price is beig used as the lever, it is the floor price that should be give more attetio i order to achieve a real shift i per capita cosumptio, rather tha just product preferece. Withi this cotext, it is importat to ackowledge that the impact of ay icrease i the floor price for alcohol will impact more o youg people, Idigeous commuities, heavy drikers ad lower socio-ecoomic groups. It appears that the most likely model that ca effectively reduce alcohol-related harm would be based o a across-the-board excise model that also icludes regulatig the floor (miimum) price, especially with regard to small cotaiers. The excise tax could be scaled withi differet product types to esure there were strog fiacial icetives for the productio of lower alcohol products (for example, low-stregth beer, wie ad RTDs), ad so that the highest-risk alcohol products (i.e. spirits, which ca more easily cause overdose) are taxed at a appropriately higher rate. I combiatio with a volumetric taxatio system, i which all products are taxed accordig to alcohol cotet, all products could effectively have a floor price based o their alcohol cotet i a 300ml cotaier. Modellig this alcohol taxatio system would be a very challegig exercise, particularly whe health advocates have very limited access to actual sales data. As oted above, competig i the alcohol market requires extesive market testig ad moitorig. This geerates a level of detailed iformatio that is ot available to health researchers ad policy makers. Perhaps just as importatly, this model would have a egative impact o some segmets particularly cask wie ad cider while advatagig other market segmets spirits ad spirit-based RTD products. It would be very difficult to gai broad political support for such a model, give the level of public ad political oppositio from powerful alcohol producers. There has bee some modellig udertake that cosidered a rage of alcohol taxatio scearios that would move the alcohol excise ad taxatio system closer to a true volumetric base, while remaiig reveue eutral withi each market segmet. These models are publicly available, but have attracted limited support as they icrease the price of cask wie ad ciders while more expesive wies are reduced i price.[36] Util public health researchers ad advocates have access to accurate sales data, ad ecoomic modellig ca be implemeted o the combiatio of floor price ad a more volumetric approach to alcohol taxatio, it is difficult to strogly put forward a particular model. At the same time, there is a substative history i Australia that illustrates the dager of chagig taxatio levels of particular products without cosiderig the implicatios both o cosumptio patters ad the developmet ad marketig of alterative alcohol products. 26

31 4.4 Drik-drivig coutermeasures Drik-drivig laws ad the associated programs of eforcemet ad social marketig are cosidered to be oe of the great public health success stories of the late 20th cetury. I Australia, state ad territory laws allow a Blood Alcohol Cotet (BAC) of up to 0.05% while drivig for full licece holders, 0.00% for learer drivers ad 0.00 per to 0.02% for provisioal drivers, depedig o the state or territory. Those who operate commercial aircraft, public or heavy vehicles, commercial vessels, machiery ad mobile plat or farm equipmet must observe the BAC restrictios required by their employer, as well as those required by law. For most adults, drikig o more tha two stadard driks o a occasio will maitai their BAC below 0.05%. The evidece for the deterret effect of such laws is strog, although the effects ca erode over time ad hece some coutries have cotiued to lower BAC limits.[13] From the 1970s, Australia states world leaders i drivig dow rates of drik-drivig through radom breath tests ad other meas. There is some evidece, albeit tetative, that havig lower BAC limits for youg drivers reduces the risk of road fatalities, especially if the BAC limit is 0.00%.[7] More broadly, there is good evidece that lower BAC limits, delayed access to full licece ad curfews for youg drivers ca be effective i reducig drik drivig amog youg people; graduated licesig schemes ca potetially icorporate all of these measures withi a sigle system.[13] Radom breath testig (RBT) has bee show to be effective i several coutries, icludig Australia, i reducig road crashes, ijuries ad fatalities.[7] The defiig feature of RBT is that ay motorist at ay time may be required to take a breast test, ad there is othig they ca do to ifluece their chaces of beig tested.[13] Research suggests that there is a strog tedecy for motorists to comply with drik-drivig laws i jurisdictios that use RBT programs because of the ucertaity about the real risk of detectio.[13] Herei lies part of the impressive cost effectiveess of radom breath testig. RBT is cosidered a superior method of eforcig drik-drivig laws tha sobriety checkpoits, which oly check drivers who are judged to have bee drikig.[13] I Australia, creatig the public perceptio that there is a high chace of beig caught drik drivig through RBT has bee achieved by a combiatio of high-visibility policig (road blocks, booze buses ) ad frequet social marketig campaigs that emphasise the likelihood of drik drivers beig detected.[7] Amog the rage of puishmets for drik drivig, the pealty that appears to have had the most cosistet impact is licece suspesio.[13] Icreasig the severity of fies ad imposig pealties such as imprisomet for drik drivig have ot bee show to result i reduced rates of drik drivig or car accidets. [13] However, it is estimated that up to 70% of people who lose their licece cotiue to drive while ulicesed, as the risk of apprehesio is relatively low.[43] The major cocers with disqualified drivers cotiuig to drive are that it udermies the effectiveess of licece suspesio ad is also liked to a rage of other high-risk behaviour such as repeated drik drivig ad speedig.[43] Court diversio of drik drivers to educative ad madatory treatmet itervetios ad the icapacitatio of vehicles usig igitio iterlock devices are regarded as effective meas of icreasig compliace with licece suspesio ad reducig recidivism.[7, 13] While there is o evidece that o-premise desigated driver programs produce egative effects, the impact of such programs is very modest ad eve with cocerted promotios they oly produce a small positive effect.[13] A Australia review of these schemes was somewhat more supportive, poitig to research fidigs that the programs do have some positive ifluece o the behaviour of youg people i selectig a sober driver, ad that give the cost of such programs is usually bore by licesed premises, there is o opportuity cost i recommedig such schemes.[7] 27

