Alcohol Misuse Review Paper 2018 Part A
Primary Author and Academic Review: Professor John Toumbourou - Professor and Chair in Health Psychology at Deakin University; Honourary Senior Research Fellow at Murdoch Childrens Research Institute.
Although the specific nature of “alcohol misuse” is contentious, with various definitions proposed by various stakeholders, this resource is concerned specifically with alcohol misuse as it affects the broader community. “Alcohol misuse” is herein referring to use of alcohol which creates negative and preventable societal consequences, such as health costs, negatively impacting family relationships and parenting skills, harm to self or others, amongst other societal impacts which will be examined in greater detail below.
Strategic & Legislative Context
Liberalisation during the 1960’s
Alcohol liberalisation is recognised as a contributing factor to the increase in per capital alcohol consumption in Australia in the 1960s and the 1970s. Alcohol liberalisation refers to the loosening of government regulations, and this increase in the liberalisation of liquor licensing laws resulted in a rise in the number of liquor outlets in Australia and also extended opening hours of premises (Commonwealth of Australia, 2008). In addition, there was also an increase in the number of numbers of licences to sell take away alcohol (Hudson, 2011).
Public health strategies from the 1980’s such as publishing guidelines and taxing high alcohol beer
The steady decline in per capita alcohol consumption in the 1980’s is attributed to the implementation of Australian public health strategies relating to alcohol. In particular, the steady decline in per capita consumption of beer can be attributed to one specific Australian public health strategy that involved having lower taxes for low strength beers, as an incentive to drink these lower strength beers over standard beers (Nielson, 2006). The significant influence of this strategy is demonstrated by the decline in per capita consumption of beer since the implementation of this strategy, to the point that it is now at a level similar to that of the late 1950’s (Hudson, 2011).
The development and publication of the Australian Drinking Guidelines by the National Health and Medical Research Council (NHMRC) in 1986 is recognised as another Australian public health strategy that may have contributed to the decrease in alcohol consumption. These clear guidelines were developed to assist Australians to drink at levels that minimise the risk of harm by setting out a framework for decision making on the best available evidence about low risk patterns of alcohol consumption (Commonwealth of Australia, 2001). These drinking guidelines have advanced as new research and evidence has become available, with the latest guidelines having been issued in 2009 (ABS, 2002).
The development of the wine industry
Whilst the trends in per capita beer consumption have steadily declined over the past 50 years, per capita wine consumption has significantly increased during this same period of time (Hudson, 2011). The consumption of wine has increased almost fourfold since the late 1940’s (Hudson, 2011), and this can be attributed to the development of the wine industry, which was largely ignited by changes in consumer tastes towards wine and also the increase in availability in relatively cheap wine (Hudson, 2011). The expansion of the wine industry can also be attribute to the favourable tax regime for wine compared to beer and spirits. This has also encouraged consumption of cheap packaged wine and production of ‘alcopops’ wine based fruit drinks (Loxley, et al., 2004).
The real costs of wine have decreased since 1999 from $1 per glass to 90 cents per glass in 2008. This is contrasted to significant increases in real costs of beer and spirits over the same period making wine a very affordable choice. The overwhelming alcoholic drink of preference in Australia shifted considerably from 2001-2007, with bottled wine being highlighted as the beverage of preference in 2008 (Hudson, 2011).
The need to prevent and reduce alcohol-related harms experienced at an individual and community level, is a priority expressed throughout the Victorian State Strategic Planning Framework [Victorian Department of Health Priorities 2007-2012, Victoria’s Alcohol Action Plan 2008-2013, Victorian Liberal Nationals Coalition Plan for Liquor Licensing]. All liquor licences, with the exception of limited licences and licences to manufacture alcohol, must have both a planning permit and a liquor licence. Practice Note 61, Licensed premises: Assessing cumulative impact (State Government Victoria, 2011) provides local governments with guidelines on how to assess the potential cumulative impacts of an application for a planning permit for a licensed premise on safety and amenity.
Liquor licences are issued, regulated and monitored by the Victorian Commission for Gaming and Liquor Regulation. The primary legislation under which these activities take place is the Liquor Control Reform Act 1998.