32 4.5 Treatmet ad early itervetio This paper cosiders treatmet ad early itervetio as essetial compoets of a prevetative approach to the harmful cosumptio of alcohol. While treatmet ad prevetio are traditioally viewed as separate ad sometimes urelated activities, it is critical that they be embraced as part of a holistic approach to tacklig alcohol problems from a public health perspective. While treatmets are primarily desiged to serve the eeds of idividuals, there are a umber of ways that treatmet ca also have a positive impact at a whole-of-populatio level: By raisig public awareess of alcohol problems Ifluecig atioal ad commuity agedas Ivolvig health professioals i advocacy for prevetio Providig secodary beefits for families, employers ad road users.[13] Brief itervetios i primary health settigs. For early-stage alcohol problems, brief itervetios are cosistetly idetified as a key igrediet i a comprehesive alcohol-prevetio strategy because they are regarded as relatively iexpesive, they take very little time ad they ca be implemeted by a wide rage of health ad welfare professioals.[7] Their beefit as prevetative measures arises from the relative effectiveess i treatig early-stage problem drikig, obviatig the eed for later more itese ad costly treatmet.[43] Brief itervetios are desiged to motivate high-risk drikers to moderate their alcohol cosumptio, ad typically ivolve oe to three sessios before or soo after the oset of problem drikig.[13] I Australia, brief itervetios, as yet, are a relatively utapped opportuity, due i part to the eed for greater recogitio of the role that the primary health workforce ca play. [43] Efforts durig the 1980s ad early 1990s to itroduce more systematic screeig, early idetificatio ad potetially brief or exteded resposes were variously tried. These icluded the Coordiator of Alcohol ad Drug Educatio i Medical Schools (CADEMS) that supported curriculum developmet for udergraduate medical studets, a rage of Geeral Practice trials (especially i New South Wales, sometimes i associatio with other specific itervetios icludig tobacco ad eve efforts to develop a combied riskscreeig istrumet for a umber of coditios) ad studies of the use of screeig istrumets (especially AUDIT) i hospital settigs. Follow-up has bee patchy, ad eve where the uptake ad utility uder experimetal coditios was promisig, the loger term effort ad cost required to achieve widespread ivolvemet has ot bee sustaied. With a sese of déjà vu, the authors ote a recet study of the effectiveess of brief itervetios i hospital emergecy departmets, which suggests that these ca potetially reduce subsequet alcohol-related ijuries sigificatly.[75] For assessmets ad brief itervetios to become part of routie practice of doctors, urses ad other health professioals, a approach at the health system level accompaied by fudig ad promotio is eeded. It is urealistic to expect overstretched health service providers to implemet brief itervetios without reimbursemet or other recogitio. While this paper especially addresses primary prevetio, it is worth otig that there remais a serious lack of accessible ad available evidece-based treatmet services for later stage alcohol depedece ad other alcoholrelated disorders across Australia (i private ad public as well as i city ad remote locatios). With a still evolvig specialist cliical workforce, there remais a relative vacuum for traiig ad professioal developmet at seior cliical levels, ad it is this group that ultimately set the stadard ad ature of practice i ay field. A commet from a seior cliicia o the more recet developmet of Medicare support for private practice GPs ad cliical psychologists is pertiet: it meas that I get all these patiets treated uder the metal health items with fudametal alcohol-related problems where alcohol was ot properly maaged. 28

33 Workplace itervetios. Australia workplaces are aother settig with great potetial for brief itervetios with at risk drikers. There are two mai ratioales for workplace itervetios with regard to the harmful cosumptio of alcohol: to improve productivity; ad to improve workplace safety.[7] I the Australia cotext, approaches to workplace alcohol issues are iflueced by occupatioal health ad safety laws ad polices, ad devisig prevetio strategies must be cosidered i this cotext. Historically, alcohol problems i the workplace have bee dealt with through employee assistace programs (EAPs) ad employers policies o alcohol ad drug use; however, there has bee isufficiet research to determie the effectiveess of EAPs i respodig to ad/or prevetig alcohol issues i the workplace.[7] Noetheless, EAPs do provide the potetial opportuity for itervetios that are kow to be effective, such as brief itervetios for high-risk drikers. A recet study of alcohol cosumptio by Australia workers ad the impact o abseteeism has poited to the eed for workplace educatio to ifluece youg employees attitudes ad behaviours regardig alcohol use.[76] The study also suggests that there is a eed to take a whole-of-workplace approach whe desigig ad implemetig prevetio strategies that target both problem drikers ad workers who drik at short-term risk levels, eve ifrequetly, because the latter have a elevated risk of alcohol-related workplace abseteeism.[76] Others have poited to the eed for addressig structural factors i the workplace as a more sustaiable prevetio measure, such as reducig stressful workig coditios that may lead to healthdamagig behaviour such as the harmful cosumptio of alcohol.[77] Alcohol problem treatmet. Iteratioally, ad particularly i Australia, the evidece base with regard to the treatmet of alcohol problems is very well developed ad is ow at the stage of determiig what is best practice rather tha attemptig to determie if treatmet ca work.[7] Effective alcohol treatmet optios iclude motivatioal iterviewig, brief itervetios, social skills traiig, commuity reiforcemet approach, relapse prevetio ad some aversio therapies.[7] There is evidece that mutual help programs such as 12-Step Facilitatio Therapy, which ecourages attedace at Alcoholics Aoymous (AA) meetigs, are particularly effective for severely depedet drikers with low levels of social support.[7] Although popular ad widely used, there are also treatmets that have little evidece of efficacy, icludig isight-orietated psychotherapy, cofrotatio cousellig, relaxatio traiig, geeral alcoholism cousellig, educatio ad milieu therapy.[7] Pharmacotherapies for alcohol depedece iclude disulfiram, altrexoe ad acamprosate. Reviews have foud that altrexoe ad acamprosate are the safest ad most effective of the three pharmacotherapies i the log ad itermediate terms, respectively.[7] Thiamie supplemetatio. A uique prevetative measure to address the risk of serious brai damage from thiamie deficiecy (kow as Wericke-Korsakoff s sydrome) that ca result from heavy cosumptio of alcohol over may years, alog with poor utritio, is thiamie supplemetatio. Sice 1991, all bakig flour i Australia has bee supplemeted with thiamie as a uiversal method to icrease thiamie levels i the diet of at risk populatios.[7] This is icluded here as a example of a prevetative measure that requires ogoig cosideratio, as there has sice bee advocacy for the removal of supplemets (icludig thiamie) by the pure food advocates ad there is cocer that the reach of thiamie i bakers flour might ot be the most cost-effective populatio measure i prevetig this coditio.[78] Sice the 1980s, soberig-up cetres have bee established i may parts of Australia, particularly Idigeous commuities, as humae forms of care for publicly itoxicated idividuals, ad as a alterative to idividuals beig arrested ad held i police cells ad watch houses.[34] 29