Some local governments in Victoria have integrated planning policies into their planning schemes to provide guidance on measures to reduce the safety and amenity impacts of licensed premises on local communities. In addition, some local governments have developed alcohol management frameworks that describe best practice management and design strategies that focus on preventing and minimising alcohol-related harms, particularly in areas that have a high concentration of licensed premises that operate after hours, and those that sell alcohol for consumption off the premises.
Impacts and Outcomes
Health Costs of Alcohol Misuse
The abuse and misuse of alcohol is associated with a number of physical, cognitive and behavioural impacts which can have profound and long term impacts on individuals, families and the broader community. Alcohol is therefore second only to tobacco as a preventable cause of drug-related death and hospitalisation in Australia (AIHW, 2012). Alcohol is the causal factor in about 60 types of diseases and injuries, and a contributory cause in up to 200 others (AIHW, 2012).
As a result, alcohol abuse and misuse is increasingly being recognised as a serious health issue that needs to be addressed by all tiers of government and health care agencies. The consumption of alcohol is an intrinsic part of Australian culture, providing a range of social and economic benefits. Most Australians drink alcohol, generally for enjoyment, relaxation and sociability (NHMRC, 2009). However, recent scientific evidence presented in the Australian guidelines (NHMRC, 2009) suggests that any potential health benefits from consuming alcohol have been overestimated. Any benefits are mainly related to middle aged or older people and only occur with low-levels of alcohol intake of about half a standard drink per day, which is within the Australian guidelines (NHMRC, 2009).The Guidelines do not encourage people to take up drinking just to get health benefits.
The abuse and misuse of alcohol compromises the health and wellbeing of the individual drinker, people around the drinker and society at large. The volume, patterns and quality of alcohol consumed influences the incidence of chronic, infectious and acute conditions. Alcohol-attributable diseases include alcohol cirrhosis of the liver, cancer, epilepsy, ischaemic and cerebrovascular heart disease. Aside from the incidence of ill health, alcohol misuse contributes to other harms such as road injury, pedestrian road injury, assault, suicide and drowning.
Foetal Alcohol Spectrum Disorder
Foetal Alcohol Spectrum Disorders (FASD) is the leading preventable cause of non-genetic, developmental disability in Australia (FARE, 2013). It is caused by prenatal alcohol exposure, and can result in neuro-developmental disorders and birth defects, often associated with poor memory, impaired language and communication, poor impulse control, and mental, social and emotional delays.
The reasons for maternal consumption of alcohol during pregnancy are varied, and may include poverty, unemployment, abuse or family violence (Government of Canada, 2014). At present, strategies to prevent and address FASD in Australia are ad hoc and inconsistently funded. There are significant gaps in prevention, early intervention and management of FASD, with the result that health professionals are not equipped to screen for potential FASD and there are insufficient early intervention options for people with FASD.
People with mental health problems are at particular risk of experiencing problems relating to alcohol (Government of Australia, n.d.). There is evidence that alcohol increases the risk of highly prevalent mental health conditions such as depression and anxiety in some people, with around 37% of people who report problems with alcohol also having a co-occurring anxiety and or mood disorder (State Government of Victoria, 2012). The risk of having a mental illness is around four times higher for people who drink alcohol heavily than for people who don’t.
Harm to Others
Harm to others as a direct result of alcohol misuse include deaths, hospitalisations, child abuse and domestic violence. This harm may be experienced by co-workers, children, household members or strangers (WHO, 2014). Disease, death and injury related to alcohol consumption are linked to economic status. People experiencing lower socioeconomic status are at greater risk of alcohol-related health issues (WHO, 2014).
Crime and Safety
Alcohol abuse is also directly associated with a range of crime and safety issues such as road traffic accidents, falls, self-harm, prematurity and low birth weight, and violence (WHO, 2014). Impacts of binge drinking include public safety and amenity (violence, property damage, anti-social behaviour and perceptions of safety, which in turn lead to health issues such as road injuries, assaults, drowning, suicides, falls, fire and smoke injuries and sexually transmitted infections.