34 However, there have bee very few evaluatios of soberig-up cetres, despite their popularity i Australia.[79] I may ways, soberig-up cetres fuctio primarily as a broad harmreductio measure, rather tha as a treatmet program. As Brady et al. describes them,[80] soberig-up cetres are ot a detoxificatio cetre, or are they aimed at log-term rehabilitatio; rather, their role is to keep people out of police custody to reduce alcoholrelated harm ad to offer practical care i a safe eviromet for a limited time, icludig protectio, shelter ad food. Nevertheless, they could provide a opportuity for itervetios that ca be effective. Sometimes related to these are ight patrols, which are a particularly commo alcohol harm-reductio strategy i may Idigeous commuities.[7] Night patrols provide trasport to safe locatios for itoxicated persos, particularly i remote areas.[7] Evaluatios of the effectiveess of ight patrols, o their ow, as a itervetio is somewhat equivocal, although they have bee rated as beig effective i commuities i reducig alcoholrelated violece ad gettig itoxicated people off the streets.[7] 4.6 Alterig the drikig cotext Because drikig takes place i a social, cultural ad commuity cotext, it follows that the harmful cosumptio of alcohol or the harmful cosequeces of this may be preveted or ameliorated though strategies that modify this cotext.[13] Such harmreductio measures are importat elemets of a overall alcohol policy, as they are geerally more socially ad politically palatable. However, harm-reductio measures should ot be cosidered as a equal substitute for the measures kow to be most effective, as measures that aim to alter the drikig cotext are comparatively uder-evaluated ad geerally possess less potetial for reducig alcohol-related harm.[13] It is clear that effective law eforcemet is the key igrediet to esure the efficacy of strategies that aim to alter drikig cotexts as a way of prevetig the harmful cosumptio of alcohol. While all Australia jurisdictios do have bas o servig itoxicated persos ad uderage persos, it is the extet to which these laws are adequately eforced that determies their effectiveess. Similarly, although very popular, the effectiveess of resposible service of alcohol (RSA) programs (also referred to as resposible beverage service, RBS) is also cotiget o proper eforcemet.[36] Without cocerted efforts by police ad/or liquor licesig authorities to eforce existig liquor laws, the impositio of RSA policies ad/ or traiig, while potetially raisig awareess of relevat issues, has limited impact o the behaviour of servers or itoxicatio levels of patros.[36] Whe highly publicised, the threat of substatial fiacial pealty has bee show to be particularly effective at motivatig behaviour chage amog licesees, which has i tur resulted i reduced levels of alcoholrelated harms, but it is ot clear whether such fiacial pealties remai effective i the log term without frequet ad highly visible examples of eforcemet.[36] There is evidece of RSA programs beig effective whe they iclude a madatory compoet combied with effective eforcemet.[13] While madatory server traiig has led to a icrease i the umber of servers udertakig traiig, program quality ad cotet differ sigificatly betwee jurisdictios, ad the high mobility of the workforce makes it difficult to sustai ad moitor. Mosher et al. assessed traiig programs offered by states ad territories that have either madatory or icetive-based laws, ad foud that the quality of programs is geerally low, with oly two jurisdictios meetig miimum stadards.[81] A further criticism of RSA traiig programs has bee that they focus solely o traiig servers, ad do ot iclude a more comprehesive commuity pla to address wider evirometal issues, a factor that limits their potetial.[82] To date, oly a limited 30

35 umber of RSA traiig programs have bee evaluated i Australia.[36] I additio to traiig bar staff i the resposible service of alcohol, there have also bee programs desiged to trai staff i maagig aggressive behaviour, give the reality that some patros may have become already itoxicated elsewhere ad that some aggressive behaviour may ot be ecessarily alcohol-related at all.[13] There have bee very few evaluatios of such programs, although there is evidece that they ca improve staff ad patro iteractios geerally, but the log-term sustaiability of these improvemets relies o maitaiig traiig ad stadards of practice.[13] Proactive policig or itelligece-led policig has bee successful i some parts of the world ad has bee partially adopted i some Australia jurisdictios.[13] It ivolves moitorig alcohol-related icidets i ad aroud licesed premises, combied with regular police visits to the licesed premises that are most ofte liked to alcohol problems. For example, the New South Wales police have adopted a system of eforcig liquor laws through the collectio of data such as feedback to police about alcohol-related crimes that have followed drikig at a specific licesed premises.[83] Kow as the Alcohol Likig Program, the itelligece-led eforcemet system has bee show to reduce alcohol-related crime, ad similar approaches are ow beig trialled ad implemeted i other jurisdictios. Volutary codes of bar practice typically take the form of liquor accords i Australia. The emergece of liquor accords as a meas of reducig alcohol-related problems i late-ight etertaimet cetres bega i Victoria i the early 1990s, ad sice the there has bee a rapid proliferatio throughout several states.[36] Accords are local, commuity-based iitiatives to ivolve licesees, other busiesses, local govermet authorities, commuity represetatives ad police, but which are implemeted ad largely coordiated by the latter to reduce alcohol-related harm i the late-ight drikig eviromet.[36] There are may possible compoets of accords, such as RSA, drik discoutig bas, traied security persoel, provisios of food, use of safe glassware ad alcohol cotaiers, ad evirometal modificatios to reduce coflict ad thereby reduce the risk of violece. [7] Few accords have bee formally evaluated, ad amog those that have, most have bee uable to demostrate effectiveess i either the short- or (particularly) log-term reductio of alcohol-related harms.[36] The appeal of accords probably rests more o the developmet of local commuicatio etworks, the facilitatio of local iput, a sese of local cotrol ad improvig public relatios through ope egotiatios tha i the actual reductio of harm. Eve so, improved commuicatio ad participatio may also be perceived as desirable ad worthwhile outcomes i some circumstaces. Loxley et al. ackowledge that there is o doubt that accords ca be a effective vehicle for itroducig some harm-reducig practices ito licesed drikig veues; however, it is recommeded that volutary regulatio such as this is accompaied by effective law eforcemet.[7] The promotio of alcohol-free evets, while popular i may coutries, icludig Australia, has ot bee foud o its ow to be effective i reducig alcohol problems.[36] Alcohol restrictios for large sportig ad leisure evets have usually bee implemeted as part of a rage of iitiatives, makig it difficult to determie their specific impact.[36] Based o evidece that some ijuries from alcohol-related violece were liked to the use of drikig glasses ad bottles as weapos, a umber of licesed premises aroud the world ow serve alcohol oly i tougheed glass or plastic cotaiers.[13] However, the soudess of this approach has bee called ito questio by a study that foud that ijuries to bar staff actually icreased whe tougheed glass was used.[13] Providig food service o premises that serve alcohol, as a way of ecouragig eatig while drikig ad hece reducig the effects of alcohol, is a popular elemet i liquor accords.[7] 31