Economic Costs of Alcohol Misuse
Economic costs attributable to alcohol to the justice and health sectors of the broader community include health care and law enforcement. The economic impacts of alcohol abuse result from the impact on the ability of co-workers to carry out their tasks and the loss of productivity and absenteeism of those who drink (VicHealth, 2012).
Economic costs to the government include resources allocated to prevention and education campaigns, research, service provision, maintenance and law enforcement. The total social cost in relation to alcohol abuse during 2004 and 2005 cost $15318.2 million, with a further $1.1 billion attributable to the joint consumption of alcohol and illicit drugs. The avoidable costs of alcohol abuse in Australia and the potential benefits of effective policies to reduce the social costs of alcohol (Collins & Lapsley, 2008).
Within the workforce the tangible social cost equated to $3578.6 million between 2004 and 2005. The tangible social costs which are borne by the community as a result of alcohol and illicit drugs being consumed together was approximately $1057.8 million (Government of Australia, n.d.).
Alcohol related issues in public spaces and places such as anti-social behaviour, property damage, litter and noise can detract from real and perceived safety and amenity. This may discourage groups such as women, children and older people from visiting certain places or using public transport. This may affect people’s mental and physical health and wellbeing through reduced physical activity and social interaction.
Australia’s overall per capita consumption of alcohol is high by world standards, with the country currently ranked within the top 30 highest alcohol-consuming nations, out of a total of 180 countries (AIHW, 2012). Although overall levels of alcohol consumption and drinking patterns have not changed substantially over the past decade, there has been an increase in the number and proportion of people who drink at harmful levels.
In recent years, there has been an increase in the proportion of people, both males and females, who are drinking at risky levels (AIHW, 2012). Between 1995 and 2007/08, the proportion of men and women aged 18 or over who drank at ‘risky or high risk’ levels for their long-term health increased for men from 10% to 15%, and for women from 6% to 11%. In addition, the average number of days per week on which alcohol was consumed increased for men and women in almost all age groups, with larger increases for women than men.
In 2010, the following patterns of alcohol consumption were apparent (AIHW, 2012):
- 81% of Australians aged 14 and over consumed alcohol;
- 47% of Australians drank alcohol at least once a week with 35% drinking less often than weekly;
- 1 in 5 Australians abstained from alcohol (including those who had never drunk alcohol and those who are ex drinkers).
The total consumption of alcohol in Australia has fluctuated over the past 50 years. From the early 1960’s onwards, apparent per capital consumption increased steadily, peaking at 13.1 litres of pure alcohol per person in 1974-75. Apparent consumption remained relatively steady for the next 5-10 years, then declined over the following decade, dropping to 9.8 litres per person in 1995-96. Apparent consumption then gradually increased to 10.6 litres in both 2006-07 and 2007-08, before declining over the past 3 years to 10.0 litres of pure alcohol per person in 2010-11.
One in five Australians (20.4%) drink at short-term risky/high-risk levels at least once a month. Put another way, this equates to more than 42 million occasions of binge drinking in Australia each year (Commonwealth of Australia, 2008).
In 2007 National Drug Strategy Household Survey, binge drinking was defined as consuming seven or more standard drinks. The term ‘binge drinking’ is popularly understood to mean someone going out to get drunk. However, the Australian Guidelines (NHMRC, 2009) do not define binge drinking because it means different things to different people, and is therefore difficult to define scientifically. Therefore, instead of the term ‘binge drinking’, the Guidelines refer to a single occasion of drinking.
Binge drinking i.e. short term consumption of alcohol at harmful levels is a prominent feature of the drinking culture in Australia. Binge drinking is defined as consuming seven or more standard drinks on any one day for males and consuming five or more standard drinking on any one day for females. This equates to drinking to the point of intoxication. One in five Australians i.e. 20.4% drink at short term risky/high levels at least once a month (Commonwealth of Australia, 2008).
Binge drinking is most prevalent among adults age 20-29, 24.9% of who do so on at least a monthly basis. Although Australian males are more likely to binge drink (17.1% of females compared with 23.6% of males), amongst teenagers, females are more likely than males to binge drink (28.3% of females compared to 24.5% of male teenagers).