36 However, the specific cotributio of makig food available o licesed premises as a way of prevetig itoxicatio has ot bee determied, ad i the case of certai foods (for example, salty sacks) there may actually be a risk of the opposite effect o alcohol cosumptio.[7] Commuity mobilisatio has bee used to raise awareess of problems associated with o-premises drikig, develop specific solutios to problems ad pressure licesees to take resposibility for some of the impacts o the local commuity, such as oise, litter ad atisocial behaviour.[13] There is o set formula by which commuity actio projects operate, as each project has differig aims ad objectives, ofte i respose to localised problems.[36] Studies overseas support the view that whe commuity mobilisatios are implemeted as comprehesive, evidece-based strategies ad are well fuded, they ca ifluece server behaviour, drikig behaviour ad levels of alcohol-related harms associated with licesed premises.[36] Although some relatively small commuity mobilisatio projects are curretly uder way i Australia, results from evaluative studies are yet to be published.[36] I geeral, commuity mobilisatio approaches have at least a temporary effect o licesed premises i terms of servig practices ad patro behaviour but i the loger term they ofte ted ot to be implemeted i a systematic way, ad prove to be expesive ad difficult to sustai.[13] 4.7 Regulatig promotio Alcohol marketig ad promotio is a global activity, with the largest corporatios promotig their products across the world.[13] Marketig strategies iclude a itegrated mix of advertisig o televisio, radio, prit media, poit of sale promotios, product desig (icludig the packagig ad amig of alcohol beverages) ad the iteret. Sposorship of sports ad cultural evets is also a commo marketig strategy used by alcohol compaies, particularly i Australia. The key questios from a public perspective are: what is the impact of marketig ad promotio o overall cosumptio ad particularly the misuse of alcohol i the commuity? what are the most effective measures for prevetig the adverse impacts of alcohol marketig ad promotio? Total alcohol advertisig expediture i Australia i 2007 was reported to be $128 millio (see Table 8). However, this figure is highly coservative, give that it geerally relates to the advertisig of products rather tha of alcohol outlets, for which alcohol advertisig expediture is ow very sigificat. Nor does it iclude sposorship, below the lie advertisig or iteret advertisig, the latter beig a sigificat growth area i recet years. I Australia, the mai sectors i which alcohol advertig expediture occurs, ad through which the greatest exposure is achieved, are through commercial televisio advertisig (38%) ad outdoor advertisig (32%). Globalised alcohol maufacturers (for example, Diageo; Perod Ricard Pacific) are amog the biggest spedig advertisers i Australia. The amout spet o advertisig by spirits ad wie producers combied, ow equals that of the traditioally domiat beer market i Australia, reflectig a icreasigly competitive alcohol beverage market. 32

37 Table 8: Alcohol advertisig i Australia by sector, advertiser ad beverage category, 2007 Sector Percetage share Rak Advertiser $ millios Aual chage Beverage category Percetage share Metro TV 33% 1 Diageo % Beer 47% Regioal TV 5% 2 Carlto & Uited % Spirits 26% Beverages Metro press 5% 3 Tooheys Brewery % Wie 21% Regioal 1% 4 Boag J & So % Premix / 6% press cider Magazies 14% 5 Perod Ricard % Pacific Radio 5% 6 Beriger Blass Wie % Estates Ciema 5% 7 Southcorp Wies % Outdoor 32% 8 Sutory % Direct mail 1% 9 Carlto Special % Beverages 10 Heieke % Others ot i top % Source: Nielse Media Research AdEx 2008 The impact of advertisig o idividuals ca be see as havig both immediate effects, such as ifluecig decisio makig with regard to brad preferece, as well as loger term effects such as reiforcig pro-drikig messages.[13] I this way, it is both the cotet ad frequecy of exposure to advertisig that ca have a impact o idividuals attitudes ad behaviours. The impact of alcohol advertisig o youg people is a area where there has bee cosiderable research, but of somewhat poor quality, yieldig coflictig results that rage from positive associatios betwee youg people who have bee exposed to ad/or ejoy alcohol advertisig ad a icreased risk of harmful cosumptio of alcohol, to egative associatios or icoclusive results.[7] Numerous studies have foud a lik betwee alcohol advertisig ad alcohol-related kowledge, beliefs ad itetios of youg people.[84] Ulike tobacco advertisig, which was baed i Australia i 1995, there are o alcohol advertisig bas i Australia, although some restrictios, icludig advertisig cotet cotrols, do apply (see further below). I Australia, alcohol advertisig is subject to a umber of differet laws ad codes of practice. The Australia Associatio of Natioal Advertisers Code of Ethics covers geeral advertisig issues. Other applicable laws ad codes iclude: The Trade Practices Act State ad territory fair tradig legislatio The Commercial Televisio Idustry Code of Practice The Commercial Radio Code of Practice The Outdoor Advertisig Code of Ethics. The Commercial Televisio Idustry Code of Practice states that advertisemets ca oly be show durig M, MA or AV classificatio periods. However, o weekeds ad public holidays, alcohol advertisemets ca be show as a accompaimet to the live broadcast of a sportig evet. Alcohol advertisig is covered i detail by the Alcohol Beverages Advertisig Code (ABAC) Scheme. The mai aims of the scheme are to esure that alcohol advertisig presets a resposible approach to drikig, ad does ot have appeal to childre or adolescets. Amog other rules i the code, the admiistratio of the followig is ofte questioed by commuity members: Advertisemets for alcohol beverages must ot depict the cosumptio or presece of alcohol 33