Although the proportion of secondary school students aged 12-17 who drank alcohol in the previous week has decreased between 1984 and 2008 (from 30% to 17% for those aged 12-15 and from 50% to 38% for those aged 16-19), there was little change in the proportion of students aged 12-17 who consumed alcohol at levels that could lead to short-term harm (risky drinking) in the previous week between 1984 and 2008.
In 2010, 20% of people aged 14 or older reported drinking alcohol at levels that exceeded the 2009 guidelines and 39% of Australians aged 12 or older drank in a pattern that placed them at risk of an alcohol-related injury (AIHW, 2012).
Population Health Planning for Alcohol Misuse
Health promotion and prevention activity relevant to alcohol and drug use can be conceptualised using a number of relevant frameworks. The Public Health Systems Model developed at the National Drug Research Institute (NDRI) (Lenton, 1996, cited by Loxley et al., 2004) in Figure 17 shows that prevention activity can be focused at a range of levels of increasing complexity, ranging from work with individuals to national and international approaches.
The Public Health Systems Model conceptualises the determinants of harmful alcohol and drug use on a continuum from macro (international mechanisms of action and contextual influences that impact large aggregate populations) to micro influences (individual drug use behaviour). Loxley et al, (2004) described the more distal influences at the international, national and state levels as social and structural determinants and more proximal influences within local communities, organisations, groups and at the individual level as risk and protective factors.
This model assists in mapping systems, pathways and strategies that connect among and between social and structural determinants and risk and protective factors and alcohol and drug use behaviours. It is clear that local community strategies will be most effective where supported by actions at higher levels.
Determinants and Risk Factors
Australia’s drinking cultures and consumption patterns are driven by a range of physical, social and economic factors associated with how available alcohol is within the community, the location of the venue in relation to sensitive uses and vulnerable groups, and the design and type of venue. Although there is no single factor that determines harmful drinking patterns, each of the determinants discussed below plays a significant role in determining the extent to which people may engage in harmful drinking behaviours.
Liquor outlet density
Outlet density is determined by the following:
- The ratio of licensed premises per head of population e.g. 22 licences per 10,000 people (Donnelly et al., 2006)
- The proportion of total licensed premises concentrated in a particular location.
- The proportion of a particular type of liquor licence of all liquor licences.
- Number of licensed premises within a specified catchment (State Government Victoria, 2011)
High densities of alcohol outlets are associated with harms including teenage drinking and drink driving (Gruenewald, 2011), medical harms, injury, crime and violence in the immediate surroundings and in adjoining neighbourhoods (Campbell et al., 2009).
Location in relation to sensitive users and vulnerable groups
Locations and groups particularly sensitive to alcohol-related health issues include young people, people experiencing social and economic disadvantage (WHO, 2014). This is particularly relevant in areas where there is a high concentration of packaged liquor licences (Livingston, 2012). Residential areas within 1.6km (Donnelly et al., 2006) of licensed premises, particularly those that operate beyond normal trading hours, may be affected by a range of alcohol-related issues including noise from people, cars and the venue; property damage; vandalism; anti-social behaviour; crimes and assaults.
The price of alcohol relative to earnings will determine how affordable, and therefore accessible alcohol is to purchase and consume. Price is an important factor influencing levels of consumption and alcohol-related harm (WHO, 2011) at an individual and community level (Leicester, 2011). Young people and heavy drinkers are particularly sensitive to the price of alcohol (WHO, 2011).
Higher density increases potential for competition and lower prices, both of which are associated with excessive alcohol consumption (Livingston et al., 2007). This is particularly relevant for packaged liquor licences (licensed supermarkets, boutique bottle shops or ‘big box’ bottle shops) in high density areas (Bowley, 2011) located in disadvantaged communities (Livingston, 2012). However there is no evidence that price can be influenced or changed at the regional or local level.
Trading hours determine when and for how long alcohol is available for purchase and consumption in licensed premises and private homes. There is a direct and positive correlation between longer trading hours (between midnight and 3am over the weekend) and anti-social behaviour, violence, fears of safety, road traffic casualties and property damage (Briscoe & Donnelly, 2001) (Wicki & Gmel, 2011). In addition, later closing times shift alcohol-related issues to later times of the night (WHO, 2011) which has implications on the demand for emergency services such as police and ambulance.