38 beverages as a cause of or cotributig to the achievemet of persoal, busiess, social, sportig, sexual or other success (ABAC 2008, Clause C (i)).[85] The ABAC Scheme is fuded ad admiistered etirely by the alcohol idustry. Commowealth ad state ad territory govermets are ivolved through oe govermet represetative o the ABAC Maagemet Committee. Despite the ABAC Scheme s rules, which discourage advertisig that has strog or evidet appeal to childre or adolescets, research shows that a substatial amout of alcohol advertisig is commuicated to youg people. For example, several advertisemets for alcoholic beverages screeed o televisio i metropolita Melboure were foud to be more likely to reach 13- to 17-year-olds tha adults (see Table 9). Table 9: Advertisig o metro Melboure televisio, year to March 2005 said or show. It is estimated that oly 3% of the total adult populatio are aware of the existig ABAC scheme ad kow what it relates to.[87] Amog the 30% of people who reported beig cocered about ay alcohol advertisig, oly 2% had made a formal complait. Some of the reasos why those who were cocered did ot make a complait icluded the belief that it would ot achieve aythig (30%), ot havig time (25%) ad ot kowig who/how/ where to complai (15%). ABAC curretly has o powers to sactio advertisers who breach the code rules; however, a Seate Committee iquiry curretly uder way is cosiderig proposed federal legislatio that would itroduce sactios o advertisers who breach the code, which would be determied by a idepedet adjudicatig pael.[88] I 2003, the Miisterial Coucil o Drug Strategy cosidered a report o the effectiveess of the ABAC Scheme that idetified the followig issues of cocer: Product Heieke Lager Cougar Bourbo Archers Spri Schapps Budaberg Rum Dry & Lime Mix Orlado Jacobs Creek Sparklig Rose Total aual sped Source: Kig, Taylor ad Carroll (2005)[86] Frequecy of ads Relative exposure (of years-olds Vs year-olds) $ 94, $ 45, $ 57, $ 36, $ 89, As a self-regulatory scheme, ABAC s effectiveess largely depeds o the idepedece of its complaits body with the powers to sactio.[43] Recet research has revealed that less tha three i 10 (28%) people surveyed reported a awareess of restrictios or regulatios coverig the advertisig of alcohol, i terms of what ca be The curret system does ot address public health cocers about alcohol advertisig ad use. I particular, most complaits about alcohol advertisig are dealt with uder the geeral advertisig complaits resolutio system rather tha the alcoholspecific system. The high dismissal rate for complaits about alcohol advertisemets heard by the ASB does ot egeder commuity cofidece i the complait system ad may discourage people from makig complaits about alcohol advertisemets. The geeral public is largely uaware of the complait resolutio system ad, i particular, how to make complaits. The system lacks trasparecy. I particular, there is isufficiet reportig of the outcomes of complaits. The curret system does ot apply to all forms of advertisig; for example, packagig, electroic advertisig, sposorships, poit of sale advertisig ad promotios. 34

39 The effectiveess of the curret system is compromised by the amout of time take to resolve complaits (MCDS 2003, upublished). While some of these cocers have bee addressed, pressure remais to move to a more tightly regulated advertisig eviromet with strict govermet cotrols. The WHO recetly recommeded that govermets be supported: to effectively regulate the marketig of alcoholic beverages, icludig effective regulatio or baig of advertisig ad of sposorship of cultural ad sports evets, i particular those that have a impact o youger people to desigate statutory agecies to be resposible for moitorig ad eforcemet of marketig regulatios to work together to explore establishig a mechaism to regulate the marketig of alcoholic beverages, icludig effective regulatio or baig of advertisig ad sposorship, at the global level. Oe of the most formidable obstacles to effective educatio ad persuasio strategies regardig alcohol (which are discussed i the ext sectio below) is product advertisig by the alcohol idustry that itetioally promotes prodrikig messages to the geeral populatio, much of which also reaches youg people. I respose, the govermets of some coutries have sposored couter-advertisig programs. [13] These might iclude public services aoucemets, or warig messages withi actual product advertisemets. However, studies suggest that couter-advertisig usually has oly limited effectiveess, ofte because it is commuicated at low frequecies ad i poorer quality productios compared to alcohol beverage advertisig.[13] I cotrast, couter advertisig i the tobacco field is of prove effectiveess, primarily because i that cotext hard-hittig messages were possible (essetially that the tobacco idustry was ot i busiess for the cosumer s good). Couter advertisig may be a more politically realistic optio tha baig advertisig altogether, ad should be strogly supported from a public health perspective, but it is importat that its message ot be compromised. Although rare, there are examples of well-plaed ad implemeted couter-advertisig programs that have had some success, particularly i buildig support for public health-orieted alcohol cotrols,[13] ad there is very strog evidece from other public health areas such as tobacco about the value of such approaches. 4.8 Educatio ad persuasio Iteratioal reviews of educatio ad persuasio strategies suggest that eve with adequate resources, such approaches have limited potetial for success o their ow.[13] Part of the reaso for this is the couter effect of powerful forces that uderpi usafe ad uhealthy drikig cultures, such as the price, availability ad promotio of alcohol products. Recet Australia research for the developmet of a atioal alcohol social marketig iitiative reports that the challege for commuicatio is that itoxicatio is closely liked to alcohol per se. Whe we simply asked participats about their earliest memories i relatio to alcohol there was a overwhelmig tedecy to leap to their first druk experiece. Further, these experieces were recalled with a sese of pride ad ostalgia, eve though the stories ievitably ivolved some embarrassmet. [89] A key elemet to the success of social marketig i the public health area is effective itegratio with ad reiforcemet by other complemetary strategies.[7] For istace, the success of social marketig i promotig quittig smokig ad road safety, icludig ati-drik-drivig campaigs, is idicative that educatio ad persuasio strategies ca be effective whe coupled with other measures such as support services, chages to the eviromet, regulatio ad eforcemet. Throughout the world, alcohol educatio i schools is a eormously popular approach to addressig the issue of harmful cosumptio of alcohol amog youg people. The traditioal alcohol educatio programs that are based 35

40 o a iformatioal approach, while still very commo, have ot bee show to prevet or reduce the harmful cosumptio of alcohol by youg people, ad i some cases have actually bee couterproductive by stimulatig a iterest i drikig amog youg people.[13] I recet years, there has bee a shift towards ormative educatio, which aims to correct youg people s perceptios about their peers drikig ad thus de-ormalise the harmful cosumptio of alcohol.[13] While this makes ituitive sese, it has bee foud that such school-based educatioal itervetios, i geeral, produce oly modest results that are short-lived uless accompaied by ogoig booster sessios. Importatly, give there are cosiderable risks ivolved i school-based educatio, it has bee recommeded that ivestmet i such programs be accompaied by a proportioate ivestmet i evaluatio.[7] There are some examples of soud outcomes but these are relatively uusual. These geerally ivolve whole-of-commuity efforts ad they are usually associated with a close evaluatio that esures they are implemeted (with modificatios through feedback) as plaed. I Australia, these iclude the School Health ad Harm Reductio Project (SHAHRP) i Wester Australia[43] ad the Gatehouse Project i Victoria, whose primary target was reduced school bullyig but where the side beefit was a comparative reductio i the use of tobacco ad alcohol.[90] Related to alcohol educatio programs for school studets are paret educatio programs. While some reviews cite promisig sigs of effectiveess, i geeral there remais a lack of research to fully determie the value of such programs.[7] Low-risk drikig guidelies have bee adopted i may coutries, icludig Australia, to provide advice o the health risks ad beefits of drikig at various levels for the geeral adult populatio, ad for particular sub-groups. Despite their popularity, there is very little research that demostrates the effectiveess of guidelies.[13] However, guidelies do potetially fulfil a importat fuctio as supportig iformatio for other measures kow to be effective, such as brief itervetios i primary care, ad as the basis for health promotio messages ad social marketig campaigs. I Australia, the curret alcohol guidelies.[91] are uder review. New draft guidelies prepared for public cosultatio are due to be fialised ad released i late The ew draft guidelies have bee iformed by updated modellig o the health risks of drikig, which have produced ew estimates of the lifetime risks of alcohol-related harm. Emergig evidece also idicates that previous studies claimig the sigificat health beefits of alcohol cosumptio have teded to overestimate the effects. The cosultatio draft idicates the mai chages are expected to iclude a ew simplified, uiversal guidelie level for alcohol itake for both short-term ad log-term risks, a ew guidelie with special precautios for childre ad adolescets, ad a ew guidelie for pregat or breastfeedig wome.[18] Warig labels o alcohol products, while ot required i Australia, have a high level of public support. Evaluatios of alcohol warig labels are geerally limited to the US experiece, where labels were implemeted i While there is some evidece of effects o kowledge ad attitudes, there is o evidece that warig labels ifluece drikig behaviour.[92] By cotrast, the tobacco labellig experiece offers strog evidece that warig labels ca be effective, ot oly i icreasig iformatio ad chagig attitudes but also i chagig behaviour. These successes of tobacco warig labels suggest that alcohol warig labels should be graphic ad attetio-gettig, should occupy a cosiderable portio of the package surface, ad should ivolve rotatig ad chagig messages.[92] Perhaps most importatly, they should complemet ad be complemeted by a wider rage of strategies aimed at chagig drikig behaviour. 36

41 5. Policy imperatives 5.1 The state of alcohol policy i Australia A recet report by the WHO wars that the differece betwee good ad bad alcohol policy is ot a abstractio, but very ofte a matter of life ad death.[13] Noetheless, it is ackowledged iteratioally that alcohol policy is ofte the product of competig iterests, values ad ideologies, ad hece is ot always based etirely o scietific evidece.[13] More specifically, the cultural sigificace of alcohol i may societies, alog with its ecoomic importace ad the political ifluece wielded by the global ad domestic alcohol beverage idustries, create a hostile eviromet for public health polices, especially those aimed at reducig cosumptio overall as a way of prevetig ad reducig alcohol-related harm. While we ca see that it is politically ecessary to have collaborative ad cohesive alcohol policy where all iterested parties are icluded, this poses sigificat impedimets to the implemetatio of the most effective prevetative itervetios. Notwithstadig this, Australia has bee assessed as beig comparatively progressive ad amog the best i the world i terms of evidece-based alcohol policy.[93] I a recet commetary o atioal alcohol cotrol policies i 18 coutries, Babor ad Wistaley [94] report that cotrary to the geerally pessimistic reports about alcohol policies, the case of Australia provides cause for optimism. This assessmet probably speaks to the relative low level of well-itegrated policies globally, rather tha a opportuity for complacecy i Australia. Stockwell (2004:[42]) has judged that while there are some sigificat disappoitmets, there are also some woderful examples of successful Australia public policies aroud alcohol from the past two decades. Amog the populatio-wide strategies that have bee successful i reducig alcohol-related harm i Australia, Stockwell highlights taxatio ad drik-drivig legislatio/eforcemet. For high-risk groups, the compulsory fortificatio of bakers flour with thiamie ad liquor licesig restrictios i some Idigeous commuities are cosidered as successes. Amog the strategies ot likely to have bee effective, Stockwell poits to the dissemiatio of atioal drikig guidelies, the itroductio of stadard drik labellig o alcohol cotaiers, ad efforts to ecourage GPs to deliver brief itervetios ad advice about low-risk drikig. Stockwell also uderlies some sigificat setbacks i Australia alcohol policy, such as the relaxatio of liquor licesig laws, which has led to the proliferatio of outlets i may Australia jurisdictios; chages to the tax rate o wie, which has ecouraged the productio ad harmful cosumptio of cheap wie; ad, sice 1997, the iability of states ad territories i Australia to collect levies o the sale of alcohol products. The recet review of alcohol policies i 30 OECD atios rated Australia as fifth overall, behid Norway (1st), Polad, Icelad ad Swede.[93] The study rated the state of alcohol policy i each of the 30 coutries by creatig a composite score based o the extet to which the coutry had adopted polices i various policy domais such as the physical availability of alcohol, prices, drikig cotext, alcohol advertisig ad road safety. 37