The maximum permissible number of patrons in a venue determines how many people can be accommodated, both within a venue and within a defined physical catchment that has a number of licensed premises e.g. an entertainment precinct. Venues such as restaurants, bars, nightclubs and pubs with patron capacities above 200 are generally considered to be the most risky, and are associated with issues such as crowding within and outside the venue, anti-social behaviour, parking and traffic congestion, assaults and excessive demands on public transport.
Venue type, design and mix
Venues such as bars and nightclubs where the consumption of alcohol is the primary activity are associated with the most harm. Venues associated with poor management styles and poorly designed internal spaces may decrease the real and perceived safety of patrons. A poor mix of venue types may reduce choice and can contribute to homogenous drinking environments that are associated with particular patron profiles.
Design of the public realm
Factors such as footpath design, location and capacity of car parking areas, street lighting, maintenance, wayfinding signage and the presence of enclosed and poorly monitored spaces can reduce the real and perceived safety of an area. On the other hand, factors such as adequate public transport, good natural surveillance and appropriately located doors and windows can enhance the real and perceived safety and comfort of both patrons and the broader community.
Australia’s varied drinking cultures date back to the initial British colonisation. Contemporary drinking cultures continue to be defined by specific social norms and values that affect the extent to which the consumption of alcohol will compromise health and wellbeing. It has been recognised that too many Australians are partaking in ‘drunken’ cultures rather than drinking cultures, and that many of the dangers of alcohol for those who drink and those around the drinker, are misunderstood, tolerated or ignored (Commonwealth of Australia, 2006). This is particularly apparent with regards the causes and effects of drinking to intoxication. The increase in the incidence of binge drinking amongst young people, particularly women, has been attributed to Australian tolerance toward youth alcohol use (Commonwealth of Australia, 2006).
Although the majority of drinking amongst Australia’s workforce takes place after hours and on days off, some does occur during the working day. Harmful use of alcohol, both during and after working hours, is associated with adverse impacts such as workplace accidents and injuries, workplace fatalities, reduced productivity, poor work relationships, and increased absenteeism and presenteeism (decreased on-the-job performance) (VicHealth, 2012). Workplaces are powerful settings for both establishing and harmful alcohol consumption cultures and supporting the promotion of health to a large audience. They are also significant determinants of the physical, mental, economic and social wellbeing of employees (VicHealth, 2012), all of which influence the levels at which people may consume alcohol.
The increase of liquor sales during December and April (to a lesser extent) (Richardson, 2012) indicate that there is a strong seasonal pattern to alcohol consumption. This pattern is also reflected in the increase in domestic violence in the months of December and January, and other public holidays such as Melbourne Cup Day.
Most of domestically consumed alcohol is consumed directly by households, presumably in private homes. However a large share is also consumed as part of a purchase of food and beverage services at venues such as bars, taverns and restaurants (Richardson, 2012).
Most adults are likely to express concerns relating to consumption of alcohol by young people in general, and binge drinking in particular. Nevertheless, in many instances young people obtain their alcohol from adults and a large proportion of young people obtain alcohol from their parents (Australian Government, 2004). Some of these adults, including parents, may be unaware of the dangers associated with underage drinking or the legislative restrictions on supplying alcohol to young people under 18. In other instances, often within migrant communities where attitudes to alcohol consumption are conservative, parents may be unaware that their children are consuming alcohol without adequate adult supervision or consent.
Adolescents who are poorly monitored begin consuming alcohol at a younger age, tend to drink more, and are more likely to develop problematic drinking patterns and effective parental monitoring may reduce the effect of peers (Australian Government, 2004).