42 The study also examied the relatioship betwee each coutry s score ad per capita alcohol cosumptio, ad foud a strog egative correlatio that implied a decrease i cosumptio of 1 litre of alcohol per year for each 10-poit icrease i the score. I other words, as alcohol policies icreased i stregth (i.e. effectiveess), alcohol cosumptio decreased. Sice the late 1980s, Australia has adopted several atioal strategies to tackle the harmful cosumptio of alcohol. Australia s first atioal alcohol strategy was completed i 1989 [95] followed by subsequet ieratios i 1996, [96] 2001, [97] ad most recetly i 2006.[6] If the success of these strategies is to be measured o the basis of ay chage i rates of overall per capita drikig, rates of adult bige drikig, rates of uderage drikig, ad outcomes such as hospitalisatios ad crime, the these strategies appear to have had oly modest success. Oe Australia commetator has said that while these documets provide the basis for a coheret ad legitimate atioal approach to alcohol there has bee poor follow-through o implemetatio.[98] A recet summary of the state of alcohol policy i Australia reported that what is eeded ow is ot so much a uderstadig of what works, but a appreciatio of how to make it work i the various cotexts i which it is implemeted [43] [emphasis added]. Essetially, eve the most effective strategies i the world will ot be effective if they are ot properly implemeted as iteded. 5.2 The best mix of itervetios While some itervetios are more effective tha others, there is o sigle strategy that ca offer a quick fix or silver bullet to the prevetio of harmful cosumptio of alcohol. The review udertake by Babor et al. (2003) [13] cocludes that a itegrated approach is required that icludes a combiatio of the strategies that are kow to be effective ad suitable for the particular cotext i which they are to be implemeted. The NDRI emphasises[36] that it is importat to cosider the quality, rather tha the quatity, of itervetios. For example, a sigle targeted restrictio (for example, hotel closig at midight) may be more effective tha a etire suite of half-heartedly implemeted, watered-dow or ill-cosidered restrictios.[36] Importatly, choosig high-quality itervetios does ot mea choosig the most expesive. I fact, may of the most effective strategies are the cheapest. A recet aalysis of studies ito the cost effectiveess of various alcohol-prevetio measures foud that there are very substatial differeces i costs ad effects, both betwee itervetios ad betwee world regios. See Table 10.[99] Radom breath testig (due to the eed for regular sobriety checkpoits admiistered by police) ad brief advice i primary care (the itervetio itself, plus costs associated with traiig) are the most costly itervetios to achieve equivalet savigs i years of health, expressed as disability-adjusted life years (DALYs) With regard to taxatio, cost effectiveess appears to deped i part o the efficiecy of the tax system ad the degree of ati-drikig setimet. I the Americas ad Europe, where like Australia, the prevalece of heavy drikig is high, taxatio was the most effective ad cost-efficiet strategy. However, by cotrast, tax is actually least effective ad least efficiet i South East Asia, where low rates of heavy drikig appear to favour more targeted approaches such as radom breath testig ad brief physicia advice.[99] 38

43 Table 10: Cost-effectiveess (average cost per DALY) of itervetios for reducig the burde of alcohol i three WHO sub-regios (at differet levels of ecoomic developmet) Itervetio Americas Europe South East Asia Brief physicia advice 776 2, Radom breath testig 1,919 2, Excise tax (curret) ,420 Excise tax (curret + 20%) ,414 Excise tax (curret + 50%) ,418 Reduced retail access 484 1,208 1,406 Comprehesive ad ba ,807 Source: Chisholm et al. (2006)[99] A more recet, Australia-based study has idetified the itervetios for which strog Australia or iteratioal evidece exists as to their potetial beefits, ad has attempted to evaluate these beefits i terms of the reductio i the social costs of alcohol-related harm it would be possible to achieve.[100] Itervetios idetified as beig effective ad for which beefits are quatifiable, iclude: Higher alcohol taxatio, icludig differetial tax rates o forms of alcohol that are particularly subject to abuse The study estimates that through the adoptio of these itervetios it would be possible to achieve a 48% reductio i alcohol-attributable deaths, alog with sigificat reductios i the social costs of alcohol-related harm. These iclude a $5.94 billio savig from higher alcohol taxatio, a $5.83 billio savig from brief itervetios, a $2.45 billio savig from partial advertisig ad marketig cotrols, ad a $0.94 billio savig from greater eforcemet of drik-drive laws. Partial or complete bas o the advertisig ad promotio of alcohol Measures to reduce drik drivig: more itesive eforcemet of radom breath testig ad lowerig the legal blood alcohol cocetratio (BAC) level Brief itervetios by primary care physicias to reduce hazardous alcohol cosumptio. 39

44 5.3 Challeges i implemetatio Australia s iteratioal score card i the area of alcohol policy appears to be quite impressive, as the reviews metioed above testify, ad may would argue that icremetal policy chage, rather tha radical approaches, is the most appropriate way to proceed. However, some have cautioed agaist takig comfort i this approach because of the cultural iertia surroudig alcohol policy i Australia, which ca be a formidable barrier to meaigful policy chages. Drikig forms part of the Australia leged, ad there is good precedet i Australia history to suggest that a radical alcohol reform ageda could provoke commuity backlash beware the wowser label.[98] A example of radical policy chage that has bee successful is the itroductio of radom breath testig, thaks i part to the accompayig social marketig campaigs that have highlighted both the seriousess of the problem ad the effectiveess of the policy respose. The level of public support i Australia for ew alcohol policy itervetios ad/or the extesio of existig itervetios is ecouragig i some areas (see Fig. 14); for example, the level of public support for measures kow to be effective, such as the strict moitorig of lateight licesed premises (75%), is relatively high. While support for measures such as icreasig tax o alcohol to pay for health, educatio ad the treatmet of alcohol-related problems is relatively lower (41%), it is a reasoably sufficiet base of public support o which to build through public educatio ad social marketig about the ratioale ad potetial beefits of such a measure. Figure 14. Support for alcohol measures, proportio of the populatio aged 14+ years, Australia, 2007 Source: AIHW 2008[2] 40

45 There are some specific challeges that go beyod public uderstadig ad attitudes. These have bee raised throughout this paper ad iclude: Natioal Competitio Policy, as it relates to liquor licesig systems, regulatig alcohol prices ad restrictig alcohol promotios The divisio of resposibilities betwee levels of govermets for key alcohol policy areas ad the historic complexity i achievig coordiated actio The ecoomic ad political importace, ad thus ifluece, of the alcohol beverage ad related idustries. These challeges arise i the cotext of broad, commuity-wide chages i the ature of work, educatio ad social coectedess, ad occur at a time whe: Alcohol sposorship of sportig ad cultural activities has replaced ad is ow promiet i may areas previously occupied by the tobacco idustry. Alcohol cosumptio is symbolically associated with positive ad pleasurable life i portrayals of Australia s history ad culture, icludig the ogoig promotio of alcohol as a ecessary igrediet of etertaimet, celebratio ad all rite of passage life course trasitios. The meu of psychoactive ad performace-ehacig substaces is icreasig i scope ad complexity withi a society that is ecouraged to focus o pleasure ad performace, ad where alcohol is see, comparatively, as the kow commodity ad thus uchallegeable (or at least acceptable). The debate regardig the positive health beefits of small doses of alcohol makes forthright messages for social marketig purposes awkward ad less memorable, ad where compromise is extracted i every effort to implemet effective alcohol harm prevetio measures. Itoxicated behaviour is regarded by may commuity members as ormal ad by may youg people as desirable. The sigificatly lower life expectacy of Idigeous people is itrisically liked to layered aetiology, icludig historic ad structural issues, social ad service exclusio, patters of alcohol cosumptio, where there is great sesitivity to progressig evidece-based approaches i some commuities ad where the cosequet immobilisatio ad iactio from the broader society is the most ready respose. There is a parallel dilemma of too much too fast, ad the possibility of eve greater broad dysfuctio if ot maaged carefully. Cosumer is a complex cocept i this field. It ca iclude both alcohol cosumers (who geerally seek liberal access to their favoured drug) ad service users who are very ofte extremely reluctat to seek help. Those who experiece the secod-had effects of harmful cosumptio of alcohol are a somewhat utapped group (icludig parets, who are the most idetifiable group, but extedig well beyod this sub-category). The extet ad level of detail of data available precludes the evaluatio of the outcomes of the icremetal ad plaed chages to the levers that ifluece alcohol-cosumptio patters, ad patters of related harm over the past decades, ad similarly make effective modellig or assessmet of the likely impact of future directed chages icomplete ad thus less reliable. 41

46 While there are few well-qualified specialists, there are may middlemaagig health ad welfare persoel implemetig itervetios that they sometimes have little faith i, ad the cocomitat low expectatios of success with patiets or cliets ca be self-fulfillig. I this cotext there is ow good evidece of what works ad we kow that treatmet, for example, ca be successful. Although may will agree with this statemet, few i the respodig idustry seem to believe it or lack the skills to utilise the most effective meas to achieve it. The views of commuity members ted to be closer to the alcohol beverage idustries preferred prevetative approaches, such as advocatig for measures icludig schoolbased alcohol educatio, the resposible service of alcohol traiig, paret support ad iformatio, ad educatio programs for specific target populatios o fetal alcohol effects. 5.4 Opportuities for actio Reflectig o the evidece regardig the determiats of harmful cosumptio of alcohol, as gleaed from the review of itervetios earlier i this paper, is perhaps a startig poit for cosiderig what the priorities for actio should be. I geeral: Whe alcohol availability icreases, alcohol-related harms are likely to icrease Whe alcohol availability decreases, alcohol-related harms are likely to decrease Whe alcohol prices decrease i real terms, alcohol-related harms are likely to icrease Whe alcohol prices icrease i real terms, alcohol-related harms are likely to decrease. I summary, chagig the physical ad ecoomic availability of alcohol is probably the most effective ad reliable way of reducig the harmful cosumptio of alcohol. As the NDRI (2007) suggests, where the ultimate aim of decisio makers is to miimise or reduce the egative impact of alcohol o the public health, safety ad ameity of a populatio, best practice is that which is evidece-based ad at very least, avoids implemetig chages likely to icrease overall availability above the curret status quo. Govermet decisio makig relatig to the availability i Australia, whether it be liquor licesig decisios or chages to the excise rates of particular alcohol products, teds to be reactioary. As a alterative, NDRI (2007) suggests that authorities ad decisio makers might cosider adoptig a pro-active style oe which ackowledges the liks betwee alcohol availability ad harms ad which plas accordigly. Optimally, such a approach would: iclude policy ad strategies based o soud research evidece for efficacy ad/or have a solid theoretical groudig; iclude processes which support the ogoig, systematic collectio of detailed objective data for moitorig ad evaluatio purposes; employ evaluatio fidigs to iform ad support future evidece-based decisios ad reliable moitorig of commuity setimet. Of course, supply reductio measures that restrict availability are ot the sigle solutio to addressig the harmful cosumptio of alcohol harm reductio ad demad reductio measures are also importat ad very ecessary. Maitaiig ad buildig o Australia s impressive track record i drik-drivig coutermeasures is a obvious elemet to iclude i a overall prevetative strategy, but it should ot be take for grated, especially give the powerful cultural forces surroudig alcohol i Australia that could udermie, stall or, worse still, reverse the gais made i prevetig ad reducig alcohol-related road ijuries ad fatalities. Brief itervetios are kow to be oe of the most effective prevetative measures ad more work is eeded to examie the most appropriate settig for such a approach. Alog with the usual health settigs cosidered, workplaces provide a widow of opportuity for reachig 42

47 thousads of Australias at the early stages of problematic drikig. This also opes a opportuity for ovel parterships. The success of prevetio i other areas of public health, such as tobacco cotrol, tells us that social marketig is a key elemet that is ecessary to iform target audieces, shift attitudes ad positively reiforce behaviour chages beig drive by other complemetary measures, such as restrictios o availability, regulatio ad eforcemet. 5.5 Priorities The itet of this paper has bee to provide backgroud iformatio about alcohol-related harm i Australia, ad summarise iteratioal best practice i alcohol-prevetio policies ad programs, rather tha to articulate a particular course of actio. However, some priorities for prevetative policies ad programs, ad for research, are most importat ad most urget, ad should be sigled out, because they represet a gap i curret practice or kowledge i Australia or because they would ehace ad/or iform existig ad ew practices. I the first istace, the major imperatives for Australia are to: 1. Reshape cosumer demad towards safer drikig through: Maagig both the physical availability (access) ad ecoomic availability (price). The high accessibility of alcohol i terms of outlet opeig hours, desity of alcohol outlets ad discoutig of alcohol products is a issue i may Australia commuities. Addressig the cultural place of alcohol. Carefully plaed, targeted ad research-based social marketig ad public educatio are required, ad will be more effective if the marketig of alcoholic beverages is restricted, icludig curbig advertisig ad sposorship of cultural ad sportig evets. 2. Reshape supply towards lower-risk products through: Chages to the curret taxatio regime to stimulate the productio ad cosumptio of low-alcohol products. Improved eforcemet of curret legislative ad regulatory measures (such as Resposible Servig of Alcohol or bas o servig itoxicated persos ad miors, or cotiuig to lower the blood alcohol cotet i drik-drivig laws). 3. Stregthe, skill ad support primary health care to help people i makig healthy choices: Supportig brief itervetios as part of routie practice by health professioals ad other health workers i primary healthcare settigs ca assist chages i drikig behaviour ad attitudes to alcohol cosumptio. This support should iclude cosideratio of buildig appropriate reimbursemets ad other icetives ito health system fudig. 4. Close the gap for disadvataged commuities: There is a eed for tailored approaches ad services to reach Idigeous ad other disadvataged groups. 5. Improve the evaluatio of itervetios through: Moitorig ad evaluatio of regulatory measures ad other programs to uderpi the further evolutio of prevetio strategies directed at iappropriate alcohol cosumptio. Developig effective models of safer patters of alcohol cosumptio i differet commuities through chages to alcohol taxatio arragemets, ad a uderstadig of the impact of differet types of alcohol outlets ad their desity o hospitalisatio, violece ad crime rates. 43

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