Some Australian parents may underestimate their consumption patterns of their children, and may be more concerned about illicit drug use than alcohol use. Others may feel pressured to accept alcohol use by adolescents as normal. Young people’s attitudes towards and patterns of alcohol consumption may be modelled on the norms, values, attitudes and goals of adults, particularly those closest to them such as their parents (Australian Government, 2004). As a result, the regular exposure of harmful drinking patterns amongst adults may normalise binge drinking behaviours by children. The NHMRC (2009) guidelines recommend that adolescents do not use alcohol prior to age 18. An increasingly important goal is encouraging children to avoid alcohol use.
Factors such as advertising, marketing and location of the licensed venue will determine how exposed individuals are to the presence of alcohol in their neighbourhood, and therefore how available alcohol is perceived to be. High exposure to alcohol can influence social and cultural attitudes to consumption of alcohol by normalising their presence in places where people conduct their day to day activities.
Alcohol advertising and promotion increases the likelihood that adolescents will start to use alcohol and to drink more if they are already using alcohol (Australian Government, 2009). Exposure to venues is determined by the extent to which licensed premises are accessible and visible from important locations such as gateways, destinations and attractions.
Footpath trading permits extend the physical area of a licensed venue within which alcohol may be consumed.
Vulnerable Population Groups
Children and Young People
Drinking contributes to the three leading causes of death among adolescents, namely unintentional injuries, homicide and suicide, and risk-taking behaviour, unsafe sex, sexual coercion and alcohol overdose (Commonwealth of Australia, 2008).
Under aged Drinking
One of the five ethical principles and goals embedded in The European Charter on Alcohol is that all children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages (WHO, 2006).
Secondary supply refers to the provision of alcohol products to young people under the age of 18 by a third party. In Victoria regulations in the Liquor Control Reform Act 1998 make it illegal to supply alcohol to a person under 18 in a private residence without the consent of the parent or guardian. This includes parents providing alcohol to their children or their children’s friends, as well as other people such as siblings and friends over the age of 18 supplying alcohol to people under the age of 18.
Some slight increases in per capita alcohol consumption in Australia over time may be attributable to the emergence of new patterns of alcohol consumption among youth and young adults, such as preloading. Preloading, which is also known as ‘pre-drinking’, ‘pre-partying’ or home drinking, is when an individual consumes alcohol before going out to a licensed venue such as a pub, bar or club (Turning Point, 2012). Recent research reveals that three quarters of Victorian youth are now preloading on alcohol (WHO, 2011). The main reason behind the emergence of this trend among young Australians is to save money, with individuals reporting that it is much cheaper to buy alcohol from bottle shops than from clubs, pubs and bars.
Preloading is often heavy drinking, to the point where many people are getting drunk before they go out. To further demonstrate this, research has highlighted that a strong relationship exists between pre-drinking and extreme binging, which is the consumption of 11 or more standard drinks in one session at least once a month over the past year. As a result of the associations and trends, preloading has been shown to considerably increase the risk of long term alcohol related harm (Donnelly et al., 2006).
Pregnant women – one in five women continues to consume alcohol while pregnant after knowledge of pregnancy, despite national alcohol guidelines which state that it is best to avoid alcohol altogether during pregnancy. (FARE, 2012).
Aboriginal and Torres Strait Islanders
Aboriginal and Torres Strait Islanders – Indigenous Australians may be up to six times more likely to drink at high-risk levels than non-Indigenous people (Commonwealth of Australia, 2008).
Alcohol consumption, together with nutrition, smoking and the use of other drugs and substances, is a key health risk factor contributing to the greater burden of ill health experienced by Aboriginal and Torres Strait Islander people. Although some studies indicate that Indigenous Australians are less likely than other Australians to drink alcohol, those who do so are more likely to consume it at hazardous levels. The National Health Survey of Aboriginal and Torres Strait Islanders in 2004-05 showed that 63% of all respondents consumed alcohol in the week prior to the interview, 16% of which had consumed alcohol at a high risk level. Indigenous males (109%) are more likely to consume alcohol at high risk levels than Indigenous females (14%) (AIHW).
Other Vulnerable Groups
- People aged 18-24 (31% of whom consume alcohol in risky quantities on a weekly basis)
- People living in rural and remote areas
- People employed in the agriculture, retail, hospitality, manufacturing, construction and financial services industries (VicHealth, 2012).
Paper continues in Part B